1 100 68 http://exhibits.library.stonybrook.edu/mfp/files/original/538bdc6ba0530077be0ac863533401f5.pdf 74bce06bc6e20def0793fd89b0e7d725 PDF Text Text 3mm mam mum mm nwrxrmuox arm: ML. WW4; or A 0A3: MA Mb. (firm) g; (\Mmc ~39:qu QNUULJ».6§~UJ\MA1 4% (0.2.1:? #:g Afod. I751: Viz/b. wk. 316% 3.17/‘3. �1. sustained by patients during hospitalisations' in mental institutions may cause disease of the nervous systemunrelated to the original illness. The trauma may be disregarded and the resulting complications may be interpreted as further progression of the original mental illness, thereby thwarting possible definitive therapy. This is most apt to occur in patients with organic psychoses. For this reason it is felt that a report of a case of subdural heaatcna developing during hospitalization in a patient with organic psychosis will be of Head trauma interest. ‘ fiftyoeight year old white feaale a nurse was admitted to Bellevue Psychiatric Hospital because of aental and personality changes. Four to five years previously the patient began to aislay objects and complained of occasional headaches. During the next two years it was noted that she would repeat herself in conversation, did not play bridge as often as before and complained of a constant feeling of fatigue. One and a half adaission to a marked change in her behavior occurred. years prior She had difficulty in asking decisions, became caliess in her dress, nislaid objects more frequently and exhibited stereotyped HISTGRY: A aoveaents (rubbing hands together, crossing legs) when excited. During the subsequent months she became ”confused" and incontinent. Prior to her illness the patient was a nurse doing private duty and was described as an excellent worker. She was. a happy individual with a pleasant and sociable disposition and had had zany friends. She had been an excellent bridge player, winning aany prises. �2. pressure was 95/60, pulse 88, temperature 98, respirations 18. General physical examination was negative. The patient was well nourished and alert. neurological examination disclosed her to be aphasic and apraetio. There were disturbances in body scheme, a left hononyuous visual field defect was present bu t the remaining cranial nerve functions were intact. There was no ataxia or inooordination. hotor power was noraal. The deep tendon reflexes were active and equal bilaterally and the plantar responses were normal. There was a left henisensory defect to pinpriek and touch. gegggégggz; hunter puncture disclosed clear, colorless fluid under an initial pressure of lho an. containing 5 lymphocytes and a total protein of 62 ng.%. The Hassernann and colloidal gold reactions were negative. X~rays of the skull and chest were negative. in electroencephalogram was diffusely abnormal containing a prevalence of slow activity maximal in the temporal and posterior parietal regions bilaterally. GOURSIa' The differential diagnosis was that of presenile and cerebral neoplasm. A degenerative disease of the brain pneuaoeneephalograa revealed generalised dilatation of the ventricular system without displacement or distortion. The cortical aarkings were increased bilaterally. The patient was kept in the hospital for further study of her mental and sensory defects. On at least one occasion during this period bruises were noted overthe patient's head and fees. these were thought to be sustained tron falls or from busping into objects on the ward. The patient remained alert and no new neurological signs developed. Approximately three EIAIIIAEIOK: Blood ‘ ' �months after admission the patient gradually became lethargic and exhibited rhythmic myoclonio movements, frequent in the corner of the mouth and the left upper extremity and occasional in the right upper extremity. A left hemiperosia developed end the patient became etuporoue. Lumbar puncture diacloeed clear, oolorleee fluid under an initial preeeure or 200 mm. and containing 3 white blood cells. Loft temporal and right A hugh oubdurel henntoma were performed. trephinationo perietal was found on the right eide. It contained dark red, liquid blood. There we: no definite aotive bleeding. The outer membrane one very thin and the inner nenbrene wee inoonepiououe. The right hemisphere wee nerkedly compreeeed and failed to re-expend after evacuation of the hlnmtona. 0n the left side there were two eubdurel membranes about 3~5 mm. apart and oontaining a small amount or yellowish fluid between then. There wee no blood. A cerebral biopsy wee teken.fron the left parietal lobe by introducing a glaee euotion tube for a distance of one inch at a right angle to the eurteoe of the cortexand eepirating a specimen. Following operation the patient became more alert but the apheeie and the disturbance in body scheme were more marked left and epeeoh was unintelligible. The myoolonie movements diaeppeered and the left henipareeie improved. Seventeen days efter operation a pneunoencephelogran showed dilated lateral ventricle: more marked on the left side. The enterior and poeterior horns were aeynaetrioal and slightly diapleoed to the left. The patient died eight days later. An autopsy was not obtained. hieroaeopio examination of the cerebral biopsy at the �shoved numerous senile plaques and time or trephinstion Alzheimer cells, oomputible with the diagnosis of Alzheimer's diseaoe. signs of progreooive diocese of the cerebral hemisphere: which this patient developed during the latter part of hospitalization were initially interpreted as the end stage of an organic psychoaia. In view of the head traumn sustained exclude done subdurel henntonn ward was the on trephination to although this diagnosis was considered improbable. That the subdurel'hanntonntn were of recent origin.end yore not present before hospitalization is demonstrated by the following observations: 1) s pneuloenoophnlogrsn prior to the progression or neurological ventriculnr showed system without a symmetrically dilated signs 'diaplaoinent or distortion and increased cortical markings nontranen the of the hematonats were very thin. 2) bilsterdlly; Patients with organic ptyohosie in nentsl hospitals are psrtioulerly prone to head trauma which may initiate subdursl hemntamn; Progressive usurologioal signs in such patients should be evaluated with this oonsiderstion in mind. The � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Subdural hematoma developing during hospitalization. Arch. Neurol Psychiatry. 1951 Aug; 66(2): 230-1 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-1-001 Date A point or period of time associated with an event in the lifecycle of the resource 1950 Creator An entity primarily responsible for making the resource Green, Martin; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/35b321c800690bb601799adad174ab44.pdf 460a6759754060bc775314593ce1e71c PDF Text Text I ‘ Table I 30 Discharge Ratings of Improvement: Ratings of imw provement at the three hOSpitals varied in format and detail» The discharge rating at Menninger Hospital was tripartite with a sep~ arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)o For this study the Menninger syndrome rating was compared to the global ratings of the other institutions, Table B. II Inter—hospital Comparison 1» The Sociopsychological Variables distribution of the variables of social class, age, education and California F Scale score is presented in Table III. Table III among the three institutions . a) Social Class: The anticipated difference in social class composition of the three institutions was observed, At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age distribution in the institutional populationso �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Subdural hematoma developing during hospitalization, Am J Psychiatry. 1950;107(5):381-3. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-1a-002 Date A point or period of time associated with an event in the lifecycle of the resource 1950 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/348b7ac617e184efef2c6c30c847fca6.pdf 36100719e5c813fdabfca556caa0ba68 PDF Text Text Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION 1950 PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER MAX FINK AND MARTIN GREEN NEW YORK In previous studies we found that the method of double simultaneous stimulation showed defects in sensation (extinction) which were not apparent on routine single stimulation. In testing two different regions of the body and various combinations it was found that extinction was apt to occur most often in the hand and least in the face. Conversely, “dominance” was greatest in the face and least in the hand. In the present communication we wish to report the results obtained on simultaneous stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syn— drome; 4) schizophrenia; 5) no disease of the brain (normal adults) and 6) normal children between the ages of four to ten years. Patients in groups 2 and 3 showed severe memory defects, confusion, poor orientation, difficulties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or fingers) were touched Simultaneously. Care was taken to make the two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked to report what he felt, and following this, where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the first examination: a) a touch on the face only (face dominance), implying no Sensation in the hand (extinction) ; b) a touch on both sides of the face (there being “displacement” from the hand to the ipsilateral face) ; or c) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that on subsequent tests he was expectant of more than one stimulus. In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislocalization was towards the face it appeared as if the face determined the direc250 �251 Perception in al.——Patterns Bender, et of type a this was that therefore, said, be might It than tion of the displacement. common less was displacement, or (b), Response dominance. face the patients in often most seen was (b) Response extinction. or (a) testing. response repeated despite persisted and with the organic mental syndrome, comment. special needs no and normal expected the was face The (c) response ipsilateral the when noted werealso Extinction and displacement including tested, subjects the all In tested. sides and hand were simultaneously left and right the between difference no was there aphasia, with those - ' of the body. the in shown is various groups the in obtained results Analysis of the following table: Hand ;/,’// Group Face Response Extinction or Displacement Number of Subjects 2 ‘4 22 20 5 53 ' 3 20 . 0 14 24 , 19 ‘ 0 6 20 ' Response _ 9 12 15 12 1 Face and Head Response ‘ 2 6 28 0 ' ‘ - 0 0 0 . j . l l of is dominance there whenever that obvious is it; foregoing the From. the hand in Dominance face. the in is it apparent another over sensation the in one "uniformly almost found was dominance Face once. notedonly did was patients These 2 and 3).. (groups changes mentalwithsevere in. _ subjects few a In repeated'testing. after hand even the not report sensation in were or stimuli, two were there told the were patients after even stances, percept one only reported they stimuli, of the of asked to watch the application sides both of stimulation simultaneous cases Inthese one. displaced these that or objection the excluding thus correctly, the face was reported once. things at _. two perceive do or able to not were those in and patients with aphasia subjects in dominance face of The'incidence, in .. patients 1 and 4) was less. In contrastto with schizophrenia (groups correctly sensations both 1 4 reported and in those groups 2» and 3, the hrst groups done not had soon if they trials, fourth third or second, the domiface on of. incidence the 5) adults (group normal of the In group the trial. on found only it was though even significant, still but least, dominance nance was face of incidence the. children normal of series In trial. a dominance first face children 3. In 2 and young in groups as the same almost was examination. first the after trials several tested was present even hand were the than other body of the When theface and parts The apparent. still was dominance face 3, 2 and in" groups calf, simultaneously thigh, penis, (breast), trunk shoulder, face, was dominance order of hand. and foot, arm . . _ �252 Weights (IL—Discrimination of Bender, et CONCLUSION In a wide variety of subjects the phenomena of extinction and displace- consistent A demonstrated. stimulation simultaneous were ment on double dominant most face the which in was established of pattern perception was and abnormal the in both noted These findings were and the hand the least. the normal subjects. In the abnormal subjects with severe mental changes, be that consistent they may extinction were so face dominance and hand used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, be to brain diffuse disease, with in appear patients which are so prominent exaggerations of the patterns found in the normal subjects, especially children. �um II mama! 0' MES 0! I‘M! w 3mm my- A! Harris 3. Bender, ILD. Pink, IL». m and lax-tin anon, LB. of lumbar fipi‘ffinfi '75; Buivenity cones. of Mieinc, 555 Sinai City. tort lelpiul, In m lupin ' 101E law c fiy Edi-y,1 and that Haunt 3.11m. from the mum; grant a ”starch by part) (in This work was aided a. by grant and part) (in service Public With of math, Institutes Inc York . city. in Cmbral of In council his: Coordinating the I‘m �1.' Previously it was shown thst exsnihstioh of the cutaneous uodelitiec by the method or double siuultsneous etisnlstion elicited defects in perception which were not sppsrent on single “extinctiont” ”obscuration,” The ss defects, desctihed etihhlstion. "displacement” and "eliesthesis'.were observed in groups of or the centrsi nervous disesse diffuse with localixed or patients systen (1) (a) (3). In esch group the defects in cutaneous per» most were stimulation double sismitsneous obtsined on ception of the rhe fece. hand the sud object in the lesst in appsrent or the was responses determine to patterns investigation present in nonnsi subjects, sduits and children,to simultaneous stisu1s~ Yarns "fece~hs.nd” observe~ head and teat the face of the tion tions in this nonnsl group were then cospsred to sole extent with the responses of pstients with orgshic mental syndrases, sphssis sud cchisophrenis. IAEIR£égc the ”non-s1“ subjects were children and sdulte. These there. subjects were persons attending hcspitsl clinics, in was no evidence or disesce or the brsin; and school children, start of disorder manifest who: no was there sud in students, personnel been had Hone of then previously system; the central nervous exslined by the nethod or double sisultsneous stimulation. the to according sge: three into groups classified were subjects 12 “adults” end 6 over end years. 7 to 3 children or to it years, For comparison with the noml goup we studied patients on 'There were three Bellevue wards of Psychiatric the iospitsl. the sod lo attempt sphssis. psychoses ~ organic schizophrenia, group: whom �2. .uno and. to separately study each or the clinionl typo: of schisophronil. float of tho puticntu ours or the paranoza, mixed or iinplc vurietiel of Iohixophrenin. the patient: uith organic montnl changes showed doreota 1n nonorw, orient¢t1on and onloulution, a: wall In other signs and symptom: oharuoteriltio or dxtruoo dileIIO of tho brain. Tho clinical diagnoael in loot of,those onuou was Althoincr'n dilt&§c, urtorionolcrotio onoop~ haloputhy, severe oorobrll ordain, brain tumor or toxic ano¢p~ who with thou mm uphuu. lubjootl mommy. ohnrnotcriltio difficultiob in columnioation. Theta who had a oonoolitant hmnipnroail or I huuiscnlory aorta? noticeable on single Itilnlation war. not inorudod in thin Curios. m '3th maroon: 2h: subject val instruotcd to‘olouo tho cyan. When thia 1p3111tcéll (chock) and tho oontrav done or either tho-root it: our. hand ninnltnnooully on. (any hand digit.) at or part lateral touohcd or stroked with tho examiner‘s ringorl. the subject: whoa two sonsntionn; only one percept one or either reported no: reported tho subject was naked 1: than. at: 3:111 unothor, and 1: no, to indiooto its loontion and quality. Following the initial trial, in each subject, tho opposite chuck Ind hand aura stimulatod 1n the 1.80 nunnor. Those tout: poquepoatod and tho result: reoordod, until tho subject: oon~ who those In both auhjootl otinnli correctly. nistontly roportod toiled to localize tho two Itinuli oorruotly otter at: or eight word an touted t1oo~ttoc,'hand~ body the of 0th.: part: triala, room-hand tho with uumung ma, “mama, penis-hand, em, tout. �otinuleé eerie! ot.stndies pin prick tions sere used in s sinilsr fsshion.w In both series, cere use taken to apply the stimuli at the me time and with the em thst'snhdects who‘nede consistentt was spherent intensity. It he would correct as soon es the stinuli were errors in reporting rsther thsn sinnltsneoutly, even if the spplied consecutively tine leg betseen stinuli was that or one or two nonente. It was slso necesssry to use neive norssl subjects, since sthects previously tested did not show the.petterns noted below. In e second sepsrste 8 ones; lhe responses obtained on the tnce~hsnd test fell into four groups: (s) s touch on the face and the hsnd, indicstins the correct end expected perception; (h) e touch on the fees only, in the head; (c) I touch on both sides or implying no eensstion the tees: and (d) s touch on the bend only, implying none on the race. flhen only one stimulus III reported the subject use ssked if there uss any other sensstion. the oocesionsl reply sue that there use snother percept, and the sthsct correctly pointed to the second locus. lhny hdhaects, however, reported thst they hsd not perceived snother stimulus, neuslly sdding the state-cut: ”In use not paying sttention - do it seein' or, ”I'm not sure - Isvhe of here" end somewhere the the was direction in over pointing it side of the body or the poorly felt stimulus. In some instances, second while correctly locslising the percept, they Iinnteered the ststenent: "It use not es strong es the other one,“ or "It doesn't seen as sharp.” Before we proceed with the results we rust define the connnnicstions other the failure or the need. In special terns �#. luhjoet to report ohm or two ninnltnnmaunly applied stimuli ha: of been called “tbs phhnhnenon gunnery extinction“ hr ”extinction“ 1n utid wharu stinmlu; tho poreeived or body the (1). the part Ill uxnultanuhulh to he "danihnnt” ta the part of thh body where thn Itinnlun nun net perceived, or parceivcd faintly. the latter aensatieh was terncd ”obnouration.' or a the diminution in quality whah tho uuhject ruparted tun nonnatiehn, hut ninloenlilod one or thun, the "ditplhccncnt' a: a peroapt in .315 to hire oeeurrea (2). ndsplaccnentu Ir. ununlxy 1n the direction or tht daninnnt ’ntinnxup and as: he puttinl hr eqnpxgte. rhe‘dilplaccucnts nttcd man» chock the side. of hand.to th1§.ner1gp tn. were :ran.the in Rarely did the displscahehts cedar to the hack or thauldor. tram the nthhdpoint {hm snalyuod result; \Ih1t1h1‘2r1hxs uqrt of initial and nuhluqnont thee¢hnnd test with touch trilla. en Ithhlltion tn. initill trial or the Inhjcetn, taco deninnnec uuu appurant 1h :11 use granny. 'lhrc_thnn half or such and none in thc race the in the schnation udulta rcported nonntl hand. lhrno Cubdoetn ninlaehlisod tho lentation 1n the hand to thn £160. In thn green: of hon-n1 children 90! under the use of hand the percept hiuloealizcd thee the or hereopt :1: reported only tha {teeddhinhnoe in a: also 1: seen face. the Ibis pattern to children tram 7~12 years of age hat.th a 10:30: extent. hand the adults‘reportod or the ham-ll suhjaotl, five indtidl or example dinplaeenont In thn an trial. only Ittnulus noted. hand was tram race to by hand extinction or by daninanee face or Ill pattern the more apparent was tune even th hind percopt of.the dinplncclant 1n nornnl �in thn patients aznninad. Xt uun.noat evident in patients with arggnic gantal chanset, 935 or when did not repert bath stimuli corrnctly. In callinntion. or uchixqphrunio lub:ectn and patinntu with aphnail runponneu lililnr to thnse of thc annual adult were observed on tum intill trial. land doninnnoe was accllionllii seen in the patient and vital: in tn. net-:1 Iahjpat. In «use. of hand dominance the race' not the reported the but percent; It was seen manual I in the initial trial on m five different net-11 Malta .. In the” instano§3. tun nubaoct ropnrtod both.ttanu11 carrectiy oh nubaoauunt tinting. In the patidntt with organic mental changes hand dauinnnee III In inconntant rtupanto and rcpeated touting the sale day or on unbloquant dawn danonntrated thy amt! usual poruiutunt pattern or dominanco. "" ' rm 1 stilulttion ,Rolponso on initini roueh 19ml Adult lam]. «mm, low emu. Totalicorrcot Pace Only luaowraae land Only 160 77 15 3 5 3-6 564 m 23 18 a 7.12 76 33 27 9 2 7: 26 n5 1 2 syndrome 120 9 9n n 3 o o Schisoyhranin (“malt-niried) mute luau: trill . i Apmu Submgguont I 23 Erialla or the 12 83 11 narnti adult. uh» nude errata initial trial, #3 were correct on the uecond and 12 on the third triul. In a to! sub: '“Vffliaur. five at Ii: trill! var. the nucOIsary berare the tun stimuli Into corructly localised. than. on �6.‘ ta be annual, althuugh complete psychologiaal (tennion during that noted VII anxiety It the with to'ploaae) interfered desire strong callinltton,er.n annual :11 aubaeetl, In rncognition the of ntiauli.v torruct early aubjoets ware Inlunnd tent. wcro.not dune. the IIB correct once those rosponae with anxiety, including abtn1npd (oven all fitter an was iith elicited error.) it trials number warn or if n¢cncd a an tritll It many aubnequont_teut1ns.: ”aét“ axmnlnntion, the at the into neoenuary_ror tn. anbaect'ta set evon cccurutoly, trtcr the ha ntinnli riported the once in tad set, of any WI; ”9,10.an in that was apparent child annual wanna th: it In testing inst canon Inn: tail: war. nocolsnry.h¢£ore the correct rotpanse was «enlistently elicited. Alta, tan child at. not tlltya dayu. many over tasting lopeutcd tubaugunnt touting. an correct of Ibis tuna daninlncc, in: shin tbs patterns hauever, olicittd natod in 36 of tho 56 childrtn tottqd, ‘In a number of instances than and reportcd tho stimuli appz1¢nttan can o; Intchcd en. child was thy But repeated an test noon corroetly. percept1onn tbs t; stimulus. on. repertod child tho «my with tm «you acted. min or “int” the tn» in: not into could tho get ehild evident that It oxtninntion, even with viaunl anal. 311 In children. in not wag apparunt vary thin diffieulty t6 the 76 give the failed 17 at anly (age: 7-12) the older group correct renponse utter th; inititl tau trials. 1.: at the nae-hand on the reports obtained repeated. A: relieved connintent s pattern. test: in mgr-:1 nubjecta also tubsocti. on tbs initial trial, face daninnncc was trivalent in all or or‘ obsmatien (a) extinction by It was: unite,” uthor " tr: m �8. or the autumn te displacement fees, or er me atmii ”.in aevertl insteneea the displacement we. in a direction tantra (1)) by O3 ' em taco. In contrast to normal adults, patient; with organic mental change: were unuhie te regert the two stimuli earreetly even utter many triele. When_the yetient reported the pereept in ane teet eorreetly, he frequently failed on tubuequent testing; It was tine Ipperent that touting en subsequent‘daye etiii elicited in and er stimuli. extinction dieeinemt m: u ntrang who made seldom unmet: to tn error apparently subject: centreet on subsequent tritiu, day: after the initial examination. the responses obteined in this group demanetrated the pattern: at tee. teetffl deninnnee in meet or the niepiaeenent of the hind percept to the tune was frequent. In tame instances dieplneement or extinctien was preeent deepite the {get that the putiont watched the applitutiea of the etinnii to the fete and hand. Extinetien was very taxman en hencieterni or heterologoun teeting while ~ fine apparent dilpieoenent neatly on heterolegeun teats. 514; the and nyhneie patient: the uehisephrenie reports gayb which were «1:111: te normal adulte. After the first tie trial: the pertentnge of errer in hand sensation was slightly higher than in the normal greup. reraietent bistrre reepoaeee were elicited from a number or the schizophrenic Inbdeetl. lheee reperte inelufied multiple responses to mingle or daubie stimuli, pereietent displacement: to one area from any other body area, ineonsittent verve end 'mimrreveruls or localiutien. day: As normal the to free with an day examinetien_and eating consecutive an the aphasia subject Iehixephrenie touting or idnlt, M �days roiled to elicit extinction phenonehe once the been eccorltely reported before. test hen ‘ comparison of the reeponeee or each or theoe groove to nultiple teeting in chain in fig. 1. A firfi 54’” Pin Phick Btiuuietioh: It in known thet the type or etinuiue epplied influence: the result: in perception. To denonetrete the importance or thie rector einiier groups of subject: were tested ueing two pin prick ineteed or two touch etilnletione. With pin prick etinnieticn ct tece end hencflfece dominance wee egein uehiteet in all the groupe. however, the incidence of error in perception of the pin prick in the head III lower than with e touch etinnloe. Ihe reeulte are recorded in IhhflcIIt Elna! II :1 ' afizaiififmfi’fim lttei tor-ll Adult correct Pace only Feccqrece Hind an}: 68 51 15 2 c flannel child, 3~6 yearn #5 lorlml Child,7~12 your! 39 50 Schizophrenin 16 26 2 1 25 1h 0 0 36 13 9 1 arsenic lentei syndrome #7 9 33 3 2 Repeated testing with two pine in the nccnfii adult subject: elicited the correct reeponeee in the initiel three trieie. Fever at the chiloren figificd to report the teat eccuroteiy after the initiel trials. ~It we: poeeibie ih_e hunter or instance: to alternate touch and pin prick etieuietiohe, end demonstrate extinction to touch, but correct localization to pin prick. loreover, with �m. abre intehae pih prick atianlatieh, extinction and diaplaeeaant were lean frequently ebaerved. vzheae phendaena, haaely extinction and diaplaeeaent were eveh.nbre apparent in the patiehta with erzahie mental ayadreaea. Bdaplaeeaeht or touch ltd-311 eauld be alternated with oerreet Idealiaatibn of pin brick atzaulatiah. A ddubihatxon or touch tb the fade had pin prick te the hand evinced the edubinetibn at displacement and obaenratioh, an the patient reported “a teach an the fade, and a dull the en the other aide {or the face).' Pin prick to the eheak and teach to the hand raaulted 1n extinction hand the pareept; be, oeeaaiehally, the rephrt or a pin prick of both an the cheek and hand. rhe aehizephrenie aubaeete were able to loealiae the pin prick accurately after the initial ten trials, an had the aerial mule: . Blflaflbazfll: mains the nethbd er dabble ainnltaneoua atinulatibn in teuta or the face and the hand a eenaiateht pattern bf reapeneea baa been observed in a variety hr aubaeota. the atinnlua to the m.’ 1: non readily perbeived than the one 1:: the me. «never, the pareept in the race influences the due in the hand, frequently canning the displacement of aehaatibh. 1h1a pattern a: reapbhaee haa been repeatedly deaehatrated in bath the annual and abnormal eubJeeta, and 1a aahireet 1h extinetibn, obaeuratibn and diablaeeaant. Extinction 1: abet and diaplaeeaeht :- leaet frequent. In eatinetien, the race pereept 1a correetly reperted aa te quality and leans, but the hand attanlua 1a not perceived at all; In all hf the rereading teat: or patient or abrnaz aubJeeta§*uhether By �11; ' tha reaponaaa were aaeurate tr not, it uaa notod that tbs stiuuius yointad to the face tirat. aubjaet almost invariably pattoived and 1a ourrectly hand perecpt tha Octaaianally iooaliaed, but anamnea a qualitative differonce, always of diaifintion. In displaeunant tha percent in the hand 1: 113* such an the or rage, tho it direttitn the face, or localiscd tn to tan ahauldor er nuak. In aunt instance: if tha taco cud tho hand at the lama aid: are stimulated, tho lubaeet occasionally 1a thaae phnnancna of 1n lane the taco. raporta tut paroapta ah: or these un1eh one with the rrtquancy haphaaard. nail. varia« druga, be attention, observed affected by may erraeta 1: tion in atilnli, ate., it: pattern 1: eonaiatent. Thea. raaponaaa to tha face-hand teat arc undifiad by nan: (b) attenttan. factor] arc flame influnnning of tbs fa) factora. or atinnlna, (a) type of stimuli, (0) simultanaity d: subject, aga (o) atrensth a: stilnlua, (t) locua of atilnlation and (3) internal with tha fragment, Etna; alter fatter! lax atate or organiaa. afipeur do change net but and that displaccnaut which Ixtinetien tbs pattern or face dalinanso. 1a in factor of tha teat a.na:or Iuardnaaa the aubaact'a 80th attention extinntiun. a: thy phannncnon of tho appearance ’)( awarenaai€£)1n.a and priviona axpnrionoa tun bring stimuli to two to were informed who Itinnli that unra adulta atria: or twanty Baoauaa proviaua of applied abouad extinction parcepta. be non. tan abet-nary rcaerd ta uaa intluensa.a response it experience in.ha1ve flatbed aw this aubjccta. tha.f1ndinga on initial trial At the Ian» wan aintniacd. experience or previoua en. tactar number the ”alert" for he the on tine tbs aubjcct was not apt to ' �of stimuli he an: ta reeeive. cannequently ene night nay thet the reason the subject perceived only one Itinulul or perceived ene and diupleeed the the other at he atinnluu in that pefifypt 4 was not peying ettentlen. this aritieinn may be valid but the Iiznifieant fact it 9 //¢w » % that the error III always aide in the hand and net in_the‘teee. I: it were mere inattention one utula expect 50! or the single response: ta dauble einultaneeue stimulation ta be in the hand end 50% in.the flee. But this type or ehance enter was not ebterved. it the single reepenaes ta double lilultaneeul Iti-nluticn 95% were at the fete percent and 5% at the hand pereept. Iain pettern of race daninnnee or hand extinction examinetionl. further during subsequent eitublilhed Ill lereovee, when dinplneenent II. seen in normal aubJeetn, it was to the race and not ta the hand. ihin pattern at face daninnnee to deuble tinultnneaul stimulation was fauna to be exnggereted in nan-.1 young children, when 83$ deuanetrated either 33nd.extinetion or displeoenent at er the hand pereept to the face an the initial triel. loreover, this high percentage of face duuinnet reiponnet peruisted on eubuequent trielE. In the elder children ulna tece delineate we: consistently demonstrable. It It: noted that the younger the ahild, the more distinct In: thie puttern of race daninnnee. awn extinetion night he Ittributed to an mummy to perceive two ltflluli at once. Ehiu particulir detect has been noted in patient: with severe until change? (“Zlf'fifievm in patient: with severe lentel changed or in young children itinuli epplied to both cheek: or both hands or.eny other two hanglegonn body even: were correctly reported as tee uenentione. Ihere it: _ �neither extinetion nor displacement. aaldstein'eKohuervatien, therafere, cannot be used an an explnnetion for hand extinetion. what matter daninanne in noted apparent flee that at It is types or etimnlltion was used. Simulteheoun pin prick stimulation: revealed the pattern of face daninenee, elthaugh with e leaner frequency than touch etinhiltiona. ether duteneeua utinuletion such :1 two tuning forks, hot and cold telperature tuhel, rtpetitive rubbing and repetitive pin prick Itianletian were Ipplied and neniteet regardless of the cuteneeun utilnletiun race daninence is flied. inphrtmee of the ainulteneity or the ”man. has nlrudy been alluded to. In eubJeetn in when extinctidn In: persistent, consecutive epplieetion or the stimuli invariably resulted in the permeption or two stimuli. In actual Idultn consecutive the nun-L1 the on the even of two trial, we ma. etiluletion extihetioa. never resulted in -euuni thin thy nerd ntinuli intensity. at these ethdien In aux-aux, the for in inn-pom: the in pattern mum eliciting ”I. stimuli here teemingly mare readily perceived than equal etiuuli. After the first few trials the etheet was able to perdeive the two stimuli, even it one we: pnintul and the other not. In and diaextinction mental hhuevee, with chnhses, organic patient: quality, the wide dinorepency in pleeenent were manifest despite a of the stimuli. aw Altering the etrength a! the Itinhli, it ran hand the at the tram extinction response pdlaihle to alternate th teak) the' ta diepleaenent were hand the stieuli percept (if .gheek (if the head stimuli were utrang). The sneeze than extinhtien ulst the the at by quality elidited altering run displacement to The ' ‘ �13. touch the to ,Ievertheleac, frna prick. pin that ia atiunli, a at. a,ua oe'aaa the part: of the body being aianltanecnaly atianlated are have patterna. theae I! etudying consideration in another already alluded to the fact that extinction ie anat cannon in the hand and leaat in the face. In teating other body areaa the incidence of extinction and diaplaceaent ia leaa than in teating and ahcnlder thigh nay hand. and the testing the face Ithat is, not elicit extinction or cbacnraticn,where the faceehand teat will. Alec, in patients with leaicnn or the brain or apinal cord, the pattern or relationahip cf the body parts tc aiaultaneoua atinnlaticn.nay be altered in a characteriatic haniaenaery or ”level leaicn' ayndreae. Aa fer the aignificance cf the pattern be can the leaning before prayer further atndiea are neceaaary would be time purely thin deducticn.aade Any at interpreted. that by gained atating ia nothing For inatance, speculative. dcainance (7). of inpliea order aenccry rcatral a daninance face Such hypetheaia ia ccntradicted by at leaat one tact, naaely the ‘chaervaticn that when the hand and fact are atimlated eimltanecualy data are hand. after'ncre Perhapa the dcninatea over the fact accumulated a aatiafactcry theory night he obtained. , QUIIIRI: hand haa and race the cf teata in pattern in perception method cf the abnaraal and anh:ecta.hy been elicited in actual dcnble simultaneous atianlaticn of cutanacua uhdalitiea. hand the of percent extinction by Face delinance, aaniteat an a in seen the hand to race, the or percent or dicplaceaent the~ and in non-a1 the adulte, in naniteatcd normal phancaencn, aeriea. the exasined in and anhaaie cchiacphrenia with patienta A �15. with in m in menu:It 1: mcntod young «mum and what ,of ditpnouont the «unfit.» bran in an...” mitten: utter may}. mun . . um. m 1: at run or unite“ denim” usual.” pattern m: 1n the a only clung. {chucking the autumn- nodanw team, a! 11th in type “mum. .cxtincuoa' at rmugnay am. ‘ �m, mm W :m. In,” Wtifll m t ‘4; “1,5151 m m m «some. mm m.“ 1.!” Id. “.3. mo mm. m, 19”.Mum-sic 3.: (I) cum... mm m mm. m, at unusual than. ”pm ma. a; M ammo 3.1.: Aug-mu m m ' Mm m mummy Mmkwém Datum 81mm!“ 11W. m. mnnmuumumumwmm mum. £1. Pittm‘03.; I. w m mum m; m. u-mmmuormmomm -.-.m: 1. (I) W 3.3. 1‘ “ ‘3) 2. (a) 3. I ‘ if... .5 . --... 08 , and - ...., 610: «.5 an .LL. -. > , ' and 813-191, 5 . 1 am. 1.1. 11.3.;and in 11.: @1162!!! 5. mwflw W mm. mmm In fit an 6. . W Warm. to mom chum- as «W 1M6 61m 72: 5 nth m to frontal am “so. «poets of m may W Auwmmmm 5mm mm manna-mm. cm, R. and m max. mam... at 1956. tn “1. 1959. and 501.515. ,5 -. ‘0 117.121., _ ‘ 8.3. ILL! (o) 50 phonon-manor 1n 5......- 1'. 9: 3.1.: 9:135:19: wholes“ 1 ”“33; of pm1p1uuea m and 11014: 11.8.: (h) m1 mm mum. an 6.1.: w by 191111101111 166-1685 19195 tuna-Mon. �PATTERNS IN PERCEPTION By: ‘I 0—m— ON SIMULTANEOUS TESTS OF FACE AND HAND Morris B. Bender, M.D., Max Fink, M.D., and Martin Green, In previous studies we found that the method of double M.D. simultaneous stimulation showed defects in sensation (extinction) testing In which routine were not apparent on single stimulation. ; the two of body and various combinations it was different regions \, found that extinction was apt to occur most often in the hand and least in the face. Conversely, "dominance" was greatest in the face and least in the hand. In the present commuhication we wish to report simultaneous on obtained the results stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syndrome; disease 5) of the no 4) schizophrenia; ,‘ brain (normal adults) and 6) four of between normal children the ages to ten years. 'Patients in 5 2 showed and severe memory defects, confusion, poor orientation, groups difficulties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or fingers) were touched simultaneously. Care was taken to make two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked tox°eport what he felt, and following this, Where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the first-examination: a) a touch on the face only (face dominance), implying no sensation in the hand (extinction); . $1.1mMuTfizA kfiWJqM 5.4.1:. �2. b) a touch on both sides of the face (there being "displacement" from the hand to the ipsilateral face); 0r 0) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that than one stimulus. on subsequent tests he was expectant of more In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislobalization was towards the face it appeared as if the face determined the direction of the displacement. It might be said, therefore, that this was a type of face dominance. Response (b), or diaplacement, was less common than response (a) or extinction. Response (b) was seen most often in the patients with the organic mental syndrome, and persisted despite repeated testing. The (c) responSe was the expected normal and needs no special comment. Extinction and displacement were also noted the ipsilateral face and hand were simultaneously tested. In all the subjects tested, including those with aphasia, there was no difference between the right and left sides of the body. Analysis of the results obtained in the various groups is shown in the following table: when �3. Group of Subjects Number 1 15 2 12 3 Face Response Extinction or Face and Hand‘ Hand Response Response ~ Displacement 9 6 O 12 O O 22 20 2 O 4 20 14 6 O 5 55 24 28 6 20 l l From - p . 19 o it is obvious that whenever there is sensation over another it is apparent in the face. the foregoing dominance of one p Dominance in the hand was noted only once. dominance Face was found almOSt uniformly in the subjects with.severe mental changes (groups 2 and 5.) These patients did not report sensation in the hand even after repeated testing. In a few instances, even after the patients were told there were two stimuli, or were asked towratch the application of the stimuli, they reported only one percept or displaced one. In these cases simultaneous stimulation of both sides of the face was reported correctly, thus excluding the objection that these patients were not able to<io or perceive two things at once. The incidence of face dominance in subjects with aphasia and those in with schizophrenia (groups 1 and 4) was less. In contrast to patients in groups 2 and 5, those in groups 1 and 4 reported both sensations correctly on the second, third or fourth trials, if they had not done so on the first trial.‘ In the group of normal adults (group 5) the incidence of face dominance was least, but still ' significant, a even though it was found only on the first trial. series of normal children the incidence of face dominance was In �In young children face dominance was present even several trials after the first examina- almost the same as in groups 2 and 5. tion. the face and parts of the body other than the hand were tested simultaneously in groups 2 and 3, face dominance was‘ The order of dominance was face, shoulder, grunk apparent. still When (breast), penis, thigh, calf, foot, arm and hand. In Conclusion: a wide variety of subjects the phenomena of extinction and displacement on double simultaneous stimulation were demonstrated. A consistent pattern of perception was established in which the face was most dominant and the hand the least. These findings were noted in both the abnormal and the normal subjects. -In the abnormal subjects withseVere mental changes, face dominance and hand extinction were so consistent that they may be used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, which are so prominent in patients with diffuse brain disease, appear to be exaggerations of the pattern found in the normal subjects, especially children. I � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. Trans Am Neurol Assoc. 1950;51:250-2. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2a-003 Date A point or period of time associated with an event in the lifecycle of the resource 1950 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Two preprints] and a reprint. Reprint from Transactions of the American Neurol Assoc. 1950;51:250-2. (abstract). Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a>; Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/abb942c109b57ff8986a7757e43563c2.pdf 23a7bbd876571d7517224c266ad15ea2 PDF Text Text Patterns in Perception on Simultaneous Tests of Face and Hand _ N...”- —-. MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK Reprinted from the Archives of Neurology and Psychiatry Septmnber 1951, Vol. 66, pp. 355-362 COPYRIGHT, 1951, .‘BY AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET CHICAGO 10, ILL. Printed and Published in the United States of America �Reprinted from the A. M. A. Archives of Neurology and Psychiatry September 1951, Vol. 66, pp. 355-362 Copyright, 1951, by American. Medical Association PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK it PREVIOUSLY was shown that examination of the cutaneous modalities by the method of double simultaneous stimulation elicited defects in perception which were not apparent on single stimulation. The defects, described as “extinction,” “obscuration,” “displacement,” and “allesthesia,” were observed in groups of patients with localized or diffuse disease of the central nervous system.1 In each group the defects in cutaneous perception obtained on double simultaneous stimula— tion were most apparent in the hand and least in the face. The object of the present investigation was to determine the patterns of in normal subjects, adults responses and children to simultaneous stimulation of the face and hand—the “face—hand” test.2 The observations on this normal were then compared to some extent group with the responses of patients with organic mental syndromes, aphasia, and schizophrenia. MATERIAL The “normal” subjects were children and adults. These subjects were persons attending hospital clinics in whom there was no evidence of disease of the brain, and school children, staff personnel, and students, in whom there was no manifest disorder of the central nervous system. None of them had been examined previously by the method of double simultaneous stimulation. From the Department of Neurology and Psychiatry, New York University College of Medicine; Bellevue Hospital, and the Mount Sinai Hospital. This work was aided (in part) by a research grant from the National Institutes of Health, United States Public Health Service, and (in part) by a grant from the Coordinating Council of Cerebral Palsy in New York City, Inc. 1. (a) Bender, M. B., and F'urlow, L. T.: Phenomenon of Visual Extinction in Homonymous Fields and Psychologic Principles Involved, Arch. Neurol. & Psychiat. 53:29—33 (Jan) 1945. (b) Bender, M. B.: Extinction and Precipitation of Cutaneous Sensations, ibid. 54:1—9 (July) 1945; (c) The Phenomenon of Sensory Displacement, ibid. 65:607-621 1951. (May) (d) Bender, M. B.; Shapiro, M. F and Schappell, A. W.: ., Extinction Phenomena in Hemiplegia, ibid. 62:717-724 (Dec.) 1949. (e) Bender, M. B. ; Wortis, S. B., and Cramer, J.: Organic Mental Syndrome with Phenomena of Extinction and Allesthesia, ibid. 59:273-291 (March) 1948. (f) Bender, M. B.; Shapiro, M. F., and Teuber, H. L.: Allesthesia and Disturbance of Body Scheme, ibid. 62:222-231 (Aug) 1949. (g) Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, ibid. 64:501—515 (Oct) 1950. 2. Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of the Face and Hand, Tr. Am. Neurol. A. 75:250—252, 1950. �2 The subjects were divided into three groups according to age: children of 3 to 6, and 7 to 12 yr., and “adults” over 12 yr. of age. For comparison with the normal group, we studied patients in the wards of the Bellevue Psychiatric Hospital. They were divided into three groups on the basis of their disease— schizophrenia, organic psychoses, and aphasia. No attempt was made to study separately the clinical types of schizophrenia. Most of the patients had the paranoid, mixed, or simple variety of schizophrenia. The patients with organic mental changes showed defects in memory, orientation, andcalculation, as well as other signs and symptoms. characteristic of diffuse disease of the brain. The clinical diagnoses for most of thesegpatients was Alzheimer’s’ disease, arteriosclerotic encephalopathy, severe cerebral trauma, brain tumor, or toxic encephalopathy. The subjects with aphasia were those who showed characteristic difficulties in communication. Those who had concomitant hemiparesis or ‘a hemisensory defect noticeable on single stimulation were not included in this series. MET HOD The subject was instructed to close the eyes. When this was done, the face (cheek) and either the ipsilateral or the contralateral hand (any part of the hand or digits) were simultaneously touched or stroked with the examiner’s fingers. The subjects reported either one or two sensations. When only one percept was reported, the subject was asked if there was still another and, if so, to indicate its location and quality. After the initial trial, in each subject, the opposite cheek and hand were stimulated in the same manner. These tests were repeated and the results recorded, until the subjects consistently reported both stimuli correctly. In those subjects who failed to localize the two stimuli correctly ‘after six or eight trials, other parts of the body were tested in such combinations as face-face, hand-hand, face-breast, or penis-hand, these stimulations alternating with the facehand test. In a second, separate series of studies, pinprick stimuli were used in a similar fashion. In both series, care was taken to app-1y the stimuli at the same time and with the same intensity. It was apparent that subjects who made consistent errors in reporting would be correct as soon as the stimuli were applied consecutively rather than simultaneously, even if the time lag between stimuli was that of one or two moments. It was also necessary to use naive normal subjects, since subjects previously tested did not show the patterns noted below. RESULTS The responses obtained on the face-hand test fell into four groups: (a) a touch sensation on the face and the hand, indicating the correct and expected perception; (b) a touch sensation on the face only, implying no sensation in the hand; (6) a touch sensation on both sides of the face, and (d) a touch sensation on the hand only, implying none on the face. When only one stimulus was reported, the subject was asked if: there was any other sensation. The occasional reply was that there was another percept, and the subject correctly pointed to the second locus. Many subjects, however, reported that they had not perceived another stimulus, usually adding the statement: “I was not paying attention; do it again,” or, “I’m not sure; maybe it was somewhere over here,” and pointing in the direction of the side of the body of the poorly felt stimulus. In some instances, while correctly localizing the second percept, they volunteered the statement: “It was not as strong as the other one,” or “It doesn’t seem as sharp.” Before we proceed with the results, we must define the special terms used. In other communications the failure of the subject to report one of two simultaneously applied stimuli has been called “the phenomenon of sensory extinction,” or “extinction.” 1”“ b The part of the body where the stimulus was perceived is said to be “dominant” to the part of the body where the simultaneous stimulus was not per— ceived, or perceived faintly. The latter diminution in the quality of a sensation was ' �3. termed “obscuration.” When the subject reported two sensations, but mislocalized one of them, the “displacement” of a percept is said to have occurred.1c Displacements are usually in the direction of the dominant stimulus and may be partial or complete. The displacements noted in this series were from the hand to the cheek of the same side. Rarely did the displacements occur to the neck or shoulder. Initial Trial—The results were analyzed from the standpoint of initial and subsequent trials. On the initial trial of the face-hand test with touch stimulation in normal subjects, face dominance was apparent in all age groups. More than half of such normal adults reported the sensation in the face and none in the hand. Three subjects mislocalized the sensation in the hand to the face. In the groups of normal children, 90% under the age of 6 yr. reported only the face percept or mislocalized the hand percept to the face. This pattern of face dominance is also seen in the children from 7 to 12 yr. of age, but to a less extent. Of the normal subjects, five adults reported the hand stimulation only on the initial trial. N 0 example of displacement from face to hand was noted. This pattern of face dominance by hand extinction or by displacement of the hand percept to the face was even more apparent in the patients examined. It was most evident in patients with organic mental changes, 93% of whom did not report TABLE l.—Response to Touch Stimulation on Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia (unclassified) ............ Organic mental syndrome ............... Aphasia ................................. Total 160 56 76 74 120 23 Correct Responses 77 10 38 26 9 12 Face Only 75 28 27 45 94 11 Face-Face Hand Only 3 18 9 5 0 1 2 14 3 O O 2 both stimuli correctly. In examinations of schizophrenic subjects and patients with aphasia, responses similar to those of the normal adult were observed in the initial trial. Hand dominance was occasionally seen in the patient and rarely in the normal subject. In cases of hand dominance the subject reported the hand, but not the face, percept. It was seen in the initial trial in five normal adults. These subjects reported both stimuli correctly on subsequent testing. In the patients with organic mental changes hand dominance was an inconstant response, and repeated testing the same day, or on subsequent days, demonstrated the more usual persistent pattern of face dominance. Subsequent Thain—Of the 83 normal adults who made errors on the initial trial, 43 made correct responses on the second trial and 12 on the third trial. In a few subjects, four, five, or six trials were necessary before the two stimuli were correctly localized. These subjects were assumed to be normal, although complete psychological tests were not made. It was noted that anxiety (tension during examination or a strong desire to please) interfered with the early correct recog— nition of the stimuli. In all normal subjects, including those with anxiety, once the correct response was obtained (even after many trials with errors), it was elicited on all subsequent testing. It seemed as though a number of trials was necessary for �4 the subject to get into the “set” of the examination, and that, once in the set, he reported the stimuli accurately, even after the lapse of many days. In testing the normal young child, it was apparent that in most cases many trials were necessary before the correct response was consistently elicited. Also, the child did not always give a correct response on subsequent testing. Repeated testing over many days, however, elicited the same patterns of face dominance. .This was noted in 36 of the 56 children tested. In a number of instances the child watched the application of the stimuli and thus reported the perceptions correctly. But as soon as the test was repeated with the eyes closed, the child again reported only one stimulus. It was evident that the child could not get into the “set” of the examination, even with visual cues. This difficulty was not very apparent in all children. In the older (ages group 7 to 12 yr.) only 17 of the 76 failed to give the correct response after the initial few trials. A\\A A\4*A\ ‘~ 90 ‘___-c\‘ ~ ‘c____ .¢—————-—._—_——__———-—c 89 Responses 70 60 Dominant Face 50 Organic Mental Syndrome c--c Children, age 5 to 6 o——o Schizophrenic Adult Normal Adult 40 % 50 20 10 1 2 3 4 5 6 10 Responses to face~hand test on initial and subsequent trials. The responses obtained on repeated trials of the face-hand tests in normal sub— jects also followed a consistent pattern. As on the initial trial, face dominance was prevalent in all subjects. It was manifest either by (a) extinction or obscuration of hand stimuli or (b) displacement of hand stimuli to the face, or, in several instances, in a direction toward the face. In contrast to normal adults, patients with organic mental changes were unable to report the two stimuli correctly, even after many trials. When the patient reported the percept in one test correctly, he frequently failed on subsequent testing. It was also apparent that testing on subsequent days still elicited displacement and extinction of stimuli. This is in strong contrast to the responses of apparently normal subjects, who seldom made an error on subsequent trials, days after the initial examination. The responses obtained in this group demonstrated the patterns of face dominance in most of the tests. Displacement of the hand percept to �5 the face was frequent. In some instances displacement or extinction was present despite the fact that the patient watched the application of the stimuli to the face and hand. Extinction was very common on homolateral or heterologous testing, while displacement was apparent mostly on heterologous testing. The schizophrenic and the aphasic patients gave reports which were similar to those of normal adults. After the first two trials percentage of error in hand sensation was slightly higher than in the normal group. Persistent bizarre responses were elicited from a number of the schizophrenic subjects. These reports included mul— tiple responses to single or double stimuli, persistent displacements to one area from any other body area, and mirror reversals of localization. These were inconsistent during an examination and from day to day. As with the normal adults, testing the schizophrenic or aphasic subject on consecutive days failed to elicit extinction phenomena once the test had accurately been reported before. A comparison of the responses of each of these groups to multiple testing is shown in the accompanying chart. Pinprick Stimulation—It is known that the type of stimulus applied influences the results in perception. To demonstrate the importance of this factor, similar groups of subjects were tested using two pinprick stimuli instead of two touch M TABLE 2,—Respoinse to Pinprick Stimulation an Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia ........................... Organic mental syndrome ............... Correct Total Responses Face Only 68 45 39 50 49 51 16 25 15 26 14 36 9 ' 13 33 Face-Face Hand Only 2 0 2 1 0 0 3 0 1 2 stimuli. With pinprick stimulation of the face and hand, face dominance was again manifest in all the groups. However, the incidence of error in perception of the pinprick in the hand was lower than that with a touch stimulus. The results are recorded in Table 2. Repeated testing with two pins in the'normal adult subjects elicited the correct responses in the intial three trials. Fewer of the children failed to report the test accurately after the initial trials. It was possible in a number of instances to alternate touch and pinprick stimulations and to demonstrate extinction to touch, but correct localization to pinprick. Moreover, with more intense pinprick stimulation, extinction and displacement were less frequently observed. These phenomena, namely, extinction and displacement, were even more apparent in the patients with organic mental syndromes. Displacement of touch stimu— lation could be alternated with correct localization of pinprick stimulation. A combination of touch to the face and pinprick to the hand evinced the combination of displacement and obscuration, as the patient reported “a touch on the face, and a dull one on the other side (of the face).” Pinprick to the cheek and touch to the hand resulted in extinction of the hand percept. or, occasionally, the report of a pinprick on both the cheek and the hand. The schizophrenic subjects were able to localize the pinprick stimulus accurately after the initial few trials, as had the normal adults. �6 COMMENT By using the method of double simultaneous stimulation in tests of the face and the hand, a consistent pattern of responses has been observed in a variety of sub— jects. The stimulus to the face is more readily perceived than the one to the hand. Moreover, the face percept influences the hand percept, frequently causing the displacement of sensation. This pattern of responses has been repeatedly demonstrated in both the normal and the abnormal subjects and is manifest in extinction, obscuration, and displacement. Extinction is most, and displacement is least, frequent. In extinction, the face percept is correctly reported as to quality and locus, but the hand stimulus is not perceived at all. In all the foregoing tests of patient or normal subjects, whether the responses were accurate or not, it was noted that the subject almost invariably pointed to the faceixsti‘mulus first. Occasionally the hand percept was perceived and correctly localized, but assumed a qualitative difference, always of diminution. In displacement the stimulus to the hand was mislocalized to the face, or in the direction of the face, e. g., to the shoulder or neck. In some instances if the face and the hand of the same side were stimulated, the subject occasionally reported two sensations in the face. None of these phenomena was haphazard. While the frequency with which any one of these effects was observed might be affected by attention, drugs, or variation in stimuli, its pattern was consistent. These responses to the face-hand test are modified by many factors. Some of the influencing factors are (a) attention, (b) age of subject, (c) simultaneity of stimuli, (d) type of stimulus, (e) strength of stimulus, (f) locus of stimulation, and (9) internal state of organism. These factors may alter the frequency with which extinc— tion and displacement appear, but they do not change the pattern of face dominance. The subject’s awareness of the test is a major factor in the appearance of the phenomenon of extinction. Both attention and previous experience can bring stimuli to awareness. In a series of 20 adults who were informed that two stimuli were to be applied, none showed extinction of percepts. Because previous experience can influence a response, it was necessary to record the findings on initial trial in naive subjects. By this method the factor of previous experience was minimized. At the same time, the subject was not apt to be on the “alert” for the number of stimuli he was to receive. Consequently, one might say that the reason the subject perceived only one stimulus, or perceived one stimulus and displaced the percept of the other, is that he was not paying attentio‘n.3 This criticism may be valid, but the significant fact is that the error was always made in the hand and not in the face. If it were mere inattention, one would expect 50% of the single responses to double simultaneous stimulation to be in the hand and 50% in the face. But this type of chance error was not observed. Of the single responses to double simultaneous stimulation, 95% were of the face percept and 5% of the hand percept. This pattern of face dominance or hand extinction was further established during subsequent examinations. Moreover, when displacement was seen in normal subjects, it was to the face and not to the hand. This pattern of face dominance to double simultaneous stimulation was found to be exaggerated in normal young children, of whom 83% demonstrated either hand extinction or displacement of the hand percept to the face on the initial trial. Critchley, M.: The Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions, Brain 72:538—561, 1949. 3. �7 Moreover, this high percentage of responses of face dominance persisted on sub— sequent trials. In the older children, also, face dominance was consistently demon— strable. It was noted that the younger the child, the more distinct was this pattern of face dominance. Hand extinction might be attributed to an inability to perceive two stimuli at once. This particular defect has been noted in patients with severe mental changes by Goldstein.4 However, in patients with severe mental changes or in chil— young dren stimuli applied to both cheeks, or both hands, or any other two homologous body areas were correctly reported as two sensations. There was neither extinction nor displacement. Goldstein’s observation, therefore, cannot be used as an explana— tion of hand extinction. It is noted that face dominance was apparent no matter what type of stimula— tion was used. Simultaneous pinprick stimulations revealed the pattern of face dominance, although with a lower frequency than touch stimulations. Other cutaneous stimulation, such as application of two tuning forks or hot and cold tubes, repetitive rubbing, and repetitive pinprick stimulation, was used, and face dominance was manifest regardless of the cutaneous stimulation employed. The importance of the simultaneity of the stimuli has already been alluded to. In subjects in whom extinction was persistent, consecutive application of the stimuli invariably resulted in the perception of two stimuli. In normal adults consecutive stimulatiOn of the face and the hand, even on the initial trial, never resulted in extinction. In these studies the stimuli were of equal intensity. This factor was important in eliciting the pattern in the normal subject, for unequal stimuli were seemingly more readily perceived than equal stimuli. After the first few trials the subject was able to perceive the two stimuli, even if one was painful and the other not. In patients with organic mental changes, however, extinction and displacement were manifest despite a wide discrepancy in the quality of the stimuli. By altering the strength of the stimuli, it was possible to alter the response from extinction of the hand percept (if the hand stimulus was weak) to displacement to the cheek (if the hand stimulus was strong). The change from extinction to displacement was also elicited by altering the quality of the stimuli, that is, from touch to'pinprick. Nevertheless, the pattern of face dominance was always apparent. The parts of the body being simultaneously stimulated is another consideration in studying these patterns. We have already alluded to the fact that extinction is commonest in the hand and least in the face. In testing other body areas, the incidence of extinction and displacement is less than in testing the face and the hand. That is, testing shoulder and thigh may not elicit extinction or obscuration, whereas the face-hand test may. Also, in patients with lesions of the brain or spinal cord, the pattern of relation of the body parts to simultaneous stimulation may be altered in a characteristic hemisensory or “level-lesion” syndrome. Further studies are necessary before the significance of the pattern can be interpreted. Any deduction made at this time would be purely speculative. For instance, nothing is gained by stating that face dominance implies a rostral order of sensory dominance.5 Such a 4. Goldstein, K.:: The Mental Changes Due to Frontal Lobe Damage, J. Psychol. 17:187, 1944. 5. Cohn, R., and Raines, G. N.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance ‘as Determined by Ipsilateral Simultaneous Stimulation, Tr. Am. Neurol. A. 74:162-168, 1949. �8 hypothesis is contradicted by at least one fact, namely, the observation that when the hand and foot are stimulated simultaneously the foot dominates over the hand. Perhaps after more data are accumulated a satisfactory theory may be obtained. SUMMARY _. “awn—a, elicited in normal and abnormal subjects by the method of double simultaneous stimulation of cutaneous modalities. Face dominance, manifest by extinction of the hand percept or by dlsplacement 0f the handmpercept to the face, is seen as a normal phenomenon, manifested1n the normal adults andin the patients with schizophrenia and aphasia examined in the series. It is exaggerated in young children and in patients with diffuse disease of the brain, in whom extinction and displacement are persistent after multiple trials. This pattern of face dominance is manifest regardless of the cutaneous modality tested, there being a change only in the frequency of extinction with change in type of stimulus. j Printed and Published in the United States of America / f / r: L/nAJ/C’ ..... . � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. AMA Arch Neurol Psychiatry. 1951 Sep; 66(3): 355-62. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2b-004 Date A point or period of time associated with an event in the lifecycle of the resource 1951 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from the Archives of Neurology and Psychiatry September 1951, vol. 66, pp. 355-362. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/945d2769d3cde3d546dfd13ec8bc4c04.pdf 7b68d01261bda3dea9d45000fea060a8 PDF Text Text The F ace—Hand Test as a Diagnostic Sign of Organic Mental Syndrome Max Fin/c, M.D., Martin Green, [M.D. and [Morris B. Bender, M.D. In the course of sensory studies by the method of double simultaneous stimulation, it has been observed that patients with mental changes may show perceptual errors which are not demonstrable by routine single stimulation.1 When stimuli are simultaneously applied to the cheek and the hand (the face-hand testz) , patients frequently report only one of the two stimuli, or when reporting the two stimuli mislocalize one to another part of the body or even into space. These changes in perception are seen on repeated trials of the face-hand test and seem to form a con— sistent part of the syndrome usually labelled “organic mental syndrome” or “organic psychosis.” SUBJECTS Four hundred patients, who manifested cerebral dysfunction in the form of an organic mental syndrome due to a variety of causes, were studied on the wards of the Bellevue Psychiatric Hospital.* Each patient manifested, to some degree, the following mental changes: (1) impairment of memory, for both recent and remote events; (2) confusion and disorien— tation for time, space, situation and body image; (3) errors on calculation and general information tests; (4) distractibility, poor attention span, inability to handle more than one situation at a time, concreteness and *This number represents several series of patients in whom the method of double simultaneous stimulation were applied. It includes all tests of the face and hand by touch, pin prick and combinations of touch and pin prick stimuli, as well as tests of body areas other than the face and the hand. From the department of neurology and psychiatry, New York University College of Medi— cine, and the department of neurology and psychiatry, Bellevue Hospital, New York City. This work was aided in part by a Fellowship from the National Foundation for Infantile Paralysis, and by a research grant from the United States Public Health Service, National Institutes of Health. Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 46 �4'7 ORGANIC MENTAL SYNDROIVIE rigidity in thinking; (5) perseveration of speech and behavior; (6) emo— tional liability and readily elicited “catastrophic” reaction; (7) loss of initiative and interest in the environment and indecent exposure and soiling of the clothing. The clinical diagnoses were varied, including chronic alcoholism, post-traumatic encephalopathy, hypertensive cerebro-vascular disease, diffuse arteriosclerotic softening, syphilis of the central nervous system and degenerative diseases, such as Alzheimer’s disease, Hunting— ton’s chorea or senility. Observations on the face-hand test in patients with organic brain disease were compared with previously obtained results of similar examinations in normal adults and children and in adult patients with schizophrenia”. The normal adults and children, including students, associates and patients in clinics, were without manifest disorder of the nervous system. The schizophrenic adults were patients from the wards of the Bellevue Psychiatric Hospital. No effort was made to group the patients into the various clinical types of schizophrenia. JMETHOD The face—hand test was applied to each of these subjects. During routine physical examination the patient was asked to close his eyes. One cheek and the contralateral hand were simultaneously touched or stroked by the examiner’s fingers. The patient was then asked what he had felt. The usual response was, “You touched me here,” while pointing to the cheek. After this initial application of the face-hand test, the patient was again asked to close his eyes and the contralateral cheek and hand were similarly stimulated. In the many instances when only one percept was reported, the patient was asked if he had felt anything else. Occasionally the second percept was reported after this question, but more often it was not. Thereafter the tests were applied to the face and hand and to other parts of the body. RESULTS In patients with the organic mental syndrome most responses to the initial and subsequent face-hand tests were of four types: (1) a touch on the cheek only, implying no sensation in the hand; (2) a touch on each cheek, implying a mislocalization or displacement of the percept evoked in the hand to the cheek; (3) a touch on the hand only, implying no sensation in the cheek; and (4) correct localization of the percepts evoked in the cheek and hand. Less frequently other responses were noted, as both percepts in the hand, or a percept in the cheek and homolateral hand implying a mislocalization from one hand to the opposite hand. In a few cases the �NE UROLOGY 4-8 percept in the hand was mislocalized to a part of the body upon which the hand was resting, out into space, or onto the examiner’s body. The following case illustrates the various responses of patients with an organic mental syndrome. Case admitted to the psychiatric hospital with a one year history of progressive difficulty in concentration, inability to continue work, mood disturbances, episodes of confusion, forgetfulness and occasional lapses into irrelevant speech. Later, following the death of his wife, he became depressed, cried frequently, and spent many hours talking to himself. The neurologic examination showed minimal right facial weakness and some gross tremors of the hands. On psychiatric examination the patient answered questions coherently and relevantly. He was euphoric and friendly. There was disorientation for time and place, his memory for both recent and remote events was poor, and confabulation was frequent. Calculation and general information tests were performed poorly. Judgment was poor and there was no insight into his difficulties. When left alone he carried on a conversation with himself, and when presented with a mirror he identified the image as that of his brother and conversed with the image, listening for replies and reporting them to the examiner. In addition, there were difficulties in expression, both verbal and written, with errors in reading, calculation and reporting numbers. He was able to carry out simple commands but made errors in imitating mouth and hand movements. He handled objects clumsily. There was right-left dis— orientation, and he made errors in naming body parts. Psychometric examination revealed a severe organic impairment with defects in memory, concentration, abstraction, and concrete verbalization. His performance on the Kohs block test was severely deficient, exhibiting ability to complete only the first two 1:——-A 60 year old man was figures. , 0n sensory examination by the method of single stimulation he could identify and localize pin prick and touch stimuli, except that stimuli applied to the left hand TABLE Stimulus Right cheek, left hand Left cheek, right hand Right cheek, right hand Left Cheek, left hand Right and left hand Right and left cheek Right cheek, left shoulder Left cheek, right shoulder Left foot, right hand Left hand, right foot Right and left hand Right cheek, right hand Left cheek, left hand Right and left cheek Right cheek, left hand Left cheek, right hand 1 Response Right and left cheek Right and left cheek Right cheek, right shoulder (P) Left cheek only Correct Correct Right and left cheek Left cheek, left shoulder Left foot, left hand Right and left foot Out into space* Two percepts right cheek Left cheek only Correct Right and left cheek Right and left cheek Type of Defect Displacement Displacement Displacement Extinction Displacement Displacement-allesthesia Displacement-allesthesia Displacement Exosomesthesia Displacement Extinction Displacement Displacement *Patient mislocalized these percepts into space, insisting that the stimulation had not been applied to his body. �49 ORG/1N1C .MENTAL SYNDROME were occasionally displaced to the shoulder or the face on the same side. There were no significant differences in temperature, Vibration, position sense, and two-point discrimination tests on the two sides of the body. Stereognosis was intact. Examinations by the method of double simultaneous stimulation elicited many defects in cutaneous perception. These were manifest by extinction and displacement of percepts. The errors were persistent despite numerous examinations and over many weeks of study. Table 1 is an extract from the record of the patient’s responses to touch stimula- tion. Similar errors in localization of percepts were found when continuous and repetitive pin prick, tuning fork and temperature tube stimulations were used. 0n simultaneous stimulation of the cheek and any other region of the body, the patient correctly localized the percept in the face but seldom perceived correctly, or at all, the other stimulus. This was particularly evident when the cheek and hand were tested, especially a cheek and contralateral hand. A pneumoencephalogram revealed symmetrically dilated ventricles without displacement. A biopsy of brain tissue removed from the right cerebral hemisphere disclosed a prominence of senile plaques, Alzheimer cells and fatty pigmentation of neurons. COMMENT In this case there was no question as to the clinical diagnosis. The is of in defects not surprising. It is significant that perception presence despite the severity of the mental dysfunction the alterations in perception were consistent and patterned. Even though the patient appeared confused he never made errors in perception and localization of stimuli on the face, whereas he frequently erred in the simultaneously stimulated hand. Extinction and displacements from the hand were frequent during many examinations. These perceptual errors were conspicuous by their consistency, orderliness and predictability against a background of apparent mental confusion. These changes can be considered a prominent sign in the organic mental syndrome. DISCUSSION Incidence of errors on the face-hand test: Of 156 patients with organic mental syndrome, 91 per cent made errors on the initial trial of the face-hand test using touch stimuli. Subsequent trials revealed a similar high incidence of errors. These errors were in a definite pattern, in which the face percepts were correctly localized, and the hand percepts either not perceived or mislocalized. Displacement of percepts from the hand to the cheek was a prominent feature during the initial few trials of the test. Errors were noted on both sides of the body and occurred on tests applied to cheek and hand on the same side of the body, or on opposite sides. In 87 per cent of the patients errors were apparent through the tenth trial of the test and persisted for many more trials. Repeated testing �NE UROLOGY 50 I 100 ~ ‘~_ 60 O RESPONSES 0*.\ Responses of normal children ages 3-6 DOMINANT Responses of schizophrenic patients FACE CENT PER 1 2 3 4 NUMBER FIG. 1. Responses on 5 6 or successnve '7 8 9 TRIALS gm multiple trials of the face—hand test to touch stimuli:. on subsequent days elicited similar errors. It must be emphasized that these patients were able to correctly identify and localize single stimuli applied to the face and hands. In significant contrast to these observations on patients with organic mental syndrome are the observations on normal and schizophrenic adults.2 On the initial trial of the face- hand test to touch stimuli, '75 of normal and the adults cent per cent of the schizophrenic adults per failed to report one of the two stimuli. As the test was reapplied, the percentage of error rapidly declined until by the tenth trial of the facehand test less than 0.5 per cent of the normal adults and less than 3 per cent of the schizophrenic adults still showed omissions or mislocaliza— tions of percepts (figure 1). However, examination of children, age three to six years, with this method again showed a very high incidence of defects on face-hand tests. The curve of responses, as noted in figure 1, is parallel to the curve of responses of the patients with organic mental syndrome. The errors persisted for many trials and were observed in testing over many days. In older children, the curve of responses ap— proached that of the normal adult. A number of factors were found to influence these responses. Such elements as the type of stimulus, the conditions of the test, the part of �51 ()RGA N10 i1! ENTAL SYNDROME the body stimulated, “set” and “attention” of the patient, the type and severity of the mental changes, and the effect of drugs were considered. Timing and type of stimulus: In previous studies on normal and schizophrenic adults,2 simultaneity, similarity and equality in strength of stimuli were emphasized as essential for eliciting these responses. In the patients with mental changes, however, these factors were not as prominent since stimuli of unequal intensity or of different modalities still elicited errors in the tests. Dissimilar stimuli, as application of a touch stimulus to the cheek and a pin prick stimulus to the hand, or stimuli of unequal intensity, as a light touch to the cheek and forceful rubbing in the hand, elicited extinction and displacement of percepts. Similarly, errors in localization were elicited even if stimuli were not simultaneous, i.e. followed one another with a lapse of a moment or two. As previously reported, these errors on unequal, or dissimilar stimu— lation were not seen in the normal or schizophrenic controls. Application of the face—hand test using pin prick stimuli elicited the same pattern of responses as with touch stimuli. Eighty per cent of the patients made errors on the initial trial and such errors persisted in 60 of incidence is This defects trials. for than ten lower, cent more per however, than in the series with touch stimulations (table 2). In some of these patients it was possible to alternate touch and pin prick stimuli, and observe extinction and displacement of the touch percepts alternating with correct responses to pin prick stimuli. In a number of the more severely affected patients, extinction and displacement of percepts were also apparent on tests with temperature tubes, tuning forks and repetitive rubbing stimulations. TABLE 2 INITIAL TRIAL Organic Mental Syndrome Normal Adult Schizophrenic Adult Modality Touch Pin Prick Touch Pin Prick Touch Pin Prick Hand or Face Only Face-Face Hand-Hand Total Correct 156 50 160 68 15 10 122 35 7’7 75 15 45 ’72 50 51 24 36 13 14 5 3 3 2 2 1 2 0 1 5 0 This factor of the type of stimulus was more prominent in the normal and schizophrenic subjects. Less than 30 per cent of these made errors on the initial trial with pin prick stimuli, and the number of errors declined rapidly until by the tenth trial none of the normal subjects and only one of the schizophrenic subjects still showed errors. �NEUROLOGY of cutaneous stimuli between various body parts was apparent. lation of dissimilar body areas with the face as one locus, the the cheeks were well localized and identified, while stimuli were either not perceived or poorly localized. Combinations SQ On stimu— stimuli to elsewhere of stimuli to the face and trunk, face and foot, face and hand, etc., repeatedly showed face dominance. In contrast, in tests with the hand as one locus, the hand percept was always poorly perceived and poorly localized. This was observed in the initial trials in the normal and schizophrenic adults, but was more apparent in multiple trials in patients with organic mental changes. By repeatedly testing various combinations of other body areas, a gradient of the sensory relationships of these areas has been established. Because the face and hand regions represented the extremes in the pattern of responses, these two regions were selected as the basis of most of the tests. Therefore, this method of examination was named the face-hand test. The errors in these examinations were apparent in tests of both sides of the body without any manifest preference. In patients with hemiplegia of recent onset and associated mental changes, extinction and displacement of percepts were apparent bilaterally, but were more prominent and more persistent on the involved side of the body. In patients with long-standing hemiplegia in whom the mental syndrome was no longer apparent, the defects were limited to the involved half side of the body? The factor of mental set: The mental set or attitude often influenced the perceptual response. Once the normal adult was examined by the method of double simultaneous stimulation, subsequent tests failed to elicit a repetition of the errors which occurred on the initial face—hand test. It was as if these subjects had “learned” the set of “two-ness.” Moreover, when normal subjects were tested with face-face stimuli, the responses were correct, and then all subsequent face-hand tests were also correct. When face-face tests were interposed among trials of the face— hand test in the patients with mental changes, they continued to make errors on tests of face and hand, even though they were correct on the face-face trial. Such errors persisted for days. Evidently mental set and learning did not alter the pattern of response. The factoq' of attention: It is well known that attention can influence 4 perception.2' In a series of 30 normal adults who were told that two stimuli were to be applied, none made errors on the initial trial of the face-hand test. However, patients with severe mental changes, who were �53 ORGANIC MENTAL SYNDROME told either before the initial trial or on subsequent trials that there would be two stimuli, still showed extinction and displacement of percepts. It was possible to have the patient, with eyes open, observe the application of two stimuli and report them correctly. Then, with eyes closed, and the stimuli applied to the same or homologous areas, the patient would report the stimuli incorrectly. The effect of fatigue on the performance of the patient has already been mentioned. It is possible to increase the errors of the patient by administering the stimuli more frequently, or by making him aware of his errors and thereby increasing his anxiety. With mounting anxiety, errors increase until culminated by a catastrophic reaction and withdrawal from the examination. A similar effect of anxiety on performance was manifest in the normal subjects. The adults with manifest severe anxiety required more trials of the face—hand test to perceive the percepts correctly than adults without manifest anxiety. Degree of mental changes: We found a definite relationship between the severity of the mental changes and the frequency of errors in perception in the patients with an organic mental syndrome. The patients varied in their mental status from mild memory disturbances and alteration in intellectual ability, to severe psychomotor retardation, amnesia, aphasia and somnolence. The responses to the face-hand test varied from occasional extinction of percepts seen in the mild cases, to con— sistent, bilateral displacement of percepts to other parts of the body, the examiner’s body, or into space in the subjects more severely affected. In a number of patients with severe head trauma or following cerebral in mental functioning was acthe improvement progressive surgery, companied by a change in response to repeated trials of the face-hand test. The responses changed from bilateral displacement and allesthesia when damage was most severe, to extinction in decreasing frequency and finally consistently correct responses as the subject improved. Perceptual errors were greatest in subjects in whom nervous system dysfunction was acute in its course with rapid onset and short duration. Patients with severe head trauma, infections of the nervous system, vascular accidents and neoplasms were more likely to show extensive changes on double simultaneous stimulation than patients with chronic alcoholism or senility. It was in these last two groups that there were a number of subjects with organic mental changes who consistently per— ceived the two stimuli of the face—hand test correctly on the initial and on multiple trials. Type of mental defect: There was no obvious correlation of the freface—hand with of in of the the single test errors symptom any quency �NEUROLOGY 54 organic mental syndrome as in patterns of thinking, spatial or body orientation, memory or calculation. Errors in perception were most apparent when disturbances in function were most widespread. A good correlation existed, however, between the patient’s alertness and the responses on the face-hand test. In patients who were apathetic or lethargic, errors on double simultaneous stimulation were most promi— nent. This was apparent in many subjects who made errors occasionally during the initial trials of the face-hand test, but in Whom errors became more frequent and changed from extinction to displacement responses as the examination continued. Similarly, in testing patients with fluctuating states of consciousness, there was a good correlation between the degree of alertness and the responses on multiple trials of the face— hand test. Some of the patients were unable to carry out tasks which had two different aspects. But despite this inability to do two things at once they were able to perceive the two stimuli applied to the sides of the face. Therefore, it could not be said that the inability to correctly perceive one of the two stimuli applied to the face and hand was due to a defect in the ability to perform a task with two different components. The factor of aphasia: Aphasia is sometimes considered a defect in mentation. Such a defect, Where severe or associated with mental changes characteristic of the organic mental syndrome, yields a picture of the pa— tient as confused. For instance, a patient with aphasia may also have a loss of memory and an inability to recall or recognize situations even after they are described to him. In order to determine whether aphasia per se will produce errors in the, face-hand test, aphasic patients, with or without such mental changes, were studied. Patients with aphasia but without mental changes did not make errors on the face—hand test, while patients with aphasia and mental changes made repeated and consistent errors on multiple trials of the test (figure 1) . Organic mental syndrome with normal responses on the face-hand test: As already noted, not all patients with an organic mental syndrome make errors in tests by the method of double simultaneous stimulation. In a series of 271 patients in whom various combinations of these tests were applied, there were 228 patients who made errors and 43 patients who gave correct responses on initial trials. Of these latter, however, there were 22 who made errors after the initial trial. The remaining 21 were correct throughout multiple trials. Of the 228 patients who made errors on the initial trial there were 28 who were subsequently correct and yielded responses similar to the normal as carried out in one series of tests. In of found 49 it the 271 patients with mental changes that was summary, �55 ORGANIC MENTAL SYNDROME yielded normal reactions. All of these 49 patients had an organic mental syndrome but in general the mental changes were not severe. lVIemory loss was spotty and the degree of orientation varied, Apathy was seldom marked. There were fluctuations in performances. At times there were long intervals, minutes to hours, during which the patient showed no apparent mental changes. Examinations during those symptom—free intervals showed the face—hand test to be normal. In several instances it was learned that the defects in memory or indifference in answering questions pertaining to orientation were‘due to an emotional depression or to a phlegmatic premorbid personality. Their organic mental syndrome was only apparent and not real. There were, however, 11 patients with severe mental changes who reported correct responses on repeated face—hand tests. Eflect of drugs: From the foregoing studies it is clear that patients with organic mental syndrome make errors in perception in double simul— taneous stimulation tests. Consequently it was thought that the mental changes induced by drugs should yield similar errors. To test this theory, normal adults were subjected to intravenous injections of 7 to 10 ml. of a 5 per cent solution of sodium Amytal administered slowly. This drug produced the usual nystagmus, dysarthric speech and drowsiness. In addi— tion, normal adults, who made no errors on the face—hand test prior to the injection, now made consistent bilateral errors. Within 5 minutes after the injection errors were apparent on many repeated trials of the test and these persisted during the period the drug action was effective. The more drowsy or intoxicated the subject became the greater the tend— ency to make errors in perception. At the onset, displacements of hand percepts were frequent, but as the drug effect diminished, displacements diminished and extinction of hand percepts became prominent—only to disappear as the subject became more alert. Similar effects have been observed in the patients with a mild mental syndrome. Where only extinction of hand percepts was apparent prior to the Amytal injection, displacement of percepts became frequent and persisted for the duration of the examination. The effect of the drug persisted for longer periods in patients with organic mental changes than in normal adults, so that displacement of percepts was manifest hours after the injection in the patient group. Similar observations on the effect of anesthetics on central nervous system function have been made in a study of normal adults subjected to varying periods of anesthesia.5 These subjects with no demonstrable disease of the brain, who made no errors on double simultaneous stimulation tests prior to anesthesia, manifested extinction and displacement of �NEUROLOGY 56 percepts in either hand on multiple trials of the face-hand test during recovery from anesthesia. When these subjects regained consciousness from a general anesthetic, they were disoriented and confused. There was a manifest correlation between the duration of the perceptual errors and the period of confusion, lethargy and apathy that followed the anes— thetic administration. Efleet of convulsions: During post—convulsive states patients frequently show confusion and other symptoms of the organic mental syndrome. Since persistent errors on the face—hand test were found in patients with mental changes due to disease of the brain or due to drug intoxication, it was thought that any one who has an organic mental syndrome, of whatever cause, should show these errors. F or this reason, groups of patients were studied in whom convulsion were induced electrically for treatment of depressions. Patients who were given intravenous barbiturate prelimi— nary to electric stimulation were not included in this group. It was found that if the post-convulsive confusional state was severe, these patients showed a high incidence of errors on the face-hand test. As soon as the confusional state cleared, the incidence of errors in the facehand test decreased. Value of the face—hand test as a diagnostic sign: In order to determine the value of the face-hand test as a diagnostic sign of severe mental changes, a series of patients were examined in the admission ward of Bellevue Psychiatric Hospital. This examination was carried out by simultaneous stimulation of the face and hand. Each patient was given a series of 10 tests. N 0 history was taken nor were other clues used to make a diagnosis. Using this method it was found that in all cases in which the face—hand test showed errors on repeated trials, subsequent psychiatric examinations disclosed the presence of an organic mental syndrome. CONCLUSIONS From the foregoing observations it is apparent that subjects with the organic mental syndrome showed persistent errors on face—hand tests. It is significant, however, that the same confused and disoriented patients did not err in a haphazard fashion. An analysis of their responses based on numerous tests showed that the errors were made in a predictable pattern. There were consistent errors in the hand percepts, whereas there were very few errors in response to the simultaneous stimulations applied to the face. Another significant point is that this pattern was found not only in patients with cerebral dysfunction, whether it was due to structural or chemical changes in the brain, but also in normal children. This was found in children in whom the brain was not altered in any manner. The latter �57 , ORGANIC MENTAL SYNDROME observation indicates that this pattern is not the result of disease of the brain, and conversely, that it is inherently organized. Moreover, it indicates that this pattern is acquired early in life. N o explanation is offered as to why these patterns are so organized, namely, face dominance and hand “extinction.” The rostral dominance theory proposed by Cohn6 cannot be supported by these observations, inasmuch as it was found that the foot dominates over the hand. This fact automatically precludes the factor of rostral dominance. Moreover, the authors do not wish to agree or disagree with the well known theories proposed by Goldstein.7 Still another point is that reactions of the child are similar to those of the senile individual with mental changes. One might draw an analogy to the Babinski sign, which is considered normal in the developing infant and abnormal in the adult. From this analogy, it might be inferred that the presence of persistent errors on the face-hand test in the adult indicates a regression to the infantile level. However, we do not wish to convey the idea that we concur with such a theory. Finally, it might be concluded that what is seen in patients with dis— ease are normal patterns of function which appear to be grossly exag— gerated. As noted, repeated errors on face-hand tests may be found in the normal adult under certain conditions, particularly when there is altered brain function. Based on this hypothesis it is felt that a good deal of information about normal function can be obtained from patients with dysfunction as a result of altered structure. Aside from the theoretical considerations it must be concluded that the face—hand test has clinical value. It is a diagnostic sign of the organic mental syndrome. The persistence of errors on face-hand tests in an adult strongly suggest an organic mental syndrome. SUMMARY Patients with an organic mental syndrome make persistent errors in tests by double simultaneous stimulation of the face and hand. The errors are usually made in the hand. These errors are made on multiple trials of the face—hand test and on subsequent examinations on repeated days. The normal and the schizophrenic adults, however, do not make persistent errors. This difference in response between these groups is so striking as to have diagnostic value. Errors of extinction and / or displacement on multiple trials of the facehand test by touch stimulation are indicative of the organic mental syndrome. In a series of patients examined in the admitting room of the Bellevue Psychiatric Hospital, these tests were applied to patients as the �NEUROLOGY 58 first questions of the interview. The diagnosis of an organic mental syn— drome was confirmed by subsequent interview in every case. The significance of these findings is discussed. REFERENCES 1. (a) BENDER, M. B., and NATHANSON, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena, Arch. Neural. & Psychiat. 642501, 1950. (b) BENDE‘R, M. B., and WORTIS, S. B.; Patterns in perceptual, motor and intellectual functions in organic brain disease, Tr. Am. Neural. A. 72:31. 1947. (C) BENDER, M. B.; WORTIS, S. B., and CRAMER, J,: Organic mental syndrome with phenomena of extinction and allesthesia. Arch. Neural. & Psychiat. 59:273. 1948. (d) BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disorder of the body scheme, Tr. Am. Neural. A. 73:170, 1948. (e) SHAPIRO, M. F.; TEUBER, H. L., and BENDER. M. B.; Disturbance of body image and allesthesia. J. New. & illent. Dis. 108:253, 1948. (0 BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disturbance of the body scheme, Arch. Neural. 10 . . & Psychiat. 62:222. 1949. BENDER. M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Tr. Am. Neural. A. 75:250, 1950. (b) BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neural. &: Psychiat, 66:35.5, 1951. BENDER, M. B.; SHAPIRO. M. F., and SCHAPPELL, A. W.: Extinction phenomenon in hemiplegia, Arch. Neural. & Psychiat. 62:717. (a) 1949. The phenomenon of tactile inattention with special reference to parietal lesions, Brain 72:538. 1949. 5. JAFFE. J., and BENDER, M. B.; Perceptual patterns following general anesthesia. J. Neurol.. Neurosurg. & Psychiat.. in press. . COHN, K.: On certain aspects of the sensory organization of the human brain: 11. A study of rostral dominance in children, Neurology 1:119, 1951. GOLDSTEIN, K.: The Organism. New York, American Book Co., 1939. 4. CRITCHLEY, M.: In order to conceive a clear idea of the pathology, we have only to imagine the physiological phenomena, already noticed, assuming a pathological character. Now, the force of these phenomena may be augmented, diminished, or annihilated. In regard to the cerebral functions, we have, in the sentient nerves, pains or insensibility; in the cerebrum itself erroneous perceptions, judgments, and colitions, or delirium; or a total deficiency of these faculties, or come; in the motor nerves continual voluntary actions; or paralysis. Hall in Lectures on the Nervous System and Its Dis-eases, published in 1876. -——Marshall �The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome 31am Fink, M .D., 111a7'tin Green», M.D., and NI 0772's B. B ender, M.D. Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY �NEW YORK SOCIETY FOR CLINICAL PSYCHIATRY The 116th Regular Meeting oI the Society WILL BE HELD AT THE BELLEVUE PSYCHIATRIC HOSPITAL LEWIS I. SHARP. M.D.. Direcior 30”! STREET AND FIRST AVENUE THURSDAY, NOVEMBER 9th, 1950 AT 8:30 P.M. PROGRAMME I. TWELVE YEAR FOLLOW-UP STUDY ON METRAZOL TREATED CHILDREN AND ADOLESCENT SCHIZOPHRENICS . LAURETTA BENDER. MD. and S’raff 2. THE FACE-HAND TEST IN ORGANIC MENTAL DISEASE M. FINK, M.D.. MORRIS B. M. GREEN. MD. BENDER. and M.D. NOLAN D. C. LEWIS. M.D. MORRIS HERMAN. M.D. Prosideni Secrefary Staff invited — Dr. Herman �4/,q/, . 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' mm in: normal 0mm (x—é—x) at «W of an. 3.6 (0—0), mm m1:- (0+m0). ”mum“ uncut: (x—h—x) m magne- lulu ”mu name me mm mm (rm-I). * In. mama or W patzlcntl sun emu. ���i/‘l/B I STANDARBIQATION OF THE FACE-HAND TEST Introduction: In previous studies a simple perceptual test, the test, race-hand test was introduced and the responses to the of normal subjects and of patient with psychiatric disorders were described in detail (1~6). sists The test con- of applying touch or pinprick stimuli simultaneously to the face and hand while the subject's eyes are kept closed. The subject is then asked localize the percepts. occur. The two stimuli correctly or the subject and Two felt and to general types of response may be may what was perceived and localized perceive only one stimulus either not perceive the other (phenomena of extinction) or misloceliae the second stimulus (phencmens of displacement) (7). Most often the mislocslisstion or displacement occurs to another part or the subject's body but occasionally there is displacement into extrspersonsl space or onto the examiner (exosomesthesis) (8). Displacement of stimuli �2. across the mldllno of the body (alleatheala) is another form of displaoomont Normal adults initial trials orrots that may show of the among occur (9). errors in perception teat. characteristically of face dominance). all subjects correctly - be those is perceivod correctly As correct (phen- additional tests are tho errors disappear so that by the.tenth to on the oonaiot of extinction of the stimulus on the hnhd wheroao the face stimulus - may done trial noarly porcolvo both stimuli and continue 0o subsoQuent trials. has been tarmod a ”negatlvo faoe~hand This type of response test." lt oocura not only with normal gdulto but also in patients wito nohlzophronla, depression, or oovoro anxiety{ In contrast to the preceding groups, patient tith' an organic mental tyhoromo show extinction‘and diaplaoef want not only during the initial trials or the ‘tost but ’ after 10 total: of testing or as long on testing is continued. Such a rooponse is termed a ”positive taco—hand �3f test.” -by A normal "positite fees-hand test“ is also manifested ohildren, normal aged persons. fectives asvwell as syndrmhe. by patients with and mental de- an organic mental ~ Because of the differentiel_response or these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it hes been noted thst patients with an organic mental syndrone vary ' greatly in the type and frequency of peroeptuel errors. Also, subjects without organic brain disease ‘ occasionally manifest a positive faoefhend test. The questions thieh arose from these observations are: 1) Is it . poeeiole to classify or standardize the different types of errons ooeuring in subjects with e positive race-hand test? 3 2) Gen these different types of response he corb related with the several groups or subjects previously mentioned?; 3) In there e type of response which can be �llld to ooour absolutely only in notiente with eeyere 4 dieeeee of the brain? 'The present study ie an attempt to enerer these questions.‘ ~ “ ‘ . lethod end Resultez. We test reviewed our previous records of the face-hand done in almost syndrome, normal 1000 adulte, patients with organic mental and schizophrenia adults, as well an in lesser numbere~of normal children, normal aged persons, and subjects with mental defioienoy, depression or severe anxiety. Additional groups or some of theee subjects were aleoteeted in different types of stimuli. e systematic manner with The criteria ueed‘to form- ulate a standardization of the race-hand test were: 1) ‘type of perceptual errorx'a) frequency or the variOue type: or error: with different types of stimuli (touch, rubbing, scratching, or pinprick); quency of errors when 3) effect on the fre~ the Subject ere-witnesses the applio' cation of the stimuli (factor of attention). Fifteen to thirty trials ' or the test were usually done for each eubjeet. �5. Based on theoe criteria, it was possible to divide oeticnte showing a poeitive race-hand test into four groups. The oheracterietio reeponeee for each group are V ' in Teble I. summarized Qheee reeponeee with examples are described more fully in the following peregraphe. mm I Features of the Different Type: of Positive Face-Hand Test \ One-glue Extinction only with , a touch stimuli, Two-Blue Three—glue Extinction Extinction ~pinprick placement with touch, rubbing with touch, rubbing, and and deep ~ stimuli die- and pinprick ’stimull Four-Rina Same as three-plus with at least one or the following feeturoe: e) exosomeetheeie b) alleetheeie c) frequent pereervetion d) occurrence of errors while subject eye— witnesses the areas stim- ulated. One~Plue Face-fiend show These Test: errors only of extinction The subjecte in this gnoup~ and not of displacement. errors occur only with touch stimuli. When pinprick �6. in need, both stimuli are perceived correctly, although errors will again uppeer when touch stimuli are reintro- duoed. A 6h year old because of a 1% men with mild diabetes was admitted year history or difficulty in walking. For at leeet the same period of time the patient had been depressed, The elept and ate poorly. and wee impotent. only neurological finding was a elow, heeitent, shuffling gait. There vascular dieeaee. payohomotor was The peripheral patient appeared depressed. showed retardation, and cried readily. Senecrium intact. Spinal fluid, eere normal. The was no evidence of The EEG, and X—reya of the spine diagnoeie wee involutional psychosis. gait difficultiea were thought to be secondary to the depression. this patient hand test. A shoeed a onesplue response on the raoe~ sample of his response: rollove: �7. ' com stinging touch: right chcokolort hand' right cheek touch loft chock—right hand touch right check—right hand '“touch loft chockwlcft hand touch right check-loft chock touch right hand-loft hand touch right chock—loft hand touch lelt chock-right hand touch loft check-right hand ' left cheek right cheek left cheek T222 of Error extinction extinction oxtinction extinction correct correct right chock‘ extinction correct correct touch right check-right hand 'right cheek touch left chock—loft hand left cheek extinction extinction pinprick right chock—left hand correct pinprick loft chock-right hand oorncct pinprick right chook-right_hand correct pinprick loft chock-left hand corrcct touch right cheek-loft hand correct touch loft check~right hand loft chock extinction ' adamant: Although this type patients with cerebral disease, it Or response occurs in is not alwaya charac{'5 w (M . [cal/ca toriatic for this group. It is also seen in caciiihf defrlswod’ a; MAJ (as: t/(O‘fili‘d 4"/ Mo, fitter (a! amt/11:5 Skits} .(achizophrcnia, and, occasionalgy, in normal adults. �8. Two-Plus Paoe~fiand Test: In this group extinction ' occurs with pinpriok and rubbing stimuli as well as with These errors.may be touch stimuli. just as frequent with both types of etimhli or may be more conspicuous with touch than sith pinpriok is not present, but or rubbing. may ooour on an A.72 year old man had a 5 weeks and Displacement occasional trial. history of mental. behavioral changes. This. consisted of disorientation, confused behavior, and internittent autism. thero was an examination organic mental syndrome characterized by partial disorientation, defects in recent and oiroumlooutions illnoss, On in answering questions, denial of and pain asymbolia. logical disabilities. l-raye were normal. memory, evasione The A There were no other neuro~ spinal fluid, and EEG, pneumoenoephalogram showed skull diffuse ,oerebral atrophy. This patient's responses on the face-hand characterise the two-plus type or response. A test sample �of these responses followc: Stimulfis touch touch touch touch touch touch lett cheek~right hand right cheek-left hand left chock-left hand right cheek—right hand right chookéleft cheek right hund~1ert hand touch right cheek~left hand I . Roseanne ngo of Error left extinction extinction extinction extinction cheek right cheek left cheek right cheek correct correct right cheek pinpriok left cheek-right hand left cheek pinpriok right cheek-left hand oorrect’ pinprick loft cheek~lort hand left.choek pinpriok right cheek-right hand right cheek pinprick left cheek-right hand left cheek Gonncnt: extinction. extinction extinction , extinction extinction This roaponco occurs most often in patientcv with cerebral disease although patients with anxiety state, I depression or schizophrenia may also exhibit it. It is not seen in normal adults. Three-Plus Paco—Hand Test: This group is characterised by the Occurrence of displacement as well as with both touch and pinprick stimuli. The extinction frequency of �10; extinction and displaoomont may be aqual or unequal and, likewise, the number of errors with touch and pinprick otimuli will be variable. A 57 year old chronic alcoholic was found in the in a stuporous condition. Hia Itroot. breath had an alcoholic odor and there oas a laceration over his right foroooad. There here no hospitol focal neurological signs. During the doy the patient graduolly Spooch woo rambling and was was and skull had savoro memory defects There were no X~ru§a were fialluoinationsti' nofonl. The diagnosis ocuto and chronic alcoholism with deterioration; A hand fluid And 35‘ expressed taranoid ideas aod was He hoatilo'hnd asafiultivo. ISpihal fully oooacioualgii. at timeo almost incoherent! oomplotoly‘diooriontod with confahulation. become first sample of this pationt'a toot, indicative of fallout: responooa on the race- a throe—plgo rooponao. in go ‘ �114‘ szg Rcaponso Stimulus of Error right chcck~left hand right chock-left hand displacement touch loft check~right hand right hand—left hand displacement touch right cheek-right hand right cheek extinction Touch touch touch loft loft cheokfiloft hand Correct cheekoright hand. left chock extinction touch right chock-loft hand right check—left check diaplacomont touch right hand-left hand .correct pinprick right chock~1c£t hand‘ right-choek-lcft chock displccomcnt pinprikk loft chock-right hand loft chock-right cheek displacement ‘ pinprick right chock—right hand right cheek left check pinprlck left chock-loft hand FourvPlus Facc~Hand Test: extinction cxtincticn This group shows the. sovercat porcoptual errors. In addition to frequent extinction and displaccment ac scan group. one or . all in the threc~pluc of the following phononcna may be sccn' with touch andfilr pinprick stimuli: 1) oxoaomcsthesia; 2) allcsthosic; 3) frequent pcrservation of responses; h) the occurrence of perceptual errors even while the subject keeps his apes open and eye witnesses tho arcas' stimulated. �12. A 60 year old man had a oriéntation, torgetfulness, examination he ShOfiBd a three year history of interest. and loan of On sovare organic mantal syndrome manifested by cemplete digorientation. marked -d6fect3, and inability to calculate. 'oodperativo. d18~ He was mamary alert There were no other neurological Spinal fluid and skull x-raya were normal. EEG and signs.' showed modernta, diffuse biaynohronoua slaving with slow alpha. A diffuse curcbral atrophy. pneumoogoephalograg disclosed A sample of the patient's roaponsee; 1ndlogt1ng a' fqur-plua face-hand tagt, is as fellows: Stimulus touch right cheek~ left hand touch left cheek» hand right aheek sonal spaco~ , v‘ right.oheok oxosomosthaaia extinction , _ oheek— lart left hand 10ft hand extinction , touch touch right hand- ‘ left-hhook-oxtrlporu , touch right cheekhand . , right right ‘, ‘ of Errér Tzfio Haazonse right cheek , oorrhot perseveration ' ' �13. touch right ohook- right chook~loft left hand touch left oheok¢ hand right pinpriok right hand loft ohook- loft right hand 'pinpriok right cheek- right right hand pinpriok loft ’lort hand loft chaok— pinpriok (eyes open) right cheek-left adamant: hand cheek—loft hand right ohook-lott left pinpriok loft chaak~ ohook ohook allosthosia displaoomont extinction _ cheek~oxtrnporaonnl apnoo displacement extinction cheek oxoaomeathosia right cheek—extrAporaonal oxosomosthoain space Throo~plua and four-plus responses invariably indicate disoaae of the brain. normal chock They are never found 1o adult: or in patients with psychiatric disorders. In oddition to tho difforont groups of subject: diaounsod above, the responses of normal children above fears 0! ago, normal hove ngod also been studiod. 3 persons, and montal defectives The distribution or the responses, or the children and aged poraooa are related moinly to age. The youngest children and the oldest adults show threo-plus and four—plus reopensoa. With changes in �age away from thine extremes, one-plus and two~plus re- spouses become more frequent. or the subjects with mentel deficiency, those with fiho lowest mental age have throe- plua and four—plus responses while one-plus and two-plus in subjects with higher mental 33035 'neoponses predominate Table II summarizes the distribution or the four different tfpes of responsesamong the various groups of subjects. ShOfl Only three-plus may be patients with and four-plus roséonses._ Such responses considered diagnostic of an organic mental syndrbme. TABLE ‘ an organic mental syndrome I; Frequency of One-Plus to Four~P1us Positive Pacerfiend Test in Different Groups of Subjects Negative Ono~ F5H.test Pius organio nental Syndrome 10% 7% 1% Normal Adults (below 60’ 99% year: or age) “yachixophrenio Adults nearly noooae- Two~ Plan Patients with anxiety nearly occae~ states all ionelly Petients with paycho~ neerly genie depression all‘ Four~ Plus Plue_ 25% 335- o o ' 25% o _ ' ' all ionally Three» rare neVer never more never never �15;- Discussion: In answer to the questions raised in the intreduetlon, our results indicate that four general types of positibe Itsce-hsnd test occur and that these different types can be correlated with different groups of subjests (Table Our attentien there was a was ii). focused mainly on the question of whether type sf response which occurred only in pamienss with severe disease of the brain. All cases with a threeplus or foursplus response have organic brain disease. Suoh'responses are never seen in nermel adults or patients- Iith psychoaenic disorders, even theugh these groups occasionally show one~plus may or two-plus responses. Patients with oerehral disease manifesting s four~ plus response invsrihbly show vsneed foam or mental changes. the severest or most adOtherwise there is no correlations between the type.n! positive faoeahand test and the severity of she senserisl defense. Same good istients with severe mental changes may have only a twenplus �» response; In addition, 10% of patieoie with an ofganio mental syndrome hove a negative face~hand ereelized that the use of ‘fov the groups 16. teet.’ It is to four ~plus nomenclature a one implies an increasing degree of cerebral ‘. -dyafunntion. This nomenclature ‘ was used because of con(1 lenience and much an implication is not intended; . We? This classification of a positiiefiface-haod should ‘ be useful clinically. In feeting neurological patients, the exect type of positive face-hand -corded, was will test should be re- rather than the deeignetion "the taceuhend test positive" as has been make it easier to of politifie faoe«hand done until now; Judge whether the Such a prooeedure particular type test manifested; indieatee definite cerebral disease or whethef‘it may not be a mnnifestatioh of anxiety or depression.‘ The use or such a classification will also make it easier to compare the response of patients at different times during their illnees. In addition. . , it should be valuable in clinical experimental work,'euoh an the reopen-e or patients to drugs. eleetroehock trentmont; ate. �17o Ema 1“,? : .A stanfiardization of the dittorgnt face-hand responses is prgsented. A fiypea of positive one-pins face—hand that consists of gxfiinotion only with'touoh stimuli. Itwo~plus reapgnsg 1a charactfigixéd by A extinction with pinprick and rubbing gtimfiix,‘gs.wéll as with touéh stim- uli? A three~plu3xfesponés consists cf extinction plus diapfiacafiont with touch, rubbing, #nd pinprick stimuli. A four—plus rggpénso has all tha charactériatics of a ‘ é three-plus rgaponsa and in addition at least one of tbs following features: a) exo§bmeathesia; b)_allesthesia;. c) pérseveration of respongea;'d) occurrenoa of evbn while the errors subject aypeyitneéaas tha Afifilication of fha stimuli. ‘Three—plfis éfidttour«plua responses invaritbly M-rindictte_¢1aeaaé of Fhé braig. One-plus and two~plua rdaponaea ocgur in patient; with brain disease but are alab maniteated by a hmélllfiumber of normal alulta and . patients with psychogenic disorders. Pationts with a; r �183 four-plus response the Invarest mental changes but show otherwise there is no correlation betwoon-tho aovopgyy' of the montql changes and the . 7- test manifested. - . face-handV.‘ typo-of'politivo (J ’ " . , 'w L �19. REFERENCES 1. BENDER, u.a., PINK; 3. and GREEN, n. - Puttarnn 1n paficegtiun on simultawawus fiesta a: face and hand. Arch.Neurol.&Pq1chiat., fig: 355—362, September, 1951. 2. M.B., and PINK, M. ~ Tactile perceptual tests in the differential diagnosis or psychiatric disorders. J.Hillaido 3032., A: 21-31, Jlnunry, 1952. 3. FINK, M., GREEN, M., and BENDER, M.B. BENDER, tastNo.an dia'noatlo 1, ‘g: h'ar8, - The raoa4hand Sign or disease or the Jan~Feb., 1952. brain. Nburolo . FINE, H. and BENDER, M.B. - Dovelopmunt of perception 9f simultaneous tnctile'stimull in normal children. 2 27-3L, January, Neurolo 1953. JAFFE, J. and BENDER, M.B. ~ Barceptual patterns fol— lowing general anesthesia. J.Nouro.Neurosurg.&Psychiat., gg: 316-321, Hovombor, 1951. and BENDER, M.B. ~ Cutaneous perception in the aged. Aroh.Neurol.&ngphint. fig: 577. 1953. g. BENDER, fl.B. - The phenomenon of sensory displacement. GREEN, M.A. ,Armh.Neurol.&Pq;oh1at., 95: 607-621 May. 1951. 8. SHAPIRO,.M.F., PINK, m. and BENDER, v.3. ~ Exosomesthesia or displacement of cutaneous sensation into extruporsonnl space. Aroh.Rouvol.8:Psgchi-.at., 9. gag: 1.81-1.93, Oct. 1952. Patterns in allasthosia body scheme 3:: other g4: 501~515, Arch.Neurol.&Pa;chiat., aensorysphohamena. Oct. 19 2. BENDER, and M.B. and NATHANSON, H. — their relaticu ta disorder or 3 �3?}!DAMIM’1'IM 63‘ m FAW $33!? a, mu: 1. Green, 3. 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I mI Immu- mu mm a: mmmd‘ «gammy. adult?!» ‘Ia-I um: roux-III �13* ”I’m: slaw in mt. ”van“ yum ohms” ‘bat a» mum um. man 1: ma autumn” Miami: m “writ: the m: to“ Wand» autumn“ of thin that and of mm mm uni t1» tarp". an» 1. Italy at isthmus clinically Match or with. rut-had unnatural“: in magma-u work ��I 3"? ’ flu-h'S-S.%F#M ___________Z;#__~__'——_ ��15 November 50 Dear Dr. Bender, of outline the studies in which Following is an I an participating under your supervision: a. Being prepared for presentation: i. Patterns in perception in simultaneous tests of the face and the hand 2. The Face-Hand test in the Organic Eental Syndrome 3. Patterns in perception in simultaneous tests of parts of the body other than the face and the hand 4. Caee report- Ethel Beckhorn Nos. 1-4 with‘Dr. Green. 5. Dyecheirie (with Dr. Shapiro) i" i‘b. Under study: 1. 08? changes following arteriography 2. Gomplicatione of arteriography; evaluation of the indications for the use of arteriogrefihy and the diagnostic value of the technic // Both of these studies with Dr. Stein. c. Proposed for study under grant by Rational Foundation > ~ for Infantile Paralysis: ',// n, , 1. Relation of sdaptation time, D. S. S. and threshold stimuli in hemiplegia 2. Patterns and factors in the responses of children to D.S.S.; comparison with patients with organic mental changes 5. Gen extinction and displacement be observed in normal subjects using threshold etimnli ? ��S.R. 5004-590M-701102(50) . Q.CITY OF 114 NEW YORK—DEPARTMENT OF HOSPITALS ....................................................................................HOSPITAL CaseNo..._....__.._____ PROGRESS RECORD Name...”...................................................................................... Admitted........................................................................ 19 .......... Ward ....................... 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V ' I ' - MMWQ M(M)/Zm i M NK‘Z me/W 5' Wbfi-gc % '4’ [find/ff IV ,7/C/Wfl7 MKLKKWWL) Wot/Logbook, ‘ ,t, 611%11f3/144». ”fa/two! 4/1“ 7- (WW) AL 14mg Ego; Kilo/offéfi: 354‘: J)»; 4995] 27134 2 WWW/4i lnfi w. M Karo-4L _ ‘4 ...mo �.i M’m a??? MM Mpg mdM gm» 9' %%-Q zf/Zex/L "0 §. ‘ 7. 'C'meioo 0 - ,'. :_ ‘ , V I‘ f 2 w"ww-wrr‘rvmrg'm'rfl’wm .‘ ‘ va ~— 4”“) A.“ I —W"%*“W, .M'MJ’ %{d’ #Cnfiwwfiu '> -- iT do n- u ,7 ��' a: @729; :x/Ma. 0W Aw, I M» WWW; cm, ”MM” zz Aggy”: —G/2/m a. V'aéém , �Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION SEVENTY-FOURTH ANNUAL MEETING, JUNE 13-15, 1949 OBSERVATIONS ON THE EXTINCTION PHENOMENON IN HEMIPLEGIA MORRIS B. BENDER MORTIMER F. SHAPIRO AND A. W. SCHAPPELL NEW YORK Routine sensory examinations are usually carried out with the method of single stimulation. This method appears to be adequate, but it does not always disclose existing defects in sensibility. For example, in a patient with a right cerebral lesion the left side of the body may be sentient to a single stimulus. However, the sensation evoked at this very point may no longer be apparent as soon as another stimulation is made elsewhere, such as on the opposite side of the body. The same change in sensation may be elicited with the method of double simultaneous stimulation. This disappearance or extinction of a sensation is not always complete. At times the patient reports a dulling or obscuration rather than extinction. Extinction and obscuration have been found in tests of all types of sensation. They may be observed in patients with lesions implicating the sensory pathways of the brain or spinal cord. The object of this study was to determine: (a) the method which is most successful in eliciting the phenomenon of extinction, (b) the pattern in which extinction manifests itself on the paretic side in cases of cerebral hemiplegia and (C) the frequency with which extinction of cutaneous pin prick sensation occurs in patients with hemiplegia. Fifty patients with hemiplegia were selected at random from the medical and psychiatric wards of Bellevue Hospital. Patients with aphasia or psychosis were included in the series only when their responses in sensory tests were consistent in one respect or another. In this study the cutaneous sensory status of patients with hemiplegia were first estimated by the customary method of single stimulation with the prick of a pin. The patient was asked to report whether he felt a sharp or dull sensation. Various regions of the body were thus tested and compared for degree of sensibility. The same patient was then examined with the method of double simultaneous stimulation. Three variations of the method were employed: (A) simultaneous stimulation of points in homologous regions on the two sides of the body, such as the right and left hand, the right and left side of face, etc.; (B) simultaneous stimulation of points in non-homologous regions on the two sides 160 �Bender, et al.—Extinction Phenomenon in Hennplegia 161 of the body, such as the right face and left hand, the right shoulder and left face, etc.; (C) simultaneous stimulation of points in two different regions on the ipsilateral side of the body, such as the right face and right hand, the right hand and right foot. On each test the patient was asked to report the location and quality of sensations. When the patient reported only one sensation, he was asked if he felt another in any other region .of the body. If he felt two sensations evoked by the simultaneous method, he was asked to compare them. RESULTS The most effective technique for eliciting the phenomenon of extinction was found to be Method B, or the simultaneous stimulation of non-homologous regions on the two sides of the body, such as the face on the healthy side and the hand on the hemiplegic side. The next most effective was Method C, or the simultaneous stimulation of two regions on the hemiplegic side, as for example, the face and hand on the affected side. Method A, or the simultaneous stimulation of homologous areas on the two sides of the body, did not reveal sensory defects as frequently as did Methods B or C. Although we have been stressing the phenomenon of extinction or the disappearance or decrease of a sensation, we have not overlooked the other aspect of the situation obtained on double simultaneous stimulation, namely, the retention of a sensation. We shall refer to the sensation which is retained as “dominant” and the one which disappears as “extinct”. Examina— tions with the various methods of double simultaneous stimulation showed existence of gradients of sensibility throughout the body. One sensory region was dominant to another. Further studies showed that these gradients were patterned. The pattern on the hemiplegic side revealed sensory dominance greatest in the face and less in descending order in the following regions— face, thigh, shoulder, foot and hand. In other words, when the face and any other part of the body on the hemiplegic side were simultaneously tested, as a rule the sensation in the face was perceived while sensation in any other one part was reported as diminished or absent (extinct). A phenomenon which appeared directly related to sensory dominance was that of “displacement”. In some instances when non—homologous regions on both sides of the body were tested simultaneously, the patient reported he felt two sensations of equal intensity, there being no extinction. The sensation was localized correctly on the normal side. However, the sensation evoked by the stimulus applied to the affected side was incorrectly localized. There was an ipsilateral displacement of the sensation toward a region homologous to the point of stimulation on the normal side. The displacement was usually toward dominant sensory regions. Thus when the patient was pricked simultaneously on the face on the normal side and the hand on the hemiplegic side, he reported that both sides of the face had �162 Bender, et (LL—Extinction Phenomenon in H emiplegia been stimulated; or if the hand on the normal side and the face on the paretic side were simultaneously tested, he claimed that both hands had been pricked. In some cases of disease of the brain the displacement phe— nomenon was the earliest indication of sensory impairment. As the disease progressed, displacement was replaced by obscuration and eventually by extinction. One of the significant findings of this study was the demonstration of sensory deficits in patients with a severe psychosis or aphasia. Usually such patients are considered incapable of giving coherent or consistent answers in routine sensory examinations. The psychotic or aphasic individual has trouble in expressing comparisons between two successively induced sensa— tions. He has less trouble when the stimuli are applied simultaneously. With this technique the psychotic or aphasic patient usually responds by pointing to the sentient or “dominant” region and he repeatedly ignores the region which is apparently “extinct”. In summary, it was found that a sensation in one region of the body is readily influenced by a sensation evoked in another area. This influence is most apparent with the methods of double simultaneous stimulation. Using these methods in patients with hemiplegia it was found that extinction occurred in 44 of the 50 patients, whereas routine single stimulus examination ’disclosed defective sensation in only 29 cases. Furthermore in 28 of the latter 29 cases the sensory defects became more conspicuous with these techniques. ����.flmwéfl nMMflL—{A‘ay /m4_g. fa/A/uc/WIZMM g/éé,‘M/£¢M �����, .p~.., ��' ‘D’Mwnrw hvflfl :- f/‘f/f’l a, am» , . MW Wm V“ ‘ “Mm ,¢__,-m..‘ w ngvm’regfiww .5 w (V) (:3) gfl/hflflflh " M 7% rfii. flé’i flmw ’2 mm //M I.“ _ ‘ ‘ ‘ . ; . \n ��wiffimfi’fi; ’ ����������51$“ “<4 3 “it wfiéu'wéi 3‘” van ���. hi illanh. ‘ , ‘ .A $1.1Hnawwlllflsfalz ”436,... 13.36 Tamrgwuau .-1...i1w.uiu.«ni.1> 53.53.», . �7,) 3“, Wu 3. ' * - “aim/ad. 4.54.wa 975‘; ‘au ) «,2; MMM) LC“ 962.7 ‘@ dflaficfi . *3 SI �����5.9.50 Sensory Studies In a discussion with Dr Bender today he made the following suggestions: 1. That studies of the face— hand, face - penis as carried out in the normal could be extended in the pattern of shoulder - foot, hand - thigh etc. This will give an outline of a homonculus of sensory dominance in the normal-2. The studies of the reaction in the normal on the abnormal in the penis and breast tests two directions: the influence of amytal might on the normal response and the responses to the test in severe the test and initial be extended in anxiety states (hysterias . . .). 3. It would be an error at the present time to describe the testing as a definite aid in the diagnosis of the organic mental syndrome. With such a figure, the physiological implications of the testing would be pushed to the background. But that if the studies can be verified as valid in OMS, then it might later be described in that condition as another test like orientation, patterns be 4. A memory, etc. special study in normal children of these undertaken. 5. The problem of Beckhorn be presented as an example of a hemisensory syndrome that appears to D83 and SS upon proper stimulation; and the effect of intersensory testing. 6. In the writing of the definitive paper on the face - hand test, the following subjects must be covered: a discussion of the various theories behind dominance as the rostral idea, medial over lateral structures (concentric), importance of sexual symbols, skin sensitivity, etc.; the possibility that the disturbance is related to the state of consciousness and not the state of the reverbalization processes (aphasia, apraxia, etc.); order of dominance; 7. fl“: 4 6) m—NMWYWKwh./Lu&m" “mu—~15 4/444./GLL; » (afldiiaruiuiii7é«vl» «Ajfaa ��w' -——-- -—-\P,K.. -7. ”w“ , -..~ » ‘ . w... «kw, - , 2"” “av 7“,:'71,~',Izfiivm"’">:_’r W."'etrwwgu—cvrw"'_nWWW'-W‘4~‘Xmu_t7$m,va'fi«mv-JzT’n-VH—W-jw ���:5,“ .p �n. amm.m,mumaamfummmmm WWIIWWthflph man. «mmmmmmmmmmw sun-1m. mmflumuhmmmamtmmmw} “mummummummmmum. 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A and «rind "am. mo na- tartan an intact. him). mad, thotvmmmlom ma xnms at that ‘91:» mm,~pm31. m umu- in imam-v uma panama... damned typo. in» we annulus... an “to tho «ya-alum 69 In this 9131.!“ that«I I out-91m mum» on the {WW Ian." A awn»a! nu 'WOPW“ Yemen: a: , W ‘Wt I ' “wt touch an ' touch tumult tench Chow-loft hm right than! loft ma~n§z was fight hm tough touch tough. ; . may“ Alma-10“. rum 13.31:! i maintain-fl cum: right hum-Mu an Mi: mam: ma «Musician ,. unnatfin utimtion mot it“ in.“ 00m." animation ' com“ dwt Bulk-tilt; land ”at; . chm-k - «tintim � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The face-hand test as a diagnostic sign of organic mental syndrome. Neurology. 1952 Jan-Feb; 2(1): 46-58. And, Observations on the Extinction Phenomenon in Hemiplegia Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-3-005 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin; Bender, Morris B.; Schappell, A. W. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 15 items, each with various amounts of pages. 1: Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 2: Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY. 3: New York Society for Clinical Psychiatry: The 116th Regular Meeting of the Society. 4: [Preprint]. 5: list of publications by Fink. 6 and 7: Drafts. 8: handwritten notes. 9: Letter to Dr. Bender from Fink. 10: handwritten note. 11: City of New York - Department of Hospitals/ Progress Record. 12: Handwritten notes. 13: Reprint from Transactions of the American Neurological Association 74th Annual Meeting, June 13-15, 1949; Observations on the Extinction Phenomenon in Hemiplegia (not written by Fink). 14: Handwritten notes. 15: typed pages. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/355c4b9504ee5dda4b99daee2b72cb14.pdf 32103451b1f3d9d0d60a0a834fb27af9 PDF Text Text Reprinted from—JOURNAL or THE HILLSIDE Vol. I, No. 1, January, 1952 HOSPITAL _ TACTILE PERCEPTUAL TESTS IN THE DIFFERENTIAL DIAGNOSIS OF PSYCHIATRIC DISORDERSl MD.2 and MAX FINK, M.D.3 New York, N. Y. MORRIS B. BENDER, Visual perceptual performance tests like the Rorschach, Thermatic Apperception and Bender Visual Gestalt tests are widely used in the evaluation of psychiatric disorders. Recently, a simple test of tactile perception—the face-hand test—has been described (2). By this test, characteristic performances of normal adults (2) and patients with diffuse cerebral dysfunction (3) have been differentiated. The face-hand test is an application of the technique of multiple simultaneous stimulation (1) . The examiner lightly touches, simultaneously, the cheek and the hand of the subject. The latter is then asked to describe and localize the stimuli. Normal adults readily name and localize the two stimuli within the initial few trials of the test. Once correct, they are thereafter correct on all similar tactile stimulation tests. In contrast to normal subjects, patients with psychoses due to disease of the brain are not able to perceive or correctly localize one of the two simultaneously applied 'stimuli, even after many trials of the face-hand test. They consistently make errors in the stimuli to the hand (and con.versely, they rarely make errors in the perception Of the stimuli to the face). This type of response has been observed in 90 per v ' From the Department of Neurology and Psychiatry, New York University College of Medicine, Bellevue Psychiatric Hospital and the Hillside Hospital. This work aided. in part, by grant #MH 139 from the U. S. Public Health Service, National Institutes of Health. 2Director of Neurologic Service, Hillside Hospital, Glen Oaks, N. Y. 3 Aided by a Fellowship from the National Foundation for Infantile Paralysis. 1 , 21 �22 BENDER — FINK cent of the patients with diffuse brain dysfunction, and has been described as a sign of the organic mental syndrome (3) . These simple tactile perceptual tests have now been applied to patients with hysteria, schizophrenia and psychic depression. The responses of these patients to repeated trials of the face-hand test will be described. SUBJECTS The subjects were patients from the wards of Bellevue Psy- chiatric HOSpital. These patients had one of the following conditions: schizophrenia, psychoneuroses, psychic depressions or organic psychoses. The patients with schizophrenia manifested the various clinical varieties of the disorder. The patients with psychoneuroses were those hospitalized for severe anxiety, reactive depression, or behavioral outbursts necessitating inpatient observation. The patients with depression in this group were predominantly young adults in whom the psychiatrist obtained a history of recent stress precipitating admission to the hospital. In addition, patients with diagnoses of “character disorder” or “behavioral disorder,” and without evidence of psychosis, were included in this group. Patients with depressions were studied in two groups. The young adults with “reactive depressions” were included in the group of patients with psychoneuroses. The second group were the older adults, in whom the diagnosis of involutional psychosis was made. In some instances, these patients presented evidence of impairment of memory, concentration, calculation, and orientation. The diagnostic differentiation of their disorder from psychoses due to disease of the brain was difficult. The diagnoses were usually made after extended periods of observation and with the aid of psychometric studies. The patients classified as having organic psychoses manifested the usual memory disturbances, disorientation, emotional lability and confusion characteristic of the “organic mental syndrome” (3) . The etiology in these cases varied between central nervous system syphilis, posttraumatic states, senility, presenile dementia and alcoholism. �TACTILE PERCEPTUAL TESTS 23 METHOD During a routine examination, the face-hand test is applied. The patient is asked to close his eyes. In the sitting position, with his hands lying naturally in his lap, the patient’s cheek, and dorsum of the hand on the side opposite to the cheek, are simultaneously touched by the examiner’s fingers. The patient is then asked “What did you feel?” The normal adult usually points to the cheek and states: “You touched me here" or “I felt something here,” making no mention of the stimulus to the hand. The patient is again asked to close his eyes, and the stimulation repeated. This time the opposite cheek and hand are touched. He is asked whether he had felt anything. The usual response is a correct localization and identification of both stimuli. If only one stimulus is reported, it is the stimulus to the cheek. At this time, the examiner asks: “Did you feel another touch anywhere else?” The normal subject usually points to the hand stimulated and admits: “I felt something there—I thought you may have brushed against it.” On the third and fourth trials of the face-hand test, the cheek and hand of the same side of the body are stimulated—first on one side and then on the other. Finally, both cheeks and then both hands are stimulated. This sequence of six tests is repeated. Subsequent to these trials, other parts of the body are tested in a similar fashion, such as cheek and foot, or breast and hand. Cutaneous stimuli other than a light touch have been used such as multiple light touches (rubbing), single pinpricks, multiple pinpricks, and less frequently, temperature tubes (hot-cold) and tuning forks (c128). With these cutaneous stimuli the obserVations are qualitatively the same as with touch stimulations, although the frequency of errors is much less (2). In each case where defects were apparent on face-hand tests, standard tests of single stimulation by touch and pinprick were applied. Only a few subjects, those with evidence of focal cerebral damage, myelopathy or peripheral neuropathy, made errors on these single stimulation tests. Their reactions were not considered in these results. ' ' �24 BENDER — FINK RESULTS The usual responses of the normal adults to the face-hand test were: (a) perception of one stimulus only—usually the one to the cheek, and only rarely the one to the hand; (b) perception of the two stimuli, correctly localized; and (c) perception of two stimuli, but one mislocalized. This mislocalization was almost always a mislocalization of the hand percept, which was displaced to the homolateral cheek. Such "displacements" were rare in the normal, but frequent in subjects with disease of the brain. Normal adults manifested incorrect type (a) and (c) responses on the initial few trials only. As reported previously, 50 per cent of the normal adults made errors on the initial trial of the facehand test; 22 per cent on the second trial; and errors became less and less frequent until by the tenth trial, less than 1/2 per cent still made errors (2). It is apparent that normal adults can readily discriminate two tactile stimuli and accurately localize these within the first few trials of the test. Also, once the normal adult was correct on one trial, he was found to be correct on all subsequent trials regardless of the body part tested or the rapidity with which the tests were applied. Adults with Psychoneuroses: Most of the subjects with psychoneuroses responded in a fashion similar to normal adults on both the initial and on multiple trials of the face-hand test. Subjects with manifest anxiety, after identifying the cheek stimulus on the initial trial, perseverated in this response. Through many trials they persisted in naming only the cheek stimulus, even insisting that there was no other stimulus. This type of report was maintained until the examiner emphasized that there were two stimuli. As soon as the subjects realized that there were two stimuli they were correct both in naming and localizing subsequent simultaneous stimuli, as well as single stimuli interspersed at random. During the time that errors were apparent on multiple trials of the face-hand test, these anxious patients never displaced a stimulus, i.e., recognized that there had been two stimuli, but mislocalized one to another body part. It was as if they were in a mental set of “oneness," and this set persisted until broken by �TACTILE PERCEPTUAL TESTS 25 the examiner. When they got into a mental set of "twoness," they were correct on all subsequent trials, perceiving and correctly localizing the two stimuli. In a majority of patients with hysteria, including those with hysterical amnesia, the face-hand tests showed normal responses. In a few the responses were abnormal. Thus there were some who reported the sensation on one side of the body correctly, but denied all stimuli on the side which showed a hysterical type of sensory defect. There were some patients who showed "allocheiria.”4 They mislocalized a stimulus from one side of the body to a homologous part on the opposite side. This mislocalization or displacement occurred from the side with hysterical defective sensation to the side with normal sensation. Adults with Schizophrenia: Most patients with schizophrenia were able to discriminate the stimulus applied to the face and hand correctly on the first few trials just as normal adults could. However, there were a number of patients in this group who presented bizarre responses. The touch stimuli were occasionally misidentified and were reported as “a burning” or “a fly crawling.” Frequently, the number of percepts were multiplied. Instead of perceiving the two applied stimuli they reported three, four or even six percepts in a variety of body parts. Similarly, a single stimulus was reported as two, three or four percepts, occasionally omitting the locus of the original stimulus. Such patients usually persisted in the bizarre behavior on repeated testing on subsequent days. In two instances, there were bizarre responses even when the test was applied with the eyes open. A number of the paranoid patients refused to close their eyes and permitted examination provided they could see. Obviously, under this condition, they were correct on all trials of the face-hand test. Patients with schizophrenia, admitted to Bellevue Hospital for frontal lobe “topectomy” operations, were able to perceive and 4The term allocheiria should be distinguished from allesthesia. According to Ernest jones, the British psychoanalyst, the crossed sensory displacement manifested by patients with hysteria is to be called allocheiria, while that shown by patients with disease of the nervous system is to be called allesthesia. Based on our experience the distinction between the two is made largely on the total clinical picture. In one there is the long history and symptoms typical of hysteria, while in the other the history and neurologic signs show patterns characteristic of organic disease (4). �26 BENDER — FINK localize the two simultaneous stimuli during the initial period of testing. During the first two weeks after topectomy operations, however, the patients manifested the “organic” type of response to the face-hand test. As will be described later, this pattern consisted of omissions and mislocalizations of stimuli on repeated testing. As the patients recovered from the operation, the errors on repeated trials of the face-hand test decreased. Ultimately, they correctly reported the simultaneous cutaneous stimuli and reacted in a manner no different from the nonoperated schizophrenic patients or normal subjects. Patients with Psychic Depression: Patients with “reactive depression" were co—operative and usually correct on the initial as well as on subsequent trials of the face-hand test. Their responses were most like the normal pattern. Of the patients with severe involutional melancholia, some were frequently unco-operative. They were suspicious of the request to keep their eyes closed and if they permitted stimulation, would report only one of the stimuli. The stimulus they reported was the one to the face. They omitted the one to the hand. Like the patients with manifest anxiety, they frequently persisted in giving one response through many trials— until the idea of “twoness” was apparent to them. Thereafter, they were usually correct in their responses (Case I). Patients with a manic excitement correctly identified the two stimuli on the initial trial of the face-hand test. On subsequent trials they were frequently unco-operative, commenting that the test was too easy, or silly; when co-operative they were usually correct on subsequent trials. Organic Mental Syndrome: The reactions of the patients with organic mental syndromes to multiple trials of the face-hand test are different from those observed in normal subjects or patients with neurosis or schizophrenia. Ninety per cent of all patients with organic mental syndrome repeatedly fail to report one of the two stimuli, or when reporting two, mislocalize one of them. Again the perceived stimulus is the one applied to the face. The Stimulus to the hand is usually not perceived or it is mislocalized. This type of response is consistent and highly predictable. A patterned response is also apparent in tests of body areas other than the face and hand. An “order of dominance” in tests �TACTILE PERCEPTUAL TESTS 27 of other body areas could be established in these patients. In this order the face is the most dominant with penis, trunk, breast, foot, thigh and hand less dominant, in descending order. When tactile stimuli are simultaneously applied to any two body areas, the errors in localization will occur in the part of lesser dominance. For example, if stimuli are applied simultaneously to the cheek and penis, the patient will report the cheek stimulus alone; but if the stimuli are applied to the penis and the hand, then the stimulus to the penis will be reported. These omissions and mislocalizations of percepts persist for many trials and on many days of testing. The inability of the patient with an organic psychosis to discriminate two cutaneous stimuli is so consistent, that it is considered a sign of the organic mental syndrome (3) (Case 2). Eflect of Electro-Convulsive Therapy: In patients with schizophrenia or psychic depressions, electro—convulsive therapy induces a similar “organic" type of reaction to the face-hand test. During the period of confusion immediately following the treatment, the patients consistently report only the cheek stimulus or mislocalize the hand stimulus to the check. This is transient during the first few treatments, but near the end of a course of therapy these reactions persist for longer and longer periods, until they are apparent hours or even days after the treatment. Patients who had a course of electro-convulsive therapy and were readmitted to the hospital after a lapse of months failed to show this “organic” re- action. CASE REPORTS The following case reports are selected as illustrating the types of responses observed. Case I: S. S., a forty-year-old woman, was admitted to the neurological service complaining of backaches in recurrent episodes of eight years. During the past year she noted difficulties in recollection and in her ability to calculate. She had been a bookkeeper and now found herself unable to calculate accurately or rapidly enough to continue work. On occasions she had misplaced valuable family possessions only to find pawn tickets in their place. �28 BENDER — FINK During interviews under sodium amytal she cried readily and related many recent family difficulties, including the suspension of her husband’s license as an auctioneer and her son's classification in IA by Selective Service. Her difficulties apparently began with these events. Medical and neurological examinations were negative except for some varying areas of hypesthesia and hyperesthesia. Psychiatric examination revealed marked psychomotor retardation. There were deficits in memory and calculation. She was able to relate details of her history and of world events, but was unable to relate details about her work or family affairs. These latter details were readily apparent, however, in interviews under the influence of sodium amytal. On simple calculation tests she made few errors, though she was slow in response. On more complex tests commensurate with her occupation as a bookkeeper, she made numerous errors and showed many hesitations. Many answers were reported questioningly. The admission clinical diagnosis was “organic disease of the brain.” This was based on such symptoms as psychomotor retardation, memory deficits and difficulties in calculation. Face-Hand Test: On the initial face-hand testing the patient persisted in giving the cheek response only for eight trials, but thereafter, was consistently correct for twenty trials. There were no displacements of percepts. On subsequent days she was correct on the initial and all subsequent tests. These findings suggested that the symptoms were not due to disease of the brain. Course in Hospital: To exclude organic disease the patient was subjected to a series of tests. Neurological examinations, electroencephalography and pneumoencephalography revealed no evidence of organic brain disease. A psychological survey revealed an average intellectual capacity (IQ 106) without any evidence of organic deterioration. The personality survey revealed severe anxiety and depression, with some bodily preoccupations. The final diagnosis was depression and the patient was discharged for further care in the psychiatric clinic. Comment: This case illustrates the problem in the differentiation of psychic depressions and organic psychoses. As a rule we found that the preservation of the ability to discriminate and �TACTILE PERCEPTUAL TESTS 29 localize double tactile stimuli speaks against organic disease. Only 10 per cent of patients with organic mental syndrome showed normal response to the face-hand tests. The converse was not true. There were no instances in which a normal person made persistent errors on face-hand tests. If errors are made, it usually turns out that the patient has disease of the brain, no matter how bizarre the mental picture may be. This is illustrated by the next case. Case 2: H. B., an elderly white male appearing about sixty years of age, was admitted by the police who found him wandering about the streets. He was unable to give his name or home address. He did not answer questions, though he spontaneously requested water and food. A few days after admission he began to speak freely, gave his name as “The Messiah” and his home as the hospital. He was facetious, quick in speech and coherent. A complete delusional system relating to God, the patient’s previous sojourn in heaven, his mission on earth, etc., was related. No other anamnestic data were available. Under further observation he showed the Ganser syndrome. For all questions of orientation, general information and calculation, he answered relevantly but was only approximately correct. He was almost but not quite right. He did not answer any questions of personal history except for the distant past and then he related a disjointed, rambling, confabulatory story. To many observers it seemed as if the patient had a “hysterical” type of psychosis. During examination on admission the patient appeared chronically ill. The blood pressure was 180/100 and urine contained four plus sugar. There were hemorrhages and exudates in the ocular fundi. Neurological studies showed absent ankle jerks, diminution of vibration sense in toes and ankles, with normal position, touch and pinprick perception. Other defects were apparent on special sensory studies. Face-Hand Test: On the face-hand test this patient presented an “organic" pattern. In the initial testing, he repeatedly reported only one of the two stimuli—that of the face. After many trials and a number of trials with eyes open, he began to report the two stimuli but now mislocalized the hand percept to the cheek. In testing on consecutive days, similar mislocalizations and omiso sions were apparent, both on the face-hand test and on similar �BENDER — FINK 30 tactile tests of other body parts. An abstract of the record, which evinces the “organic” pattern on double simultaneous stimulation testing with light touch stimuli is presented here. Stimulation Right cheek, left hand Left cheek, right hand Right cheek, right hand Left cheek, left hand Right and left cheeks Right and left hands Right cheek, left hand Left cheek, right hand Left cheek, left hand Right cheek, right hand Response Right cheek Left cheek Right cheek Left cheek Correct Correct Right and left cheeks Right and left cheeks 2 percepts left cheek Right cheek » Further neurological studies revealed a diffusely abnormal electroencephalogram; a symmetrically, diffusely dilated ventricular system on pneumoencephalography; and evidences of organic deterioration on the psychological tests. Course in the Hospital: Under observation the patient showed a gradual and persistent improvement. After six weeks in the hospital he recalled some facts whichled to his entering Bellevue. He remembered his address and social security number. As he improved clinically errors on the face-hand tests became infrequent. When the errors were sparse, intravenous administration of three grains of sodium amytal produced once again the persistent omission and mislocalization of percepts characteristic of the organic mental syndrome. Comment: Here is a patient who was thought to be hysterical but the face-hand test contradicted this impression. The persistence of errors on multiple trials of the face-hand test made us think of an organic disorder. The subsequent special Studies confirmed this suspicion. CONCLUSION ‘ As with visual perceptual tests, such as the Rorschach, this simple tactile test- the face-hand test—has been found to be useful �TACTILE PERCEPTUAL TESTS 31 in evaluating psychiatric patients. Anxiety, paranoid attitudes, autistic thinking and misinterpretation of environmental stimuli are manifest on face-hand tests. Characteristic behavior patterns are seen in some schizophrenic and hysteric patients. In the evaluation of patients with mental changes due to dysfunction of the brain the face-hand test is of diagnostic significance. The inability of these subjects to discriminate the two simultaneous stimuli on repeated trials and the characteristic errors of omission or mislocalization of the hand stimulus are unique. Such errors are not observed in normal, schizophrenic, hysteric or depressed adults. REFERENCES (l) Bender, Morris B.: “The Advantages of the Method of Simultaneous Stimulation in the Neurological Examination." Med. Clin. North America, 32: 755-758, 1948. (2) Bender, Morris B., Fink, Max and Green, M.: “Patterns in Perception in Simultaneous Tests of Face and Hand." Trans. Am. Neurol. Assoc, 75: 250-252, 1950; and Arch. Neurol. da- Psychiat., 66: 355-362, 1951. (3) Fink, Max, Green, M. and Bender, Morris B.: “The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome.” Neurology, 2, 1952. (4) Jones, Ernest: “The Pathology of Dyscheiria." Rev. 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Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Tactile Perceptual Tests in the Differential Diagnosis of Psychiatric Disorders. Journal of the Hillside Hospital 1: 21-31, 1952. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-4-006 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from Journal of the Hillside Hospital Vol. I, No. 1, January, 1952 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/dd6aa613ad864b41d42710aa943de4df.pdf e331912b9bfc1f22ac2706d3f155e8a5 PDF Text Text 5 ,fi, . 1 Confinia Neurologica 9/ NEURQPHYSWLUEY [ABQRMURY HILLSIDE HOSPITAL GLEN OAKS' N' Y- Borderland of Neurology -— Grenzgebiete der Neurologie Les confins de la Neurologie Edidit: E. A. SPIEGEL Basel S. KARG ER Separatum Vol. 12, Fasc. 4 (1952) : 3 . New York Printed in Switzerland From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellevue Hospital, New York City A Clinical Evaluation of Carotid Angiography by MAX FINK and JOSEPH M. STEIN ._.I I ‘ f .3 I Since carotid angiography has become a routine procedure in the management of intracranial conditions, an evaluation of its use is necessary. Both the indications and hazards of the procedure must be considered in recommending it for diagnostic purposes. It seemed valuable, therefore, to review the angiograms done on the neurological service of a general hospital. During the past 20 months, 117 percutaneous diodrast angiograms were completed by members of the resident house staff. The majority were done di- rectly by the authors. A variety of neurological conditions including suspected brain tumors, vascular anomalies, subdural hematomas, vascular diseases and diffuse degenerative diseases were selected by the attending staff as suitable candidates for angiography. In each case, a percutaneous carotid angiogram was performed according to the usual descriptions (1). Either local infiltration by novocaine or general anesthesia by pentothal or surital was used. A CournandGrino needle was inserted into the carotid artery at the level of the thyroid cartilage. In most instances the common carotid artery was cannulated; in a few instances the internal carotid alone. Ten to twelve cc. of 35 % diodrast solution were used in each injection. A simple manual multiple cassette holder was used. This permitted three consecutive lateral films and a single anteroposterior (A—P) view. In each case the A—P and lateral films were immediately developed, and, if indicated, the injection was repeated. If no pathology was noted on these films, the procedure was repeated on the other side whenever advisable. Bilateral procedures were carried out in 26 subjects. �182 Max Fink and Joseph M. Stein Results Diagnoses of various conditions were made prior to angiography. Of these, “brain tumor suspects” made up the largest group; suspected vascular anomalies and subdural hematoma were the next largest groups (see Table I). The interpretation of the films was based on descriptions by Moniz (2 a), Lima (2b), and Green and Arana (l b) . Brain Tumor Suspects Of 55 patients in whom intracranial masses were suspected, angiographic diagnoses of brain tumor were made in thirty. Of these, 25 were confirmed by subsequent surgery or air studies. Confirmation was not obtained in three patients because further studies were contraindicated by patient’s age or family’s refusal to give permission. In two cases the angiograms were interpreted incorrectly and these cases are described. Case I: D.H. a 48 year old woman was admitted to Bellevue Psychiatric Hospital because of headaches and progressive confusion. The examination revealed early papilledema, left central facial palsy, skull tenderness on the right and memory deficits. An electroencephalogram showed a right cerebral focus. Bilateral carotid angiography under general anesthesia revealed definite elevation (displacement) of the parietal branches of the right middle cerebral artery. Subsequent to this procedure the spinal fluid syndrome was noted to be positive for active syphilis. Anti-luetic treatment was instituted and the patient improved rapidly. Five weeks later, the right carotid angiogram was repeated. These films showed the parietal vessels to have a normal configuration. Case II: 0. 0., a 64 year old male was admitted because of recent onset of grand mal seizures and left-sided weakness. Examination revealed a mild left hemiparesis, most marked in the lower extremity. There was a positive Babinski response and increased reflexes. The cerebrospinal fluid syndrome was normal. A right carotid angiogram under local anesthesia was performed and demonstrated good filling of the anterior and middle cerebral arteries. There was straightening and depression of the pericallosal artery on the lateral views; and increased vascularity near the termination of the anterior cerebral artery on the A—P film. These changes were interpreted as evidence of a parasagittal tumor mass displacing blood vessels. A pneumoencephalogram was done and this did not demonstrate the mass. The patient improved without treatment and was discharged. He was readmitted a few weeks later with evidence of an acute brain stem syndrome. In View of the course of the illness and multiplicity of lesions, it was believed that the patient’s symptoms were due to degenerative changes, and not a neoplasm. No further studies were undertaken. In this group of suspected brain tumors 22 angiograms did not show any pathology. Eleven of these were confirmed by air studies or autopsy. In two patients, however, satisfactory angiograms failed to demonstrate lesions later demonstrated by other studies. �A Clinical Evaluation of Carotid Angiography 183 III: F. M., a 57 year old man was admitted to the hospital because of left hemiparesis, bladder and bowel incontinence, and grand mal seizures of 4 weeks duration. On examination, there were severe personality changes, and a spastic left hemiparesis with pathological reflexes. Cerebrospinal fluid syndrome was normal. A right carotid angiogram under pentothal anesthesia was done. Two sets of lateral films and one A—P view were taken. The films showed no evidence of cerebral tumor. One week later a ventriculogram demonstrated a large right fronto-temporal mass. The presence of a malignant glioma was confirmed by surgery. Case IV: J. S., a 49 year old man developed left sided seizures and aphasia during hospital treatment for furunculosis. On neurological examination there was evidence of a lesion in the right hemisphere. On skull x-ray the pineal shadow was shifted to the left. An arteriogram on the right side under general anesthesia was done and no pathology demonstrated. A pneumoencephalogram, however, revealed a deformity of the right frontal born. The patient expired one month after angiography and at postmortem, multiple cerebral abscesses were demonstrated bilaterally. Case Other erroneous angiographic diagnoses were made in patients who proved to have vascular thromboses. In two patients with signs of a brain tumor, the angiograms revealed an avascular area in the parieto-temporal region with displacement of middle cerebral vessels. Surgical exploration revealed edematous necrotic brain tissue, without evidence of tumor. Each case came to autopsy, and TABLE I ANGIO GRAPHIC DIAGNOSES Group No. of Patients Intracranial Mass Vascular Anomaly and Aneurysms Suhdural Hematoma Occlusive Vascular Disease Other (f) 55 _ Pos. 30 Pos. Neg. Not Diagnosis Diagnosis Incorrect Neg. Diagnostic (3) Confirmed Confirmed Diagnosis 22 3 25 1 2 21 17 9 9 (d) ll 11 7 13 2 4 10 8 — — l ll 4 (b) 1 (c) 9 6 (e) 7 — 1 —— 5 —— —— Notes: (a) Technically unsatisfactory films. (b) Two cases confirmed by surgery but 7 other patients'with anomalies demonstrated on arteriograms were not subjected to further studies. (c) The 11 patients with negative arteriograms were not subjected to further study. ((1) Includes seven diagnoses of subdural hematoma, one of intracerebral hematoma and one of brain tumor. (e) F ailurc of the anterior or middle cerebral, or internal carotid artery to fill on at least two consecutive injections, while the remainder of the circulation filled well. (f) Includes three “follow-up” angiograms, seven patients with difiuse degenerative disease and three patients with lesions of the skull. �184 Max Fink and Joseph M. Stein in both, thrombosis of a branch of the middle cerebral artery was found. The angiograms could not be differentiated from those seen in cases of tumors in the same region. Vascular Anomalies: Twenty-one patients suspected of intracranial vascular anomalies or aneurysms were subjected to angiography. The angiograms were bilateral in only three of these, and unilateral in the other nine. One set of films were not satisfactory and were not repeated. Seventeen of these patients had manifested spontaneous subarachnoid hemorrhages. In nine cases an anomaly was clearly outlined on the arteriogram. Five of these were aneurysms at the base, and four, vascular malformations of the hemisphere. No anomaly was demonstrated in eleven cases. Confirmation of findings by other methods of study was most difficult to obtain in this group. In the nine cases where the anomaly was demonstrated, further confirmation was achieved in two cases. In one, an angiomatous malformation was amputated at operation. In the other, an aneurysm of the anterior communicating artery was dissected at post mortem. Air encephalograms were normal in two patients, despite the angiographic evidence of a large angioma of the cerebrum. The specificity of angiography in the diagnosis of vascular malformations is demonstrated by such cases. Of the eleven patients with negative angiographic findings, two were subjected to air studies. These films were normal. The other nine patients were discharged without further study. Subdural Hematoma: The diagnosis of subdural hematoma was made angiographically in seven of seventeen patients suspected of traumatic intracranial hematomas. The characteristic separation of the vascular patterns from the internal table of the skull as seen on the A—P projection was the basis for these diagnoses. In each of these cases the diagnosis was confirmed by trephination. Furthermore, in the eight patients in whom a diagnostic vascular pattern was not seen, diagnosis of no blood in the subdural space was made. These diagnoses were all confirmed by pneumoencephalography. In two patients angiography demonstrated an intracerebral mass, rather than a subdural process. In one case, this diagnosis made it possible for the surgeon to approach the lesion by a well localized and definitive procedure. The diagnosis was confirmed in the second at autopsy. Vascular Disease: Angiographic studies were done in 11 patients in whom occlusive vascular disease was believed to be the basis �A Clinical Evaluation of Carotid Angiography 185 for their neurological findings. Failure of a portion of the vascular distribution to fill on two consecutive injections was observed in seven of these cases, and normal vascular patterns were seen in the other four. In the first group incomplete filling of the middle cerebral artery was seen in four cases; of the anterior cerebral artery in one case; and of the internal carotid artery in two cases. The vessels which appeared involved on the films were in each instance the same vessels as indicated by the patient’s clinical syndrome. In four of these patients pneumoencephalography demonstrated areas of atrophy in the involved region of the brain. In one case, post mortem studies confirmed the angiographic findings. No confirmation was obtained in the other six cases. Miscellaneous Group: Of the 13 angiograms in the group, seven were done in patients with diffuse cerebral disease of a degenerative type. These films were not characteristic but in each case air studies demonstrated an enlarged ventricular system without shift or deformity. In three patients with lesions of the skull angiography failed to demonstrate any cerebral involvement. Pneumoencephalograms were done in only two of these patients and were normal. Complications: In an evaluation of the indications for a diagnostic procedure the incidence and severity of complications must be considered. In this series of 117 angiographic studies, 36 patients suffered a total of 43 complications. There were five cases with severe and permanent complications. In all other instances the complications were mild and transient. Of the transient complications, 22 hematomas of the neck were recorded. This was recorded only when the hematoma was large. In one case, in a child, the hematoma was large enough to cause tracheal shift and respiratory difficulties. It was necessary to intubate the patient and maintain the airway during the evening of the procedure. Transient hemiparesis or transient increase in an existing hemiparesis was seen in 7 cases, and a grand mal seizure was observed in 2 patients. In each instance the phenomena disappeared within 48 hours. In 4 cases urticaria, chills and vomiting followed angiography, and seemed to represent an allergic response to the diodrast. In one patient, in whom a vascular anomaly was demonstrated, fresh blood was manifest in the spinal fluid the morning after the procedure. Of the severe complications, death occurred within 24 hours of angiography in two patients (cases V, VI). In three other patients �186 Max Fink and Joseph M. Stein severe complications were directly related to angiography. In a young child an osteomyelitis of the transverse process of the fifth cervical vertebra resulted after a difficult cannulization (case VII). A permanent mixed aphasia (case VIII) and an intensification of a pre-existing hemiparesis (case IX) were also observed. Case V: G. B. male, 62. Craniotomy, three months before arteriography, had demonstrated a right middle fossa spongioblastoma polare which was spreading along the sphenoid ridge and had crossed the midline. The patient completed a course of x-ray therapy and was alert and ambulant. A vertebral angiogram was suggested to evaluate the intracranial mass. The patient was sedated with demerol, scopolomine and luminal. Three injections of 11 cc. each of 35% diodrast, were made. The record states that: “while attempt was made to enter right common carotid, patient became cyanotic, respirations shallow, and pulsations of the artery, which were strong, became weak.” The patient expired within 20 hours after developing hematemesis, melena, and two grand mal seizures. No autopsy was obtained. Case VI: R. W., a 40 year old male, was admitted because of sudden onset of headache and stiff neck. The spinal fluid was grossly bloody and the diagnosis of a spontaneous subarachnoid hemorrhage made. Patient developed pneumonia and ran a septic course. This responded to antibiotic therapy and patient seemed well one month after admission when he developed a second episode of subarachnoid bleeding. One week later, while patient was comatose, a right carotid angiogram was done. The films were not diagnostic and patient expired within 18 hours of the procedure. An aneurysm of the anterior communicating artery with hemorrhage extending into the lateral ventricles was seen at post mortem. Case VII: N. B., a 5 year old girl, was admitted because of petit mal seizures for two months. Examination demonstrated left homonymous hemianopsia and an electroencephalographic focus of abnormal activity on the right parieto-occipital region. A right percutaneous carotid angiogram was done under general anesthesia, with difficulty, and a normal vascular pattern demonstrated. Patient had a large hematoma of the neck with tracheal shift, necessitating intubation that night. Patient recovered rapidly, but complained of pains in the neck and kept the head fixed with chin turned to the left. Repeated x-ray examinations eventually disclosed an area of rarification in the transverse process of the fifth cervical vertebra. This responded to immobilization and chemotherapy. When seen six months later, the child had recovered completely. Case VIII: M. C., a 30 year old male, was admitted to the neurological service because of left sided headaches of a few years duration and three episodes of loss of consciousness during the previous six months. On examination there was diminution in perception of tactile stimuli in the right hand. This defect was exaggerated by double simultaneous stimulation. Electroencephalography demonstrated a persistent focus in the left parietal region. The pneumoencephalogram was normal. A left percutaneous carotid angiogram was done. Four injections of diodrast were made. After the last injection a complete hemiplegia, hemisensory syndrome and hemianopsia was observed on the right. The patient was totally aphasic but responsive. During the ensuing weeks the weakness and sensory changes cleared, so that when seen one year after the episode, only minimal sensory changes in the �A Clinical Evaluation of Carotid Angiography 187 right upper extremity were observable. The aphasia, however, after some initial resolution, persisted. The patient expressed himself with difficulty and made many errors, could not carry out complicated commands, and made errors in imitating mouth and hand movements. The angiographic films were interpreted as within normal limits except that the vessels of the middle cerebral group were few in number and widely separated. Case IX: E. B., a 64 year old man, was admitted because of headache and “nervousness” of some months duration; and repeated episodes of loss of consciousness without convulsive movements for one month. On examination there were mental changes, hyperreflexia and a positive Babinski on the left, but no manifest weakness or sensory changes. A right percutaneous angiogram was done with local anesthesia using four injections of diodrast. Immediately after the last injection the patient lapsed into a torpid state, his eye movements became dissociated, and the left upper and lower extremities were flaccid. During the ensuing days, the torper diminished until the patient could respond verbally to command, but the hemiplegia became spastic. It persisted until the patient was transferred to another hospital one month later. The angiograms were interpreted as normal. A pneumoencephalogram revealed bilaterally dilated ventricles Without shift or distortion. A number of factors such as sensitivity to the contrast medium the amount of drug and rapidity of injection (3b), and existing hypertension (3 c), have been suggested as causes for complications. In the present series, these factors are not outstanding in the patients who developed complications when these are compared to the uncomplicated cases. Either conjunctival or intradermal diodrast sensitivity tests were carried out in every subject. In one case, the onset of wheezing, sweating, and palpitation after the intradermal test caused us to cancel the studies. In all other subjects, including the patients with complications, the sensitivity tests were negative. This was notably true in the four patients who developed “allergic-like” reactions of urticaria, chills, and vomiting, following the angiography, but who failed to react to the test dose. There is no apparent relation in the data between complications (excluding hematoma of the neck) and the number of injections of diodrast (see Table 2). (3 a), TABLE II No. of Injections No. of patients with complications No. of patients without complications * 1 1 3 more than 2 0 9 3 6 4 5 6 6 2 1 6 0 27 22 13 8 3 Total" 16 85 Excluding 16 uncomplicated cases in whom total dosage was not recorded. Similar analyses of the factors of anesthesia and the number of carotid punctures at one session (unilateral or bilateral angio- �188 Max Fink and Joseph M. Stein graphy), reveal no significant correlation between these factors, taken singly, and the incidence of complications. Arterial hypertension was not a contraindication in the selection of patients for angiography. Ten hypertensives (all with diastolic pressures of 100 mm. Hg. or more, and systolic pressures of more than 160 mm. Hg.) were subjected to angiography, and in none of these were there any complications. Of the patients with severe or transient complications (other than hematoma of the neck) none had hypertension. Discussion Recent reviews have emphasized the diagnostic reliability of carotid angiography in vascular anomalies (4), suspected brain tumors (lb, 5), traumatic cerebral states (6), and occlusive vascular diseases (7). Our observations confirm the recommendations of the authors in the first three groups. Prior to angiography’, the diagnosis of vascular anomaly could not be confirmed except by surgical exposure or autopsy. Since air studies are not reliable in demonstrating vascular anomalies or is choice of in establishing the procedure angiography aneurysms, such diagnoses. In 43 % of the patients in this series in whom such a lesion was suspected, the anomaly 'was satisfactorily demonstrated by angiography. In an unpublished series of similar cases studied by one of us (Fink) at Montefiore Hospital, five aneurysms were demonstrated in 14: suspects. Similar results are recorded by other authors (4), and numerous recommendations have been made to increase these results. Routine vertebral injection, combined with bilateral carotid punctures, will demonstrate anomalies in the posterior portion of the Circle of Willis (14). Oblique A—P views at 45 degrees have been recommended to demonstrate small aneurysms of the carotid (4 (1). With these modifications in the procedure, it is to be expected that the incidence of positive identification of anomalies will increase. The role of angiography in the management of spontaneous subarachnoid hemorrhage is not clear. Recent reviews emphasize the importance of demonstrating the lesion where surgical intervention is indicated (4b, e). The effect of angiography during the acute phase of bleeding has not been clarified. Many authors have recommended angiography only after the bleeding has ceased. Others, such as Wechsler and Cross (7 b), suggest early use of angiography during active bleeding. This principle of waiting until bleeding ceased was adhered to in the cases in this series, and no statement of the effect of angiography on bleeding can be made. �A Clinical Evaluation of Carotid Angiography I89 Angiography is the diagnostic procedure of choice when a supratentorial brain tumor is suspected. It is recommended for lesions located in the anterior two-thirds of the cerebrum. Occipital lobe, posterior fossa and some midbrain tumors are not consistently demonstrable by this technique. Angiography is recommended in subjects with papilledema, since this procedure, unlike air studies, does not make immediate surgical intervention necessary (5, 7). Furthermore, numerous reports emphasize the differences in the patterns made by gliomas, meningiomas, intracerebral hematomas and vascular tumors (1, 2, 3c, 5). Such clues are helpful to the surgeon in planning the operative procedure. In a few of our cases, multiple foci of a metastatic tumor were demonstrable on the films, clarifying the management of the case. Such discriminations are usually not possible by other diagnostic techniques. The diagnostic reliability of angiography in cases of brain tumor is high. In this series, 25 of 29 confirmed brain tumors were outlined by angiography. In a series of 96 brain tumor suspects, 39 of 42 verified neoplasms were demonstrated (5 a). In the series from Montefiore Hospital angiography revealed the neoplasm in 45 of 52 confirmed cases. Similar satisfactory correlations are seen in the negative angiograms of these three series. This diagnostic reliability of 88 % compares favorably with encephalography. The value of air studies in brain tumor diagnoses has been frequently reported. In one such study by Grant (8), ventriculography demonstrated the lesion in 130 of 150 cases—an incidence of 87%; while pneumoencephalography in 69 cases, revealed the tumor in 81%. Further indications for angiography are in cases of traumatic intracranial hemorrhage. Numerous reviews emphasize the displacement of the anterior cerebral artery and separation of the fine vessels from the calvarium on the A——P film as diagnostic of subdural hematoma (6). Furthermore, angiography differentiates intracerebral and subdural lesions, altering the surgical approach (6 a). This was clearly demonstrated in two of our patients in whom subdural hematoma was suspected, but in whom the angiogram demonstrated an intracerebral mass. In cases of cerebral vascular accident angiography appears less helpful. Failure of a vessel to fill may be due to a variety of reasons including slowing of the circulation, vascular spasm, and anomalies of the system. These factors have been emphasized (7b). Angiography, however, is not contraindicated in vascular disease. It provides a useful means in differentiating a thrombosis from an intracerebral clot, or from a tumor, in cases where the diagnosis is unclear. �190 Max Fink and Joseph M. Stein While the indications for angiography are many, they cannot be evaluated without a discussion of the risks involved. The complications of the procedure are of three types: (a) transient local phenomena; (b) transient cerebral vascular phenomena; (e) permanent severe deficits. In the first group of transient phenomena are burning pains in the head during injection, hematoma of the neck, and allergic reactions. Hematoma of the neck is a potentially dangerous complication (see our Case VII) but in a recent review no sequellae were observed (9). Allergic reactions are infrequent and usually mild. It was noted in this series that the routine intracutaneous or conjunctival testing for sensitivity was not found satisfactory in predicting these complications. Transient hemiparesis, aphasia, seizures and elevated blood this In (10). have been following angiography reported pressure series these complications were observed in nine cases—an incidence of 8%. A similar incidence was observed in the Montefiore Hospital series. That these phenomena are probably due to temporary vascular insufficiency (spasm?) is evidenced by the clinical pattern of neurological findings and their duration. Of seven patients with hemiparesis, the deficits had disappeared within three hours in three patients, while in three others it was gone in 24 hours. In one of the subjects angiography was repeated in the other side six days later, without complication. In the seventh patient, arteriography had demonstrated an aneurysm of the internal carotid artery on the left and the common carotid artery was ligated on that side. One month later, angiography was repeated on the right side and following the first injection of diodrast, the patient developed a right hemiplegia. This disappeared during the ensuing 72 hours. Vascular syndromes of the anterior and middle cerebral arteries have been observed. In one patient a lower limb monoplegia developed after two injections of diodrast. A third injection on the same side was done within 15 minutes of the appearance of the defect. The arterial views obtained showed good filling of all branches. The monoplegia disappeared within 12 hours. These complications were not observed in patients with hypertension. Deterioration of a patient’s condition or death following angiography has been reported in a number of instances. Bull (5d) summarizes the mortality rate of the procedure as 3 per 1000, which he states compares favorably to ventriculography. More recently, Dunsmore, Scoville and Whitcomb (10b) report three fatalities in 147 cases, and Olsson (11) reports three cases of “deterioration of patient’s condition” in a series of 360 angiograms. �A Clinical Evaluation of Carotid Angiography . 191 There were two fatalities in our present series, and one patient had a severe aggravation of a pre-existing hemiparesis. Each of these patients, like those of Dunsmore, Scoville and Whitcomb and Olsson, were severely ill before the procedure. In contrast to this are the large series of Curtis (5b), Wickbom (1 c), Torkfldsen (Sc), Lindgren (la), and Green and Arana (1b) wherein no deaths were related to the procedure. It is possible that with widespread use of angiography, subjects with more advanced cerebral lesions are selected for these studies and the risks thereby increased. A number of reports by Olsson and associates (3b, 11, 12) emphasize the summation of the toxic effects of large doses of diodrast given over a short period of time. They indicated the nature of the toxicity as an increased permeability of the blood vessels and a change in hemodynamics. Furthermore, the relation between concentration of diodrast and toxicity was demonstrated by Cross (13) when he introduced diodrast for angiography. His observation that seizures follow the use of 50% and 70% diodrast has been confirmed by numerous investigators. Despite the use of 35% diodrast and low total dosages of diodrast, in this series, complications ensued. There was no significant relation between dosage and complications. Other factors must be operative and some hint has been given in the observation on circulation time (41') and the effect of other injurious agents summating with diodrast (3). Conclusion Angiography is preeminent in the management of cases of intracranial disease suspected of vascular anomalies, supratentorial tumors, and traumatic hematomas. It is a satisfactory non-surgical method of demonstrating a vascular anomaly, malformation or aneurysm. In the diagnosis of supratentorial masses it will outline 90% satisfactorily. In addition to establishing the presence of a tumor, arteriography is superior to other diagnostic technics in yielding evidence as to the type of mass and its locus. In cases with papflledema, surgery is not made immediately mandatory by the procedure. It is not a satisfactory method in demonstrating obscure and diffuse lesions of the ventricular system, or tumors of the posterior fossa or occipital lobe. In cases of traumatic intracranial lesions, angiography is a satisfactory method in outlining subdural hematomas, and differentiating such lesions from intracerebral hematoma or tumor. �192 Angiography is Max Fink and Joseph M. Stein thromboses cerebrovascular in not clearly helpful and hemorrhages. would and not transient, the for most part, Complications are, are The complications in cases. most the limit procedure seem to bilatnumber or anesthesia, not directly related to hypertension, factors a Other play diodrast. of erality of injections, or amount is necessary. further and role study more important Summary reviewed were carotid angiograms A series of 117 percutaneous in involved angiography. risks and for indications the to evaluate studied including supraconditions were intracranial of A variety and hematoma traumatic anomalies, vascular tentorial tumors, of intraevidence with disease. patients Fifty-five cerebrovascular cranial tumors were subjected to angiography, and a positive in confirmed were These diagnoses diagnosis was made in thirty. films misinterpreted. the were subjects In two only of the cases. 83% in in confirmed 50%; were the diagnoses Of the negative films, demonlater lesion show fail a to did the angiograms only two cases intracranial with suspected 21 Of patients strable by air studies. of In two outlined angiography. by vascular anomalies, nine were air manifest on not revealed anomaly an these, the angiograms traumatic of suspected of seventeen patients studies. In a group in made seven was diagnosis positive intracranial hematoma, a in cases, eight findings the well negative as as These diagnoses cases. all conwere in two demonstrated cases, intracerebral tumors and lesions cerebrovascular of In studies. cases firmed by subsequent complications Transient value. of diagnostic not angiography was consisted and of the one-third patients, in of angiography were seen In urticaria. and seizures, of hematoma of the neck, hemiparesis, These and severe permanent. five patients (4 %) complications were discussed. factors the and described cases are cerebral of angiorisks limited the conclude that authors The of the in usefulness management its from detract do not graphy intracranial vascular malformations, suspected supratentorial tumors and traumatic lesions. Zusammenfassung 117 durch perkutane Injektion in die Arteria carotis gewonnene und Indikationen der Gesichtspunkte Angiogramme werden vom Geffifianomalien, Tumoren, Gefahren besprochen. Supratentoriale der GehirngeffiBe und Erkrankungen Haematome traumatische �A Clinical Evaluation of Carotid Angiography 193 werden besprochen. 55 Patienten mit Zeichen von intrakraniellen Tumoren wurden mit Angiographie studiert; in 30 wurde eine positive Diagnose gestellt. In 83% der Falle wurde die Diagnose bestatigt. In 2 Fallen wurden die Filme falsch gedeutet. In 50% der negativen Filme wurden die Diagnosen bestatigt. Nur in 2 Fallen vermochte das Angiogramm nicht eine durch Luftfiillung demonstrierbare Lasion zu zeigen. In einer Gruppe von 21 Patienten mit vermuteten intrakraniellen GefaBanomalien wurde in 9 Fallen die GefaBstfirung demonstriert. In 2 dieser Falle zeigte Angiographie die Anomalie, wahrend Luftfiillung ein negatives Resultat ergab. In einer Gruppe von 17 Patienten mit Verdacht auf traumatisches intrakranielles Haematom wurde eine positive Diagnose in 7 Fallen gestellt. Diese Diagnosen, wie auch die negativen Befunde in 8 Fallen, und intracerebrale Tumoren, die in 2 Fallen demonstriert wurden, konnten durch weitere Studien bestatigt werden. In Fallen von Gehirnlasionen, die durch GeféiBprozesse bedingt waren, hatte Angiographie keinen diagnostischen Wert. In 1/3 der Falle kam es zu voriibergehenden Komplikationen (Haematoma des Halses, Halbseitenlahmung, Kréimpfe, Urticaria). Bei 5 Patienten (4%) waren die Komplikationen schwer und dauernd. Diese Falle und ihre Besonderheiten werden besprochen. Die Autoren gelangen zu der SchluBfolgerung, daB die begrenzten Risiken der cerebralen Angiographie von der Anwendung dieses wertvollen Verfahrens in F fillen von GefaBanomalien, supratentoriellen Tumoren und traumatischen Lasionen nicht abhalten sollen. Résumé Les auteurs passent en revue une série de 117 angiographies carotidiennes percutanées, dans le but d’évaluer les indications et les risques qu’elles comportent. La série d’afi'ections intracraniennes étudiée comprend des tumeurs supratentoriales, des anomalies vasculaires, des hématomes traumatiques et des affections vasculaires du cerveau. Cinquante-cinq patients présentant une symptomatologie de tumeur intracranienne furent soumis a l’angiographie et un diagnostic positif put étre fait dans trente cas. Ces diagnostics se confirmérent dans 83% des cas. Chez deux patients seulement, les radiographies furent mal interprétées. Parmi les angiographies négatives, 1e diagnostic clinique fut confirmé dans 50% des cas; dans deux cas seulement les angiogrammes ne montrérent pas de lésion qui, plus tard, put étre mise en évidence par injections d’air. Parmi 21 patients suspects d’anomalie vasculaire �194 Max Fink and Joseph M. Stein intracram'enne, 9 purent étre révélés par l’angiographie. Dans deux cas, les angiogrammes révélérent une anomalie que les ventriculogrammes n’avaient pas rendu manifeste. Dans un groupe de 17 patients suspects d’hématome traumatique intracranien, un diagnostic positif fut confirmé dans 7 cas. Ces diagnostics, de meme que les résultats négatifs de 8 autres cas, et les tumeurs intracérébrales démontrées dans 2 cas, furent tous c0nfirmés par des études ultérieures. Dans les cas de lésions cérébrales d’origine vasculaire, l’angiographie est restée sans valeur diagnostique. Des compli— cations passagéres de l’angiographie furent observées dans un tiers des cas et consistérent en hématomes de la région du cou, hémipareses, crampes, et urticaire. Chez 5 malades (4%), des complications durables et plus graves apparurent. Ces cas sont étudiés en détail et les facteurs on cause discutés. Les auteurs concluent que les risques limités de l’angiographie cérébrale ne sauraient faire renoncer a une méthode aussi utile pour le diagnostic des malformations vasculaires intracraniennes, des tumeurs supratentoriales et des lésions traumatiques. REFERENCE S 1. a) Lindgren, E.: Br. J. Radiol. 20, 326, 1947. — b) Green, J. B., and Arana, R.: Am. J. Roent. and Rad. Ther. 59, 617, 1948. — c) Wickbom, 1.: Acta Radio]. Suppl. 72, 1, 1948. — 2. a) Moniz, E.: “L’Angiographie Cérébrale”, Masson & Cie, Paris, 1934. — b) Lima A.: “Cerebral Angiography”. Oxford Univ. Press, London, 1950. 3. a) Olsson, 0.: Acta Radiol. 35, 65, 1951. b) Broman, T., Forssman, B., and Olsson, 0.: Acta Radiol. 34, 135, 1950. — c) Torkildsen, A.: Acta Psych. and Neur. Suppl. 55, 1, 1949. — 4. a) Lowman, R. M., and Dufi, S. D.: Amer. J. Roent. and Rad. Ther. 53, 341, 1945. — h) Poppen, J. L.: Radio]. 53, 347, 1949. — c) Wickbom, I.: Acta Radiol. 34, 387, 1950. — d) Lo'fstedt, S.: Acta Radiol. 34, 339, 1950. e) Wechsler, I. 5., Gross, S. W., and Cohen, I.: J. Neur. Neurosurg. and Psych. 14, 25, 1951. — f) Raney, R., Raney, A. A., and Sanchez-Perez, J. M.: J. Neurosurg. 6, 222, 1949. — 5. a) Culbreth, G. E, Walker, A. E., and Curry, R. W.: J. Neurosurg. 7, 127, 1950. — b) Curtis, J. B.: Brit. J. Surg. 38, 295, 1951. — 0) List, C. F.: Radio]. 55, 327, 1950. ~ d) Bull, J. W. D.: Postgrad. Med. Jour. 26, 157, 1950. — e) Fabritius, H. F., Frovig, A. G., and Kristiansen, K.: Arch. Neurol. and Psychiat. 61, 352, 1949. — 6. a) Wickbom, I.: Acta Radiol. 32, 249, 1949. — b) Kristiansen, K.: Surgery 24, 755, 1948. — c) Webster, J. E., Dawson, R., and Gurdjian, E. S.: J. Neurosurg. 8, 368, 1951. ~ d) Raney, R. B., and Haney, A. A.: Calif. Med. 73, 342, 1950. — 7. a) Govons, S. R., and Grant, F. C.: Arch. Neurol. and Psychiat. 55, 600, 1946. — b) Wechsler, I. S., and Gross, S. W.: J. A. M. A. 136, 517, 1948. — c) Lusignan, F. W., and Gross, G. 0.: Calif. Med. 73, 240, 1950. — d) Alorris, A. A., and Fulcher 0. H.: Surg. Clin. North Amer. 30, 1783, 1950. — 8. Grant, F. C.: Arch. Neurol. and Psychiat. 27, 1310, 1932. — 9. Berdal, P., and Emblem, L.: Acta Psych. and Neurol. 26, 1, 1951. — 10. a) Chusid, J. G., Robinson, F., and MargulesLavergne, M. P.: J. Neurosurg. 6, 466, 1949. b) Dunsmore, B., Scoville, W. B., —— -— —— �A Clinical Evaluation of Carotid Angiography 195 and Whitcomb, B.: J. Neurosurg. 8, 110, 1951. — 11. Olsson, 0.: J. Neural. Neurosurg. and Psychiat. 12, 312, 1949. — 12. Broman, T., and Olsson, 0.: Acta Radiol. 30, 326, 1948. — 13. Cross, S. W.: Arch. Neurol. and Psychiat. 46, 704, 1941. — 14. Sugar, 0., Holden, L. B., and Powell, C. B.: Amer. J. Roent. and Rad. Ther. 61, 166, 1949. �[ha / A M777, APP/f5; (#4)/7.rz. omen tummu W mm “KW W II: link, 3.». ma asap}: :1. Stein, IL». .7"*'*‘ , 9W .m § "v.1 "t; , ‘ waiver-1w canon of Indiana and the lam-01931.11 8min if the aura mun-u. hollow Rental, lav mark 633:. - .V T?!“ 1* ' = ' �line. antacid aaczozruphw tn mum of 1:1th an: bocgnn a ruuttun proaofiuro'xn cautions. In ovulation at 18.. no in nun-um. lath 15h. inflation and mm at cm proa«dun mt be amid-M in humans it for «lacunae aux-pom. 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Into taken. in: films A two thouod no ovidonoo or lorehrol tumor. can rock Into: a vantrtoulogrln dolonotrotod a large right con“ trontooto-porol IISI. Ibo protons. of a malignant slioln ill tin-0d by ournory. : Goo. IV; 3.3.é°:bzzkzoor old man developed loft stood toizuroo Iphlliu during/$rottlont for turunonlooil. on anurolucicll ennuinltion chore woo ovidonoo at n lotion in tho risho honiophoro. en Ikull x—ro: tho piuill outdo! In: shirtod to tho 102%. An ortorioaru on on right nu scum). mom-1a m and done ond no pathology dononotratod. ma A pnounoonoophnlosrln, houovor, revollod a dofornity of the right frontal horn. in: patient uzpirod on: lonth otter oust-graph: and ot pout. norm, mum} emu-u 0”qu mm anon-mm autumn. 9th.: erroneous onaiocrlphio d1oanoIOI our. and. in patient. who provod #0 have vooonlor throubosoo. In tlo potionto with Iisnl the oncxosru-o rovoolod on oraoaulnr are: in tho poricto-tonporol vision with dioplooonont o: Iiaolo oorohrll voooolo. Surgical exploration rovoolod odouotono necrotic brain tilooo, without ovidonoo of tolor. loch oooe oono to antopoy and in both or I brain only». man:- or . branch or. on. man «mm mm m rm. o:m angiogruno onulo not be dittoronttotod from thou. noon in on... tnnoro 1n the Inn: raglan. Vaoogggg.tnoup11oog fluonty~ono patient: Iuopootod or intro» ' ornniol vaooulor Inouolioo or Quintin-o not. oubjootod to lnslo~ stools. 1h» Insaosrunl wort billtdrtl in only throo or thooo. and ���7. mt N contact“. um“. m nu In this aorta of 117 WWMB 36 ”tum- “from a to“: at is «unusual. and peanut «mutation. In an mm can with the «mutation and at in Of the a»: mo «Quantum. 22 m «W mm m an mum. man: mm. mm MmmuMuHthmm-uw. ammo. in am. mutumnmwummmmm' manta: mun It as mm to tntubtn m yum: mmmmmmmmmumpmmm; mun mom mm: man a «um mummuwmu. mnmmnmmomm a nun“. :3 Wk mm. m within . an ou- pm mm #8 W. talcum-Wont... cummmuurmmwowhy. all no.“ to rcpt-aunt an mung mpm h m atom-Mt. Inmautmh umummmmmmmrua Hummutumnmauammmm W.a: m mm causation. loath um um Mr. in in ”man (mu 7. n). In tum ash-r W or 1“ mm. Inamcuul‘uumum otmmvmupmuat th:mn mm mm mm m s difficult W31“ (mo m). W: m spa-nu (em um m mmmuu-n a: Mum mm“ («m I!) m an. «W. mum: sum emanation we «may “um 80 an A m mm. panamamumnmmmmmmmmmuu a Wow. than. 11mm Mm m twink“ I mm mm. tau ”Omnimtm ma. all... 63. elm was... an muons am and Mt. A completed a 13W and as most“ to «3.1qu war» a: may mm mam was ���10. at 1a.; or np1nud¢c on. mth. aunne1ausntgt u1thout convulu1vo unvunnne: for «nan-11:11:,» and a pou1t1vt lub1nlk1 on than mm mm tbs 10:1.ths no I sensory «Itasca am», Winn lua1tcut weaknass a: ‘ 1 31331 percutancona In31u3zun was inns u1th 10011 tainthna1n nn1n3 {our 1njoot1ons of diodralt. >xllad1a$oly Ittcr tho last 1nJ¢¢t1an thy pat1ont lapsed 1319 a 102911 3:11., M1: cyuruovanantt 3101.0 d1llo¢18ttd, and tan loft layer and In!!! tatul1t1o§ I09. N mum nonpanfl anon. am the tmu Mum mm m Vtrhully to «allnnd. but tum han1pl¢31t booinpit10at 00114 tplnt1c. It porn1ltad ant11 tn. put1on1 its trunnruraod to ancillt anap1¥I1 can nanth 11102. tn31usrnll I110 tatcrprttod an annual. A pnaulalnoaphnlo~ 3run.rovualtd b1latcrnlxy 61.301 vuntr1c10u u1thout nh1tt er 1%. .d1lvort1an.1 walker (31) the at stator: that’s: Ions111v1ty tn the eonsrust Indtwn, amt a; m me many at 1111009103 (33), and mum tar «aupl1ant1onl In in. prusuat 19:10., till. {natori It. nut ant-taun1n3 1n tn. pat1enta uh. 107110301 «unpliont1aa- when tunic tr. 01.31301 10 tin hwptrtonn1un (38), havu bola a133Ot$ed as OIIIOI _ unoonpl1enta1’onacs. l1thsr eonsaapt1v11 at 1ntaadnrlal aiadrnst gonn1t1v1ty tent: turn cnrr1od out 13,0?!93 luhaoot. In out cute, in: cane: at «humus, means, an: myzuum mu- the m: am» an to ouncol tan I9I11II. 3111th mm 1B1: In 111 1mm: 1n51ud1n3 an. athgr turnouts, amuuum, m Im1t1uty to». m mun. Ill notably true 1n tbs {tar pat1outs who dtvu1opod “n11.331c~ rsaot1ons of urtiolr1t, oh111n,“ van1t1n3, tolleu1a3 tho In31osraphy. but who £11101 to rule: to tbs tent 4916. Shaw. 1: an apparent rolae1an 1n tho ant: bntanon «anp11out1ons 11km” �13.. (luntudias hunttuun If In. it. acct) and tin ms it 13:00t10an 1 2 3 mania: or 1n1¢otzunn t 5 6 Iflfl"th‘fl‘6 lo. .1 patiouta 11th cu-pzioctiaun'l e 6 6 I 1; lo. at pt... without «uncanny 3 9 1m :38 ' it Ebfiazfi ' o 16 '3 as *Ixnluata; 16 Inna-plsnusad «Isa: 13.1huu tutu: data.» uua ngt rocordnd. o: m t’utoru or nae-than and m' author I: carotid punstaraa at on. Ion-1:: (unilaturtl or bilaterll Iagiacrlph!) rtvttl as significant entrolltton botluon thtao riotorl. 3mm mm» t3. inolaunno at calvlaltxaau. Arm-1n max-«mun m in a eonmuuan in m. poxootxon or patzants tar Ingtosrlphy. ihn.hw)hrtoanzvoa (:11 with diastnlia prisaurio at zoa-n. It. or'nnvi. and urtialto ar0§turtu at more than lfiaun. In.) It». subjueted to nasitgrOphy, and in nan. at Shut. the. that. lay tonplioaticna. .0: thn paticnta with Icvorc up titan singly. and -- ‘tsnnszont oclplzsafiiaan («chit than hGIRQfllfl ot‘tho unak) aunt and V hrpdrfllnlzan. unseat mortal: hart alphlatlid tan diagnottta rtlzuhalat: it alrutid lasincruah: 1n vascular nan-alto: (k), auapoetod brutu talnru (lb. 5), tram-I310 aurchmt1~utdbn (6). tan ooaluntvu vascular axsaaaon (7). our ebucrvataons coatirn.thn rocounnadatzana at tho ham 1:. um run m m.in. _ diagnnst- a: van¢u1nr nan-n17 could nut he ountlmuld Cincpt iv insulin} Impaiurt at luttpuy. Itnte sir trudiyi are nut vuiiuilo 1n dlnanntrntins vautnlur annualaos a!”IEIIrIIIITMInfltflcrlrhr“tfimifilfipiifltiuri"ttwin%00w%nwiiitblllhins Iran? to ausiouruphw. �13. sign ailsnnsts. Xn-hafi at th@“p&t10nfis in this surint-An shun.nnth , n luntan was unspoctea, tho yam-p1: was natzutaggarilr“dauauntmatad um «am: or miagrap‘hy; man ‘mnu‘blishad w am» um“ lbnte£tta0lnbsp£bai, five anenrwnnn wore dn-waatritoa-an la anapoota. fitnilar ”caulk: are rooardea by tthar filth!!! {¥), can anagrams mmemuona have. hem nae ta inn-cue than Wis. Routine mtehml injectim, scanned with bilateral 6:th panama. will «laminate maladies 1n the posterior portion at the 611-010 at ‘flillin (1!). Oblique A.P views tt #5 403:... have been ruoanuoadnd to damonltratc until aneurysms er tn. aaratid (#d). with thtne noditicatiana 1n~the prooed&re, 1t 13 to—bq§gxpeoted that the incidence at positive 1d¢ntfliut1m at will the rule of angiogrnphy 1n the management or apontansaua am” mm. Iuharaahnoid hannrrhnes 13 not alear. Recent review: emphlstxo in. 1n»9rt&a¢e of alnnnltrtting tha Xenian nhmrs turaiaal intervaattun 1! indiettnd (fit. a.) !hc affect of Iaszonxlphw 03:13: twat. it. 53:10 a: blending his act beta a1nr::1¢d. lung nuthnra tutu roan-acalid :a;1¢lxnphy only :ttor tho blending has 09:306. 0th.». such an (m. mm «:1: m u mama-v man m nun mm. m. mun um... um um mu m tn in 5::o0t in mum: and adhorul at 4 or the cases thin 3095's, and no ntutqnnnt of tho Inciozraphw an binoding can be undo. Aagiogrnyh: in tho diagnoctio panoodnro o: «halt. visa a Quaratoatawiil human tumor :1 auspoetod. it 1: rcounnandnd tar Ionian: lecafiol in :3. Iatortcr tlu~thsrds a: tht_¢¢rolvun. ana$p1tt1 1th.. posterior toast and nuns unabrszu innnru a». uni conntttnntly Mutable by this Hath pip111@dama, team”. 11mm“! in lawn” WW ant unltki ztntc than venucdnro, lit ntuditc. anon ��1‘. In snot: or cnrcbgll vuucniqr;acutdant,Incifllllvi¥~tnrflfirl,1003 helpful. .rlilurv 0:,a rental to £111 any Do an: t. u.vurtety t: mamas 310m»:ntm1umut1m. .mmm min. in! ”mm at m sum. mm mum mm boon ”but!“ (75). 1;- aot ,imwmwludzu Mimi!» mum man. It proud” \- mam. mu 1i: arm-gamut” o. twain tron m tntrusarnhmtl 010%, or f!!! a tunes, in OIIOI Ihnre tho I1tsnonll-as mucus W. unelcwr. ' flhile the indications tar angiography are many, that cannot be evaluated uithuut ; aincuauian at thy risk: involved. ‘iha emm911a1~ ,tiuau or the praceanre are a: turccthpoat.(n) trunnient latul phcnunanlg (b) trannient cerebral vascular phenlnnnlg (o) pcmlanant 2mm «£1411». , xn the vburaias Dfllnl 1n the :1“:ng at trmniont mama m m It‘d during 1nJooeton, hauttuul in.tho noak, and ullorzie venetiann.. numatann.1n the acek in a potentially dangcraus samplicntien (see aur.Caso VII) but in a ragent review no Inqucllas varc,aha§rve¢=(9). »Allor¢10 notation: «we larreqaant and usually llld. .1: in: nat¢¢ in thin action that fins manila. intvaautlanouu or csngunntivua talking tar sensitivity It: not fauna untitraotorw $n prudiottus finale-clnpliotticnl. lblnninat,hun1paanszs. aphlltl. :eiunros nna citritod blaod pruuunre haw: hath reported fallouina unstogrtphv (16). In that series than. qunmlieationn n!!! OttarVQdfin nine canal »~ an incidenae of 35. {A similar tantdanao uni-nhucrvud In tho lbntcrluao Ibnpaell 30:103. lint.th030 Philll'n!.!rfi pribttly in: to tunporary vaaaulnr innutriuionflr (I’lfllfl) 1: I71lnnn¢d by the cliniunl pattorn at nourolngzctl findings and thair‘dnrutzun.. at asv¢u 3:310:90 with �it. M101” 15. m an tin-00 unwanted 01ml: than. 0m:- it no so” in an laws. In m panama, mu m of the amsun autograph: m "mm in a. 0M um 01: an um, 01MB «manna. In tho 0mm: mum, Woo-0m banana-«10, and tm mammmuumamummuamnmm left me the 0min 1mm that m m»: later, in» first 0m may m 0100. an mm m mind”that run an tho 0100 and mum M01090! 0 right M4- 13:00:10! 0: 01941-0“. tho MWMmth-Wflm. Vacant OW M 0mm mm.» 9103“. of that mun-101- hue been observed. 02:0: m 13300151”: in: do» within 15 010010 plant 0 1000: am manna 007010904 0:? “can”. third Quintin 0: m "I! 0140 In an. A mm 0: tin 09m“ 3: m «rent. an. m mumnmnwsmnmgumma. within Wu. omnuum m0 not unwind: 61mm m. 19 in ”#103150 01th W103. 6menoun-1mm.» a: 0 ”um '0 condition or men nun-1a; wemyhymummmmammumm. mud) , them-.1319“: ormpmuamxm. mam Mm :um «mare; “may to «unanimity. um many. and mu.» (1») mart «no 1080110100 mm.and80011110 0: “data-imam u: clown (11) than 1n mu mm. anus, 1." ”that“ ”mum” in a «£100 a! 36° won-000. no" mo in «hung: in an:- pmmt 005-100. an: m patient and 0 «m. nunvation 0f than at 0. pvt-mung Mum. 111 b01020 W10. 80071110 and tin pmodm‘e. in contrast 00 this In! 0! than 90810330, 111:. mum at 910003. 1:090 0010:“: m the 10:30 has.“ of M1: (53); , �(5e), Won (14), m um he), muten w deaths flare related ta precadure.‘ (1b) thawein no 16. and mm It 13 tum passablc adrlannd that with vidnupread use a: angzoeraphr, Iubfieatu titl.naro cerebrul lesions tru selccted far these stud1eu and tha rink: fiharlhv 1n¢rcanod. A what 9: mm: by 01:36:: am manta: (BB. 11, 12) alphantxs tho-launntxon at tho taxis atteatn o: 31:30 limit a: diodmalt given ovar a abort 99:10! a: fians. '1hor tailgatic in. nature at the toxicity Is an inoréégea permanbility at tho blood 1.33:1! and u chanxe 1n hennaynlaieh. Furthlxflflliy aha rolatian between canoentrt~ ma taunt; m, mean-am I» am: (13) when no am or introauegd dladraxt far Instagruphy. a1: abtathtiun that seizures £0116! thc use at 595 and 70% éiearaut has been ovatimnné by unmitiul amt invautizatarb. auspite thc use at 351 diodrast and law total Gasman: er diodraat, in this series, eumplications ensued. share I81 no nisni~ tioaat rnlntiaa between.dosasc 1nd canaliettionn. ethar raetars ' not he ”mum and same elrculntian tint (#t) and mung ma «team: V ' H 31.3 ‘71... i mummy mt. has been given in the “amnion an tau affect of other 1nJurious flaunts (a). eri 8h. moment a: em: or man. cranial aiaenaa :uupoeted or raueular animalios. an;znt¢atar1t1 talcum. and traumatic hu-Itunns. IS 1: n natintcetory non*lurzie¢1 ntthad at dtnunutrntina I Visuallr annuals; nnltoznation or ‘nourrnn. 1. 1:: in: dilsnoail of Iupratuntorill.llnlts it will takiinc 9Q! tttinruntarlly. In,udfl1t1¢u to catnblzlhinz thn pzoqanao at a kunnr. :rtorauarapny 1! unparacr ta 0th.: asnannstto tookaios 1n yialazna calling. I: to it. typo ot’lnul lad 1t. local. In Cl!!! with In �17. a not and. Wkly “at”: by tn mm ohacuro 13 mined-II». It alt a Inttlthstaww'litind'13.!UIlaatulflmaa or flu. and mm. mum of tho nah-unlu- min, or mimic: fun w ”0199.15”. I»... 1. a in «us of tantrum mam, m Mm» «turns»: arm "flunk: mm proucdnri. m: mm mm. a intricarutrll hilatlll tiastlt-Ilah MW m emu mum «now am» mu. at taunt. 10.113» tram 1: 1. eon-punts” mg. “I? tho mt pm, Wink. and would not in no“ mu. he savanna.» m no. tn was flu not "mm u human-1m math-nu, min or tutor: uncanny d: tunings. a sum: of «mu. r010, and "My 1. mum. pm a mu W mm m W «mud Woman part-mt Mm m rm an: m mm "an“ mm: mm”no: a: A 117 hum. mam o: ta risk: of Ingiography. no author. «mum: that the 1mm talifittionl and mt: ot at the mum” do «mu m autumn: an the meant or mean: alumna”, mum mmtarial brain Wm ms! was not 13th 1.1;- 10am. ' u ,____ __ _#».47.L_...;M._.z _,_..._.,___L__, .__u “A, . �RUIIARY eeriee a: 117 pereuteneoue oerotid ensiosreee were revieeed to eveiuete the indidetione for end rieke involved in engiosrephy. Petieute with e veriety or intredreniei conditione were etudied including eupretentoriel tenure, veeeuier endeoliee. A treaeetio heeetaee end eerebroveeduler dieeeee. titty-rive petiente with evidence at intreoreniel tenure were eueJeeted to engiogrephy, end e poeitive diesnoeie eee eede in thirty. fheee diesnoeee were auntie-ed in 83$ or the eeeee. ’ In duly tee eabjedte were the tiiee eieinterpreted. or the aegetive tilee. the diegnoeee were dentineed in 50!; in only tee men an the ensiosreee teii to aim e leeion um- deeenetrehie b7 eir etudiee. or 21 petiente eith euepeeted intreereniel veeduler endedliee, nine were outlined by ensiosrephy. In tee of theee, the engiosreee reveeled en end-e11 not eeniteet on eir etudiee. In e group at eeveuteen petiente euepeeted o: treneetie intreoreniei heeeteee, e poeitive diesnoeie wee eede in seven eeeee. Theee diesnoeee ee well ee the necetive findinse in eight ceeee, end intreeerehrei theere deeonetreted in ten ceeee, eere e11 contimeed by euheeeuent etudiee. In oeeee at cerebroveeduier leeione ensiogrephy wee not at diecnoetio veiue. Treneient ddeplieetione of engiogrephy were eeen in one—third of the petieute, end edueieted or heeetaee or the neck, heeipereeie. eeieuree, end erticerie. In five petiente (I!) eoepiicetiene eere eevere end peeeenent. Sheee oeeee ere deeerihed end the restore diecueeed. Ehe ‘Vl eethere deecrihe the ueetulneee or engiosrephy in �“Hermann“ been»: intact-mill condition: . they canal“. that tho united risk: of cerebral miomphy 69 not data“ from it: ”0mm”. in the summon: a: mammal vacant alternations. unopened «panama-1.1 man and human hum. the variety or ��mm rams. LG. and mummy, L: mum...» my... warms,anion-mph: ma cox-chm than”. mu.lgu_gnl.mz¢hiat. omml Q}, 359“"368: ‘9’11: 39”intmmiu (1) new. I. : mummy in polt~trmtio 2w¢2583 “tam; 19‘9. 910‘ ES. 4““ WWI. m at in the (1») lumbar, 19W. intmmid 3.: 9mm}. maximum? 755468, W001: (o) 5. 6. WI! New ' . _ mm. 3!; 3.8.: m dammit er mum. B. m 3.!" mm, by intact-unis! tutu-mic humane axiom”. J. Imam- . (6) Q5, 363~376o N17. 1951- LB. and um. ‘.l.8 Eh. contribution at «roam 1950. mm. angina-mm in “tannin. «mam. : m $2-3m, catcher, of (3) mm. 3.3. and mm. 1.6.: Wriemphic visualisation 600-618, 251. lesions. mh.!m1.ggzehiu. ammuni19‘6“3.; (b) mm. 1.3. and mm, mm carom}. Marion-why in191.8. nub-mountain Mum. g.i.l.i.. 1.36: 517-581, M... (a) mzm. 1.1:. am mm. 6.6.: mum-min autograph: in the tmmnt at «1'0an maul” accident: . can: .M. , m (4) 7. ,_ V (a) LA. and mm, 9.3.: carotid minmtw; It: ".1130 sum. in pun-.11 t 121th conditim. M£11mgorth “or. , 8. m, the mmmolwruzohint. 31; : thrionlmaphy m mmmmw. mu- um. be. 1.31m: . localization had tram: or 111%”:er 1310-13“. June, 1932. m, P. and Pmuunum «mud miouaphy: m, "farm” ine“ iota blob. laurel” I»: complications in th- and pun-ms. ‘10 . 11. b with special 11: been to the larynx. 16;; 1-6, Juan-r1. 1951. 1. sad mum-amen, 1.2.: umimt 3.6., trauma,with. cyan. union-why. Lima“. unbnl 32-191. in unpainted 19‘9466 “ll, number. g; of (b) mm, 3.. 36mm. VJ. and unseen, 3.: cmuaum 1951. 110418, angina-why. g4, mum. , g; ham, India a: tar emtmt 0. cerebral unplug £01m» won, 312-316, lov.,19't9. a: dim» type. 1 .lmu Joni-elm. "paint. E; (u) a » to a aid 01,8861. 0.: 103.3ch of «mm: bland vouch 336~3#8, Indian or the “adult group. mm We}... 32; lava-tho, 1m. pines in aux-01min]. 13. @038, am. u 8mm}. ”tomography: It: 704-711., Oct... 12 . 1*. mm, contra-t ‘1'. ‘ «lanolin. Arch.lm¢1.flgguat.. 53!. 6.. mm , run. and 3.3.: Vertebral 'W tokflflnt. ‘ rm. 166.5182, "bm’lg‘g. ‘ u‘doMc; £12. 19“. Wm. 83131 o � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A clinical evaluation of carotid angiography. Confin Neurol. 1952; 12(4): 181-95. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-5-007 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Stein, Joseph M. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and publication. Confinia Neurologica. From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellvue Hospital, New York City. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Basel; New York: Confinia Neurologica Contributor An entity responsible for making contributions to the resource Spiegel, E. A. Published http://exhibits.library.stonybrook.edu/mfp/files/original/159923c8867e9781f49e8300e7f3e2d3.pdf 560d0723c8cbc5298ad5e04e592ff291 PDF Text Text 0 Reprinted from the A. M. A. Archives of Neurology and Psychiatry October 1952, Vol. 68, pp. 481-490 Copyright, 1952, by American Medical Association EXOSOMESTHESIA OR DISPLACEMENT OF CUTANEOUS SENSATION INTO EXTRAPERSONAL SPACE MORTIMER F. SHAPIRO, M.D. MAX FINK, MD. AND MORRIS B. BENDER, M.D. NEW YORK MONG phenomena that may be apparent during examination of patients with disease of the sensory pathways is mislocalization of a sensory stimulus. It has long been known that a person with a sensory defect, as seen in the common varieties of cerebral hemiplegia, may inaccurately localize stimuli applied on the paretic side. Such point mislocalizations are apparent in examinations using a single stimulus and have been described in detail by Head} These mislocalizations can be accentu— ated by the use of double simultaneous stimulation techniques.2 In addition, when these techniques of examination are employed, other varieties of mislocalization, such as displacement,3 become apparent. Displacement is the patterned mislocali— zation of one of two stimuli simultaneously applied to different body areas. The direction of displacement is in a definite pattern, which is dependent upon the parts of the body stimulated. Characteristic of mislocalization so far reported has been the fact that their extent was within the limits of the patient’s body. In the course of studies of cutaneous perception, we observed a new form of displacement in which the patient consistently and in a predictable fashion mislocalized stimuli into extrapersonal space. This type of displacement we have termed “exosomesthesia.” 4 Exosomesthesia is not a commonly observed phenomenon. More than 400 patients with brain disease were examined at Psychiatric Pavilion of Bellevue Aided by a Fellowship from the National Foundation for Infantile Paralysis (Dr. Fink). This investigation was supported in part by research grant #MH-139 from the United States Public Health Service, National Institutes of Health. From the Department of Neurology and Psychiatry, New York University College of Medicine, and the Neurological Service of the Mount Sinai Hospital and Bellevue Hospital Center. 1. Head, H.: Studies in Neurology, London, Oxford University Press, 1920, Vol. 2. 2. Bender, M. B.; Shapiro, M. F., and Schappell, A. W.: Extinction Phenomenon in Hemiplegia, Arch. Neurol. & Psychiat. 62:717-724 (Dec) 1949. Bender, M. B.; The Advantages of the Method of Simultaneous Stimulation in the Neurological Examination, M. Clin. North America 32:755-758 (May) 1948. 3. Bender, M. B.; The Phenomenon of Sensory Displacement, A. M. A. Arch. Neurol. & Psychiat. 65:607-621 (May) 1951. 4. The term was derived by Dr. Judah A. Joffe (Hinsie, L. E., and Shatzky, J.: Psychiatric Dictionary, New York, Oxford University Press, 1940) from the Greek 55w, out of; will“, body, and 41709710”, perception by the senses. �2 7 Hospital Center by routine and specialized sensory tests. Exosomesthesia was observed in only 15 cases, an incidence of about 3%.5 The following case reports illustrate the phenomenon and demonstrate some of the conditions under which it was observed. CASE REPORTS CASE 1.—H. M., a man aged 64, was admitted to the Psychiatric Pavilion of Bellevue Hospital with a history of progressive mental changes of six years’ duration. The first four years of illness were marked by slowly progressive impairment of memory, concentration, and other intellectual functions and by increasing apathy to his' environment. In the last two years there was rapid exacerbation of this condition, resulting in the loss of his job as a store manager. During this period his speech became increasingly garbled and stammering. He vacillated between irritability and complete apathy. He was occasionally incontinent, ceased bathing, had difficulty in dressing, and was sometimes so forgetful and confused as to wander into the street without his trousers. Routine Neurologic Examination—In walking, the trunk was tilted to the right, and there was a tendency to drag the right lower extremity. However, there was no significant motor weakness, reflex change, or tonus abnormality. Coordination tests were well performed. The cranial nerve functions were intact. Vibration sense was correctly perceived only in the clavicles and the head, while position sense was lost in the fingers, wrists, toes, and ankles bilaterally. Temperature differences were poorly perceived except in the face area. His responses to touch and pinprick stimulation will be described later. A mild degree of “mixed aphasia” was present. This speech difficulty was evident only by special testing or when the patient was fatigued by prolonged examination. There was a fluctuating dyspraxia of moderate severity. Occasionally he had difficulty in dressing, being unable to handle buttons and sleeves. However, he could perform such functions as feeding himself, combing his hair, and other routine daily tasks. He was usually unable to mimic the more complicated patterns of the hand-praxis tests. An electroencephalogram showed bilateral diffuse abnormality, with decrease in amplitude and intermittent suppression of activity over the parietal regions. A pneumoencephalogram disclosed bilaterally dilated ventricles and moderate “cortical atrophy,” particularly in the left temporal lobe. Psychiatric Status—Although the patient was oriented for place and situation, he made errors as to date and time of day. There were defects in recent memory, concentration, calculation, and ability to assume the abstract attitude. He usually sat placidly staring into space or wandered aimlessly about the ward. He did not mix with other patients. When approached by members of the staff, he was friendly and passively cooperative. Testing procedures were approached with cheerful indifference. When, however, he was pushed into test situations greater than his capacity, he reacted with increasing irritability and tension, eventually culminating in a “catastrophic reaction.” At such times he would become red in the face, shout that he knew the answers but did not want to continue, and suddenly begin to weep. Body Schema—He was able to distinguish the right side of his body from the left, but was unable to make this distinction on the examiner’s body. He had no difficulty either in locating midline structures of his body, such as the nose, mouth, chin, umbilicus, and penis, or in pointing to his eyes. With eyes open he readily found both ears; but when his eyes were closed he groped about his face for several seconds before locating them. He could point to his thighs, knees, ankles, and toes but could not point to any specific toe other than the big toe. He frequently had difliculty in locating portions of his upper extremities. If asked to point to his shoulders, he correctly located one shoulder but then groped behind his neck looking for the other. This defect was even more noticeable in trying to find the “other” elbow and wrist, and greatest in trying to find the “other” hand. His search for the “other” hand or wrist was bizarre. He would look under the pillow or rummage under the mattress, becoming tense and Fink, M.; Green, M., and Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology 2:46-58 (Jan-Feb.) 1952. 5. �3 insisting it was lost. It should be emphasized that, despite the great difficulty in locating parts of his body, the patient was able to name the body parts, except the fingers and toes. This was true whether the part pointed to was on the patient’s or on the examiner’s body. Sensory Status—(w) Single Stimulation: He had difficulty in differentiating between the sharp and the dull end of a pin. This defect was present throughout the body, although he made significantly fewer errors in the face and hands. Touch stimulation was poorly perceived. Usually he could not state whether or not he had been t0uched. Again, there seemed to be relatively better preservation of this modality in the hands and face. Except under special conditions of examination of the hands, to be described later, the patient was able to locate the site of a pinprick by pointing. However, if the pin was repetitively and rapidly applied to one region, or if the prick was steadily maintained at that one place, he could not locate the point of stimulation. He would make frantic, random searching movements over his body, and not infrequently around the bedclothes, grimacing as though in pain and exclaiming that he was trying to remove the pin. If asked where he was being pricked, he dis— regarded the question and continued to try to remove the stimulus. This phenomenon occurred on stimulation of any portion of the body but was most apparent when the hand was tested. (b) Double Simultaneous Stimulation: The phenomena of extinction and displacement were frequently observed in tests of different body areas by simultaneous tactile stimulation. On stimulation of the face and hand, stimuli to the hand were not perceived or were mislocalized to the cheek. In tests of homologous body areas (as hand-hand) extinction of one percept was common. The side on which the stimulus was not perceived fluctuated, so that at one moment only a. right—sided stimulus was perceived and a few moments later only a left-sided stimulus was perceived. Exosomesthesia—Whenever his palm was in contact with a portion of his body or any other object, and the dorsum of that hand was pricked with a pin, the patient consistently mislocalized the stimulus. This mislocalization was to whatever object the palmar surface of the hand was touching. For example, if the patient’s hand was resting on his thigh and the dorsum of the hand was pricked, he insisted that the thigh had been touched, and not the hand. This mislocalization —exosomesthesia—occurred to the thigh, abdomen, leg, or face and was present with stimuli to either hand. It was observed even when the patient was urged to look at the hand during the application of the pin. Exosomesthesia could not be elicited, however, by stimulation of the palm or palmar surface of the fingers when the dorsum of the hand was resting on a portion of the body. Furthermore, localization of stimuli to the dorsum of the hand was correct if the hand was held in space. Mislocalization also occurred to objects external to his body. If his palm was resting on a table or on his bed, and the dorsum of the hand was pricked with a pin, he would point to these objects and state that the pin had been applied “there.” When questioned, he stated that the hand had been touched but continued to point to the bed or table. Frequently, however, he insisted that it was the bed or table that had been touched, and not his hand. If asked how he could feel the bed being pricked with a pin, he would become tense, avoid the question, and insist, “You touched the bed, not me.” Displacement into extrapersonal space was not eliminated by simultaneous stimulation, even when extinction of one of the percepts occurred. For example, if pins were simultaneously applied to the dorsa of the hands while the palms were resting on a table, he would report feeling only one pinprick, that on the left (or right, as dominance fluctuated) and point to the place where the left hand had been resting, saying. “You touched the bed there.” This phenomenon of displacement into extrapersonal space occurred daily during a period of more than two months. C 0mment.——~In this patient a requisite to displacement into space was that the palm of the hand be in contact with an external object. In other words, there were two cutaneous stimuli simultaneously in operation, namely, the pinprick on the dorsum of the hand and the pressure of the object in contact with the palm or fingers. A single stimulus, such as pricking the dorsum of a hand held in space, did not elicit the displacement. �4 Exosomesthesia was elicited only on stimulating the hands. This occurred even though single pinprick was perceived more sharply in the hands than in any other area except the face. Although this patient showed inability to locate correctly parts of his own and the examiner’s body, it does not necessarily mean that exosomesthesia is determined by this particular type of disorder in body scheme. The following case illustrates the phenomenon of exosomesthesia in the presence of the patient’s ability to locate body parts. 2.—E. K., a woman aged 52, was admitted to the neurologic service of the Mount Sinai Hospital in August, 1950, with a history of grand mal seizures. She had been in good health until 1947, when there appeared sporadic, momentary sensations of “blacking out.” About two years before admission she began to suffer monthly grand mal seizures. There was no aura. Routine examination on admission showed that her status was within normal limits except for anosmia in the right nostril. There was no organic mental syndrome. X-ray studies revealed evidence of a subfrontal neoplasm. On August 12 a craniotomy was done, and after amputation of a portion of the right frontal lobe, a large bilateral subfrontal meningioma was excised. Her postoperative course was stormy. For two weeks she was semistuporous. She responded only to massive, painful stimulation, and these responses were limited to vague, ineffective attempts to push away the stimulus. In this period she lapsed several times into coma and showed Cheyne-Stokes respiration. The Babinski response was obtained bilaterally. Her pupils did not react to light. From about Aug. 23, 1950, the patient improved slowly and steadily. She began to respond verbally, and contact could be maintained for short periods. Vision, which had apparently been absent, began to return, although right homonymous hemianopsia remained for some time. A marked organic mental syndrome characterized by confusion, disorientation, and anosognosia, was present. Routine Neurologic Examination.——Neurologic examination in September, 1950, disclosed right homonymous hemianopsia, severe impairment of visual acuity with bilateral secondary optic nerve atrophy, nystagmus in all directions of gaze, a bilateral Babinski sign, and a mild degree of aphasia. Position sense, vibration sense, and temperature perception were unimpaired. There were difficulties in perception of touch and pinprick stimuli, as described below. Psychiatric S'tattusr—The patient was usually friendly and cooperative. However, she was frequently irritable and would not permit examination. She was disoriented as to time and occasionally to situation, but not to place. There were defects in retention and recall, covered by confabulation. She was euphoric and displayed little self-restraint or concern in social situations. Usually she would lie with her body fully exposed. Not infrequently she soiled herself or wet the bed. Anosovgnosia was prominent. Body Schema—On command, the patient was able to identify and locate correctly parts of her own and the examiner’s body, such as the ears, eyes, feet, and parts of the upper extremities. She exhibited some confusion about the right and the left side of the body. Sensory Status.—(a) Single Stimulation: The patient perceived single pinprick stimuli well, although she made occasional nonpatterned errors in localization. These errors were more frequent on the left side. (b) Double Simultaneous Stimulation: On simultaneous application of pinprick to the two sides of the body, except the hands, extinction on the left or displacement on the left toward the level of the right—sided stimulus was the usual response. Homolateral simultaneous stimulation on the right side of the body showed no extinction, but stimulation on the left side elicited frequent extinction and displacement. CASE Exosomesthesia.—Displacement into extrapersonal space occurred when the left hand was pricked at the same time that either the right hand or the right cheek was stimulated. The phenomenon could also be elicited when the left hand and any other area of the left side of the body were simultaneously stimulated. Under these conditions the patient mislocalized the stimulus to the left hand into space near that hand, or to the object on which the hand was lying. For example, if pinpricks were �5 . simultaneously applied to the right cheek and the left hand, the patient indicated she had been pricked on the right cheek and the arm of the chair on which her left hand had been resting. As a rule she answered by pointing. If asked to verbalize, she would say, “The right cheek and about here,” (pointing to the chair arm or into space near her left hand). If asked directly. “Was your hand touched?” she would avoid the question, responding only, “Here,” pointing at the same time to the left chair arm or into space. It is to be noted that, except under the special condition of simultaneous stimulation, the patient was always able to point to or to name her left hand on demand. If pricked simultaneously on the dorsa of the left and right hands, she correctly localized only the stimulus on the right, both by pointing and by stating, “My right hand.” The stimulus on the left, however, was localized only by pointing to the chair arm and saying, “Here.” If asked whether the chair arm and not her left hand, had been touched, she answered, “No, here,” pointing to the chair arm. When pinpricks were applied to the left hand and, at the same time, to another area on the left side of the body, a similar displacement into space was evident. Usually the stimulus to the left hand was mislocalized onto whatever structure the hand was resting or else 'into contiguous space. The other stimulus on the left side was usually correctly localized, though this stimulus, too, was occasionally displaced into space. When this double displacement occurred, the patient would state that she felt two stimuli and would point into space to the left of the arm, stating, “Here and here.” These mislocalizations were repeatedly observed during a period of a month and were not always limited to the left side. They were occasionally observed to occur on the right side. At these times localization on the left was always correct, as indicated by pointing and by verbalization. C omment.—Exosomesthesia was elicited in this patient only under the condition of multiple simultaneous stimulation. It could not be elicited by single—stimulation methods. Also significant is the fact that exosomesthesia was apparent even though there was no gross disorder in body scheme on routine testing. Furthermore, it is evident that her errors in localization were not simply inability to point to or identify parts of her body by name, as ordinarily she experienced no difficulty in doing this. on command. Both patients mislocalized percepts to parts of the body, to objects, or into space contiguous with the area stimulated. Occasionally, we have also observed displacement of a stimulus to the person of the examiner. Usually such percepts are mislocalized to a homologous portion of the examiner’s body; e. g., a stimulus applied to the patient’s hand is reported by him as though it had been applied to the examiner’s hand. Rarely, the mislocalization is to any part of the examiner’s body. This type of displacement is illustrated in the following case. man aged 52, was admitted to the Psychiatric Pavilion of Bellevue Hospital with the complaint that he had become confused and depressed. For about a year he had been disoriented and confused as to date and his relationship to people and had wandered about the city aimlessly. He had been admitted to the Farm Colony about a half-year before and had worked as a barber until the week before his admission to the hospital. Routine N emologic Examimtion.—Neurologic examination showed normal gait and station. Coordination tests were well performed. The reflexes were active bilaterally, with normal plantar and abdominal responses. Cranial nerve functions were normal. The sensory status showed changes, but only with special methods of testing. A pneumoencephalogram demonstrated moderately dilated ventricles, without shift or deformity, and some dilated cerebral sulci. Psychiatric Status—A severe organic mental syndrome was evident. In the ward he sat quietly for hours by his bedside, taking little interest in his surroundings. When approached by members of the staff, he appeared perplexed but was affable. During the testing procedures he was cooperative unless confronted by a test situation in which the examiner demanded tasks CASE 3.—-R. M., a ‘ �6 ‘ beyond his ability. At such times he showed a “catastrophic” reaction, became excited, and discontinued his efforts in the examination. He was disoriented for time, place, and situation. However, he was able to find his way about the ward, locating his bed, the nurses’ desk, the doctor’s office, and the lavatory. Severe difliculties in intellectual function were observed. He was unable to give an adequate history. He could not recall the examiner’s name or the events of several hours before but did not confabulate. Calculation and symbol—identification tests were poorly performed. Severe aphasic difficulties Were evident. He was unable to name common objects, clothing, or most parts of the body. He could not comprehend written commands, nor could he write, but he was able to follow simple verbal commands. Mild dyspraxia was demonstrated in his attempts to imitate finger and mouth movements. However, he was able to dress, feed, and otherwise care for himself. Body Image.—He had difficulty both in naming body parts and in locating them by pointing. The defects were severest in the fingers, wrists, and elbows, and occasionally the feet. There was difficulty in right-left orientation. Sensory Status—(a) Single Stimulation: Routine sensory studies of touch, pinprick, and vibration stimuli showed no consistent impairment. These stimuli were usually correctly localized and described. Occasionally a single stimulus to the hand or forearm was displaced to a contiguous object or to space about the upper extremity. (b) Double Simultaneous Stimulation: On double simultaneous [touch] stimulation the patient displayed extinction and displacement of tactile stimuli. This was most evident in trials of the face—hand test 6 but was seen in tests of other body parts as well. For example, on simultaneous stimulation of the cheek and the opposite hand, he would either report only the stimulus to the cheek (extinction of the hand stimulus) or report a stimulus to each cheek (displacement of the hand stimulus). The pattern of sensory dominance was that usually seen in diffuse cerebral disease, the face being most dominant, the hand least.5 There was no lateral dominance. Exosolm-esthesriav.—Displacement into extrapersonal space was occasionally observed on single stimulation. This displacement was from the hand, forearm, or elbow to space contiguous to the part touched. Exosomesthesia was, however, markedly exaggerated when double simul— taneous stimulation was employed. Again, the areas from which the phenomenon was most frequently observed were the hands, forearms, and elbows. For example, when stimuli were applied to the dorsa of the hands as they were lying on the patient’s lap, he pointed to space in front of his knees. If asked to state where he had been touched, he would say, “The hands,” but would continue to point to the space in front of his knees. Exosomesthesia was rarely noted when other body parts, such as the cheeks or shoulders, were simultaneously stimulated. Occasionally it was found that on tests with double simultaneous stimulation the patient mislocalized a stimulus from his body to the homologous region of the examiner’s body. For instance, when the hands were simultaneously touched, he would grasp the examiner’s hands and affirm he had been touched “there.” Despite the examiner’s insistence that the stimulus had been to the patient’s hands, the patient would persist in pointing to the examiner’s hands. When asked to name the parts touched, he would say “There, there.” The same phenomenon was occasionally observed on simultaneous stimulation of the two elbOWS or cheeks. It was significant that this mislocalization to the examiner’s body occurred even when the patient was urged to look at the stimulations. It was observed that emotional tension, increase in the rate of testing or undue prolongation of the examination increased the incidence of exosomesthesia. For example, to initial application of pinprick to the right hand and the left cheek, the patient reported only the face percept, omitting the hand stimulus. Later, he localized the two stimuli to the cheeks. As the examination progressed and the physician speeded up the testing, the patient became tenser. He then localized the face percept correctly but insisted that the hand stimulation was into space in front of the hand. Finally, both stimuli were displaced into space or to the examiner’s body. These phenomena were observed daily over a period of 2% months. . Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of Face and Hand, Tr. Am. Neurol. A. 75:250-252 (June) 1950; Patterns in Perception on Simultaneous Tests of Face and Hand, A. M. A. Arch. Neurol. & Psychiat. 66:35‘5-262 6. (Sept) 1951. �7 Comment—While single stimulation occasionally produced exosomesthesia in this patient, the phenomenon was more pronounced under conditions of double simultaneous stimulation. This patient also mislocalized stimuli to the examiner’s body. Emotional tension, prolonged examination, or increase in the rate of testing exaggerated the phenomenon of exosomesthesia. GENERAL COMMENT On consideration of these cases, it is immediately apparent that exosomesthesia is associated with a severe organic mental syndrome. Therefore, it might be argued that exosomesthesia is merely a manifestation of the patient’s mental confusion; that the patient simply points into space because he is confused. However, we have examined many severely confused patients and found exosomesthesia only rarely. Moreover, exosomesthesia is a patterned phenomenon, demonstrable in each patient under defined conditions, predictable as to the area from which it will occur and the extrapersonal spatial region to which the sensation will be projected. For example, in Case 1 exosomesthesia could be elicited only from the hand, and only when the dorsum was stimulated at the same time that the palm or fingers were in contact with another object. Displacement under these circumstances was usually not haphazard. As a rule it occurred to the object touching the palm or fingers. In Case 2 exosomesthesia could be elicited only by double simultaneous stimulation. It was seen most clearly in the hand and could be elicited only unilaterally at any one examination. Again, the displacement was not haphazard; the stimulus as a rule was localized to extrapersonal space contiguous to the area actually stimulated. In Case 3 the phenomenon was observed again under conditions of double simultaneous stimulation, and the displacements were either to space contiguous to the stimulated area or to homologous areas of the examiner’s body. It is significant that these displacements could be elicited even when the patient was urged to look at the application of the stimuli. Moreover, even when the examiner pointed out the error in localization and emphasized the implausibility of the response, the patient characteristically insisted on the correctness of the mislocalization. Factors Inflnencing Exosoimesthesiax—Many factors influence the appearance of exosomesthesia. Except in children under special conditions, it has been observed exclusively in patients with severe mental changes resulting from disease of the brain. It is influenced by the type of stimulus used and the rate of stimulation, as well as by the element of simultaneity of stimuli. Moreover, the emotional state of the patient has a significant effect on the phenomenon, as does the part of the body stimulated. In some cases exosomesthesia has been made apparent by administration of small doses of amobarbital sodium. These factors will be discussed. (a) Bilateral Cerebral Disease: The symptom background in every case of exosomesthesia is an organic mental syndrome secondary to bilateral cerebral disease. We have not been able to demonstrate exosomesthesia in an adult unless there were severe mental changes. But, as previously noted, it is a rare phenomenon, and only a few patients with severe organic mental syndrome show it. In 400 patients with organic cerebral disease, of varying severity, exosomesthesia was observed in approximately 3%.5 Even in these patients it was not manifest in every examination, and its frequency was readily altered by changes in the conditions of testing. It is therefore evident that severe bilateral cerebral disease in itself is not sufficient to produce exosomesthesia. �8 That simultaneous stimulation may elicit sensory phenomena not apparent on single stimulation has previously been demonstrated.2 For example, a hemisensory syndrome in a hemiplegic patient may not be discernible except under conditions of double simultaneous stimulation. Thus, single stimulation may be well perceived and localized by the patient, but the addition of a second stimulus simultaneously applied may so affect integration that the phenomena of extinction, obscuration, and displacement become apparent. Similarly, simultaneous stimulation elicited exosomesthesia when it was absent on single-stimulus examination, or exaggerated it when it was occasionally manifest on routine stimulation. In Cases 1 and 2 simultaneous stimulation was a necessary condition for eliciting the phenomenon. It could not be demonstrated by single stimulation. In Case 3 exosomesthesia could occasionally be elicited on single stimulation, but with simultaneous stimulation the phenomenon was demonstrated with much greater frequency. (c) Type of Stimulus Most Effective: Of the various stimuli used in these examinations, such as single touch, single pinprick, repetitive touch, and repetitive pinprick, it was noted that repetitive touch stimuli were most effective in eliciting exosomesthesia. This was especially true on double simultaneous stimulation. (d) Effect of the Patient’s Emotional State: Exosomesthesia was exaggerated by alterations in the test situation which made performances more difficult. Increasing the rate of stimulation or unduly prolonging the examination increased the displacements to extrapersonal space. If the examiner was deliberately critical of the patient’s errors, the phenomenon also appeared with greater frequency. These factors increased the emotional tension of the patient and if carried further produced a “catastrophic” reaction. (e) Effect of Drugs: It has previously been demonstrated that difficulties in perception may be exaggerated by barbiturate intoxicants.5 Amobarbital sodium was administered intravenously in doses of 3 to 7 grains (0.2 to 0.45 gm.) to patients with diffuse cerebral disease. Prior to administration of the drug, these patients manifested the phenomena of extinction and displacement of percepts on simultaneous tests, but not exosomesthesia. While under the influence of the barbiturate, three patients showed exosomesthesia, in addition to extinction and displacement. In two other patients, in whom exosomesthesia had been elicited only after a protracted testing period, the administration of amobarbital sodium elicited exosomesthesia at the onset of testing and exaggerated the phenomena of extinction (2)) Effect of Simultaneous Stimuli: and displacement. Relation of Exo'somest‘hesia to: Extinction, Obscumtioln, and Displacement—In our experience, whenever exosomesthesia has been observed, the phenomena of extinction, obscuration, and displacement are also present. Exosomesthesia, how— ever, is a rare phenomenon, whereas extinction, obscuration, and displacement are commonly observed. Moreover, whereas extinction, obscuration, and displacement are frequently seen in adult patients with mild cerebral dysfunction,5 displacement into extrapersonal space is present only in cases of severe mental changes due to disease of the brain. It may therefore be concluded that exosomesthesia in adults represents a severer type of cerebral dysfunction than other simultaneous stimulation phenomena. �9 Relation of Exosomes'th‘esia; to Body I mage.——It might be said that exosomesthesia is a pathologic extension of the body image. The normal person is continually extending the boundaries of this image. For example, Head cites the examples of the woman with a feather in her hat who “feels” when the feather is touched, and the surgeon who handles his probe as though it were an extension. of his fingers.1 In the normal person, however, these extensions of the body image are fluid, immediately reversible, and clearly recognized by the subject as artificial. The surgeon, for example, is able at any moment to redefine correctly his body image. He “knows” that the probe is not his finger. In the group of patients described above, however, the extension of the body image seems to operate in a pathologic, rigid form. Under certain conditions these patients lose the ability to maintain a realistic definition of the limits of their body. They behave as though portions of the contiguous external world are concretely incorporated into the inner image of their body’s extent. Although we may consider exosomestheisa as a specialized body-image disturbance, it should be noted that patients who do not show difficulties in identification and location of body parts still may show mislocalization into extrapersonal space. On the other hand, patients with an inability to identify or locate their body parts on command do not necessarily manifest exosomesthesia. In similar fashion, there is no necessary relationship between exosomesthesia and position-sense difficulties. A patient (Case 3) who manifested displacement of sensation into extrapersonal space did not make errors in routine tests of position sense in the extremities. This is consistent with observations previously made by Head1 that localization of single stimuli is not functionally related to sense of position of the extremities. Role of the Hand—Although displacement into extrapersonal space has been elicited from various areas of the body, it has been observed to occur most frequently from the hand. Moreover, in no case has it been elicited from another area and been absent from the hand. This predilection for the hand is consistent with the manner in which other dysfunctions of the nervous system are reflected. As a rule, when the functioning of one side of the body is impaired through cerebral disease, the disorder is most manifest in the hand. Thus, in the usual hemiplegia resulting from a capsular lesion the paresis, body-image disturbance, and sensory loss are most prominent in the hand and fingers. In these patients, and in others with diffuse cerebral disease, the phenomena of extinction, obscuration, and displacement are also best elicited when the hand is tested. Furthermore, studies of the order of sensory dominance of various areas of the body demonstrate that the hand is in the lowest rank. This is true of the dominance order of patients with cerebral disease,5 and also of normal subjects, both adults and children.6 Similarly, when allesthesia is observed, it is seen most clearly in the hand. Bender and Nathanson 7 described a case in which the clinical course was reflected in a Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, Arch. Neurol. & Psychiat. 64:501-515 7. (Oct) 1950. ‘ �10 waxing and waning allesthesia. As this patient improved, the areas from which the phenomenon could be elicited diminished, until finally allesthesia was demonstrable only in the hand. In autotopagnosia the hands are more profoundly affected than other regions. Finger agnosia, possibly the earliest sign of body-image disturbance, is frequently seen in the absence of other gross disturbances of the body schema. Furthermore, phantom limb, anosognosia, causalgia, and synesthesia are phenomena in which the role of the hand is especially prominent. Just as these pathologic phenomena are manifest in tests of other body parts, but are most clearly demonstrable in the hand, so, too, exosomesthesia, though occasionally demonstrable elsewhere, is most apparent in examination of the functions of the hand. Exosomesthesia in the N ormal C hild.—It has been observed that sensory phenomena which occur in patients with cerebral dysfunction may be found in the nor— mal young child.6 Similarly, exosomesthesia, which we have never found in adults except when there is severe cerebral disease, can be readily observed in children up to the age of 4 years. In examination of a large series of normal children it was noted that the initial responses of children to double simultaneous stimulation fre— quently included exosomesthesia, although the commoner responses were extinction and displacement. Exosomesthesia was rare, however, after the initial few trials. The frequency with which exosomesthesia may be seen in children up to the age of 4 years suggests that it may represent, in the child, a “normal” developmental stage in the organization of perception. Its appearance in adults with severe brain disease may possibly be, as with other pathologic phenomena, a regression in function to a previous level of sensory integration. SUMMARY , The patterned mislocalization of tactile stimuli into extrapersonal space is described and termed exosomesthesia. Exosomesthesia is observed in patients with severe organic mental syndromes. It is apparent only rarely on single tactile stimulation and is more readily elicited by the technique of double simultaneous stimulation. It is exaggerated by fatigue, rapid testing, and increased emotional tension. Barbiturate intoxication also may elicit or exaggerate the phenomenon. Exosomesthesia is most apparent in stimulation of the hand but has been observed in tests of other body parts. While it may be considered a pathologic extension of the body image, it is not dependent upon concomitant body-image disturbances. Although exosomesthesia has been observed chiefly in patients with severe mental changes, it is not a manifestation of confusion, but is a patterned, predictable phenomenon. It may be a regression, in patients with cerebral dysfunction, to a previously “normal” stage in sensory development, as suggested by the fact that it is readily observed in simultaneous tactile tests of young children. Printed and Published in the United States of America �EXOBOMIBTHIBIA OR DIEPLkGIIIIT 0P OBTlfllflfls 83N3£TIOIIINQO EantuflRSOIAL BPACE‘ EV Martino:- F. Shapiro. am. an: Fink, K.D.'* and Kerri: B. Bender, H.D. ., " "i 3”“ a"? ,y. Univcruity College or’ncdieiuc and tn. 3 enrol 651331 Service of thc Haunt flinfii ficlpital Ind lollcvuo fibflpitfll, I0! Yer! 0131. 'Dntdod by a flullaulhip tram thy lationnl roundntion for Infantile QJ‘ V‘W‘ , g j , ‘9ar111510. ibis investigltion in. lupportod, in partin:by a rouonroh grant stutt- Public not ammo. mum or fianlth. aun-139 tram tho unit.d Inltitutel fl �Among phenomena bbeb new be epperenb during exe-inebion or petienbe eith dieeeee or the eeneory pebbueye is nielooelisebion It individual with e eeneory defeat, on eeen in the cannon vuriebiee or cerebrel beniplegie, any looeiioe ineoonrebely ebiuuli applied on the of e eeneory etienioo. bee long been known that on ‘ perebio bide. point nielooelieebiono ere epperenb in exelinetionl ueing e eingie ebiunlue, end have been deeoribedbin detail by Hood (1). These nationalisation: can be eooentuobed/b‘e uee or double Snob einnlbeneoue obi-ulebion techniques (2).- In eddidon, when theee technique. of exeninetion Ire enployed, other veriebiee or nielooeiieetion,-euob ee diepieoenent (3). become apparent. niepleoe-nnb ie the petberned nielooelieebion or one or two ebinnli eiunlbeneouely applied to different body areas. The direction or diepleoeuent ie in e definite pattern, which is dependent upon the parts or the body Ibilnleted. choreoterietio of nieiooelieetion on for reported bee been ‘ tho fact bhet their lxtent VII uibbin the lilibl of the patient’l body. In the oouree or obodiee or outeneoue peroeption we obeerved I new torn or diepleoenent in which the patient oonoietenbiy end in e prediobeble reebion nielooelieel obi-n11 into extra-pereonei epeoe. Thin type of diepieoenont on have teamed “exoeo-oebheeie'.¢ of the derived by Dr. Judeh A. Jotte, Editor 19%0, the tron Press. Oxford Boivereity reyobietrio biotic: none", , by ”eiotheeie”, perception body; the Greek "one", out or; 139 FI?’!53'€5§E eeneee. wee ll; Exoeoleebbeeie ie not e commonly oboerved phenomenon. more than #00 patient: with brain dieeeee were examined at Bellevue Peyobietrio Hoopibel by routine end epeoielieed eeneory beete. �2. Shoeoneetheeie wee obeerved in only 15 oeeee ~ en incidence of ebout 3! (5). who following oeee reporte illustrete the phehoaenon end deoonetrete eoee o: the oonditione finder which it wee obeerved. Case 15 H.I., e 6% year old male, wee admitted to Bellevoe Peyohietrio noepitel with e hietory or progreeeive sentel cheeses or eix years doretion. The firet tour yeere or illneee were lurked by eloely progreeeive ilpeirnent of memory, oonoentretion end other intellectual funotione. end inoreeeing epeth: to hie environnent la the leet teo ii yeere thie oondition exacerbated rapidly, reeulting the lone of hie Job ee e etore neneser. During thie period hie epeeoh bean-e inoreeeingly serbled end Ito-nerihg, Be veeoilleted oolplete epethy.i. 1*: f”;irTWT€nL. he wee oooeeionelly incontinent. mm bathing; nee dittioulty in dreeeing, end wee eoneti-ee eo forgetful end oonrueed ee to wander into the etteet eithout hie troueere. Routine georologio Ian-ioetion; In welkins the trunk wee tilted to the right end there wee e tendency to drag the right, lower extreaity. However, there wee no eignitioent motor weekneee. reflex change or tonne ebnor-elity. Coordination teete were well perromned. The oreniel nerve function: were intact. Vibretion eenee wee correctly perceived only in the oleviolee end the heed, while poeition eenee wee lost in the tinsere, eriete, toee end enklee bilaterally. Temperature difference: were poorly peroeived exoept in the teoe.eree. hie reeponeee to touch end pin prick between irritebility end nild degree or “mixed epheeie" was present. This epeeoh difficulty we: evident only epeoiel testing or then the petient wee retigued by prolonged eti-uletion will exeeinetion. be deeoribed leter. A by there one e fluctuating dyeprexie of noderete eeverity. �3. Occuionally n. ma difficulty in drawing, being unable to handle button: and alaavca. however, he could partonn Inch tunaticna aa reading hinaalr, ccwbing hia hair and cthar routine daily taaka. Ha waa naually unabla to wiwic tha aura ccwplicatad pattarna of the hand~praxia tanta. licetrcancaphalcgrwa ahcwad_bilatcral dittuao abncmnality. with dacraaaa in awplituda and interwittant auppraaaion or activity ova: tha pariatal regiona. Pnauacancaphalcgranldiaclcaod bilaterally dilated vanericlna and wodarato “cortical atrophy". particularly in an ion moral lobe. szphiatric Statua; Although tha patiant waa ariantcd for place and situation, he wada crrora an to data and than or day. Thar. war. datacta in vacant unwary, concentration, calculation and ability to aaauln the abatract attituda. no uwually aat placidly ataring intc apaca or wandered aialaaaly about tha ward. Ia did hat win with cthar pationta. whcn approachad by tag atarf he waa friendly and paaaivoly cccparativa.' Tasting proceduraa ware approachad with a chaarful indittcranca. Hhan, hcwavcr, ha was panhad into Boat aituaticna :raatar than hia capacity, ha reactad with incrwaainx itvitability and tanaicn, avantually calainating in a “cataatrcphic reaction.” it such tiwna ha would baccwa rod in tho taco, about that ha know tha ahawara but didn't want to continua and mcccniy basin to map. a. waa can. to distinguish tho right aid. or his: body tro- the 1321:; but waa unable to wake can distinction on tha miner's body. 11. had no difficulty either in locating nidlinc atruccuraa or hia body, auch aa tha uoaa, heath, chin. nabilicua and pania, or in pointing to hia cyan. With oyoa cpan ha readily fauna W ' �e. hath eere, but when hie eyee were cloned he seeped ebeut hie teee for eeverel eeeende betere leeetlns then. he eeuld'belne to hie thighs, kneee, ankles end tees but could not point to any epeclrlo toe ether thin the his teen. frequently had Alrtlculty 1n locetlns port1ene or hie upper extrenltlee. It eeked to point to hle ehouldere. be correctly located one ehoulder, but then grayed behind his neck locking for the other. This defect was even more noticeable in trying tn find the ”other" elbow and wriet, and creeteet in trying to find the "other" hind. file eeereh for the ”other" hand or wrist Be bizarre. He would parts of hie body, the look under the pillow, or rummage under the nettreee becnnlng tenee and ineietius it we. lost. It should be eupheeieed that despite the great difficulty in lecetlns was petlent was able to name the body parts. except the tinseve end toee. This was true whether the pert pointed to nee on the petient'e or on the examiner'e body. 33939;; Stetueg (e) ééfifil? Btlnhletlon: He had difficulty in differentleeins between the sheep end dull end of e pin. This defeat wee preach: throughout the body, elthoush he made eignitieently fewer erreee 1n the reee end hende. Touch atlauletian was poorly perceived. Heuelly he coulé not state whether or not he had been tauched. Again, there �5. «m to be relatively better preoorvotion or this modality in ' the hand: and face. Except under opooiol oonditiono or examinotion of tho hands, to he described liter, the patient who ohle to locate the eite of it the pin on. repetitively and or it the priok woo steadily maintained a pin prick by pointing. however, rapidly applied to one rosion, at that one place, he could not looeto the point of otinmlotion. tendon scorching lav-neat: over hio body and not infrequently around the bed olotheo. srinaoing on thouah in pain and exoloinins that he one trying to renove the pin. If ookod He would make frantic, where he one being priokod, ho diorozorded the question and con» mm on tinued to try to move the stimulus. "m. phmmnon stimulation or any portion or the body, but who most apparent when the hand no tested. (h) Double SiuultOneouo ethnolotigg; Tho phone-en: or oxtinotion end dioplooo-ont were frequently ohoerved in tests or different body area- by oilultoneouo tactile otiuuli. 0n etinnletins tho race and hand. otinuli to the hand we». not perceived, or nioloooliaod to the cheek. In touting honolosoue bod: stone (on hondvhond) extinction of one poroept III col-on. The side on which the stimulus III not pcrooivod fluctuated, no that at one uooont only a right-sided stimulus one perceived and o for momentleter, only a lott~oided etinnloo not perceived. Exooonootheoio; Whenever his pal: who in oontoot with a portion or his body or any other ohJeot, and the dorouh of that hand In: prioked with o pin, the patient oonoiotently nioloohliaod the �6. ottuulun. this nialooaiisation who to whatever object the phi-tr tartan! of the hand was touching. For txlhplc, 1f the pntioht'l hand was routing on his thigh and the doroun of tho hand VII priokod, he insisted that tho thigh had boon touched, and not the hand. Th1: ninlootlisntion ~ oxooonoothooio - occurrod to the thigh, obdonnn, 105 or (too, had who present with stimuli to oithor hind. It Ill observed even when the patient who urged to look 1t tho hlhdt durtng the application or the pin. nah-anesthesia could not be elicited, however, by otinulhtion of tho pnln or polmar curtuoes of tho ringer! uhnn the aorta: of tho hhné ill rooting on a portion or the My, runner-more. ionization or dorul hand amnion um correct 1! the hind III hold in space. Iloloooltsntion also ooourrod to abduct: external to hit body. It h1o pal: ill rooting on I tabla or on his bad. and the doroun of tho hand It; prioknd with I pin, ho would point to those ohjooto and 091th thlt tho pin had been $991106 "thmru." Whoa quantionod. ho hinted thlt tho hand had huen touched, but continued to point to tho bid or table. Proquontly. however. ho'inntotod thht it on. tho bod or tohlo that hon boon touohnd thdhnntphhohhnnd. Ir alkod how he could too;_tho bod being priokod with a pin he would booonn ton... avoid the queut1on and inliot ”you touohod the bed, not In". III not ell-inatod by Itlhltanooun stimulution, oven whnn extinction of one of tho parocpto occurred. for 03:391., 1! pins hero oinulthnoouoly applied to the aorta of both hands Ihllo tho pal-n wore resting on o table, he would report fetish; only on. p1n prick, that on tho loft (or right, a: dominance fluctuhtod) and point to thn plloo whore the loft hind huh boon rooting. saying ”you touohod the bed thoro.” Displheonont into outrouporoonnl than. �this phone-enon or dilplucancnt into cxtra~peroonal tpnoe occurrcd daily during e period or over two nonthn. Commont: In this paticnt a rccuicitc to dimplecenmnt into space was that the pmlm or the hand be in contact with an external object. In other words. then. were two cutaneooo stimuli limnltcnecully in operation, nemoly the pin prick on the doreun or the hand and tho pro-lure or the object in contact with the palm or ringcro. A single nti-nluc. eooh II pricking the dornun or e hand held in upeoe. did not elicit the dicplnccmnnt. luoeomeutholih III elicited only on otimullting the hands. mu oocumd am though Ilmle pin print as: perceived me cum: in the hand: than in any other areo. excepting the thee. Although thin potient showed In lnability to oorroctly locate phrte or his own and tho esnminor's body, it doc: not necoecnrily amen that exolcnelthscic in dutenmined by thie particular type of disorder in body ache-n. the following case illustrate. the phenomenon or exoocmeetheaiu in the preeonce or to. patient'n some: to locate body pam. can. 23 l.l., a 52 your old woman, III edmitted to the. Neurolosio Service of the flaunt Sinai hoeoitdl in August 1950 with I history of grand hnl eelxuroo. She had been in good honlth until 1937 uhcn there appeared sporadio, noncntnry ecnuutione of "blacking out." About two year: before hdniehion she began to suffer Ionthly ' Ill leisurel. There was no euro. Routino exeminntion on admiulion III within normal limits, oxoept for dnolmia in tho right nontril. there one no organio honthl cyndromo. apocinl x~rcy studiel reveoled evidonoo or a oohfronthl grand necplcen. an August 19th a oreniotoly mm: done and following amputation of e portion or the right frontal lobe, a large bilateral �8. ‘tub-troattl III umniaginnn was axcitcd. nor pout~opcrutive courts an; stormy. For tut lacks an. saui~stup¢rann.r 3h. raupondod anly ta lassive, painful stimu— than: renpanuaa flirt limited to vague ineffective nttenpta ta.punh Quay tat stimulun. In this pcriod the lnpuod uovcral tin»: latian, irate and om um: "sputum um chem-Magma did not Bar rttpannoa rare pruatnt. pupil: mutem ublmkl retot to light. tn. pltiint inproved slowly and steadily. an. hogan to rtlpond vcrbtlly and contact could be maintained far short poriodn. Vinita, union and apparently been absent, begin Frau about Augunt 23, 1950 to rcturn, tlthough a right unnonyloul halinntpuia tiltinofi for Dunn tino. A Iarkod orgtnic nanttl syndrtlo characterised by confusion. disorientation and nuouognusin was prcnant. Routine laurolggic xxnlinntion: laurtlosit exnuination in aoptonbor 1950 diteltuoa a right honcnynnun honiunopnil, asthma impairment of vilual Inuit: with bilatorul nocondnry Optic atraphy, urttaslnl in all directions or ante, bilaterally patitiv. nabintki night. and a nild dogree or uphatin. Position nan... vibration and tonporntur. porcuptian wire unimpairtd. Thor. were difficulties in perceptien or touch Ind pin prick stimuli at anacribod belwu. Puzehiutric Status: The patient was usually friendly and cooperative. Bouvver, the III frequtntly irritable 1nd unuld not pomnit culmination. an: an. dilaritnt-d II to tins and notational: to situation, but not to placa. Thar: var. defeat: in retention Ind maul covered by contabulatian. am am euphoric and 41:91:,“ littlc self restraint er aoneern in social oituatiana. Usatlly uh: would lie with her body fully oxpoaod. not intrtqunntly she toiled �bereelt or wet the bed. Anaeognoein In: prominent. Bod: Scheme: 0n contend the petient we: able to identity lbette correctly parts of her can and the examiner's body, such In ears, eyee, feet and parts of the upper extremities. She exhibited name oenfueion about the right and left eidee a! the bady. end Season; statues] (a) siggie atiuulntian: The patient perceived single pin prick cumin mi, eitheugh m undo 0003:1011“ nompntterned em» in localisation. Theta errors were more frequent on the left side. (b) Double ginniteheaue stimuletion: 0n sinulteneouu epplicetion of pin prick: ta both tides or the body (excluding the hands) extinction on the left, or dieplaceaent on the left toward the level at the right-aided stimulus were the usual reepaneee. amneleterll linulteneaus etimuletion on the right side or the body shaved no extinction, but ntinuiatian on the left side elicited frequent extinetian and displacement. Runneleetheeieg Dieplaeenent lute extra—portend! space either occur-m than the lettihahdawn pridked at the me time the right hand or right cheek were stimulated. The phenamenon could u ' ulna be elieited then the left hand and day other are: or the left side or the body were simultAneeualy etimnleted. Under theee conditions the patient nislocelixed the stimulus to the left bend.inte evade near that hand, or to the object on whieh the mind was lying. For example. it pin pricku were e’imltehemu applied to m right cheek and the 1m; tune, the patient indicated she had been pricked on the right cheek and the are or the chair on Ihich her left bend had been renting; As 1 rule ehe answered by pointing. I: neked to verbelise the ebuld any, “the right cheek end about here,“ (painting to the their emu er into space near be: lett �10. hand). 1! ssksd dirsotiy, “was year hsnd touched,” sh. sauld avoid the gunmen mymzug can; "use," pointing st m um em to tbs 10ft oasis sun at ta spans. It is to be netsd that oxespt undsr the spssisl condition at sinultsnsaus stimulation tbs patient was always sbls to point tu as to ash. hsr‘istt hand on dsssnd. 1r prieksd silnltsnsuusiy an tho dorss or was isrt sud right hands. shs carrots}: localissd only tbs stimulus an tbs right, been by painting sad ststins. “I: right hand.” 2h! stilnlus an the new-y». m 190311104me by painting to m chair s:- and saying, “asrs.* 'It ssksd lasthsr the «hair sun. sud not but 10!: hand use issn toushsd, shs snsssrsd. ”as. hs:s’ pointing to tbs chair an, sun. Inna pin prints ssrs spplisd to tho lsrt hand. sad It the suns «ins, to snethsr sass on the 1st: sids or any baay,s 51-11.: dispisosssus into spsos III status. Ususlly tbs stisulus to tbs lift hand was sislosslissd onto Instsvsr structurs the hsnd sss rusting at else t9 contiguous spsos. tbs uthsr‘stflsuius an tbs 10ft sids was ususiiy oarssotly locslissd, though this stimulus too It: onessionsiiy displaced into spans. when this doubis displsosssnt oocurrsd, tho psiisnt.soula stats sh. rsit eve stimuli and staid paint inte space to tbs lots sf tbs ans. stating "bars and have”. !hsss saslosslisstiens ssrs rspsstsdiy ohssrvsa during s period or s.smnth, sad wars not sissys limited to tbs 1st: lids. tbs: ssrs ecossionslly obssrssd to scan: on sh. right sins. At an... c1... localisation on tho lots its slings aorrsot ss indiestsd by pointing and vsrbslisstion. . siioitsd in this pstisnu only the oenditian or Imitiplo smsuitsnsaus sci-ulstian. It scald can-snsz Ixososssthssis was ' under not be sliaitsd by .1331. summon isthmus. mo signifiosnt :- �11. that oxooonoothooid Ill appoxont ovoa though thoro In. no gross diuordor in body ooh... on routine touting. rurthonuoro, it is evident that bar errors in localisation not» not oi-ply on inabiiiiy to point to or identity park: or her body by nine. ll ordinarily the exporidaood no difficulty in doing this on oonldad. In hoth onto. paranoia word nioiooolinod to part. or the body, to abstain. or into npnoe contiguous with tho tron stinulotod. ooouoiondliy. we have nine observed dilpldodnant or a stimulus to the pardon or the can-inor; Usually ouch percent: art nioloodlilcd to o homologous portion of tho cal-inor'o body, 0.3., a otilniud appliod to tho potiont'u hand in reportod by hin.oo if it had been oppiiod to tho tau-inor'o hand. 'narolr, tho nioioodlizntion ll to any part? of the oxaniner'o body.‘ this §ypo or dioplaoonont is illuotmttod in the following on... also 3; 1.1., o 52 your old male, to: aduittod to Boliovuo Payohiltrio Hoopitll with the oonplnint that ha pad hood-o oontuoed and doprooood. for about a yetr ho had boon disoriented, oootnsod on to date dud rolutionohipo of pooyIi, and had uialdred ubout the 01¢: dill-nix. a. and been to um um colony about a mu “ you: beforo, and had uorkod no d harbor until tho rook before his mum“ to the hupiui. mum ' Slowing shouod non-o1 tomnod. lm;gio fixation! leurologiool examination gait and Itation. coordination Scots our. '01: per- lagrrotioxoo wore doiive bilaterally with normal plantar and undo-inol.rolponnoo. Cranial norvo runoiiono ward now-n1. otltuo thouud Ohtnxil, but only by opooidi nothodo or testing. A pnou-oonoophalogrnu dononotrutod nodordtoly dilated ventrioloo "ith°“t '31" 0’ def°flitia Ind ton. dilated cerebral ouloi. 098.1110 mu} Indra. Status I donoory Militia 3 m “. �12. evident. 0n the word he eet quietly for boure by hie bedside taking little interest in hie surroundinge. 'Ihen opproeched by the eterr he eppeered perplexed but one erreble. During the teeting procedures be one cooperative unleee confronted by e teet eitoetion in which the emeniner demanded teeke beyond hie ebility. At theee ti-ee he showed e ”ceteetrophic' reeotion, bece-e excited end diecontinued the exeeinetion. Re wee dieoriented for time. place, end eituetion. However, he nee eble to find hie Hey about the nerd, looeting hie bed, the nnreee deek, the dootore office end the lavatory. severe ditticultiee in intellectual function were obeerved. He nee oneble to give en edeqnete bietcry. fie could not recell the examiner's none nor the evente or several houre before, but did not contehulete. Celculetion end eyebol identification teete were poorly performed. severe epheeic difficultiee were evident. Re nee uneble to none cannon objecte, clothing or moat body perte. He could not colorehend written collende nor could he write, but he wee able to einple verbal cannon. lilo dreorexie nee demonstreted in hie ettenpte to imitate ringer end mouth novenente. nouever, he lee able to drone, feed, end otherwise cere for hinoelt. Bod: gaggeg He bed difficulty both in neling body perte, end in locating the: by pointing. the defect: were Imet eevere in the fingers, wriete end elbows, and ooceeionlly feet. There nee difficulty mm ‘ ' in right-10ft orientetlan. age-or: Statue; (e) giggle Stinuletionx Routine eon-cry etudiee or touch, pin prick and vibration eboeed no ooneietent inpeinlent. Theee �13. correctly looalieed and deaoribed. Oooaaiohally a eihgle stimulue to the hand or toreahn wee dieplaoed to a contiguous object, or to apaee about the upper extremity. (h) Double Simultaneoae stimulation: 0n double aiaultaneoua touch atinolation the patient dieplayed extinction and dieplaoaleht atianli or were ueually tactile etinali. lhie he would trials or the teoemhand teete or other body parte as well. to: on ai-nltaneouely etindlating the cheek end the oppoeite hand either report only the etioulue to the cheek (extinction of text (6), hot example, nae moat evident on nae eeen in the hand etianlua) or would report e etmlulue to eeoh oheek (displacement or the hand stimulus). The pattern or seneory doainanoe wee that oeoally eeen in ditruae cerebral dieeaee, the race being aoet dominant. the hand leaet (5). There nae no lateral doaihanoe. Rho-oaeetheeia; Dieplaoeeent into extra-pereonal apece eaa oceaaionelly ohaerved on single etiaulation. This displaoeaent vae fro- the hand, forearm. or the elbow to apaoe oontiguoue to the part touched. lxoaoaeetheeia was however aarkedly exaggerated when double einultaneoua atuuuuon was employed. Again the am. from which the phenomenon was noet frequently dheerved were the hands. toreeraa and elbovl. tor ext-pie, when etieuli were applied to the dorae or both hande ae they were lying on the patieht'e lap he pointed to epeoe in front of his kneea. It aaked to etate where he had been touched he uould say. "the hande" but would continue to point to the epaoe in front or hie knees. laoeo-eetheeie nae rarely noted when other body parta. euoh ae oheeke or ehouldere were simultaneoualy stimulated. Occasionally it one found that on teete with double allula taneoue atinulation the patient nielooeliued a etihnlue tron hie body to the hoaologoue region or the exeeiner'e body. For inetanoe, when both hand: were oinultaheoualy touched he would grasp the exauiner'e �1%. binds and strin- ho had boon touched “there.” Dsopito tho sxosinor's insiotsnoo thst tho stinnlu: hsd boon to tho outiont'o hoods, tho pstiont would persist in pointing to tho oxouinsr's hands. When asked to noon the ports touched, he would on: 'thsro. thorc." The fill. phonononon Isl occasionally observed on liltltsnoons sti-nlotions or both elbows or ohooko. It was signirioont that this nislooslisotion to tho oxosinor's body occurred oven thou tho potiont urgod to look ot tho otinnlotiono. It III observed that onotionsl tension, inoresoing tho rot. or touting or unduly prolonging the oxasinotion, inorossod tho inoidonoo of oxosolosthosis. ror ext-910, to initisl sppliostion was of pin priok to the right hand and loft chock, tho pstiont reportsd only tho the. psrospt, quitting tho hsnd stimulus. Lstor, ho localised the two othnulino tho ohooks. As tho sxoninotion pro« groslod sad the phyoioion opsodod up the testing. tho patient boot-o sore tohss. no thin looslisod tho toos pore-pt correctly, but innistsd thst the hand otimlntion as into upon. in front at the hand. tinslly both stimuli our. displaced into spooo or to tho oxaninor's body. those phononons wort obsorvod dsily over s period of two and a half unhthl. Coulent: Hhilo single stimulation occasionally produced oxooolnlthosio in this individual, tho phenomenon Ill note pronounced under conditions of double oi-ultonoouo Iti-nlstion. this ntiont sloo lioloooliood stilnli to tho oxsninor's body. lhotionol tonoion, prolonged canninstion, or inorossing tho onto or touting exaggerated the phone-anon or ozosonosthosin. Bisousoion; In oonoidoring thou. ossoo it is illodistoly opporont thst oxooolosthosis is osoooiotod with o savor. orgsnio �sentsl syhdrose. therefore, it night he ersued thst exoscseethesis ‘is sorely e ssniteststiou of the petient's sentsl contusion; thst 15. the petient sisply points into spsce becsuse he is confused. However, we hsve eyesined sssy severely confused pstieuts end found exososesthesis only rarely. moreover, exososestheeie is e petterned phenomenon. desonetrstle in eschvpstieat under defined conditions, predicteble ss to the eree tron which it will occur end the extra» personel spetisl region to which the sensation will be projected. For exemple, in Case I, exoscsssthesie could be elicited only from the head end only when the dorsus use etisuleted st the sese tine es the psls or fingers were in contsct with smother object. Displscesent under these circusstsuoes use ususlly not hephsssrd. sis s rule it occurred to the object touchins.the palm or fingers. In exososesthesis could be elicited only by double silulteneous stteulstion. It see seen most clearly in the head end could be elicited only unileterslly st say one exesinetion. Again the Case 2, displace-eat use not hspheesrd; the stimulus es s rule use locslised to extre-pereonsl speoe contiguous to the eree sctuelly stilulsted. In Cece 3 the phenosenon use observed sgsin under conditions or double sinnltsneous stimulation. end the displsceseuts were either to spece contiguous to the stisnlsted eree, or to honologous srees of the exsliner'e body. It is signifiosnt thst these displscesente could be elicited even when the or the stimuli. pstients to look st the epplicstion the ensuiner pointed out the error were urged noreover, even when in looelisstion end esphssised the i-plsusebility or their response. the pstiente chsrecteristioelly insisted on the correctness of the nislooslistion. rectors Influencing lxososesthesisa There ere esny rectors which influence the sppesrsnce of exoeosesthesis. Except under specisl conditions in children, it �16. has been obeerved exclueively in patiente uith severe mental chensee reeulting true dieeeee or the brein. It ie influenaed by the type of etianlue need. the rate or etiluletion. ee veil an by the elelent of einnlteneity or eti-mli. loreover, the e-otianel etete at the petient nee e eignificent effect the phenuuenon ee doee the pert or the body etinnleted. In ease oeeee exoeaneetheeie nee been nude epperent by edeinietretion at eeell doeee or enoberbitei eodiun. :heee feature will be diecueeed. (e) Bilateral Cerebrel Dieeeee; the emlptae beekground in every eeee or exoealnetheeie ie en arsenic uentel eyndraee eeoondery to bilateral ceretrel dieeeee. we have not been eble to denonetrute exeealeetheeie in en adult unleee there «ere eevere neutel thengee. But,ee previouely noted,it ie e rare phenonenou end only few or the individuele vith eevere arseniereentel eyndruee show it. In boo patiente with arsenic brain dieeeee at verging eeverity, exoeaneetheeie ee- obeerved in ephroxintely as or the one: (5 ). Even in then patiente, it wee not leniteet in every exeeinetion. end it: frequency vee reedily eltered by «bungee in the oonditione of teeting. It ie therefore evident that eevere bileterel oerebrel dieeeee, in iteelr, ie not sufficient to produce exoeoleetheeie. (b) Irrect or Binnlteneaue atiunli: whet einnlteneoue eti-uletion nay elicit eeneory phenaleue not epperent on eingle eti-nletion nee been previouely denonetreted (2). tor exllple, e henieeneorw eyndrtne in e heeiplegia petient he: not be diecernihle except under eonditione or double ei-nlteneuue etinuletion. Tune. single etilnietion may be well perceived end latelieed by the petient. but the eddition at e eecond etinulue einulteneouely applied .1: no effect integration thet the phenomene of extination, obecuretion end diepleaeeent become epperent. on �17. ‘ m ‘sullarly, “alumnus “mutton elicited “comma 1: an aunt an angle annulus umlnulon. or magnum 11: when 'oun 1 n In Manama: mun: and 2. man. stimulation. In ulmltmem «mung» am a menu»: “mum on for aligning the phonon-anon. It could not be amount-um by tingle uttunlatlan. In am 3, ant-tumult could “nationally onum on .112ng stimulation. but annulment “mutton dmmtum flu. inhuman run much water frequency. b0 (a) :12! a! gtggglu! Inst lrtbotgvug or tub vurioua Uzi-”11 and in that Manama. mix as final. when. :5.le pin prick, ripotltlvc tauch and rlpctltlvc pin prick. it It: noted that mutt" tmh "man mm was: «1'00th 1!: allowing cucum- thuu. m. m «mull: two on double almlum Itimlltion. (a) gram o: t! "time's an»! momentum-la anal um amt-mud hr 31%.!!qu in th- m: “mum which and» mum“. not. difficult. lama tbs n“ of “hunting, artho unduly prolonging mn~m~ml Imo. tantalum 1mm“ Alta, 11‘ the the Multan-nt- to twin" was deliberately critical or the mtlmt'o 0mm, tho phonmmm appomd with 5mm futon mam-d an. action“ switch at tho Imam”. patient, and 1t amt-d mun-r. prom.“ I "ututmphlo" mctlan. m man of m: It In» boon pmlmly dmtnm that arugula» in pomcpucm my be magnum by mum-ac. (0) nous-mu: team an administered lutnvmmly la 400.30! or 3 to 7 srllnl tn pltlonta Ilth altrus. ctrohwll distant. Prior to am “nutrition. thou patent! mnltum the phone-on. at «amulet: and dllplumt at pump” on ““1”me tutu, but lntuloanta not. (5) . alumnus“. m1 lo under the lntlmmc or the Whitman �18. three pationta ahovad oxoaoneatheaia. in addition to extinction and displacement. In two other patienta. in whoa axoooaootheaia has boon alioited only after a protraoted taating period. the administration or anoharbital aodiua elicited exoaoaeatheaia at the onset or teating and exaggerated the phone-one of extinction and displace-ant. Relation of lxoaoleotheaie to Extinction, Ottonretion and Diaplaoalent: In our experience. whenever exoooaeatheaia haa been observed. phonon-nu of extinction, obeouration and displacement are alao preaent. lxoaoaoathaeia, hou‘var. ia a rare phone-anon, whereae extinction, ohaouration and diaplaoolent are eon-only ohaerved. loreover. ahareaa extinction, otaouration end diaplaoaaont ere treouontly aeon in coult patient: with lilo cerebral dyoronotion (5). diapleoelent into extranperooael opeoe 1a only preaont in oaaaa or severe aental ohangea due to diaeaae ot-the brain. It may therefore he oonoluded that exoeolootheaia in adult: repreaenta a aora severe type or oarebrel dratunotion than other oiaultenaoua m otiaulation phone-one. nalation of Ixoaoleatheaia to gag: logger It night he aeid that exoaoaaatheaia ia a pathologio extenaion or the body image. The normal individual is continually extending the boundariea or thia image. For example, need oitae the eta-plea of tho lolan with a teeter in her hat who “real!" when the feather ie tonohod, and the aurgeon who handlea hia probe as though it were an axtanaion or hia tingera (1). In the normal individual, holever, theae extension. of the body 1-130 art fluid, illediately raveruibla and clearly recognised by the individual aa artificial. the surgeon for example, ia able at any'nolent to redefine correctly hia body Liege. no “known" that the prob. it not his finger. In the group or petionta ’ �19. described above. hosover. the extension of tho body isage scans to operate in a pathologio, rigid tons. under certain conditions these patients lose the ability to ssintain a realistic definition of tho lisits of their body. The: behave as though portions or the contiguous external world are concrsteix incorporated into tho inner image of their body's extent. Although say oonsider exosoaesthesis- a spooiaiiaed body ilage disturbance it should ho noted that patients who do not show we diftionlties in identifioation location of body parts still us: show aisiocaiisstion into estrsapersonsl space. Convorsely, patients with so atolhility to identity or locate their body parts on oosssnd. do not neoessariiy sanirest eaosoassthesis. In similar fashion, thers is no necessary relationship between ascsoaoothsais and position sense difficulties. A patient (Case 3) who manifested displacessnt of sensation into extrs~personai space, did not asks errors in routine tests a: position sense in” tho extresitiee. this it oonsistent sith observations previously ssdc by Head that localiation of single stilnli is not functionally roleted to senss of position or the extrusities (1). non or the land: Although displsoelont into extrs~persona1 space has been elioited tron various areas or the body, it has been observed to ooouh lost frocoentiy tron the hand. loreover. in no ossc hoe it been elicited from another area and been absent tron and 1 the hand. this oredileotion tor the hand is consistent with the ssnncr in shioh other dysfunctions of the nervous system are reflected. As a role when tho functioning of one side of tho body is impaired through cerebral disease the pathology is soot saniast in the hand. �20. lhne 1n the annex heuiplegit reeultina tram e capeulur leeion the pereeie, body image diuturhenoe end eeneory late ere use: pruexnene 1n the hind Ind (insert. In the-e petaente end in other. eleh dzrruee cerebral dieelee the phennlenl a: extinction. eheourltion end diepleoenent Ire elee beet e11¢18ed when the head in teeeed. lurthenlore. etufliee at eh. order at eeneory dullnenee or verioau ereee or the had: Genoa-trite the hand in the lowest hunk. thie in true in the eminence order or petunia with cox-em), dieeue (5). and mm nor-e1 eubjeete, both edulte and children (6). stallerly, then elleetheaie 1: oheerved, 1% 1e eeen she: olenrlr 1n khe head. Bender tad lethnneon (it) deeovihed e «nee 1n ehioh'the clinical courae III reflected in e waxing end unnans alleetheexe. Ae than petient inpraved, the trees from ehseh the phenunmaen oould be elicited amniniehed. ale delohetreble only in the hand. until finally alleethneie In entotopegneeie the hands hre ante proraundly effected thin other regiane. ringer Isnneie. paneibly the enrlieet etsn or body image dieturbenee, 1- trequentlr eeen 1n the eheenae or other groee dieeurbanaee or the bed: eehnne. Furthemeore, phantom 11gb, tnoeosnoeia. cluellsxn and eyneetheeie Ire phenalnne in which the role a: the hand 1e eepectclly praninent. Just an en». ”811010310 puma-em uniteet in tests or other body parte. but 3:. that aleerly delonetrehle 1n the hand. so the. exoealeetheete, though nonunionnlly delanetrnhle eleevhere, layman: apparent in exnlihntion of the function! at an. hand. 14: It hne been observed that luaealeytheele 1n the ham-e1 eeneory pheno-mne which aoeur 1n pettente with cerebral dylrunction m �.1 {{{{{ 21. h any bu fauna in tho annual young child (6). Similarly. have unvor fauna in adult: nxecpt than QSOOGIOIthlltl, thick I. that. in lirkod cornbrnl Ginsu... nun b0 roadily obnorvod in childrcu up to in. ago or tour. In urn-ining a 13:30 302103 of norm. chiidm it u. now that the initial mpm or ohildron to iambic ninnitunooal Itinuiation fruqunatly incinnnd' axoianucthnuia. nithough tho nor. can-an rosponnos In». «xtinctian and dispinou-ont. lionenusthonia was IIrO. havuvor. utter tho initili til trinis. In» truqunaa: with union uaonalusthnain.nnw he noon in children up to tho as. or tour insanity that it an: roprouont. in thy child, 3 ”annual" dovelopnuntai Itsse in on: ergnnisation of perception. It: uppourunan in uduits with novor. brain €110.30 any possibly ha. I. with aunt: pathologio phauulcnu, a rungIIion in function to a pruvioul iovvi at ntnnory integration. aBIIiII; lillooIIilation of tnotil. Itflluli into axtrn~poruuna1 space is dcnarihad tad tar-pd alone-cathonii. Bantu-nathnlil 1' aha-trod in pationta with saver. organic unntal lynarunon. It in apnaront only very rural: on tingle tactilu Itilnintion and in not. readily elicitdd by tho t'ahnituo of Gambia lilnltnnsoul atiunlntian. It is exaggcrntod by fatigue, rigid touting find incrOIlld unotional tonlian. lurhitnrttc intaxiention also may elicit or uxnggorlto the phauuncnon. Eh. pattoraod linsannathnuin in swat apparnnt in Itinniutian of the hand, but his bOCn obsorVCd in tiatl of othnr body part0. flail. it an: be canaidorod t pathologio axttntian of an. bad: image, it is act dopondcnt upan othcr ¢on¢anitunt body inns. disturbanotl. �nelmthOllt Mu bola observed chltfly 1n gamma nth nun natal chanson, u 1: not a manna» or contusion, but a patterned pnucun- phonmnm. It may be a "mum,“ patient: win: Mum}, animation. to I 93110th “new” was. in smear «alumna, u mated by the rut Although that 1t 1. «mum. "Ian: abut-"d in cinnamon- men. tut: 91‘ mg �1. 2. 1mm, 3.: Studies London, 1920. (a) £3. &1mm in lourolcgy, Vol. II, Oxford Univ. Prom, ammo, Id. lad wanna, Mm: Extinction mu, inILL, humans“. mu.xm1.unzuhut., g2; 717-725 phenomenon member, 19%. m, m. as: Itnuutien (b) r advantage. or the method at unannounthe neurological omimtion. monument: Anal-1c... 11.3.: 12.; 755-458. 1n V was. mm: he pheamnm or union unplacuo‘nt. mm, Awhmmelwr .. u. 9 607-621, lay, 1951. (I) MIR, LB... SWIM), IJ‘. lad gutuiugggo: the body team. W Arcth m fl.gm1.uq¢nug., a 1 m 3.1“: - ind anaemia §£L tea-am. Jeannine” ‘ (b) LB. and “We! 11.: Pattern: in alumni: their unfit»: to disorder of find: when and other unto” phone-m. 5. vm, I... film, I. Ind g5; 501615, October, m and 1950. tun-mm tut mm, Maximum sign or untrue heatnmiymejnmlm, 3!. £6.58, 1952. 6. (I) and mm, In Datum 1n perception I... rm,atII.no. on IMltlmm 0! Ind land. I I 250-»252, June, 1950. aura“) LBJ m, (2:) an , 809mb“, 1951. 0. . . 111.8. mm, I. and 11.: mm, mm, {out or and hand. “autumn no. §§: 355-362. £8 Patterns 11: . ”nation mammobgguglg8%.. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Exosomesthesia; the displacement of cutaneous sensation into extra-personal space. Trans Am Neurol Assoc. 1952; 56 (77th Meeting): 260-2. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-6a-008 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource Shapiro, Mortimer F.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Bender, Morris B Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from the A.M.A. Archives of Neurology and Psychiatry, October 1952, Vol. 68, pp. 481-490 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/9cd1485c72c87cfe41a9b822584a53cf.pdf 399d53acd860a7f8f327c824ea2685e0 PDF Text Text Reprinted from the A. M. A. Archives of Neurology and Psychiatry October 1952, Vol. 68, pp. 481-490 Copyright, 1952, by American Medical Association EXOSOMESTHESIA OR DISPLACEMENT OF CUTANEOUS SENSATION INTO EXTRAPERSONAL SPACE MORTIMER F. SHAPIRO, M.D. MAX FINK, MD. AND MORRIS B. BENDER, M.D. NEW YORK phenomena that may be apparent during examination of patients with AMONG disease of the sensory pathways is mislocalization of a sensory stimulus. 'It has long been known that a person with a sensory defect, as seen in the common varieties of cerebral hemiplegia, may inaccurately localize stimuli applied on the paretic side. Such point mislocalizations are apparent in examinations using a single stimulus and have been described in detail by Head.1 These mislocalizations can be accentu— ated by the use of double simultaneous stimulation techniques.2 In addition, when these techniques of examination are employed, other varieties of mislocalization, such as displacement,3 become apparent. Displacement is the patterned mislocalization of one of two stimuli simultaneously applied to difi’erent body areas. The direction of displacement is in a definite pattern, which is dependent upon the parts of the body stimulated. Characteristic of mislocalization so far reported has been the fact that their extent was within the limits of the patient’s body. In the course of studies. of cutaneous perception, we observed a new form of displacement in which the patient consistently and in a predictable fashion mislocalized stimuli into extrapersonal space. This type of displacement we have termed “exosomesthesia.” 4 Exosomesthesia is not a commonly observed phenomenon. More than 400 patients with brain disease were examined at Psychiatric Pavilion of Bellevue Aided by a Fellowship from the National Foundation for Infantile Paralysis (Dr. Fink). This investigation was supported in part by research grant #MH-139 from the United States Public Health Service, National Institutes of Health. From the Department of Neurology and Psychiatry, New York University College of Medicine, and the Neurological Service of the Mount Sinai Hospital and Bellevue Hospital Center. 1. Head, H.: Studies in Neurology, London, Oxford University Press, 1920, Vol. 2. 2. Bender, M. B.; Shapiro, M. F., and Schappell, A. W.: Extinction Phenomenon in Hemiplegia, Arch. Neurol. & Psychiat. 62:717-724 (Dec.) 1949. Bender, M. B.: The Advantages of the Method of Simultaneous Stimulation in the Neurological Examination, M. Clin. North America 32:755—758 (May) 1948. 3. Bender, M. B.: The Phenomenon of Sensory Displacement, A. M. A. Arch. Neurol. & Psychiat. 65:607—621 (May) 1951. 4. The term was derived by Dr. Judah A. Jofie (Hinsie, L. E., and Shatzky, J.: Psychiatric Dictionary, New York, Oxford University Press, 1940) from the Greek 3w, out of ; mind, body, and al’dfiww, perception by the senses. �2 Hospital Center by routine and specialized sensory tests. Exosomesthesia was observed in only 15 cases, an incidence of about 3%.5 The following case reports illustrate the phenomenon and demonstrate some of the conditions under which it was observed. CASE REPORTS CASE 1.—H. M., a man aged 64, was admitted to the Psychiatric Pavilion of Bellevue Hospital with a history of progressive mental changes of six years’ duration. The first four years of illness were marked by slowly progressive impairment of memory, concentration, and other intellectual functions and by increasing apathy to his environment. In the last two years there was rapid exacerbation of this condition, resulting in the loss of his job as a store manager. During this period his speech became increasingly garbled and stammering. He vacillated between irritability and complete apathy. He was occasionally incontinent, ceased bathing, had difficulty in dressing, and was sometimes so forgetful and confused as to wander into the street without his trousers. Routine Neurologic Examination—In walking, the trunk was tilted to the right, and there was a tendency to drag the right lower extremity. However, there was no significant motor weakness, reflex change, or tonus abnormality. Coordination tests were well performed. The cranial nerve functions were intact. Vibration sense was correctly perceived only in the clavicles and the head, while position sense was lost in the fingers, wrists, toes, and ankles bilaterally. Temperature differences were poorly perceived except in the face area. His responses to touch and pinprick stimulation will be described later. A mild degree of “mixed aphasia” was present. This speech difficulty was evident only by special testing or when the patient was fatigued by prolonged examination. There was a fluctuating dyspraxia of moderate severity. Occasionally he had difficulty in dressing, being unable to handle buttons and sleeves. However, he could perform such functions as feeding himself, combing his hair, and other routine daily tasks. He was usually unable to mimic the more complicated patterns of the hand—praxis tests. An electroencephalogram showed bilateral diffuse abnormality, with decrease in amplitude and intermittent suppression of activity over the parietal regions. A pneumoencephalogram dis— closed bilaterally dilated ventricles and moderate “cortical atrophy,” particularly in the left temporal lobe. PsychiatricStatus—Although the patient was oriented for place and situation, he made errors as to date and time of day. There were defects in recent memory, concentration, calculation, and ability to assume the abstract attitude. He usually sat placidly staring into space or wandered aimlessly about the ward. He did not mix with other patients. When approached by members of the staff, he was friendly and passively cooperative. Testing procedures were approached with cheerful indifference. When, however, he was pushed into test situations greater than his capacity, he reacted with increasing irritability and tension, eventually culminating in a “catastrophic reaction.” At such times he would become red in the face, shout that he knew the answers but did not want to continue, and suddenly begin to weep. Body Schema—He was able to distinguish the right side of his body from the left, but was unable to make this distinction on the examiner’s body. He had no difficulty either in locating midline structures of his body, such as the nose, mouth, chin, umbilicus, and penis, or in pointing to his eyes. With eyes open he readily found both ears; but when his eyes were closed he groped about his face for several seconds before locating them. He could point to his thighs, knees, ankles, and toes but could not point to any specific toe other than the big toe. He frequently had difficulty in locating portions of his upper extremities. If asked to point to his shoulders, he correctly located one shoulder but then groped behind his neck looking for the other. This defect was even more noticeable in trying to find the “other” elbow and wrist, and greatest in trying to find the “other” hand. His search for the “other” hand or wrist was bizarre. He would look under the pillow or rummage under the mattress, becoming tense and ' Fink, M.; Green, M., and Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology 2:46—58 (Jan-Feb.) 1952. 5. �3 insisting it was lost. It should be emphasized that, despite the great difficulty in locating parts of his body, the patient was able to name the body parts, except the fingers and toes. This was true whether the part pointed to was on the patient’s or on the examiner’s body. Sensory Stanton—(w) Single Stimulation: He had difficulty in differentiating between the sharp and the dull end of a pin. This defect was present throughout the body, although he made significantly fewer errors in the face and hands. Touch stimulation was poorly perceived. Usually he could not state whether or not he had been touched. Again, there seemed to be relatively better preservation of this modality in the hands and face. Except under special conditions of examination of the hands, to be described later, the patient was able to locate the site of a pinprick by pointing. However, if the pin was repetitively and rapidly applied to one region, or if the prick was steadily maintained at that one place, he could not locate the point of stimulation. He would make frantic, random searching movements over his body, and not infrequently around the bedclothes, grimacing as though in pain and exclaiming that he was trying to- remove the pin. If asked where he was being pricked, he disregarded the question and continued to try to remove the stimulus. This phenomenon occurred on stimulation of any portion of the body but was most apparent when the hand was tested. (17) Double Simultaneous Stimulation: The phenomena of extinction and displacement were frequently observed in tests of different body areas by simultaneous tactile stimulation. On stimulation of the face and hand, stimuli to the hand were not perceived or were mislocalized to the cheek. In tests of homologous body areas (as hand-hand) extinction of one percept was common. The side on which the stimulus was not perceived fluctuated, so that at one moment only a right—sided stimulus was perceived and a few moments later only a left-sided stimulus was perceived. Exosomesthesia.——Whenever his palm was in contact with a portion of his body or any other object, and the dorsum of that hand was pricked with a pin, the patient consistently mislocalized the stimulus. This mislocalization was to whatever object the palmar surface of the hand was touching. For example, if the patient’s hand was resting on his thigh and the dorsum of the hand was pricked, he insisted that the thigh had been touched, and not the hand. This mislocalization —exosomesthesia—occurred to the thigh, abdomen, leg, or face and was present with stimuli to either hand. It was observed even when the patient was urged to look at the hand during the application of the pin. Exosomesthesia could not be elicited, however, by stimulation of the palm or palmar surface of the fingers when the dorsum of the hand was resting on a portion of the body. Furthermore, localization of stimuli to the dorsum of the hand was correct if the hand was held in space. Mislocalization also occurred to objects external to his body. If his palm was resting on a table or on his bed, and the dorsum of the hand was pricked with a pin, he would point to these objects and state that the pin had been applied “there.” When questioned, he stated that the hand had been touched but continued to point to the bed or table. Frequently, however, he insisted that it was the bed or table that had been touched, and not his hand. If asked how he could feel the bed being pricked with a pin, he would become tense, avoid the question, and insist, “You touched the bed, not me.” Displacement into extrapersonal space was not eliminated by simultaneous stimulation, even when extinction of one of the percepts occurred. For example, if pins were simultaneously applied to the dorsa of the hands while the palms were resting on a table, he would report feeling only one pinprick, that on the left (or right, as dominance fluctuated) and point to the place where the left hand had been resting, saying. “You touched the bed there.” This phenomenon of displacement into extrapersonal space occurred daily during a period of more than two months. Comment—In this patient a requisite to displacement into space was that the palm of the hand be in contact with an external object. In other words, there were two cutaneous stimuli simultaneously in operation, namely, the pinprick on the dorsum of the hand and the pressure of the object in contact with the palm or fingers. A single stimulus, such as pricking the dorsum of a hand held in space, did not elicit the displacement. �4 Exosomesthesia was elicited only on stimulating the hands. This occurred even though single pinprick was perceived more sharply in the hands than in any other area except the face. Although this patient showed inability to locate correctly parts of his own and the examiner’s body, it does not necessarily mean that exosomesthesia is determined by this particular type of disorder in body scheme. The following case illustrates the phenomenon of exosomesthesia in the presence of the patient’s ability to locate body parts. CASE 2.-—E. K., a woman aged 52, was admitted to the neurologic service of the Mount Sinai Hospital in August, 1950, with a history of grand mal seizures. She had been in good health until 1947, when there appeared sporadic, momentary sensations of “blacking out.” About two years before admission she began to suffer monthly grand mal seizures. There was no aura. Routine examination on admission showed that her status was within normal limits except for anosmia in the right nostril. There was no organic mental syndrome. X—ray studies revealed evidence of a subfrontal neoplasm. On August 12 a craniotomy was done, and after amputation of a portion of the right frontal lobe, a large bilateral subfrontal meningioma was excised. Her postoperative course was stormy. For two weeks she was semistuporous. She responded only to massive, painful stimulation, and these responses were limited to vague, ineffective attempts to push away the stimulus. In this period she lapsed several times into coma and showed Cheyne—Stokes respiration. The Babinski response was obtained bilaterally. Her pupils did not react to light. From about Aug. 23, 1950, the patient improved slowly and steadily. She began to respond verbally, and contact could be maintained for short periods. Vision, which had apparently been absent, began to return, although right homonymous hemianopsia remained for some time. A marked organic mental syndrome characterized by confusion, disorientation, and anosognosia, was present. Routine Neurologic Examination—Neurologic examination in September, 1950, disclosed right homonymous hemianopsia, severe impairment of visual acuity with bilateral secondary optic nerve atrophy, nystagmus in all directions of gaze, a bilateral Babinski sign, and a mild degree of aphasia. Position sense, vibration sense, and temperature perception were unimpaired. There were difliculties in perception of touch and pinprick stimuli, as described below. Psychiatric Statue—The patient was usually friendly and cooperative. However, she was frequently irritable and would not permit examination. She was disoriented as to time and occasionally to situation, but not to place. There were defects in retention and recall, covered by confabulation. She was euphoric and displayed little self-restraint or concern in social situations. Usually she would lie with her body fully exposed. Not infrequently she ,soiled herself or wet the bed. Anosognosia was prominent. Body Schema—On command, the patient was able to identify and locate correctly parts of her own and the examiner’s body, such as the ears, eyes, feet, and parts of the upper extremities. She exhibited some confusion about the right and the left side of the body. Sensory Status.—(a) Single Stimulation: The patient perceived single pinprick stimuli well, although she made occasional nonpatterned errors in localization. These errors were more frequent on the left side. (b) Double Simultaneous Stimulation: On simultaneous application of pinprick to the two sides of the body, except the hands, extinction on the left or displacement on the left toward the level of the right-sided stimulus was the usual response. Homolateral simultaneous stimulation on the right side of the-body showed no extinction, but stimulation on the left side elicited frequent extinction and displacement. Exosomesthesia.——Displacement into extrapersonal space occurred when the left hand was pricked at the same time that either the right hand or the right cheek was stimulated. The phenomenon could also be elicited when the left hand and any other area of the left side of the body were simultaneously stimulated. Under these conditions the patient mislocalized the stimulus to the left hand into space near that hand, or to the object on which the hand was lying. For example, if pinpricks were �5 simultaneously applied to the right cheek and the left hand, the patient indicated she had been pricked on the right cheek and the arm of the chair on which her left hand had been resting. As a rule she answered by pointing. If asked to verbalize, she would say, “The right cheek and about here,” (pointing to the chair arm or into space near her left hand). If asked directly. “Was your hand touched?” she would avoid the question, responding only, “Here,” pointing at the same time to the left chair arm or into space. It is to be noted that, except under the special condition of simultaneous stimulation, the patient was always able to point to or to name her left hand on demand. If pricked simultaneously on the dorsa of the left and right hands, she correctly localized only the stimulus on the right, both by pointing and by stating, “My right hand.” The stimulus on the left, however, was localized only by pointing to the chair arm and saying, “Here.” If asked whether the chair arm and not her left hand, had been touched, she answered, “No, here,” pointing to the chair arm. When pinpricks were applied to the left hand and, at the same time, to another area on the left side of the body, a similar displacement into space was evident. Usually the stimulus to the left hand was mislocalized onto whatever structure the hand was resting or else into contiguous space. The other stimulus on the left side was usually correctly localized, though this stimulus, too, was occasionally displaced into space. When this double displacement occurred, the patient would state that she felt two stimuli and would point into space to the left of the arm, stating, “Here and here.” These mislocalizations were repeatedly observed during a period of a month and were not always limited to the left side. They were occasionally observed to occur on the right side. At these times localization on the left was always correct, as indicated by pointing and by verbalization. C 0mment.——Exosomesthesia was elicited in this patient only under the condition of multiple simultaneous stimulation. It could not be elicited by single—stimulation methods. Also significant is the fact that exosomesthesia was apparent even though there was no gross disorder in body scheme on routine testing. Furthermore, it is evident that her errors in localization were not simply inability to point to or identify parts of her body by name, as ordinarily she experienced no difficulty in doing this on command. Both patients mislocalized percepts to parts of the body, to objects, or into space contiguous with the area stimulated. Occasionally, we have also observed displacement of a stimulus to the person of the examiner. Usually such percepts are mislocalized to a homologous portion of the examiner’s body; e. g., a stimulus applied to the patient’s hand is reported by him as though it had been applied to the examiner’s hand. Rarely, the mislocalization is to any part of the examiner’s body. This type of displacement is illustrated in the following case. CASE 3.—R. M., a man aged 52, was admitted to the Psychiatric Pavilion of Bellevue Hospital with the complaint that he had become confused and depressed. For about a year he had been disoriented and confused as to date and his relationship to people and had wandered about the city aimlessly. He had been admitted to the Farm Colony about a half-year before and had worked as a barber until the week before his admission to the hospital. Routine N euro'logic Examination—Neurologic examination showed normal gait and station. Coordination tests were well performed. The reflexes were active bilaterally, with normal plantar and abdominal responses. Cranial nerve functions were normal. The sensory status showed changes, but only with special methods of testing. A pneumoencephalogram demonstrated moderately dilated ventricles, without shift or deformity, and some dilated cerebral sulci. Psychiatric StaWs.——-A severe organic mental syndrome was evident. In the ward he sat quietly for hours by his bedside, taking little interest in his surroundings. When approached by members of the staff, he appeared perplexed but was affable. During the testing procedures he was cooperative unless confronted by a test situation in which the examiner demanded tasks �6 , beyond his ability. At such times he showed a “catastrophic” reaction, became excited, and discontinued his efforts in the examination. He was disoriented for time, place, and situation. However, he was able to find his‘way about the ward, locating his bed, the nurses’ desk, the doctor’s office, and the lavatory. Severe difficulties in intellectual function were observed. He was unable to give an adequate history. He could not recall the examiner’s name or the events of several hours before but did not confabulate. Calculation and symbol-identification tests were poorly performed. Severe aphasic difficulties were evident. He was unable to name common objects, clothing, or most parts of the body. He could not comprehend written commands, nor could he write, but he was able 'to follow simple verbal commands. Mild dyspraxia was demonstrated in his attempts to imitate finger and mouth movements. However, he was able to dress, feed, and otherwise care for himself. Body Image.——He had difficulty both in naming body parts and in locating them by pointing. The defects were severest in the fingers, wrists, and elbows, and occasionally the feet. There was difficulty in right-left orientation. Sensory Statute—(a) Single Stimulation: Routine sensory studies of touch, pinprick, and vibration stimuli showed no consistent impairment. These stimuli were usually correctly localized and described. Occasionally a single stimulus to the hand or forearm was displaced to a contiguous object or to space about the upper extremity. (b) Double Simultaneous Stimulation: On double simultaneous [touch] stimulation the patient displayed extinction and displacement of tactile stimuli. This was most evident in trials of the face-hand test 6 but was seen in tests of other body parts as well. For example, on simultaneous stimulation of the cheek and the opposite hand, he would either report only the stimulus to the cheek (extinction of the hand stimulus) or report a stimulus to each cheek (displacement of the hand stimulus). The pattern of sensory dominance was that usually seen in diffuse cerebral disease, the face being most dominant, the hand least.5 There was no lateral dominance. ,Exosoimestheyiat—Displacement into extrapersonal space was occasionally observed on single stimulation. This displacement was from the hand, forearm, or elbow to space contiguous to the part touched. Exosomesthesia was, however, markedly exaggerated when double simultaneous stimulation was employed. Again, the areas from which the phenomenon was most frequently'observed were the hands, forearms, and elbows. For example, when stimuli were applied to the dorsa of the hands as they were lying on the patient’s lap, he pointed to space in front of his knees. If asked to state where he had been touched, he would say, “The hands,” but would continue to point to the space in front of his knees. Exosomesthesia was rarely noted when other body parts, such as the cheeks or shoulders, were simultaneously stimulated. Occasionally it was found that on tests with double simultaneous stimulation the patient mislocalized a stimulus from his body to the homologous region of the examiner’s body. For instance, when the hands were simultaneously touched, he would grasp the examiner’s hands and affirm he had been touched “there.” Despite the examiner’s insistence that the stimulus had been to the patient’s hands, the patient would persist in pointing to the examiner’s hands. When asked to name the parts touched, he would say “There, there.” The same phenomenon was occasionally observed on simultaneous stimulation of the two elbows or cheeks. It was significant that this mislocalization to the examiner’s body occurred even when the patient was urged to look at the stimulations. It was observed that emotional tension, increase in the rate of testing or undue prolongation of the examination increased the incidence of exosomesthesia. For example, to initial application of pinprick to the right hand and the left cheek, the patient reported only the face percept, omitting the hand stimulus. Later, he localized the two stimuli to the cheeks. As the examination progressed and the physician speeded up the testing, the patient became tenser. He then localized the face percept correctly but insisted that the hand stimulation was into space in front of the hand. Finally, both stimuli were displaced into space or to the examiner’s body. These phenomena were observed daily over a period of 2% months. Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of Face and Hand, Tr. Am. Neurol. A. 75:250-252 (June) 1950; Patterns in Perception On Simultaneous Tests of Face and Hand, A. M. A. Arch. Neurol. & Psychiat. 66:35-5-262 6. (Sept) 1951. ' - - �7 Comment—While single stimulation occasionally produced exosomesthesia in this patient, the phenomenon was more pronounced under conditions of double simultaneous stimulation. This patient also mislocalized stimuli to the examiner’s body. Emotional tension, prolonged examination, or increase in the rate of testing. exaggerated the phenomenon of exosomesthesia. GENERAL COM MENT On consideration of these cases, it is immediately apparent that exosomesthesia is associated with a severe organic mental syndrome. Therefore, it might be argued that exosomesthesia is merely a manifestation of the patient’s mental confusion; that the patient simply points into space because he is confused. However, we have examined many severely confused patients and found exosomesthesia only rarely. Moreover, exosomesthesia is a patterned phenomenon, demonstrable in each patient under defined conditions, predictable as to the area from which it will occur and the extrapersonal spatial region to which the sensation will be projected. For example, in Case 1 exosomesthesia could be elicited only from the hand, and only when the dorsum was stimulated at the same time that the palm or fingers were in contact with another object. Displacement under these circumstances was usually not haphazard. As a rule it occurred to the object touching the palm or fingers. In Case 2 exosomesthesia could be elicited only by double simultaneous stimulation. It was seen most clearly in the hand and could be elicited only unilaterally at any oneexamination. Again, the displacement was not haphazard; the stimulus as a rule was localized to extrapersonal space contiguous to the area actually stimulated. In Case 3 the phenomenon was observed again under conditions of double simultaneous stimulation, and the displacements were either to space contiguous to the stimulated area or to homologous areas of the examiner’s body. It is significant that these displacements could be elicited even when the patient was urged to look at the application of the stimuli. Moreover, even when the examiner pointed out the error in localization and emphasized the implausibility of the response, the patient characteristically insisted on the correctness of the mislocalization. Factors Influencing Exosomesthesia.—Many factors influence the appearance of exosomesthesia. Except in children under special conditions, it has been observed exclusively in patients with severe mental changes resulting from disease of the brain. It is influenced by the type of stimulus used and the rate of stimulation, as well as by the element of simultaneity of stimuli. Moreover, the emotional state of the patient has a significant effect on the phenomenon, as does the part of the body stimulated. In some cases exosomesthesia has been made apparent by administration of small doses of amobarbital sodium. These factors will be discussed. (a) Bilateral Cerebral Disease: The symptom background in everycase of exosomesthesia is an organic mental syndrome secondary to bilateral cerebral disease. We have not been able to demonstrate exosomesthesia in an adult unless there were severe mental changes. But, as previously noted, it is a rare phenomenon, and only a few patients with severe organic mental syndrome show it. In 400 patients with organic cerebral disease, of varying severity, exosomesthesia was observed in approximately 3%.5 Even in these patients it was not manifest in every examination, and its frequency was readily altered by changes in the conditions of testing. It is therefore evident that severe bilateral cerebral disease in itself is not sufficient to produce exosomesthesia. �8 Effect of Simultaneous Stimuli: That simultaneous stimulation may elicit sensory phenomena not apparent on single stimulation has previously been demonstrated.2 For example, a hemisensory syndrome in a hemiplegic patient may not be discernible except under conditions of double simultaneous stimulation. Thus, single stimulation may be well perceived and localized by the patient, but the addition of a second stimulus simultaneously applied may so affect integration that the phenomena of extinction, obscuration, and displacement become apparent. Similarly, simultaneous stimulation elicited exosomesthesia when it was absent on single-stimulus examination, or exaggerated it when it was occasionally manifest on routine stimulation. In Cases 1 and 2 simultaneous stimulation was a necessary condition for eliciting the phenomenon. It could not be demonstrated by single stimulation. In Case 3 exosomesthesia could occasionally be elicited on single stimulation, but with simultaneous stimulation the phenomenon was demonstrated with much greater frequency. (6) Type of Stimulus Most Effective: Of the various stimuli used in these examinations, such as single touch, single pinprick, repetitive touch, and repetitive pinprick, it was noted that repetitive touch stimuli were most effective in eliciting nexosomesthesia. This was especially true on double simultaneous stimulation. (d) Effect of the Patient’s Emotional State: Exosomesthesia was exaggerated by alterations in the test situation which made performances more difficult. Increasing the rate of stimulation or unduly prolonging the examination increased the displacements to extrapersonal space. If the examiner was deliberately critical of the patient’s errors, the phenomenon also appeared with greater frequency. These factors increased the emotional tension of the patient and if carried further produced a “catastrophic” reaction. (e) Effect of Drugs: It has previously been demonstrated that difficulties in perception may be exaggerated by barbiturate intoxicants.5 Amobarbital sodium was administered intravenously in doses of 3 to 7 grains (0.2 to 0.45 gm.) to patients with diffuse cerebral disease. Prior to administration of the drug, these patients manifested the phenomena of extinction and displacement of percepts on simultaneous tests, but not exosomesthesia. While under the influence of the barbiturate;'three patients showed exosomesthesia, in addition to extinction and displacement. In two other patients, in whom exosomesthesia had been elicited only after a protracted testing period, the administration of amobarbital sodium elicited exosomesthesia at the onset of testing and exaggerated the phenomena of extinction and displacement. Relation of Exosomest‘hesia to Extinction, Obscumtvian, and Displacement—In our experience, whenever exosomesthesia has been observed, the phenomena of extinction, obscuration, and displacement are also present. Exosomesthesia, however, is a rare phenomenon, whereas extinction, obscuration, and displacement are commonly observed. Moreover, whereas extinction, obscuration, and displacement are frequently seen in adult patients with mild cerebral dysfunction,5 displacement into extrapersonal space is present only in cases of severe mental changes due to disease of the brain. It may therefore be concluded that exosomesthesia in adults represents a severer type of cerebral dysfunction than other simultaneous stimulation phenomena. (13) �9 Relation of Exosomesthle'sia to- Body I wage—It might be said that exosomesthesia is a pathologic extension of the body image. The normal person is continually of cites the Head of examples For this boundaries example, the image. extending the woman with a feather in her hat who “feels” when the feather is touched, and the surgeon who handles his probe as though it were an extension of his fingers.1 In the normal person, however, these extensions of the body image are fluid, immediately reversible, and clearly recognized by the subject as artificial. The surgeon, for example, is able at any moment to redefine correctly his body image. He “knows” that the probe is not his finger. In the group of patients described above, however, the extension of the body image seems to operate in a pathologic, rigid form. Under certain conditions these patients lose the ability to maintain a realistic definition of the limits of their body. They behave as though portions of the contiguous external world are concretely incorporated into the inner image of their body’s extent. Although we may consider exosomestheisa as a specialized body-image disturbin identification difficulties show do who be not that noted should it patients ance, and location of body parts still may show mislocalization into extrapersonal space. On the other hand, patients with an inability to identify or locate their body parts on command do not necessarily manifest exosomesthesia. In similar fashion, there is no necessary relationship between exosomesthesia and of manifested who dis-placement A difficulties. 3) (Case patient position-sense sensation into extrapersonal space did not make errors in routine tests of position made by observations with is consistent previously This in extremities. the sense Head1 that localization of single stimuli is not functionally related to sense of position of the extremities. Role of the Hand—Although displacement into extrapersonal space has been elicited from various areas of the body, it has been observed to occur most frequently from the hand. Moreover, in no case has it been elicited from another area and been absent from the hand. This predilection for the hand is consistent with the manner in which other the when As functioning reflected. rule, of a the are nervous system dysfunctions of one side of the body is impaired through cerebral disease, the disorder is most manifest in the hand. Thus, in the usual hemiplegia resulting from a capsular lesion the paresis, body-image disturbance, and sensory loss are most prominent in the hand and fingers. of the cerebral diffuse disease, with phenomena in others and these In patients, extinction, obscuration, and displacement are also best elicited when the hand is tested. Furthermore, studies of the order of sensory dominance of various areas of the body demonstrate that the hand is in the lowest rank. This is true of the dominance order of patients with cerebral disease,5 and also of normal subjects, both adults and children.6 Similarly, when allesthesia is observed, it is seen most clearly in the hand. Ben7 described a case in which the clinical course was reflected in a Nathanson and der Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, Arch. Neurol. & Psychiat. 64:501-515 7. (Oct) 1950. �10 waxing and waning allesthesia. As this patient improved, the areas from which the phenomenon could be elicited diminished, until finally allesthesia was demonstrable only in the hand. In autotopagnosia the hands are more profoundly affected than other regions. Finger agnosia, possibly the earliest sign of body-image disturbance, is frequently seen in the absence of other gross disturbances of the body schema. Furthermore, phantom limb, anosognosia, causalgia, and synesthesia are phenomena in which the role of the hand is especially prominent. Just as these pathologic phenomena are manifest in tests of other body parts, but are most clearly demonstrable in the hand, so, too, exosomesthesia, though occasion— ally demonstrable elsewhere, is most apparent in examination of the functions of the hand. Exosomesthesia in the Normal Child.—-It has been observed that sensory phenomena which occur in patients with cerebral dysfunction may be found in the nor— mal young child.6 Similarly, exosomesthesia, which we have never found in adults except when there is severe cerebral disease, can be readily observed in children up to the age of 4 years. In examination of a large series of normal children it was noted that the initial responses of children to double simultaneous stimulation frequently included exosomesthesia, although the commoner responses were extinction and displacement. Exosomesthesia was rare, however, after the initial few trials. The frequency with which exosomesthesia may be seen in children up to the age of 4 years suggests that it may represent, in the child, a “normal” developmental stage in the organization of perception. Its appearance in adults with severe brain disease may possibly be, as with other pathologic phenomena, a regression in function to a previous level of sensory integration. SUMMARY The patterned mislocalization of tactile stimuli into extrapersonal space is described and termed exosomesthesia. Exosomesthesia is observed in patients with severe organic mental syndromes. It is apparent only rarely on single tactile stimulation and is more readily elicited by the technique of double simultaneous stimulation. It is exaggerated by fatigue, rapid testing, and increased emotional tension. Barbiturate intoxication also may elicit or exaggerate the phenomenon. Exosomesthesia is most apparent in stimulation of the hand but has been observed in tests of other body parts. While it may be considered a pathologic extension of the body image, it is not dependent upon concomitant body-image disturbances. Although exosomesthesia has been observed chiefly in patients with severe mental changes, it is not a manifestation of confusion, but is a patterned, predictable phenomenon. It may be a regression, in patients with cerebral dysfunction, to a previously “normal” stage in sensory development, as suggested by the fact that it is readily observed in simultaneous tactile tests of young children. , Printed and Published in the United States of America � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Exosomesthesia; the displacement of cutaneous sensation into extra-personal space. Trans Am Neurol Assoc. 1952;56 (77th Meeting):260-2. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-6b-009 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from the A.M.A. Archives of Neurology and Psychiatry, October 1952, Vol. 68, pp. 481-490 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/796682f73a8899c60e07650432e2be6b.pdf 47708d42bc2c57225df86d2abf4a24c9 PDF Text Text W“ m mate” om' n“, 0" a: “e, x I! ‘e swam mature: M Md." 'ene etmluletlon or the tune and the head.w1th cuteneeue etilull e ceneleteht pattern or reepanee hee been oheerved 1a which errore in perception ere Ib’. frequent an the head then on the reae. In thle fleet eltuetlon the reee 1e eeld to he dullnent over the head. the pettern or teoe dullnenhe cen he found in nah-e1 end eohleophrenle ednlte hue 1e verticalerlr evident in petleute with oreehle eentel eyndruee end in children 3 to 6 yeere or eye. rhe pattern wee eo eoneplouohe thet 1t pranpted as to etuay different etilulue ooehauetlohe in order to detehelhe whether eoneletent petterue occur for body part: other then the reee end head. The eehhod at heeelns 1n hhe preeent etudr wee elesler to theh deeorlhed prevtouely. The euhjeet wee requeeted to alone hle eyee end twh perte at the had: were teuohed eteulteneauely. he wee eehed whet he felt end to loanltee the eel-fill. Teenty heeleute with arsenlo wentel eyndehee due to altruee Meet» at the brain formed the sun group or etheote . The following pert: or the body were etudledz tece, ehoulder. head. heck. hreeet, ehdalen. aenltel eeglou. buttock, thigh end toot. All #5 peeelble ouehlnetlone between these body perks were heeted e9 the: eeeh or the ereee wee teeted 1n ouehtnetlon with every other eree. fen heehe or eeoh cuehlnetloh were done in every petlent in e tench-leed cheer. !heee included teetlnz the body ereee 1n hath hetereloeoue end haeoleterel reletlohehlpe. Flee hundred and tart: teat: or elehlteneune 0n elwulteneoue etheuletlon were done on each patient. eeoond group of 178* euhgeote eoneletlhs at 660 nereel edulte, 58! echleopheenlo edulte end she patiente with arsenic hence: eyhdrnee A �studied. the etheote in theee groove eere teeted with eiualteheoue etinnli out not in en hen: oomhinetione ee eee done in were eleo the previoue group. Only 13 or the t5 poeeihle bod: continetione were studied end different groove of petiente were need for each continetion. it leeet lo teete were done on every patient. Pertiouler ettention eel directed to the initiel reeponee. the reeponeee on eilnlteneoue teeting in ell euhjeote fell into two senerel groupe. rhe etheot either reported both eti-oli correctly or reported only one etieulue ooereotly end either did not perceive the eeoond eti-ulue (extinotion) or'nielooelieed it (diepleoeeent). rho totel number or errors in peroeption over one pert or the body ee ooeoeteo to the other part of the body in eeoh continetion eere euelyeed by etetietioel lethode. In the tiret group or 20 petiente with orgenie heeiu dieeeee teeted h: the aethod of multiple triele there were 27 oolhinetione in ehioh the difference in the mocha: of extinction end dieoleoenent in the two body perte teeted eee etetietioelly eicnirieent. this occurred in ell continetione in ehioh one or the two perte nee the reee, the genital tone (nele end tenele), or the head. In the continetione involving the teoe or the cenitel none errore ih per» oeption were more frequent in pert: or the body other then theee bod: ereee. the (poo end the genital zone ney be eeid to he dolinent to ell other ereee or the body. In combinetione involving the head there eere uooeerrore in peroeption or the head etinnlue then in en: other pelted part or the body. ‘rhe hand new be eeid to be the leeet dolinlnt are. or the body. there were four additional combinationin which dominance wee Innifeeted. !he hottook wee doniuent over the heok aha ehoulder. the breeet wee dolinent over the heck, end the heck lee douinlht over the thigh. �3. 4‘.“ in anniyuil of tho rcspensca or and accend group at pitiontn with organic Iantal nvndrunn who HUI. touted in u tingle bady ounbinatien with.» than in multiplt culbinltions ahowua a liliilr pattern. inn». unto I few important axooptionn howrvor. who race an: round to b. otvonsly dominant ever tha genital tout, the foot duuinunt over the thigh And tho buttock duninant over tho fact. .. _ they. relationuhipu wart not tpplront in in. group or patients tottod by tn. Inthod of multiple trials. Th. foregoing rcuuits that that an inns. or duubic uinuitanaaul ”manna in panama um auntie mm, swarm. the "rim part: or the bear cxhibit a infinite volttianship to on. another: fihin 1i aunitoutcd hi Vlrvins accrue or dnlinnnoc which.lay ht can~ Iidorod a: gradient 0: nonnation. it the top of en. gridiont in V ' . m «um Ian. in slightly 1.» doninnnt um the he. the mu. but in dalinnnt «var all other part: of tn. bad: and i: thnrgby tho host bad: tron in tho order of dalinanoc. it tho 9th.! 0nd of tho gradient is en. hand. In. runninins aria. at thu body tail bctuoon tho no. Ind um and an acne. mu. body pm. mud in oeubinntion Iii: «flab other failed. for tho most part, to yield differtnoos in duninuaoc’cnous than other. Th0 combinstionl in which daninanoc who Innitontod showed a tondcncy for the hulbek, than-0n. brains, and taat to ho tho mare dominant part: uni tho hack. magnifier, denim“ par:- within this firm. rand cum to be the In tun series or nanlni and nahisophrcnie adult: that. uvrc only tun «albinationl in uhieh Eh. dirrorgnoo in the number at error: men in“ between the two ptrti ati-ulatod it! statintioclly significant. duninant over eh. bruit: and the brnant wax dominant ovar tn. hind. In both instance: in. pitttrn or danintnoa in: ailiitr to that Icon in patient: with organic anneal Iyndrnnn. Th. rhea III �m mm or ammo. duomtmtod by suntan-m "Inns in flinch the no. Ind tho him! for! 2!!! at"... of I Mont the body pain hu :1» been dam-tum 1n mucosa other than than with eman- «mm. or the mean. when include nomx 01:11am 3 to 6 or m, nut-t1 adults with transient damnation or the built: an. to imam“, unamor among m «lacuna-hook therapy, in! under 7 your: . not all th- :utnum mu, ma), «noun Mult- with mum use ymine we: ombmuona have been «an: Mu. flavour, at then ammun- um have been smut! a pattern 1: atom: in mm the no. 13 the most dominant m: and flu hind the lone 60.1mm. for n the»: to «at: u. mm or 4mm“ mun, none in It appear. to b. an inherent ”turn 9: organization within the mm}. ”an“: man 1.. exaggerated in tested in than ' u «than. patient: an: u m «an. or the pram. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Order of dominance in cutaneous perception. Trans Am Neurol Assoc. 1952; 56 (77th Meeting): 238-40. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-7a-010 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource Green, M.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Bender, M.B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/e80dbde06dd20201f1e94a10beff3999.pdf 14b484b6bedc00163228f7cd6f29a33a PDF Text Text Reprinted from the A. M. A. Archives of Neurology and Psychiatry August 1954, Vol. 72, pp. 233-255 Copyright, 1954, by American Medical Association PATTERNS OF PERCEPTUAL ORGANIZATION WITH SIMULTANEOUS STIMULI MORRIS B. BENDER, M.D. MARTIN A. GREEN, M.D. AND MAX FINK, M.D. NEW YORK TUDIES of function of the nervous system by any one method will show patterns. This is a general law which applies to motor, perceptual, and psychic functions. Patterns of functions are present in the normal as well as in the abnormal state. For example, normal subjects show variations in the ability to discriminate two closely applied points in different regions of the body. Thus, the pattern for two—point discrimination is one in which the finest differentiation is at the tongue or finger tips, while other parts of the body, such as the back or the thigh, require a greater distance between two points before discrimination of “twoness” 2 be made.1 Pearson the pattern for the normal sense of vibration to According can is one in which the threshold is low at the clavicle and high over the sacrum. In vision discrimination of targets under daylight illumination is best in the central, and poorest in the peripheral, portion of the perimetric field. And so it is with all other modalities. Each sensation has a pattern in space as well as in time. Each of these patterns is obtained by adopting procedures in which a single stimulus figure is used in testing the subject. In measuring sensation, we know that there are many factors which influence the perceptual response. Intensity and duration of stimulus, the stimulus figure, the locus in the sensory field, the attention and intellectual capacity of the subject are but a few of the determinants. Recently we have stressed symmetry as having a bearing on perception.3 Still another factor is age.4 For instance, there are some perceptual examinations which could not be carried out in children because the ability to respond to these tests depends partly on the ability to concentrate on a particular problem and to cooperate over a matter of many minutes. These are two properties which most very young children do not possess. Moreover, we have found that reactions in the old are not the same as those in the younger subjects. Another condition which influences the perceptual response is the number of stimuli employed at one time. Two stimuli when applied simultaneously may yield responses which are different from those to stimuli applied in succession. Simultaneous touch of the face and hand may be perceived only on the face, whereas when each of these parts is successively touched with an interval of one or more Post—Doctorate Fellow, United States Public Health Service (Dr. Green). Paper read at the Fifth International Neurological Congress, Lisbon, Sept. 7—12, 1953. This work was aided, in part, by a fellowship grant from the National Foundation for Infantile Paralysis and the Neurologic Research Fund of the Mount Sinai Hospital. From the Department of Neurology of the Mount Sinai Hospital, and the Department of Neurology and Psychiatry, New York University College of Medicine. �2 seconds, the same subject perceives each stimulus. The simultaneous application of more than two stimuli may yield other types of perceptual reactions. Cohn5 applied three stimuli all at once and obtained results which were different from those elicited with conventional single stimuli in the same areas. In 1893 Krohn 6 investigated the effects of simultaneous touch stimulation of multiple (seven) regions of the skin in normal subjects. Parts of the trunk, extremities, forehead, and, at times, the chin were touched simultaneously by tambours. With these tests the subjects made errors in localization of the applied stimuli. However, no distinct pattern was sought. In analyzing Krohn’s material, we found a suggestion of a pattern in that there were less errors over the back than over the front. This study was interesting but not very illuminating. The technique of double simultaneous stimulation had been known since the 7 of 1882 time Hippocrates. In Oppenheim mentioned the method in his textbook. Since this description there had been few intensive studies of the method until 1943, when one of us began a series of investigations. During the past decade we have examined several thousands of subjects with this technique. As we gathered our data, it was noted that in tests involving asymmetrically placed stimuli certain regions of the body yielded correct .responses, while others yielded consistently incorrect responses. On numerous simultaneous stimulations of the face and hand a distinct pattern of response has been observed in which errors in identifying and localizing the stimuli on the hand became apparent. Conversely, there were very few errors in perception of the stimuli on the face. In this test situation the face was “dominant” to the hand. Face dominance has been found in normal adults, but it is particularly evident in patients with disease of the brain, in very aged persons, and in normal children, 3 to 6 years of age. This pattern of response, namely, face dominance, has been found so consistently that it prompted us to study body combinations other than that of the face and hand. The object of this investigation was to determine the order of dominance when various combinations of two parts of the body were tested in this manner. A preliminary note on this study was reported at the 76th Annual Meeting of the American Neurological Association, in June, 1951.8 METHOD AND SUBJECT MATERIAL The method of testing was the same as that described for the face-hand test in previous communications.9 The subject was requested to close his eyes, and two parts of the body were simultaneously touched or stroked. He was asked what he felt and to localize the stimuli. If only one stimulus was reported, the subject was then asked if another was felt. The subjects used in these studies consisted of patients and normal adults and children. Series I: Patients who showed mental changes or an organic mental syndrome* as a result of disease of the brain, such as arteriosclerotic encephalopathy, senile psychosis, severe cerebral trauma, Alzheimer’s disease, toxic encephalopathy, or brain tumor. In general, patients with severe mental changes who made many errors on simultaneous stimulation tests were chosen for a special study group. Patients with aphasia, hemiparesis, or a hemisensory defect were included in another group. Series II: Normal children and adults. The normal children were taken from a day—care center and an orphanage. The normal adults were patients on the wards of the general hospital, those attending hospital clinics, and Army inductees. None of the normal The mental changes which make up the organic mental syndrome consist of a combination of at least three or more of the following manifestations: impairment in orientation, memory, calculation, or general information; rigidity and concreteness in mental performance, and marked fluctuations and inability to perform when there is more than one aspect to a situation. * �3 children or normal adults had manifest disease of the nervous system. They had not been previously examined by the method of double simultaneous stimulation. We also examined a group of older people. These were presumably normal, although cerebral arteriosclerosis could not be entirely excluded in people between the ages of 65 and 90 years. Series III: Patients with schizophrenia or manic depressive conditions. These patients were adults in the wards of the Bellevue Psychiatric Hospital and Manhattan State Hospital. No attempt was made to study the specific types of schizophrenia. Most of them were of the paranoid, mixed, or simple schizophrenic varieties. Inasmuch as previous investigations have shown that patients with severe mental changes due to disease of the brain and normal young children made frequent errors in tests of simultaneous stimulation, it was natural that we should make the most extensive studies on these two groups.10 Also, since normal adults make few errors after the first two to three trials on double simultaneous stimulation, it was not possible to detect a pattern in these subjects. From these three series of cases we studied several groups in detail. Group A, which was studied in the greatest detail, consisted of 20 patients with organic mental syndrome (10 males and 10 females). These subjects were tested with the method of double simultaneous stimulation of different parts of the body and in multiple combinations. The following parts of the body were examined: face, shoulder, hand, back, breast, penis, pubic region in females, buttock, thigh, and foot. Patients were tested while they were completely nude and, for the most part, while they were standing. The specific areas stimulated for certain parts of the body were as follows: the dorsum of the hand; the dorsum of the foot; the anterior aspect of the thigh; just below the scapula on the back; close to the midline on the buttock; the nipple and areolar area of the breast; the lower quadrant of the abdomen; the tip of the penis or the mons veneris. Of these body parts there were 45 possible double combinations. It should be noted that the combinations were of regions distributed along the longitudinal axis of the body. Each patient was tested in all 45 combinations in. a random but similar order. Twelve tests were done for each combination. These consisted of five tests of the two body parts in a homolateral relation, five tests of the two body parts in a heterologous relation, and two tests in a homologous relation, one for each of the body parts. There were 240 tests in every combination for the total group. Each patient received 540 tests. The other group, Group B, which we studied in great detail, using thousands of trial tests, consisted of 40 normal children between 3 and 6 years of age. In 20 of these children (12 boys and 8 girls), all body combinations of two were tested except those involving the genital zone. In the other 20 children (12 boys and 8 girls), the genital region combinations were tested as well as some of the other body combinations. The testing was carried out in the same manner as described for patients with disease of the brain except that only half as many tests in each combination were done. The genital zone was usually touched directly, with the child partially nude. The remaining unexposed body parts were usually tested through the clothing. To supplement these studies, we also examined a group of 692 normal adults, 605 schizophrenic adults, and 664 patients with organic mental syndrome. However, these subjects were not tested as intensively as those of the above two groups. Different body combinations were tested in different subjects. Only one of the following body combinations was tested in any one subject for 10 trials or more; face—hand, face-breast, face—penis, face-back, face-foot, face— shoulder, shoulder—hand, breast—hand, penis—hand, thigh-hand, foot-hand, thigh-foot, breast-foot, breast-thigh, buttock—foot, penis-foot, shoulder—foot, and shoulder-breast. The two parts of the body were first touched in two heterologous relations and then in the two homolateral relations. Particular attention was directed to the first response. If an error was made in any one test, that particular test was repeated until the patient was correct, or for at least five times if the error persisted. At least 10 trials were done on each patient. Stimulation of the unexposed parts of the body, except for the penis, was done through clothing. The penis was touched directly. The pattern of dominance has also been studied incidental to other investigations on perception in groups such as Group C, comprised of patients with focal brain disease manifested by hemiplegia or aphasia 11; Group D, patients with long—standing or congenital blindness; Group E, patients who had congenital or long—standing deafness; Group F, normal adults recovering from general anesthesia or while under the effect of intravenous amobarbital (Amytal) sodium 12; Group G, psychiatric patients receiving electroconvulsive therapy; Group H, mentally �4 defective adults,13 and Group I, very aged or senile adults.4 It must be emphasized, however, that we did not test all the possible combinations of body parts in every one of these groups except in Groups A and B. The emphasis was mainly on determining the relationship of the face and the hand to the rest of the body areas. The results obtained in these incidental studies showed that the pattern of dominance was similar to the one obtained in this study of patients with severe mental changes due to disease of the brain. RESULTS The responses on double simultaneous testing of any two parts of the body fell into several groups. Using the face—hand combination as an example, the subject may report the following responses, as recorded in Table 1. Responses in which there was extinction or displacement“? of the stimulus over one area in any combination were tabulated as a single type of response. For example, in the face-hand combination responses in which the face stimulus was correctly perceived but in which extinction or displacement of the hand stimulus TABLE 1.—Pattem of Responses to Double Simultaneous Farce-Hand Tests Combination of Body Parts Simultaneous touch of face and hand ‘ Possible Response (a) Face-hand Classification Correct (b) Face only Extinction Face Extinction Hand Displacement Face (c) Hand only (d) Face-face Dominance None (e) Hand-hand Displacement Hand (f) Face-other part of body Displacement Face (9) Hand-other part Displacement Hand (h) Face-and a in space part Exosomesthesia Face Exosomesthesia Hand of body (i) Hand-and a part in space occurred were tabulated together under “face” responses. Each of the responses indicates dominance of the face over the hand. Hence, the reason for grouping them under “face dominance.” Face dominance responses were much more fre— quent than any of the hand dominance responses. The responses for all the body combinations were tabulated in a similar manner. For the patients with organic mental syndrome and for the normal children tested in all body combinations, the “dominant” responses for one part of the body as compared with those of the other part of the body in each combination were analyzed by the t test. The initial responses of the normal and schizophrenic adults and of the other patients with organic brain disease tested in a single combination were analyzed by the method of chi-square. There were a small number of responses The failure of the subject to report one of two simultaneously applied stimuli has been called “the phenomenon of sensory extinction,” or “extinction.” The part of the body where the stimulus is perceived is said to be “dominant” to the part of the body where the simultaneous stimulus is not perceived. When the subject reports two sensations but mislocalizes one of them, the “displacement” of a percept is said to have occurred. Displacements are usually in the direction of the dominant stimulus and may be partial or complete. Occasionally, one or both stimuli are displaced into the extrapersonal space. This has been termed “exosomesthesia.”14 1' �5 TABLE 2.—Res[>onses of Twenty Patients with Organic Mental Syndrome to Simultaneous Tests of Different Body Combinations Dominant Dominant Responses Other Total Errors* Face Part Face Combinations Face-genitals .................. FACE-abdomen i .............. FACE-buttock ................. FACE-breast .................. FACE-foot .................... FACE-back .................... FACE-shoulder ................ FACE-thigh ................... FACE-hand .................... 68 109 79 122 89 105 154 37 78 60 104 66 95 127 85 145 104 149 31 31 19 18 23 10 27 19 4 Responses Genitals Combinations Genitals-face ................... GENITALS-abdomen .......... GENITALS-buttock ........... GENITALS-breast ............. GENITALS-foot ............... GEN ITALS-back .............. GENITALS-shoulder .......... GEN ITALS-thigh .............. GEN ITALS-hand .............. Total Errors Geni- Other 68 121 78 106 138 98 90 124 143 Dominant Hand Combinations Hand-FACE .................. Hand-GENITALS ............ Total Errors Hand-ABDOMEN ............. Hand-BUTTOCK ............. Hand-BREAST ............... Hand-FOOT ................... Hand-BACK .................. Hand-SHOULDER ........... Hand-THIGH ................ 149 143 152 132 163 136 97 127 142 ____/Lfi Other Hand Part 4 145 132 131 109 134 117 69 107 114 11 21 23 29 19 28 20 28 H% Buttock Combinations Buttock-FACE ................ Buttock-GENITALS ........... Buttock-abdomen ............. Buttock-breast ................ .................. BUTTOCK—back ............... BUTTOCK-shoulder ........... Buttock-thigh ................. BUTTOCK-hand Buttock—foot ............... 79 78 99 94 118 104 93 105 132 Other 19 12 38 55 43 79 65 45 109 60 66 61 39 Part 75 25 28 60 23 Abdomen Combinations Abdomen-FACE ............... Abdomen-GENITALS ......... Abdomen-buttock ............. Abdomen-breast ............... Abdomen-foot ................. Abdomen-back ................. Abdomen-shoulder ............. Abdomen-thigh ................ ABDOMEN—hand .............. 109 121 99 111 104 97 90 115 152 r Foot-FACE .................... Foot-GENITALS .............. Foot-abdomen ................. Foot-buttock .................. Foot-breast .................... Foot-back ..................... Foot-shoulder ................. Foot-thigh ..................... FOOT-hand .................... 89 138 104 118 100 105 96 125 136 23 23 58 75 41 49 51 77 117 66 115 46 43 59 56 45 48 19 Breast Combinations Breast-FACE .................. Breast-GENITALS ............ Breast-abdomen ............... Breast-buttock ................ Breast-foot .................... BREASToback ................. Breast-shoulder ................ Breast-thigh ................... BREAST-hand ................. 122 106 111 94 100 77 121 85 163 Shoulder Combinations Shoulder-FACE ................ Shoulder-GENITALS .......... Shoulder-abdomen ............. Shoulder-BUTTOCK ........... Shoulder-breast ................ Shoulder-foot.................. Shoulder-back ................. Shoulder-thigh ................. SHOULDER-hand ............. 154 90 90 93 121 96 131 93 127 der Part 27 20 32 28 69 45 53 58 107 127 70 58 65 52 51 78 35 20 Responses ' ' _fi 18 22 56 39 59 55 52 48 134 104 84 55 55 41 22 69 37 29 Responses Back Combinations BaCk-FACE .................... Back-GENITALS .............. Back-abdomen ................. Back-BUTTOCK............... Back-BREAST ................. Back-foot ...................... Back-shoulder ................. BACK-thigh ................... BACK-hand .................... Total Errors 105 98 97 104 77 105 131 127 97 r—A—fi Other Back Part 10 15 53 25 22 56 78 86 69 95 83 44 79 55 49 53 41 28 Dominant Responses Responses Total Errors 21 Dominant Dominant f—A—‘l Shoul- Other 131 Total Other Errors Breast Part Responses Foot Combinations 29 61 55 46 44 58 76 78 92 38 56 58 53 32 39 31 Dominant Dominant r———A‘—fi Other Total Errors Foot Part 37 29 12 22 23 15 20 30 11 ,__JL_____ Total Ade- Other Errors men Part Responses Buttock 31 92 66 84 115 83 70 94 132 Responses Dominant Total Errors Part Dominant Responses '— tals Thigh Combinations Thigh-FACE ................... Thigh-GENITALS ............. Thigh-abdomen ................ Thigh-buttock ................. Thigh-breast ................... Thigh-foot ..................... Thigh-BACK ................... Thigh-shoulder ................ THIGH-hand .................. Total Errors 104 124 115 105 85 125 127 93 142 r-_A_—fi Other Thigh Part 19 30 39 60 37 48 41 35 114 85 94 76 45 48 77 86 58 28 Two hundred tests done in each combination were analyzed statistically. The remaining 40 tests in each combination were of homologous body parts and did not lend themselves to this type of analysis. i Capital letters indicate dominant part as evidenced by a t test value of 5% or less. * ‘ �6 which were difficult to interpret, and there were a few that showed characteristic perseveration in behavior. These responses were not included in the statistical analysis. Extinction and displacement occurred in all of the body combinations tested in all groups. The incidence of these phenomena varied with the method of testing. On testing body parts in a heterologous but bilateral relation, extinction and displacement occurred with approximately equal frequency. With tests involving ipsilateral body parts, the majority of errors consisted of extinction. 1. Patients with Organic Mental Syndrome—In Group A 20 patients were tested in all the combinations of the body; there were 27 combinations in which the difference in the frequency of extinction and that of displacement in the two body parts tested was statistically significant, as evidenced by a t test value of 5% or less (Table 2). This difference occurred in combinations of the face and TABLE 3.—Response on the Initial Trial in Patients with. Organic Mental Syndrome Tested in a Single Body Combination Responses Indicating Dominance of Body Part Combination of Body Part ,——-——A———fi B A FACE * FACE FACE FACE FACE SHOULDER BREAST PENIS FOOT THIGH FOOT BUTTOCK PENIS Shoulder Shoulder * Hand Breast Penis Back Foot Hand Hand Hand Hand Hand Thigh Foot Foot Foot Breast N o. of r—A gfi Other Responses .. Subjects Correct 156 15 17 136 44 8 7 21 1 0 17 21 17 37 23 2 4 O 0 1 2 5 2 2 0 2 0 71 30 30 30 9 32 51 12 7 31 6 10 49 23 60 35 40 23 13 8 19 5 8 1 3 B 5 6 30 7 15 25 21 O 30 12 5 Capital letters indicate dominant part as evidenced by a chi-square value of 4 12 8 4 1 1 9 1 5 0 5% 1 or less. other parts, the genital region (penis in males and pubic region in females) and other parts, or the hand and other parts. In combinations involving the face or the genital region, errors in perception were infrequent. Therefore the face and the genital region may be termed as dominant to all other parts of the body. In combinations involving the hand, the opposite phenomenon occurred; errors in perception were more frequent in the hand. The hand may be classified as the least dominant area of the body. Thus, in face-hand tests the results may be expressed either as degree of face dominance or that of hand errors. There were four additional combinations in which dominance was manifested. The buttock was dominant to the back and shoulder, the breast was dominant to the back, and the back was dominant to the thigh. The remaining 18 combinations showed no domi— nance between the two body parts tested, as evidenced by t values greater than 5% (Table 2). These 18 combinations were retested in a different group of 20 patients. The method was similar to that described previously except that the order of testing was more randomized. When the statistical probabilities of the two series of tests were combined, all of these combinations again failed to manifest dominance. �7 An analysis of the responses of the group of 664 patients with organic mental syndrome tested in single rather than multiple body combinations showed a similar pattern (Table 3). There were no instances in which dominance in this group was different from that of the preceeding group. However, some combinations manifested dominance which was not shown in the first group. Thus, the face was dominant to the genital region; the foot was dominant to the thigh, and the buttock was dominant to the foot. In summary, the foregoing results show that double simultaneous stimulation tests of parts of the body exhibit a definite relationship of one part to another. This is manifested by varying degrees of dominance, which may be considered as a gradient of sensation. At the top of the gradient is the face, the most dominant part of the body. The genital region is slightly less dominant than the face but is dominant over all other parts of the body and is thereby the next body area in the order of dominance. At the other end of the gradient is the hand, the least dominant part of the body. The remaining areas of the body fall in the gradient between the ‘ loo— I’ACE PERCENTAGE 0r ooutNAN'r RESPONSES GENITAL R [6| 0 N ABDOMEN BUTTOCK BREAST 6° 5° FOOT BACK SHOULDER TH IGH 4° HAND 30 20 no 0 BODY PART FIG. I. ORDER OF DOMINANCE IN PATIENTS WITH ORGANIC BRAIN DISEASE face and genital region and the hand. These parts include the shoulder, foot. thigh, and the areas on the trunk. W'hen tested in combination with each other, these body parts failed, for the most part, to yield differences in dominance among one another. There was a tendency, however, for the buttock, abdomen, breast, and foot to be dominant to the back, shoulder, and thigh. The order of dominance of all body areas may be illustrated by comparing the total number of dominant responses for each area in the group of 20 patients tested in multiple combinations (Fig. l). N ownal C lzildrew—It has been shown that normal children make errors in simultaneous cutaneous sensory tests just as do patients with an organic mental Syndrome. There was one striking difference, however, between the two groups. 2. Children tended to learn the correct response as the tests were repeated over a period of days, whereas patients with an organic mental syndrome showed but temporary learning tendencies. They soon forgot what they learned and again made the errors. When various combinations of two parts of the body were tested in the young children, an order of dominance became apparent, just as in the patients with an �8 organic mental syndrome. The order of dominance in normal children resembled, to a considerable extent, that found in patients with diffuse brain disease. The face was the most dominant and the hand the least dominant area (Fig. 2). The genital region was not so dominant as in patients with organic disease of the brain, since it failed to show dominance to the shoulder, back, and breast, although it was dominant to all other areas. In tests involving the genital region many children snickered, laughed, or showed other signs of special awareness of the sexual organs. Some refused to be touched there and became uncooperative. Because of this atti— tude, it was necessary to obtain the parents’ permission for the test. The order of dominance for the rest of the body areas in these children also showed little difference from that noted in patients with disease of the brain (Table 4). In only one of these combinations was dominance different from that demonstrated in patients with an organic mental syndrome. In children the foot was dominant to the buttock. The same combination tested in the group of patients with an organic mental syndrome showed the buttock dominant to the foot. IOO so PERCENTAGE 0‘ DOMINANT RESPONSES °° ,0 FACE GENITAL REGION SHOULDER roor co aurrocx BREAST so BACK THIGH 4° ABDOMEN HAND 30 20 l0 0 BODY PART FIG. 2. ORDER OF DOMINANCE IN NORMAL CHILDREN 3-6 YEARS OF AGE Normal Adults.—Several groups of normal adults were studied. In previous communications the responses of simultaneous touching of the face and hand were reported. The results showed a high face dominance. Examination of other body combinations showed a tendency to similar pattern, as recorded in the foregoing paragraphs (Table 5). However, the data obtained in combinations other than the face-hand were not very reliable, because the number of experiments were too few in number. It should be noted that the normal adult very readily grasps the idea of “twoness,” or the concept that two stimuli are being used. Consequently, his chances of yielding a single response on repeated tests are small, especially if he once correctly reports the perception of the stimuli. Thus, it would be most difficult for us to get a large number of statistically significant data for other body areas. In order to obtain reliable data it would be necessary to test a very large number of normal adults by statistical methods. For the time being, most of our emphasis was placed on testing patients with organic brain disease, young children, and very old adults. Judging from our data, it may be presumed that the complete order of dominance observed in patients with organic disease would also be present in the normal subject if a greater number of subjects were tested. 3. �a m 9 TABLE 4.—Responses of Normal Children Three to Six Years of Age to Simultaneous Tests of Different Body Combinations Dominant Dominant Responses Face Combinations FACE-genitals i ............... FACE-shoulder ................ FACE-buttock ................. FACE-foot .................... FACE-breast .................. FACE-back .................... FACE-thigh ................... FACE-abdomen ............... FACE-hand .................... Total Errors* 57 79 52 77 74 74 47 66 71 Responses ,._—A_fi Other Face Part 38 65 35 65 65 55 38 19 14 17 51 64 Genitals Combinations Genitals-FACE ................ Genitals-shoulder .............. GENITALS-buttock ........... GENITALS-foot ............... Genitals-breast ................ Genitals-back .................. GENITALS-thigh.............. GENITALS-abdomen .......... GENITALS-hand .............. 12 9 19 9 15 7 Total Errors r—Afi Other tals Part Geni- 57 56 65 87 74 62 81 19 28 45 78 46 39 65 65 79 81 88 Dominant Hand Combinations Hand-FACE ................... Hand-GENITALS ............. H and-SHOULDER ............ Hand-BUTTOCK .............. Hand-FOOT ................... Hand-BREAST ................ Hand-BACK ................... ................. Hand—THIGH Hand-ABDOMEN .............. 71 7 88 66 72 72 79 85 76 86 9 7 5 9 17 15 27 15 Other Part Shoulder Combinations Shoulder-FACE ................ Shoulder-genitals .............. Shoulder buttock .............. Shoulder-foot .................. SHOULDER-breast ............ SHOULDER-back ............. SHOULDER-thigh ............. 64 79 59 67 63 62 70 49 SHOULDER—abdomen. .. . . . . . SHOULDER-hand ............. 71 Total Errors 79 56 67 63 77 84 59 Buttock Combinations Buttock-FACE ................ Buttock-GENITALS ........... Buttock-shoulder.............. Buttock-FOOT ................ Buttock-breast ................ BUTTOCK-back ............... Buttock-thigh ................. BUTTOCK-abdomen .......... BUTTOCK-hand ............... 52 65 67 66 59 76 66 56 72 Part 17 20 42 21 30 49 31 40 67 35 45 25 45 29 27 35 16 5 74 66 Foot Combinations Foot-FACE .................... Foot-GENITALS .............. Foot-shoulder ................. FOOT-buttock ................. Foot-breast .................... Foot-back ..................... FOOT-thigh ................... FOOT-abdomen ............... FOOT-hand .................... Total Errors 12 9 32 45 32 31 47 40 63 Breast-FACE .................. Breast-GENITALS ............ Breast-SHOULDER ........... Breast-buttock ................ Breast-foot .................... BREAST-back ................. Breast-thigh. . ................ BREAST-abdomen ............ BREAST-hand ................. 74 74 77 59 61 64 50 64 79 9 28 21 29 29 42 26 47 62 65 46 56 30 32 22 24 17 17 Dominant . Back Combinations Back-FACE .................... Back-GENITALS .............. Back-SHOULDER ............. Back-BUTTOCK ............... Back-foot ...................... Back-BREAST ................. BACK-thigh ................... Back-abdomen ................. BACK-hand .................... Thigh Combinations Thigh-FACE ................... Thigh-GENITALS ............. Thigh-SHOULDER ............ Thigh-buttock ................. Thigh-FOOT ................... Thigh-breast ................... Thigh-BACK ................... THIGH-abdomen .............. THIGH-hand .................. * 47 81 59 66 65 50 77 66 76 r—A—fi Other Thigh Part 9 16 20 35 18 24 28 42 49 38 65 39 31 47 26 49 24 27 Part 65 78 31 21 29 35 18 17 9 Total Errors 74 62 84 76 66 64 77 61 85 r- Responses Back 19 23 29 27 35 22 49 27 70 Other Part 55 39 55 49 31 42 28 34 15 Dominant Responses Total Errors Other Dominant F—‘A—fi Other Breast Part 65 28 42 32 21 29 20 26 7 Foot- 77 87 63 66 61 66 65 57 72 Responses Breast Combinations 14 28 25 31 56 55 Responses Dominant Total Errors Part Dominant __Jk_fi Other tock der 39 48 59 Responses f—But- 9 Shoul- Other Dominant Total Errors 28 23 16 16 Responses r-“—"'"—-—\ Hand 9 Dominant Responses Total Errors 38 28 20 Responses Abdomen Combinations Abdomen-FACE ............... Abdomen-GENITALS ......... Abdomen-SHOULDER ........ Abdomen-BUTTOCK .......... Abdomen-FOOT ............... Abdomen-BREAST ............ Abdomen—back ................. Abdomen-THIGH ............. ABDOMEN-hand .............. r———*—fi Total Ade- Other Errors men Part 66 81 74 56 57 64 61 66 86 15 16 26 16 17 17 34 24 71 51 65 48 40 40 47 27 42 15 One_hundred tests done in each combination were analyzed statistically. The remaining 20 tests in each combination were of homologous body parts and did not lend themselves to this type of analysis. 1 Capital letters indicate dominant part as evidenced by a t test value of 5% or less. �10 In testing normal subjects it was noted that they responded by mentioning the face as being the area touched and only when questioned further did they mention the hand. In other words, there was a preference for the face in the response. In another series of simultaneous tests of 20 normal adults the following method was used. Twenty normal adults were informed that they were to be touched on two regions of the body and that they were to report only one of the two places stimulated. The eyes were closed during these tests. Ten tests were done in 8 body combinations in a random fashion (tests involving contralateral and homolateral used in working out the order of in similar that of the to a manner body) parts TABLE 5,—Response on the Initial Trial in N ormal Adults Tested in a Single Body Combination Responses Indicating Dominance of Body Part Combination of Part r———&———-—m Body A FACE * FACE Face Face Face Face BREAST Shoulder Penis Thigh Foot Thigh Breast Shoulder Breast * No. of: B Subjects Correct Hand 160 94 17 30 31 30 76 30 30 30 54 30 30 32 18 77 58 Breast] Shoulder Penis Back Foot Hand Hand Hand Hand Hand Foot Foot Breast Thigh 9 25 22 26 40 24 17 17 44 16 23 19 9 78 29 6 4 6 5 0 0 2 0 2 2 0 0 3 2 2 7 2 6 7 2 1 3 9 6 7 6 o 1 2 4 3 of. 5% 0 or less. 6.—Simnltaneons Touch Stimulations of Various Body Combinations Body Combination Face-hand ............................................... Face-thigh ............................................... Face-shoulder ............................................ Face-foot ................................................ Shoulder-hand ........................................... Hand-thigh .............................................. Thigh-foot ............................................... Hand-foot ............................................... There were . . 0 4 31 2 11 . Other Responses 5 2 2 1 1 Capital letters indicate dominant part as evidenced by a chi-square value TABLE * ,———J\—-q A B 200 * r—«Choices Given—fl Hand 40 Face 160 Face Face Face Shoulder Hand Thigh Hand 175 142 167 158 141 103 114 Thigh Shoulder Foot Hand Thigh Foot Foot 25 58 33 42 59 97 86 tests for each combination. dominance in Groups A and B. There were 200 tests in each combination. The 6. in Table recorded results The not are investigated. genital regions were From an analysis of Table 6 it is obvious that the face is the part of the body which is chosen oftenest when it and other parts of the body are touched simul— taneously. These findings support the results obtained by other methods. However, this method of selection, when the subject knows that two parts of the body are being touched, did not reveal the expected hand inferiority. This finding does not necessarily detract from observations obtained by the methods described above, where the subject was to report what he perceived after he was touched in two places without warning. After this series of tests each of these 20 subjects was asked to indicate which part of the body they were the most and the least aware of during testing. The results are tabulated in Table 7. �11 Of significance in both sets of these experiments is the fact that the face shows a high dominance. However, it must be stressed again that the last two methods do not reflect the low order of hand dominance. 4. Adults with Schizophrenia—When these patients made errors, the errors were similar to those obtained in normal adults under the age of 65. Each patient showed significant dominance of the face to the hand as well as to the foot, the breast to the hand and foot, and the penis to the hand and foot (Table 8). The relationship of all the body areas has not been worked out so completely in these subjects as in the preceding groups. The difficulty in demonstrating the a“ TABLE 7.——Responses of Twenty Patients as to Areas of Greatest and Least Dominance Body Part Most Aware of Face .................................. Face and foot ........................ Face and thigh ....................... Hand .................................. Foot No. of Body Part Least Aware of Subjects Thigh .................................. 10 Subjects 16 1 1 1 .................................. TABLE No. of 1 Foot .................................. Hand .................................. Shoulder and thigh ................... Foot and shoulder .................... Not asked .............................. 1 1 8,—Response on the Initial Trial in Schizophrenic Adults Tested in a Single Body Combination Combination of Body Part ,——————J% A B FACE * Face Face Face FACE Face Shoulder BREAST PENIS Thigh Foot Thigh BREAST PENIS Shoulder * 4 3 1 Hand Breast Penis Back Foot Shoulder Hand Hand Hand Hand Hand Foot Foot Foot Breast No. of Subjects Correct 72 24 52 23 29 25 81 30 42 37 13 31 77 43 2 19 29 2O 3!) 31 15 30 30 30 28 15 9 17 15 9 Responses Indicating Dominance of Body Part f————N———fi A B Other Responses 46 2 11 2 4 4 2 2 14 3 7 12 8 8 44 19 11 8 4 19 8 3 0 3 3 0 0 1 3 3 9 1 1 6 2 10 1 1 1 2 3 8 2 1 Capital letters indicate dominant part as evidenced by a chi-square value of 5% or less. complete pattern in schizophrenic patients was the same as that encountered in normal adults. They showed fewer perceptual errors on simultaneous tests than did either patients with organic brain disease or children. These errors occurred only during the intial trials, so that one subject could be tested for only one body combinationi~ There were a number of patients with schizophrenia who presented bizarre responses. The touch stimuli were occasionally misidentified and were reported as “a burning” or “a fly crawling.” At times the number of percepts were multiplied. Instead of perceiving the two applied stimuli, they reported three or more percepts in a variety of body parts. Similarly, a single stimulus was reported as two or more percepts, the locus of the original stimulus being occasionally omitted. Such patients usually persisted in the bizarre responses on repeated testing on subsequent days. Several of the paranoid patients refused to close their eyes but permitted examination provided they could see. I}: �12 Senile Adults.—Studies of body combination tests in senile adults 65 to 96 of the disease in with found those of similar results showed to patients age years brain and in very young children.‘ The most dominant region was the face and the least dominant the hand. In plotting the errors on face-hand tests in normal subjects of all ages, we found that children under the age of 6 years and adults over the age of 65 show the greatest incidence. 6. Supplementary Studies of Blind or Deaf Subjects.——While we were conducting the foregoing experiments, we, naturally, tried to find an explanation for face dominance. One of the thoughts we entertained was that normal subjects developed the concept of the face being foremost in importance. It might be assumed that the earliest sensory image a subject experiences would be the sight of the mother during infancy. Therefore, the earliest memory of a person and his selfidentification would be the visual image of a face. Moreover, young children who are asked to draw the picture of a man draw the face first and foremost, paying less attention to other parts of the body. Goodenough 15 made similar observations on the drawings of mentally retarded persons and patients with disease of the brain. Since visual memory and imagery of a face would seem to be important in one’s sensory experience, it was thought that the congenitally blind might not respond as the normal subject does when he is tested with cutaneous stimulations. With this in mind, a series of congenitally blind children and another series of adults with an organic mental syndrome and long-standing acquired blindness were tested with double simultaneous stimulation of the face and hand. Results showed that there was no difference in the pattern of response between the blind and the normal subjects. A. Blind Subjects: I. Children. Forty-two normal children (3 to 14 years of age) with congenital blindness were tested in face-hand and hand-foot combinations. Ten tests (heterologous and homolateral parts of the body) were done for each combination in a random order. The results obtained were as follows: 1. Of all children 6 years of age or younger who were congenitally blind, 79% showed persistent errors after 10 trials of testing. 2. In the face-hand combination tests the following responses were obtained: 5. Face Only Face-Face Hand Only Hand-Hand 202 34 2 1 3. In the foot—hand combination tests the responses were as follows: Foot-Foot and Partial Displacement of Hand-Hand Hand Stimulus Hand Only Foot Only 51 26 26 9 4. The pattern of all errors throughout the testing was the same as that for normal children without blindness. II. Adults. Ten adults with an organic mental syndrome and blindness acquired after childhood were tested with multiple face—hand tests. All showed persistent errors. The analysis of all the errors are as follows: Face Only 100 Face-Face 7 Hand Only Hand-Hand 1 1 From this analysis it is obvious that preservation of vision in infancy is not essential for face dominance. �13 B. Deaf Subjects: We also thought of other causes for face dominance, namely, that the touch applied to the face was not only felt but reinforced by the sound stimulus produced by the touch on the face, which is so near the ear. To establish or exclude this possibility, we studied a series of deaf people. Thirty-two adults with deafness acquired in early infancy or childhood were tested with multiple face—hand tests. These subjects were otherwise normal. They had no evidence of disease of the brain. The results are indicated in Table 9. Again we found face dominance. Hearing did not seem to be a factor in face dominance. COMMENT From the foregoing studies it is obvious that we have been investigating perceptual functions from the standpoint of patterns. For many years Lashley§ has been stressing the fact that the data obtained on neurologic examination should always be analyzed with reference to pattern of activity. We did this in the compilation of our own results. By clinical observation we learned that when the cutaneous sensory field is examined under conditions of simultaneous stimulation a distinct pattern is discerned. The pattern is most apparent in testing two non— TABLE 9.—Incidence of Errors for Deaf Subjects, Initial and Subsequent Trials Total No. of Initial Trial—*fi—fi Subjects Correct Face Only Face-Face 32 Hand Only 9 19 2 2 r—-———~—Initial and Subsequent Trials———fl Face Only 86 Face-Face Hand Only Hand-Hand 1 4 0 symmetric regions, far removed from each other and situated along the longitudinal axis of the body. The resultant interaction between these two sensory stimuli yields a characteristic pattern. In studying the data, it was learned that the face is the most dominant region of the organism. The genital zone is next in the order of dominance, while other parts of the body follow in a gradient, with the hand mani— festing the least dominance. Thus, the most conspicuous gradient is between the face and the hand. The pattern of response we obtained by testing with the method of double simultaneous stimulation has been found consistently on numerous occasions, under a variety of conditions, and in many groups of subjects. In considering our results, we naturally ask what the organizing principle of this perceptual pattern might be, or with which neurophysiologic or psychophysio— logic data it may be correlated. Why is the face the most dominant and the hand the least dominant? Why does the genital region show a high dominance? What determines such an order of dominance? Is it acquired by learning; is it inherent, or is it a product of each? If it is inherent, what role does the body image play? Anatomic or Neuro-“Electrical” Studies—In considering the anatomic substrate, we find no apparent correlation of findings elicited on electrical studies of the cerebral cortex with areas of the body which show dominance by our method of stimulation. Some aspects of tactile sensory interaction have been discussed by § References 16 through 18. �14 1" in their and Bard Marshall, Woolsey, mappings of the cerebral cortex of the cat and monkey by the method of evoked action potentials. The map of the “sensory cortex” as determined by electrical stimulation or evoked action potentials does not serve to explain the order of dominance. It might be supposed that the degree of dominance found in a part of the body would be proportioned to the area in the cerebral cortex in which this part of the body is electrically represented. However, this is not the case. The face and the hand, the most and the least dominant areas. respectively, in our system of testing, have approximately equal representation in the homunculus of the human cortex as determined by the method of electric stimulation of the cerebrum.20 It is not certain whether electrical studies on neuron action will give us the answer, for, as Lashley has repeatedly pointed out, most studies are made on surgically isolated or anesthetized animals, and these are far from being in a physiologic state. Our own clinical studies show patterning of sensory interaction in the physiologic state of man, whether there is or is no disease of the brain. This is a physiologic fact. The meaning of this fact, however, is not as yet clear. This patterning of sensory interaction does not occur in any one region of the cortex. It is the result of integration of perceptual function, which takes place in the entire brain at the cortical, thalamic, and even lower levels of the nervous system. There is no doubt that sensory interaction occurs, but that this interaction is patterned and how it is patterned is still a mystery. Psychophysiologic S‘tudies.—Our own psychophysiologic data also fail to shed any light on our problem. Studies of thresholds of cutaneous sensations, types and nature of stimuli, and attention of subject and sensorimotor responses did not offer clues to a solution. Critchley,21 in his interesting article on tactile functions in the blind. suggested that face dominance may be due to the sensitivity of the skin. It does not seem to be a matter of thresholds,” for we have been working with crude supraliminal stimulations. The stimuli we employed consisted for the most part of firm taps or scratching and slapping of the face and hand, or repetitive or moving stimulations, such as rubbing. Moreover, the tactile thresholds. as obtained in different regions of the cutaneous sensory field by use of the method of von Frey,23 using von Frey’s hairs (Table 10), or with a stimulus such as pinprick (Table ll), show no strict correspondence to the “dominance” values obtained by the method of simultaneous tactile or pinprick stimulations. The use of stronger or more noxious stimuli, such a pinpricks, will reveal a lower incidence of errors, but the pattern of dominance will be the same. Nor is there any correlation between the acuity of the sense of two—point discrimination and the order of dominance. It will be recalled that the ability to discriminate two points at the finger tips or at the hand is much greater than that at many other parts of the body, excluding the lips and tongue; yet the hand shows the lowest order of dominance. This lack of correspondence is contrary to the hypothesis proposed by Denny-Brown, Meyer. and Horenstein, who studied patients with lesions of the parietal lobe.“ In our studies of normal subjects and of patients with disease of the brain, including that of the parietal lobe, we find no correlation between incidence of errors as elicited by the method of double simultaneous stimulation and the two-point discriminative potentialities of a given cutaneous area. �15 Still another factor to consider is that of attention. Critchley,“ in a series of papers, claims that it is a lack of attention which causes the imperception of one of the two simultaneous stimuli in patients with lesions of the parietal lobe. As expected, this type of sensory defect is apparent only on the side opposite the cerebral lesion. It is especially pronounced in the hand and least manifest in the face, thus reflecting a pattern with an order of dominance similar to the one illustrated in normal children and in subjects with diffuse disease of the brain. If this pattern in the parietal lobe lesion is interpreted as due to a lack of attenTABLE 10.—5timulus Threshold for Pressure, in Grams per Square Millimeter, After von Frey Cornea ................................... 0.3 Conjunctiva ............................. 2.0 Tongue ................................... 2.0 ...................................... 2.0 2.5 ....................................... Finger tip ................................ 3.0 Eyelid (edge) ............................. 3.0 Infraorbital area ........................ 3.0 Forehead ................................. 3.0 Hollow of palm .......................... 7 Dorsum of fingers ........................ 5.0 Upper arm, flexor surface ................ 7 Thigh, inner side .......................... 7 Forearm, flexor surface .................. 8 Nipple .................................... 8 Anterior edge of deltoid ................. 9 Anterior edge of axilla .................. 11 Xyphoid process ......................... 11 Mucosa of. check .......................... 12 Nose Lip 12 15 16 16 16 16 17 26 26 26 27 27 27 28 Prepuce ................................... Spinous processes ........................ Medial edge of scapula ................... Deltoid muscle ............................ Upper arm, extensor surface .............. Abdomen .................................. Orifice of urethra ......................... Thigh, outer side ......................... Areola of breast .......................... Undersurface of breast ................... Sole, noncalloused part ................... Tibia ...................................... 28 Forearm, extensor surface ................ 33 Inguinal area ............................. 48 Glans penis ............................... 111 Sole, calloused part ....................... 250 11.—Stimulus Threshold for Pain, in Grams per Square Millimeter, After van Frey TABLE Cornea .................................... Conjunctiva .............................. ..................................... Abdomen ................... ............... Forearm Flexor surface ........................ Extensor surface . E yelid 0.2 2 10 15 . Upper arm ................... Flexor surface ........................ Outer condyle of humerus ................ ..................................... ....................................... Cheek Calf Hand, dorsum ............................ Foot, dorsum ............................ Calf ....................................... 20 30 30 30 30 30 Upper thigh Outer surface ------------------------ 30 Inner surface ......................... 30 Extensor surface ..................... 40 50 FOOL dorsum ............................ . 1v Edild’ dorsum 100 llbla """""""""""""" ...................................... Internal malleolus ....................... Hand, palm .............................. Sole, callouscd portion ................... Finger tip ................................ 00 110 130 200 300 tion, it must be that the inattention is only on one side of the body, and particularly in the hand. In other words, the term inattention becomes synonymous with defective perception produced by the parietal lobe lesion. Nevertheless, attention tends to modify perceptual responses. According to William James, “when the things to be attended are small sensations and when the effort is to be exact in noting them it is found that attention to one interferes a good deal with the perception of the other.”46 But does this explain the pattern in dominance or in errors in perception as illustrated in Figures 1 and 2? It might be claimed that man pays most attention to the face because he is most interested H References 25 through 28. �16 in this part of the body. Such reasoning may explain face dominance, but it does not account for the frequent errors made in the hand stimulus. The latter finding would imply that man pays the least attention to the hand, less than to any other part of the body. Now, it is hardly likely that one pays less attention to one’s hands than to one’s back. Yet, according to our data, the back dominates over the hand, implying that man is more interested in his back than in his hand. This is contradictory, and it becomes obvious that attention does not account for the order of dominance as depicted in Figures 1 and 2. A defect in attention may crystallize but not determine the pattern of perception as elicited by the method of double simultaneous stimulation. Further evidence against the attention theory are the recent experiments by Hooker.29 He found an order of dominance in sensation, using double simultaneous touch stimulations, in the human fetus. Eventhough the response to stimuli in his experiments involves an order lower than that implied in our results, there was a distinct pattern under his conditions of testing in which attention was not a factor. When there was simultaneous cutaneous stimulation of the face and hand, the dominant motor response was that typical of the face. An important principle to consider in the study of patterns of response to sensory stimuli is that every sensation has a motor component. Thus, when we request the subject to report what is felt when the face and hand are touched simultaneously, there must be an efferent, or a motor, element. The patient replies verbally and tends to point to the spots touched. In a series of face—hand combination tests or in combinations involving the face and another body part, it was shown that the face is the first to be indicated, whether it is pointed to with the hand or announced verbally (Table 6). Since the hand is used in the pointing, it would be the last of the two (face and hand) perceived regions to which the sub— ject would point. On the contrary, the face would be the first to be indicated. This, however, is not always the case, for when both stimuli are perceived, the hand is sometimes the first to be indicated. This is particularly evident in combinations which do not include the face. When both hands are stimulated, the incidence of errors is very low and the subject often uses either hand to point to the other. Learned and Inherent Perceptual Organization—Perceptual organization or sensory correlation may proceed along two lines: (1) learning or individual acquisition of perceptions and (2) inherited or genetically determined perceptual patterns. Acquired perceptions are organized in the course of experience by the postulated mechanisms of pattern identification, by a selective process, by sym— bolization, and by conceptual organization. As Nissen states, “Symbolization helps in perceptual organization also in connecting percepts with concepts to specific 30 responses.” 1. Learning Factor: There are many who believe that all perceptions and perceptual patterns are acquired. Most perceptual reactions are learned during the maturation period or infancy. In our own studies of perceptual patterns under conditions of double simultaneous stimulation, we believe that awareness of the part of the body, such as the genital region, is an example of learning. Infants or children learn of and become aware of their genitals. Initially, when the pattern was demonstrated in adults with disease of the brain, the high dominance manifested in the genital region was not too surprising. The interpretation was that, due to its special sexual connotation acquired by learning, there is more “awareness” of �17 stimuli applied in this area. The question then arose as to what the pattern would be in very young children. If sexual “awareness” was not yet operative, that is, if the child had not yet learned of the social significance of the genital organs, one might assume that there might be less dominance of the genital zone than in adults. However, in our studies we found that young children were indeed “sensitive” about their genitals. Most of the children under 6 years of age, even the very youngest, who were just about able to cooperate in the perceptual tests, were reluctant to expose this area or showed some form of embarrassment or curiosity when their genitals were touched. Some refused to have more than a few tests done at one time. Evidently this increased “awareness” is learned prior to 3 years of age. Since we found a high dominance for the genital area in children, it might be inferred that this high dominance is related to a sexual awareness which was probably learned in the first two to three years of life. Schilderfl pointed this out in his discussion of the principles concerning the libidinous structure of “the body image.” # He stated: The attitude toward the different parts of the body can be determined by the interest the persons around us give to our body. We elaborate our body image according to the experiences we obtain through the actions and attitudes of others. The actions of others may provoke sensations when they touch and handle us. But they may influence us also by words and actions which direct our attention to particular parts of their body and our own body. . . . Early infantile experiences are of special importance in this connection but we never cease gathering experiences and exploring our own body.31 These principles of symbolization in perceptual .organization apply to genital as well as to other regions of the body. From the psychoanalytic, or Freudian, point of view the face and the mouth participate in the oral stage of body image, or, more correctly, of body schema development. The same school emphasizes that the genital region plays a great role in the development of the organism. Therefore, it should not be surprising to find the face and genital regions almost on the same level of dominance as determined by double simultaneous stimulation. References 31 and 32. # Smythies,33 in a philosophical paper, criticized the confusion and the loose use of the term “body image.” Thus, (a) there is “the body image” which describes “a visual, mental, or memory image of a human body, one’s own or someone else’s.” Body images are experienced. (b) Body schema should be used only in its original sense. It is part of the subconscious mind, and thus its presence is inferred, and not experienced. The experiments of Stratton are a good example of almost a pure disorder of the body schema. (c) Body concept is a conceptual constellation and depends largely upon the proper function of the relevant memory mechanisms. Anosognosia is an example of disorder of the body concept. (d) “The perceived body,” or another name for it, “postural model of the body,” a term to be applied to the somatic sensory field—directly experienced inside central consciousness. An example of this is the experience of having a phantom limb or autotopagnosia. The perceived body is identifiable with the “body image in the brain.” (e) Actual physical body is a physical object and not the same as the perceived body. What one perceives as to body parts does not always correspond to the actual position of the physical body and vice versa. An example of this is found in the patient’s experiences in mescaline intoxication, where the perceived body is not the same as the physical body. Also the postures assumed in some of the dyskinesias are not always perceived. (f) Body image in the brain of the physical body (theory of psychoneural identity). The homunculus as determined by electrical stimulation or destruction of brain tissues is an example. While we agree with Smythies criticisms, it is sometimes extremely difficult to use his classification of “experiences and description of the human body.” Nevertheless, in our subsequent discussions we shall try to use his terms wherever possible. fl �18 Even though Schilder * proposed these theories, there are no clear—cut experi— ments to show that the face is sensitized the most, and, for that matter, that the hand is sensitized the least, in the maturation of the normal infant or child. As a matter of fact, in the same book Schilder emphasized the importance of other structures in the construction of the “body image.” In considering “sexual sensitization” of body parts in adults, one must compare such erogenous zones as the breast and buttock with the genital region. Yet analysis of our data reveals no undue dominance of the breast and buttock over nonerogenous regions, such as the foot or abdomen. Perhaps there would be no incongruity in dominance of erogenous zones if we interpreted our data from the standpoint of age, sex, personality, and social background of the subject. Under such conditions we might have found different gradients in each group and concluded that sensitizations of the body parts by learning are, after all, important, but not necessarily the principal factor in determination of the pattern. In this connection the question of the development of the “body image” arises. How does the “body image” develop? Schilder admits that we have no reliable information as to how this development takes place. He said that there is “reason to believe that there is an inner development, maturation, . . . and there are inner factors, which are given in the organism and comparatively independent of experience which determines this development.” He also believed that “the process of maturation gets its final shape through individual experience.” Thus, there is a factor of maturation which forms the basic structure of the body image, whereas experience and learning influence the trends of the development. Maturation and learning are essential features of all types of development, whether it is body image, body schema, body concept, perceived body, or perception itself. These conclusions are partly supported by the experiments of Gesell.34 If this sort of reasoning, namely, development of the body image in infancy, accounts for face—genital dominance, what explains the inferiority of the hand, as determined by this series of tests? When the hand is considered in the spectrum of the “body image,” there seems to be no prominent reason for its inferior position. According to Schilder, the hand is an important structure in the formation of the “body image.” The “body image” is continuously influenced by the almost constant optic image of its hands. One sees his own hands more frequently than any other part of his own body. In fact, perceptually and from the motor standpoint the hand is one of the most important structures in the “perceived body.” Katz 35 says that the hand makes the most vivid impression. Despite this, it is curious that the hand is least dominant when it is tested simultaneously with another body part. 2. Inherent Factor: Thus far we have discussed the factor of learning in perception as the basis for the pattern we obtained on double simultaneous stimu— lation. It is possible that “learning” during infancy might explain part of, but not the entire, pattern of sensory organization under conditions of double simultaneous stimulation. However, our results show that the factor Of “learning” did not enter in our own tests. An analysis of the responses obtained on the first trial in many children showed that the face was most dominant and the hand was least dominant. In this situation there was no opportunity for learning; yet this pattern was found on the initial tests in most subjects. The same consistent initial response was obtained * References 31 and 32. �19 in tests of combinations of other body regions, such as the hand and the thigh, etc. These findings strongly suggest that the patterns we obtained are not the result of a learning process during testing but may be due to inherent sensory organization. This theory is supported by the preliminary studies of Hooker.29 Working with human fetuses, he found that double tactile simultaneous stimulation of the face and hand resulted only in the face reactions. When the hand and foot were tested, there was only the hand response. Thus, there was an order of dominance in which the face dominated over the hand and the hand over the foot. Although the pattern Hooker obtained in the fetus is not exactly the same as the one we obtained under our conditions of double simultaneous stimulation in young children, the fact remains that a pattern has been observed before the organism had an opportunity to learn. Carmichael,36 after reviewing the available experimental data, concludes that there is only little evidence that learning modifies fetal behavior. If it is assumed that the pattern is determined inherently, one should consider the role the body image plays in organization of perception or in the order of perceptual dominance. 3. Organization of Perception in the Perceived Body, Body Image, and Body Concept: (a) Perceived body. In a discussion of the inherent properties of perception we must consider the role of the “perceived body.” There is a theory that mid— line structures of the body dominate over the lateral or peripheral parts. In his monograph on the body image, Schilder emphasized the dominance of the midline structures. This theory considers the long axis of the body as being the dominant over other regions. Part of the same theory is that proximal parts of a limb dominate over distal regions. In our own experiments it is true that the face and the genital region, both midline or axial regions, are the most dominant parts of the perceived body. However, this axial theory does not account for the gradients as depicted in the graph we plotted from our data. There are some midline or axial structures which show no significant dominance over the lateral parts. Thus, the foot, a lateral area, is dominant or equal to the thigh, which is a proximal area, and to the buttock, which is an axial structure. Moreover, there is a differentiation of dominance along the longitudinal axis of the body itself. Thus, the face or the genital region is dominant over the abdomen, buttock, or midback. A second hypothesis is the one proposed by Cohn.37 This is similar to the first. Cohn proposed that the pattern of dominance, as elicited by the method of double simultaneous stimulation, is inherently organized on the basis of rostral dominance, i. e., the theory that the face is the most dominant part of the organism, while the remaining body areas show a descending gradient along the longitudinal axis. The rostral parts are dominant over the more caudal areas. This theory is consistent with the extensive observations on the development of the vertebrate nervous system, in which a rostral—caudal gradient is demonstrated in phylogenesis.38 This gradient is manifest in the progressive differentiation of the rostrum until, in Mammalia, the cerebrum is fully differentiated. The gradient is also manifest in biochemical and physiologic reactions at each phylogenetic level. Similar gradients have been demonstrated for the musculoskeletal and gastrointestinal systems. A rostrocaudal order of sensory development has also been shown to exist in onto— genesis in studies of the fetus with single stimulations.39 More recently, Hooker 29 found such an order in human fetuses when the face and hand, or hand and foot, were touched simultaneously. Our own data support this theory of rostrality only in part, inasmuch as there is face dominance. However, other facts tend to contra- �20 dict the theory of rostrality. There is no continuous downward gradient between the rostral and the caudal region. Even though the face is most dominant, there are caudal body parts which are dominant over some of the more rostral regions. For example, the foot is dominant to the hand and the thigh. Most significant is the dominance of the genital region to all more rostral areas except the face. From the foregoing data one must conclude that the concept of rostrocaudal order of be the fetal There the is not beyond applicable stage. organization may sensory factor of learning and maturity in the postnatal stage. More studies of double simultaneous stimulation in different parts of the body of the human fetus, particularly the genital region, may shed more light. Similar studies in the first year of life will help us in understanding the development and organization of perception in man.40 (1)) Body image and body concept. Another theory can be evolved in considering the relation of the body to its inner self or that of the ego to its outer world. This concept implies that the ego has a center and a periphery region, just as the perceived body has an inside and an outside. We observe ourselves (inside) as we observe others (outside). When one thinks of himself, what Schilder called autoscopy,32 there is an image of one’s own face. This is a good example of what is meant by body image. Children in making drawings of a man indicate the face, while other parts of the body are less often illustrated.15 Even congenitally blind children, in whom the hands and fingers are of especial importance, model the head 41 and the region of the mouth as being the most conspicuous”? too large as being In expressing the concept of the ego in terms of body parts, the face is visualized is face the most The other than structure. the to more foreground comes any or distinguishing part of the organism itself. The face represents the most central or inner portion of the ego. In narcissism the self-interest in one’s body is directed chiefly to the face. Claparéde,42 in his studies on localization of the self, concluded that the ego is conceived as being in the head. More specifically, he believed the center of the ego is situated between the eyes. As for the genital region, there are of the this would who body the identify area psychoanalysts, particularly many, with the inner part of the ego. The part of the body which has to do with reproduction is probably just as “deeply in” or central in the organism’s concept of the body as is the head, with its face, mouth, eyes, etc. In considering the genital region, it is not always easy to determine whether the importance attached to this part of the body is due to inherent or to acquired factors. There is a great deal of literature on this subject, but it is still difficult to ascertain what role the inherent factor plays as opposed to the learning factor. Applying the theory of centrality, i. e., that the face-genital regions are innermost in the ego and in the body concept, we are faced with the problem of fitting the hand into this theory. In contrast to the concept of the face or genitals being central, the hand is mostly on the periphery. The hand is the medium with which we or our ego makes contact with the peripheral or outside world. The hand is on the periphery of our ego structure and, with the aid of vision, is the most important tool for exploration of the outer world. One might argue that the foot, although a distal structure, also makes contact with the outer world. However, in this task the 1' von Stockert, F.: Quoted by Critchley.21 �21 hand, in most instances, is used more than the foot. Moreover, the impression gained is that the foot is more inward—it seems more protected and hidden by shoes. In summary, it would appear that from the standpoint of body concept organization within the ego, the face and the genitals are the most inwardly situated, while the hand is least centrally or most peripherally situated in the conceptual organization of body parts within the ego. Now if we correlate the latter hypothetical pattern with the pattern we found in our perceptual tests, we create some sort of congruity between the two, namely, (a) face dominance as obtained on perceptual tests with face as the most inner portion of the ego, and ([9) hand inferiority with hand as the most peripheral portion of the ego. From this it might be inferred that the ego may play a role in the determination of the perceptual pattern. We realize that this is a highly theoretical explanation. Obviously, the concept of the hand being the most distal, and the face the most central, portion in the organization of perception in body image needs testing. We also realize that our results may be colored by an obscure artifact, although we have checked our data by a variety of methods and conditions of testing. If this concept is at all valid, it should be applicable to functions other than those of cutaneous senses. Thus, the concept of “central” portions dominating over the periphery may be found in studies of vision. Observations drawn from patients with mental changes consequent to diffuse brain disease show domination of central over peripheral vision. Goldsteini and others have found that in these patients constricted fields of vision are not uncommon. When such a patient is instructed to fix at a central target and report whether he sees another target simultaneously in the periphery of the field, the response is that the central target is observed and not the one in the periphery.45 In studies of visual responses of these patients to rapid exposures of images with groups of figures, it was noted that they reported what they saw in the central portion of the field only, often not observing the peripheral figures. Similar results were obtained in tachistoscopic examinations of mentally defective persons. In all these cases the results were uniform, namely, the perception of the central, but not of the peripheral, figures. Thus, when the cutaneous sensory field is compared with the visuosensory field, the face seems to correspond to the macular region, and the hand, to the most peripheral part of the field of vision. On further com— parison, it might be inferred that central vision is identifiable with the ego in the same manner as is the face. The optic image we have of ourselves or of others is situated in the central portion of the field of vision. Our ego is projected in the central regions of the perceptual field. In considering these patterns for perceptual function, we touched on the topic of conceptual functions. When the subject of the ego is discussed, a pattern for thinking becomes obvious. It is well known that most of our thoughts are pointed directly or indirectly toward ourselves, and we think least of what is most peripheral to or away from the ego. This subject has been amply discussed by William James in his “Principles of Psychology.” The object of mentioning the parallel was to point out the principle that similar patterns exist in all types of perceptual functions, as well as in conceptual and motor functions. :1: References 43 and 44. �22 SUMMARY Tests of simultaneous tactile stimulation involving many different body combinations were applied to patients with an organic mental syndrome, normal children, normal adults, and schizophrenic adults. By the use of these simultaneous touch stimuli, a pattern in cutaneous perception was demonstrated in which the face, as well as the genital region, was the most perceptive or dominant body area, whereas the hand showed the least dominance. The remainder of the body regions fell between these two extremes in the form of a mild gradient. No one theory adequately explains the organization of this pattern. Learning and maturation are probably factors, but it appears to be mostly inherent. The pattern is found in the normal subject but is accentuated in the presence of disease of the brain. REFERENCES Head, H., and others: Studies in Neurology, London, Oxford University Press, 1920. 2. Pearson, G. H. J.: Effect of Age on Vibratory Sensibility, Arch. Neurol. & Psychiat. 20:482-496, 1928. 3. Jaffe, J., and Bender, M. B.: Factor of Symmetry in the Perception of Two Simultaneous Cutaneous Stimuli, Brain 75:167—176, 1952. 4. Green, M. A., and Bender, M. B.: Cutaneous Perception in the Aged, A. M. A. Arch. Neurol. & Psychiat. 69:577-581, 1953. 5. Cohn, K: On Certain Aspects of the Sensory Organization of the Human Brain: III. Patterned Response to Three Simultaneously Applied Cutaneous Stimuli, Neurology 2‘»:140-143, 1. 1952. An Experimental Study of Simultaneous Stimulations of the Sense of Touch, J. Nerv. & Ment. Dis. 20:169-184, 1893. 7. Oppenheim, H.: Diseases of the Nervous System, Neurol. Centralbl. 4:529—533, 1885. 8. Green, M. A.; Fink, M., and Bender, M. B.: Order of Dominance in Cutaneous Perception, Tr. Am. Neurol. A., pp. 238—240, 1952. 9. Bender, M. B.: Disorders in Perception, American Lectures in Neurology, No. 120, Springfield, 111., Charles C Thomas, Publisher, 1952. 10. Bender, M. B.; Fink, M., and Green, M. A.; Patterns in Perception on Simultaneous Tests of Face and Hand, A. M. A. Arch. Neurol. & Psychiat. 66:355—362, 1951. ll. Bender, M. B.; Shapiro, M. F., and Schappell, A. W.: Extinction Phenomenon in Hemiplegia, Arch. Neurol. & Psychiat. 62:717-724, 1949. 12. Jaffe, J., and Bender, M. B.: Perceptual Patterns During Recovery from General Anesthesia, J. Neurol., Neurosurg. & Psychiat. 14:316-321, 1951. 13. Fink, M.; Green, M. A., and Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects, J. Nerv. & Ment. Dis. 117:43-49, 1953. 14. Shapiro, M. F.; Fink, M., and Bender, M. B.: Exosomesthesia or Displacement of Cutaneous Sensation into Extrapersonal Space, A. M. A. Arch. Neurol. & Psychiat. 68:481-490, 6. Krohn, W. 0.: 1952. Goodenough, F. L.: Measurement of Intelligence by Drawings, Yonkers-on-Hudson, N. Y., World Book Company, 1926. 16. Lashley, K. 5.: Problem of Cerebral Organization in Vision, Biol. Symposia 7:301-322, 15. 1942. Lashley, K. 8.: Functional Interpretation of Anatomic Patterns, A. Res. Nerv. & Ment. Dis., Proc. (1950) 30:529—547, 1952. 18. Lashley, K. 5.: Serial Ordering of Action, in Cerebral Mechanisms in Behavior, edited by L. A. Jeffress, New York, John Wiley & Sons, Inc., 1951. 19. Marshall, W. H.; Woolsey, C. N., and Bard, P.: Observations on Cortical Somatic Sensory Mechanisms of Cat and Monkey, J. Neurophysiol. 4:1-24, 1941. 17. �23 20. Penfield, W., and Rasmussen, T.: The Cerebral Cortex of Man: A Clinical Study of Localization of Function, New York, The Macmillan Company, 1950. 21. Critchley, M.: Tactile Thought, with Special Reference to the Blind, Brain 76:19-35, 1953. 22. Berlin, L. ; Goodell, H., and Wolff, H. G.: Relation of Pain Threshold and Pain Intensity to the Phenomenon of Extinction, Tr. Am. Neurol. A., pp. 229-231, 1953. 23. von Frey, M.: Beitrage zur Physiologie des Schmerzsinns, Ber. u. Verhandl. konigl. siichs. Gesellsch. Wissensch., Leipzig, Math.—phys. C1. 47:185-196 and 283-296, 1894. 24. Denny-Brown, D.; Meyer, J. S., and Horenstein, S.: The Significance of Perceptual Rivalry Resulting from Parietal Lesion, Brain 75:433-471, 1952. 25. Critchley, 26. Critchley, M.: The Parietal Lobes, London, Edward Arnold & C0., 1953. M.; Russell, W. R., and Zangwill, 0.: Discussion on the Parietal Lobe Syndromes, Proc. Roy. Soc. Med. 44:337-346, 1951. 27. Critchley, M.: Problem of Awareness or Non-Awareness of Hemianopic Field Defects, Tr. Ophth. Soc. U. Kingdom (1949) 69:95-109, 1950. 28. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions, Brain 72:538-561, 1949. 29. Hooker, D.; Early Human Fetal Behavior with a Preliminary Note on Double Simultaneous Fetal Stimulation, A. Res. Nerv. & Ment. Dis., Proc., to be published. 30. Nissen, H. W.: Phylogenetic Comparison, in Handbook of Experimental Psychology, edited by S. S. Stevens, New York, John Wiley & Sons, Inc., 1951. 31. Schilder, P.: The Image and the Appearance of the Human Body, Psyche Monograph No. 4, London, George Routledge & Sons, Ltd., and Kegan Paul, Trench, Trubner & C0., Ltd., 1935. 32. Schilder, P.: Mind Perception and Thought in Their Constructive Aspects, New York, Columbia University Press, 1942. 33. Smythies, J. R.: Experience and Description of the Human Body, Brain 76:132-145, 1953. 34. Gesell, A.: Maturation and Infant Behavior Pattern, Psychol. Rev. 36:307-319, 1929. 35. Katz, D.; Gestalt Psychology, translated by R. Tyson, New York, The Ronald Press C0., 1950. 36. Carmichael, L.: Ontogenetic Development, in Handbook of Experimental Psychology, edited by S. S. Stevens, New York, John Wiley & Sons, Inc., 1951. 37. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation, J. Nerv. & Ment. Dis. 113:471, 1951. 38. Child, C. M.: Origin and Development of the Nervous System, Chicago, University of Chicago Press, 1921. 39. Hooker, D.; Prenatal Origin of Behavior, Porter Lectures, Series 18, Lawrence-Kansas City, University of Kansas Press, 1952. 40. Carmichael, L.: Onset and Early Development of Behavior, in Carmichael, L., Editor: Manual of Child Psychology, New York, John Wiley & Sons, Inc., 1946. 41. Bakwin, R.: The Blind Child, J. Pediat. 35:120-128, 1949. 42. Claparede, E.: Note la localisation du moi, Arch. Psychol. 19:172, 1924. 43. Goldstein, K.: Constriction of Visual Fields, Arch. Neurol. & Psychiat. 50:486-487, 1943. 44. Goldstein, K.: Mental Changes Due to Frontal Lobe Damage, J. Psychol. 17:187-208, 1944. 45. Bender, M. B., and Teuber, H. L.: Ring Scotoma and Tubular Fields: Their Signifi- cance in Cases of Head Injury, Arch. Neurol. & Psychiat. 56:300-326, 1946. 46. James, W.: The Principles of Psychology, New York, Henry Holt & C0., 1890; reprinted by Dover Publications, 1950. Printed and Published in the United States of America �F‘J‘ 5‘ ~24" amass or by Doctors: PM“. cameraman urn axmrunous mm: lorriskl‘. lender, sum A. a... m In: nun Several series of noraal adults, norsal children. patients with organic aental eyndroee and patients with schisophrenia.were tested‘ i for the1r ability to perceivesiaultaneoue tactile stiauli. Iith his eyes closed. the subject was touched sisultaneonelyx on two different areas of his body and ashed to report what he perceived and to localise the percepts. the responses to this aethod of testing , in all subjects fell into two general groups. The subject either reported both stisuli correctly or reported only one correctly and either did not perceive the second stiaulus (extinction) or sislocalised it (displaceaent). If the right face—left hand were tested, for 'esasple. the subject sight report the face stiaulus correctly and either not perceive the stisulus on the hand or aislocalise the hand stianlns to the left cheek and so report that he felt a single stisulus on each side of the face. *1sentyy patients with organic sental syndroae and 20 noraal children 3-d years of age were tested in all possible coabinations of two between the aajor body areas. lach subject received 540 tests in a randos order.. Testing was done with the subject cospletely nude. When the incidence of errors in the different body areas was analysed by statistical sethods, a significant and similar relationship between these areas was found in both groups of subjects. lrrors were least fequent in the face and genital sons. These were designated as the scat dominant regions. lrrors were aost frequent in the hand when it was tested with any other body part. when all the body parts were thus coapared, a gradientias established with the following order of dosinance: the face and genital region. followed by abdoeen. breast, buttock, foot. back. shoulder and thigh. Bosinance was least apparent “in the hand. �Thros other groups consisting of 593 norssl adults, 53: schizophrsnio adults sod 527 pstionts with orgsoio’ssntslisynorons ' sore tsstodwin.vsrioos body ooshinstions. In those coshiostions is lvhich.¢osinsnos was sppsrsnt, the order of dosinsnoo sss.sinilar. 'to that found in tho prooooding groups. this ordor oi.dosinsnco on oisoltsnoous stinulstion sppssrs .to ho so ishsrsnt psttsrn or organisation. It is prosont in nor-31 children 3~8 yosrs of sgs sad in nor-slisdults. Tbs psttsrn is sxsggorsfod sad Inch sors sppsrsnt in pstissts with disosss of tho brsin. h I I V _ lerioos thsoriss oxplsining this psttsrn, particularly.tho‘ closonsss of tho toes sud gsnitsl rsgions, sill ho disousssd. ,' , '.‘ 4 I C’v w?” 4.4/{L4/1A r” . If- 7” (Ia . .\ fin. .‘ " , an.“ "the 1 ‘3 a, , v .h ‘7“ ‘v‘ _. A ‘ ,3. '1 I" .iv / as“ f’ M “ , a 3i“ x' - ‘ , ' z’ i » � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns of perceptual organization with simultaneous stimuli. AMA Arch Neurol Psychiatry. 1954 Aug; 72(2): 233-55. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-7b-011 Date A point or period of time associated with an event in the lifecycle of the resource 1954 Creator An entity primarily responsible for making the resource Bender, Morris B; Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from the A.M.A. Archives of Neurology and Psychiatry August 1954, Vol. 72, pp. 233-255 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/a1c70b872beb13c5b56dba9ecef3099b.pdf de32dee2acdbbfa2e67eb3cd0c31e52d PDF Text Text Simultaneous of Perception Tactile Stimuli in Normal Children Max Fin/z, M.D. and Morris B. Bender, M.D. Normal adults readily identify and localize tactile stimuli applied simultaneously to the face and the hand (the “face-hand test”).1 While half the subjects perceive stimuli incorrectly on the initial trial, all are accurate by the tenth trial of the test. Young children, however, find the task of identification and localization of two skin stimulations difficult. They report only one of the two stimuli, or, if they report the two, frequently mislocalize one of them. The omission or mislocalization of stimuli is not haphazard but follows a consistent pattern in which stimuli to the face are readily appreciated (“most dominant”) while those to the hand are not (“least dominant”). In order to determine the pattern of “dominance” in children and the age at which such tactile perceptual tasks are correctly performed, a study of normal children was undertaken. The responses of children to the face-hand test and to simultaneous tactile tests of other body parts were ascertained. SUBJECTS AND METHOD Three hundred normal children between the ages of three and 15 were examined. They were from a neighborhood child care center, from the wards and clinics of Bellevue Hospital, and children of neighbors and friends. They were without manifest disorder of the nervous system. A few children at two and a half years of age were included in the three year age group, but younger children were generally not able to comprehend the test. The subjects were examined individually, but there were many who were examined in a day-room in full view of other children. The child was engaged in play and when toys were available they were used to gain his confidence and interest. At some time during play, the face-hand test was introduced. From the department of neurology and psychiatry, New York University College of Medicine and the Bellevue Hospital, New York City. This work was aided in part by a fellowship grant from the National Foundation for In- fantile Paralysis, and by a grant-in—aid from the Coordinating Council for Cerebral Palsy in New York City, Inc. Read at the fourth annual meeting of the American Academy of Neurology, Louisville, Kentucky, April 24, 1952. 27 Reprinted from NEUROLOGY, Minneapolis, January, 1953, Vol. 3, No. 1 �28 NE UROLOGY For the face—hand test, the child was told: “I (examiner) am going to touch you,” and he was to “touch the same place I touch.” He was asked to close his eyes. The examiner, with the fingers, then touched simultaneously a cheek and the dorsum of the contralateral hand of the subject. The child was asked what he felt, and to point to the sites stimulated. After this response, the child was asked to close his eyes again, and now the opposite cheek and hand were similarly stimulated and the report recorded. If only one response was given to this trial, the child was asked if there had been another stimulus anywhere else. Following these two trials, the cheek and hand on the same side of the body were tested in a similar fashion. The fifth and sixth trials were not of asymmetric body parts but simultaneous stimulation of both cheeks or both hands. The following various types of stimulation were used: heterologous stimula— tion of asymmetric body parts on opposite sides, as right cheek and left hand; homolateral stimulation of asymmetric body parts on the same side of the body, as right cheek and right hand; and homologous stimulation of symmetric body parts, as both cheeks or both hands. Such tests were repeated in each child until at least ten trials were recorded. Subsequent tests of other body parts, performed in a similar fashion, were introduced until at least 20 consecutive trials were observed in each subject. A number of modifications had to be introduced for young children. Many would not play the game with eyes closed, but insisted on keeping their eyes open. In such cases the tests were applied with eyes open. Also, a large number of three and four year old children insisted on pointing to the examiner’s hands and face on the initial trials. For these children, a few trials of single touch stimuli applied to the thigh, chest or hand were introduced, until they grasped the concept of pointing to their own bodies after the stimulation. These single trials were carried out with eyes open. After the series of double simultaneous stimulation tests were completed, single stimuli were applied to various body parts to exclude from the normal focal difficulties. with subjects any sensory group The children were asked what they had felt and to point to the places stimulated. Verbal reports of the locus of stimulation were not accepted. It was occasionally noted that children would correctly name the parts stimulated, i. e., the cheek and hand, but then point to both cheeks, or to two places on one cheek. It seemed as if naming the locus yielded more accurate responses than did pointing. These tactile tests were repeated on consecutive days, or subsequently after a lapse of a few days or weeks in some children. At such times, cutaneous stimuli other than light touch were added to the testing. These included repetitive touch (rubbing), single pin prick, and repetitive pin pricks. RESULTS Incidence of errors: Young children made many errors on face-hand tests. Eighty per cent of children under the age of six failed to localize both stimuli �PERCEPTION OF TACTILE STIMULI IN CHILDREN I00 m 2, E ,_ 9 II m p. k no: m at “J ,— uzJ u o: to u. 100 90 (“C9, ‘ 80 85 70 L2 so 2 | 4 5 6 7 8 9 IO I2 ll .‘N‘K ‘ . '\ x. _ __ “t“ c: In a. 3 '_ ‘~~. \._x_x_‘. - \K 3 0 \,\,. -----------.‘ I‘. E 20 ‘ \ LA— 30 ‘. .- 8 so c: 0 4o o 30 40 ‘- 60 o. 50 -------------- 70 Z 60 \ ' 90 r: ~-.. a . ,_\.-___..‘ 29 _ 3 ......... . YEARS 5 YEARS 7 YEA S .----I ~~~~~ o .......... 9 YEARS L345 NUMBER OF TRIAL AGE Graph 1. Graph 2. during the initial ten trials of the face—hand test; many of these even with eyes open. In the older children the number of failures fell sharply (graph 1) so that only 2 per cent of children in the 11 to 15 year age groups continued to make errors after the initial ten trials. Apparently the ability to identify two simultaneously applied tactile stimuli was directly related to the age of the child. This ability was also related to the number of previous trials of the face-hand test. In table 1 the trial of the test after which the child was consistently correct is recorded. The last column of the table includes all the subjects who made errors in the first ten trials, and on many trials of the test beyond the tenth. Graph 2 illustrates this relation for selected age groups. Type of testing: In these studies homolateral and heterologous stimulations were carried out at random. Errors were made by subjects of all age groups in tests of either type. Homologous tests, such as both cheeks, or both hands, randomly interspersed in the testing after the fourth trial, elicited correct reof this served clue While all the older to in as a some cases. nearly sponses TABLE 1 NUMBER OF TRIALS OF THE FACE-HAND TEST NECESSARY FOR PERSISTENT CORRECT RESPONSES ( Age 3 4 5 6 7 8 9 10 ll 12 13—15 Total Number of Subjects 39 34 37 36 26 22 23 20 21 24 29 Touch Stimuli) 1 2 — — — — — 2 — —— l 4 2 2 6 8 6 2 6 8 3 7 4 10 Trial Correct 3 4 5 6 7 l l 1 l 6 3 4 5 2 4 6 — —— 3 2 2 — 5 4 l 6 4 l 8 9 — 2 1 — 2 — l — — —- — 2 2 5 4 — — 1 2 2 1 — 2 2 2 — 1 — — — — 1 — — — — l 2 1 — -- — — — l 2 l l — 1 — —— — 2 Errors Beyond 10 Trials 34 28 28 22 10 4 3 2 0 2 0 �30 NE UROLOGY children that two stimuli were being applied, it did not seem to alter the results in the younger children. In these subjects subsequent trials of the face-hand test were incorrectly reported, even though the responses to the symmetric stimuli had been correct. The perception of symmetric stimuli was much better than asymmetric stimuli. Subsequent testing: Of the total group of children studied, face—hand tests were repeated at varying intervals subsequent to the initial testing in 40 children. Of the children under the age of six, subsequent testing elicited the same difficulties with face—hand tests as was evident on the initial examination. In a few children over six years of age, who seemed to have grasped the concept of two stimulations in the initial testing, errors were manifest on subsequent days. It was as if many trials were necessary for successful learning of the task, and then, even though the task was successfully completed, the learning was temporary. These observations are in contrast to those made in normal adults, in whom subsequent testing did not elicit the errors of the initial test.1 Type and pattern of responses: The errors (table 1) made by children on repeated trials of the face-hand test were of six types: (a) a touch on the cheek only, implying no perception in the hand; (b) a touch on each cheek, implying a mislocalization of the stimulus applied to the hand; (0) a touch on the cheek, and a second touch on the shoulder, neck or elbow, implying a partial mislocalization of the stimulus applied to the hand; (d) a touch on the hand only, implying no perception in the cheek; (e) a touch on each hand implying a mislocalization of the cheek stimulus to the hand; and (f) one or two touches on the examiner’s body, implying a mislocalization away from the child’s body. Face dominance (responses (I, b, c) was apparent in all age groups. It was most manifest as extinction“ of the stimulus to the hand (response a), and was seen in 62 per cent of the errors. Mislocalization of the hand stimulus to the cheek (displacement) was observed in 31 per cent of the errors. While most of the displacements were observed in tests involving cheek and hand on opposite sides of the body, 7 per cent of the errors were displacements from the hand to the cheek in the simultaneous stimulation of homolateral body parts, e. g., right cheek and right hand. At such times the child pointed to the cheek once, saying “a touch here,” and then, moving his fingers 2 to 3 centimeters lower on the cheek, saying “and here.” Other types of displacement were infrequent. There were partial displacements from the hand to the shoulder or neck. Mislocalization of a stimulus across the midline of the body, known as allesthesia,3 was occasionally apparent in the stimulus to the hand on heterologous testing. Furthermore, children *The failure to report one of two simultaneous stimulations has been called “extinction” of a stimulus? The mislocalization of a percept to the homologous body part of the second stimulus is called “displacement.” The mislocalization of a percept in the direction of the second stimulus is called “partial displacement.” In each instance, the stimulus which is correctly reported is said to be “dominant.” �PERCEPTION OF TACTILE STIMULI IN CHILDREN 31 under five years of age frequently mislocalized the initial stimulation away from their body to parts of the examiner’s body or into space (response 7‘). This phenomenon, known as exosomesthesia,4 persisted in some children despite repeated stimulations with the child’s eyes open, and despite the examiner’s insistence that it was the child who had been touched. Another phenomenon was seen during homolateral testing. The child reported only the stimulus applied to the cheek. If the examiner asked insistently, “Did you feel another touch anywhere else?”, a number of children hesitatingly pointed to the symmetrical point in the Cheek on the opposite side of the body. In order to determine whether this was a unique or a systematic phenomenon, tests of other body parts were carried out. In homolateral tests of foot and hand, shoulder and hand, and cheek and foot, the same phenomenon was observed. The child first reported only the foot, the shoulder or the cheek—and then, when the examiner insisted on a second locus, pointed to the opposite foot, shoulder or side of the face. Furthermore, in some young children the phenomenon appeared on single stimulation. Single stimuli applied to any body part were localized correctly. If the examiner then insisted that there had been a second stimulus, the child pointed hesitatingly to the symmetric part on the opposite side of the body. As already indicated, hand dominance (responses d and e) was infrequent. It was observed in 7 per cent of the errors on face-hand tests. In all subjects in whom it was apparent, subsequent trials of the face-hand test manifested the pattern of face dominance. Relation of hand and foot: In tests of parts of the body other than the face and hand, the hand was always least dominant and the cheek the most. Simultaneous tests of foot and hand, the foot-hand test, were introduced after the initial ten trials of the face-hand test in most children. In the foot-hand test, foot dominance was apparent in 51 per cent of the responses (see table 2). It was demonstrated by hand extinction, by displacement of hand stimuli to the foot, and by partial displacement to the thigh, knee and leg. TABLE 2 FOOT-HAND TEST ( Touch Stimulation Bilateral Ipsilateral Stimuli) Total Trials 53 48 Responses Correct 21 23 Foot 17 16 Hand 1 3 F oot— Foot 10 3 Partial F t.—F t. 2 3 HandHand 2 O Other stimuli: A small group of children who made errors in tests repeated at varying intervals were examined with other cutaneous stimuli. Extinction and displacement phenomena were present in face-hand tests using pin prick, repetitive pin prick and repetitive touch (rubbing) stimulations. While the number of errors with these stimuli were fewer than with touch stimuli, the �32 NE UROLOGY still extinction hand of and dominance face was apparent. pattern DISCUSSION The ability to identify and localize simultaneous stimuli separated from each other at some distance is a complex function which gradually develops during the first decade of life. It is a relatively unstable ability, for many Focal discriminations. such disturb of the the in state can organism changes cerebral disease as in hemiplegia5 or parietal lobe lesions,2 spinal cord lesions,2 and diffuse brain diseases such as toxic states, senility and inflammatory conditions6 can so alter tactile discrimination that the phenomena of extinction and displacement become prominent. Errors in simultaneous tactile tests are the of the trials few initial the test—during adults normal in during apparent period of learning.1 Persons subjected to large doses of barbiturates,6 electroshock therapy6 or anesthesia7 also manifest such inability. A prominent feature in all groups is the uniformity of face dominance. When discrimination of simultaneous stimuli is interfered with, for whatever stimuli the in hand and the stimuli not the made to in the are errors reason, to the face. The corollary of “face dominance” is “hand extinction.” It, too, is apparent in all subjects and under the variety of conditions studied. Furthermore, in an “order of dominance” other body parts are between these two limits. Studies in patients with hemiplegia5 and patients with severe mental of dominance order revealed have disease6 of brain result an a as changes of face-shoulder—trunk-thigh-foot and hand. Insofar as these other body parts were studied in these children, a similar order was observed. Since dominance is evident in young children, it appears that the pattern of dominance is an inherent function of the organism. This childlike way of responding to simultaneous tactile stimuli is exposed and exaggerated in adults under a variety of pathologic conditions. these of dominance rostral to explain has Cohn a theory suggested Recently observations.8 Our observations are not in accord with such a theory. The dominance of the foot to the hand in children, as well as the dominance of with of series hand in the two foot and to patients large buttock, thigh penis, diffuse brain dysfunctionfv9 make such an explanation untenable. with in with children normal in findings patients of findings Comparison those with children in the On mental findings comparing syndrome: organic previously reported in patients with severe mental changes due to brain dysfunction,6 a close similarity in performance is observed. In both groups the ability to discriminate simultaneous stimuli is limited. On non-homologous tactile tests, such as the face—hand test, errors are made on initial and subdisis the of stimulus most While extinction frequent trials. error, a sequent with a and children both In errors is occur patients, common. placement done be stimuli. of Furthermore, frequently testing cutaneous may variety with eyes open, and in many instances with repeated verbal clues that there is of factor The not prommade. still and learning are stimuli, errors two are inent Since testing on subsequent days will elicit the previous patterned errors. �PERCEPTION OF TACTILE STIMULI IN CHILDREN 83 In Gestalt terms, patients with organic mental defects and children have diffi— culty in extracting a complex sensory “figure” from the “background” of the total sensory “field.” Significantly in each group there is no difficulty in identifying simultaneous stimuli if the stimuli are applied in symmetric regions of the body, such as each hand or both sides of the face. Here, each stimulus figure has a common background in terms of body image, namely the hand.10 Face dominance is apparent in both groups. It is manifest not only on tests of face and hand but also on tests of face and other body parts. Also, insofar as it was tested, the order of dominance for other body parts is similar. While extinction and displacement are the most frequent types of error, other phenomena are elicited in both children and patients. Partial displacements, e. g., the mislocalization of the percept from the hand to the shoulder or neck on the face-hand test, are occasionally observed. The phenomena of allesthesia and exosomesthesia are seen in the more severely affected patients and in the youngest children; both are frequently associated in the same subjects. In allesthesia, the subjects usually localize the cheek stimulus correctly but mislocalize the hand stimulus to the opposite hand or elbow, In exo— somesthesia, the stimuli are mislocalized either to space in front of the subject or to the examiner’s body. This phenomenon was frequent in the youngest children, and despite the examiner’s urging that the child point to its own body, the child persisted in such mislocalizations until a trial of the face-hand test was performed with eyes open. In addition to these phenomena which appear spontaneously, patients with organic mental syndrome also manifest another response to simultaneous stimulation first noted in children, i. e., on homolateral testing only one stimulus (the cheek) is spontaneously reported; but when the examiner insists, the second is mislocalized to the opposite cheek. Since the patients show so many similarities to young children in their responses, it was predicted that they would also show this phenomenon. In a series of patients with severe mental changes, homolateral tests of the cheek, hand, foot, shoulder and thigh were applied. When only one stimulus was reported, the examiner asked for the locus of the second stimulus. Responses were obtained in 20 per cent of the patients, and in each one the second stimulus was mislocalized to the symmetric body part. Furthermore, in some subjects the same phenomenon was observed with single stimulation. This phenomenon appears to be similar to the completion phenomenon described in Gestalt literature as “closure” and “good continuation.” These are usually described for other sensory modalities. When a circle is tachistoscopically exposed in the visual field so that half falls on a hemianopic field, or if a cross is exposed so that the center falls in the blind spot, many subjects report a complete circle or cross. This “completion” occurs for “good” figures. In simultaneous tactile studies, symmetric figures appear to be the “good” or “strong” figures. �NE UROLOGY 34 CONCLUSIONS Ability to identify and localize asymmetric simultaneous tactile stimuli develops gradually during the first decade of life, and is present in 80 per cent of normal children by the age of eight. Symmetric stimuli are more readily localized and this ability is well developed in normal three year old children. 2. The errors on asymmetric (bilateral and ipsilateral) stimulation involve either extinction (only one of the two stimuli is reported), or displacement (one or both stimuli are mislocalized). Whenever extinction and displacement occur, stimuli to the face tend to be correctly reported. This face dominance is found at all age levels tested. 8. One can conclude that extinction and displacement of tactile stimuli, as well as face dominance, constitute a normal and consistent pattern of rechilin these addition In children. observe, in to one can responses sponse dren under six years of age, the phenomena of allesthesia, exosomesthesia and partial displacement as normal reactions to simultaneous tactile stimulation. 4. The difficulties in recognition of simultaneous tactile stimuli, as shown by young children, reappear in the same fashion in adult patients With focal or diffuse dysfunction of the brain. The abilities of tactile discrimination acquired by the child during growth are lost by the adult who develops mental changes as a result of cerebral damage. 1. REFERENCES M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests 0f face and hand, Th Am. Neurol. A- 751 250, 1950; BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. 5‘ P sychiat. 661355, 195.12. BENDER, M. B.: Extinction and prec1p1tation of cutaneous sensations, Arch. Neurol. 8c Psychiat. 54:1, 1945; KOLB, L.: Observations on the somatic sensory extinction phenomenon and the bOdY sch—eme after unilateral resection of the posterior central gyrus, Tr. Am. Neurol. A' 75: 1950' 3- BENDER’ M' 3'; WORTH, 5' B" and CRAMER’ J“: Organic mental syndrome w‘th phenomena of extinction and allesthesia, Arch. Neurol. & Psychiat. 59:273, 1948. 4' SHAMRO’ M . F .'’ FINK’ M. ’ and B ENDER ’ M. B.: Exosomesthesra, or the phenomenon 1c e ment of sensation into extra p er o f di spa 8‘ Psychiat. 68:481’ Neurol. Arch. space, $109221 717, 1949. 1. BENDER, _ 5' _ _ M. F and Extinction phenomenon in FELL , A . W, .. hemiplegia, Arch. Neurol. 8c Psychiat. 62: BEND-ER M B . SHAPIRO SCHAP- M. 3,; The face-hand test as a diagnostic sign of organic mental syndrome, Neurology 2:46, 6. PINK, M_; GREEN, M" and BENDER, 1952, J” and M. B.: Perceptual patterns during recovery from general anesthesia, J_ Neurol., Neurosurg. & Psychiat. 14:316, 1951_ 8 . COHN, R., and RAJNES, G. N.: On certain aspects of the sensory organization of the human brain: A study in rostral dominance as determined by ipsilateral simultaneous stimulation Tr Am Neurol A '74'162 1949. COHN, R.: On certain aspects of the human brain: sensory organization of the . . .1 f A Ch‘d‘en’ II Neurolsggljylfllgastlrgsfiommancem 7_ JAFFE, BENDER, 1 9. GREEN, M., FINK, M., and BENDER, M. B.: . . . Order 0 f dominance in cutaneous perception. Tr. Am. Neurol. A. In press. 10. JAFFE, J., and BENDER, M. B.: The factor of symmetry in the perception of two simultaneous cutaneous stimuli, Brain 75: part 2, 167-176’ 1952’ �All, [:w.,¢ffl (f P Aflu‘ f 1 \. 3/“5 ”a...” «w 0' V -—« ‘ "1“" ‘3'". :’ I ‘1 - momswammanual I! W swam new m cm h I“ m, I.B.*’ ' and MM! 3. Bind”. Id). mun-11:16:11.0. ’0 «mum»: 11» 3.11m mama, 1m: 1m: mum tar mama. "Aida! w 1 numbin- fro- the national Pauly-1: . than mil: III um. 11: out, by a mat-1114M contact“ for Cerebral any in In tori: easy. In: . m the 0991141th �1. max: 160mm and 1mm mun «mu appliad “minnow” $9 tho that and tho ma (flu ”fleas—hand lam]. adult. taut”) (1). una1o halt aha aubaaota ara inanrract on tha 1n1t1a1 trial. all ara «errata hr Ina tenth trial at tho taut. than: childran, hauavar, find thla tank or teantatyins and laaaliatna can akin “mutton! mums. may mm only ma of til. we atianll, at 1: thaw rapart tho tan. traauautly'ataloaaltaa «no or than (1). 1h» allaazan orjuaalaoaltaattan or actual: 1a not haphaaard but fallaaa a «cantatant pattarn 1n.wh1¢h atmauli to tha taco ara raaa117 appraeiatad (Wand: doaanant') lhilfl thaaa ta ta. hand ara not (”laaat duatnant'). In ardar to datawaflna aha aca at ahxah anon taetila paraaptual taaka arr carraetxy partamaad and tho pattara or “daainanaa” in ohildran. a atudw at naaaal childran was undareakan. 2h. aaaponaaa or ahildran to tha taaanhand taut, and to ataultanaaua taetila taaha at othar bad: parts, I!!! aaaartalnad. m mm. M aura «mm m:- a M15hmm «mu um aaraa altnaaa at lallavua Hospital. eara cantor. are: fiba and and childran a: naishbara and trianna. an»: aura lithmnm aanitaat ataardar of tha aarvaua .1".Im A tau childran at two and a halt yaara or an. aura inclnaad in tha that. win! asp gruup, but ganaraxly, yuanaar children wart not aha. ta culprahann tho taut. Qua childran mama aaaaanad individually. in: that. aura nun: who aura asaainad in a dar~roua in full via! at ethar aubsaata. 1h» ehtla III ansasad 1n play and ahnn toys vara available thaw aura and to sun tho mum «mum. and trauma. at amfiaa during �2. W “atom to” an intimate“. rer tat rue-Mad «at, the «mu um um: tho 91.7, ”I (Matt) a mains to touch you,” and ho m to "touch the «no plan. I touch.” no m and to 31m hit or». the minor, with an ringers, then $5..“an mm $ «but and tho donu- ot the hand what m “in“. a» «mu m um m tilt. Ind to point 39 HI. um “mama. m” tt“ mpmu, the an: m and to “on M: om mun. lad an the opposite emu-tutor”. at mm. can mun-1: imam, tall tho more an. mpmo no man to ma mu. tn. child m chock and hand 1: only 1: than “W um an bun new «mm: an." that no trial. the shock and hand an tho um 31“ at tho body an “and in 1 3mm mum. m um and not. or "pawn body Mt int 01mm tutu trul“mum a: mm: «mm or both m. vmm up» at ”1le m m. «mum an m - “Mex-01m” «mum of ”M910 316.3, luft Mud; parts body on meat. u 213% chock and 'hmlaum” “mutton or ”mutt-to may put: an the um “do or t!» body, I: right chock and right hand. and madam" “mutton or ”mud. body nuts, I. both checks or both man. 1!: «oh child until at hut «a tuna: war. Such mt- nu mm mad“. Bub-cam: «at. a: at»: W mu, portend in a 11-11” fauna”. mu 5.3::ch mu} at last 20 «mun cm).- were ovum 1:: «oh mun. A mm.- at modification: and to tundra. um: an am with ma aloud, but imam men mu tho me: in". mind would not play the hoping m1:- Qm can. In “sacrum. he introduced ta:- yams Aloe. tMomhrotMandtmmem - �3. chum insist“ on pointing to m minor: ms: mm! m. an the mun mm . For than «mm. a flu train a! 31min touch mama. mind to m- tm. «m: a: hand an mm“, W "man. rm. um. with an will km the the «can» of pointing to their own My gm: can-1d out with «you upon. mu emu. am is!» «mu or am» Immanuel twain tutu an «alarm. 31ml. um: In. ”and ta Mm but: mm to mime any ”5.106“ run run imam-y In Monti” m m mm). Th0 the ltro childrun plan “mum. an mt accepted. comet]; ml. the but than pom: to «and u 1: did pointing. m. that that hid {bit ‘ Iaknd Vorhnl find to point ta mm: at the km. of ”melon It an «autumn; noted that child!» would MI “mum. 1..., ma. chock and m. chub. a- to We! also” on one «book. It the 1m- yxolm non «amt. mm“ than m m m. mun tutu are muted «was» an, or ’ on tub-mun: after a up» a? a um, «hum tn an or miss 1.11 um «mm. “1-311. other than light touch mm mm to the unsung. Th.“ manned tomb (rubbing), uncle pin puck. and mouth. pan prion. A: not: mum; m: may gunman“ gt; tutu. mun" Young «at cum I“: my mm on m or calm-on and» the or an $31106 to localllo both ntfllull during tho initial tfin trails of the {mum mt; any of rub 0n- opon. In the older of children. tho I) go that ton amply tutu-hand Mr not MC»: ham: (W �M muormmmmmumtormmeum: «manned to lake emu after the initial ten trifle . Aypemtly the ability to identify two Immemly applied mule ennui me directly related to the we of the «and. m- «mu» m the related tn the mm or previous mu of the face—head tent. fun. I, the tr“). 0: the teet after which the alum nee eminently cmeot 1e recorded. The net «Inn of the hue mama» en the etheote who nude emre 1a the nut ten mun; end on may triu- at the teet the tenth. Graph II 11130th thin vellum tar “looted use m etimlettm man; In Wme. em» In theee mute”). Ina heterolesm were carried out at random. Errata were slide by eubJeete at all ese in teete or either type. 95' me Wham teete. mt: ee both chem, or bath heme. maul: intenpereea in the teeting after the fourth mn. elicited can-eat renames in nearly e11 onee. Me true «reed u e clue to em or the older children that two etmn were being applied. it did not “an to alter the reenlte 1n the younger «mum. In the“ eubjeete “ohm teet mm amarmtu Warm, even though the reenmeee to the ”metric etinuu m been amt.perception of mute «m: an moi: better this: “metric “mu. “tenant MM‘ or the totel of ammo“ emu, m I'm-bend teete were «Noemi; tflele or the ‘l‘he A ’ . reputed at “mm tntemle eubeeemt to initial touting in to children. or the children under the ace an. mmumt tut-1m engage the em ditfiaultiee emu teete over 6 um me etmutione the of “cum evident an the mute). examination. In e ten children or «use, who seemed to lave the concept or two in the auntie). tenths, emu were meanest on W �5._ lubiOQnflnt mooaum 43):. It III 1mm a; it'unay trials aura nooonuary tar of the tuk. and aim, mm though the tuk Inna-unrully aunplotod, tho laurntnz uni tauparlrw. than: abacrvutxonn are in central: to that: undo in nernnl Odnltl. in lawn tubaoqnant flouting did not ultelt tho error! 0: Ch. initiil cost (1). $223,535,!Itt953lggbggggggggg; by mum, on Muted its arrow: m (Ethic I) and. mu. or m tum-Inna m: am at an typed: (n) u touoh on the chuck only. implying an pcrcoption in an. hand; (b) a touch on ouch chock. tnvlyins I Italoclllsntian of thc stinulna :pplicd to the bind: (a) a touch on thn dutch, and u aecend tuueh on the uh auldnr. neck or elbow, implying u partial tion or the act-ulna upleud to tan hand; (d) a touch on n13100¢11la~ tbs hand only, Ilplring no porodpttoa 1n thn chock; (a) n taucu on cash hand implying a niuloealisattan at the chuck stimulus to thn bind. and (f) on. or tun taught: on tut alaninor's body. implying a um W m- Illlocllillw the «Inw- body. Flea "dalinundo” (rtspanuoo a, £9 3) an: appurvnt 1n I11 as. grdupl. It nun Inst unnzthnt as c:t1nction* or the uttnulun to the hand (response 3). tad II! Icon in 6a! of thc errata. lialocnlizatton or the hand Itilnlut tn ch. chock (dtnplnoqnnnt) wt: obaorvod in 31! or en. 03:93.. flail. Hunt at thy dinplaocnnutl var. obnorvud ‘03:: involving in abnok and hind an appetite class or the body. I! of tho aurora was: ddnpllaclauts tram the hand to tun shack in tho w I rm 1m ‘*vwr‘ Trt“7~ «*~ 1* urn 9 ?“ie' 4L1“ .r‘mr 3 "'1 anon dlzlod “untinatian' at a nut-alum. Ifll omnlilatton or x gore t to tho hdualasduu bod? part of thy nueand stdlmnnn tn dulled «up tomcat.” at a wept 1n the “mum of the ltdond act-min. 1:unlmnmum culled "partial In much instinct, tho ntzluznl which 1: corruotly rapewtuddiaplncunnut.” 1: said to be “dominant.“ . m w �6. sinnltunoans ntflnnlattua at hannzutavll body parts. 0.3. right ¢hsok and right hand. At auah tilt. the chilc Iould point to the catch once, saying ”a touch hit..” and than. raving his finger: 5-3 can. lint! an the aback, 3&7. ”and hurt.“ 0th.: typcn at «Laplaoa-nat Hurt turraquont. intro wort partial dimplaocnnntl frnn‘thn hand ta the nhauldcr or nook. llllocalisltian or .- anuzmu (3) t stinhlu: mat!!! the uidliuo of tho body, known m ”mama: imam in the «mm. to the touting. rurthoanuro, childrin under {Iva years or as. :rvqulntly'ninlooulssnd ta. Initial utiuulation away tram thair body to part: of tho nan-anor*a boar 9: into space (rampant. r). rhi- pupae-aaan. known a: ifioflHIOIihllil (u), per-11:06 in OHIO children despit- rupeutad lt1-n1a330an vita tn. child'- are: open. and despite tan ell-Lucr'u tastntcnat that 1: III the child hand an hutcralacoun that had beta tauahnd. A Anothor phannnnnoa III Inna during ho-mlatovnl touting. ihe child uuuld ropnrt only tn. ttxunlun applied to the check. It the uxtntnor askod insistinsly. ‘Bid yuu r001 anothnr touch anywhnro also?" alanine: at nhildrun quld hanttatingly point to the syn-etrlanl point‘ln tan ordor to chock on tho apposito side or the body. detomnxnp uhofihar this vac a unigua or I Iritalntte phenanonon. In tout. or «that bed: parts var. carried out. In henolcternl tests or root and hand. showman: Ind hand. and about and rant. the It.» phanoInnan.flla ohm-twee. in. «E114 txrnt reported only the feat, tho thauldor er ‘a. catch - and thou, whoa tho attains? inaxated a acoand locus. point-d to the appositu fact, guanine» an aids of thy rice. on Furthanlaro, in non. young «aileron, tho phnnulanou appeared on linslc :ttnulatiou. singlu atannli applied in any body part would bi correctly localixac. It tho ‘mlninor adv insisted that "tram , _,_, L¥=§ ‘&:‘-’ �7. churn had bcon a Iguana skinning. the child petntod hnl1tltznaly appease aid. e: um body. uni-ms pm on to m an 0.1mm indium. and 4mm“ (mpmu g and g) an tnnu-hnnd was intrnqunnt. It nus abnothd 1n 7’ of in. crrarl tents. In all tubdcatl 1n wasn't: an: appurunt, uuhuoqucnt a: tan ruao~hnnd tout unairnatnd can pn‘%crn at run. A. trial. dcnlnnnoo. other sun had: aggggggggg£,§ga§,gag;zgg§L, In taut. or part. or ulnar! 10¢It admin-at uhnn tho ran. and hand, tun hand It. loot. salultunooun tent: or 190$ and hand. tn. toot~annd tout. worn introdaaod after the initial ton 8:111! at tn. taco-hand tact 1n Inn: ohildrtn. In 8h. feat-hind tent. feet 11). dauinnnao In: taparont in 5x! at tho rcupanloa (In. that: and th. cup-k tho nanitoat by hand axttnottou; by dinning-nun: a: hand actual: and to uh. tout; and by par£111 displucullut to the this». knot, 1.3. who and. Irruru §§§55;5L,A 3-513 area» or childrou. It was with 0th.: in tents repentod at varrtns tutorVIJu warn nunltnod cutuusoun Itinnli. Izttnotian Qua allpllaulant phone-nan.unro prick prettnt 1n tacoohnad tent. Etta: pin pr1ok. rupotxtivc pin uuaxo tn. gumbo: at and rcpotitivo touoh (rubbing) attlulitionl. tuudh uttunzi.m orrorl with than. stimuli I‘l‘ town: than with of tuna dunialnoc and bind untiuotzon In: ntill laplrcnt. ~ W pattern ability to idontitr tad 100311£0 sepnruhod tron ouch 9th.» at nun» «titans. Th. ntnultanoonn lit-n11 LI 3 culplcx runntion 1: agenda of 1110. It grudullly dcvnlup: during tn. £12.: tho attic of tho a relatichy unltahlo ab1lity. tar Inn: china»: in otrobrnl alt-n:grannimn eta diutnrb tuna disarm-tnntlonn. focal which �8. in heeipiegie (5) er perietei lobe ieeione (a); epinei cord leeiane (23); end difruee brain dieeeeee ee taxie etetee, seniiity end inflammatory aenditiane (6) zen eo alter tactile dieerininetiaa that the phenunene of extinction and diepieeelent became pruninent. lrrere in simultaneoue teetiie teete ere apparent in aerial eduite flaring the initiel tee trieie at the tent -- during the period or “learning” (1). Pereene eubaeotod to ierge doeee or barbituratee (6), electromehook therepy (6) or eneetheeie (7) eieo leniteet such en inability. ' pro-inent feature in all sreupe ie the unifornity of race dominance. when dieerieinetion or eieuiteneeue stimuli in interfered with, for thetever reeeon, the errors are made in the etmluli to the head and not in the etinnii to the tece. The cavalier: or “face delinenee” ie “hand extinction.“ it, too. is apperent in e11 etheete end under the variety or ccnditioue studied. further-ere, in en ”order or daninenee” other body peril ere A tee limite. Bennie: in petieute with helipiegie (5) end petiente with eevere mental chensee ee e reeuit or brain between theee dieeeee (6) here revealed an order at equinenee or teee~ehoui¢er~ trunkathixh-teot and bend. Ineorar ee theee other body parts were etudied in theee children, e eieiler order tee observed. Since dominance ie evident in young children, it eppeere that the pattern or dominenae in en inherent function or the arsenien. This chidiheed new of reeponding to einniueneaue tactile stimuli in expoeed end exaggerated in edulte ander e variety or pathological oonditione. Recently Cohn bee suggested a theory at reetrli dominance to explein theee obeervetione (8). Our oheervetione are not in accord with each a theory. The dominence of the-toot to the hand in �9. children, an wall I. the douinlnco of penis, buttock, that and thigh to the hand in two large aerial of patients with diffuae bruin artfunction (6, 9) Elk. such an explination untenable. a in lethal Childrun with Findiggu‘;g PM oclparins Eh. tinfiinsu in ohildron with than. prawiounly roportod in patient. with .QVOTC Inuit: chtngos an. to hrnin dylrunetian (6), a clot. nililnriey in pariah-anon in obturvod; In both group: tn. ability to dilcrilihtti Silaltnntoul Itiluli in lilitod. 0n aon—hanolosous tactilu touch. Inah II the rte-«hand hatt, error: it. 0n and: on initial and suhncnunnt triulu. Hhilo astinntioa or a thinning 1! the unit Iroquant error. diaplhoalnnt 1! cannon. In both childvun and viii-nth, errors occur with a vurioty at cutnnoons Iii-n11. lurthnmnmrv. touting In: tritulntly h. done with 01': open, and in sin: ihntcnooa. with ropaatod Vtrhal ulna: that than. tr. ewe atiluli and still arr!!! Ito undo. 1h. {later or learning 1: not pro-inont niuoo touting on tableau-ht any: will olioit tho previous pattctnod errata. In Gottfllt tum-n. patient. with organic anneal dctocta and ohildron have dirtiauity in extracting a ao-piua non-cry ”right!” frun thy ”buneroani” of the total Ionlary "field.” Significantly in each group inure in no difficulty in idantitying. linultanoaua Iii-uli if thy stimuli are applied in syn-attic regions at tho body, Inch it each hind or both 3140. ot-thn than. 3390, each Itilnlun figure ha. a cal-an background in turns of body insgo, unholy, en. "mm." (in), In both groups. that dalinlnco it apparcnt. It in InnlfGIt not only on test. of tuna and hund but Illa on teats or that had othcr body part3. Alto, innotlr II it II! tostod, thn order of dunintnec for othcr body part. in lililnr. while extinction and displaculont are the halt frequent typco �10. or error, othcr annualanu are elicitcd in both children ind patinnta. Partial dinplusoamnta. 0.5. tan uislocalisation of thc pochpt tram tho hand to in. nhaulder or neck on the racowhnnd test, It. cool-ioually obnervod. Th. phcaonnnn or ”allouthnsia" Ina ”axe-anesthesia“ are seen in the more severely affictcd patiatn and an. raunxoat childrvn; bath are franunntly unlooiuted in the same subjeeta. In nllcpthoaia, tat uuhjootu usually localine tbs chock ltinmluu correctly but niuloauliuc the hand Itilulus to thc appetitt hand or clbav. In cxosaunathouia, the ttinnli are ninlocslizod either to Iptcc in front of th: subject er to the uxnnincr'i body. This phcuancnon was frequent in the youngest ohildrcn, Ind despit¢ the nan-ingr'a urging the child pdrnilted in web the cum to point to its on niuloellisationn until I trial of the flag-hand toot nus perfornnd m, with eye: open. nation to than phenomena mm- apantaneaualy, patient: with orgtaio umutul syndruno also naniront Iuother respaano In sauna to simultaneous stimulation rirut noted in children. 1.3., an honolnteral rice-hand testing only on. stimulus (the aback) in spontaneously reported; but yuan tho examintr insists. tbs second it ninlocnlixod ta thn apposite chuck. since the pationtl than IO Ian: niuiltritics in their reapoaacs to young children, it was prodiatod that they would ulna ahcu this phnnannnau. In I series a! patient. with tavern nautal chins... hamolateral taut: or the cheek, nine. (out, thouldor and thigh wart avplicd. ”bun uni: ant nth-alum III reported, the aI-inor Inked for the loan. at the scoond ntinulua. Runyon... varb obtained in 20% of thc patientl, and in each one tn. second utiuulus an: uinlcotlixod to thy ayunetric body part. Purthornarv, in none subjects tbs name phenomenan III observed with single utilnlntion. �11. This phone-soon sppssrs to ho sisilsr to tho cosplstiou phone-soon described iu dostslt litersturs ss 'closurs” sud ”good oontinnstion.” fhsss srs—usoslly describsd for othsr ssnsory Iodslitiss. Uhsn s circle is tschistoscopicslly sxpossd in tho visual risld so thst hslr fslls on s hssisnopic risld. or it s cross is exposed so thst tho contor tolls in tho blind spot, ssny subjects rsport s cosplsts circls or cross. This ”cosplsticn' occurs for “good” figurss. In sisnltsnsous tsctilc studios, syn-stric figurss spoosr to to tho "good“ or ”strong" figurss. W ’ l. shility to idshtiry sud locsliss ssyI-stric simultaneous tsctilc stisuli dsvslops grsduslly during ths first docsds of lits, using prsssnt in 80‘ or nornsl childrsn by tho sac of sight yssrs. Syn-stric stfl-uli soc smrs oosdily locslissd and this shility is ssll dsvolopsd in non-s1 three your old children. 2. the own on umtric (hilstsrsl sud ipsilstsrdl) sti-nlstion involvs sithor extinction (only cos of the two stisuli is rsportsd). or displscslsnt (cos or both stimuli srs nislocsliscd). Hhsnsvsr sxtihcticn and displscsssnt occur. stimuli to tho tscs tend to to corrsotly rspostsd. this "fscc dcsdnshcs' is found st sll sgs lsvsls tsstsd. 3. ans can concluds thst sstincticn sud displsoslsnt or tsetils stisnli. ss ssll ss rscs dosinshcs, oonstituts s now-s1 sud consistent pottsrn ct rsspohss in childrsn. In sddition to thsss rssponsss ons osn observe, in childrsn under six yssrs or age, tho phsncsons or sllssthssis, sacsosssthssis sad psrtisl displscsssnt ss nonssl resctions to silultsnsous tsctils sttlnlstion. h. rho difficulties in rscosnitioh ct silnltsasons tsctils stimuli, ss shown by young childrsn, rssppssr in tho sons rsshion �12. in adult patient! with focal or dittuuo dyutuaatian or the bwltn. The abilities or taettlc discrimination acquired by the child aura»; growth are lost by tbs adult who develop: Inntal change. an I rniulfi of cerebral Gianna. �13. fllFMGE m, 1;; (a) 1. and mm, 11.: Pattern. in pox-owner! l. rm. tut. or no. and hand. Tram.An.umol.Auoc.l ILL, tn 31-111mm: 250-252, June, 1950. ' W, PINK. I. mm. 11.3.,tutu 8:) alumnae“: or no: and hand. §_6_g_ mm, unutionn. a. (3) ._ 309mb“, 1951. 11.: in perception Pattern: mh.nm1.tn Mutt" and pmlpttation of autumn ntmtien ”chasm-111.Iul'lzomnt.l 2.}. 1-9. July, 195. 11.3.; «11m extinction In: Observttionu on tho scuttle of thc unilaton'liinuction utter body and the phone-anon patent: central gym... $311.43.!mol.Auoc., 15}. June. 1950. 11.11.. mm, 3.3. and mm, 1.: tax-mun ”111111 amore“ mm, of extinction and ant-than. Amhgmflfiflnhut. with (D) 3. 355.362, and um 1101.3, 9mm 11.3.: humane-u, or the I. or1.,dnpnocunt rm, I. andormm situation into exam-personal men. human 7111 preparation). 1. 31112130, 5. SHAPED. NJ. and SCEM’PILL, 1.3.: ntinntion I.B., mm, phone-anon 1n 11.111103“. mh.£om1.trnzah1ut.l Q. 7174'”, Decanter, 19kg. $3.1 m two-dune tent is tad m, m, stagnant“ sign or organic until Imam. umlm‘ g; It. I!” a 6. FIRE, 7. J. and mm, ILB. Parceptual ptttomu during maven um, IMIthOIiI. J. gurolquhzcmt.‘ .134. moral rm 316—321, 3951. 136.58, x ' (a) com, R. and RAM, 0.3.: 011Aeon-tun "peat. of the unnory organisation or the has»: but!" study in rental «drum. n «teamed by unilateral umltmomn stimulation. mm.m.nm1. """""""""""""'""'"""" 8. ”.00., It! 10. Mo 19%. or the union crewman at certain “poet: A dwinunoc 111 children. or 11. rantml Itudy the bum brain: (11) ' 169, com, Rd On ”union, 3;, 119-122 (nu-ch) 1951. 31., ”It, I. and mm. 11.3.: 0rd» of ammo. 1n tactile mm, perception. (in prepmtion). the are. tint: J. and mm II.B.: m tutor or ulna-ybe1n911111121106)? ””8, (to or two simultaneous 311th “1.1111. Min, �m; mm or May or the now-83M mt aw Comet Rupmurp. (Touch 1‘93- Nahum ' sex-nu) WAGorgoot manure. effluent: 3 39 t 31» 5 37 ,6 36 7 26 8 22 9 23 10 20 11 21 12 an 13-1529 iggggglgg rump-mm all " 1025 ~-1_-11-.2 ~~1.22»1~ .21321--».‘, --125n~2. 1262~122~ £63-21-a- 28‘sal--26515-1--6821-1-21 3746 -3..n106#21~-2 33 ‘28 28 22 -_ 10 x 3 a 0 2 o �W Foot-Band iblt (Touch Stimuli) '8!IIBIITIUR"“TU!I£ IRIALS .0 00 O Foot n , Ft.~lt. Kind talatoral 53 21 17 1 10 2 2 Ipuilaturnl #8 23 16 3 3 3 0 �" FER CENTOF GROUP ,, I: \. 4’ PER CENT ERROR AFTER k O! 39V 8 N O (,J O 43 O U1 O ERRORS MAKTNG IO 63 O K TRIALS \l O 03 O «0 O OOI �THE MOUNT SINAI HOSPITAL NEW YORK CITY MONTHLX NEUROLOGICAL RESEARCH SEMINAR TUESDAY 27, NOVEMBER BOARD ROOM - 2nd 8:30 P. 1951 M. FLOOR ADMINISTRATION BUILDING EQGMM THE PERCEPTION OF MUETIPLE STIMULI Ia II. DR. MEX FINK AND DR. MARTIN GREENE: TACTILE D.D.S. DR. ROBERT L. KAHN AND DR. EDWIN A PATTERNS WEINSTEIN: OF RESPONSES ON (UNTITIED PAPER) DR. W. S. CHAIRMAN BATTERSBY �} r l x } um um. W“; % flu—é“: 145m’ "I 5’44. 1’31“ _ 4L ‘ 3, ,. I Q ~ ‘ _n ‘flu‘ I... A..— "-4 A4— ‘fl‘ N11,, ’ .‘ “ ������Fluid Spinal Findings Following Cerebral Angiography Joseph M. Stein, M.D. and Max Fink, M.D. WITH increasing use of cerebral angiography, the problem arose as to whether the procedure, of itself, produced changes in the cerebrospinal fluid. Fortyeight hours after angiography a spinal fluid examination in a patient suspected of a brain tumor revealed a cloudy fluid with 3,000 white blood cells per cu. mm. Prior to angiography the fluid had been clear, colorless and without any cells. As no information concerning the relationship of pleocytosis to angiography was available, it was decided to study the changes in the spinal fluid by the usual clinical methods. Spinal fluids from 21 patients were examined prior to and following angiography. Lumbar punctures prior to angiography were done at various intervals, but all punctures following angiography were performed between 12 and 24 hours after the procedure. In each instance the spinal fluid was exam— ined for color, cell count and total protein content. All angiograms were percutaneous, using 35 per cent Diodrast as the contrast medium. Maximal Diodrast volume was 70 ml. at one procedure. While the majority of patients were subjected to unilateral carotid punctures, bilateral punctures were done in four, and combined bilateral carotid and vertebral punctures in one patient. Either intravenous Pentothal (14 cases) or local procaine (seven cases) anesthesia was used. RESULTS Of the 21 subjects, significant changes in the spinal fluid following angiography were seen in only two cases. In one, a patient with a cerebral angiomatous malformation and multiple aneurysms, 5,000 red blood cells per cu. mm. were seen in a pink spinal fluid. In the second, a patient with a chromophobe adenoma of the pituitary gland, the protein content of the spinal fluid changed from 89 to 151 mg. per cent; also, seven lymphocytes per cu. mm. were recorded when previously there had been none. In all other subjects, changes in color, protein content and cell count were not significant. Three subjects showed transient hemiparesis following anFrom the department of neurology and psychiatry, New York University College of Medi— cine and the neurologic service (third division) and psychiatric division, Bellevue Hos— pital, New York City. Reprinted from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, N0. 2 137 �NE UROLOGY 138 giography, and in none of these were there significant changes in the spinal fluid. Since Diodrast can cause changes in membrane permeability,1 and the spinal fluid reflects such changes, it could be postulated that a relationship between complications following angiography and changes in the spinal fluid might exist. Such changes were not demonstrated in the present cases. F urther investigations with more exacting techniques for protein determination and protein differentiation are indicated. CONCLUSIONS Neither a marked pleocytosis nor a marked increase in protein content of the spinal fluid are usual concomitants of Diodrast angiography. It may be concluded that when such spinal fluid changes are found they are unrelated to the procedure. REFERENCE 0.: Cerebral angiography: Tolerance for contrast media of diodrast type, 1. OLSSON, J. Neurol, Neurosurg., 1949. 6c Psych, 12:312, �afnuéwlc4’43hm 774449711 Min-1. KM spam: main findings mnmm mum: mug-play Alon/«4J7? 4.5;}2 zlr" 777': 137-? L/r—s g- If...” no 3"}! ”in. l“ Bax flak $.13. inoronuiag II. or norohrul ungiogrlyhr up i!!! toot aoarruncoa with in. )robluu of uhothcr tho proaodurn.?ut itaolr. pruduaad dhnagoo in the earnbrospianl fluid. rawtyunéght hour: utter ungiegrnphg; a spinal fluid unanianttca int: yqtimut In.unme900%“ o: a and; 27mm with blood tall: pow cubic willltcr. ?tlew to unsiegruphy eh. {lama and without any any. ma how infant“ clan containing tan rolgtleaahlp or pluoaytouta to ungtuguufiny in. avgllablo. 1% Ian aoasdod to study flu. dhanfiog 1h tho spinal Wick m mu m. mum . a.“ am. ”mm. llnid by fibe_unus1 01131931 nnfihndu. ‘ Spinal fluids tram tuouty-uno pationta wank $munincd print to and running mum-33mg. 1mm: pun-mm Mar to nag!“— phy tor. don. at various ia$¢rvnln._huk :11 pun-tufics rolluuinu Ina glogruphy uumo partarnma hofiuoonyln anfl SQ hear: fiitor in» procew tying: {tula can «hunlncd for 00109. 0011 gaunt ‘nd total protein ooatnnt. £11 angiogru-I Inn. pnruutaaonua. uniac;aifl aladraut an Eh. «entrant Infilllm Hand-:1 dioarunt doing. via 70'. a! an. atsa Isaac, “anal. Eh. aujoritx at pgticnta wort auh1oato¢ to unilateral anvctid puuttnruug hilnwurnl gunnturua vat. dam. in fan: putluntn darn. In Ogah {uncanno ch» 3 an! canbinofi bilazqrul suretzd and v.:%.hrn1 in «at. Eifihar intravunoun ponaothal (I! an...) a: local nrmuntun (v 0....) uaaaehnain van 3308. 3 �gggultgt or uh. twentybonp‘nnbjootl, signirionnt «nausea in the ”spinnl fluid thlloving-angiogruphy warn anon in only two out... In «an. a pttiunt with n acrobtul nugiountoua malformation and multiplo unnuryunu, 6000 rod blood «.11: pl? cubic millitor won. in a pinkidh colorod spinal fluid. In the uncond. u pationt with n ohrauophobo adonaln or the pituitary gland, thy pictoll content of tho lbinnl fluid oh‘ngod Iran 89 uilligrml por'uone ta 161 3111151.: par cant. Alto. lava: lynphonyton per aubio mils noon lilihor wort I And racowdod whoa prbviaunly thorn bud boon noun. In ‘11 nth.» nubjootu. chanson in 90102. praz-in aunt-n: call count war. no: significant. Ebro. subjects aurforod trsnn- in.noao wcro thnr. significant august. in tun apinul fluid. In two subjectl. fine apinnl fluid romainod an» ohangod. In thy third. far aronntod :04 blood cell: and twa nymphooytoo per eubio nillilitor turn notod, what. non. had boon inacn prior to thy pron-aura. Binao diodrune can onus. ohungon in membran- perusubilsey (1}. find tho spinal fluid reflect. august: in cm. manna... u my be paw-ha than a. rel-Mon menu ounplicntiann find such change: axintn. audh changun Into not do- iont haniparonil. and nonntrntod hart. vurchsr inyuatigntioaa vith.noro oxnoting tooha bio: for protein dutorninntion and protein ditrurontiation are in» diontod. W . ploooytonin nor a ngrkad inoronno in protoiu content of an. [pinnl fluid urn uuuul oonoanituntu or aiodrn-t angiogruphy. it'nuy ho aonaluaod Shut ihon Inch apin;l fluid chanQOa urn found. thqy uri unrolatod to an: groundnut. llithnr : lurkod �HO! £3523 ' Angiogmphy: relax-ma. {for 01am. 0.: 00113an 01' Contact M1. Diner“: . o J. Roux-o]... Mum-m... a: hymns. 33:313—816. (am. i949. �x- "e" ' " "-’ - 1' ' I?“ .. J- A" J , ~ ~‘,"~’rnr -m. _.—»,-nn,v~..wni~ ~- 1-... . l“. 9,, .w. Presented at the Fourth Annual Meeting - American Academy Louisville of Neurology - April, 24, 1952 Dr. Costello, Members, and Guests of the Academy: In the course of sensory studies by the method of dou- learned that normal adults readily identify and localize the tow stimuli within the ini- ble simultaneous stimulation, we tial Young ten trials of the test. children, however, seemed could not identify both sti- to make persistent errors. They muli, or if identifying the tWO stimuli} they could not localize them. In order to study the responses and their relation to the age of the subjects, face-hand tests-~the prototype of simultaneous tactile tests—~were applied to 300 normal children ranging in ages from 5 to 15 years. The children were all without manifest disorder of the hervous system, and were from child care centers, hospital clinics and children of neighbors and friends. In the course of some nlay with each child, the examiner introduced the fiace-hané test. In this test, the child closes his eyes, and the examiner, with his fingers, simultaneously touches the subject's cheek and dorsum of his contralateral hand. The child is asked to point to the places where he per- the child is asked to close his eyes, and the test repeated-~with opposite cheek and hand stimulated. Subsequently cheek and hand on the same side of the body and simultaneous stimulation of both sides of the face, or both hands are included. At least ten consecutive trials of the face-hand test are recorded for ceived each tje child. stmmuli, and the report is recorded. Again �2. Eighty percent of children under six years of age failed to localize both stimuli correctly during the initial ten trials. The number of errors fell off sharply among the older children, so that only 2% of children in the 11-15 year age groups continued to make errors after the tenth trial.\ This is represented in the first graph--.. Apparently the ability to localize two simultaneously applied tactile stimuli is directly related to the ageof the subject. This same relationship is represented in the second graph. The percent of the subjents in each age group making errors on each trial of the test is compared for representative age groups. Ihe older children manifest an ability to learn from previous trials of the test while the younger chil- dren do not. incorrect responses of all children were of two types--failure to identify one dfithe two stimuli, called "extinction", hr, identifying two stimuli but mislocalizing The 'one of them termed "displacement". Extinction of hand stimuli observed in of the errors, while displacement was in 51%. The preponderance of errors were in the perception of the stimulus to the hand. The stimulus to the cheek was almost was 62% correctly reported. This ability to identify the cheek stimulus in preference to the stimulus to the hand was pre— viously observed in normal adults and termed "face dominance." always face dominance was uniformlylapparent in the children of all age groups in theseries. The errors were apparent in tests involving the cheek and hand on Opposite sides of the body as well as cheek and Such ! i �5. I ’ ‘ I" hand on the same side of the body. WhileverrorSawere frequent in tests of face and hand, chillren made no errors in identi- fying symmetric stimuli, as both cheeks. In the younger children, partial displacement from hand to homolateral shoulderder or neck, or displacements from a hand to the oppo- site hand(allesthesia), or even into snace in front of the child(exosomesthesia) were seen. The incidence of these dis-placements was less than 4%. Since these phenomena were so apparent in younger children and became less frequent with increasing age, it was concluded that extinction and the varieties I of displacement are normal phases in the degqlopment of the response to simultaneous tactile stimuli. In normal adults and older children, such phenomena are apparent during the initial trials only. From these studies it was concluded that the phenomena ’of extinction and displacement are normal phases in the dev elopment of the perception of simultaneous tactile stimuli. Face gew A Ar: 4,»- a. v12.w_ at all age level; and is an inherent pattern of organization of function. Ihe perception of simultaneous tactile stimuli is directly related to chronological dominance is observed age, being gradually develOped in the first decade of life, and being well developed in 80% of children by the age of 8 years. e MW. ._ L. �EBRUPHYSIOLUGY “¢ ,_ 4, .4. lAB'RATOT‘Y HILLSIDE HOSPITAL GLEN OAKS. N. Y. é 0......w...y -,..‘u.- ’. ”luau s..»—..._ Perception of Simultaneous Tactile Stimuli *in Normal Children wrvq Ira ‘ r , A» “WV-'1.......;.,...«-_'.... [Wax Kin/L, M.D. and Morris B. Bender, M.D. r 1w l . V» ~4M-I’an‘,‘ . “and” ...-...a_.~.......~.w:..c- Amman...» .. -_. .w Normal adults readily identify and localize tactile stimuli applied simul1 taneously to the face and the hand (the "fface--l1and test”). While half the subjects perceive stimuli incorrectly on the initial trial, all are accurate by the tLIItlI tIi Il oi the I:.est Young children, however, find the task of identification and localization of two skin stimulations difficult. They report only one of the two stimuli, or, if they report the two, frequently mislocalize one of them. The omission or mislocalization of stimuli is not haphazard but follows a consistent pattem in which stimuli to the face are readily appreciated (" most dominant" ) while those to the hand are not (' least dominant” ). lII mdeI to determine the pattern of' dominance” in children and the age which such tactile peiceptual tasks are correctly performed, a study of at normal children was undeitaken. The responses of children to the face- hand test and to simultaneous tactile tests of other body parts were ascertained. SUBJECTS AND METHOD . ca...” .‘firw' -‘-—<-“-~»—« — ' \, Three hundred normal children between the ages of three and 15 were examined. They were from a neighborhood child care center, from the wards and clinics of Bellevue Hospital, and children of neighbors and friends. They were without manifest disorder of the nervous system. A few children at two and a half years of age were included in the three year age group, but younger children were generally not able to comprehend the test. The subjects were examined individually, but there were many who were examined in a day-room in full view of other children. The child was engaged in play and when toys were available they were used to gain his confidence and interest. 'At some time during play, the face-hand test was introduced. From the department of neurology and psychiatry, New York University College of \icdicinc and the Bellevue Hospital, New York City. This work wIs aided in part by a fellowship grant from the National Foundation for In- fantile Paralysis, and by a grant-in-aid from the Coordinating Council for Cerebral Palsy in New York City, 'Inc. Read at the fourth annual meeting of the American Academy of Neurology, Louisville, Kentucky, April 24, 1952. 27 Reprinted from NEUROLOGY, Minneapolis, January, 1953, Vol. 3, No. 1 ,. ’ 4 I» J �’3 NEUROLOGY 28 ._»--.A:::’mwww Nu... .. P... I. . ,u.‘ w» 'm ....-w)»...._»:,..- .. “1'3““- :7 —y’u«~¢_-'”’(, . A a ""‘f-u-mmfir »« ...._,......> .I, . ww‘.MF—b—4w‘ For the face- hand test, the child was told: "I (examiner) am going to touch you, and he was to "touch the same place I touch." He Was asked to close his eyes. The examiner, with the fingers, then touched simultaneously a cheek and the (lorsum of the contralateral hand of the subject. The child was asked what he felt, and to point to the sites stimulated After this response. the child was asked to close his eyes again, and now the opposite (both and hand were similarly stimulated and the report recorded. If only one Itsponse was given to this trial, the child was asked if there had been another stimulus anywhere else. Following these two trials, the cheek and hand on the same side of the body were tested in a similar fashion. The fifth and sixth trials were not of asymmetric body parts but simultaneous stimulation of both cheeks or both hands. The following various types of stimulation were used: heterologous stimulation of asymmetric body parts on opposite sides, as right cheek and left hand; homolateral stimulation of asymmetric body parts on the same side of the body, as right cheek and right hand; and homologous stimulation of symmetric body parts, as both checks or both hands. Such tests were repeated in each child until at least ten trials were recorded. Subsequent tests of other body parts, performed in a similar fashion, were introduced until at least 20 consecutive trials were observed in each subject. A number of modifications had to be introduced for young children. Many would not play the game with eyes closed, but insisted on keeping their eyes open. III such cases the tests were applied with eyes open. Also, a large number of three and four year old children insisted on pointing to the examiner’s hands and face on the initial trials. For these children, a few trials of single touch stimuli applied to the thigh, chest or hand were introduced, until they grasped the concept of pointing to their own bodies after the stimulation. These single trials were carried out with eyes open. After the series 'of double simultaneous stimulation tests were completed, single stimuli were applied to various body parts to exclude from the normal group any subjectswith focal sensory difficulties. The children were asked what they had felt and to point to the places stimulated. Verbal Ieports of the locus of stimulatiOn were not accepted. It was occasionally noted that children would correctly name the parts stimulated, i. e., the cheek and hand, but then point to both cheeks, or to two places on one check. It seemed as if naming the locus yielded more accurate responses than did pointing. These tactile tests were repeated on consecutive days, or subsequently after a lapse of a few days or weeks in some children. At such times, cutaneous stimuli other than light touch were added to the testing. These included repetitive touch (rubbing), single pin prick, and repetitive pin pricks. _ . . . ~‘~- .mh—wwyfln NJ,“ e., .va RESULTS .....-..-~_.- «-~ - ' ’ children made many errors on face-hand tests. Eighty per cent of children under the age of six failed to localize both stimuli I ncidcnce‘of errors: Young , 2mm, �PERCEPTION OF TACTILE STIMULI IN CHILDREN 29 iooJ 90‘ 3 < 60 E .. 704 9 6° . '1 3 50a S ‘0 :2 i g a: 0: “‘ , _ . ~....._.. 1“ 90 5 \.\ 70‘ 3 5 ‘- 604 ‘ “\ \‘\ \ 10‘ \“ ‘~.‘ /\ . . 304 ’i H.“ . 3 2° ‘~. 5‘56739Dll12046 ‘ U ”M " “~- J vans -- -- s vans ' ‘04 3 x . so g . -\ . no x3 \s 30‘ ' \-\...-. ‘4‘. nuns ..... ' -~-- 9 , ‘K vans n '5J4ST709210MEG names Y CF TRIAL AGE Graph 1. , m~w-~m \‘x‘ ‘ it 6'20 2f IOO l g D- I: ~—«—-~-..‘..__;__....~_ x Graph 2. during the initial ten trials of the face-hand test; many of these even with eyes open: In the older children the number‘of failures fell sharply (graph 1) so that only 2 per cent of children in the 11 to 15 year age groups continued to make errors after the initial ten trials. Apparently the ability to identify two simultaneously applied tactile stimuli was directly related to the age of the child. This ability was also related to the number of previous trials of the face-hand test. In table 1 the trial of the test after which the child was consistently correct is recorded. The last column of the table includes all the subjects who made errors in the first ten trials, and on many trials of the test beyond the tenth. Graph 2 illustrates this relation for selected age groups. Type of testing: In these studies homolateral and heterologous stimulations were carried out at random. Errors were made by subjects of all age groups in tests of. either type. Homologous tests, such as both cheeks, or both hands, randomly interspersed in the testing after the fourth trial, elicited correct‘respouses in nearly all cases. While this served as a clue to some of the older .W....m~. TABLE . a . . t (Touch Stimuli) c . m-‘Wn Age ...._.-.m..;. 3 4 Total Number of Subjects 39 S4 37 36 26 5 6 7 8 9 10 WWM..W~«.».-.A_. 1 NULIBER OF TRIALS OF THE FACE-HAND TEST NECESSARY FOR PERSISTENT CORRECT RESPONSES 11 12 13—15 ‘22 - 23 20 21 24 29 2 1 3 Trial Correct 4 5 6 8 - — 1 2. 4 -- 1 6 6 3 2., 4 2 5 -2 1 — - -2 1 — — 1 — 1 -3 1 8 2 6 6 8 3 7 4 10 2 . 4 5 2 4 6 -— 5 4 I 6 4 1 1 2 2 2 2 - — l 2 1 1 1 1 — 1 — -1 — 2 2 9 2 ,- - — — 2 - - - 2 l - 2 — 1 — - - — Errors Beyond 10 Trials 34 ' 28 28 22 10 4 3 2 0 2 0 �NEUROLOGY p , it did not seem to alter the hildrcn that two stimuli were being applied, trials of the insults in the younger children. In these subjects subsequent the responses to the lee-hand test were incorrectly reported, even though stimuli was of mmetric stimuli had been correct. The perception symmetric ,iuch better than asymmetric stimuli. of children studied, face-hand Subsequent testing: Of the total group to the initial testing in fusts were repeated at varying intervals subsequent of six, subsequent testing elicited it) children. ()f the children under the age on the initial examhe same. difficulties with facc~hand tests as was evident seemed to have grasped who six years of age, ,nation. In a few children over manifest on were errors in the initial testing. ghc concept of two stimulations learnsuccessful for 3ubsequcnt days. It was as if many trials were necessary completed, successfully task was the ‘iig of the task, and then, even though These observations are in contrast to those made ‘gie learning was temporary. elicit the errors of the {i normal adults, in whom subsequent testing did not tidal ".4 I test.1 (table 1) made by children on Type and pattern of responses: The errors six of types: (a) a touch on the i'peated trials of the faCe-hand test were touch on each cheek, heck only, implying no perception in the hand; (b) a the hand; (0) a touch implying a mislocalization of the stimulus applied to neck or elbow, implying in the cheek, and a second touch on the shoulder, the hand; ((1) a touch on to stimulus applied partial mislocalization of the in the check; (6) a touch on each he hand only, implying no perception cheek stimulus to the hand; and (f) of land implying a mislocalization the examiner’s body, implying a mislocalization away pie-or two touches on the grom the child’s body. all age groups. ’It was Face dominance ( respbnses a, b, c) was apparent in hand the (response a), and host manifest as extinction“ of the stimulus to hand stimulus to of the Mislocalization .'as seen in 62 per cent of the errors. of the errors. While cent 31 observed in per he cheek (displacement)i was and hand cheek in tests involving observed {rest of the displacements were displacements of the were errors 7 in opposite sides of the body, per cent of homolateral stimulation simultaneous the in check the hand to tom the child pointed the times such At hand. ody parts, e. g., right cheek and right 2 to 3 his fingers b the cheek once, saying 5‘a touch here,” and then, moving lentimeters lower on the cheek, saying “and here.” Other types of displacel‘nent were infrequent. There were partial displaceshoulder or neck. Mislocalization of a stimulus ;ients from the hand to the occasionally apparfeross the midline of the body, known as allesthesia,3 was children Furthermore, testing. hand heterologous the on to int in the stimulus p , - “ ,, simultaneous stimulations has been called "extinction” :The failure to report one of 'two of of the second a percept to the homologous body part 3i a stimulus.2 The mislocalization of the direction the in of mislocalization a percept iimulus is called "displacement." The the stimulus which is each " instance, In displacement.” artial is called lacond stimulus iorrectly reported is ‘said. to e "dominant." . i . . , l . �PERCEPTION OF TACTILE STIMULI IN CHILDREN 31 under five years of age frequently mislocalized the initial stimulation away from their body to parts of the examiner's body or into space (response f). This phenomenon, known as exosomesthcsia,‘ persisted in some children despite repeated stimulations with the child's eyes open, and despite the examiner's insistence that it was the child who had been touched. Another phenomenon was seen during homolateral testing. The child reported only the stimulus applied to the cheek. If the examiner asked insistently, “Did you feel another touch anywhere else?", a number of children hesitatingly pointed to the symmetrical point in the check on the opposite side of the body. In order to determine whether this was a unique or a systematic phenomenon, tests of other body parts were carried out. In homolateral tests of foot and hand, shoulder and hand, and cheek and foot, the same phenomenon was observed. The child first reported only the foot, the shoulder or the cheek—and then, when the examiner insisted on second locus, pointed a to the opposite foot, shoulder or side of the face. ,Furthermore, in some young children the phenomenon appeared on single stimulation. Single stimuli applied to any body were localized correctly. part If the examiner then insisted that there had been a-seeond sti‘mulus,'the 'ch'ild— pointed hesitatingly to the symmetric part on the opposite side of the body. As already indicated, hand dominance (responses (1 and e) was infrequent. It was observed in 7 per cent of the errors on face-hand tests. In all subjects in whom it was apparent, subsequent trials of the face-hand test manifested the pattern of face dominance. Relation of hand and foot: In tests of parts of the body other than the face and hand, the hand was always least dominant and the cheek the most. Simultaneous tests of foot and hand, the foot-hand test, were introduced after the initial ten trials of the face-hand test in most children. In the foot~hand test, foot dominance was apparent in 51 per cent of the responses (see table 2). It was demonstrated by hand extinction, by displacement of hand stimuli to the foot, and by partial displacement to the thigh, knee and leg. - _‘ _ _ . .- _-~qu.-. ‘ 7 TABLE 2 FOOT-HAND TEST _W&-u.~.“.~w (Touch Stimuli) 5......“ Stimulation Total Trials .., -_._... is a- Bilateral Ipsilateral 53 48 Correct 21 23 Foot 17 16 Responses FootHand Foot 1 3 10 3 Partial Hand- 2 3 2 0 Ft.-Ft. Hand ”ma—”Ayug. .. . A .. r M»~..-.._—t_.. I Otlzcr stimuli: A small group of children who made errors in tests at varying intervals were examined with other cutaneous stimuli. repeated Extinction and displacement phenomena were present in face-hand tests using pin prick, repetitive pin prick and repetitive touch (rubbing) stimulations. \Vhile the number of errors with these stimuli were fewer than with touch stimuli, the i , ,_ ' �w“ o a. ‘NHJa-w ' 32 . NEUROLOGY I still apparent. pattern of face dominance and hand extinction was _ ._ f DISCUSSION __ NM... . ~‘ak ,..,~ .... -V~’W~¢-—/“A... -Mww ,rw ‘r f ,. ‘....-._..u-n-. v“\——»\‘ ‘. < r 3 The ability to identify and localize simultaneous stimuli separated from each other at some distance is a complex function which gradually develops for many during the first decade of life. It is a relatively unstable ability, Focal discriminations. such changes in the stateiof the organism can disturb lesions,2 cord lobe lesions,2 spinal cerebral disease as in hemiplegia" or parietal and diffuse brain diseases such as toxic States, senility and inflammatory conditions" can so alter tactile discrimination that the phenomena of extinction, and displacement become prominent. Errors in simultaneous tactile tests are of the test—«luring the apparent in normal adults during the initial few trials of doses barbiturates," electroperiod of learning.1 TPersons subjected to large such inability. shock therapy“ or anesthesia" also manifest A prominent feature in all groups is the uniformity of face dominance. When discrimination; of simultaneous stimuli is interfered with, for whatever in the stimuli reason, the errors are made in the stimuli to the hand and not It, too, extinction.” is "hand dominance" _to the face. The corollary of "face Furstudied. of conditions 'is apparent in all subjects and under the variety these two between thermore, in an "order of dominance" other body parts are mental with and severe patients limits. Studies in patients with hemiplegia“ of dominance order revealed have disease“ an of brain result a as changes other these body parts of face—shouldcr-trunk-thigh-foot and hand. Insofar as dominance Since observed. order similar was these children, in a studied were of dominance is an is evident in young children, it appears that the pattern inherent function of the organism. This childlike way of responding to simultaneous tactile'stimuli is exposed and exaggerated in adults under a variety of pathologic conditions. has suggested a theory of rostral dominance to explain these Recently observations." Our observations are not in accord with such a theory. The dominance of the foot to the hand in children, as well as the dominance of with penis, buttock, foot and thigh to the hand in two large series of patients untenable. such make explanation an diffuse brain dysfunction,“ Comparison of findings in normal children with findings in patients with organic mental syndrome: On comparing the findings in children with these previously reported in patients with severe mental changes due to brain dysfunction,6 a close similarity in performance is observed. In both groups the ability to'discriminate simultaneous stimuli is limited. On non-homologous tactile tests, such as the face-hand test, errors are made on initial and subdissequent trials.‘ While extinction of a stimulus is the most frequent error, with a placement is eommon. In both children and patients, errors» occur be done frequently Furthermore, stimuli. cutaneous testing may variety of with eyes open, and in many instances with repeated verbal clues that there of learning is not promare two stimuli, and still errors are made. The factor the elicit will patterned errors. previous days on subsequent inent since testing mgvfi . ; ' ' vb...“ .. ,r» ...- -,4‘-.;.,.va‘ . A. w, .. ~’M"|,.I vauy—as , " ' m-.. .... v -.... *qu...‘ {U thn A ' -....;..W" A... .‘- " " "‘W , A AA i. 1 1» 1 1 1 l i ‘ �PERCEPTION OF TACTILE STIMULI IN CHILDREN ‘ 3‘3 In Gestalt terms, patients with organic mental defects and children have difficulty in extracting a complex sensory "figure” from the "background" of the total sensory "field.” Significantly in each group there is no difficulty in identifying simultaneous stimuli if the stimuli are applied in symmetric regions of the body, such as each hand or both sides of the face. Here, each stimulus figure has a common background in tenns of body image. namely the hand.” Face dominance is apparent in both groups. It is manifest not only on tests of face and hand but also on tests of face and other body parts. Also, insofar as it was tested, the order of dominance for other body parts is similar. ' While extinction and displacement are the most frequent types of error, other phenomena are elicited in both children and patients. Partial displacements, e. g., the mislocalization of the percept from the hand to the shoulder or neck on the face-hand test, are occasionally observed. The phenomena of allesthesia and exosomesthesia are seen in the more severely affected patients and in the youngest children; both are frequently associated in the same subjeets. In allesthesia, the subjects ,usually localize the cheek stimulus correctly but mislocalize the hand stimulus to the opposite hand or elbow. In exo~somesthesia,—the stimuli are mislocalized either to space in front of the subject or to the examiner’s body. This phenomenon was frequent in the youngest children, and despite the examiner’s urging that the child point to its own body, the child persisted in such mislocalizations until a trial of the face-hand test was performed with eyes open. In addition to these phenomena which appear spontaneously, patients with rganie mental syndrome also manifest another response to simultaneous stim. ulation first noted in children, i. e., on homolateral testing only one stimulus (the cheek) is spontaneously reported; but when the examiner insists, the second is mislocalized to the opposite cheek. Since the patients show so many similarities to young children in their responses, it was predicted that they would also show this phenomenon. In a series of patients with severe mental changes, homolateral tests of the cheek, hand, foot, shoulder and thigh were applied. When only one stimulus was reported, the examiner asked for the locus of the second stimulus. Responses were obtained in 20 per cent of the patients, and in each one the second stimulus was mislocalized to the symmetric body part. Furthemiore, in some subjects the same phenomenon was observed with single stimulation. This phenomenon appears to be similar to the completion phenomenon described in Gestalt literature as “closure" and “good continuation.” These are usually described for other sensory modalities. \Vhen a circle is taehistoscopically exposed in the visual field so that half falls on a hemianopic field. or if a cross is exposed so that the center falls in the blind spot, many subjects report a complete circle or cross. This “completion” occurs for “good" figures. In simultaneous tactile studies, symmetric figures appear to be the "good” or "strong" figures. R‘f. , » — “A... .......~-........1 ~ — - AI.- jar-rs: x ., r;'34 �l _‘ Amw— 9 , ..»—-w»4 ‘-‘*V—~.. » ._......-.-... Ms- 34 '1 CONCLUSIONS 1. Ability , NE U ROLOCY , to identify and localize asymmetric simultaneous tactile stimuli develops gradually during the first decade of life, and is present in 80 per cent of normal children by the age of eight. Symmetric stimuli are more readily localized and this ability is well developed in normal three year old children. 2. The errors on asymmetric (bilateral and ipsilateral) stimulation involve either extinction (only one of the two stimuli is reported), or displacement (one or both stimuli are mislocalizcd). Whenever extinction and displacement occur, stimuli to the face tend to be correctly reported. This face dom-’ inance is found at all age levels tested. 3. One can conclude that extinction and displacement of tactile stimuli, well as as face dominance, constitute a normal and consistent pattern of rein children. ,In addition to these responses one can observe, in chilsponse dren under six years of age, the phenomena of allesthesia, exosomesthesia and partial displacement as normal reactions to simultaneous tactile stimulation. 4. The difficulties in recognition of simultaneous tactile stimuli, as shown by young children, reappear in the same fashion in adult patients with focal or diiluse dysfunction of the brain. The abilities of tactile discrimination acquired by the child during growth are lost by the adult who develops mental changes as a result of cerebral damage. i . f . .. .-.-~vku-»~‘. .. , _ - - - . REF E1112. ’CES M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Tr. Am. Neurol. A. 75: 2'50, 1950; BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. & l’sychiat. 662355, 1951. BENDER, M. B.: Extinction and precipitation of cutaneous. sensations, Arch. Neurol. 61 Psychiat. 54:1, 1945; Kora, L.: Observations on the somatic sensory extinction phenomenon and‘ the body scheme after unilateral resection of the posterior central gyrus, Tr. Am. Neurol. A. 75: 1950. BISNDER, M. 13.; WOR'I‘IS, S. 8., and CRAMER, 1.: Organic mental syndrome with phenomena of extinction and allesthesia, Arch. Neurol. 8t Psychiat. 59:27}, 1948. SHAPIRO, M. F.; PINK, M., and BENDER, M. 13.: Exosomesthesia, or the phenomenon of displacement of sensation into extra-personal space, Arch. Neurol. 8t Psychiat. 68:481, 1.. BENDER, -<.»»N.-.~,.--~c¢-v--_.a . _ . .. .,.....-._..a..- . .. . . 1952. ’ M. 8.; SHAmno, M. F., and SCHAPPELL, A. W1: Extinction phenomenon in hemiplegia, Arch. Neurol. 61 Psychiat. 62: . BENDER, t l l e I lbs: - 3w 1?, M . Q33. (TFGJN'zX’UwAaQ , i l l 5...”... . . . . 717, 1949. FINK, M.; GREEN, M., and BENDER, M. 13.: The face-hand test as a diagnostic sign of organic mental syndrome, Neurology 2:46, . r 1952. JAFFE, J., and BENDER, M. B.: Perceptual patterns during recovery from general anesthesia, J. Neurol., Neurosurg. a Psychiat. 14:316,1951. COHN, R., and Rum-:5, G. N.: On certain aspects of the sensory organization of the human brain: A study in rostral dominance as determined by ipsilateral simultaneous stimulation. Tr. Am. Neurol. A. 74:162, 1949. COHN, R.: On certain aspects of the sensory organization of the human brain: II. A study of rostral dominance in children, Neurology 1:119, 1951. GREEN, M., FINK, M., and BENDER, M. 3.: Order of dominance in cutaneous perception. Tr. Am. Neurol. A. In press. JAFFB, 1., and BBNDER, M. 8.: The factor of symmetry in the perception of two simultaneous cutaneous stimuli, Brain 75: part 2, 167-176, 1952. , . l .. .- .-—-.... -~..—....- __.. ‘me—M . Mums—can 7—. . �PERCENT OF GROUP ERRORS MAKING 03 U" mo O _ m u ZCmeD A m OT: m finch? u m o........v..m.o . _i 2% (be; /C1{»c {ram 62' (2» , — x? "55"” 512/ p i M1144}; ZI“:.Y&A‘4 6A., 1M (.4: V7 “"' c / d4 A [7 5‘" r’,'. :e 7§~<1 593%“ 75/075 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Perception of simultaneous tactile stimuli in normal children. Neurology. 1953 Jan; 3(1): 27-34. And, Spinal Fluid Findings Following Cerebral Angiography. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-8-012 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 8 items. 1: Reprint from NEUROLOGY, Minneapolis, January, 1953, Vol.3, No.1. Read at the fourth annual meeting of the American Academy of Neurology, Louis-ville, Kentucky, April 24. 2: [preprint] and graph. 3: Monthly Neurological Research Seminar, Nov. 27, 1951, Mount Sinai Hospital, New York City. 4: Report of Activities. 5: 2 items - Spinal Fluid Findings Following Cerebral Angiography; Reprint from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, N0. 2 AND [preprint]. 6: Presentation at the Fourth Annual Meeting - American Academy of Neurology - April 24, 1952, Lousiville; presented to Dr. Costello, members, and guests of the Academy. 7: Xerox of Perception of Simultaneous Tactile Stimuli in Normal Children. 8: graph. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/cda4311bdad6b67d755b69d80816976c.pdf 2b63fbc4853cb463227378ec92424d29 PDF Text Text [Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 117, No. 1, Jan. 1953] PERCEPTION OF SIMULTANEOUS TACTILE STIMULI BY MENTALLY DEFECTIVE SUB]ECTS*1' MAX FINK, M.D.;t MARTIN A. GREEN, M.D.§ AND MORRIS B. BENDER, M.D. In studiesof the perception of two tactile stimuli applied simultaneously, it has been demonstrated that patients with diffuse brain dysfunction make errors. They persist in making errors either in re— porting only one of the stimuli (extinction) or in mislocalizing one or both stimuli (displacement). When errors are made in simultaneous stimulation of face and hand (the face—hand test) (I), the errors are in the recognition of the stimulus applied to the hand. The percept in the cheek is correctly reported. This “face-dominance” is apparent on initial test trials of normal adults. Similar results have been obtained in tests of young children. Children under the age of six years respond to simultaneous tactile tests almost with the same frequency of errors as do patients with dif— use brain dysfunction. With these facts before us, it soon became ap— parent that mental age was a factor in the perceptual response. There— fore, a study of the responses of mentally retarded adults with mental ages of young children was undertaken. Simultaneous tactile tests were applied to a group of mentally defective patients, and three aspects were studied: their responses to the tests; the order of dominance; and the relation, if any, to standard psychometric tests. SUBJECTS AND METHOD Fifty—seven mentally retarded adults from the wards of Letchworth Village, New York were examined. They ranged in chronological age from 13 to 41, and in mental age from two years, six months to nine ‘From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurologic Service of Bellevue and the Mount Sinai Hospital, New York. fRead before the Seventh Annual Convention and Scientific Program, Society of Biological Psychiatry, Atlantic City, May 11, 1952. IThis work aided in part by a Fellowship from the National Foundation for Infantile Paralysis. §Post—Doctorate Fellowship, United States Public Health Service. Work aided, in part, by a Grand—in—Aid #MH-139 from the United State Public Health Service, National Institutes of Health. [43] �Max Fink, Martin A. Green, and Morris B. Bender 44 years, eight months. The figures for mental ages were those recorded in hospital records reflecting performance on Stanford—Binet tests; and in each instance, the most recent estimate was used. RESPONSES TO SIMULTANEOUS TACTILE TESTS ON INITIAL AND SUBsEQUENT TRIALS FACE-HAND TEST 100 odul‘l’s wifh orqanic ------------ .. mental sqndrome 0O RESPONSES oO \l O DOMINANT 01 O a! O adult-mentally defective §O FACE PERCENT N0! 00 .. 0 0O 2 3 4 adult-normal 5 6 7 TRIAL NUMBER 8 9 10 showing responses to simultaneous tactile tests on initial and subsequent trials of the face-hand test in adults with organic mental syndrome, normal children of three to six years, mentally defective adults, and normal adults. FIG. I.—-Graph The subject was asked to close his eyes. Following this, he was simultaneously touched on the right cheek and the dorsum of the left hand. The examiner asked: “What did you feel?” If there was no response, the examiner said “Did you feel me touch you” and “Point to the place Where I touched you.” After this test the subject was again asked to close his eyes and the left cheek and left hand were stimu— lated, and the reports recorded. Subsequent tests included stimulation of left cheek and right hand, right cheek and hand, both cheeks, and both hands. This sequence of six trials was then repeated so that a total of 12 tests involving the cheek and hand combinations were carried out. Subsequently, tests of other body parts, as hand—foot, cheek—shoulder, thigh—foot, shoulder—thigh, cheek—foot, and shoulder—hand were intro— duced—four trials of each asymmetric combination and one trial each of the symmetric body parts. The entire sequence of tactile tests was completed with a repetition of trials of the face-hand test. �Perception of Tactile Stimuli by Mental Patient: 45 RESULTS On the initial trial, 98 percent of mentally retarded subjects reported the stimuli incorrectly. Eighty percent reported the face percept only, omitting the percept to the hand, a type of sensory extinctionfi“ The remainder localized the face percept correctly, but mislocalized the second percept to the opposite check, a type of sensory displace— ment. No subjects reported the stimulus to the hand alone or mislocalized the cheek stimulus to the hand. These responses are expressions of “face dominance.” Face dominance was also apparent on subsequent trials of the facehand test. Fifty percent of the subjects failed to localize the two stimuli correctly during the first ten trials. They repeatedly failed to report the hand stimulus or repeatedly mislocalized it. The phenomenon of extinction was manifest in all subjects; while in 46 percent, displace— ment of percepts were also reported. A smaller number (38 percent) showed perseveration of responses, i.e., reported previous stimuli even though new stimuli had been applied to different parts of the body. The phenomenon of allesthesia (mislocalization of a stimulus across the midline to the opposite side of the body) (2) was occasionally observed. Only one patient demonstrated exosomesthesia (the displacement into extrapersonal space) (3). Half of the subjects succeeded in localizing and identifying the two stimuli during the initial ten trials. Their ability to localize the stimuli in the face—hand tests was carried over in the subsequent testing of other body parts. A few subjects, however, after correctly identifying the stimuli of the face-hand tests, made occasional errors during the testing of other body parts. These errors were almost exclusively in a failure to report one of the stimuli; neither displacement or perservera— tion was manifest. In all subjects simultaneous stimulation of homologous regions, e.g., cheek-cheek, or hand—hand, were interspersed throughout the testing. Errors were infrequent on such tests, even in those subjects who made persistent errors on stimulation of asymmetric regions, e.g., cheekhand. Such errors were observed in 15 subjects (26 percent) but only on occasions were the errors in a pattern as seen in a patient with a hemisensory syndrome due to a focal cerebral lesion. Relation to Mental Age—There was a definite relation between the incidence of persistent errors and the mental age of the subjects. Table I presents subjects grouped according to mental age (as determined by standard Stanford—Binet testing) and their responses to simultaneous tactile tests. It will be noted that there is a gradual fall *For convenience in writing we will call this type of response under conditions of double simultaneous stimulation extinction. �Max Fink, Martin A. Green, and Morris B. Bender 46 in the incidence of persistent errors on simultaneous tactile tests as mental age increases. TABLE Mental Age Group (year—month) I No. of Subjects Persistent Errors By 10 Trials 10 10 10 12 10 0 2-6 to 3—11 4—0 to 4—11 5—0 to 5—11 6—0 to 6—11 7—0 to 7—11 8—0 to 9-6 Correct 7 3 6 4 5 2 11 4 7 9 3 1 Relation of Body Parts—During the initial ten trials, face dominance was manifest in all subjects. In the subsequent tests of other body parts, additional patterns of “dominance” appeared. This was represented in the subject’s inability to identify and localize one of the stimuli or to mislocalize one percept in the direction of the second stimulus. As already intimated previously, the locus of the stimulus which is correctly reported is said to be “dominant.” In tests of cheek and shoulder, and cheek and foot, face dominance was observed (Table II). In tests of foot and hand, and shoulder and hand, both foot and shoulder are dominant over the hand. In the relationship of thigh and foot, and shoulder and thigh, both foot and shoulder are dominant over the thigh. TABLE II.——RESPONSES ON MULTIPLE SIMULTANEOUS TACTILE 57 MENTALLY DEFECTIVE SUBJECTS Total No. of Tests in All Patients TESTS IN .M Body Combination” FACE—hand FACE—foot 576 163 FACE-Shoulder 184 SHOULDER—thigh 170 SHOULDER-hand 151 FOOT—thigh 170 FOOT—hand 231 Incorrect Responses Correct Responses face or hand face and hand face or foot face and foot 315 36 face 64 9 9 or shoulder 15 252 128 face and shoulder 105 shoulder or thigh shoulder and thigh shoulder or hand shoulder and hand 45 12 63 3 foot 42 foot 58 or thigh 1 7 or hand 33 113 85 foot and thigh 11 1 foot and hand 140 *Capitalized letters (under Body Combination) indicate dominant part as manifest by t—test value of 5 percent or less. The differences in the incidence of errors in difl’erent body combinations are largely due to the order of testing and the factor of learning. �Perception of Tactile Stimuli by Mental Patients 47 DISCUSSION These results when compared with those obtained in previous ex— periments show that there is a striking similarity in the performances of patients with organic mental syndrome due to diffuse cerebral disease or dysfunction (4a), to normal children below the age of seven years and to mental defective adults with a low mental age. The similarity lies in the types of responses, the persistence of errors, and in the order of dominance. Extinction and displacement phenomena are frequent in all three groups. The responses are apparent on the initial and on subsequent trials. In addition, allesthesia and exosomesthesia are occasionally ob; served. The subjects in each group manifest an inability to identify and localize asymmetric stimuli, that is, cheek and hand. Symmetric Stimuli, however, as stimuli applied to both hands, are well localized, even by the most mentally retarded subjects, by patients with severe brain dvsfunction, and by the youngest normal child. In every group the errors of localization persist through many trials of simultaneous tactile tests. The subjects are unable to localize the two Stimuli despite verbal clues offered by the examiner, such as asking whether there had been another Stimulus. The errors are present even when the subjects are tested with eyes open. The persistence of errors on repeated trials in the mentally deficient adult, in the patients with mental changes, and in normal young children is in marked contrast to the ease with which normal adults correctly localize and identify the stimuli. The performances of these subjects are illustrated in the graph (Fig. I) which compares the percentage of errors during the initial ten trials of the face-hand test. It should be noted that the curve for the mentally defective adults includes 15 subjects who have a men— tal age of seven or more years (Table I). This will account for the curve being below that of normal children whose average mental age was rarely above seven years. Furthermore, the order of dominance observed in mentally re— tarded subjects is similar to that reported for patients with organic mental changes (4b). Face dominance is seen in all subjects, while the hand dominance is hardly manifest. The other body parts are between these limits. As in patients with organic mental changes or very young children one may be inclined to explain the inability of the retarded adults to localize the two Stimuli as due to “confusion” or “inattention.” Such an explanation is unwarranted because these subjects can perceive and localize symmetric Stimuli and the errors are not haphazard. The �48 Max Fink, Martin A. Green, and Morris B. Bender errors show in a pattern so that almost all errors are in stimuli to the hand and none in stimuli to the face. Furthermore, this pattern persists in tests of other body areas and is similar to patterns described for other groups of subjects (5). A comparison of the observations in normal young children and in the mentally retarded adults reveals a striking similarity in perform— ances when the mental ages of each group are compared. In both groups, there is a change in performance about the mental age of six years. It may be concluded that the face-hand test reflects the same performance ability as the Stanford—Binet test. The face—hand test has validity as a convenient approximation of performance above and below a mental age of seven years. SUMMARY The face—hand test and simultaneous tactile tests of other body parts were applied to 57 mentally defective adults. Their chronologic ages ranged from 13 to 41 years and their mental ages as determined by Stanford—Binet testing ranged from two years, six months to nine years, eight months. On the initial trial 98 percent failed to localize both stimuli and on subsequent trials 50 percent made persistent errors beyond the tenth trial. The errors were made in stimuli to the hand whereas stimuli to the face were correctly reported. Extinction, displacement, allesthesia, and exosomesthesia were observed. These performances of the mentally defective adult to the face-hand test are strikingly similar to the responses of patients with diffuse brain disease and of normal children of six years or less. Furthermore, there is a definite relation between the persistence of errors and the mental age of the subject. It is concluded that the face—hand test reflects the same performance as the Stanford—Binet and has validity as an approximation of performance above and below the mental age of seven years. REFERENCES Bender, M. B., Fink, M. and Green, M.: Patterns in perception on simultaneous tests of face and hand. Arch. Neural. &' P5ycl1iat., 66: 355, Sept. 1951. 2. Bender, M. B. and Nathanson, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena. Arch. Neural. 6' P5yc/zz'at., 64: 501, October, 1950. 3. Shapiro, M. F., Fink, M. and Bender, M. B.: Exosomesthesia or the phenomenon of displacement into extra—personal space. Arc/2. Neural. é‘r Psychiat. (in press). 4. (a) Pink, M., Green, M. and Bender, M. B.: The face—hand test as a diagnostic sign of organic mental syndrome. Neurology, 2: 46, Jan. 1952. 1. �Patients Mental Stimuli by Tactile of Perception 49 in cutaneous dominance of order The B.: M. and Bender, M. M., Fink, (b) Green, perception. Trans. Amer. Neural. Assam, 74: 1952. in Extinction phenomena W.: A. and Schappell, F. M. 5. Bender, M. B., Shapiro, hemiplegia. Arch. Neurol. 6' Psychiat., 62: 717, Dec., 1949. 1150 PARK AVE, NEW YORK 28, N. Y. �~ a!" hfmaulffifig PIIOI?IIOI I! 0' SIIULRAIIOUB 3- _ «- $555!”? ‘ “my“, 1.; -A?» if} iflcllhl ITIIULI IIIIALEY 931301173 BUBJIB!£.* By In: vink, 3.»... Ina-tin A. Green. _ 8.3..” and florria B. Bondar, u.n. «mach-r r“ 3'" a” on Collegp or undicina and tho Neurolozze service of null-vac nouns Sinai Hospital, low York city. ‘. . 9*!h1u vnrk aidod a 1' in part for Infantilc Paralyuin. "M"; by a "‘"‘ " J, 73‘; "u f and tho Ftllauuhsp from the latiennl ronnunt1an . afitPott-Dootortte Fellaunhip, Unitcd States Public fibulth surviec. Hark aided, in part. by n Grantuinind #HH~139 from the United 3t&to Public ahalth Servico. National Inatitutas'ot finnlth. �1. In etudiee or the peroeption of two teetile stimuli applied eieoiteheoueiy, it hee been denohetreted that petiente with diffuee brain dysfunction Ink! errors. Qhey pereilt in liking. errore either in reporting only one or the etinnii (extihetioh) or in nielooeiieihc one or both etiwnii (diepleeeleht). when error: ere eede in ei-aiteneoue stimulation or face and head (the teoe~hend test) (1) the errore ere in the reoocnitidn or the etiluiue eppiied to the head. it. peroept in the cheek it correctly reported. This “reoe—deninanoe” ie eppereht on initial tent triele of aerial edulte. Siniier reeuite have been obteihed in teete or youn‘ children. children under the ene or six yeere reepond to ei-nlteheoue tactile teete eieoet with the eene treeuehoy or errore ee do patients with diffuhe brain dylfunotion. Uith thete flute before’ on, it eoon beoene apperent thet eentei esp wee e rector in the peroeptuei reepohee. Therefore. e study or the reeponeee or mentally retarded eduite with mental egee or young children wee underteken. aieoiteheoue teotiie teete were eppiied to e group or mentally detective petiente. end three eepeote were studied: their reepoheee to the tests; the order or doeinenee: end the reletion, it eny. to standard peyohdletrio teete. am no me neateily on! Pitty~eeven reterded eduite from the werde or Letohworth Viilege, lew York were examined. whey ranged in chronologioei ego from 13 to #1. end in wentei use from two yeereueix nonthe to nine veers-eight nohthe. The figuree tor'uehtei eaee were thoee recorded in hoeoitei record: reflecting pertoreenoe on stenrord~nihet teete; end ih.eeoh instance, themeoet recent eetinete “I “I'd e �its subsoot sss'ssksd to class his oyss. Following this ho sss sinultsnsously touched on tho right ohsok sod tho dorsal of tho loft hsno. rho oxsninor asked: ”tht did you tool?" If thsro uss no response. tho oxssinor sskod "Did you tool as touoh you'.snd-“?oint to the plans shore I touchsd you." Aftsr this tsst the subjsot sss sgsin sokod to class his syss sod tho lsrt ohssk.snd loft hsnd stisulotsd, sud tho rsports rooordsd. subssQusnt tssts inoludsd stmsulstion of lsrt ohssk and right hsno, right ohosk sud hsad, both chooks,snd both bonds. This ssquonoo or six trials sss than rspsstsd so thst a totsl or 12 tssts involving the chuck; Ind hand ounbinstions ssrs carried out. Subsequsntly, tosts or other body ports, on hsod~root, ohssk-shouldsr. thigh-toot, shouldsr-thigh. ohook~£oot, and shouldorvhsnd sore introduced ~ four trials or osoh ssyulstrio oosbinstion sad on: trisl esoh of tho symmetric body parts. tho ontirs musnos or mum tssts omlcm with s rspstition or trisls of the tsoo~hsnd test. m assault: 0n ths'initisl trisl, 98! of nontslly rotsrdod subjects roportsd tho stinuli inoorrsotly. light: psr osnt rsportsd tbs fsos porospt only, omitting the psroopt to ths hand, a typo or ssnsory sxtiuotion.’ so. rssnindor looslissd tbs tsos psrospt oorrsotly, but mislooslisod tho second poroopt to tbs opposits chock, s type of sensory displsosssnt. It subJsots roportsd tbs stimulus to tbs hand olom or nialoosliud musk stimulus to the Fla'Ior dofi§3nisnos in writing so will osll this typo or rssponso undsr conditions or double simultaneous stimulation as extinction. RID Pl; �3._ are unprbtnionn or “race dunintnoa." tact dulinnnn- an: also apparent on subuognlat triuln of rib: flacuhnnd tent. titty per cent at eh. handouts failed to lootliue the two stimuli oorrtetly during the firflt ten trillu. 1hr! rupoatediy thilod to vaport tn. hand atinulun or repoatedly nialoetlized it. 15h: phenomenan at extinction was manifest in all lubaoatsg while in forty~six per cont, displuocunnt or poroupta I've alto reportad. A smaller number (335) shorad perceverutien or runponlon; i.e.,_ri§;r§od previous stiuuli even though now stimuli had hc¢n~aapli¢d ta different part: of thn hady. The phenomenon of cilanthnniu (miulooalisntian of a stimulus across th. nialinn to the opposite 3140 at tho body) (3) was ooaaaiannlly obnorved. Only out phtiant dauonutrltod oxotaneutheuia (the dinplaooaonz into extra-pornonnl npaeo) (3). all! or the number or nubjoota uncooeaed in localising and identifying the two stimuli Grins the initial ton trinlu. Their nhility to 1033113. the Itimuli in tho thee—hand tents una carried over in thn auhnoquont testing or other body parts. A for Inbaoetn, amour, actor aomctly identifying m5. sen-mu at the hem-hand haiku. made oaacaiennl errata during the testing or other body parts. ihole errors flute tlnmut again-ivoly in a failure to roport one ork‘ the stimuli . mum displacement of ”mat-tum Ion unite“. In all subject. sinultanoaul Itiunlation or hauologoun ii rngienl. 0.5. aher-ohnck, or hand*hnnd. wort intoruporled throughout the touting. 3mm mm infrequent on men tutu, «ms in those subject: who and. periisuont error. on neinulction at hand. Ehunu annponnou asymmetric regions, 0.3. chairman. fifteen subjects (26!) but only Mowers were chums! on occasions ware in thc error: in a �#. pattern as toga in t pttiont with n honiuoanory syndrnna dun ta 3 tonal cornbral Ionian. Relation to at." definite relation betunen thu 1nc1denoo or perintent 0mm and thc maul m or the subarea. run- I mount. .ubjootnerupod acaardins to nantul net (at dateruined by utcndard There wan a Stanfordwauant to:t1ns) and their respanaoa to ainultannaua tactile be noted that there in sauna; in the tutu.” It an insidonon or porozatcnt errors.on Innultnnaou: unul m 1mnnfin. mam. m am m; an tactilo test. an th- "$33“ $233.1. 1o 0 14: 7 3 93313:“ f (yrnrdnanthn) to 3-11 Mo to Mn 5-0 to 5~11 10 10 I 5 6.0 ta 6~11 1-0 to 7.41 12 5 7 11 a 9 8-0 to 9-6‘ I 1 3 2-»6 ‘ nolntion of 3352 Pitts! During the initinl ton trials, faae daninnan. was manifest in 311 lubjoata. In the subsequent tent: or ather body parka. ndditionnl pattcrnn of "dominance” appeared. This wt: ruprnutnzod 1n the aubjeot's inability to identity and localize on. of an. utiuuli or to niulooalitn on: poroept in an. dirlotion or thfi Ionand Itinulua.' As already intimated previoutly eh: Lyon: 0: the stimulus which in correctly reported 1: natd ta be ”daminanc". In tent: at check and shoulder. and cheek and fact, face dominance was �5’ obcurvod (Elblc II). In toot: both root and thauldcr at tnxgn It. to tho hand. in.tho rulatzonnh39 thigh. both too: and shoulder are dominant and shoulder and root, daninnnt to tho thigh. and or toot and hind. and shoulder and hand. ‘ BL! 11 alsronsna O! NHLEIPLE 81IULEARIGUS 2ACTILI TESTS BBFIGEIVI sunqsces retal £25: 6nnb1nnt10n' lumber of Toot. in Incorrect All Patient: lACI~hnnd 576 'Acl»foot 163 {AGE-shoulder 184 ‘ 8300LDIR~thigh 170 alonlflll¢hnnd 151 Factuthigh 170 toetuhnnd 231 I! 57 NBNEALLY Carroct Duo. 315 or Rand Rosaenaou Paco 1nd Band Fan. or loot taco and root Faee or Shouldor Rougonaol 36 252 9 128 9 Face and Shoulder 105 15 shoulder and Thigh shouldcr or finish Shouldcr or Hand 3 Shouldgg and 33nd #5 63 12 ‘ 113 Font or fhigh root and Thigh Foot ar Hand Foot and 81nd #2 » (under Body cambination) letterI/indtoatc dominant part *g;pltalilod 63‘ 10.3 17 33 111 1&0 as manxregt by t~toae va1ue of differenaei in tho incidence of errors in airfarent body combination: is largely duo to the order of talking and the factor or lcarning. Ema I ../ �6, amacuggxggg inane reunite when compared with thoae attained in previous experiments then that there in e striking similarity in the per- patient: with organic mental tn diffuee cerebral disease or dysfunction (23). normal children below the use of seven yeere end mental defective adults with e low mental age. The similarity lien in.the type: of reapeneee. the pernietenee 5: errors, and in the order of dominance. Extinction end diepleeenent phenanenn are frequent in all three groupe. Ibo responses are apparent on the initial end an Isabeeeuent triele. In addition, allettheeia and exonemeetheeie are formeneee of syndrome due I oeellioneily obeerved.. the eubJeote in each group unifeet an inability to identity Ind leeelile lay-nettle stimuli. thet is, cheek and hand. Symmetrie ntinnii. however, at etinuli applied to both hands, are well the most nanny named subjects. by patients with very severe brain dysfunction and by the younspnt annual child. In every group the errors or localizatien persist through many trial. of simultaneous teetiie tests. The subject: are unable ta lonelise the two Itinuli despite verbal clues uttered by the whether there had mu another etinuiuu. owner. each The errors are present even when the subjects are tented with eyes upon. The pertietenee of error: on repeated trial: in the mentally deficient eéuit, in the patient: with mental chance: and in annual young children it in marked contrast to the ease with which harnei adults correctly iooeiise and identify the stimuli. The per~ tornnneee or these tubaecte are illustrated in the graph which ieeeiised, even by u mam _ �7:. compare. their our cent error: during the initial ton trials of It Ihould be noted that the curve for the nontally deroctivo adult. includes 15-Iub1003! who have a mental age or 7 or more yuart, (see~!able I). rhia will account for, tho curve being below that or honnal children whose average mental tho race-hand tout. age was rarely above-7 yearn. Further-coo, tho order or conihahce observed in aoutally rotardcd subjects ia similar to that reported for pationta with organic nohtal chahuoa (at). Pace dominance in poem in all aubjeota, while thh hind dominance la hardly annifeat. The other body part. are tetuecn theaa linita. A: in patientc with organic tental chancea'or very young children one nay be inclined to explain the inability or the retarded adults to localine the two utiauli aa due to ”confusion” or "inattention." such an explanation in unnarranhcd hecanaa these subject. can perceive and localite Ion-atria Itinnli and the errata are not haphaaard. The errors shoe in a pattern to that clncut all emu are in stimuli to the hand and none in stimuli to the race. rurtheraore, this pattern per-iota in tecta or other body areaa la similar to patterns daaoribod for other group: of athects (2). A comparison of the ohcervaticna in normal young children and in tho mentally retarded adult. reveal: a striking ainilarity in perforntnoet than the mental age: or each group are oomparcd. In both groupa, there in a chahgc in pcrtor-ahcc about tho mental age or six soars. It may be concluded that the race-hand teat reflecta and the same performance ability an the stanrood~nihot tent. tho race~hahd tent has validity ac a convenient approxmuation at per» formance above and below a mental age of seven yearn. �8. tout and tinnitunnnu: tactila tact. or nth-r body part: unto Ipplioa to 57 noatnlly narcotivc adults. Qatar chronological asst runcpd from.13 to #1 start and taut: anntal yourn-é month. 1303 as dotcrldnld by stanrord~nanot touting rangpd Iran a The facauhnnd ,to 9 yearaufinonthlp Eris} 9&§.tlilod to 1903118. both act-“11 and an oubuogupne grin}: 50! and. persistent error. hoynnd can 0n tbs 131%151 trial. 1h. errors flit! lid. in Itlluli to en. hind whovotl 'auumu so. the has am ”metal: "parka. ‘xxtmouon, dinpnomnt, touch . allalfihosia and oerquIthnuin wort obocrvod. ihnlo parrot-anac0: tbs Inntally detoetivo'aault to an; tacoohand tent at. utrakxngly similar tn the response: of puttcntn with dztruto brain agnonua and of normal children I59 :1: 13:23 or loan. rurthnmnaao, thorn in a dotinihn rclation botuoon tho p02— uittcnno of utter: and tbs anneal as. at tho aubJoot. It 1: con~ gludnd thnt tn. floc-hnnd toufi rotloots ch. sane pgttarllnno as tho senatord~31unt and has validity as tumgpprnximntion or performance V above and below tn. acntal an! or seven yours. �mung 9. ‘ 3.3., rm, I. and «am, Ila rue-m 1n nonunion mm. 1n nimltmeouo tent: or race and hand. ArchJomlJnnzohnt. 1. fig, 355-352. 809%... 1951. 14., am, II. and mm, mm: The raeomand tut u an, a. diagnostic up) or organic mental undress. Inna-019g, g; ‘6“58; m, JW ll... um, I. 1952' and cutaneous perception. m, Mn..mx-.lourol.unoou H.3J The - order of in denim 195:. 7k: 11.3. and summon, HA utter-nu 1n alluthuu mm, than relation to diaerdor or body when and 0th» and unset-i 950. gs: 501615, October, SEAPIRO, ILL, 21m, 14. and mum, 14.8.: nouns-thou: or the plum-anon of dilpllomnt into ours—personal snot. phenomena. Atheurothghiut. , Archmoumhhrqrohut. (in m, ILL, .5. December, 1919. ) Vi crib ./ 7 {(12% 3!!“‘130, NJ. {aha-noun. 1:: 11031910311. ' pan) and WRAPPELL, AMA Minot“!!! Arch.murol.&Pazch1at.. fig; 717-3724. �1% 1139:. 1. Graph gnawing runponnou tugs: ta ninultuniaua tantilo on in1t1a1 5nd subocquant trials of tho in adults with organic mental faoe‘hand test ‘ayndrunn. normal children. age 3~6 yonrt. mantally defective adults and normal adults. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Perception of simultaneous tactile stimuli by mentally defective subjects. J Nerv Ment Dis. 1953 Jan; 117(1): 43-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-9-013 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin A.; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 117, No.1, Jan.1953 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/7defb938ce2262c49752d69a21de6f6d.pdf 5a753824ca2576c05cbbf0c478051e0c PDF Text Text Spinal Fluid Findings Following Cerebral Angiography Joseph, M. Stein, M.D. and Max Fink, M.D. WITH increasing use of cerebral angiography, the problem arose as to Whether the procedure, of itself, produced changes in the cerebrospinal fluid. Forty— eight hours after angiography a spinal fluid examination in a patient suspected of a brain tumor revealed a cloudy fluid with 3,000 white blood cells per cu. mm. Prior to angiography the fluid had been clear, colorless and without any cells. As, no information concerning the relationship of pleocytosis to angiography was available, it was decided to study the changes in the spinal fluid by the usual clinical methods. Spinal fluids from 21 patients were examined prior to and following angiography. Lumbar punctures prior to angiography were done at various intervals, but all punctures following angiography were performed between 12 and 24 hours after the procedure. In each instance the spinal fluid was exam— ined for color, cell count and total protein content. All angiograms were percutaneous, using 35 per cent Diodrast as the contrast medium. Maximal Diodrast volume was 70 ml. at one procedure. While the majority of patients were subjected to unilateral carotid punctures, bi— lateral punctures were done in four, and combined bilateral carotid and ver— tebral punctures in one patient. Either intravenous Pentothal (14 cases) or local procaine (seven cases) anesthesia was used. RESULTS Of the 21 subjects, significant changes in the spinal fluid following angiography were seen in only two cases. In one, a patient with a cerebral an— giomatous malformation and multiple aneurysms, 5,000 red blood cells per cu. mm. were seen in a pink spinal fluid. In the second, a patient with a chromophobe adenoma of the pituitary gland, the protein content of the spinal fluid changed from 89 to 151 mg. per cent; also, seven lymphocytes per cu. mm. were recorded when previously there had been none. In all other subjects, changes in color, protein content and cell count were not significant. Three subjects showed transient hemiparesis following an— From the department of neurology and psychiatry, New York University College of Medicine and the neurologic service (third division) and psychiatric division, Bellevue Hospital, New York City. Reprinted from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, No. 2 137 �NE UROLOGY 138 giography, and in none of these were there significant changes in the spinal fluid. Since Diodrast can cause changes in membrane permeability,1 and the spinal fluid reflects such changes, it could be postulated that a relationship between complications following angiography and changes in the spinal fluid might exist. Such changes were not demonstrated in the present cases. F urther investigations with more exacting techniques for protein determination and protein differentiation are indicated. CONCLUfiONS Neither a marked pleocytosis nor a marked increase in protein content of the spinal fluid are usual concomitants of Diodrast angiography. It may be concluded that when such spinal fluid changes are found they are unrelated to the procedure. REFERENCE 1. OLSSON, 0.: Cerebral angiography: Toler- ance for contrast media of diodrast type, J. Neurol., Neurosurg., 1949. 6c Psych, 12:312, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Spinal fluid findings following cerebral angiography. Neurology. 1953 Feb; 3(2): 137-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-10-014 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource Stein, Joseph M.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from NEUROLOGY, Minneapolis, February, 1953, Vol.3, No.2 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/7e92065b94f7b6d5425d61aa477e6ec4.pdf e45a9c50dfd09b37a641b179b46ee31a PDF Text Text ABSENCE OF A PARENT AS A SPECIFIC FACTOR DETERMINING CHOICE OF NEUROSIS Preliminary Study SIDNEY TARACHOW, MD.1 and MAXIMILIAN FINK, MD.2 New York, N. 'Y. Psychoanalytic experience has made important contributions to the problem of the differential etiology of various neuroses, psychoses, and character disturbances. This has been accomplished chiefly by the identification of the decisive areas of conflict in the patient. Among the factors involved are the nature of the instincts in the conflict, the time of the decisive conflict, the intensity of the frustrations or traumata, the availability of substitute gratifications, and the characteristics of the historical situation (Fenichel, 1). It is difficult to evaluate the specificity of any one of these factors in the choice of a particular neurosis. Recent investigations tend to show that while a particular neurosis may apparently be an expression of conflict at a certain level of development, nevertheless experiences at some earlier or previous level may produce tendencies which provoke, potentiate or distort conflicts of a subsequent period of development. With increasing psychoanalytic knowledge, the task of isolating concrete factors influencing specific choice of neurosis becomes ever more difficult. It becomes even more difficult if one attempts to assess the intangible factor of ego strength of an individual in his struggle to control and express his various instincts or his attempts to fashion defenses or character traits. Nevertheless, it 1Attending Psychiatrist, Hillside Hospital, Glen Oaks, N. 2 Fellow in Psychiatry, Hillside Hospital, Glen Oaks, N. Y. 67 Y. �68 TARACHOW—FINK should be possible to find a way of approaching mental operations in a systematic way which would lead in the direction of solving the problem of specificity of choice of neurosis. In seeking a systematic way to solve this problem, it occurred to us that perhaps certain elements in the external historical situation might lend themselves more easily to the preliminary steps of such a search. If a certain external historical situation were isolated and studied, perhaps it could be correlated with certain invariable psychic consequences. Freud (2) made such an observation when he noted that men who have weak or absent fathers tend to develop homosexual trends. The external historical factor we selected was the presence or absence of both parents during the important developmental years of the child. We decided to investigate the relation of this external factor to the success or failure of the resolution of ambivalent feelings, the ability to fuse the instincts of love and hate. For reasons to be noted we selected hysteria and obsessive-compulsive neurosis as the clinical expressions of the success or failure of the fusion. We then set up the following hypothetical basis for this study and made a tentative prediction of the data to be discovered. A child brought up by both parents will solve the problem of resolu— tion of ambivalent feelings more satisfactorily than a child who has lost one parent for any significant period of time. A child facing only one parent does not have both his love and his hatred equally and freely available to be directed to the parent. If he loves the single parent the hate will tend to be repressed, and vice versa. A child with both parents, on the other hand, has two objects against whom both sides of the ambivalence can be directed in turn. He can hate one and love the other, or the opposite. Two objects give the child much more liberty than one. This freedom would not hinder resolution of ambivalence, but rather facilitate it. He would have all his feelings relatively more available to him in comparison to the child with one parent. When the time arrives for the necessary fusion of feelings for more mature relationships the child who had had both parents is in a better position. Both sides of the ambivalence having been available, the fusion is more complete and normal. The other child, having relatively only one side of the ambivalence available, never succeeds �CHOICE OF NEUROSIS 69 in fusing his ambivalent feelings and remains with a burden of one-sidedly more repressed and defused instinctual feeling. According to our hypothesis the child who had two parents and had succeeded in fusing his feelings would tend to develop hysteria, if he developed a neurosis. The other child would tend to develop obsessive compulsive neurosis. This follows from the familiar psychoanalytic formulations of defused ambivalence in the compulsive neurosis and the fused genital level of feeling in hysteria. This hypothesis was tested by consulting the case material from Hillside Hospital. We searched for clearly defined cases of each category and studied the incidence of absence, death or loss of one parent for any reason whatever. Only clear-cut cases were used. All mixed and intermediate syndromes were eliminated, as were phobias and anxiety states. Sixty-one records have so far been found suitable: of these, twenty-seven were patients with conversion hysteria and thirty-four with compulsive-obsessive neurosis. Separation from a parent was defined as the absence of a parent for periods exceeding one year before the child’s fifteenth year of age. Note was made of the time of the separation, the reason, the duration, and the age of onset of the neurotic symptoms. Of the twenty-seven patients with conversion hysteria, three (11%) were subjected to periods of separation. In each the separation occurred between the ages of five and nine; in two by death and in one by emigration. In the latter the period of separation was of six years’ duration. Of the thirty-four patients with obsessive-compulsive neurosis, fifteen (44%) suffered extended periods of separation. Nine occurred between the ages of five and nine, four before the age of five, and one each at thirteen and fifteen. Separation was caused by death in nine subjects, hospitalization in three, and emigration in three. In the latter the separation lasted from one to three years, during the child’s age of three to seven years. In four subjects there were double separations. In one subject there was hospitalization of a parent for a year, return home as an invalid for two years and then death. In three other subjects there was death of one parent and illness of the other at another time in the child’s life. In all instances the parental loss occurred before the clinical onset of neurotic symptoms. �70 TARACHOW—FINK These data point in the same direction as the hypothesis suggested, namely, that loss of a parent tends to increase the difficulties of solving the problem of ambivalence.3 So many other factors enter into the situation that we would limit ourselves to the conclusion that these findings warrant further study of the suggested correlation. Other studies of parental deprivation have taken a somewhat different direction. Oltman et al. (5) studied the difference in rate of parental deprivation, comparing various psychoses with neuroses. They found that the incidence of loss of a parent did not vary in schizophrenia and manic-depressive psychosis from their control group, while psychoneuroses were higher. Their control group was State Hospital personnel, with 32 per cent deprivation. Psychoses showed 34 per cent and the neurotic subjects 49 per cent. The psychoneurotic group was not diagnostically further differentiated. Madow and Hardy (4), in a study of clinic population in the Army, found parental deprivation by death in 36 per cent of the neurotics. They used as a control, life insurance statistical tables which indicated an 11 to 15 per cent incidence of parent loss before the age of sixteen. A third study (3) of a student health clinic population in a State University indicated that 31 loss of neurotic the cent through subjects reported parent per death, while only 131/2 per cent of the controls (normal students) did. None of these workers were searching for the factors we are, and there is no breakdown into the various neurotic categories. These observations cannot be used comparatively with our specific point in mind. In general the data from the literature indicate that the incidence of parent loss is greater in neurotic subjects than in psychotic and control groups, although the various control groups show a lack of uniformity. Our own subjects taken as a group (this excludes many mixed neuroses, phobics and anxiety states) show an average incidence of parent loss of 30 per cent. The incidence in the obsessional neurotic is higher than in the cited controls, while in hysteria it coincides with the lower percentages of the controls. Apart from the subtleties of the psychodynamic processes which this study overlooks there are also gross difficulties in evaluating 3Chi square was calculated as 6.32 which is significant at the .01-.02 level. The chi square was corrected for continuity by Yates’ method. �CHOICE OF NEUROSIS 71 the statistics. First of all, the sampling is small. This will be remedied as the study continues. No other study differentiated among the neuroses, and diagnostic criteria probably vary from one institution to another. This study can be refined and develoPed in a number of directions. The dynamics with reference to the separation could be explored. The presence or absence of parental surrogates should be looked into. Other factors of separation such as deafness or blindness or parent’s going out to work must all be considered. SUMMARY A hypothesis was formulated stating that unresolved ambivalence (instinct defusion) may be related to the absence of one parent during the critical formative years. It was tentatively predicted that obsessive-compulsive neurosis (illustrative of instinct defusion) would therefore show a high rate of parental deprivation and that hysteria (illustrative of instinct fusion) would show a low rate. The actual data were: thirty-four cases of obsessive-compulsive neurosis showed 44 per cent of parental loss: twenty-seven cases of hysteria showed 11 per cent parental loss. We consider this at least a provocative difference. Even though many intrapsychic factors enter into the problem of unresolved ambivalence, these data warrant further study along these and related lines. REFERENCES (l) Fenichel, 0.: The Psychoanalytic Theory of Neurosis. New York: W. W. Norton 8: Co., 1945. :2(2) Freud, S.: Three Contributions to the Theory of Sex. In The Basic Writings of Sigmund Freud. New York: Modern Library, 1938. (3) Ingham, H. V.: A Statistical Study of Family Relationships in Psychoneurosis. Am. J. Psychiat., 106:91-98, 1949. (4) Madow, L. and Hardy, S. E.: Incidence and Analysis of the Broken Family in the Background of Neurosis. Am. J. 0rthopsychiat., 17:521-528. 1947. (5) Oltman, J. E., McGarry, J. J., and Friedman, 8.: Parental Deprivation and the “Broken Home” in Dementia Praecox and Other Mental Disorders, Am. J. Psychiat., 1082685-694, 1952. �Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume II, Number 2 April, 1953 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A statistical study of a psychoanalytic hypothesis: absence of a parent as a specific factor determining choice of neurosis. Journal of the Hillside Hospital, 2: 67-71, 1953. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-11-015 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource Tarachow, Sidney; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume II, Number 2 April, 1953 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/ee9acc31c3d43280c2889e28c2a5cbdf.pdf bf2464ff0c5b85a41fb05f4bcfd6dfb6 PDF Text Text Inlnary tor All (—1143 . turner 0’ Ilill'lflfiflfi IA‘IIIHIhTI 6' Pllfilpilflfl In: #13:. u.n.. Horton lathnnsoa. I¢E., villi: a. nits-an, I‘D. tad Harris I. laudmr, l.n. ottoat at antravuaona barbiturutu an tbs parcnptxen of Itltlpl. saunltunoauu antantoun atmnuli In. obsnrvud in lawn. groupa o: nor-s1 subjectt. puttantu with Iiitfllt and lawn! our.» bani 41:051., tptlul word 10-103. and psychoconic disordqu. Itch in. attain-d hetero and utter the :10! idltltltrtm ties of 2 1/25 uulution of Indian snytsl tn dost: o: 3‘15 to 6.50 an. to nyatusnnu. slurred upcoah, ‘ttxza and drauaantsu upponrcd, The haltnd tun simulttunoua tacit}. tints war. :9plind. 2h: assaincr ntunltaanounty tauahnd tn. lubjout In two plaacs - such ll tn. abbot and tho hand - and tutti his ta p.9ort that wt: ialt* ib3t§ tart rupaatnd with Vtrtoul boa: «ouhtlltiens. tad thu report: rueardod. It» ottcnts a! median atrial on Indul1:30: 0th.: than touch ‘Qf. sane inronttgntcd. In :11 labJoctn Indian ‘Iflt‘l etuuod arrow. in tin par~ caption a! tbs uisnltaaaafin stimuli. Ibrfltl nuhjoats taunt tun tnxxuaact e1 tn. barbiturate trcqauntly rcportod only «In at tho two stinnlt (onttantton); a. ., tn tho acubtnutton at £30. and hand only the stimulus to tat tnao was royortud. It‘s. trrarn into tt3nsannt :nd tlnntuntod during tho parted a! «was :atton. tn. indoetlan was 31.11:: bohavtar van untod £3 »»1¢, duproauian. paticntniv1th paychoanatu dtnovdurn schisophrnntu)¢ - 1 u �In puttoats with acrobrnl disease, uaytul brought out anioets ant privaoualy appaiunt or oxnguuruttd oxinttng .113: of 63:1uautioa. In this group tun orrnru U‘t. not. pronounced, porstntcd tor lessor porleds, ind abound 1's: tluatuttlon thfin :3 ch. nor-n13. 1h 9&ttontc with~£oanl carohrul dlflitit with 00:50:: daftots continua to any urea at thn body. anytaz brought out utter: which var. ant apparcnm ova: vith Ixnnltnanou: test: Ind 1t daftnnd tort nightly tho oxtnnt of tho teaser: disturbanco. Qttiuntn with diffuse aorubrul dyntuantion rho pruvtounly and. no orroru on atuultnnnoun tnatllo tautg, lhflflid rcpoatod Otters a: cxttnntton tug diuplnecnnnt as both 314.: at tn. body utter anal: dalos o: a-wtal. Pntxonts who angina uxtinattan or displgoonnnt prior to tha anytnl pertornod attiarantly sitar tin drug tn: xtvcn. Errata heath» nypnrnnt in body part: which print to tho naytnl ‘DIO rupartad oarruatly. Furthnr-oru, tho phannuoa: o: oxouounuthnsia (displaoalant to astrupfirnoall apnea), allcun than (duplwmnt to tho «man. an) «mom» son: (incenplntc apailatcrsl displneoaunt) var. also ovidont. In ‘11 pationta with orgnnio unatll uyndron. tn. duration at tho porcoptuul otter: ‘3: troqunntly 1033.: than the OUOrt 31.3; of drug sattan. Th. porcuptufil ahtfllhi lustod lancer thin in noruul m mt»: “suchctu attor stutznr downs tad var. norc canntstcat. :3 10310:. of tho aptnal nard, tho scanary dl£octn banal! not. ;ppnront: cutinntion could ho clxaitod «var : mutant unit and tho 1.?!1 at sonnet: 4.103: bouts» not. flittinct. In two �inntsnoOI. hounvur, t prsvtounly duturnlnod tensor: 1:!31 could not be olinltod :ttur tho anytul. In tout. o: othor century functions, nystncuun on datcct torvnrd can. In: ‘holiuhod during the potion at drug n¢tten, tad ch. concomitsat vxlutl disturbunncn (blurring and oaalllopllu) use unwed. suzmu, ”that: an tiuitm «mm a shelttton uanll d1.1:ution of this syupton nttor tho insection at of unytul. ow downs val thorn ta ultor tho porcupttoa a! ntuult¢nooun tacttln stimuli in all nubjoots. Thar. was an nltaratson in annnrtl paracptutl tauntian as wall as th. 19¢t1~ laud porutptunl luantlout. ’laistzng nonuary dyltuactiau its oumutod with the ”actuation of «not: not previously mm at. it... slt-tntxonn 1n porecption var. 31.11:: to thou. lollowtax prolonsud unsuthnutn er cloctrolhuck thortpv. Intrsvonoun barw bituruto any to a «metal tdaunat in oltattin; or oxnggnrutlnc nournl dystunottun. that. routtnn nuanzaatiou yield: equivocal 53553513 rumults. Xutruvonoau unytul �\V‘ “I ' Reprinted from TRANSACTIONS AMERICAN NEUROLOGICAL ASSOCIATION 1953 NEIIRIIPHYSIIILIIEY LABZ’IIA'TII'W’ HILLSIDE HOSPITAL GLEN OAKS, N. Y. EFFECT OF INTRAVENOUS BARBITURATE ON PERCEPTION MAX FINK MORTON NATHANSON PHILIP S. BERGMAN AND MORRIS B. BENDER NEW YORK The effect of intravenous barbiturate on the perception of multiple simultaneous cutaneous stimuli was observed in large groups of normal subjects, patients with diffuse and focal cerebral disease, spinal cord lesions and psychogenic disorders. Each was examined before and after the slow administration of 2% per cent solution of sodium amytal in doses of 0.15 to 0.50 Gm. As nystagmus, slurred speech, ataxia and drowsiness appeared, the injection was halted and simultaneous tactile tests were applied. The examiner simultaneously touched the subject in two places—such as the cheek and the hand—and asked him to report what was felt. Tests were repeated with various body combinations, and the reports recorded. The effects of sodium amytal on modalities other than touch were also investigated. In all subjects sodium amytal caused errors in the perception of the simultaneous stimuli. Normal subjects under the influence of the barbiturate frequently reported only one of the two stimuli (extinction) ; e.g., in the combination of face and hand only the stimulus to the face was reported. These errors were transient and fluctuated during the period of drug action. Similar behavior was noted in patients with psychogenic disorders (psychoneurosis, depression, schizophrenia). In patients with cerebral disease, amytal brought out defects not previ— ously apparent or exaggerated existing signs of dysfunction. In this group the errors were more pronounced, persisted for longer periods, and showed less fluctuation than in the normals. In patients with focal cerebral disease with sensory defects confined to one area'of the body, amytal brought out errors which were not apparent even with simultaneous tests and it defined more clearly the extent of the sensory disturbance. Patients with diffuse cerebral dysfunction who previously made no errors on simultaneous tactile tests, showed repeated errors of extinction and displacement on both sides of the body after small doses of amytal. Patients who showed extinction or displacement prior to the amytal per— formed differently after the drug was given. Errors became apparent in body parts which prior to the amytal were reported correctly. Furthermore, the phenomena of exosomesthesia (displacement to extrapersonal space), allesthesia (displacement to the opposite side) and partial displacement . 244 5’) «L I �Fishman—Intracranial Pressure 245 (incomplete ipsilateral displacement) were also evident. In all patients with organic mental syndrome the duration of the perceptual errors was frequently longer than the Overt signs of drug action. The perceptual changes lasted longer than in normal subjects after similar doses and were more consistent. In lesions of the spinal cord, the sensory defects became more apparent; extinction could be elicited over a larger area and the level of sensory defect became more distinct. In two instances, however, a previously determined sensory level could not be elicited after the amytal. In tests of other sensory functions, nystagmus on direct forward gaze was abolished during the period of drug action, and the concomitant visual disturbances (blurring and oscillopsia) also disappeared. Similarly, patients with tinnitus reported an abolition or diminution of this symptom after the injection of small doses of amytal. Summary: Intravenous amytal was shown to alter the perception of simultaneous tactile stimuli in all subjects. There was an alteration in general perceptual function as well as the localized perceptual functions. Existing sensory dysfunction was exaggerated with the production of defects not previously apparent. These alterations in perception were similar to those following prolonged anesthesia or electroshock therapy. Intravenous barbiturate may be a useful adjunct in eliciting or exaggerating neural dysfunction, where routine examination yields equivocal results. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effect of intravenous barbiturate on perception. Trans Am Neurol Assoc. 1953; 3(78th Meeting): 244-5. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-12-016 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Nathanson, Morton; Bergman, Philip S.; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprinted from Transactions American Neurological Association. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/ec4cf1a3f19d135cdae9a13c9adf5bf5.pdf 067f3d4f0480ecc6b50bb9561e8d4277 PDF Text Text Standardization of the Face-Hand Test Martin A. Green, M.D. and Max Fin/z, M.D. the face-hand test, has been introduced in previous studies and the responses of normal subjects and of patients with psychiatric disorders described in detail?“ The test consists of applying touch or pinprick stimuli simultaneously to the face and hand while the subject’s eyes are closed. The subject is then asked to describe and to localize the percepts. Two general types of responses occur. The two stimuli may be perceived and localized correctly, or the subject may perceive only one stimulus and either not perceive the other (phenomenon of extinction) or mislocalize the second stimulus (phenomenon of displacement).7 Most often the mis— localization or displacement occurs to another part of the subject’s body, but occasionally there is displacement into extrapersonal space or onto the examiner (exosomesthesia).R Displacement of stimuli across the midline of the body (allesthesia) may also occur.” Normal adults show errors in perception on the initial trials of the facehand test. Characteristically these errors consist of extinction of the stimulus to the hand whereas the face stimulus is perceived correctly (phenomenon of face dominance). As tests are repeated the errors disappear so that by the tenth trial nearly all subjects correctly perceive both stimuli and then continue to be correct on subsequent trials. This type of response has been termed a “negative face-hand test.” It occurs not only with normal adults but also in patients with schizophrenia, depression, or severe anxiety. In contrast, patients with an organic mental syndrome show extinction and displacement after ten trials of testing or as long as testing is continued. Such a response is termed a “positive face-hand test.” A “positive face-hand test” is also manifested by normal children, normal aged persons, and mental defectives. Because of the differential response of these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it has been noted that patients with an organic mental syndrome vary greatly in the type and A SIMPLE PERCEPTUAL TEST, From the department of neurology of the Mount Sinai Hospital and the Hillside Hos— pital, New York City. This work was aided in part by fellowships from the United States Public Health Serv— ice (Dr. Green) and the National Foundation for Infantile Paralysis (Dr. Fink). Reprinted from NEUROLOGY, Minneapolis, March 1954, Vol. 4, No. 3 211 �NEUROLOGY 21:2 frequency of perceptual errors. Also, subjects without organic brain disease occasionally manifest a positive face—hand test. The questions which arise from these observations are: 1) Is it possible to classify or standardize the different types of errors occurring in subjects with a positive face-hand test? 2) Is there a correlation between the types of responses and different groups of subjects? 3) Is there a type of response which can be said to occur only in patients with severe disease of the brain? The present study is an attempt to answer these questions. IVIETHOD AND RESULTS Previous records of the face-hand test were reviewed for almost 1,000 patients with organic mental syndrome, normal adults, and schizophrenic adults, as well as lesser numbers of normal children, normal aged persons, and sub— jects with mental deficiency, depression, and severe anxiety. Additional groups of some of these subjects were also tested in a systematic manner with dif— ferent types of stimuli. The criteria used to formulate a standardization of the face—hand test were: 1) type of perceptual error; 2) frequency of various errors with different stimuli (touch, rubbing or scratching, and pinprick); 3) effect on the frequency of errors when the subject observes the application of stimuli (factor of attention). Fifteen to 30 trials of the test were usually done for each subject. TABLE 1 FEATURES OF POSITIVE FACE-HAND TESTS (Persistent errors after 10th trial) One—plus Extinction only with touch stimuli. Two-plus Extinction with touch, rubbing, and pinprick stimuli. Occasional dis— placement with touch stimuli. Three-plus Extinction and displacement with touch, rubbing, and pinprick stimuli. F our—plus Same as three-plus with at least one of the following features: a) exosomesthesia, b) allesthesia, C) frequent perseveration, d) occurrence of errors while subject watches the stimuli being applied. Based on these criteria, it was possible to divide patients showing a posi— tive face-hand test into four groups. The characteristic responses for each group are summarized in table 1. These responses with examples are described more fully in the following paragraphs. One-plus face-hand test: Subjects in this group show errors only of extinction and not of displacement. These errors occur only with touch stimuli. When pinprick is used, both stimuli are perceived correctly, although errors will again appear when touch stimuli are reintroduced. Case 1.—A 64 year old man with mild diabetes was admitted with a history of difficulty in walking for the previous year and a half. For at least the same period of time he had been depressed, slept and ate poorly, and was impotent. The only neurologic finding was a slow, hesitant, shuffling gait. There was no evidence of peripheral vascular disease. The patient appeared depressed, showed psychomotor retardation, and cried readily. The sensorium was intact. Spinal fluid, electroencephalogram, and roentgenograms of �STANDARDIZATION OF FACE—HAND TEST 213 the spine were normal. The diagnosis was involutional psychosis, depressed type. The gait difficulties were thought to be secondary to the depression. This patient showed a one-plus response on the face-hand test. A sample of his responses follows: Stimulus touch touch touch touch touch touch touch touch touch touch touch pinprick pinprick pinprick pinprick touch touch Location right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand right cheek—left cheek right hand—left hand right cheek—left hand left cheek—right hand left cheek—left hand right cheek-right hand left cheek—left hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand right cheek—left hand left cheek—right hand Response right cheek left cheek right cheek left cheek correct correct right cheek correct correct right cheek left cheek correct correct correct correct correct left cheek Type of error extinction extinction extinction extinction extinction extinction extinction extinction Comment: Although this type of response occurs in patients with cerebral disease, it is not always characteristic for this group. It is also observed in patients with depression, as this case illustrates, and may occur in anxiety states, schizophrenia, and, occasionally, in normal adults. T wo-plus face—hand test: In this group extinction occurs with pinprick and rubbing stimuli as well as with touch stimuli. These errors may be just as frequent with both types of stimuli or may be more conspicuous with touch than with pinprick or rubbing. Displacement is not present, as a rule, but may occur on an occasional trial. Case 2.—A 72 year old man had a five week history of mental and behavioral changes. These consisted of disorientation, confused behavior, and intermittent mutism. Examination showed an organic mental syndrome characterized by partial disorientation, defects in recent memory, evasions and circumlocutions in answering questions, denial of illness, and pain asymbolia. There were no other neurologic disabilities. The spinal fluid, electroencephalogram, and skull roentgenograms were normal. A pneumoencephalogram showed an increased amount of air over the cerebrum and increase in the size of the ventricles. This patient’s responses on the face-hand test characterize the two-plus type of response. A sample of these responses follows: Stimulus Location Response Type of error touch left cheek—right hand left cheek extinction touch extinction right cheek—left hand right cheek left cheek—left hand touch left cheek extinction touch extinction right cheek—right hand right cheek touch correct right cheek—left cheek touch correct right hand—left hand touch extinction right cheek right cheek—left hand left cheek—right hand left cheek extinction pinprick �214 NE UROLOGY Stimulus pinprick pinprick pinprick pinprick Location. right cheek—left hand left cheek—left hand right cheek—right hand left cheek—right hand Response correct left cheek right cheek left cheek Type of error extinction extinction extinction Comment: This response occurs most often in patients with cerebral dis— ease, although occasionally patients with anxiety states, depression, or schizophrenia may also exhibit it. It is not seen in normal adults. Three-plus face-hand test: This group is characterized by the occurrence of displacement as well as extinction with both touch and pinprick stimuli. The frequency of extinction and displacement may be equal or unequal and, likewise, the number of errors with touch and pinprick will be variable. Case 8.——A 57 year old chronic alcoholic was found in the street in a stuporous condition. His breath had an alcoholic odor and there was a laceration over his right forehead. There were no focal neurologic signs. During the first hospital day the patient gradually became fully conscious. Speech was rambling and at times almost incoherent. He was completely disoriented and had severe memory defects with confabulation. He expressed paranoid ideas and was hostile and assaultive. There were no hallucinations. Spinal fluid and skull roentgenograms were normal. The diagnosis was acute and chronic alcoholism with deterioration. A sample of this patient’s responses on the face-hand test, indicative of a three-plus response, follows: Stimulus touch touch touch touch touch touch touch pinprick pinprick pinprick pinprick Location right cheek—left hand left cheek—right hand right cheek-right hand left cheek—left hand left cheek—right hand right cheek-left hand right hand—left hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand Response right cheek-left cheek right hand—left hand right cheek correct left cheek right cheek—left cheek correct right cheek—left cheek left cheek—right cheek right cheek ' left cheek Type of error displacement displacement extinction extinction displacement displacement displacement extinction extinction Four-plus face-hand test: This group shows the most severe perceptual errors. In addition to frequent extinction and displacement, as seen in the three—plus group, one or all of the following phenomena may be seen with touch and pinprick stimuli: l) exosomesthesia; 2) allesthesia; 3) frequent perseveration of responses; 4) occurrence of perceptual errors even while the subject keeps his eyes open and sees the areas stimulated. Case 4.—A 60 year old man had a three year history of disorientation, forgetfulness, and loss of interest. On examination he showed a severe organic mental syndrome manifested by complete disorientation, marked memory defects, and inability to calculate. He was alert and cooperative. There were no other neurologic signs. Spinal fluid and skull roentgenograms were normal. The electroencephalogram showed moderate, diffuse, bisynchronous slowing with slow alpha. A pneumoencephalogram disclosed abnormal increased amounts of air in the subarachnoid spaces overlying the cerebral cortex. A sample of the patient’s responses, indicating a four-plus face-hand test, follows: �STANDARDIZATION OF FACE-HAND TEST Stimulus touch touch Location right cheek—left hand left cheek—right hand touch touch touch touch touch pinprick pinprick pinprick pinprick right cheek—right hand left cheek—left hand right hand-left hand right cheek—left hand left cheek—right hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand pinprick ( eyes open ) right cheek—left hand Response right cheek left cheek— extrapersonal space right cheek right cheek correct right cheek—left cheek left cheek—left hand right cheek—left cheek left cheek right cheek left cheek— extrapersonal space right cheek— 215 Type of error extinction exosomesthesia extinction perseveration displacement allesthesia displacement extinction extinction exosomesthesia exosomesthesia extrapersonal space Comment: Three-plus and four-plus responses invariably indicate disease of the brain. They are never found in normal adults or in patients with psychogenic disorders. These responses have been occasionally seen, however, in normal children under the age of six,4 aged persons without manifest disease of the brain,6 and mental defectives.10 The distribution of responses of children and aged persons are related mainly to age. The youngest children and the oldest adults show three-plus and four-plus responses. With changes in age away from these extremes, one-plus and two-plus responses become more frequent. Of the subjects with mental deficiency, those with the lowest mental age have three-plus and four-plus responses, while one-plus and two-plus responses predominate in subjects with higher mental ages. Table 2 summarizes the distribution of the four different types of responses among the various groups of subjects. Only patients with an organic mental syndrome show three-plus and four-plus responses. Such responses may be considered diagnostic of an organic mental syndrome. DISCUSSION In answer to the questions raised at the outset of this paper, our results indicate that four general types of positive face-hand tests occur and that TABLE 2 PERCENTAGE FREQUENCY OF ONE-PLUS TO FOUR-PLUS POSITIVE FACE—HAND TEST IN DIFFERENT GROUPS OF SUBJECTS ‘ ............. ................... Patients with anxiety states ............. Organic mental syndrome Normal adults (below 60 years of age) Schizophrenic adults Patients with psychogenic depression (all age groups included) . . . ............. . Negative F-H test Oneplus 10 99 7 nearly all occasional occasional 70 22 all nearly l Twoplus 25 0 Three- plus 33 O F ourplus 25 0 rare never never rare never never 0 0 8 �216 NEUROLOGY these types can be correlated with different groups of subjects (table 2). Our attention was focused mainly on whether there was a type of response which occurred only in patients with severe disease of the brain. All adult subjects with a three-plus or four-plus response have organic brain disease. Such responses are never seen in normal subjects or patients with psycho— genic disorders, even though these groups may occasionally Show one-plus or two-plus responses. Patients with cerebral disease manifesting a four-plus response invariably show the severest or most advanced form of mental changes. Otherwise there is no good correlation between the type of positive face-hand test and the severity of sensorial defects. Some patients with severe mental changes may have only a two—plus response. In addition, 10 per cent of patients with an organic mental syndrome have a negative face-hand test. It is realized that the use of a one to four—plus nomenclature for the groups implies an increasof because used This nomenclature of cerebral was dysfunction. degree ing convenience and such an implication is not intended. This classification of a positive face-hand test should be useful clinically. In testing neurologic patients, the exact type of positive face—hand test should be recorded, rather than the designation “the face-hand test was positive” as has been done until now. Such a procedure will make it easier to judge whether the type of positive face-hand test indicates definite cerebral disease or whether it may be a manifestation of anxiety or depression. The use of such a classification will also make it easier to compare the response of patients at different times during their illness. In addition, it is valuable in clinical experimental work, for it has been applied in studies of the effects of drugs on perception and the responses of patients to electroshock treatment. In such studies alteration in perception can be measured by observing the duration and incidence of the variety of positive face-hand tests during the periods of testing. SUMMARY A standardization of the face-hand test is presented. A positive face-hand test is designated as one in which errors persist after the tenth trial. Four classes of positive face-hand tests are recorded. A one-plus face-hand test consists of extinction only with touch stimuli. A two-plus response is char- acterized by extinction with pinprick and rubbing stimuli, as well as with touch stimuli. A three—plus response consists of extinction and displacement with touch, rubbing, and pinprick stimuli. A four-plus response has all the characteristics of a three-plus response and in addition at least one of the following features: a) exosomesthesia; b) allesthesia; c) perseveration of observes while the of (1) applicasubject even errors occurrence responses; tion of the stimuli. Three-plus and four-plus responses invariably indicate disease of the brain in subjects over the age of six years. One-plus and twoplus responses occur in patients with brain disease but are also manifested disorders. with adults and of normal number small psychogenic patients a by �STANDARDIZATION OF FACE-HAND TEST 217 Patients with a four-plus response show the severest mental changes but the converse is not true. There is no correlation between the severity of the mental changes and the type of positive face-hand test manifested. Usefulness of this classification in the study of patients clinically and in experimental work is suggested. REFERENCES 1. BENDEn, M. B., FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. & Psychiat. 66: 355, 1951. [O . BENDER, M. B., and FINK, M.: Tactile per— ceptual tests in the differential diagnosis of psychiatric disorders, J. Hillside Hosp. 1:21, 1952. . FINK, M., GREEN, M., and BENDER, M. B.: The face-hand test as diagnostic sign of disease of the brain, Neurology 2:46, 1952. . FINK, M., and BENDER, M. B.: Development of perception of simultaneous tactile stimuli in normal children, Neurology 3:27, 1953. . IAFFE, J., and BENDER, M. B.: Perceptual patterns following general anesthesia, ]. Neurol., Neurosurg. 81 Psychiat. 14:316, 1951. 6. GREEN, M. A., and BENDER, M. B.: Cutaneous perception in the aged, Arch. Neurol. 6: Psychiat. 69:577, 1953. The phenomenon of sensory . BENDER, M. B.: displacement, Arch. Neurol. & Psychiat. 65: 607, 1951. . SHAPIRO, M. F., FINK, M., and BENDER, M. B.: Exosomesthesia or displacement of cutaneous sensation into extrapersonal space, Arch. Neurol. & Psychiat. 68:481, 1952. 9. BENDER, M. B., and NATHANSON, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena, Arch. Neurol. & Psychiat. 64:501, 1952. 10. FINK, M., GREEN, M. A., and BENDER, M. B.: Perception of simultaneous stimuli by mentally defective subjects, J. Nerv. & Ment. Dis. 117: 43, 1953. �EIWRDIZATION OF m FAGEwm MT 3y “mm I. ‘0 “NC“, Do und In: rank. n. n. ibis tort 1;: e status Publia Hoalth dation of n‘% ' _fi{ p 9'» 1 arson) and survioo (Br. thy Huttonnl ‘ <" ' ’ ' ” Faun- Infantila Paralysis (Dr. Pink). Eran an. Dognvunont or Hourology at thn noun: stnui Hospital and tho 311 lid. Houpitnl. �Introduetiunt In priviaul studies a tinplo poro‘ptufil taut, uh. rnoia hnnd fiast. was intradnoed and tha rbnfionnon bf normal anbjtetn 1nd or pationta with ptyohittrio d1noranrl w¢r¢ dglcribod 1n dbttil (lab). Tho tout aanniuta or applying tough or pinpriok .ltinnli nimnltnnsounly to tha tact und.hund uhilo the aubjuot‘n ayes hr. closed. it. lubjoot in than aambd to annariba and to lootliso thn poraapta. Two gannrul type: or roaponsol Gaunt. who five stimuli may bu poreoivod and localized oorruotly. 0r, thn nubjoae may piranivo only on. atiuulus and cithor*nat porn enivo the ofihtr (phnnennnan at astinotian) or maniacaliaa thn sooand stimulus (phannmnnon or diuplacaannt) (7). fiaét ottcn ~fih¢ mislaealiuntién or diaplaéqnnnt «can»! to anathnr pirt at tho wubjoot’s body, but oooailunally thtrn 1n dilplaaahont into oxtrtparuonnl apnea or onto thy axmnxncr‘(axoaamolthnaia) (8). Difiplgotnoht at stimuli turns: the midlino or thn body ($110.» thosln) nu: also onenr (9). flornnl adult: show 0r§oru 1n perception.au tbs initinl ‘ r mu.- a: I tho tuna-hum 4 «at. cmctcrnuaaxy than error: sonaiut or oxxznetion of thy thinning to fin; hand than... tho raga Itimnlna is perceived aorrcotly (phcnamonon at face again,nnuo). A: thn that: arc ropoatad thy error: d£luppoar so thnt by th. tonth trial nearly :11 subjcctu norraetly paragQfia both stimuli and than oontinnu to bq corruat on tubauqunnt trigll. This typo or roaponno has bran tonmnd a “nagativo raco~hnnd tout.“ It ooourn not only with manual adult: but also in pttzontn �2. ‘vith :6h1uayhruniu, dtproaaion. or savor. anxiety. Kn contrast to tho proo¢d1ng aubjaats, pa§1nnts w1th tn uorganio mnntnl nyndrumn aha! qxt1not1on and displnecnant Artur 10¢ tr1a1: or toating ar-II long It touting 1- continued. Such t npupcnlc~1n‘tpnmnd u ”posit1vu {nonwhind tout." A *poaitivu ftoo~hnnd tout" 13 claw unnLroutod by normnl uh1ldrtn, normal ugud,p¢auann. Ind:mantnl dofoat1vol. Bananas of thy dirforont1a1 rnlpenao of thaao aoviral swung! at luhjoetl, an. faoo~hnnd test has banana astral ul1n~ toally 1n dataating tho prosoneo or orggn1e brain d1aoAIo. During the court: or our stud1al, hawovor.,1t ha: boan noted >that pntiants with 1n grannie nantql syndrann Vtrylgrontly 1n the type and traquancy or porcoptuul Grrort. Also; nfibjactn I ' without organ1o brt1n é1aoalo occasionally mnn1t¢at a pauitivc raccuhnnd test. 1h: quantionn finish arias from that. abnorvutionn an: 1) .1: 11'. poneiblo to elmxfi or mandamus an. autumn 'typu: or orrafa aouurr1ng 1n'1gbjooti v1th I panit1v§ fteowhnnd 80:12:13) In fibfiro A oorrulnt1on botuuon thb typca or roqpannol and dirrorun1_gr¢upa or aub:¢atn?; 3) in than. a typ. or ronponno Ih1ah can bu ugid to ocaur gal: in pitifintl v1th_nav¢ro 61301:et uh. bra1n? the proncnt Itfidy is an uttqipt to ‘nalur than. questionapv I. 04 1 d B! ‘ t lb roviornfi our provleus record: gt ‘ 1h! tuna-hand 103% in nlmnat 1000 pat1onta with organic mnntnl syndroma, normal adults, and Inhiaoyhrohia adults. an wall an in longer numdam. born of normal.ohildrun, normal 130d porlena, and ambient: with �3. m.nt:1ld¢rieigncy. dnprnaulon and lottrn anxiuty. Additional stamp! of menu of than. uubjcotl taro 31-0 toatna in a lyutmm— gtic mannar'vifih filrtoront typaa of stimuli. The aritoria ulna to fonmultt. a Itandnrdixntion or the raaouhrnd tout wire; 1) typo of poraoptunl 2) frnQunney of various arrays (touch, rubbing at nergtehing. and p1n~' crrnr: airroront stimuli prick): 3) offset on thy troguoney or orroru vh¢n tho cubjoet noes tha appliantion at tho I§1IM11 (taotcr or dttcntien). Firtaon to thirty tritla at tho tait wuro naually done for wifih Onah cubjoet. « criterig, it in: possiblo to divida pa § tianti sharing a positive ftoomhnha tqst into {our group:. Th» oharaaterintie rouponnu: for etch gréup arc summarized in Tabla I. 'ThoIoAroapann g with oxnmplo; art angeribad morn fully in tho {allowing par‘grapha. Based an.thnUO Fuataruu a: Ponitzvo~nuac-aana’roatn _(vors1£tont prrorn attdr 10t§ firiil) W 1 M." Situation Extinction W Wm» 1 am plan mt1not1on with tough, und dinpltéo— anly with tauah stimuli rubbing. and 'mant with P181314“ touch, rubbing stimuli. ,tnd pinpriak occasionul stimuli 41: laocmant Ii tauah ‘ u)oxolamauthsaiu b)nllaathsai‘ ‘ , nttmuli. a: thug... with n: loaat can or uh. following {autumn ‘ o)trnquont porn¢v~ «ration d)qc¢urr¢nen of errors while just watch»: sub~ ithmuli buing nppliod. uh? �h. gnoePlgn.Fheoen§gd Tout: Tho subjects in thia group that error: only at Ixtinatioh and not at displahanant. Thou. errata oaour only with tauoh stimuli. Whon pinpriak is usod. both utinnli up. poruoivoa aornootly, although arrhra will agnhn appatr lhln touhh stimuli urn rhihtroduaod. Gun. 1: tad with 3 A 6h your aid huh with mild dinhotpl pus t6n1fi* xi your hiltary a! dittiaulty in walking. Fbr at I... patina 0: than hm had boon dnprogacd, alnpe .and ht. pearly. and It. impatanfi. 'Tho only unurologiaul finding was t slow, halitant, nhurfllng shit. Thor» was nh ovidnnn: 10am: tho ot‘poriphortl vuioulhr dis-coo. Eh. pationt‘nppoarud doproiaod, 'IhoVGd payahanotor rotnrdutian, tnd dried handily. The non» aorium in: intact. Spinal fluid, slactrocnhaphulogrtm, ertys at tho spin. ward normal; who tional psychoazu. dopranlod type. hheught to he sccahdnry to thi diagnosis In: involuu The gait difficultiau tar. dnpronhion. _ this patient thalcd l anonpluaerIpanlfi tout. A sample at his ruxponaaa follows: on tho tau-«hand ‘ ‘ Stimulus gggatiog touch right ohnak*lott hand ’ wypg of figugcns; firrar right shook: axeinotion hoxtinntion 10ft shack tough loft chock-right touah' right ehaokwright hand right South 10ft annex—loft hand touch right ohhak~lnrt ahock earnest» aerroet right handwlott hand right ohsaknloft hand right dhaok tauah touch and hand Int: chagh about» uxtinotioh cxtinotion ' extinction �5. lart ahnak~r1ght hand left «human 2mm tauah touch touch right man 101“: pinpriok pinyrick pinprl ck pinprick touoh> entrust eon-cot. riwt aha-ehwrigfi hand mud“: hand right absoknlort-hand lore dh¢ek»right hand right nhotkwright hand 1am; ehcokdgft ma‘ right «haiknlgrt hund wt ”chock-avian: hum loft . ~ chock check axnination «attraction aorrooh correct garnet“ «may ‘ aorroot 1st: abut: .munctxm ggggggfi; Althnugh thia typc or.rcnpanno aoafira in patiwntl teach aorabrnl diuaano, 1t 1: not dlway: entruatcvistie for this group. It is Also abhcrvué‘tn patiunts Iifihéaprolaion, wifih : thlg anal illuitratas} aehisofihranin, and. ocassiénally,'1n nunnnl a¢ulta; P; V,Eh.0+H Id ’rt In this graup axtinction ooeurt Iifih pinpriek nag rubbing stimuli a: lull én‘vith taudh #tim» all. than; arrora mgy ha junfi an froqugnt with bafih.typta at stimuli er may be met. conspiauouj\vith-tauah‘fihnn with pinfi prick or'rubbinga Biapluaunnnt 1; not yrbsnntg an a rule. and may occur xn anxioty at§t¢t, an & 7 L , but may auour on Case 1!: '1 tn,aoedligna1 téinls 72 year o;d man had a 5 ' . WIOK history of anneal and bahnxioral;ohangoae Eben. ganniatcd ar'éiaor10n~ tatian. confused bdhnviar. and intarldtéant muslin; On oxnmp inntion thara Inn gn organic mnntql lyndran. charactarisod by partial dinoriontation. 60:00:: in ruannt unwary, OthianI �Z~g‘ s7”! ind otteumloauhlann 1n annu¢r1ng quastians, daninl or 1113..“j and pain uuynhoiit. Thar. var. no ofihor nunrolagioal dilw mutton. mo spin-.1 mum. olootraonaaphuagm. and “all xnrnys Ibru ndrmal. A pnaufiooneaphalognmn unusua'un 1n¢ro.nad «flaunt of air ovor uh. aorobrum and inaroaaa in tha 3110 at tha ventricles. was: pat1¢nt§a raafionloa'on tho tuco-hugd taut untran- torls. tho tvaapgul typa at ruaponao. spannon taller: samplc of thnsc raw A \ a ‘ 3352395; Tg£;o;t _“§au¢h aggntgan 1.x: abnohuright hand 10ft «hack axfiinotian tcudh right ahaak~1at£ hnnd right thinstion ' 3tg55;un left r.t§ugna tbuah V. tough touch toudh ’ right right right right enaok~1a;m hand ‘” ' unsurpright hana din:k-1.ft-ahodk hundnlurt hand «hookvlhft hand lgtt ahnuk Oxtlnntinn right chnub extinction‘ about «errant eorruat ' pinpriek loft ghostwright hand right chock wyxtinstian 1.1: chuck oxtinctian pinpriok ptnprick pinpriok pinprlok right ahcokalort hand oorreat 1.x: ehaakwlort ngna right chant~r1ght hand lart ' oxtinutidn oxtinctian 10ft chick cxtinotion 1¢ft ahhek~right hind adamant: Thin ruaponaa eocuru mast urban 1n pntianta with cornbrul 6119110 altheugh oncasianally ptt£¢ntl with anxigty itibfllp dnprossion or duhinophronia naq'alto cxhibit it. It in not soon in nounnl ndulta. ahflak right ehnok �0‘: 75 gaggovgggg §33A~§g§§ ruAtt IhAA by thy ooaurrunco of diApLAeanAnt bath touch And pinprick atzmuli. group wall AA who And displaoumanm 1A chArAatAriAAd Axtinction with frAquAnoy of extinction AA , any bA’Aqual cr unsquAl And. likAAiAA, Aha number 0: errors Aibh touch And pinpriak'will bu AArAAbIA. 6139 III: strict in the holia odor There AArA hoapital ntuporoun oundition. A And thArA AAA thA pAtiAnt rumbling And caaplataly diacriuntod gnnfahulation. 31A brAAth hAd an Alena HA 3 lAAArAtion gradually bAoAAA fully oonaaioun. At tihnn Alnolt inoohArAnt. EA AAA. And had AAVArA salary axprAAAAd pArAnoid idAAA and A3AAA1§1VA._ whArA Aura And Akull X-rAJA AArA nanmAl. Th. diAgnosil Asamplq of thin pAtiAnt'a A tout. indiactivo or giggyggg saw. A ggaation my“ dunk-daft hand . touch loft touch right touch urt chum-hrs hAnd Quota-wright ham. ' mamm hum! touch right aha-kaloft uhAARArxsht hAnd hAnd loft hoatilo III aunt. fluid and taco-hand fallow-t right abuzz- ‘ with EpiuAl T§£§ogf 333223;; ' lnft AAA AAA rAAponAAA on Ah. thrAAapluA rauponsa, touch dAtAAtA no hAllueihAtianA. .Ahronie ALedholium with anteriorAhion. ” found in AAA ovor his right torAhAAd. no fooAl nnurologieAl signs. During uh. tirut AAy SpAAAh WA» 57 yoAr old chrenio Alcdhalio A chock ‘ diuplmmnt . hand;mm 1cm; hum! displaemne right about anemone»: came: lcts aback extination right diaplaeAaont loft ahAAk~ ohAAk �touch right hand-10ft pinpriak ; pinpriak hand comet right ahaok~lort hnnd A)right left an: 1m; chfiokumght hand I pinpriak pinpviek Fb ' ‘ ' right chock-«right. hand lcrt «hank-lnrt‘hnnd Flu; Hand chaokn diaplaoamant «bank cheat» right ahnek right ohm: lfitt ; aback displaefimnnt . oxemauon axtinutien ‘oat This greup shown tho aovcrast poréoptual arrara. In addiiion to rr$quont «xtination lné ainplaeomnnt, an noon in thn thrno~p1us group, on. or .11 at fiba folloiing , with touah and pinprlak afiimnli: 1) uxunanalthnninx 2) allouthoditi 3) truqnnnt pur~ agvcratian at responlttt h) tho oocurrcnnn or paranptunl arrorn ngn-uhzid find aubjoat kaopu hxl'cytu opan and 109: tht Irilfl fibenamnnn may be mean flimuntud. Gas: 60 ycnr old man hgd a thrai your hiatary or disoricntution, forgatrulnnla. ‘ndVIOIl of intaraut. an axum~ 1n£ti¢u h. ahawqa a 3.1.». argania mantal nyndroun manirnqttd by cauploto disaritnt‘tian, marked,m¢mary actuati, and inabilo ity to atliulato. H. In: alart and cooporteivo. whore wire no other naurological algal. Spinal fluid gnd akull Xbrnya XVI ‘uuro manual. A EEG-abound anagruto, diffuse. biaynahranoul alaning with 110! alpha. A pneumnonnephalogrum discloscd dbnormal increasod amount: of air in th» aubnrachnoid apnea: overlying the anrobrti eortox. A Iamplo of tho pationt'u rnuponuua. indicating a four. plus tacowhnnd tott, tollavla ’ f �95 Stimulus. tough touah Typa . mastic»: ' right obnokuloft hand 19ft chnekhright hand ‘ » of Emu Rcaw‘ right aback axtinctian left oxosomoathoslu :- chatk~ oxtruporuonnl apa¢o tough right thehwright touch loft touch tnunh right handplaft hand right ahaak~lort hand tench loft aback-right pinpriak right aback-loft ptnpriak pinpriek pinpriok 10ft chookbright hand lart right ahookaright right 10ft ohuak~lort h:nd 1.1% chook- axoaanosthnaiu pinpriek right chopkwleft right oxaaamaathclia (ayes Open) . r. . . adamant: 1 hand chnokwlerfi hand right «hank right cheek torrent right aha¢k~ qxtinetion poraevoration aiaplaeanant hand 10ft chock 10ft ehaak10ft hand allouthaslt hand right displtaunant hand hand 10ft ohnak~ aback ohock . dho¢k «xeraporlonal span. shack» nztrtparuannl oxtinatien txtinctian :pton rhrno—plun and roufiwplul vniponsos invarisbly inninatogdinoani of thofibrain. inn: 1:. nnvur fauna in normal fidults or in patiants with plyahogonin diuordgru. I fihnaa rbaponses have bash oocasionnlly noon, howuvor, 1n nerull childrnn undsr the as. at at; (h); agad potions withuut (6) had manual dnroetivna (19). manifoat disaaso or thfi brain rho diltrdbution of tha ruapanseu a! the ohildron and ugod poruanl are rolatnd ntinly ta ago. in. yaungnnt childrun and tho oldnlt adult. show thruo~p1u1 ind rourwplub rulponqon. �16. Wifih thin. «hangs: in age away tram untruunu, ono~plun Ind Iroqunht. or the tubjccbs lith.nnntal dtfiei¢nny, than. with in. lowgat annual agthavo fibroeoplun':nd teurvpluj roupannaa whila ona~plus and two91ua rcapensoa prndaminutu in nubjnota with highnr’mnntal twowplua rulponsaa baoama mare _ I aguu‘ II aummurises thn dintribution a: tbs four different typaa at rulpnnyeu twang tbs variau: groups or aubjoetl. Gnly Tabln ‘pgtlonts with In argania mmntal syndrana.nhow unreguplus and rourbplua teaponaoa. Such roapunaes may be aansidorad ditgu nbstio or an organic unntul ayndrumn. mm ;; Prwqusnay or 0n¢~P1uu to Faun-Elna Tfiat in Dirforant Gwoupa nogntlvu Gaga Pku Organic Hantal syndruua adult: (below your: a: as.) Norunl taut 60 99% Schizophrtnia Adult. Patimntu with anxiety nnarly Patients with plyahn~ -7o% states , asarly genie dnproasian (all age grnupa inaludad) W! "' 19% Tue? Three Paar- Plgg‘ Plus 7% 25% 33% 25% 15 o o a dooaa~ :11 Paaittvo at Subjects Four~P1un P§uu P;ul rarg new.» navor ionglly oooas- ray. navar‘ novor all tonsil: 22% 85 o o , In unavor to the questions railed in tn» introduation, our rounltu indicnto that four gonoral typos of paaitiva �.11. faooahand touts occur‘gnd that than. typo: «an bo carrolatod with airfaront greupn at aubjoats (Tablc II). Our attention Ill fauna-d mainly on thg question cf fihathar there in: a typ. or rouponse which oeaurrod only in pubinnts with savart 4180330 of chi bra1n._ All adult subjootn with u thrionplun . - or rourwplua v.3ponno haw. orgtn1o brain dictate. Suéh rua uponaou 1:3 nave: icon in manual subjgatu er patient: with payahogan1l disardnrn, even though than. group. any oocunlonnlly than onnnplun or twonplua traponnnn. ' Patigntn with atrabral dinette manifesting a four-plus nonpango invaritbly that tho novonast or must udvunnod foam of mantul abungal. Othorulao thaw. in nu good aorrolat1an botwoon thy typo at pou1tivo tiéowhand tout 1nd tho soverreyv 9f thn unhaorial daroatn. 3am: putionta with aovnro monfial ahnngps may'havo anxy; two«p1ua vouponso. 1n additian, 105‘ or pationtu with an orgnnIo manealinyndromn.hnvh a magazivo faaa~hand taut, It is rhalisod that tho use of I one to taut» plun nonnnoiutur. £6» Eh. groups umplies an inoronfiing dagruc or aeropral'dyatunation. This namnnslntumo van used because of aonvonicnaa and aunh an implicition in not intended. Th1; olauitiaatlnn af 3 poauin rues-hand test should be useful elinioglly. 'In téufiing nouiologioal patients, uh. cxaat type or positive taco-hand tout Ihauld be renordpd. rather thtn tha datlgnation ”the tao§~haad test was positivo' until nan. Bach a proeoduro «111 makd 1t Judgo whatnot tha typo or poaitivo runomhand fiont as has buon don. aasiar to indicatcs dotinita oorabrnl discus. or whnthnr manifcptntiou at tnzitty or dapruauian. who it may be c use or much a ' �12. alanairication will also make it easier to ounpuio tho roayenno or patlontl at diffcrtnt tin»: during thuir illniaa. In ad» dition, 1t. 1. “1mm. in cumin). “perm-am work, for it has bean aypllod in studio: or thn urfpetn otdrugn on pircaption, and tho rutponlal at pat1¢nta t6 olootrouhook truatu want. in aueh Itudioa altnrution in pottuptian can be mat» . stand by abaovwing tbs duration and tho incidnnao cf thn varioty at positive tano~hnnd tests during tho period: of teating. Sulnagz: ' stundardizttian of tha {tonohand tout in prntontod. A positive faoouhnnd taut it danorihod In on. in uhiéh orrart portint .13.: tho_tunth trial. Pour clause: of positivo tuto— A hdnd teats urn racerdod. ann~p1ua fnoo~hand A tott aensiafil of oxtination only with touch stimuli. A tro~plun renponso is charuatoriaod by axt1notion with p1npr1ck und rubbing atims uli, fl as ‘ill an Iith touch stimuli. thrna~p1us nonponno tontlata or oxtinoticn and displaeumont 11th tough. rubbing, tad pinpriak stimuli. A rourbplup runyonao ha. til tho tharhl aotariatica of a throu~p1ul response and invadditian at least one at thn following ronturos: a) Oxasamntthoaia; b) ulleathnlinz A . c) poraovonntion af roaponnasz d) ooourrenao or errors even whilo tha subject 8063 tbs application at the stimuli. Throo~ plus and four-plus weaponnea invaritbly indicate dinette of tbs bra1n in subject: evor tho ago of :11 yours. 0no~plua and trauplun roapqnaea occur in ptt1antn with brain disnaac amall number of normal adult: and but are 3139 maniteathd by a ptt1ontn with paychogonia‘diaoranrt. Patients with a faur~plul �I “‘"’ 13l- tho ”want maul change; but flan canny“ 1.8 not Ema. morn is no corraluion human t)» unrity of the manta), uhmgu m4 tho or punitive: rum-hind z'oapcmao show taut tn. awaited. m unfulnbu or this the study at panama clinically and in it indicatad. _ cluuu‘iutim in 01$“:de work �I -m...‘ ‘ ‘ hm W l: BEXEER, ‘BENDER. in hhn :nd GREEK, fl.: .é.:355. 1951. K.B.: FINE, «option on sinnlt 2. . 3.3.; on: tout: of fans and hsnu. and FINK, Hg: airfarontill gufiiglgfido H032. Patterns in par» M. Arab. Tactile parcoptual taata diagnouia or payohiutriu diuordnrl. ital. 1952. 3. FIRE. 3.: GREEHA M. and BERDER, M.B.: The faoe~hnnd test. nign of diieasa of the bruin. yourologz‘g: :3 dig zontio .7. , FIKK, H. and.BENU£R. K.B.x . simmltnnnout 1327p 1953* J“FFE' Duvnlopmnnt tactilu stimuli in 5' ‘nd 333933* unsathanin. ggggral ,3 W md- 7. 8'. BENDER, a H.B.z SHAPIRQ. HiF0‘ BEHDER, M.B.: Th9 phcncmanun PM, . 3 «hi .‘ghzslé, . 'Wmcx. and nonnnl childronw agggggggz “'B-' Pofocptunl pace-an: follavinsj. .3 urcgflc a: ,GREBH. at pdrcqptian or .3 entanooun‘pcroaytion 1n uh. £29.35“. 1953» er Ionaory diuplucunynt. @607. E. and 1951- Vii-159””. “‘8‘; Exosmnthuin or displacannnt or outnnoonu nonnation inté axtraporaondl upuca‘ figg§.fliggo;.&Pnzah15§. 駧hfll,‘1952. 9. ‘nfiann, 3.5. and Hamunnaen, u.: Pattorna 1n alloltbouia tad thair rulation to disordnr of boay sebum. and other: scnsery phnnamann. Arah.xourol.&9azehiat. ég3501, 1952. 10. fl.B¢t y.".Pt19n or I!" GREEN, MuAu ”4 51mm tanaaua stimuli b montully aorontiva subjects. J-nOPV‘aatnm:3; m1 3. 1953. m. W. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Standardization of the face-hand test. Neurology. 1954 Mar; 4(3): 211-7. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-14-018 Date A point or period of time associated with an event in the lifecycle of the resource 1954 Creator An entity primarily responsible for making the resource Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and Reprint. Reprint from NEUROLOGY, Minneapolis, March 1954, Vol.4, No.3 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/4092f702c20d2db606a33fb51b3082e2.pdf eb5e272391290df4e9e5af41a15c37b2 PDF Text Text THE “AMYTAL TEST” IN PATIENTS WITH MENTAL ILLNESSl ROBERT L. KAHN, Ph.D.,2 MAX FINK, M.D.,3 EDWIN A. WEINSTEIN, M.D.4 and Recent studies have demonstrated the value of utilizing amytal sodium as a diagnostic test for the presence of brain damage (9, 10, ll) . Under the influence of this drug, certain changes in orientation and awareness of illness occurred in patients with brain disease that rarely appeared in persons without demonstrable brain pathology. These changes included patterns of disorientation for place, time, and person, and verbal denial of illness and incapacity. In addition to disorientation and denial of illness, other changes in verbal pattern and the nonverbal aspects of behavior occur in both patients with brain disease and in normals.l5 All of these aspects of behavior have contributed to an understanding of the relationship of the psychological and physiological effects of the drug and the role of language in adaptation to stress. Until now the normals have consisted of patients with peripheral nerve, spinal root and cord lesions and miscellaneous medical and surgical conditions. There has been no systematic investigation of patients with mental illness unassociated with demonstrable brain changes. 1From the Neurological Services of Hillside Hospital and The Mount Sinai Hospital, New York. This investigation was supported in part by the Medical Research and Development Board, Office of the Surgeon-General, Department of the Army under Contract No. DA-49-007-MD-376 and by a grant-in-aid from the Lilly Research Laboratories. Dr. Max Fink was aided by a fellowship from the National Foundation for Infantile Paralysis. 2 Research Assistant, Hillside Hospital, Glen Oaks, N. Y. 3 Research Director, Hillside Hospital, Glen Oaks, N. Y. 4Consultant, Neuropsychiatric Division, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C. 5 Normal is used here to refer to patients without evidence of brain disease. 3 �4 KAHN—FINK—WEINSTEIN The purpose of this study is, by the administration of the test to a series of patients hospitalized for mental illness, to: (l) evaluate further the diagnostic validity of the procedure; and (2) compare the patterns of altered symbolic expression found in mental patients with those shown by other groups. METHOD Consecutive admissions to Hillside Hospital were selected. Patients who had recently received electroshock treatment or who were clinically disoriented were excluded. Sixty-eight interviews were essayed: eight patients refused the test, three showed insufficient physiological effects, and one patient was grossly disoriented in the pretest interview, leaving a total of fifty-six patients who were adequately studied. No attempt has been made to classify the patients according to clinical diagnosis, although most were considered to have schizophrenic or depressive reactions. Thirty-four women and twenty-two men were tested, the ages ranging from sixteen to sixtyfive, with a median of thirty-six years. TEST PROCEDURE Immediately before and during the administration of amytal sodium, each patient was examined systematically for orientation and awareness of illness. These questions were based on previous observation of certain patterns of disorientation and denial observed in patients with brain disease (6, 7) and are as follows: What is your main trouble? Why did you come here? Where are you now? What do you call this place? What kind of place is this? Where is this place located? How far from here do you live? Have you ever been in any other hospital of this name? Where were you last night? What is today’s date? What month is this? What year is this? What time is it now? What part of the day is it? Who am I? Have you ever seen me before? Along with the routine test, the patients were asked two additional questions to obtain further material for the study of patterns of symbolic expression: If you could have one wish what would you wish for? Can you think of a joke? The amytal sodium was given intravenously in a solution of 0.5 �“AMYTAL TEST” IN MENTAL ILLNESS 5 gm. in 10cc. of distilled water at a rate of 0.05 gm. per minute. As the drug was administered the patient was asked to count backwards from 100 to l. The injection was continued until the patient showed rapid nystagmus on lateral gaze in each direction, slurred speech, errors in counting backwards and drowsiness. These were regarded as indicators of the physiological effects of the drug. The total amount injected depended on the appearance of a maximal effect of the drug. In this study the quantity given ranged from 0.2 gm. to 0.5 gm. When the physiological action of the drug was manifest, the patient was interviewed with the same series of questions. If an error was made, the question was repeated immediately to determine its persistence. Only persistent errors have been regarded as indicative of brain disease since it has been found that normal controls may make transient mistakes (9). RESULTS Prior to Administration of Drug These patients as a group showed many overt indications of fear and distrust in the test situation. This was shown by the large number who refused the test altogether. Some wanted to consult their doctors or their families first, while others were too frightened to enter the examination room. Even among those who took the A. Behavior test there were numerous manifestations of distrust. Several were reluctant to lie down—one sitting up throughout the entire procedure, one constantly keeping one foot on the floor, and several keeping their heads raised. Many patients asked for specific details of the test—its purpose, what drug they were getting, why they were selected, whether this was a “truth test,” whether the results were confidential and, commonly, whether they would go to sleep or not know what they were saying. One patient asked if he were going to be killed. Another asked that a nurse be present. Some patients asked us to postpone the procedure or said, “I shouldn’t have come.” These manifestations of evasion and suspicion were much more marked than were encountered when the test was administered to patients in general hospitals. Unlike patients with physical diseases who usually gave as a “wish" a statement about getting well or leaving the hospital, these patients gave many more wishes outside the immediate situation, such as “that all men in the universe should live in peace and harmony” or “good health for the �6 KAHN—FINK—WEINSTEIN sick world,” or “my daughter should marry a nice fellow.” Further, there was a greater tendency for patients to answer the questions using syntax involving the third and second person as “you might say I had a slight nervous breakdown” or “my main trouble is my stepmother.” Patients with physical ailments are much more apt to limit the expression of their difficulties to the first person as “I have diabetes.” B. Changes in Behavior Accompanying Amobarbital Sodium Persistent Errors: Positive Reactions Five of the fifty-six patients showed persistent changes of behavior similiar to those found in brain disease. In a previous report (10) positive reactions were graded from one to four plus, depending on the number of manifestations of disorientation and denial shown. On this basis, the five positive cases in this study showed a one plus reaction. The test was repeated in three of these cases and showed a persistence of the one plus result in two and a negative result in the third. Of these five patients, three showed evidence of brain disease by other methods of study. One, a boy of eighteen, had a positive face-hand test (2), an abnormal EEG record, and an elevated spinal fluid protein on two occasions. Another was a case of Parkinsonism. The third showed a memory defect on psychological tests. One was a sixty-four-year—old man who persistently referred to “Sydenham Hospital” while under the influence of the drug. He had a normal EEG and no presumptive evidence of brain disease. The other patient located the hospital in “Oakland Park” after having placed it correctly in Glen Oaks prior to receiving the drug. The second administration of the test in this man gave a negative result. 1. Transient Errors Transient errors (i.e., errors which were either spontaneously corrected or corrected when the question was immediately repeated) in orientation and awareness of illness have not been regarded as diagnostic indices of brain damage. In persons with physical incapacities, the incidence is low, having been found in 16 cent per of the original series of fifty control subjects (9). In the present study, however, eighteen patients, or 32 per cent, made such errors. These included giving the incorrect year, naming the place as “Hillside Oaks" and “Psychiatric Institute” and confabulating having 2. �“AMYTAL TEST” IN MENTAL ILLNESS 7 been at home or in a friend’s house the night before. Some patients used euphemisms such as “a place to help people get well,” “a place for recuperation,” “a place to teach health to sick people,” “a clinic,” and “the greatest hospital with the most stupendous doctors,” whereas prior to receiving the drug they had simply stated that they were in “Hillside Hospital.” When the questions were repeated, however, the original response was again given. Other Alterations in Language The use of the second or third person in response to questions about illness and hospitalization was noted twice as frequently as in the pre-drug interview. Another person became the subject of the sentence or another person performed the action or became involved in an experience, whereas previously the patient had described his symptoms in the first person. Thus the reason for hospitalization originally given by one patient as “I was getting worse and desperate for help” was changed to “the hospital had a lovely reputation.” Another patient who had detailed his problems in the first person before receiving the drug talked about a friend who had cancer. The change frequently took the form of concern over the health of relatives. The wish “that I never get sick" was changed to “I wish that my kid would stay well.” There was more of a tendency to employ clichés as “nothing to fear but fear” and ”not for publication.” There was also more selective specificity in answer to questions. Thus patients who had originally said that they had come to the hospital for some illness replied that they had come because their doctors had sent them. Other patients gave their location in a more precise way, stating for example that they were in “a treatment room leading off the corridor.” Cryptic remarks were occasionally given, as in the instance of the patient who, when asked for a wish, said “If you could help me out then I wish you wouldn’t, and if you could then I wish you would.” These patterns were not qualitatively different from those used by patients with physical incapacities where displacement to the third or second person, greater specificity and selectiveness of response and increased use of clichés and slang also occur. 3. 4. Jokes In many patients the response to the request to tell a joke seemed to be a symbolic representation of some problem relating to illness, hospitalization, the procedure itself or their interpersonal relations. �KAHN ——FINK—WEIN STEIN 8 The content of these responses in relation to the illness will be considered in a separate paper and only the pattern will be reported here. Of fifty-three patients, fifteen did not respond either before or during drug administration. Eleven patients answered by referring literally to their difficulties as “It would be a good joke if I could go home,” or “The joke is my being here." Six patients used this type of personal reference both before and during the administration of the drug, while five responded in this fashion only after injection. Thirty-two patients gave the usual form of structured joke, the account of the action or experience of some third person symbolizing some aspect of the patient’s problems or motivation. Usually patients who responded to the question in this fashion in the pre-drug interview used the same pattern after the injection. Seven told the same joke, while different stories were related in fifteen instances. Here the tendency was toward a more allegorical representation of the problem. Eight patients told a joke before receiving the drug but not after, while eight related a story only with the drug. Psychomotor Reactions These changes included withdrawal, overactivity, alterations in mood and the appearance of comic or melodramatic “ludic”6 behavior. Twelve patients showed withdrawal reactions. In the extreme form the patient failed to respond to any questions for periods ranging from several minutes to half an hour. In other instances the questions had to be repeated several times to elicit a response, there was incoherent mumbling or neologisms, and incomplete sentences were used. As such times the withdrawal appeared to be a selective process, since the inadequate response occurred primarily with questions relating to the patient’s illness. When questions of a more innocuous nature were asked, such as the date or time of day, the patient often answered quickly, clearly and completely. Marked withdrawal has been unusual in control patients in general hospitals but has occurred frequently in patients with brain disease. Ten patients were overactive during the test. Usually this consisted of restlessness, shivering, rhythmic movements of the head, hips or legs, eye blinking, or repeated fussing and adjusting of clothing. One patient showed behavior which resembled catatonic posturing. 5. 6Ludic is the term used by Jean Piaget (5) to describe the play, imitating and pretending aspects of behavior in young children. See also VVeinstein et a1. (8)- �”AMYTAL TEST” IN MENTAL ILLNESS 9 Alterations in mood were noted in sixteen patients. The predominant change was in a euphoric direction, although in two cases the patient became tearful and depressed toward the close of the interview. Euphoria was shown by increased smiling, giggling or laughing, joking and expressions of well-being. Some patients commented that they thought they had “one drink too many." Paranoid attitudes as indicated by threatening remarks and gestures and cursing were sometimes intermingled with euphoric manifestations. Thus one patient, who said he felt good and “would like this more often,” answered with such expressions as “What do you think it is, you goddamn fool” and “How the hell would I know.” The incidence and degree of these euphoric and paranoid reactions was comparable to those previously found in both normal control and brain diseased groups. Varying degrees of ludic behavior were shown, but were especially prominent in sixteen patients. In several cases this behavior was noted in counting backwards while the drug was being injected by variation in tempo, alternately slow and fast, or use of a sing-song rhythm. One patient barked out the numbers in a staccato fashion, while another overemphasized the pronunciation in telephone operator fashion. One patient responded throughout the interview with an exaggerated syllabic accent and dramatic pauses. Another used “French” expressions such as “00, la, la.” Several staggered excessively when brought back to the ward, particularly when they were in sight of the other patients. One patient, who acted in a dramatic, comic manner throughout the test, spontaneously remarked, “I need applause.” Such ludic behavior is difficult to grade statistically but was in general more marked than had been observed in the previously studied control groups. Six women patients showed some form of altered sexual behavior under the influence of the drug. This ranged from holding the examiner’s hand and such remarks as “dear” to the behavior of one patient who tried to kiss the examiner. A few others manifested hip movements suggestive of sexual activity or partly exposed themselves in restless leg movements. DISCUSSION The results of the study provide further evidence of the validity of the procedure as a diagnostic test for the existence of structural brain disease. Of the fifty-six patients tested, “positive” results were �10 KAHN—FINK—WEINSTEIN obtained in five. The others showed behavior more like that of patients without evidence of brain damage in that they did not develop enduring patterns of disorientation or persisting delusional denial of illness and incapacity. In a previous study of psychotic patients in a state hospital (9) , only one of twenty-five, a sixty-fouryear—old woman hospitalized for thirty-five years, had a positive result, a one plus response. This compares with a figure of 1 to 2 per cent positive in over one hundred and fifty normal controls and an incidence of 65 per cent in over four hundred patients with brain disease tested in two general hospitals. It may be concluded that while it is possible for a patient without demonstrable brain disease to yield a positive result, the difference between patients with brain disease and other groups is statistically significant. In three of the five cases giving positive results, there was other evidence of brain disease. One patient had Parkinsonism, in another the clinical history and finding suggested a chronic encephalitis, while in the third, degenerative or arteriosclerotic disease of the brain was likely. One of the other positive results was found in a patient over sixty years of age. Adequate control studies on the effect of age on the results of this test have not yet been completed. It is possible, however, that positive reactions may occur in older persons comparable to the finding of slow waves in the EEG record (1) and to changes in the perception of simultaneous tactile stimuli (2, 3). These results suggest that in a group of patients with “functional” psychoses there are some with disease of the brain which of methods of the be demonstrated by appropriate application may examination. The amytal procedure and the face-hand test of perceptual function introduced by M. B. Bender and associates (2) are examples of such techniques and should be employed as part of the diagnostic work-up of a mental hospital. In considering the alterations in symbolic expression shown by these patients it is necessary to review some data relating to the mechanisms of disorientation for place and time and denial of illness. These phenomena are not defects directly attributable to brain damage in the sense that they are the manifestations of the loss of a functional modality represented in some area of the brain. They are, rather, forms of adaptation or defense that the patient uses in situations of stress in a milieu of altered neural function. In disorientation, the misnamed time or place is the symbolic representation of some motivation of the patient, usually related to his illness, not a manifestation of memory defect. Thus the patient �“AMYTAL TEST” IN MENTAL ILLNESS 11 is apt to state a time antedating his illness; to give the name of a small hospital or a place where he has been for some trivial illness; to locate the hospital near his home; or to confabulate that he has left the hospital. In effect, the patient is expressing his problems in another language where places, persons and times are not used in their original referential context but as vehicles for the expression of the individual’s own motivations. Although an impairment of brain function is necessary to provide the type of neural organization for the maintenance of this new symbolic system, the behavior itself is the result of the interaction of a number of factors—what Wilder (12) has called the organism-environment-observer complex. This includes not only the neural organization, but the fact of the disability itself, the patient’s motivation to be well, the interpersonal situation of the interview, and the patient’s previous life experience and personality. For example, if the interview is carried out with sterile water, there are very few changes in language. Patients with similar brain lesions may show markedly different reactions under amytal sodium because of different types of personality and attitudes toward incapacity. It is quite conceivable that if this test were carried out under very stressful conditions as in a concentration camp, then disorientation and delusional denial might occur in persons without evidence of brain damage. In interpreting the effects of barbiturates one must distinguish between purely neurophysiological manifestations such as nystagmus and alterations in the EEG record, which occur universally, and adaptive symbolic changes such as withdrawal, ludic behavior, humor, disorientation and changes in syntactical tense and person. It has been pointed out that even such indubitable neurological manifestations as drowsiness and ataxia operated as language as well. The amytal procedure is a stressful one and, contrary to popular belief, the drug does not “abolish” anxiety but rather provides a milieu where it is converted much as a schizophrenic uses a delusional system or a dreamer expresses a problem in hallucinatory personifications. The relation of humor to other forms of symbolic adaptation was of interest. Some of the jokes given used the mechanism of disorientation as in the case of the patients who referred to a hospital (West Hill) as “Mess Hill,” or to “Hillside Cabaret.” Others used verbal denial, as stating that the reason for coming to the hospital was “because I’m well.” In the usual structured joke the patient represented his problems in language involving third persons, more �KAHN—FINK—WEINSTEIN 12 material symbols (often relating to sex, food, death and violence) and the past tense. From this study one cannot state that mental illness is or is not an “organic” condition. What can be stated is that these patients exist in a very stressful environment. This is evident not only by behavior before receiving the drug but by the larger number of transient errors in orientation and awareness of illness, the greater occurrence of ludic behavior and withdrawal and the more frequent use of clichés, euphemisms and expressions involving the third and second person as compared to the responses of patients in a general hospital. SUMMARY The amytal test was given to fifty-six patients in a mental hospital. Five patients, three with other evidence of brain damage yielded a positive result. The results are interpreted as giving further evidence of the value of the procedure as a diagnostic test for brain damage. 2. Mental hospital patients showed more transient disorientation and denial, more withdrawal and ludic behavior and more changes in the syntactical aspects of language than did a group of patients with physical disabilities, but without evidence of brain damage previously studied in a general hospital. 3. It is considered that this greater use of means of symbolic adaptation is additional evidence that patients with mental illness operate in a milieu of greater stress than patients with physical 1. incapacities. REFERENCES Barnes, R. H., Busse, E. W., and Silverman, A. J.: Prevalence and Significance of Electroencephalographic Abnormalities in Normal Old People, Third Inter. Congress of Electroencephalography and Clinical Neurophysiology, 79. (2) Bender, M. B.: Disorders in Perception. Springfield, 111.: Charles C. Thomas, (1) 1952. Fink, M., Green, M., and Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. (4) Green, M. and Bender, M. B.: Cutaneous Perception in the Aged. A. M. A. Arch. Neurol. (9 Psychiat., 69:577-581. 1953. (5) Piaget, J.: Play, Dreams and Imitation in Childhood. New York: W. W. Norton, 1951. (6) Weinstein, E. A. and Kahn, R. L.: Syndrome of Anosognosia. Arch. Neurol. <5. Psychiat., 64:772-799. 1950. (3) �“AMYTAL TEST" IN MENTAL ILLNESS (7) (8) (9) (10) (ll) (12) 13 Weinstein, E. A. and Kahn, R. L.: Patterns of Disorientation in Organic Brain Disease. J. Neuropath. & Clin. Neurol., 1:214-225, 1951. Weinstein, E. A., Kahn, R. L., and Sugannan, L.: Ludic Behavior in Patients with Brain Disease. This Journal, 3:98-106, 1954. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Brain Disease. Am. ]. Psychiat., 109:889-894, 1953. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Malitz, 8.: Serial Administration of the “Amytal Test” for Brain Disease: Its Diagnostic and Prognostic Value. A. M. A. Arch. Neurol. (S- Psychiat., 71 :217-226, 1954. Weinstein, E. A. and Malitz, 8.: Changes in Symbolic Expression with Amobarbital Sodium (“Amytal Sodium”). Am. ]. Psychiat., 111:198-206, 1954. Wikler, A.: Opiate Addiction. Springfield, 111.: Charles C. Thomas, 1952. �u. «a... as "am; W' I! ’51!” um MM.» 1m. L. tell. ”.3. mm: LB. 0 III A. "mun. mt:nu. leuelegloel mm e! Innu- lealul beetle lent um halal. lee reel. and W1 me. the _Mlmulgetmmiapnmu mtnmmmzm e! the” tau-teen m Develop-at lee“. eum e! le. WM‘MWIQH‘. tummmwu tree the hilly meme “metal... mu by e teller-up tree the hum). mum tel- Intent“. um mm». 1' �-L. IOC.‘C utudicfl unfit daunuutlntod $ht thll .2 I‘llllinu nnytul social in n atasunntte it‘s for $h0 990...». o! Irtta dn-ugo. (1) (I) (a). ends: the tazluouat a! this drug. olrtntn chnaat- tu aria-Sutton uni usnrunnsu a! allnouu ocuurrod 1a pattoutn with brain «titan. tint rural, appotrod 1n.p¢:soaa without Innmnn%rublo brutn pathology. 1!... eunuch. tnoludnd‘pattowan a! asaowttntnttoa tar plint. tin. uni pariah an! vtrhul dauttl at 111...! “In incapacity. studs... «tint pattatts a! alturod nyuboxto nzpvtnnton turn found in addition to tin «hangs: in ortaatntion Ind umnrououu 01 11150.: oaaurrtns in tin pronanan a! hrtta dtiitli. It Inthnao II. indicatod that thaiq «tannin in vurbu: p$ttara :ad nonpvcrbul Impact. 01 bahtvtor tantrihatod ta II Indornt‘ndtag at tho psychophyltologtanl cttnots a! tin drug and ti. 203’ 01 ltlcuugo 1n &dnp~ an... ‘0 until no. tho control cramp. it's colltntnd a! puttnuta with yortphcr:l atria. cptnsl root In! our! lotion: ant Ilaccllnanoun Indian: uni aarglaul cauda‘anun. that. In: boon no IyItOIttlo tuvnut- am. “me. a: ”that: an aunt unu- Wat“ can mm» Ital: chain's. It. pntpoactot a! tit tant to n Intton 01 pnxtoutu Inuvitaltaod In! unatal £11.»... to: 1) ovuluntc turthnr tho dtucuncttc validity at tho pcooo‘uro. 3“ this study in, by the administration “to ”tum o: um «smug W1“ tom 1We units: 3&ttoat- with than; lhfl'! otlur a) fig Omnnflcustv. putt-3t. udltltlous t6 grunts. lllllidt lonpltul v.39 lcloatod. i£d vacantly rocutv.‘ olnatmoachoot trtatnnax or who v.90 alt-teal}: diaorinntoi tor. IIBII‘O‘a $11t1~tifiht satcrvltun U‘f. 0:33:06. night ytttauta twinned tho taut. thruc alumna innutttctou‘ who �«i- an unattaiul “1mm. m m ”that m puny (Wham m pro-um utmm. than; a to“; a! to nun“ m m: mm“); “in“. I. “W m m and. u “but, tho 3““th «mam iuhtsam ta cltntail diucaoati. u1*&auci flout ttri caln$dtru£ $6 is?! and 13 I» mm mutton. nutptm at pm“ tum: W“. a.“ mum Inn 16» u. «an with a “can at :1 m mn. him and data; m taunts-anon a mu]. owl-taunt); a: mm. «a ”that u: «and tutmumuy tar ”atom. at “luau. W muons an band on ”aim anor— nuou at «mun ”km a! amtntnun n4 «aux ohm“ n ”tints um um. “um (42 (a) m m u sum: laminae-1y an truth? It: am you cm W? "on mahmnutmpw Wimotymutm? me grammar? 1: your mum mutuapuu MM? ”iu'tmhmumuuv mm but a m at!» man: at an W? M «It you an this? night? Int M W's «in? Int mill 1. ti“? “at ya: it 1- st? u. n I!“ m a! the that “no n It an" Inn put «or ms In “in" a: m Am vi.“ ti. mtm Mt. tho ”$1.31! m and «udtuml mum to out“: turn“ mum: to: at um 01 5mm 0! "about: cat’s-«Mon: I! you that 0! n m on“ haw Mu mu mt mu m ”at In? a» 39“? m mu: mm an aim mum}: 1: a «mum at «utum mm at a an a! 0.0! h at! mm”. tho ”that m and to «on» A. a. manta“ I“ m no: 109 to 1. m tumult us mum“ at“ no pun.“ am up“ ”um a am: use an m “mu“. “m“. an“. as cm" a: own“ mm“ m mun». nu. ma «sum 0.5 in 1. 10“. of W“ �*3. “amm- o: u. mum: «tau a: no a... no tout mt injnotod anyondcd on tin apptsrnnno a! u naslnnl uxtcnt at tho trig. In tut! atudy tan qfinntttr 311:3 rascal iron 0.! an to 0.5 03. than tan phyulaloflianl nation .1 ti. drug was nunttosfi. tic pgttoat In. xitcrvtvvud with t). nguo tartan o! quoutitufl. I! an ¢rror was main fin. quanttnn.van rtpuutod aluodiutcly to actor-tn. its parttatinaa. a;1y porutntant armor: Igru boon rngnvdod an tudtsattvo u! truth dtuouou 31am. 3% hi. but: tound that tarsal auntrolu any unit ttuamiant nintulou (1). . Inhavtar . in» t9 . 13$: uttan a: . rtcnc paticut. us I grow» filowud Inn, owurt tfidlaattanl a! tour Iii Ctnfirtflt in tit tilt iitlutttu. fhti was shall. by tho titan :nlbcr vb» 2633.06 tho tout nltogntlor. Son. iua&cd ta calault that! doctor: at tint: inntltan 1131:. watt. othsru war. tau frightenud to .fitfl? tho caantnattoa soon. 3"» 3.3:; than. via tcotilhu its: that! unit nalbcraus naniloatnttonu at dintwuat. Savnrul flirt raiuotaat at 1:. 401a - on. flitting up throughout the cutaro procedurc. on. Gonna illtll Utopia: all fact on tin 1100:. ktuptlt that! than tttaad. Inns patients tutti tor apoettta Gettilu a! tit tout - it: ’II’OIO, Ihlt drug thaw tut. ;n%tlug. why the: It?! uoln¢t0d. Ihnthnr this II! a ”truth tant”. Ibuthor ti. results var. euniidnntlll and. unusual}. vhnthnr that would 30 ta slut; at not hunt want ti.) Ilrt nsgtuc. an. putaoat Into: 1: ho vIrQ '91-; to h. hillod. Aunthnr 3330‘ thtt : turn. be pruunnt. I... tatttntn ‘33ud an to potty-nu and acvarul tun granular. or 3‘1: "I abouldn't 5": ¢nnn.” than. u:a110ututtona o: ovation sad tuapaeton vars haul an». marina than unto announsqrud thin tun tout 1‘s tdiifliutCtOd to putIQntu 1: stunts! Inu3ttnls. BIltkn pntiontu with phyttaul alsoasu: vim usuully 3:1: ti s "stat” a st;tunnnt than: Ifl‘tllt will or tnavta: It: houpttul. thQfli puttonsg �'T ant: taro Uilhll autitda tn. tumullnta nttnsti‘g. Inch ll “tilt :11 3‘: in tin IIIVirflO should 11'. in punau an: h:rnouy* tr ”good intlth 1.! tin ntct unfit? II ”I; lifl‘ht‘t nhnuld flirty a lion tollut.' turthurunmt. titan vat & [rcattr toxicity in tit: group in czar... tilt: gnu. distthXttnu in turns .1 aqua athnr pcraan :3 ”13!.Iiflht an: I but a llxaht Iorvcuu trashinvn” OH “I, uni: trout}: in ny‘ugglagthtr.” Alfihtthtta1_sndtuu. 1) lorntutcna gyrornz fithttvo Innattona 11'! a! ti. ‘0 pattnust nhnuod pcruzatant ohms... of Io~ hgvtor stutlir co tin-c could in hrtlu flaunt... it u IIU'IOII rarest (l).puuattvu tauntinn: that gvnlud tron an» to soar plus anpculinc en ti. lumbar at nuntloatuttoan a! itnursoattttoa nah 6.33:1 chain. on tbtt 5.31.. tho lava pontttvo «use: 1: :81: study thou-d a an; plus roasting. it. tout was rcpoutud tn turn: at those «:30: sud-nbolod a ports-tuna: a! th. an. plan rauult in tun and n Ingnttvc ranalt 1n tho thlrd. a: than: £11. putxnntn. turn: lhfllid «vidnnoc of hrtln taunts. by athnr nothads oi atudy. Out. a haw 01 It. had a pauittvu Inoonhlnl fitnt (6). ti 33:09:51.356 toourd. sun nu titrated uptunl fluid protoil on two Oflflhfitflll. Anetta: it! u «an. o: Paritnnantnn. r30 thtrt attuan psych-mun mu. mam: at tho u. a in: vus$ttvn an... had 0th.: fliflll of br‘tn difitllfl. an. In: t 64 run: 91‘ Inl‘vho porbtltontly tOIOWROd to ”Byflnahnl annpttnl" ‘hili ands! tho inslumauo at tho drug. It had a nnrnnl BEG :34 no prouu-pttwu Ovtdtiui a! brain dtloan¢. fit. othtr puttnut loath4 1h; Ioaptt‘l ti "auklaua.snrlfi altar h‘vtnc pinata it narroatlv in exam Oahu proav to rtoutving tho drug. Tin flaccid tautntntrttaon at tho toit in this has ' , m , .-‘ , .. at»: unvb n.3oust110 mum litflltn a) trgggtnut Irrorns 1r£anxcns array: (a.¢§ iVFORfl 'hiflh var: otthot $90.30 ulnouuly corrected or oowrnotod who: tn» ancatian nun iuuodttttly rn’nntnd) tn cranniatlnn and :nurvaaas a: titans: haw. not bat: ra~ �ubm mm u «W‘u u but; «an. :3 ampmm: nun. .mm:Oriflfllfll a! ti. untowar. II unaxrol.tfibsn¢tu (1). In the preaeat «tidy. Icaad nclttou. tin zlcilnnno in luv. hxvais b¢tn aortas of no £3 19% includod ¢$Viit tho luaorroct puttomnn, or 33%. III» neat trworx. rant. eats" au‘ *fltyuhtntrtn Initituad' ti"”l111l$dl 91:30 in. Iflhlfil than. fifi hunt or 1‘ a friend’s blunt ‘hn utult hon: tiring ochlttulnt1:¢ tat such I» "t plaoc to but. .0033. boxorc. Ian. pustunau «nod cuphauttul ”a piaan t¢ tctah honlth to bank rtcnpcrnttan," tar "a plan; vu11.* not hospital with tun not: ntmaunduuu panama.” ”u “Ilhtfl” tad “thy cronttst drag char but simply tut rocctvin: to print shnranu I!!! dilitrfl.” mm “at thy um “I 331th ”pittl.” M flan motion! m Bivtfl. rtponxtd. tunnvnr. tun arisinnl rampant. run anti: tbs lacuna at third airman in rtuponun to was Intod twist it lrcqummh and hospitaltnttion i11n¢as about qunuttaun booth. in» iflhaoct 0! pinion anothir tuttrviov. yrcudvuc tin 1: 1: as or stain. turalvod tcttau the patterned parucn santhar or tbs statnan: had dynaribufi it: tun patio-t prcvtauuxy 'hnr¢xa exportnnoo 1: an for huapttnltnutmu: ayuntuun in it! first action. Tins til ratio: Thu ‘ at. at mm m mum «umxu :19“ by an ”aunt u «z umhad”um ’ 1 lowly "mum.” "the mun. in law In abused to uobnll in tho mm mm n: «mud m m “tun am m Thu Qfifllll drug tnlknd thaut a tritnd who htd onnaor. 0N0! filo htnlth a! tolnttvos. tho aonauru at for: tha toot trcqnoutly vuuld ohuugud to "t ui¢l that my on: tie!“ Invue jut “thnfi t Isak tiaalrtac tho ill ntny unit.“ Thar. "anth&ac mo was tare Qt 1:32 but taut? and eliahlitii an ?Iot tar yubllcntten.* that. in: tits ;.tondna¢y ta 0:919: ¥uun puttanss It. stloattva spoctitatty in audit! to quantlaun. for non. 111:..hanpttul tho ca has oust tan: that said had originally doowtrs ha! tilt $hfll. Git“! rtrllo‘ thtt tbs! had noun inaiuat tbttr Iowa �cxuupla finalists guru that: Ififlltibt tn t not. ’Uflaiifl way stuttn‘ tar that tic: ivy. In ”t traatngut roe. lindins at! thc corridor." in tho Lustunaa at tho cryptic tilt!!! taro ocaasleually [1103 I! could help :0 out thin p;t1¢nt who. who: 13306 :0: a 11.». 3‘14 ":1 you I with you 3: you «call than I with you wasti‘. Thifli pattorna Ifift net aititrant 12am thus. used fly itnlau‘t. ti! tho tutti-or patient: vtth-phynsnnl.tnaa'ooittcl that. dtnplnetntut to Ind atonnd yoxuau. gruntnr apoetliaity and .alnctzvonou: a: ruppoulu at tn¢rosaod use of aliahfii and filtflfl tor. notud uadmr tbs tnfluttcc tn. drug. 4» 12w. In I311 pstttntn thfl rouyoano to thc rtflflflit in tall 3 prfibluu rulnttng John doc-Id to-ba & tribulia rupwosuntntson of nuns inaction. $0 illnous. houpttalinstion. tn: procedurc ttaclt or tint: centidnrcdv finial rolttxuns. 1h: aoutont at tats. rfiiwfiflfltl will bu at “ hint. rcpartud b. vtll p&t$ara and 9.17 it. papa: Iipttttfl udllutnn 53 pntiauts, 16 did not roapond cathnr hetero or flaring dru; 4111£~ trutian. llovun pattcnt- aavvcr-d hyirntorrtn; ta thsir can x! :nltiua 1n tun {first yuruon.uu¢h a. “:t would b. a spot int. I anal could no hunt? or “thy Join in my bctns but.." at: pafituttn adulntna thin try: at purnaanl rctcronan both taint. gut dating tin tr;tton $1 tun drug '31:. 11v: runpondnd tn thln~£aahtnn only titar utructurdd Alénottob. titrtrwtvo pattuats guru thn asunl turn at an a ' a: tilt third 303:. In theta. tho taaouax a! tin unttnn.ur umpnrtonn; tritium: or par-on :ppnutcd to nyutalauo not. :upnct a! £3. pnttnmt‘a ‘hau nottvuttog. annuity pttzalas who rcupondod to tho «nosttoa a: ch. 1133103 in tin primdntg antirvxcv unad tho ‘5‘; pattutn nitat wail. ‘lfiflflliti indaatxon. aovoa 01 than. patlnntn told tho I!IO John It: tovird float} might pattonta problem. th. at reprouontatton u not. ulltgnrtcal static: war. rolatod in 15 tantsaats. In?! tho tnaluley : ”John” bum mum m» m m an aura ran. um: um“ " �1 47“ 2.13th 3) Gianna. tualudod withfiruuul, avarauttvtty. ultaruttouu. u'pnnrunnn 91 unite er lixodrnuttta ”ladle” hohavtor. an... in loot uni tit it: Cruz. th: rulntud a story 011, with Tvtlvu pataontn thaw-d Itil‘rllII rcaattous. Ia tho lfltlflll for. tho puticut tuilod ca rosyend to any quantaonn tow ported: 13:11.. luau novtrnl innntdn co halt II hour. In othnr anutnuaau tho quouttunn had rntpnauo; tint. In: tn:ohorou‘ Innhltagi or analogiaua and tuna-plat. Icutcnunu Iflrfl ulna. At finch tans. tin withdrawal sayqarcd t: to u solauttvu pruuocs s‘nuc tin tu§d¢QIuto roupous¢ oocurrvd 9:133:11: with qn3;ttona rotating O0 tit ptttont’u illnonu. what quatttoun a! u fifi!‘ tuaoaunnn tfltflrfi via. to no rapdutna,novurnl tin.» ta filiait int. or its. a! n tin pattnlt often unnuoraé unwakly. «13:91: and aauplntcty. quknd Itthlrmlal in: not: unnuunl control puxlontu ta ulnar:l hospitnln hut in: oaaurrod tttqucntly tn taint. such an tho dag, LI patxcntn ittl hrt13.d1:0uno. Tb: patient: unto ovorlutivn aural. tho 303:. Infinity tit: countutod 0d *hyttuta uncut-at: of tan baud. at»: or Inna. a}. bliskiuu, a? v.9uxtod ifilfiiflfl and adaasttt' at elatitla. taunting: tho pttitnxu boos-n vary riitlaan. nut up in 5.6. sud Inliltti on having a algnrottu. an. unison: sinned prolalcou uhtvurinc at It: Uliil. bcdy tor nlvurll Iiifllfifl. titular thuvud bthnvtnr vital roan cabana ontntostc ponawtnc. uponttnaoualy balding an. urn in it: at! law atvbrnl utuutou and thin holdtu. 1t 1: vnrtnu$ paitttain pliant by tho Usualllr. (stilts: 11%.?t‘tfill 1n toad taro nottd in 16 putlontu. it. pr.» aunt‘s was an “uuptnrtc diruction, lithouch in its 0...: ‘DG pgttuut itann. tanrlul sad Quartilud tawgra tun alone at tho 1n$¢rvtau. Implawta in: slow: by tactanlod untltic, fltltltit'or laughtng. 5ohuu| Ind larvalfltalt a! vullabltlc. I... pitttttu Gauntltad thtt tho! KIII‘I thoucbt tho! hut ”on. GU!!! ‘00 I031.“ fihranotd attituinu In tattontod �.3. w tantalum min mm mm and mm m mum at”. utnclod~vith ouphnrta unntfoutattann. it»: on. pattuns, who till I! :alt 330‘ and “vtuld 1110 than unto otttu.” antvmmtd quanta... with such tzpwnanlauu us “that «a you tat-k it in. IE“ dealt-n 10.1” and “not boll fiflfll‘ 1 tauv.” Thu iactdnnoa :nn anuvau a! thil. oaptartc ranutxoun was cougarghln tn than. pravtausly tau-d in both nor-n1 it. «0.12.1 sad ital: dilussud cvuuva. Vurvtng ingrown a! suit. inhuviac var. Ihfliu, but IOU. ill patxonln. In ntvbru1.oaaan this hohtvtur it. until in tint! stunting baakaurd; Ihili tin drag It; 301:: imitatod. I... vurtod in. tango o1 th¢ir oonattac. altnrnntcly filfi' sun 1.3:, at tuna a tiuzwaanc rhythm. an. patient bartnd out tit IHIDUII it m aaaoaiullr vauntntnt in 16 mm» mm“ um» mtm mwmam m wmntm :- ‘ollphonn aparttor annulus. ga. pntitnt rcopouaol tittaghnut tin tstnrvtuv wit! nxxugnrntud nyllnbta unacnt gun druuutic pant... tn0$lr flflfi‘ ”triath“ oxprofintens Inch an "an. 1:. 1:.” low «In! uttsunro‘ mainly ma brought m: to m ward. platinum” um an in in stgtt at tho ether pstiaats. out Bitiltt, who actod in s art-nth: tin taut. upongannaunly tauntini *1 li.‘ applause.” Inch ladle huha'tor is diffiuult to grad. stutlctlonlly but it. In contra! not. ItrlOd thin 3:6 30.. abuarvtd in tin prtvtouuly ntullol control Iron... 81: canon puttuntu ibfl'fld saw. for. of filitrfld count; it» hatter and»: In. anxlutncc at tho crux. thia raaaod tron tilting ch! onnninug’u It‘d and Vbrhtl rauurln can: a: calling than “dust" to tho huhuvtor or an. putlatt uh. triad to Etna ti. nunuiulr. A for atlnru ratatou‘od It: Invoucnt: Ilcguatlvn at fituual activity at ynrtly-oa’0001 tin-n.1th in rattloul 10c Invclcntc. gnu «nude unannr throughout axncuasxal the tumult: a! tin Itfiflr gravid. :uritur duta ro'nrlilc �.9- "1““, u imam tut far can «tum. a a! the prwodum tho at tho M of aluminum: In“: “at“. mun: nu. chum a flu. the ”an“ mud ”yo-tun" mo nu um um Mint” ma ‘W 1- “ti up: in an «item 0!. Malay Mum ”am“ of imam-gm or mama. «luau: mu). «1’ film: as may. :3 a ”cum “W a! ”you“: ”that: in a at“. butt“ (1). only an o! a. n a you on “at a! put-«tn without m M manna“ for 8! ms, and n mitt" m1: 0! «a 31m. is» I “an a: 1 «u ”out” m1“ u our no m1 mmh m n inseam. 01 m 1- m m ”cm“ with ma “mu mm 1: ma «mu mmn. 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It a with)... to no than: u um am a tit m 1: on,» mm. “I not“ (7) m t. a th- wart“. if imlfim a! nun! ”in.“ with an“). “no m1“ «can! tut in g 0! flu in“ Ilth ~mum1" Wm thin II! to m '1“! «17 by tin ”pliant“ 0! nun a: in I“ m tam-nu tut utm a: ommtm. a» “muby and minus: (a) Ll. at ”mutual {mun m min a! mu Manna» an autumn he ”any“ 1: wt a: th W. man W cm man“ new m W.W W Watt �VF . «10~ "T diacloottc Iflrknl’ or ;.ann$n1 hanpttgx. 1‘ annitdbriac tun nltatfitiuna in mytholis czprunatoa about: by than. pltliitu it in noccuuary an raviiw you: grovioua fittn t01n¢tll‘ mo tho Ianlsnlsuu a! luu;:tcntnttol for place tad ttloihnd 6.31:1 at tllnnat. It hit but: 589*! tit: thouo phanouana 3!! an: 60:06:: Iaroain I: nttrthutuhlo ta brill using. 1113!. runs; that tiny arc tun mafitfilu rattan: or tut In“: or u :uaaiiennl 001.11%: rcprcn-ntod 1: I... tent at tho brain, Thur arc. rtthnr. tor-a at ninytutton or fiotcnsn that It. pntltut usnn in situations a: Itvcsa in n niltau of altcrcd luaral inacttnn. In dxnurinututiau, ti. stanuuqd tine-at plan. in tha uylhtiaa ruprcuontutxum or new; letifttifll a¢_thn ynttunt. usually thst a! hdbu GOItI¢ null and iota: homo ant a nanatoatntlou at 19:: a! unwary. That it: gattnnt in apt to stttn a tint untoautiuc :1: 11130.33 to .11: tit a... a: a small hospital at & vixen that. hs'hn- but: far noun-tttvtnl illnnia; ta least. tum hospital 33:: hit noun: at to uohxniulaxc tint ha has 10:: the knapittl. In cltnet, the ytttans 1n oxygenatus his 1: mt»: when puma. pinata: us than no no: in that: «algxn‘l retornnttul aunuoxt but it vuhielsu tor in: exproslanl WM a: the 1W muamva mu manta“. 1mm: ‘.. 1mm at mu {aunties in noeoasary to prnvid. can typo a: neural orgnnisttton in! ‘hn nuantonanee of this new synbolie synten the behavior 113.11 a: tin tOtult a: tin tuturtntton or t numb.» at ttatort u vhtt 1331.! (I) It! cull-d tn. orgnutuumvnviranmaat—ohfiurvur euuplnx. wax: tualud0t not «:1: tbs antral arznnt:at1an. but the ltct $1 tau disability ttucll. tho putlogt'n untivltion ta b: I'll, tn. tnturpnrooatl tituttton a! $I. intaxvicv. and the paticnt'a 11!. axpcriauct and parsoaaltty. tar .i‘nplo. 1! tin interview in warriod out with utcrxli I;to: that. am. In ch33... 8| lungsmtp. If tho oat-tun! docs not qunctten tho pttlaut to limit: you to slap. haunt: with, “It!” man 1am my what marital: ditteront rgnctinun flldfir unytal madiuu bocxuuc ox dittovunl typcu of puricn:lxty Ind uttstndua taunt! incapacity. �-11canxrol pattantu mitt physlaul disabiltttofi ain'toexskud with hint: dlncauo. vita quittiunnd unfit: smrtni todtun. ‘law «he! ulturuttana in lttcfllflfl. Tho: «a nut deny thuir tiflt’fifiltt‘i in qadnrw 13¢ ‘tluntaunl itniion nor an thug than luutl‘u diuortcatnttun tar plaeo or tint. fin! to hau0Vtr. "Iinautcrnwwt" quantinns about illltui it! an: 0! than ”oblon- ta mu 0! am»: an. tuphnnlauc. humor. “1“. Ind «lights. I. n.prcriou- ntndy (3) 1t in; potatud out that vita tun pattcat tuxrodumod nuathar ’Ofiflfl nttcr toagtviac tin drug I. it. up: nnuoasartly ruvunltau that had htthgruo Dana ”ro’wouaud” but yum oitlu clovosntng bin tuclluul 1a a nun mm mxulmtm. ”ml“ «mu». who um: 91 no a: a. tuna“ m. m M he that in. ion: unployod. :ppaaru to h. thfit a! siting tin strong a! ti. tuvsrnuncntnl attusttun tan or ultcrtna tit unurul orunltluttou in first-h tit incllrould In! tho tansuilcd an. at tlnpttv. unehnatlli. la prcvlonn studio. (3) (19). it kiwi itlealnoi its '13::ttotaut a! it. ctphorlu ‘sfl ludto bahnrtar tilt II Otttu notod 1%tt unytnl cudtun. 1% it: pointed out thut tutu hihtvlflt «quid not to intarptotud tiny}: in.Instantaal-phnyiolaui¢nl tart. flint ta ”onrttcll imprunstau” or as a ”rulounu at anhtbtttOH.” lhthur. tiny It. tynbol;¢ unit: at annptattau an it» unu-nrha1 upturn cougar-b1. to tho ammunitiant ahaaunc in vuriu: zanannuo. on» anuno‘ stat. that tic Gran Ithflfl or an. annual. Inn ”than “11 John putat- lm mum hdotnwt, but not ti. ithctton vial: afihsru do no ant: Its}. undnr tum firu‘. i‘éiclttuc that t titlur. par It to $011 u sitar thn titlioaoo at got. don: not ruyruntnt *tnhlhtttun” vital 13 “rattan-i? ph1u1olnalaaIXI by thu'drua. rattantn v.0. ‘nlnd to talk 33km. io¢;unn tn Ifllfil. tun patina: alto: uaaroano: hit natal... not 1: a turutl ruxnrcatttl eonttxt but in u u;ubolt¢ ptttqrs uttltxtns‘trnnstnas doatul. diturtOltattnn and ittgla¢cnunt ta titties pfiruon. raw uxtlpln. than nahgd why It can. to the inupttnl u yuttnnt uncifil rcpt}. booaauo "I“: 1011.“ til at»: tutad manta no I Ina. night titan! _ , i �”'er «u- ""‘T “Illluado aahnrotl“ I! h. porntstn in much rtnpouluu. 1‘ may to an indianttou a! brutn diamana, but t: thy VQI’OII'I as. trniaitlt In! ungrat‘lly $1 vuiiixn‘ by "ha, ha” tiny £90 annatdnrvd an JONDI. 0i! Vfllhfl anarcusod not telling. ahaut tun honyitn1.vhurt in! but tenacity hat: a puttnnt by votorrtnc ta 1: 3; ”Int: 3311.” in than! attunfitani thy patxtnt x: utilising 1h» man. at th- houyltul at g nynbalia Action for tho rcyrosoltttanu o! ht: prabltnn. Thouu.pst1ontn, in thutr rnipoasuu to tho pracn‘uvu I’DOI'~ :0 to rtnoiblo tn; normal group in he». reagents thnu that :sa tho group with hvaxn dullflb. thiy 416 not dxrnatly dun: tun cssntauno»o¢ problonn an: did tho! show lnattnu pattornu of disortan‘utton. tin Iyubaliu avionics air. of tin nan. typo atcd hr tho mortal Illu'. tho: did an. tn... houovdr. t¢ a grants! Court. as ovidsauu‘ Ir it. 1313.: nutter of trnalltat after; in ortcgtatton and ¢strauauu a! tllnnua. tar: lads: hahnvtar and much not. unriayenntVtaaan Ind.utth~ drnunl. Tics. rusponscs. «ouplcd with chucrvutlan o! thn intatnaactn to: hohuvtar, nuggtntu that tho total situation cantata. III. I‘lfliin tul Ifittfirflflh than 3!. ¢n¢ouaturaa thin tho taat ts “.06 with ’attalsu in a gunnrtl hospital. : �W. W“. ‘0‘. I“ “it. In! ("My“) mtw) In“ ’o‘o. It... ‘9‘“. “midi... o: 3.41m Lunatic m 1-0.: 3. Mama. ”max... mun: 1o a 0.: LJ. I. “mun.LA... an.thoI.L.. tutu-n. m an”. You“ ct tar ”Aura man an: manna» W:and um. LBJ. him. its mt. m1. m 11: 3:1th $11-$28, mu. mud: 3. «man. LA. and an“. 5.: in swu- Win A... J. puma». (”m1 Mia"). mm u. wt»: a.“ | 9m. . max. W W“. a! 3.5. m m. 3.1“: «man. 1. 1m. m*. Mind I“ “with” “3 "'9 8. luau“. SJ. «1 an. id“: attun- at atom-mutton ”am. J. mm“. m 6113. m1... 1: 6. a: ' ‘ ”at“ 3. arm. a... I. and um. $3.: I» mm tutu m. a! Egg-mun an erg-nu In“: W.lom1m.m«-u. ‘ g c MI... mu. mu... tum. Add mm“ an mm. M ammo-9mm“ “uranium 1. m1 autumn 10. of and I m. on um Wu many-«Mm mum 3.1.: MW meat“: 1- the u“. I ”I Linn. LIA. not. lam}. ad mun... It: 613-881.. nu. finial». Au can» Luann. human. mm c. W, 10. "mun. LA... ma. LL. and . l»: mu ”no: 3: “cm. with It“: Mum. 3. It In“ mung. 1. m ”that: LMWW ‘r �Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume IV January, 1955 Number 1 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The “Amytal test" in patients with mental illness. Journal of the Hillside Hospital., 4: 3-13, 1955. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-15-019 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Creator An entity primarily responsible for making the resource Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Weinstein, Edwin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and Reprint. Reprint from Journal of the Hillside Hospital, Volume IV, January, 1955, Number 1. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/f36132b2b1eb8c86e51e7a9456e9e17d.pdf aca2be98c9971c66ad807e1d64ee1b8a PDF Text Text Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume IV July, 1955 Number 3 ��DELUSIONAL REDUPLICATION OF PARTS OF THE BODY AFTER INSULIN COMA THERAPY1 ROBERT L. Ph.D.,2 N. GRAUBERT, M.D.,3 and MAX FINK, M.D.4 KAI-IN, DAVID In recent years studies of behavioral changes occurring in altered states of brain function have gone beyond the description and interpretation of isolated phenomena. Emphasis has been placed on such factors as the particular environmental situation in which the behavior occurs, the total constellation or syndrome of associated behavioral changes, and the influence of the premorbid personality. Using these additional methods of study it has been demonstrated that many types of behavior found in brain disease are not defects, such as impairment of perception or memory, but represent forms of adaptation to the stress of illness (16). It has also been shown that various phenomena are not bizarre curiosities or unrelated fragments of neurological dysfunction, but form part of an orderly and meaningful pattern of an altered interaction with the environment. This report of a single case is presented because of the unusual opportunity it provides to study some of these behavioral changes. First, the patient was in a psychiatric hospital, under observation and in psychotherapy for four months, which made it possible to have an accurate and comprehensive picture of his behavior prior to brain damage. Secondly, the neurological symptoms were of rapid 1From the Research Service, Hillside Hospital, Glen Oaks, New York. This investigation was supported in part by grant M-927 from the National Institute of Mental Health of the National Institutes of Health, Public Health Service and by a fellowship of the Dazian Foundation for Medical Research (Dr. Kahn). This paper was read, in part, at a meeting of the New York Society for Clinical Psychiatry at Hillside Hospital, on March 10, 1955. 2Research Assistant, Hillside Hospital, Glen Oaks, New York. 3Resident Psychiatrist, Hillside Hospital, Glen Oaks, New York. iDirector of the Research Service, Hillside Hospital, Glen Oaks, New York. 134 �REDUPLICATION OF BODY PARTS IN I.C.T. 135 onset and actually developed in the presence of the examiners. Finally, it was possible to observe the patient intensively for a prolonged period afterwards, so that the subsequent changes in behavior could be adquately studied. It is the purpose of this report to evaluate (1) the significance of the alterations in behavior, particularly the delusion of having extra parts of the body, and (2) the implication of the subsequent change in behavior for the understanding of the mechanism of somatic therapies. CASE HISTORY Present Illness The patient, a 34-year-old man, became acutely ill the night of September 25, 1954. Standing with clenched fists, gritting his teeth and without saying a word, he kept his wife in a corner of their bedroom for hours. The patient's family summoned a psychiatrist who referred him for immediate hospitalization. He received 15 electroshock treatments in a three~week period with some improvement. On transfer to Hillside Hospital, however, the patient was lethargic and failed to answer many questions. He said that he had come to the hospital for such reasons as “stomach disease,” “to talk over something with my wife,” and “to prepare myself for an examination." He felt he was being watched; that he was influenced by voices coming through the heating system; was being poisoned from a distance; and that there were changes in his body. He said he knew the exact minute when his wife was being unfaithful to him and expressed feelings that the world was coming to an end. There were frequent auditory hallucinations of being called unpleasant and derogatory names. Past History and Premorbid Personality This was the patient’s first recorded psychotic episode. He is the youngest of five siblings, being the only boy. His father and mother were continually busy running a candy stand, and the patient was cared for primarily by his sisters. As a child he was dependent, demanding, and sought to be the center of attention. He developed a flair for comedy and playing the clown to the extent that he was expected to have a career as a comedian, and on one occasion won second prize in an amateur show. At 12 years of age he became interested in playing drums. This became his sole preoccupation, for he devoted every spare moment to them. The patient suffered episodes of rheumatic fever at 10 years of age and again at 20 and, �136 KAHN—GRAUBERT—FINK at these times, was pampered by his family. During his late adolescence he was withdrawn, spending much of his time at his parents’ candy stand. He became overly concerned with his appearance and masculinity, brushed his hair for lengthy periods, exercised to acquire a good build, worried about his chest expansion and, according to his family, stared at his reflection in a mirror “kind of waiting for hair to grow on his chest." He spent much time exercising his left arm because he wanted it to be as strong as his right. He was concerned about a tooth that had not developed fully on the right side of his mouth. To prevent people from noticing this he developed the habit of talking and laughing out of the left side of his mouth, giving the appearance of facial asymmetry. He never enjoyed or settled down to any work. Besides his efforts as a comedian and drummer, he worked in a pocketbook factory, in a ladies apparel concern, and wrote songs and short stories. He was discharged from one position because he clowned all day long amusing his co-workers. He became a beautician after a friend interested him in it. He wanted to quit this too, but remained at the insistence of his fiancee. He was not ambitious for money, but very much wanted to find a place for himself, needing reassurance about his sense of belonging. Although he comes from a secretive family where each member keeps things to himself, the patient was de— scribed as warm and friendly and drawn to the cause of people he considered the underdog or discriminated against. He was sentimental, being quite upset when having to visit someone in a hospital. He was overly sensitive and easily hurt, though not argumentative. The family reported a change in his behavior during the past six years. He had become more secretive about his friends and activities. He went with his fiancée for more than a year before anyone in the family knew about it. He developed many somatic complaints so that frequent visits were made to his physician, without his family’s awareness. Similarly, he told no one that he was in psychiatric treatment, and maintained his secret even though he found it necessary to steal money from his mother’s store to for pay this. He also kept secret his difficulty in hearing for many months. During the war he was drafted into service, became worried about having to go overseas, and sought and received a medical discharge because of rheumatic heart disease. Since 1948 he has been in intermittent psychiatric treatment. This was begun at the persuasion of a friend who was in therapy. The psychiatrist stated that the main effect of the therapy was to get him to look for some �REDUPLICATION OF BODY PARTS IN I.C.T. 137 kind of work, although he confirms the patient’s inability to hold one job for any length of time. During this period two of his sisters have been under extensive psychiatric treatment for severe phobic reactions. He has been married for 21/2 years, never having dated much previously. His mother believes this the result of his being “pretty much of a home boy” and his fears about his rheumatic heart. His sister, on the other hand, reports that the mother made him feel guilty about leaving her alone in the store. She said he felt the responsibility of helping his mother ever since his father’s illness and death, and that he expressed feelings of guilt in leaving her to get married. The patient met his wife in 1951 at a party, and was married in 1953. During the first two years of their marriage, the patient’s wife had two miscarriages. The second one in particular affected the patient. Soon thereafter he complained that there was something wrong with him, that he was not enough of a man, and that there must be a sickness in his body causing his wife to have abortions. He became increasingly depressed, withdrawn and fearful. Later, he became convinced his wife was unfaithful to him and that his wife and brother-in-law were conspiring against him. Course in Hillside Hospital During his hospitalization he became more withdrawn, and careless in his appearance and in the care of his room. He had little contact with other patients, and was preoccupied with his delusional thoughts and hallucinations. Physical examination revealed a presystolic and systolic murmur at the apex and a systolic murmur at the base without accentuation of the pulmonary sounds, or signs of enlargement of the heart. His blood serology was negative. There were no neurological findings except for right facial asymmetry and bilaterally diminished hearing. An electroencephalogram shortly after admission showed well-modulated, occasional random 5-7 cps activity, with 90% alpha. It was interpreted as showing minimal abnormality, consistent with drowsiness or a history of recent electroshock therapy. An amytal test for brain disease (13) was done on November 24, 1954. There was no change in orientation or awareness of illness, but he became more communicative and showed less overt tension during the procedure. Insulin coma treatment was instituted on December 8, 1954, and he had his first coma on December 30. During the course of 18 coma treatments there was no significant change in �138 - KAHN—GRAUBERT—FINK behavior until the morning of January 27, 1955. On that day he had his 19th treatment, was given 370 units of insulin, and went into coma for an hour and 50 minutes, comparable to his previous reactions. Following gavage he did not respond in the usual time, and he was given glucose intravenously. He awakened promptly, and was responsive, but a marked right hemiplegia was noted. He lay in bed with his head and eyes deviated to the left. There was no evidence of aphasia when tested for naming objects. He had a right facial paresis and a right homonymous hemianopia on confrontation. Reflexes were diminished on the right with a positive Babinski, and there was a right hemisensory syndrome with extinction on simultaneous stimulation tests. He raised his left arm on command but failed to respond when told to move his right arm. When his right arm was raised by the examiner and he was asked to identify it, he looked at it for some moments and said it was a “stranger” and “an intruder.” He reported smilingly that there was an extra arm on the right. He was unable to move his right leg on command, and he asked if it were his own. saying that he had seen him sometime in the past. The patient consistently showed this phenomenon of the reduplicated arm for the next hour. He referred to it as an “extra arm,” “a third arm,” and “a bootleg arm,” or personified it as a “stranger,” "this intruder” and “that fellow.” When his right arm was shown to him, he denied knowing whose arm it was, asking one of the attendants, “Did you slip me this arm—did you pick this old at an up auction in the neighborhood?” Another time when asked to whom it belonged, he said “I’m willing to pay a reward for it, and you’re asking me point blank.” He said he was sure that the arm was not his because “it doesn’t extend from my body” and “the dirt under the fingernail is not recognizable.” The patient denied any disability of his own right arm, but said he’d never seen the extra arm work. He said, “My arm I can move with a brain impulse; this one I have to move manually since it isn’t mine.” During the course of questions about weakness in his right arm he said, “If that extra arm belongs to me, then I’m sicker than I thought I was.” The patient did not react to painful stimulation applied to his �REDUPLICATION OF BODY PARTS IN I.C.T. 139 right arm or leg. Even with his eyes open and his attention directed to the point of stimulation, he denied perceiving any stimulation on the right arm, saying “You’re not fooling me—you’re not touching me—you’re touching this third arm, that intruder.” He correctly identified stimuli applied to the right shoulder, but from the elbow down the touch was displaced to the extra arm. The patient lay with his head and eyes deviated to the left throughout the examination. He had difficulty perceiving any stimulus in the right side of space, a phenomenon which has been termed “spatial inattention." When given phrases to read he ignored the right side, reading only the material on the extreme left. Thus, “GOOD HUMOR ICE CREAM” was read as “GL.” When his right arm lay at his side he had trouble finding it. Once, when he was asked to show it to the examiner, he looked over his left side only and said, “I think I’ve been robbed—where is it?” A lumbar puncture was done and a clear, colorless fluid obtained. The fluid was under increased pressure even though the patient was relaxed. The pressure was recorded as 300 mm., the total protein was 32 mg. per cent, and there were two white cells per cubic mm. During the ensuing hours the patient continued to be euphoric and loquacious. He recited long-forgotten lessons and parts of neurological texts whose source was unknown to him. For instance, he gave a complete description of the course of the facial nerve, and described the muscles of the face, calling them by their correct Latin names. He laughed frequently, and recited cryptic remarks as “in the instrument—insulin—instrument—insulin—instrument ward.” Disturbances in memory or recall were not elicited. The delusional “extra arm” disappeared. An electroencephalogram obtained that afternoon was flat in all leads on the left side and showed random 5-7 cps activity, chiefly on the right side. Both alpha and beta were prominent on the right side only. The record was interpreted as showing diffuse dysfunction with left-sided accentuation. In the afternoon the patient was subdued. The weakness of the leg and arm showed some resolution. His relationship to his therapist was completely changed compared to his previous behavior. There was a complete absence of anger, negativism, withdrawal and depression. He clung to his doctor, shook hands, held him back and did not want to be separated from him. He was pleasantly preoccupied with the morning’s episode and joked about it. He was eager to communicate, and even his hearing seemed to have improved. The next morning the patient was depressed, restless, bewildered, �140 KAHN—GRAUBERT—FIN K slow in answering questions and failed to respond when asked about his illness. He spoke in a low voice, at times inaudible. He was disoriented for time of day and was aware of “numbness” in his right arm. He spontaneously asked, “What happened to me—why am I taking all this depletion?" Minimal weakness of the right arm and leg were noted. There was astereognosis in the right hand, but tactile stimuli were correctly localized, and there was no evidence of hemianopia or inattention. When asked about the extra arm the patient was vague and evasive, but did say, “Evidently somebody else was with me and it was their arm I picked up." That afternoon the patient was given 0.5 gm. amytal sodium. Besides its use as a test for organic brain dysfunction, the drug was given in an attempt to elicit the delusion again (14). At this time there was neither a change in orientation nor a recurrence of the reduplication. There was, however, a marked change in mood and language. The patient became very euphoric and talkative. His speech was characterized by ornate, circumstantial, pedantic, histrionic, and cryptic features, with much use of clichés. For example, asked about the extra arm, he said, “I think it will come looking for me when and if the occasion is propitious, as it were.” When asked why he was here, he said, “On the recommendation of the right honorable Dr. Fink, most distinguished doctor on the eastern seaboard Atlantic area whose fame has spread far and wide." Several times he blurted out the cryptic remark—“transference of aggression." When asked what he meant, he said, “If you can’t kick your mother-in-law in the head, you try your father-in-law.” When asked about his arm the patient was evasive, circumstantial and jocular. For example, asked how the extra arm was different from his own arm, he said, “How was it different? For one reason, in the sensitivity of feel. I raised up my left arm and that was all right. When I went to raise up what I thought was right my arm that was all right. But when I went to raise this third arm I did not feel any sensitivity when raising it, lifting it, touching it or otherwise in no manner could I relate it to my corpus—.” When asked about weakness in his right arm, he said, “It feels little less a dynamic in its volition, and I’m tempted to believe in its delivery, as it were.” While the delusion was not present at this time, the patient insisted that there had been an extra arm the day before, saying, “I was lying in bed and it came to my aware the presence of another arm in my bed.” When he was told that the extra arm was really his own right arm, he said, “Well, I’ll tell you. I never argue with �REDUPLICATION OF BODY PARTS IN I.C.T. 141 facts. You see if you’re surmising that it was, and I were to agree, it would be only for professional courtesy’s sake.” Or at another time, when the possibility of the extra arm was being questioned by the examiner, the patient said, “I don’t think it was mine. It might have been mine, you see, but then I would have to have a comprehensive knowledge of the numerous preponderous volumes of ancient history in associated situations. And then I might be even able to volunteer that extra leg which you spoke of before—and beyond. I might even—be able to extend some photographs of the uterus which I own. If I could have the extra arm, the additional leg, and as I said, other things.” For the next two days he continued to be depressed, spoke slowly in a low voice, and showed no spontaneity. He complained of feeling “depleted.” There was no difficulty getting him into a conversation and he would elaborate in a circumstantial way about the pain in his head and the numbness in his hand. He refused to get into conversation about his extra arm, saying, “You're making fun of me." Neurological examination was completely negative. An electroencephalogram on February 2, 1955 showed a resolution of the asymmetry and abnormality of the previous record. It was similar to that obtained on admission. The patient was given amytal again on February 2 and 9. On both occasions he showed a similar response to that obtained on January 28, with euphoria and changes in language. His attitude, however, toward the extra arm and to the weakness of his right arm was altered. He now said that the extra arm might have been a hallucination due to the drugs he was receiving. He also admitted having had weakness of his right arm, saying, “To the best of my recollection there was a general weakness which might have had a specific attenuating dilemma in the appearance of an arm which might have been, to some degree, in a state of difficulty.” On March 2, he was given amytal again. This time his reaction was more like that seen on admission, although he became slightly euphoric and loquacious toward the end. In the weeks following the eventful insulin coma, there was a change in his clinical behavior. He appeared more sure of himself, and was co-operative and friendly. He started to press for his discharge. He said that there were things to be done which he, and not somebody else, should do, but would not specify these things. His wife visited him and told him she had decided to divorce him and would not accept him back in his home. The patient took this announcement without overt emotion. He was unable to give any reason for his wife’s plans, and stated that he forgot to ask her why. �142 KAHN—GRAUBERT—FINK He still wanted to be sent home as soon as possible because, he said, he was ready to take up some kind of business. He felt that he had failed up to now because of reasons unclear to him, but that if he were careful, it would not happen to him again. This behavior was markedly different from that shown admison sion. In contrast to hisprevious aggressive, uncommunicative and withdrawn behavior, he was co-operative, ingratiating, overanxious to please, and made attempts at socializing with other patients. His of a psychiatrist. DISCUSSION The delusion of reduplication of parts of the body has rarely been reported. The earliest reports are by Bechterev (1) in 1926 and Ehrenwald (3) in 1930. In 1935, Schenderov and Gamaleja (9) described six cases and suggested that more might be found if the phenomenon were better known. In these early studies the phenomenon was regarded as a neurologic curiosity and was explained on the basis of sensory disturbances. In the work of Critchley (2), who reported a similar case in 1952, it was considered as a manifestation of disturbance in “body image" due to a parietal lobe lesion of the nondominant hemisphere. In 1954, four cases were reported by Weinstein et al. (14) demonstrating that the phenomenon could not be explained on the basis of sensory impairment, and was not dependent on a focal parietal lesion. They interpreted the delusion as a symbolic phenomenon rather than a sensory or perceptual disturbance, and showed that it occurred only in a setting of diffuse cerebral dysfunction. indiThey cated that parts of the body were redupli‘cated which were defective in some way, regardless of whether or not there was any neurological involvement. It was pointed out that the delusional reduplication of body parts is but one manifestation of reduplicative phenomena. Thus reduplication for time, place and person has also been reported (11). In reduplication for time the patient confabulates that a present experience has also been experienced at a time in the past. For example, a patient identifies members of the staff as old friends or relatives. Reduplication for place is the confabulation that two or more places with the same name and similar attributes exist, when actually. there is only one. Thus, a patient may say there are two �REDUPLICATION OF BODY PARTS IN I.C.T. 143 hospitals with the same name and same staff, but locate one closer to his home and describes it as a hospital which treats convalescent or minor cases only. In reduplication for person the patient confabulates the existence of two persons when there is actually only one. One woman, for instance, said she had two sons, one named “Bill,” and the other “Willie," when actually she had one son named William. It was shown by Weinstein et a1. (14) that reduplication was usually expressed in more than one modality. All patients with delusional reduplication of body parts showed, in addition, reduplication for time, place and/or person. In the present case the patient also expressed temporal reduplication, describing one of the examiners as someone he had known prior to his hospitalization. The symbolic importance of the various phenomena of reduplication is evident in their motivational character. In the perception of a doctor as an old friend or a relative the patient is reassuring himself that he has less to fear than he would from a total stranger. In reduplication for place the patient who locates the extra hospital near his home or describes it as treating only convalescent or minor cases is minimizing his illness. The patient who confabulated having two sons, while denying her own illness, complained that poor “Willie" was in an accident and was afraid that something terrible had happened to him, thus displacing her concern from herself to the extra person. The delusion of reduplication of parts of the body also is a mechanism facilitating denial of illness. While the patient states that there is nothing wrong with his own body, it is the reduplicated arm or leg which is said to be weak or impaired. In the present instance the patient, who in his premorbid behavior was excessively worried about bodily ailments, was unconcerned about his severe disability. Instead, by denying having any trouble with his arm and saying it was the ”extra” arm that didn’t work, he was able to maintain his euphoria and jocularity. While reduplication is shown mainly as a symbolic adaptation to the problem of illness, it may also be a symbolic expression of other wishes, needs and feelings. For example, a patient with intractable pain had been noisy and demanding and had aroused the antagonism of members of the staff. Following a course of electroshock therapy her complaints of pain were gone and her relations with the staff were considerably improved. Along with other changes in orientation, she confabulated that there were two Mount �144 KAHN—GRAUBERT—FIN K Sinai Hospitals, the old one where people were mean to her, and the new one where everybody was so nice (12). The delusional reduplication of parts of the body appears to be related to certain aspects of the premorbid personality. In the present case, and in those reported by Weinstein et al. (14), all the patients demonstrated a special concern with the symbolic importance of physical characteristics. Our patient was concerned with his build, the strength of the muscles of his left arm and the presence of hair on his chest. He was also sensitive about a tooth which had not come out fully and attempted to conceal it. In the earlier study (14) a patient who had developed the delusion of multiple heads following a craniotomy, had been preoccupied with his baldness and had engaged in numerous extramarital affairs to prove that he was capable of attracting women. A patient, who confabulated having three eyes, was very sensitive about a prosthetic eye and would face people directly forward so that divergence Of his eye would not be noticed. He was also preoccupied with his build and physical appearance, engaged intensively in Yogi and Judo, and was concerned with his ability to satisfy his wife sexually. In recent writings on “spatial inattention” (16, 17) it has been indicated that this, too, represents a form of symbolic adaptation. In this case the patient consistently avoided looking to the right side, was unable to find the “extra” arm when it lay at his side, and only read the extreme left part of phrases shown to him. This behavior facilitated the denial of weakness of his right arm as well as helped maintain his delusion of the extra extremity. His personality also showed features that have been described as characteristic of persons with “spatial inattention” (17). He was very secretive, especially in recent years, and seemed overly concerned with the symbolic significance of violence, as shown by his discomfort on visiting hospitals, his fear of going overseas and by an apparent confabulation that he had once been a secret witness to a murder. The marked ludic behavior shown by the patient during the period of his delusion and during the later amytal tests is also related to his premorbid personality. He was described as having been a good mimic with a flair for clowning. Ludic behavior has also been regarded as a form of adaptive behavior (15) in which the patient acts out a feeling of well-being, implicitly denying his illness. It is of theoretical interest that the delusional reduplication and “spatial inattention” occurred with right-sided symptoms. Disorders of the “body image” and spatial awareness have been regarded as characteristic of nondominant lesions. In this case, with apparent �REDUPLICATION OF BODY PARTS IN I.C.T. 145 dominant hemisphere involvement but without aphasia, it was possible to study these behavioral changes as clearly as with nondom— inant lesions. One must conclude that in the usual case of a dominant lesion, pathology which is sufficiently extensive for these changes to occur, will also result in an aphasic disorder which masks the phenomena. The neurologic lesion which was the basis for the reported of diffuse behavior in alteration dysfunction a and was phenomena the cerebrum with accentuation of the left hemisphere. Such disturbances in neurologic function are not uncommon in insulin coma therapy, and are the result of persistent cellular dysfunction despite restoration of the glucose level of the blood. While one may ascribe etiological importance in the production of this patient’s hemiplegia to the history of rheumatic fever and the cardiac murmurs, this is not warranted considering the absence of other rheumatic phenomena either before or subsequent to the event. It is more meaningful to regard this incident as one manifestation of the central nervous system damage incurred by prolonged hypoglycemia. Such manifestations include all aspects of nervous system functions including seizures, transient hemiplegia and aphasia, confusional syndrome and Korsakoff psychoses, prolonged coma and death (6). Recent studies of the electroencephalographic changes during prolonged coma (18) and minor neurologic signs following insulin coma treatment (19) amplify the variety of neurologic sequelae of this treatment. The importance of cerebral damage in the mechanism of somatic therapies has recently been re-emphasized by Weinstein and Kahn (12, 16). They suggest that improvement following somatic therapies is characterized by manifestations of denial in a milieu of altered brain function. A study in this laboratory (5) has supported this hypothesis concerning electroshock therapy; Improved patients showed significantly earlier and more persistent alterations in brain function as measured by the amytal test (13) and by serial electroencephalographic studies (4), and more changes in language and behavior indicative of denial, than did patients who failed to improve. Recent case reports of the effects of prolonged insulin coma by Revitch (8), Kwalwasser and Caplan (7), Shagass and Rowsell (10), and Yeager et a1. (18) point to the behavioral improvement and discerebral when of damage superschizophrenic symptoms appearance venes. In this patient, too, there was an immediate, marked and cerebral with concomitant behavior damage. in change persistent �KAHN—GRAUBERT—FINK 146 It was possible here to demonstrate not only explicit verbal denial of illness, but other aspects of denial as reduplication, spatial inat- tention and changes in mood and language. Thus, the observations in his case are consistent with the hypothesis of Weinstein and Kahn. Further studies of the role of premorbid personality in denial, and on the mechanism of somatic therapies are now in progress. SUMMARY AND CONCLUSION A case history is presented of a 34-year-old man with a fourmonth history of acute mental illness who was placed on insulin coma therapy. After his 19th coma he developed a right hemiplegia, hemianopia, hemisensory syndrome and “spatial inattention,” and became ludic, euphoric and loquacious.'At this time he showed delusional reduplication of body parts, expressing the conviction that while there was nothing the matter with his right arm, there was an “extra" arm in his bed which did not belong to him and which did not work. 2. The significance of reduplication is discussed in terms of a symbolic adaptation to illness. This phenomenon, as well as his other changes in behavior such as “spatial inattention" and ludic behavior, is considered to be related to his premorbid personality. 3. The presence of these phenomena in a case with right-sided symptoms is considered with reference to anatomical localization. These findings contradict the traditional view that “body image" disorders and “spatial inattention” depend on a nondominant hemisphere lesion. 4. The subsequent changes in the patient’s behavior, in which he showed complete recovery from his illness, is discussed in terms of its implications for the mechanism of action of insulin coma therapy. The results are considered to support the theoretical view that improvement in the somatic therapies is characterized by manifestations of denial in a milieu of altered brain function. 1. REFERENCES Bechterev, V. M.: Obozr. Psikh., 1926, cited by Schenderov and Gamaleja. Critchley, M.: A Phantom Supernumerary Limb after a Cervical Root Lesion, Arq. Neuro-Psiquit., 10:269-275. 1952. (3) Ehrenwald, H.: Altered Perception of the Body Image with Consequent Psychosis in Left Hemiplegia. Mschr. f. Psychiat. u. Neurol., 75:89-97, 1930. (4) Fink, M. and Kahn, R. L.: Relation of Electroencephalographic Changes and Improvement in Electroshock Therapy. In preparation. (1) (2) �REDUPLICATION OF BODY PARTS IN I.C.T. 147 Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation Between Altered Brain Function and Denial in Electroshock Therapy. In preparation. (6) Kalinowsky, L. B. and Hoch, P.: Shack Treatment, Psychasurgery and Other Somatic Treatment in Psychiatry (2nd ed.). New York: Grune 8c Stratton, (5) 1952. and Caplan, M.: A Case of Prolonged Insulin Coma: Treatment. This Journal, 1:145-155, 1952. Revitch, E.: Observations on Organic Brain Damage and Clinical Improvement Following Protracted Insulin Coma. Psychiat. Quart., 28:72-92, 1954. Schenderov, L. I. and Gamaleja, K. N.: Peculiar Disturbance of Body Scheme in Hemiplegics (Pseudomelia). J. Nevrol. Psihhiat. i Psikhogig., 4:361-372, (7) Kwalwasser, S. (8) (9) 1935. and Rowsell, P. W.: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma. A.M.A. Arch. Neural. (‘5' Psychiat., 72:705-711. 1954. (11) Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Phenomenon of Reduplication. A.M.A. Arch. Neural. & Psychiat., 67:808-814, 1952. (12) Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat., (10) Shagass, C. (13) (14) (15) (16) 109:22-26, 1952. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium") in Brain Disease. Am. J. Psychiat., 109:889-894, 1953. Weinstein, E. A., Kahn, R. L., Malitz, S., and Rozanski, ].: Delusional Reduplication of Parts of the Body. Brain, 77:45-60, 1954. Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease. This journal, 3298-106, 1954. Weinstein, E. A. and Kahn, R. L.: Denial of Illness. Springfield, 111.: Charles C. Thomas, 1955. (17) Weinstein, E. A., Kahn, R. L., and Slote, W.: Withdrawal, Inattention and Pain Asymbolia. A.M.A. Arch. Neural. (9 Psychiat., in press. (18) Yeager, C. L., Simon, A., Margolis, L. H., and Burch, N. R.: Electroencephalographic Studies in Posthypoglycemic Coma. J. Nerv. & Ment. Dis., 118:435-441, 1953. (19) Ziegler, D. K.: Minor Neurologic Signs and Symptoms Following Insulin Coma Therapy. J. Nero. (3' Ment. Dis., 120:75-78, 1954. �6&3»; a; M '4 ’ u ��an m w ‘~ w m at m w m was. M M , ' , .. ”MW; mm a; m. . M3mg, W M §F mm man—5.... ������������mmmmmwwmmmiw- mummmuummmnmmmmm~' hag-6“} m IZLv*"' ,-Mv.-..‘w+,w A .w ~ ��' ~19- a We "a u ' of W M w W m M a -::.,.; m m mm mm M m u m . ���WW*WWMWW“WWMMWW ‘ WMWNWWWQfliwwm‘ a m. m m mm m mm w - Wmmwgmmwwmamwmw . *meummmim «WM W W M Wm w w m «mm W (X); . mammary In wmmmmmmwmwmm �,, m w W» m W mm m m ��m mM m - , �Vt,“ ~ m as. a. m » ~ ~ ‘ - � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Delusional reduplication of parts of body after insulin coma therapy. Journal of the Hillside Hospital, 4: 134-147, 1955. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-16-020 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Creator An entity primarily responsible for making the resource Kahn, Robert L.; Graubert, David N.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from JOURNAL OF THE HILLSIDE HOSPITAL Volume IV July, 1955 Number 3. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/d4673cc7ac4d3b5481723b3db49559a7.pdf 7cd1e7dcb45e0955ceb3d6c8e6eafcd7 PDF Text Text Relation of Amobarbital Test to Clinical Improvement in Electroshock Robert L. Kahn, Ph.D., Max Fink, M.D. Glen Oaks, N.Y. and Edwin A. Weinstein, M.D. Bethesda, Md. Submitted for publication February 23, 1956. Hillside Hospital (Drs. Kahn and of Research (Dr. Weinstein). Fink). Walter Reed Army Institute supported in part by the Medical Research and of the Surgeon General, Department of the Office Development Board, and grant M-927 from the DA-h9-OO7-MD-376; No. under Contract Army, of the Mental National Health Institutes of of National Institute Health Public Service. U.S. Health, This investigation was �\ theories about the mode of action of electroshock therapy have been offered, the relationship among neurophysiological and psychological factors remains poorly understood (1,2). Although While many changes in brain function may be demonstrated on electrical recording, such evidence of impaired function has not been correlated with the degree of psychiatric improvement. Similarly, although memory defects learning ability are common manifestations following the administration of electrically induced convulsions, their severity is not an index of therapeutic outcome. It would appear that the results of ordinary clinical and laboratory procedures and psychological tests do not furnish adequate criteria for a correlation of the alterations of behavior with the changes in brain function. In previous studies (3) it has been suggested that the therapeutic action of electroshock therapy was related to the production of a milieu of brain dysfunction in which denial of illness (anosognosia) might occur. A concept of anosognosia was advanced which included not only denial of hemiplegia and blindness but denial of many other aspects of illness and problems of living. It was indicated that anosognosia was not explicable as a focal deficit but was, rather, a manifestation of a reorganization of perceptual symbolic function in which the patient represented his problems in an altered language pattern. In the verbal sphere these language patterns included explicit denial, disorientation for place and time, reduplication (reduplicative paramnesia), paraphasia, and confabulation. The patient's feelings about his illness and incapacities could also be manifested in nonverbal aspects of behavior, such as selective and impaired �-2withdrawal, inattention, and muteness (akinetic mutism), altered sexual behavior, and euphoric, manic states. The particular form of symbolic adaptation that was used was of the premorbid personality. closely related to features These changes in behavior were found commonly with infiltrating neoplasms, with acute vascular lesions, particularly when associated with subarachnoid bleeding, and following lacerating brain injury. electroencephalographic records showed diffuse slow-wave rhythms, and it appeared that the lesions affected the diffuse projection systems rather than any specific discrete projection area. Similar forms of behavior may appear after the operation of prefrontal lobotomy and, in more transitory form, after the administration of electroshock convulsions. When the degree of brain damage was insufficient to permit the elicitation of explicit denial and disorientation on ordinary clinical examination, these phenomena might be observed when the patient was interviewed after the intravenous administration of amobarbital (Amytal) sodium. This observation furnished the basis for the "Amytal test" for brain damage, in which the persistence of certain patterns of denial and disorientation are considered as evidence of impaired function (h,5,6,7). It was reported that in some patients receiving electroshock treatment for intractable pain, the amobarbital test, which was previously negative, became positive after a number of convulsions. Others received as many as 18 shocks without change in the results The of the amobarbital test. It was noted that in patients who gained �-3- relief from their complaints of pain, the amobarbital positive, whereas in those patients tests became continued to complain of pain the amobarbital tests remained negative. The purpose of the present paper is to determine the relationship between the clinical response to electroshock treatment and the results of the amobarbital test in patients hospitalized for psychiatric illness. who METHOD patient was given a series of amobarbital tests. In this test, the patient is asked a standard group of questions pertaining to orientation and the awareness of illness. The drug is then administered intravenously in a 0.5% solution at a rate of 0.05 gm. Each cc.) per minute until nystagmus, slurred speech, drowsiness, and errors in counting backward are noted. The same questions are then repeated. The following changes, when persistent,are called "positive" and are deemed indicative of cerebral dysfunction. 1. Complete denial of illness2. Denial of major aspects of illness, such as attributing entry into hospital to a trivial or past illness. (1 hospital, either its proper name or in terms of some euphemism, such as "rest home". h. Displacement of the location of the hospital, such as to another city3. Misnaming the 5. Confabulated journey. Reduplication of the hospital, such as the patient's stating that he is in another hospital of the same or similar 6. �name. 7. Disorientation for time of day with confusion of day and night. 8. Gross him a 9. The misidentification of the examiner, such as calling "lawyer" or an "entertainer". Disorientation for year. patient was given his first test prior to treatment and was retested at weekly intervals. All patients in the series had negative amobarbital tests prior to the flfitiation of therapy. Treat— ments were administered three times a week, so that the patients were generally tested after every third treatment. A test was given two days after a treatment and was continued at weekly intervals after the termination of therapy until the result had become nega- tive. Electroencephalographic records and standard tests of memory and learning ability were also given, but will not be considered in detail in this paper. POPULATION patients at Hillside HOSpital receiving electroshock with the Reiter Electrostimulator were studied. The patients were not selected by us but were taken on the basis of consecutive referrals by the clinical staff. Some patients were necessarily excluded because their treatment was terminated or interrupted before they were adequately studied. Another patient was omitted because he had manifestations of brain disease and a positive amobarbital Twenty—four �-5- test prior to electroconvulsive therapy. The number of treatments varied from 9 to 33. Patients who showed clinical improvement tended to receive fewer treatments. Some of this variability could also be ascribed to differences in the inclination of the resident psychiatrists to use this form of treatment. One patient decided for himself that he had had enough treatment and eloped. Diagnostically, the patients consisted of lh with depressive reactions, 9 with schizophrenia, and l with manic reaction. There were 15 women and 9 men, and the ages ranged from 2h to 68, with a median of h? years. Evaluation of Response to Electroshock Therapy: All patients were observed for at least eight weeks after completion of treatment. Determination of the patient's response to electroshock was made on the basis of the resident psychiatrist's impression, staff opinion, the nurses' notes, and the clinical evaluation of one of us (M. F.), who supervised the treatments but was not aware of the amobarbital test results. On this basis the patients were divided into three groups. cases in this group were regarded as showing recovery or marked improvement. These patients no longer showed the symptoms which brought them into the hospital: their doctors felt they were better, and the nurses noted them as being able to sleep without medication, eating better, getting along with the other patients, and participating in hospital activities. A. Markedly Improved: The 11 Moderately Improved: The six patients in this group showed some improvement but continued to manifest indflations of mental B. �-5- illness. patients typically showed symptomatic relief; ELEL’ acute depressive features might be gone, but the dramatic change, so evident in the first group, was not apparent. Each patient continThese noticeable disturbance, such as obsessional thinking, paranoid ideas, or somatic preoccupation. ued to show some C. seven Minimally Improved or Unimproved: patients in whom change was not showed only equivocal or In this group was clearly noticeable or transient improvement. placed who Some showed fluctu- ations in behavior, at times appearing somewhat improved. But the change was not sustained, so that by the end of treatment they appeared much as they did before. We are aware of the difficulties in evaluating improvement. Others may have differed in the estimates of changes in these patients. In any case, by using this threefold classification, the differences between the first and the third group will be distinct. OBSERVATIONS Distribution of Positive Reactions: The number of amobarbital tests given to each patient during the course of electroshock A. to 13, depending on how long treatment was maintained. In Table l the data are shown for the number of tests given during treatment and the number and percentage positive for all the patients ranged from 3 in each group. The markedly improved patients showed many more positive reactions than the unimproved group, with the moderately improved patients between these groups. Every markedly improved patient had at least one positive amobarbital reaction during �-7the other hand, one of the moderately improved patients and five of the unimproved patients never showed a positive result. A comparison of the results in each group, using the x2 test, is statistically significant at better than the 1% level of treatment. 0n confidence. B. Positive Reactions at Each Stage of Treatment: In the Figure the groups are compared for the percentage of patients in each group who had positive results at each stage of treatment. Almost half the markedly improved patients had positive reac- tions after only three treatments, and all had positive reactions after seven to nine treatments. In the unimproved cases, on the other hand, the number of positive reactions was small and there was no consistent increase during the course of treatment. Again, the moderately improved group tends to fall between the other two. Fig: Percentage of positive amobarbital test reactions occurring in each group at different stages of treatment. patients received more than 15 treatments, the data are not presented beyond this point because the number in each Although some group became too small for purposes of comparison. Four of the unimproved patients received more than 20 treatments, with consis- tently negative amobarbital test results. One of the moderately improved patients received over 30 treatments, with only an occasionally positive reaction. �-8- variations in the persistence of positive reactions from week to week. With at least two consecutive positives as the criterion of persistence, 0. Duration of Positive Reactions: There were nine of the markedly improved, two of the moderately improved, and only one of the unimproved group showed persistent positives. After the termination of treatment all patients but one had negative amobarbital reactions nine days after the last convulsion. The remaining patient developed a negative test during the second week after treatment. Factor of Age: Since the patients in the markedly improved group tended to be older persons suffering from depressive reactions, it is conceivable that the difference in amobarbital test results D. related solely to age and only coincidentally to clinical improvement. Underlying this is the assumption that the older person is more likely to show signs of altered brain function when given electroshock. In Table 2 the mean age for each group is shown. It is apparent that the first two groups were older than the may be patients. Yet, while the mean age of the moderately patients is slightly higher than that of the markedly group, these patients still had significantly fewer positive unimproved improved improved reactions. the number of positive reactions during treatment is for each group when the analysis is limited to patients more In Table shown 3 years of age. In this Table the relationship of positive reactions in the different groups remains unchanged from that when than hO �-9the groups are considered as a whole. OTHER ASPECTS OF BEHAVIOR Apart from explicit denial of illness and disorientation, there were changes in behavior that occurred both under the influence of the drug and clinically during the course of treatment in signifi— cantly progressive fashion in those patients who improved. These aspects may be divided into verbal and nonverbal communication. A. Changes in Verbal Language: These changes consisted of denial expressed in evasion, in negative expressions, and in the use of a syntactical pattern involving the third and second persons. patients gave such answers as "It's hard to say", or "I forgot", or "I don't know; I've been waiting for the doctors to tell me." The change in syntactical pattern is When asked about illustrated their symptoms, "It's they call a depression", or "I'm afraid somebody will get hurt", or answering the question "What is your main trouble?" with "What is your main trouble?" by such remarks as what patients would talk of a relative who was sick. In patients who improved there was a notable development of such patterns in a nondrug interview. One such patient, for example when asked prior to the start of treatment what his main trouble was, said, "I’m depressed." After two treatments he answered the question with "I don't get along well with my mother-in-law." After five treatments he said, "I don't get what you mean"; after eight, "I get sick; that's all I know." After 10 treatments he said, "Right now, it's that I don’t see my wife," and after 11 treatments he said, Sometimes �-10"In what way do you mean?" and "I don't know how to explain it." termination of treatment, his main trouble was given as "I want to get home", followed by an account of how "good" his wife At the was. the other hand, the increased use of these language patterns did not occur. They were not present in In the unimproved group, some and were on minimally or inconsistently noted in others. In some patients there were actually fewer such language patterns under the effects of the drug than there had been in the of the unimproved preamobarbital interview. B. Changes in Nonverbal Behavior: reactions occurred frequently in the markedly Euphoric in both clinical and drug interviews most improved group, less often in the moderately improved group, and least often in the group which were considered unimproved. In the patient classed as manic, euphoric behavior present in his clinical behavior and was not changed by amobarbital. Changes in sexual behavior appeared during the amobarbital interviews of four of the markedly improved patients but in only one patient in each of the other categories. This took the form of trying to hug or caress the examiner, making remarks with sexual content, or engaging in masturbatory activity. A patient in the unimproved group showed this behavior both during pre-drug interviews and under the influence of amobarbital. unimproved Withdrawal or markedly improved "selective inattention" was was shown by patients, particularly during the 9 of the ll drug phase of the �amobarbital interview. This behavior consisted of failure to answer the questions about illness and hospitalization or responding in dysarthric and cryptic fashion. This reaction under the drug occur— red only once in each of the other groups. It was of interest that two patients in the unimproved category who appeared withdrawn before the test became more responsive under the influence of the drug. COMMENT results of the amobarbital tests in these patients indicate that there is a relation between clinical improvement and the production of brain damage or an altered state of brain function as determined by this particular method of examination. In patients The who improve, the amobarbital test becomes consistently positive early in the course of treatment. In moderately improved or unimproved patients there are fewer positive reactions and their frequency does not increase with more treatments. With other methods of evaluating brain function such close correlation was not present, all patients abnormalities in the electroencephalographic record and impaired learning was found as frequently in patients who improved as in those who do not. The significance of this relationship may be more clearly appreciated by a consideration of the changes in symbolic function that occur in states of altered brain function. It has been useful in studying the behavior of patients with alterations in brain function to distinguish between defects in the as showed formation of symbol patterns and changes of language patterns which �-12- interaction in the environment. In the first category may be included many types of memory defects, dyscalculia, topographical disorientation, and aphasia. A patient with such a memory defect cannot select elements of experience, classify them into significant units, and arrange them into a temporal pattern. These defects are observed with diffuse cortical lesions and probably occur universally after shock treatments in transient fashion. They are, however, related very remotely, if at all, to therapeutic outcome. Alterations in the mode of interaction in the environment are exemplified in the various patterns of disorientation and denial and in the amnesias that are noted with lesions of the diffuse projection systems, in chronic barbiturate intoxication, and following electroshock convulsions. Here there is no defect in memory, awareness, or perception as such, but the patient selects or rejects certain aspects of the environment for the expression of his own motivations. In disorientation for place, for example, the misnaming and mislocating of the hospital serve as symbolic representations of the patient's feelings about his incapindicate abilities shift in the a and problems be well and go home. mode of as the manifestation of his need to not that the patient is unaware of his -- often It is is in an absolute sense. He of the hospital and expresses "aware- problems and does not know where he commonly "remembers" ness" of his unawareness the name difficulties in other contexts of language. The is, rather, of the far greater degree to which he is expressing his own motivations in his perception of the temporal, �-13- aspects of the environment. In considering what constitutes therapeutic improvement, it is evident that the evaluation that is commonly made by a hospital spatial, personal, and somatic the particular types of symbolic adaptation and defensive operations that are used. If the patient denies that he has any problems or that he is troubled by them, or if he cannot recall any, he is rated as improved. Such patients characteristically appear affable and uncomplaining, their manner reinforced by cliches and banalities, themselves adaptive forms of staff large part depends in on that general memory impairment does not persist after electroshock but that there is a selective "forgetting" of traumatic material in the patient's life. This does not mean that he has developed a better understand— ing of his interpersonal relationships or has acquired "insight“. The observation is also significant in explaining why, although electroshock may have a short-term beneficial effect, evaluation of long-term results shows little difference between treated and untreated cases. Also, the fact that therapeutic improvement did not result in patients with negative amobarbital tests suggests that methods of administering electroshock by minimally affecting brain function, such as a unilateral seizure, will not prove generally efficacious. From the immediately practical standpoint, the amobarbital test given after the third or fourth treatment may be of language. Many studies (8,9,10,11,12) have shown prognostic value. The amobarbital test is not in itself a direct index of brain �-114- in that it measures some particular modality of dysfunction or brings out a specific defect. Rather, under the conditions in which it is given, one deduces impaired neural function by reason of the change in the organization or pattern of language in which the patient expresses himself. A positive result requires not only damage certain degree and type of impairment of brain function exist but that the patient employ verbal denial and disorientation as adaptive mechanisms. It would be expected that among patients with equivalent degrees of brain damage the highest incidence of positive that a amobarbital tests would occur among those who characteristically use denial as an adaptive mechanism in stress. In relating these findings to the mode of action of electroshock and other somatic therapies, several considerations seem of importance. There is a combination of an added stress and a change in brain function. The milieu of brain function determines the pattern or organization of the adaptive behavior which can be most clearly formulated in terms of language. These include not only verbal patterns of denial and disorientation, elicited with the aid of the drug, but changes in syntactical patterns indicative of an altered relationship of the self in the environment. There were also indications that in the improved patients there were more all types of symbolic adaptation, nonverbal as well as verbal. Thus, a patient who appeared withdrawn both in the predrug and in the drug interview had a poorer prognosis than the patient The who became withdrawn only under the effects of the drug. changes in �-15- patient who showed altered sexual behavior under the effects of the drug had also exhibited this behavior during the clinical question- ing as well and did not improve with treatment, whereas the four patients manifesting sexual behavior only under effects of the drug did improve. It is likely that the faculty of changing symbolic patterns regardless of content is a factor in therapeutic improve- ment. SUMMARY patients referred consecutively for electroshock treatment were given amobarbital (Amytal) tests before and at regular intervals during and following the course of treatment. There was a close relationship between the short-term response Twenty-four to treatment and the results of the amobarbital tests. The much patients showed early, persistent, and increasingly positive reactions during the course of treatment. Unimproved patients showed no positive reactions, or showed them infrequently and inconsistently. An intermediate group, who showed moderate clinical improvement, showed more positive reactions than the unimproved group but fell far short of the much improved group in the incidence of positive reactions. Changes in language and nonverbal forms of behavior related to denial were most consistent and pronounced in the improved group, improved interviews not employing drugs. These observations indicate that clinical improvement in elec— troshock requires the creation of conditions of altered brain function in which new patterns of symbolic adaptation can be maintained. even in �TABLE 1 Distribution of Positive Amobarbital Tests During Treatment No. of Tests Given During Markedly improved Moderately improved Unimproved (7) (11) (6) No. % Treatment Positive Positive 50 38 76 39 15 38 hS 6 13 �TABLE 2 Relationship of Clinical Improvement To Age Mean Agez Yr. Markedly improved Moderately improved Unimproved (7) (11) (6) h7.6h 50.00 35.29 �TABLE 3 Distribution of Positive Amobarbital Tests in Patients More Than ho Years of Age No. of Tests Given During Markedly improved Moderately improved Unimproved (3) (10) (5) No. % Treatment Positive Positive h6 35 76 3h 15 hS 17 �REFERENCES 1. Gordon, H.L.: Fifty Shock Therapy Theories, Mil. Surgeon, 192: 397, 19h8. Kalinowsky, L.B., and Koch, P.H.: Shock Treatment, Psychosurgery and Other Somatic Treatment in Psychiatry, Ed. 2, New York, Grune & Stratton, Inc., 1952. 2. Weinstein, E.A. and Kahn, R.L.: Denial of Illness: Symbolic and Physiological Aspects, Springfield, I11., Charles C. Thomas, 3. Publisher, 1955. Weinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.: Diagnostic Use of Amobarbital Sodium in Organic Brain Disease, Am. h. J. Psychiat., 112: 889-89u, 1953. Weinstein, E.A., Kahn, R.L. and Malitz, 5.: Serial Administration of "Amytal Test" for Brain Disease: Its Diagnostic and Prognostic Value, A.M.A. Arch. Neurol. & Psychiat., 11: 217-226, S. 195k. Weinstein, E.A. and Malitz, 3.: Changes in Symbolic Ex— pression with Amobarbital Sodium ("Amytal Sodium"), Am. J. Psychiat., 6. lll= 198-206, 195h. 7. Kahn, R.L., Fink, M. and Weinstein, E.A.: The "Amytal Test" in Patients with Mental Illness, J. Hillside Hosp., Q: 3-13, 1955. 8. Carter, J.T.: Type of Personal Life Memories Forgotten Following Electra-Convulsive Therapy, Am. Psychologist, g: 330, 1953. 9. Janis, I.L.: Psychologic Effects of Electric Convulsive Treatments: I. Post-Treatment Amnesias, J. Nerv. & Ment. Dis., 111: 359, 1950. �-210. Korngold, M.: An Investigation of Some Psychological Effects of Electric Shock Treatment, Am. Psychol., g: 381-382, 1953. 11. Teicher, A.: The Effect of Electroconvulsive Therapy on the Visual Reactions of Schizophrenic Patients, Am. Pszchol., hhS, 1953. 12. Person, Alexander, L.: Am. J. Psychiat., Effect of Electroshock 109: 696-698, 1953. on a "Normal" Q: �Reprinted from the A. M. A. Archives of Neurology and Psychiatry July 1956, Vol. 76, pp. 23—29 Copyright 1956, by American, Medical Association lee/whorl .725! to o/flmoéaréita/ C/inica/ E/ectrodhocé jm/orouement in ROBERT L. KAHN. Ph.D. MAX FlNK. M.D.. Glen Oaks. N. Y. and EDWIN A. WEINSTEIN. M.D.. Bethesda. Md. lllllllllll|l||[|[|IllllllllllIlllllllllllllll|IIIlIllIlllllllIlllIll|||l||llIll||l|lllllllllllllllllllIlllllllllllllllllllllllllllllllllllIllllllllllllllllllU While many theories about the mode of action of electroshock therapy have been offered, the relationship among neurophy— siological and psychological factors remains poorly understood.* Although changes in brain function may be demonstrated on electrical recording, such evidence of impaired function has not been correlated with the degree of psychiatric improvement. Similarly, although memory defects and impaired learning ability are common manifestations following the administration of electrically induced convulsions, their severity is not an index of therapeutic outcome. It would apclinical of results the that ordinary pear and laboratory procedures and psychological tests do not furnish adequate criteria for a correlation of the alterations of be— havior with the changes in brain function. 3 it has been suggested studies In previous that the therapeutic action of electroshock therapy was related to the production of a milieu of brain dysfunction in which denial of illness (anosognosia) might occur. A concept of anosognosia was advanced which included not only denial of hemiplegia and Submitted for publication Feb. 23, 1956. Hillside Hospital (Drs. Kahn and Fink). Walter Reed Army Institute of Research (Dr. Weinstein). This investigation was supported in part by the Medical Research and Development Board, Office of the Surgeon General, Department of the Army, under Contract No. DA—49—007—MD—376; and grant M-927 from the National Institute of Mental Health of the National Institutes of Healthy U. S. Public Health Service. * References 1-2. blindness but denial of many other aspects of illness and problems of living. It was indicated that anosognosia was not explicable as a focal deficit but was, rather, a manifestation of a reorganization of perceptual symbolic function in which the patient represented his problems in an altered lan— guage pattern. In the verbal sphere these language patterns included explicit denial, disorientation for place and time, reduplica— tion (reduplicative paramnesia), paraphasia, and confabulation. The patient’s feelings about his illness and incapacities could also be manifested in nonverbal aspects of behavior, such as selective withdrawal, inat— tention, and muteness (akinetic mutism). altered sexual behavior, and euphoric, manic states. The particular form of symbolic adaptation that was used was closely related to features of the premorbid personality. These changes in behavior were found commonly with infiltrating neoplasms, with acute vascular lesions, particularly when associated with subarachnoid bleeding, and following lacerating brain injury. The elec— troencephalographic records showed diffuse slow—wave rhythms, and it appeared that the lesions affected the diffuse projection systems rather than any specific discrete projection area. Similar forms of behavior may appear after the operation of prefrontal lobotomy and, in more transitory form, after the administration of electroshock convul— sions. When the degree of brain damage was insufficient to permit the elicitation of explicit denial and disorientation on ordi— nary clinical examination, these phenomena might be observed when the patient was in— terviewed after the intravenous administra— tion of amobarbital (Amytal) sodium. This �observation furnished the basis for the “Amytal test” for brain damage, in which the persistence of certain patterns of denial and disorientation are considered as evi— dence of impaired function.T It was reported that in some patients receiving electroshock treatment for intractable pain, the amobarbital test, which was previously negative, became positive after a number of convulsions. Others received as many as 18 shocks without change in the results of the amobarbital test. It was noted that in patients who gained relief from their complaints of pain, the amobarbital tests became positive, whereas in those pa— tients who continued to complain of pain the amobarbital tests remained negative. The purpose of the present paper is to determine the relationship between the clinical response to electroshock treatment and the results of the amobarbital test in patients hospitalized for psychiatric illness. Method Each patient was given a series of amobarbital tests. In this test, the patient is asked a standard group of questions pertaining to orientation and the awareness of illness. The drug is then administered intravenously in a 0.5% solution at a rate of 0.05 gm. (1 cc.) per minute until nystagmus, slurred speech, drowsiness, and errors in counting backward are noted. The same questions are then repeated. The following changes, when persistent, are called “positive” and are deemed indicative of cerebral dysfunction. 1. Complete denial of illness 2. Denial of major aspects of illness, such as attributing entry into hospital to a trivial or past illness 3. Misnaming the hospital, either its proper name or in terms of some euphemism, such as “rest home” 4. Displacement of the location of the hospital. such as to another city 5-" 6. 7. 8. 9. 1' Confabulated journey Reduplication of the hospital, such as the patient’s stating that he is in another hospital of the same or similar name Disorientation for time of day with confusion of day and night Gross misidentification of the examiner, such as calling him a “lawyer” or an “entertainer” Disorientation for year References 4-7. The patient was given his first test prior to treatment and was retested at weekly intervals. All patients in the series had negative amobarbital tests prior to the initiation of therapy. Treatments were administered three times a week, so that the patients were generally tested after every third treatment. A test was given two days after a treatment and was continued at weekly in— tervals after the termination of therapy until the result had become negative. Electroencephalographic records and standard tests of memory and learning ability were also given, but will not be considered in detail in this paper. Population T wenty-four patients at Hillside Hospital receiving electroshock with the Reiter Electrostimulator were studied. The patients were not selected by us but were taken on the basis of consecutive referrals by the clinical staff. Some patients were necessarily excluded because their treatment was terminated or interrupted before they were ade— quately studied. Another patient was omitted because he had manifestations of brain disease and a positive amobarbital test prior to electroconvulsive therapy. The number of treatments varied from 9 to 33. Patients who showed clinical improvement tended to receive fewer treatments. Some of this variability could also be ascribed to differences in the inclination of the resident psychiatrists to use this form of treatment. One patient decided for himself that he had had enough treatment and eloped. Diagnostically, the patients consisted of 14 with depressive reactions, 9 with schizophrenia, and l with a manic reaction. There were 15 women and 9 men, and the ages ranged from 24 to 68, with a median of 47 years. Evaluation of Response to Electroshock Therapy. ——All patients were observed for at least eight weeks after completion of treatment. Determina— tion of the patient’s response to electroshock was made on the basis of the resident psychiatrist’s im— pression, staff opinion, the nurses’ notes, and the clinical evaluation of one of us (M. F.), who supervised the treatments but was not aware of the amobarbital test results. On this basis the patients were divided into three groups. A. Markedly Improved: The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer showed the symptoms which brought them into the hospital; their doctors felt they were better, and the nurses noted them as being able to sleep Without medication, eating better, getting along with the other patients, and participating in hospital activities. B. Moderately Improved: The six patients in this group showed some improvement but con~ �tinued to manifest indications of mental illness. These patients typically showed symptomatic relief; i.e., acute depressive features might be gone, but the dramatic change, so evident in the first group, was not apparent. Each patient continued to show some noticeable disturbance, such as ob— sessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally Improved or Unimproved: In this group was placed seven patients in whom change was not clearly noticeable or who showed only equivocal or transient improvement. Some showed fluctuations in behavior, at times appearing some— what improved. But the change was not sustained, so that by the end of treatment they appeared much as they did before. \Ve are aware of the difficulties in evaluating improvement. Others may have differed in the estimates of changes in these patients. In any case, by using this threefold classification, the differences between the first and the third group will be distinct. TABLE Markedly improved (11)-__ Moderately improved (6)-Unimproved (7)____________ Treatment 50 39 45 Amobarbital No. % Positive Positive 38 15.93 6 .4, 76 38 13 treatments, and all had positive reactions after seven to nine treatments. In the unim-proved cases, on the other hand, the number of positive reactions was small and there was no consistent increase during the course of treatment. Again, the moderately improved group tends to fall between the other two. IOO 90 80 Observations ._ MUCH IMPROVEDUI) ---- UNIMPROVEDU) .\/ '-—MOD.IMPROVED(6) 70 AMYTAL A. Distribution of Positive Reactions.— group, with the moderately improved pa— tients between these groups. Every markedly improved patient had at least one positive amobarbital reaction during treatment. On the other hand, one of the moderately improved patients and five of the unimproved patients never showed a positive result. A comparison of the results in each group, using the X2 test, is statistically significant at better than the 1% level of confidence. B. Positive Reactions at Each Stage of Treatment—In the Figure the groups are compared for the percentage of patients in each group who had positive results at each stage of treatment. Almost half the markedly improved pa— tients had positive reactions after only three Tests During Treatment No. of Tests Given During REACTIONS The number of amobarbital tests given to each patient during the course of electroshock range-d from 3 to 13, depending on how long treatment was maintained. In Table 1 the data are shown for the number of tests given during treatment and the number and percentage positive for all the patients in each group. The markedly im— proved patients showed many more positive reactions than the unimproved of Positive l.——Distribution 60 50 POSITIVE 4O 3O 20 PERCENTAGE 5 4-6 NUM BER 7-9 lO-IZ I3-I5 0F TREATMENTS Percentage of positive amobarbital test reactions occurring in each group at different stages of treat— ment. Although some patients received more than 15 treatments, the data are not pre— sented beyond this point because the number in each group became too small for purposes of comparison. Four of the unimproved pa— tients received more than 20 treatments, with consistently negative amobarbital test results. One of the moderately improved patients received over 30 treatments, with only an occasionally positive reaction. C. Duration of Positive Reactions.— There were variations in the persistence of positive reactiOns from week to week. With at least two consecutive positives as the criterion of persistence, nine of the mark— edly improved, two of the moderately im— proved, and only one of the unimproved group showed persistent positives. After �the termination of treatment all patients but one had negative amobarbital reactions nine days after the last convulsion. The remaining patient developed a negative test during the second week after treatment. D. Factor of Age—Since the patients in the markedly improved group tended to be older persons suffering from depres— sive reactions, it is conceivable that the difference in amobarbital test results may be related solely to age and only coincidentally to clinical improvement. Underlying this is the assumption that the older person is more likely to show signs of altered brain function when given electroshock. In Table 2 the mean age for each group is shown. TABLE 2.——Relationship of Clinical Improvemen To Age Markedly improved (11)_______-____-___-___________ Moderately improved (6) ___________________________ Unimproved (7) ____________________________________ Mean Age, Yr. 47.64 gggg it is apparent that the first two groups were older than the unimproved patients. Yet, while the mean age of the moderately improved patients is slightly higher than that of the markedly improved group, these patients still had significantly fewer positive reactions. In Table 3 the number of positive re— actions during treatment is shown for each is limited to pa— when the analysis group tients more than 40 years of age. In this Table the relationship of positive reactions in the different groups remains unchanged from that when the groups are considered as a whole. Other Aspects of Behavior Apart from explicit denial of illness and disorientation, there were changes in be— havior that occurred both under the in-fluence of the drug and clinically during the course of treatment in significantly progres— sive fashion in those patients who improved. These aspects may be divided into verbal and nonverbal communication. A. Changes in Verbal Language—These changes consisted of denial expressed in evasion, in negative expressions, and in the use of a syntactical pattern involving the third and second persons. When asked about their symptoms, patients gave such answers as “It’s hard to say,” or “I forgot,” or “I don’t know; I’ve been waiting for the doctors to tell me.” The change in syntactical pattern is illustrated by such remarks Amobarbital Tests in Patients More Than 40 Years of Age TABLE 3.——Distribution of Positive No. of Tests Given During Markedly improved (10)--Moderately improved (5)-Unimproved (3) ____________ _ Treatment 46 34 17 N0. % Positive Positive 35 15 0 76 45 0 as “It’s what they call a depression,” or “I’m afraid somebody will get hurt,” or answering the question “What is your main trouble P" with “What is your main trouble?” Sometimes patients would talk of a relative who was sick. In patients who improved there was a notable development of such patterns in a nondrug interview. One such patient, for example, when asked prior to the start of treatment what his main trouble was, said, “I’m depressed.” After two treatments he answered the question with “I don’t get along well with my mother-in—law.” After five treatments he said, “I don’t get what you mean": after eight, “I get sick; that’s all I know.” After 10 treatments he said, “Right now, it’s that I don’t see my Wife,” and after 11 treatments he said, “In what way do you mean?” and “I don’t know how to explain it.” At the termination of treatment, his main trouble was given as “I want to get home,” followed by an account of how “good” his wife was. In the unimproved group, on the other hand, the increased use of these language patterns did not occur. They were not present in some and were minimally or inconsistently noted in others. In some of the unimproved patients there were actually fewer such language patterns under the �i L’ effects of the drug than there had been in the preamobarbital interview. B. Changes in Nonverbal Behavior.— Euphoric reactions occurred in both sistently positive early in the course of treatment. In moderately improved or unimproved patients there are fewer positive reactions and their frequency does clinical and drug interviews most fre— not increase with more treatments. With quently in the markedly improved other methods of evaluating brain func— group, less often in the moderately im— tion such close correlation was not presproved group, and least often in the ent, as all patients showed abnormalities group which were considered unim— in the e1ectroencephalographic record and proved. In the unimproved patient impaired learning was found as fre— classed as manic, euphoric behavior was quently in patients who improved as in present in his clinical behavior and was those who do not. The significance of this relationship may be more clearly not changed by amobarbital. Changes in sexual behavior appeared appreciated by a consideration of the during the amobarbital interviews of four changes in symbolic function that occur of the markedly improved patients but in states of altered brain function. in only one patient in each of the other It has been useful in studying the becategories. This took the form of try— havior of patients with alterations in ing to hug or caress the examiner. mak— brain function to distinguish between ing remarks with sexual content, or en— defects in the formation of symbol pat— gaging in masturbatory activity. A terns and changes of language patterns patient in the unimproved group showed which indicate a shift in the mode of this behavior both during pre—drug inter- interaction in the environment. In the views and under the influence of amobar— first be included many category may bital. types of memory defects, dyscalculia, Withdrawal or “selective inattention” topographical disorientation, and aphasia. was shown by 9‘ of the 11 markedly im; A patient with such a defect memory proved patients. particularly during the cannot select elements of experience, drug phase of the amobarbital interview. classify them into and significant units, This behavior consisted of failure to an— them into a temporal arrange pattern. hos— the about illness and questions swer These defects are observed with diffuse pitalization or responding in dysarthric cortical lesions and uni— probably occur and cryptic fashion. This reaction under versally after shock treatments in tran— the drug occurred only once in each of sient fashion. They are, however, related the other groups. It was of interest that if at all, to therapeutic remotely, very two patients in the unimproved category in the mode of inAlterations outcome. who appeared withdrawn before the test teraction in the environment became more responsive under fluence of the drug. the in- Comment The results of the amobarbital tests in these patients indicate that there is a relation between clinical improvement and the production of brain damage or an altered state of brain function as de— termined by this particular method of examination. In patients who improve, the amobarbital test becomes con— are exemplified in the various patterns of disorientation and denial and in the amnesias that are noted with lesions of the diffuse projection systems, in chronic barbiturate intoxication, and following electroshock convulsions. Here there is no defect in memory, awareness, or perception as such, but the patient selects or rejects certain aspects of the environment for the expression of his own motivations. ln disorientation for place, for example, the misnaming and mislocating of the �hospital serve as, symbolic representa— tions of the patient’s feelings about his incapabilities and problems—often as the manifestation of his need to be well and go home. It is not that the patient is unaware of his problems and does not know where he is in an absolute sense. He commonly “remembers” the name of the hospital and expresses “awareness” of his difficulties in other contexts of language. The unawareness is, rather, of the far greater degree to which he is expressing his own motivations in his perception of the temporal. spatial, personal, and somatic aspects of the en— Vironment. In considering what constitutes thera— peutic improvement, it is evident that the evaluation that is commonly made by a hospital staff depends in large part on the particular types of symbolic adaptation and defensive operations that are used. If the patient denies that he has any problems or that he is troubled by them, or if he cannot recall any, he is rated as improved. Such patients char— acteristically appear affable and uncom— plaining, their manner reinforced by clichés and banalities, themselves adap— tive forms of language. Many studies: have shown that general memory impairment does not persist after electroshock but that there is a selective “forgetting” of traumatic material in the patient’s life. This does not mean that he has developed a better understanding of his interpersonal relationships or has ac— quired “insight.” The observation is also significant in explaining why, although electroshock may have a short—term bene— ficial effect, evaluation of long—term results shows little difference between treated and untreated cases. Also, the fact that therapeutic improvement did not result in patients with negative amobarbital tests suggests that methods of administering electroshock by minimally affecting brain function, Such as i References 8-12. a unilateral seizure, will not prove gen— erally efficacious. From the immediately practical standpoint, the amobarbital test given after the third or fourth treat— ment may be of prognostic value. The amobarbital test is not in itself a direct index of brain damage in that it measures some particular modality of dysfunction or brings out a specific defect. Rather, under the conditions in which it is given, one deduces impaired neural function by reason of the change in the organization or pattern of language in which the patient expresses himself. A positive result requires not only that a certain degree and type of impairment of brain function exist but that the patient employ verbal denial and disorientation as adaptive mechanisms. It would be expected that among patients with equivalent degrees of brain damage the highest incidence of positive amobarbital tests would occur among those who characteristically use denial as an adaptive mechanism in stress. In relating these findings to the mode of action of electroshock and other somatic therapies, several considerations seem of importance. There is a combination of an added stress and a change in brain function. The milieu of brain function determines the pattern or organization of the adaptive behavior which can be most clearly formulated in terms of language. These include not only verbal patterns of denial and disorientation, elicited with the aid of the drug, but changes in syntactical patterns indicative of an altered relationship of the self in the environment. There were also indications that in the improved patients there were more changes in all types of symbolic adaptation, nonverbal as well as verbal. Thus, a patient who appeared withdrawn both in the predrug and in the drug interview had a poorer prog— nosis than the patient who became withdrawn only under the effects of the drug. The patient who showed altered sexual behavior under the effects of the drug had also exhibited this behavior during �the clinical questioning as well and did not improve with treatment, whereas the four patients manifesting sexual behavior only under effects of the drug did improve. It is likely that the faculty of changing sym— bolic patterns regardless of content is a factor in therapeutic improvement. REFERENCES Gordon, H. L.: Fifty Shock Therapy ories, Mil. Surgeon 103 2397, 1948. 1. The— 2. Kalinowsky, L. B., and Hoch, P. H.: Shock Treatment, Psychosurgery and Other Somatic Treatment in Psychiatry, Ed. 2, New York, Grune & Stratton, Inc., 1952. Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects, Springfield, Ill, Charles C Thomas, Publisher, 3. Summary Twenty—four patients referred consecu— tively for electroshock treatment were given amobarbital (Amytal) tests before and at regular intervals during and fol— lowing the course of treatment. There was a close relationship between the short—term response to treatment and the results of the amobarbital tests. The much improved patients showed early, persistent, and increasingly positive reactions during the course of treat— ment. Unimproved patients showed no positive reactions, or showed them in— frequently and inconsistently. An inter— mediate group, who showed moderate clinical improvement, showed more posi— tive reactions than the unimproved group but fell far short of the much improved group in the incidence of positive re— actions. Changes in language and nonverbal forms of behavior related to denial were most consistent and pronounced in the improved group, even in interviews not employing drugs. These observations indicate that clinical improvement in electroshock requires the creation of conditions of altered brain function in which new patterns of symbolic adaptation can be maintained. 1955. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbi— tal Sodium in Organic Brain Disease, Am. J. Psychiat. 112:889-894, 1953. 4. Weinstein, E. A.; Kahn, R. L., and Malitz, 5.: Serial Administration of “Amytal Test” for Brain Disease: Its Diagnostic and Prognostic Value, A. M. A. Arch. Neurol. & Psychiat. 71 1217— 5. 226, 1954. \Neinstein, E. A., and Malitz, 8.: Changes in Symbolic Expression with Amobarbital Sodium (“Amytal Sodium”), Am. J. Psychiat. 111:198-206, 6. 1954. Kahn, R. L.; Fink, M., and Weinstein, E. A.: The “Amytal Test” in Patients with Mental Ill— ness, J. Hillside Hosp. 4:3-13, 1955. 7. Carter, J. T.: Type of Personal Life Memo« ries Forgotten Following Electro—Convulsive Therapy. Am. Psychologist 8 :330, 1953. 8. Janis, I. L.: Psychologic Effects of Electric Convulsive Treatments: I. Post—Treatment Am— nesias, J. Nerv. & Ment. Dis. 111:359, 1950. 9. Korngold, M.: An Investigation of Some Psychological Effects of Electric Shock Treat— ment, Am. Psychol. 8:381—382, 1953. 10. Teicher, A.: The Effect of Electroconvulsive Therapy on the Visual Reactions of Schizophrenic Patients, Am. Psychol. 8:445, 1953. 11. Alexander, L.: Effect of Electroshock on a “Normal” Person, Am. J. Psychiat. 109:696—698, 12. 1953. Printed and Published in the United States of Amerira � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of amobarbital test to clinical improvement in electroshock. AMA Arch Neurol Psychiatry. 1956 Jul; 76(1): 23-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-17-021 Date A point or period of time associated with an event in the lifecycle of the resource 1956 Creator An entity primarily responsible for making the resource Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Weinstein, Edwin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from the A.M.A. Archives of Neurology and Psychiatry July 1956, Vol. 76, pp. 23—29. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/ac5e73da19470d46979be1d3e57b7963.pdf 289f176e87e6c22e9a18830dea076106 PDF Text Text Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume V April, 1956 Number 2 �EVALUATION OF HIGH-DOSE RESERPINE THERAPY FOR RELIEF OF ANXIETY1 MORTON WACHSPRESS, M.D.,2 ARNOLD G. BLUMBERG, M.D.,3 MAX FINK, M.D.,4 and JOSEPH S. A. MILLER, M.D.5 ‘ During the past few years increasing interest has been shown in the role of drugs in psychiatric practice. Previous studies on the usefulness of extracts of Rauwolfia Serpentina at this hospital demonstrated minimal value for this drug in alleviating anxiety symptoms (4). In the light of these studies which contrasted with more recent enthusiastic reports, an investigation of the effectiveness of large doses of reserpine in relieving anxiety symptoms and altering behavior was undertaken. Numerous reports have appeared in the past two years describing the effectiveness of reserpine in reducing aggressive and assaultive behavior (2, 5); alleviating manic states (14); and reducing the need for electroshock therapy (10). The reports of its potency in reducing anxiety, affecting neurotic symptoms or altering depressive symptoms (6, 12) have been less laudatory. In addition, reserpine-induced depressions have been noted in the course of treatment for hypertension (9, 11). No evidence has been forthcoming that reserpine has altered the course of a psychiatric illness, although many reports emphasize the quieting effects of the drug or its usefulness as an “adjuvant to psychotherapy” (7). This investigation was undertaken to determine the usefulness of reserpine in a voluntary psychiatric hospital population treated in an open ward setting. A double-blind placebo controlled study with 1 From the Research Service and Medical Department of the Hillside Hospital, Glen Oaks, N. Y. ZSenior Resident Psychiatrist, Hillside Hospital, Glen Oaks, N. Y. 3 Associate Visiting Physician, Hillside Hospital, Glen Oaks, N. Y. 4 Director of Research, Hillside Hospital, Glen Oaks, N. Y. 5 Medical Director, Hillside Hospital, Glen Oaks, N. Y. 67 �68 WACHSPRESS—BLUMBERG—FINK—MILLER large fixed doses of drug was selected as a technic of evaluation for this study. The evaluation of improvement in a psychiatric patient under therapy presents problems which are all too familiar to careful investigators in the field. In a hospital environment where the total therapeutic regime combines to produce improvement, the evaluation of the effect of a drug must be carefully controlled. Certain criteria must be established to differentiate between improvement consistent with the course of the disease, and improvement greater than what may be expected from the normal course of hospitalization. To properly attribute improvement to a drug the following criteria should be satisfied: the patient should improve while receiving medication; this improvement should be greater than at the time when the medication is replaced by suitable placebo medication; and improvement should be reproducible at a later date with a similar drug dosage. The use of a double-blind placebo controlled study provides a method for such an evaluation and it is doubtful if definitive conclusions are justified in the absence of such studies (3). To further minimize the subjective factor in the clinical evaluation, rating scales have been employed, despite their well-known limitations. In this study, the revised rating scale of Malamud and Sands (8) was utilized to provide further experience for the observers in standardizing their reports and to permit a constant frame of reference for changes in symptoms and behavior during therapy. METHOD The patients in this study were those who presented, both subjectively and objectively, severe anxiety and agitation. They were selected from the patients recommended by the resident psychiatrists for electroshock or drug therapy. The final decision as to which patients should receive reserpine was made by the two psychiatrists working on the study, who based their selection on the presence of severe anxiety and tension symptoms. Of the original group of seventeen, fifteen patients completed the study. Two male patients, one diagnosed as schizophrenia and one as psychoneurosis, discontinued the treatment because of increasing tension, agitation and nausea while on the drug regimens. Of the seventeen patients, eleven were diagnosed as schizophrenia, five as psychotic depression and- one as mixed psychoneurosis. There were eight males and nine females. The age range was 19 to 52 with a median age of thirty-three. �EVALUATION OF HIGH-DOSE RESERPINE 69 Each patient was observed for a period of twelve weeks. Every patient received an intramuscular injection of 2cc. of reserpine6 and five tablets daily throughout the twelve-week period. Depending on which regimen was selected, placebo tablets and injections were substituted for the drug. The four regimens were: reserpine, 10 mg. daily—5 mg. orally and 5 mg. intramuscular; (2) reserpine, 5 mg. daily—orally; (3) reserpine, 5 mg. daily—intramuscular; and (4) placebo only. (1) Regimens were selected in random order by the internist, and the regimen was unknown to the patient, therapist, evaluating psychiatrist or nursing personnel. Weekly psychiatric evaluations were done on each patient by an evaluating psychiatrist. A modified Malamud scale was employed as well as the subjective reports of the patient and the impressions of the observer. The patients were concurrently studied by the internist at regular intervals. Blood pressures and pulse rates were measured in a sitting position on casual examination at irregular intervals. Only two patients could be classified as hypertensive before treatment. Each patient was weighed weekly. A radioactive iodine determination was performed before starting treatment and repeated no sooner than three weeks after instituting treatment with an effective dose of reserpine. Routine blood counts, urinalyses and other laboratory tests were conducted as indicated. RESULTS Psychiatric Observations Of the fifteen patients, seven showed a significant alteration in behavior which could be related to drug dosage. Of these, three showed a relief of anxiety and tension, and four, an increase in depression, tension and agitation. The remaining eight patients manifested no change in behavior. In addition, the two patients who discontinued the drug regimens did so because of an increase in tension and anxiety accompanied by nausea and vomiting. We are indebted to the Ciba Pharmaceutical Company for the reserpine (Serpasil) and placebo medication used in this study. 6 �WACHSPRESS—BLUMBERG—FINK—MILLER 72 total scores, an item analysis of the individual behavior items was undertaken. Those representative items were selected which clinical experience suggested might reveal changes due to drug action. The items chosen were: feeling, mood, motor activity, and thought processes. An analysis of these scores failed to indicate any consistent difference in these characteristics in the patients as a group. Regarding the differences in the drug regimens, it was the clinical impression of the evaluating psychiatrists and resident therapists that more moderate doses of reserpine were preferable, giving fewer objectionable symptoms. Six of the fifteen patients were subjectively worse on the daily dose of 10 mg. These six included A. 8., one of the patients who improved on drug regimen, and two of the four patients whose condition became worse. Toxic Symptoms Of seventeen patients who started on the study, two stopped because of side effects. These patients manifested increased tension and anxiety, in which nausea and vomiting became prominent symptoms. Numerous other side elfects were observed, and the incidence of each is noted in Table II. Drowsiness and dizziness were seen in most of the patients, but caused serious difficulty in none. Six TABLE I BEHAVIORAL RATINGS—TOTAL SCORE H.C. G.W. ES. M.C. R.S. R.D. A.S. F.G. S.G. LE. M.D. S.K. P.M. A.L. M.B. Sex Age F F M F F M F F F M F F M M M 24 52 45 19 19 20 46 28 37 50 42 37 22 37 22 Diagnosis Schiz. No Medica tion Placebo 27 Invol. Mel. Schiz. Schiz. Schiz. Schiz. Invol. Mel. Schiz. M.D.D. M.D.D. Invol. Mel. Schiz. Schiz. Schiz. Schiz. 23-36 20 35,36 30,35 37-46 29-35 34,30 12-19 20 27 36-45 16-22 27,25 27-38 6-9 23-43 16-30 18-29 18,9 19-33 26-28 53 46—57 51,64 57,66 Oral Intramus- Combined cular 15 17 28-34 50,53 23,25 27,26 38 29-39 2542 18 20-31 26 40 15,3 45,31 22,15 47,31 25,28 28 27 34 16-28 20-26 23,27 28-36 12,15 29-40 20 29 27 18—26 16—30 53 44,61 53 32-51 51-56 27 825 12,13 37,39 29—38 19 25-38 63—55 �EVALUATION OF HIGH-DOSE RESERPINE 73 patients developed a Parkinsonian muscular rigidity, which disappeared within a few days after the drug was discontinued. Four patients had one or more episodes of generalized flushing lasting up to twenty-four hours. This occurred in patients on placebo as well as on drug, and was interpreted as an allergic reaction to impurities in the intramuscular solution. TABLE II TOXIC EFFECTS Incidence ................................. ................................. ...................... Nausea .................................... Parkinsonism ............................... Painful legs ................................ Hot flashes ................................. Restlessness ................................. Swollen feet ................................ Drowsiness Stuffy nose Dizziness and Weakness l4 13 10 7* 6 4 4 3 l In 2 patients nausea was accompanied by vomiting and was a factor in discontinuing treatment. * Depression The enhancement of existing depressive symptoms was noted in three patients, and in another, depressive symptoms appeared where none had been evident before reserpine therapy. In each instance, electroshock therapy was recommended and improvement resulted. Electroshock therapy induced a remission of the anxiety and tension components of the illness, as well as the depressive. Of the eight patients who manifested no change with reserpine, two were eventually treated with electroshock, without clinical improvement. Physiologic Observations The systolic blood pressure was reduced in fifteen of the sixteen patients observed over an extended period of time. The magnitude of this lowering was between 10 and 20 mm. Systolic blood pressures between 90 and 100 mm. were not unusual while on treatment and were not accompanied by adverse symptoms. Table III represents average figures for the highest and lowest blood pressure and pulse rate recorded during each regimen. There �74 WACHSPRESS—BLUMBERG—FINK—MILLER drop in both systolic and diastolic blood pressure and in pulse rate with reserpine therapy. There is no difference in the hypotensive or bradycardiac effect of intramuscular or oral administration of 5 mg. reserpine; nor is there any indication that a dosage of 10 mg. produces a greater effect on blood pressure or pulse rate than 5 mg. These observations are consistent with previous reports of the flat dose response curve for reserpine (1). is a significant TABLE III Medication Range Systolic Range Diastolic Pressure Pressure Range Pulse Rate Placebo 135-117 5 mg. p.o. 5 mg. i.m. 10 mg. combined 116—108 118-106 119-109 84-69 70-64 71-63 68-61 98-7 8 74-67 74-68 78-68 Most patients on reserpine reported an increase in appetite, and there was a tendency for these patients to gain weight. In seven patients, such gains varied from 3 to 20 pounds on the entire treatment program. Three patients lost weight and four showed no change. There was no consistent change in the radioactive iodine (1-131) uptake following the administration of reserpine. Nor could a correlation between weight change and this index be found. Thus, only two of the patients who gained weight had a decrease in the iodine uptake. One patient who lost weight had a rise in iodine uptake. It was concluded that the weight gain and increased appetite were not related to alteration in thyroid function. DISCUSSION High-dose reserpine therapy did not affect the symptoms of anxiety or tension in these patients. For the most part, patients were made uncomfortable by the high doses used in this study. Of the three instances where a relationship between changes in anxiety and tension could be related to drug dosage, two were noted in severely ill patients in whom overactivity and agitation were first controlled. The relief of anxiety was secondary to the decrease in motor excitement. The previous study at this hospital demonstrated the limited usefulness of low-dosage reserpine therapy for the relief of anxiety. Considering this, and the results of the present study of �EVALUATION OF HIGH-DOSE RESERPINE 75 high-dosage reserpine, it may be concluded that reserpine therapy, either in low or high doses, has limited use for its relief of anxiety symptoms in this hospital’s population. Its use is further limited by the exacerbation in depression which was observed. Our observations, however, tend to support the reported usefulness of this medication as a sedative in the control of destructive and overactive behavior. This is seen in our two cases (R. S., M. B.) and in a series of other overactive patients at the hospital who were noted to respond to the sedative action of reserpine when this was introduced in lieu of restraints and massive sedation. The doses of reserpine in this study were generally too high. Patients were unable to tolerate 10 mg. without uncomfortable side effects. In no instance were the side effects severe or disabling, however, and in each instance the symptoms responded to a decrease in drug dosage. The symptom of depression, however, has assumed special significance in these patients. Reserpine exaggerated this symptom and, in one instance, elicited a depression with suicidal trends. The reports of increased depression (9, 11) are thus confirmed; and the usefulness of electroshock therapy in relieving these depressions can be re-emphasized. In this regard, the earlier enthusiastic reports of the usefulness of reserpine as a substitute for electroshock therapy (10) need reassessment. Reserpine is no substitute for electroshock therapy in the treatment of depressive states. It may substitute, however, for the use of electroshock as a sedative in the management of overactive and assaultive behavior. This study exemplifies the advantages and disadvantages of a drug evaluation study by the double-blind placebo method. With a limited number of subjects, it is possible to obtain a meaningful evaluation of the primary effects and complications of a medication. The drug effects may also be separated from the natural course of the illness, and from the investment of the therapist in the conclusions. Such a technic has the following limitations: rigidity of dosage; inability of the therapist to separate drug-induced effects from alterations in the disease process during the study period; and the necessity of the selection of patients who are tractable and can tolerate discomfort for extended periods. Furthermore, such a study may rob the therapist of his faith in the drug as a therapeutic vehicle, and thereby limit the patient’s response to the physiologic effects alone. It also limits the therapist’s control over the care of his patient, and thereby arouses feelings of helplessness and apprehension in the therapist. In such instances, the cooperation of a mature �76 WACHSPRESS—BLUMBERG—FINK—MILLER therapist is essential because there is considerable opportunity for the manipulating, demanding, and paranoid patient to arouse the therapist’s anxiety and hostility to the experimental program. This study also provided an opportunity to assess the usefulness of rating scales. In assessing the changes seen during treatment the rating scales failed to provide any information not available in the descriptive statements. They did provide, however, a frame of reference for the many items of the psychiatric interview that needed rating, and provided a base for the comparison of observations made by different observers. ' SUMMARY AND CONCLUSIONS In a double-blind placebo evaluation of 5 mg. and 10 mg. doses of oral and intramuscular reserpine, fifteen voluntary hospitalized psychiatric patients with severe, overt symptoms of anxiety were studied. Three patients manifested relief of anxiety related to drug dosage. In twelve patients no relief was noted, and of these, four exhibited severe depressive reactions which eventually responded to electroshock therapy. Cardiovascular effects of high doses of reserpine were not significantly different than previously reported effects of low dosage. There was no evidence that reserpine altered thyroid function, although weight gain frequently occurred. The usefulness of high-dose reserpine therapy in the relief of anxiety symptoms is limited. The dangers of induced depressions, as well as the rationale of placebo studies and psychiatric rating scales are discussed. REFERENCES (l) A. M. A. Report of Council On Pharmacy and Chemistry, J. A. M. A., 159: 1206, 1955. (2) Barsa, J. A. and Kline, N. 8.: Treatment of Two Hundred Disturbed Psychotics with Reserpine. J. A. M. A., 158:110, 1955. (3) Beecher, H. K.: The Powerful Placebo. J. A. M. A., 159:1602, 1955. (4) Blumberg, A. G., Cohen, L., and Miller, J. S. A.: The Effect of Rauwolfia Serpentina on Anxiety States. This Journal, 3:140-146, 1954. (5) Cowden, R. C., Zax, M., and Sproles, J. A.: Reserpine—Alone and as an Adjunct to Psychotherapy in the Treatment of Schizophrenia. A. M. A. Arch. Neurol. c9" Psychiat, 74:518-522, 1955. (6) Drake, F. R. and Ebaugh, R. G.: The Use of Reserpine in Office Psychiatry: Preliminary Report. Ann. N. Y. Acad. Sci., 61:198. 1955. (7) Hoffman, J. L. and Konchegul, L.: Clinical and Psychological Observations on Psychiatric Patients Treated with Reserpine: A Preliminary Report. Ann. N. Y. Acad. Sci., 61:144, 1955. �EVALUATION OF HIGH-DOSE RESERPINE 77 Malamud, W. and Sands, S. L.: A Revision of the Psychiatric Rating Scale. Am. ]. Psychiat., 1042231, 1947. (9) Muller, J. C., Pryor, W. W., Gibbons, J. E., and Orgain, E. 8.: Depression and Anxiety Occurring During Rauwolfia Therapy. J. A. M. A., 159:836, (8) 1955. (10) Noce, H., Williams, B., and Rapaport, W.: Reserpine (Serpasil) in the Man- agement of the Mentally Ill. 1. A. M. A., 158:11, 1955. (ll) Schroeder, H. A. and Perry, H. M.: Psychoses Apparently Produced by Reserpine. ]. A. M. A., 1592839, 1955. (12) Smith, S. K.: The Use of Reserpine in Private Psychiatric Practice. Arm. N. Y. Acad. Sci., 61:206, 1955. (13) Wilcoxon, F.: Some Rapid Approximate Statistical Procedures. New York: Am. Cyanamid Co., 1949. (14) Zeller, W. W., Graffagnino, P. N., Cullen, C. F. and Rietman, H. J.: Use of Chlorpromazine and Reserpine in the Treatment of Emotional Disorders. 1. A. M. 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WPWMItWWMWWWWMWfl mmmwrwwwamm www.mdm mudmwtmdmmmgflwmmaa mmw,nwnMwmm,u-mwwrnmm eta-attuned. «mwmmwmumum It‘tmumnfimw mmmummmflwm mm,m,mtommuummmam mmuuMuummzumfiuumewmw. mnmhwmm(uulgll}mdiaum¢towwmfifl pumatmmmmmwummmmuumaw WMWqun-uwmummm‘mm dermma-mmsmmuwmw. hm wnmnumenémng.umwmmmm. 213mm wnmuadMumeW,ummwmm “WMaMMmdrwm mwmdmmm, m mummmm,mum;WaWW umrdmwwm(6)mm‘mmmmumat WWWHWMWMMWM mm; www.mrmemudmmamuam �45w W mwumolmmaw(h)mw stunt. ma: them in an Wanna-ab. tmm Wu mm. x: w aubmm,m.mmmumm,uumuummm ofmmflmmxmfiumm. mwmmmmmmmmmammmmuuwmn hWMMnWanfim‘fitMMOfibcth amattmhm MWMmmumhdtmfhum mwmmmrmmmmgmmmmmm. Mammmmmmms mwuwmuwa wwuhmumwmumnmumumm-w «ummmmmmmwummde m tncmle w Mum Mama, m W ammmdeWtuwmmdmuammfiam disco-arm and pariah. wwwzmth‘aW-mm a: «mud-u «3' “was Wt: mm mm m. m.mung MW hunt» m,mwmdtmmmumm1umuumm mmmwmm-mmsmmmmwpwum to «V WthWfiWflWfi. my thy thew: my many me! can Wk). mum. MWMWthyummmdnm mamaamumm. mwmmtm-I mammmtmwmmmmmmmmmm www.mha‘Mdnhrm-twmm imammmnummMMnm-mmmnmmrm cumin-um». ”mummmmwwmmm ‘ �htW,M'W£5mmmn.Mdonl WWII: Wt: mm W ammgmfiWd-mtymm Mupmmm «a mtmcnlnr mm, mm nmpamummm mammumw; MmamummmmWWnWMmW WhWW. Wmuudmmammmmummw ‘ ~ 7 mmmum wommmmmmamm mt. mummy mama. wand mun, awwwu w.» mm aw mmdmmmwnmmam magnum mmawmiamJummm mammmmmnmnmmmmm ��70 WACHSPRESS—BLUMBERG—FINK—MILLER In the improved patients, an alleviation of anxiety was apparent and related to drug administration. M. B., a 22-year-old male, diagnosed as paranoid schizophrenia, was anxious, depressed, withdrawn, blocked, delusional and hallucinating. He had been hospitalized for three of the previous five years, and had received courses of insulin coma and electroshock therapy with only transient periods of improvement. After five months of hospitalization at Hillside Hospital he showed no improvement. During the drug regimens, there was a diminution in his anxiety, depression, agitation and preoccupation with delusions. These symptoms recurred when on placebo medication. Introduction of the drug regimen again resulted in the alleviation of these symptoms, with the progressive amelioration of his depressive feelings. With the reduction of his drug dosage to mg. oral, he again manifested a recurrence of symptoms, only to have them relieved by the combined (10 mg.) regimen. The patient was maintained on this treatment and discharged, improved, six months after the treatment was instituted. A. S., a 46-year-old hypertensive woman, manifested severe tension, anxiety, depression, tremulousness and insomnia, which had fluctuated over a two-year period. Her diagnosis was involutional melancholia. While on 5 mg. drug regimens, there was considerable relief of anxiety with a decrease in tremulousness. Insomnia became less, but her depression was unaffected. Placebo regimen resulted in a recrudescence of her symptoms. The combined (10 mg.) drug regimen increased the feelings of depression, induced somatic complaints and failed to abate the anxiety. A lowering of her medication to 5 mg. resulted in a repetition of the period of relief of anxiety and tremulousness. The patient was discharged, improved, on this dose of oral reserpine. R. S., a 19-year-old girl with hebephrenic schizophrenia, was overactive, anxious, tense, fearful, and manifested both ideas of reference and auditory hallucinations. Electroshock and insulin coma therapy afforded her only transient relief. While on 5 mg. drug regimens, she became less active, less anxious but more depressed. Her dress became bizarre. When placebo medication was introduced, her hallucinations ceased, her anxiety was more manifest but the depressive features were less. On combined drug regimen, she became calmer, more controlled in her behavior, but the bizarre appearance and ideational disturbances persisted. In these three cases, a relationship between drug regimens and the relief of anxiety symptoms could be demonstrated. In both M. B. 5 �EVALUATION OF HIGH-DOSE RESERPINE 71 and R. S., the overt manifestations of severe schizophrenia were sufficiently modified to permit participation by the patient in milieu and psychotherapeutic programs. In the other twelve cases, no such relationship could be demonstrated. Of the four cases in whom the drug regimen induced increased symptoms, each manifested severe depressive feelings, crying spells, and one, suicidal preoccupations. The following case exemplifies the group. G. W., a 52-year-old single woman, was admitted with a sevenyear history of depression and hypochondriasis. A previous course of electroshock therapy was not completed because of injuries sustained in a fall. She was tense, anxious, tremulous and depressed. While on drug regimens she became more depressed and retarded. Her anxiety and agitation increased. With placebo medication there was some amelioration of these symptoms. Electroshock therapy was instituted. She received fifteen treatments, with a rapid relief of her tension, anxiety and depression. She was discharged one month later, much improved. There were eight patients in whom the drug regimen or placebo periods were indistinguishable. There was neither a relief nor an exaggeration of symptoms. The following case history illustrates the group. F. G., a 28-year-old woman, had a two-year history of severe anxiety, tension, feelings of depersonalization and obsessive ruminations which followed the birth of her first child. She had previously been treated with insulin coma and three courses of electroshock therapy, with only transient relief. During the periods of reserpine study, she showed no change in her symptoms while on drug or placebo regimens. The changes in behavior determined by psychiatric interviews and rated according to the Malamud scale are represented in Table I. In these tables, the figures represent the total scores for each observation period. The higher scores indicate deviation from more “normal” behavior. The “control period” is a period of observation without any drug medication. While the table lists the different regimens in a definite sequence, the actual sequence varied from patient to patient, in a random fashion. A statistical study, using Wilcoxon’s method of paired replicates, (13) demonstrates no significant difference in the group between any of the drug or no-drug periods. Because no significant change was demonstrated in the study of � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of high dose reserpine therapy for the relief of anxiety. Journal of the Hillside Hospital, 5:67-77, 1956. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-18-022 Date A point or period of time associated with an event in the lifecycle of the resource 1956 Creator An entity primarily responsible for making the resource Wachspress, Morton; Blumberg, Arnold G.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Miller, Joseph S. A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. 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Kwalwasser: Confin. neurol. 16, 88, 1956 Printed in Switzerland From the Research Service of Hillside Hospital, Glen Oaks, New York Relation of Changes in Memory and Learning to Improvement in Electroshock 1' ** Max FINK *, KORIN By Hyman and Simon KWALWASSER *** Read by title. This investigation was supported in part by a research grant M-927 from the National Institute of Mental Health, Public Health Service. Received the annual $ 100 prize awarded by the Electroshock Research Association. * Research Assistant (psychology). ** Director of Research. *** Associate Medical Director. T �In the course of studies of the relation between altered brain function and improvement following electroshock therapy, the present investigation of memory functions was undertaken. By serial testing of learning and recall variables, an attempt is made first to study and quantify memory changes; and then to determine the relationship between therapeutic outcome and such changes. Amnestic effects during electroshock therapy are commonly observed, and are both of practical and theoretical interest. Although differences in methodology, materials, subjects and electroconvulsive techniques make direct comparison difficult, a few conclusions related to the questions of concern in this study can be derived from published investigations. The majority of investigators state that no significant memory loss or other intellectual impairment remains two or three weeks after treatment 1—4. One study 5, however, noted that 5 patients, otherwise fully recovered, reported defects affecting long familiar names of 6 and Zubin places, found no indication lasting a year or more. persons �Korin, Fink and Kwalwasser 89 that electroshock destroyed memory traces, and concluded that where memory loss persists, the progress is one of slow recovery rather than obliteration. In studies of personal memories selective circumscribed amnesias at least four and five weeks after therapy are described for material elicited in pretreatment interviews 7' 8. The amnesias, however, are construed as due to subtle emotional factors, rather than permanent 8 memory loss. From such observations, Janis postulates that memory impairment facilitates repressions and thereby reduces affective disturbances. Regarding the question of memory impairment as a prerequisite for improvement, Wilcox 9 notes that three techniques of electroconvulsive therapy, namely, the “organic shock”, the “standard” or Cerletti and the “brain-facilitation” techniques, are based on concepts which attribute varying degrees of importance to amnestic change. Studies based on the “brain-facilitation” technique where the low current type Reiter and “brief-stimulus” electrostimulators are used, emphasize the diminished memory change induced as compared to the “standard technique”, although reported therapeutic results are analogous 1°. Hoch and Kalinowsky 11, believe the “standard” technique to be the most effective therapeutically; and numerous clinicians using the “organic-shock” method hold that a 12. is for of electroshock essential success therapeutic regressive type 13 Wilcox of In a specific study this problem, recently found no relation between improvement and either the treatment induced confusion seen immediately following an initial Reiter electroshock, or after a series of ten electroshocks. Method and Materials The subjects are 40 consecutive patients referred for electroshock treatment and 21 untreated controls at Hillside Hospital. The clinical diagnosis in the electroshock patients include involutional depression, 7; manic depressive psychosis, 18; reactive depression, 4; paranoid schizophrenia, 3; catatonic schizophrenia, 5 and hebephrenic schizophrenia, 3. The depressed patients tend to be older — between 40 and 68 years of age; the schizophrenic patients are younger, between 24 and 40 years. For the untreated group, patients designated as possible electroshock candidates were selected. They are a representative sample of the electroshock group matched proportionately with respect to diagnosis, age, education and previous electroshock treatment. The Reiter CW 47 C electrostimulator was used in all cases. Treatment was administered on alternate days 3X per week, and was reduced after the second week depending on the clinical condition of the patient. 8 Confinia Neurologica, Vol. 16, No. 2/3 (1956) �90 Korin, Fink and Kwalwasser, Relation of Changes Methodologically, the study involves a test of the ability of patients to recall an original learning of lists of eight, three letter common words, at weekly intervals under two conditions: (a) immediately after an interpolated learning of a list of nonsense syllables; (b) after a ten minute rest period during which a copy of “Life” magazine is read. The choice of testing method and materials was based on studies in retroactive inhibition which indicate that the degree of retention of a learning task varies with the type of activity interposed between an original learning and the later measurement of retention. Thus, by interpolating nonsense syllables and the reading of a magazine on separate test days each week, two indicators of recall function of varying sensitivity are obtained. In the test procedure lists of common words and nonsense syllables are arranged according to established experimental procedures respecting successive consonants and vowels 14. Each list of words was presented manually on flash cards by the examiner. The time interval of exposure was not definite during learning and seldom exceeded five seconds. For recall, however, 10 seconds was uniformly permitted. In the presentation of the lists for the interpolation condition the common words were presented for a maximum of ten trials; or less if the list was learned earlier. The list of nonsense syllables was then similarly presented. In the no-interpolation condition the learning procedure was similar, except that reading “Life” magazine was substituted for the nonsense syllables. Each condition was tested weekly on non-electroshock days, alternating between successive treatments. The control group was tested in the same way, twice weekly for five weeks, to simulate the testing for 12 electroshock treatments. Following completion of treatment, ratings of improvement were determined independently by the supervising psychiatrist on the basis of observations of ward behavior and psychiatric interviews. The improved patients were those in whom there was a marked change in behavior, and whose acute symptoms had subsided. In the moderately improved The behavior but in persisted. transient there change symptoms a was group, unimproved patients were those in whom symptoms persisted or increased and in whom there was no change in behavior. Results (I) Original and Interpolated Learning. Impairment in learning function occurred during treatment in the electroshock group. This was seen in the increased mean number of failures to learn the words and syllables as the number of treatments increased (Fig. 1). The decrement in learning is maximal in the 4—6 and 7—9 electroshock periods. In the 10—12 treatment period this decrement in learning ability decreases. This decrease may be the result of a change in therapy from three to two treatments weekly in many of the patients. Considerable recovery in learning function 3—4 administered when at day intervals. treatments are occurs �in Memory and Learning to Improvement in Electroshock 9]. RELATION OF ERRORS IN LEARNING TO ELECTROSHOCK TREATMENT 50 \ / +/_____ n‘ + 0Z 40 2 E 30 Lu .1 E U) (I O ELECTROSHOCK GROUP 0—4- 0—0 LEARNING 0F NONSENSE SYLLABLES LEARNING OF COMMON WORDS UNTREATE o GROUP + o---+ + 0—--o LEARNING LEARNING or Nonsense POST POST TREATMENT 3 WK. SYLLABLES or connou wonos 20 O: 5 IO 0 PRE TREATMENT I «3 4 -6 7-9 IO-I2 POST TREAT— MENT I WK. TREATMENT ZWK. INTERVAL OF TREATMENT Fig.1 Following termination of therapy, the decrement in learning is completely reversible, so that the mean errors are significantly fewer than pretreatment. For the untreated group, the errors decreased in each of the simulated intervals of electroshock (Fig. 1), probably due to the factor of practice. These data for original and interpolated learning indicate therefore that a significant decrement is obtained during electroshock which is reversible after termination of therapy when intra-individual comparisons are made. This observation confirms previous reports 1—4. (II) Recall-Interpolation and N o-Interpolation. On tests of recall of learned words after interpolation, the decrement from pretreatment was significant at the l per cent level for all intervals of treatment in the electroshock group. In contrast with the original and interpolated learning which was first significantly altered during the 4—6 treatment period, the recall function was significantly impaired within the 1—-3 interval (Fig. 2). When evaluations are made of recall of the learned word lists after reading “Life” magazine (“no-interpolation”), the changes are similar �92 Korin, Fink and Kwalwasser, Relation of Changes . RELATION OF RECALL OF COMMON WORDS TO ELECTROSHOCK TREATMENT RECALLED WORDS COMMON a "°__-_ .—a o——--""° MEAN ELECTROSHOCK GROUP +——+ no INTERPOLATION o mrenpounou UNTREATED GROUP 4----+ o---c PRE TREATMENT l-3 4-6 7-9 IO-IZ POST TREATMENT l WK. POST TREATMENT 2 WK. N0 INTERPOLATION INTERPOLATION POST TREATMENT 3 WK. INTERVAL OF TREATMENT Fig. 2 to those obtained for original and interpolated learning. These observations indicate that the type of activity interposed between an original learning and a later measurement of retention is an important and useful factor in eliciting subtle changes in function. Post therapy, the decrement is reversible for both interpolation and no-interpolation recall. The foregoing results indicate that a significant memory change occurs within the 1—3 treatment period and that recall following interpolation is a more sensitive measure of change in function than learning. (III) Relation of Recall and Learning Responses to Improvement. In the analysis of individual data for the relation of recall function to clinical improvement, the scores of 38 patients, treated three times 3 Of assessed. week for least weeks, these, twenty-nine were at per showed a pattern of decrement in recall function (scores of zero or below pretreatment). Of the matched controls, four showed the same pattern of decrement in recall in a similar testing period while seventeen showed no decrement. �in Memory and Learning to Improvement in Electroshock 93 The treated patients were then characterized as to improved, moderately improved, and unimproved by the supervising psychiatrist in charge of the electroshock treatment unit. The number of subjects in each group are tabulated according to memory loss in Table 1. ' TABLE 1 Decrement and No Decrement Groups During Recall Compared with Respect to Degree of Improvement Improved Moderately Improved Unimproved Decrement No Decrement l2 2 4 1 13 6 To facilitate statistical study the improved and moderately improved groups are combined, and compared with the unimproved group. A chi square of .22 indicates that no significant difference between these two groups exists. Thus, there is no indication that clinical improvement is necessarily related to decrement on interpolated recall tests. Following this analysis for recall, the data for the learning of common words is similarly evaluated. Of the 38 patients, 26 showed a pattern of decrement in learning function (number of errors above pre-treatment), and 13 showed no decrement (errors below pretreatment score). In the control group of 21 subjects, only one subject was in the decrement range. When these patients are grouped according to their psychiatric ratings, there is an apparent relationship between improvement and decrement in learning (Table 2). This relationship, however, is not statistically significant by the chi square test. It is concluded, therefore, that no relation exists between clinical improvement and decrement in the pattern of learning. The above patterns of response are based primarily on changes during the 4—6 and 7—9 intervals of treatment. For the majority of patients, these are points of maximum decrement, and at such times electroshock therapy was reduced or discontinued. Five patients, however, were treated three times per week for 18 or more treatments. Clinical changes during this period were minimal and following . �Korin, Fink and Kwalwasser, Relation of Changes 94: TABLE 2 Comparison of Degree of Decrement During Learning with Ratings of Improvement Decrement +++ ++ Improved 7 (44%) 3 Moderately Improved 2 (40%) 0 Unimproved 4 (24%) 3 No Decrement — —— + (18.5%) 2 (12.5%) l (20%) (18.5%) 3 (18.5%) 2 (12.5%) 2 (12.5%) 1 (20%) 1 (20%) 1 (6%) 6 (35%) termination of therapy, all were rated as unimproved. The learning patterns in these patients remained at a minimal or no decrement level throughout. For recall following interpolation, however, these patients showed a decrement during treatment with scores below both pretreatment and also post therapy. Thus, these patients did show evidence of brain dysfunction by the more sensitive recall interpolation variable. Nevertheless, failure to develop changes in the learning function after relatively prolonged treatment suggests that improvement is unlikely when there is minimal brain dysfunction. This interpretation of the data is supported by the findings of Kahn and Fink 15 who, in this laboratory, used the electroencephalogram and Amytal tests 16 as indices of cerebral change, and found a high correlation between degree of brain dysfunction and improvement. Discussion In similar investigations of memory function with lists of words and syllables, the learning task was completed before therapy and recall was tested at varying intervals after termination of therapy. In this study serial measures of change in learning and recall obtained on the day following treatment are assessed. As group data, they verify the findings of other investigators that significant decrements in learning and recall functions occur during electroshock which are reversible by the third week following termination of therapy. Recall after interpolation is the most sensitive indicator of dysfunction. For this variable, a significant pattern of decrement is evident in 29 of 38 of the electroshock group. Thus, the majority of these patients show some quantifiable memory change during treat- �in Memory and Learning to Improvement in Electroshock 95 in the occurs impairment significant a memory ment. Furthermore, 24 hours measurable is 1—3 which the treatments between week first electroReiter the is This though EST. even true after the single stimulator used here is reported to minimize amnestic efi'ects. During and second the is during only significant the impairment learning, week 7—9 4th the In and interval). (4—6 of weeks treatment third This of the scores. less is learning there impairment (10—12 interval) of method treatment of is artefact particular a an however, change, clinical favorable reduced is a as electroshock frequency whereby 7—9 interval, the the between Thus, becomes apparent. response 20 others are on reand discontinued is 12 of patients treatment of the mefor peak most patients Nevertheless, duced treatment. ninth and treatments. fourth the between reached is decrement mory time. this derived is benefit at therapeutic Seemingly, greatest When the patients categorized according to individual patterns of their with ratings and compared recall are both learning in response of improvement, a relatively high proportion with marked memory brain that dysfunction This finding fail suggests to improve. changes induce sufficient is a to recall and not measured learning 36 by as per Wilcox her in reached conclusion A by similar was effect. therapeutic 13. this in The data study confusion of to relation of therapy the study further indicate that when only minimal memory impairment deveresult. is to likely no improvement after prolonged treatment, lops While some of the patients in this study seemed to benefit thera- peutically with minimal memory impairment within ten treatments, of indices brain dysother with marked showed changes usually they 15. As these patients are and EEG test the Amytal such function as in rather treatdiscontinued early reduced or frequency placed on receivwith them patients is to there no opportunity compare ment, similar fashion, basis. In week times three a 20 a on treatments ing also has and of lack improvement no between change a relationship been observed in a study of eosinophile levels following electroshock 17. is here measured not as induced the impairment Although memory subtle remains that the possibility related to improvement, directly 7» 3 memories selective of the facilitate repression changes memory reinforce which such denial, reactions defensive as of or the emergence mechanisms defense 15. these induced by behavior in Changes changes used in this those than other with measurable be techniques may study. �Korin,Fink and Kwalwasser 96 Summary and Conclusion Studies of changes in learning and recall function during electroshock were undertaken. Group data indicated: (1) a significant decrement in the recall of common words following the interpolated learning of nonsense syllables which persisted during all intervals of treatment (P = .01) for both intra- and inter-group comparisons; (2) a significant decrement in learning at the 4—6 and 7—9 interval of treatment where change from intra-individual pretreatment scores was maximum; (3) the return of both learning and recall functions to the pretreatment level or better within 3 weeks of termination of treatment. Analysis of individual patterns of response indicated that 29 of 32 patients showed a pattern of decrement following recall with interpolation during treatment. When the improved and unimproved patients were evaluated res P ectin g the P resence of memorY imP airment, no si gnificant difl'erence was obtained between the two groups. It is concluded that electroshock with the Reiter CW 47 C electrostimulator (1) induces memory change as measured here and that such change is reversible; (2) that marked memory changes are not a prerequisite for improvement but that (3) the lack of marked memory changes with 20 treatments is associated with lack of improvement. Bibliography 2 — 1947. abnorm. 206, Brower, D., and S. OppenP.: J. soc. Psychol. 42, heim: J. gen. Psychol. 45, 171, 1951. — 3 Luborsky, L. B.: J. nerv. ment. Dis. 107, 531, 1948. - 4 Michael, S. T.: Arch. Neurol. Psychiat. Chicago 71, 362, 1954. — 5 Brody, M. D.: J. ment. Sci. 90, 777, 1944. 6 Zubin, J.: J. Personality 17, 33, 1948. 7 Janis, I. L..' J. Personality 17, 29, 1948. — 8 Janis, I. L., and M. Astrachan: 9 — 1951. Wilcox, K. W.: Papers of Michigan abnorm. 501, 46, Psychol. soc. J. 1“ Liberson, W. T., and — 1949. Arts and of Letters 35, 357, Science, Academy P. H. Wilcox: Digest Neurol. Psychiat. 13, 292, 1945. 11 Hoch, P. H., and L. B. Kalinowsky: Shock Therapy: Psychosurgery and Other Somatic Procedures in — 12 Kennedy, C. J. C., and D. Anchel: & 1952. New York Grune Stratton, Psychiatry. 13 — 1942. Wilcox, K. W.: Confin. neurol. 14, 318, 1954. 317, 22, Psychiat. Quart. 14 Stevens, S. S.: Handbook of Experimental Psychology. J. Wiley & Sons, N.Y. 1951. — 15 Kahn, R. L., and M. Fink: Relationship between Altered Brain Function and Denial in Electroshock Therapy. Presented at American Psychiatric Association Meeting in Atlantic City, May 1955. — 1“ Weinstein, E. A., R. L. Kahn, L. A. Sugar17 1953. Amer. L. Alexander, S. P., and J. and Linn: 109, 389, J. Psychiat. man F. Neander: Arch. Neurol. Psychiat. (Chicago) 69, 368, 1953. 1 Stone, C. — —— —— —— �April 15, 1955 Relation of Changes in Memory and Learning to Improvement in Electroshock* by Hyman Max Korin, M.S. (1) Fink, rm”). (2) and Simon Kwalwasser, M49. (3) From the Research Service of Hillside Hospital, ulen Uaks, New York *This investigation'was supported (in part) by a research grant from the National Institute of HA92? Mental Health, Public Health Service: (1) Research.Assistant (peychology) (2) Director of Research (3) Associate Medical Director �Relation of Changes in Memory and.Learning to Improvement in Electroshock In the course of studies of the relation between altered brain function and improvement following electroshock therapy, the present investigation of memory functions was undertaken. variables, an attempt is made serial testing of learning By first to study and quantify and recall memory changes; and then to determine the relationship between therapeutic outcome and such changes. effects during electroshock therapy are commonly observed, and are both of practical and theoretical interest. Although differences in methodAmnestic ology, materials, subjects and electroconvulsive techniques make direct compar- ison difficult, a few conclusions related to the question of concern in this study can be derived from published investigations. The majority of investigators state that no significant other intellectual impairment remains study, (5) however, noted that two memory loss of or three weeks after treatment (l-h). patients, otherwise fully recovered, reported defects affecting long familiar names of persons and places, lasting a year or more. Zubin, (6) found no indication that electroshock destroyed.mems One 5 cry traces, and concluded that where memory loss persists, the progress is one of slow recovery rather than obliteration. In studies of personal memories selective circumscribed amnesias at least four and five weeks after therapy are described for material elicited in pretreatment interviews (7) (8). The amnesias, however, to subtle emotional factors, rather than permanent vations, Janis (8) postulates that are construed as due loss. From such obserb facilitates repressions and memory memory impairment thereby reduces affective desturbances. Regarding the qestion of memory impairment as a prerequisite for improv- that three techniques of electroconvulsive therapy, " " the the standard or Carletti and the "brain-facil"organic shock", namely, ement, Wilcox (9) notes itation " techniques, are based on concepts which attribute varying degrees of importance to amnestic change, Studies based on the "brain-fanilitation" tech» �-2nique where the low current type Reiter and 'brief-stimnlus' electro-stimulators are used, emphasize the diminished memory change induced as compared to the "stand~ ard technique", although reported therapeutic results are analogous. (10) Kalinowsky (11), believe the "standard" technique is Koch and the most effective therap- clinicians using the "organic-shock" method hold that a therapeutic of electroshock is essential for success (12). In a regressive type eutically; and numerous specific study of this problem, Wilcox (13) recently found no relation between either the treatment induced confusion seen immediately following initial Reiter electroshock, or after a series of ten electroshocks. improvement and an METHOD AND MATERIALS. The ment and 21 subjects are ho consecutive patients referred for electroshock treatuntreated controls at Hillside Hospital. The clinical diagnosis in the electroshock patients include involutional depression, 7; manic depressive psychosis, 18; reactive depression, h; paranoid schizophrenia, 3; catatonic schizophrenia, 5 and hebephrenic schizophrenia, 3. The depressed patients tend to be older - between to and 68 years of age; the schizophrenic patients are young- years. For the untreated group, patients designated as possible electroshock candidates were selected. They are a represenative sample er, between 2h and he of the electroshock group matched proportionately with reSpect to diagnosis, age, education and previous electroshock treatment. The was Reiter CW h? C electrostimulator was used in all cases. Treatment administered every day, and was reduced after the second week depending on the clinical condition of the patient. test of the ability of patients to recall an original learning of lists of eight, three letter common words, at weekly intervals under two conditions: (a) immediately after an interpolated learning of a list of nonsense syllables; (b) after a ten minute rest period during which a copy of "Life" magazine is read. Methodologically, the study involves a �The choice of testing method and materials was based on Studies in retro- active inhibition which indicate that the degree of retention of a learning task varies with thetype of activity interposed between an original learning and the later measurement of retention. Thus, by interpolating nonsense syllables and test days each week, two indicators of recall function of varying sensitivity is obtained. In the test procedure lists of common words and nonsense syllables are the reading of a magazine on separate arranged according to established experimental procedures respecting successive consonants and vowels (1h). Each cards by the examiner. The time list of words was presented manually on flash interval of exposure was not definite during learning and seldom exceeded five seconds. For recall, however, 10 seconds was uniformly permitted. lists for the interpolation condition the maximum of ten trials; or less if the list was In the presentation of the words were presented earlier. The list for a common learned of nonsense syllables was then similarly presented. In the no-interpolation condition the learning procedure was similar, except that reading "Life" magazine was substituted for the nonsense syllables. Each condition was tested weekly The on non-electroshock days, control group was alternating between successive treatments. tested in the same way, twice weekly for five weeks, to simulate the testing for 12 electroshock treatments. Following completion of treat- ratings of improvement were determined independently by the supervising psychiatrist on the basis of observations of ward behavior and psychiatric interviews. ment, The improved patients were those in whom and.whose acute symptoms had subsided. there was a marked change In the moderate improved group, there was a transient change in behavior but symptoms persisted. were those in in behavior. whom symptoms in behavior, persisted or increased and The unimproved in whom patients there was no change �RESULTS 1. Original and.Interpolated Learning - in learning function occurred during treatment in the electrogroup. This was seen in the increased mean number of failures to learn the and syllables as the number of treatments increased (Fig.1). The decrement Impairment shock words in learning is maximal in the h—6 and 7-9 electroshock periods. In the 10—12 treatment period this decrement in learning ability decreases. This decrease be the result of a change in therapy from three to two treatments weekly in of the patients. \ Considerable recovery in learning function occurs when at 3-h ments are administered day mean many treat. intervals. Following termination of therapy, the decrement reversible, so that the may in learning is completely errors are significantly fewer than pretreatment. For the untreated group, the errors decreased in each of the simulated intervals of electroshock (Fig. 1), probably due to the factor of practice. This'data for original and interpolated learning indicates therefore that a reversible which obtained significant-decrement is during electroshock after is termination of therapy when intra-individual comparisons are made. This obser- _vation confirms previous reports (l—h). II. Recall—Interpolation and no-Interpolation Ontests of recall of learned.words from pretreatment'was significant at the l after interpolation, the per cent level for decrement all intervals of treatment inThe electroshock group. In contrast with the original and inter- polated learning which was first significantly altered during the h-6 treatment period, the recall function'was significantly impaired Within the 1-3 interval. (Fig. 2) When evaluations are made of recall of the learned word lists after reading "Life" magazine ("no-interpolation"), the changes are similar to those obtained for original and interpolated learning. These obserbations indicate thatthe type �later of activity interposed between an original learning and a measurement of re- tention is an important and useful factor in eliciting subtle changes in function. reversible Post therapy, the decrement is for both interpolation and no-interpolation recall. foregoing results indicate that a significant The in the 1-3 treatment period sensitive measure of change III. occurs with- that recall following interpolation is in function than learning. and a more Relation of Recall and Learning Responses to Improvement In the analysis of individual data for the relation of recall fun- ction to clinical improvement, the scores of week memory change for at least 3 weeks, were assessed. Of 38 patients, treated three times per these, twenty-nine showed a pattern of decrement in recall function (scores of zero or below pretreatment). of the pattern of decrement in recall in a similar matched controls, four showed the same testing period while seventeen showed no decrement. The treated patients were then r‘cate'gorizled. as to improved, moderately improved, and unimproved by the supervising psychiatrist in charge of the electro~ unit. The number of subjects in each group are tabulated accordloss in Table 1. shock treatment ing to memory Table I. Decrement and No Decrement Groups During Recall Compared with Reapect to Degree of Improvement. Decrement Improved 12 Moderately Improved h Unimproved To No 13 facilitate statistical study the Decrement 2 ’ 1 6 improved and moderately improved groups are combined, and compared with the unimproved group. A chi square of .22 indicates that no significant difference between these two groups exists. Thus, there is no indication that clinical improvement is necessarily related to decrement on interpolated recall tests. �this analysis for recall, the data for the learning of common words is similarly evaluated. Of the 38 patients, 25 showed a pattern of decrement in Following learning function (number of errors above pre-treatment), and (errors below pre-treatment score). In the control group of ment only one subject was When is 13 showed no in the decrement range. relationship between improvement and decrement in learning (Table 2). is not statistically significant This relationship, however, concluded, therefore decrement subjects, 21 these patients are grouped according to their psychiatric ratings, there an apparent It is decre- that by the chi square relation exists between clinical no test. improvement and in the pattern of learning. Comparison of Degree of decrement During Learning with Ratings of Improvement. Table 2: Decrement +++ 7(ML%) 3(1805%) Improved 2(h0%) 0 Unimproved h(2h%) 3(18.5%) Improved Moderately ++ - + No Decrement - 2(12 05%) 2(1205%) 2(1205%) 1(20% l(20%) l(20%) 3(18.5%) 1(6%) 6(35%) patterns of response are based primarily on changes during the and 7-9 intervals of treatment. For the majority of patients, these are The above h—6 at such times electroshock therapy was reduced or discontinued. Five patients, however, were treated three times per week for 18 or more treatments. Clinical changes during this period were minimal and points of maximum decrement, and following termination of therapy, all were rated as unimproved. patterns in these patients remained at a minimal or For recall following interpolation, however, these no decrement patients The learning level throughout. showed a decremhnt during treatment with scores below both pretreatment and also post therapy. these patients did show Thus, evidence of brain dysfunction by the more sensitive re- call interpolation variable. 1“evertheless, failure to develop changes in the learning function after relatively prolonged treatment suggests that improvement is unlikely when there is minimal brain dysfunction. This interpretation of the �data is supported by the findings of Kahrland Fink (15) who, in this laboratory, used the electroencephalogram and Amytal tests (16) as indices of cerebral change, and found a high, correlation between degree of brain dysfunction and improvement. DISCUSSION In similar investigations of the learning task memory function with lists of words and syllables, before therapy and recall was tested at varying was completed intervals after termination of therapy. In this study serial measures of change in learning and recall obtained on the day following treatment are assessed. As group data, they verify the findings of other investigators that significant decrements in learning and recall functions occur during electroshock which are reversible by the third week following termination of therapy. Recall after interpolation For is the most this variable, a significant pattern of sensitive indicator of dysfunction. decrement is evident in the electroshock group. Thus, the majority of these patients show memory change in the first the single some of 38 of quantifiable during treatment. F'urthermore, a significant memory impairment occurs week between This EST. is reported to 29 the 1-3 treatments which is true even though the Reiter minimize amnestic effects. measurable 2h hours after electrostimulator used here During learning, the impairment significant only during the second and third terval). In the hth is is weeks of treatment (h-6 and 7-9 in, interval) there is less impairment of the learning scores. This change, however, is an artefact of a particular method of treatweek (10-12 ment whereby electroshock frequency becomes apparent. is reduced as a favorable clinical response Thus, between the 7-9 interval, 12 patients are discontinued and 20 others are reduced. Nevertheless, for most patients the peak of memory decrement is reached between the fourth and ninth treatments. Seemingly, greatest therapeutic benifit is derived at this time. When the patients categorized according to individual patterns of response in both recall and learning are compared with their ratings of improvement, a �relatively high proportion with marked memory changes fail to improve. This finding suggests that brain dysfunction pg; §g_as measured by learning and recall is not sufficient to induce a therapeutic effect. A similar conclusion was reached by Wilcox in her study of the relation of confusion to therapy(13). The data in this study further indicates that when only minimal memory impair- after prolonged treatment, of the patients in this study ment develops no improvement While some seemed is likely to result. to benefit therapeutically with minimal memory impairment within ten treatments, they usually showed marked test changes with other indices of brain dysfunction such as the.EEG and.Amytal (15). As these patients are placed on reduced frequency or discontinued rather early in treatment,'ueiris no opportunity to compare then with patients re- ceiving 20 treatments on a three times a week basis. In similar fashion, a relationship between lack of change and also been observed. in a study of eosinophile levels following electroshock (17). no improvement has Although the induced memory impairment as measured here related to improvement, the possiblity remains that subtle ilitate is not directly memory changes fac- the repression of selective memories (7,8) or the emergence of de- fensive reactions such as denial, which reinforce changes in behavior (18). Changes induced by these defense mechanisms may be measurable with techniques other than those used in this study. �SUMMARY AND CONCLUSION Studies of changes in learning and recall function during electroshock were undertaken. data indicated: (1) a significant decrement in the recall of common words following the interpolated learning of nonsense syllatles which persisted Group all intervals during of treatment (P = .01) for both intra parisons; (2) a significant decrement in learning at the and h—é enter group and 7-9 comp interval of treatment where change from intra-individnal pretreatment scores was max(3) the return of both learning and imum; level or better within 3 weeks recall functions to the pretreatment of termination of treatment. Analysis of individual patterns of response indicated that 29 of 32 pat- ients Showed a pattern of decrement following recall with interpolation during treatment. When the improved and unimproved patients were evaluated respecting the presence of memory impairment, no significant difference was obtained between the two greups. It is or induces 2) that that electroshock with the Reiter CW h? C electrostimnlat-“ change as measured here and that such change is reversible; concluded memory prerequisite for improvement but that'changes with 20 treatments is associated with lack marked memory changes are not a 3) the lack of marked memory of improvement. �[REFERENCES l. Stone, C.P.: Losses and Gains in Cognitive Functions as Related to Electroconvulsive Shocks, Journal of Abnormal and Social Psychology, ha: 2-6-21u, (April) 19u7. 8.: Effects of Electrcshock Therapy on Mental Functions as Revealed by Psychological Tests, Journal of General Psychology, g5: 171-188, (April) 1951. Brewer, D. and Oppenheim, ,The Luborsky, L.B.: Psychometric Changes During Electric Shock Treatment, JOur. Nerv. and Ment. Disl, 191: 531-536, (June) l9h8. - Michael, S.T.: Impairment of Mental lfunction During Electric convulsive Therapy, A.M.A. Arch.Neurol. and Psychiat. 11:362-366, 195k. Brody, M.D.: Zubin, J.: Prolonged Memory Defects Following Electrotherapy, Jbur. Ment. Sci. 90: 777-779, (July) 19hh Functioning in Patients treated with Electric Shock Therapy, Journ/ pf Berspnality, 17: 33-h1, (April) l9h8. Memory Janis, I.L.: Fellowing “lectroc Convulsive Treatments, JOurn. of Personality, 11: 29-32, (April) 19h8. Memory Loss Janis, I.L.and.Astrachan, M.: The Effect of Electroconrulsive Treatments on Memory Efficiency, Journ. Abner. and boc. Psych., fig; 501511, (October) 1951. 9. wilcox. . K;W;: Psychological Studies in filectroshock Therapy, Michigan Academy of Science, Arts and J«etters, 357-368, l9h9. ii: Electric Uonvulsive Therapy: 10. Liberson, W.T. and wilcox, PlH.: Comparison of Brief Stimuli Technique with the Friedman Wilcox - Reiter Technique, ”igest Neural. and Psychiat. 12; 292-302, l9h5. — L.B.: Shock Therapy: Psychosurgery and Uther Somatic Procedures in Psychiatry, Grune and Stratton, New York Hoch, P.H. and Kalinowsky, 1952. 12. Kennedy, C.J.C., and Anchel,D.: Regressive Electric Shock Thur: Treatment in Schizophrenics Refractory to Other Shock Therapies, Psychiat. Quart. fig; 317, 19h2. 13. Wilcox, K.W.: finia S.S. Stevens: 1951. 15. Confusion and Therapy in Electroconvulsive Treatment, ConNeurologica, lg; 318-326, l95h. Handbook of Experimental Psychology, J. Wiey and Sons, N.Y., Fink,M .: Relationship Between Altered Brain unction and Denial in Electroshock Therapy, Presented at American Psychiatrifl Associatimn, May 1955. Kahn, R .L. and - �.12- 16. Whinstein, E.A., Kahn, R.L., 5ugarman, L.A., and Linn, L.: The Diagnostt Use of Amobarbital Sodium ("Amytal Dodiumf') In Brain Disease, Amer. Jour. Psych. ;92: 889-89h, (June) 1953. 17. Alexander, S. P. and Neander, J.F1: Adrenocortical Responsivity to Electic Shock Therapy and Insulin Therapy, Arch. Neurol. and Psychiat. 92: 368-371;, (March) 1953. �up“ ELECTROSHOCK RESEARCH ASSOCIATION DFF'GERS 1954‘1955 DR. PHILIP a. REED, (Ex-Plaza.) 1800 E. TENTH S12, INDIANAFULIS 1. IND. on. TITUB H_ HARRIS, 316 STRAND, BALVESTDN, TEXAS DR. HOWARD D. FAEINB 2314 AUBURN AVENUE, CINCINNATI 19. :1th DR. ERNEST H. PARSONS DR. BERNARD L. PAGELLA, FEES. a. 5131. 57.. New YORK 21. N. Y. DR. WILLIAM L. HOLT, dflq VICE-FEES. ALBANY HOSPITAL. ALBANY, N. Y. DR. PAUL H. WILCDX, SEC'Y-TREAI. 526 w. TENTH 5T.. TRAVERBE ClTv. MIGHi us (“dun“) nggg; may PRLLE AWARD 8, 1955 Atlantic City, m.J. Prize Paper: at on of Uh 'earnin to es ‘n memorr nd in electroshock 1m rovement by Korin, a.S. Fink, M.D. Hyman max and Simen nwalwasser, m.D. hillside Hospital, Glen Oaks, m.r. the Prize Committee, wish to congratulate the authors on their excellent paper. Our decision was made because this paper is based on a carefully worked out research design and reports the development of a sensitive measure of the transient mental impairment occurring following elecfipshock convulsions. We anticipate that this method will have broad ap;licatmon in the evaluation of the various physiodynamic We, therapies." Enclosed herewith is a check for $100.00 to be divided among the authors. iguana liBernard L. Pacella, m.u. i M; ta ”William L. «4 /,/% 7w, 3m. nolt, dr., :7 7v - . ~p . MIA/Mb» PM Paul Wilcox, H. m.u. 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Psmgs tho stage at metabolism at museum in the tether stats muted or barbiturate 11:12th «mime! is the pmestt than. study is éiftwent in the am]. Wimto poisoning. negate has Maptic 1.. pm 193a appmmum than mm“). ta in mutating gamma. appears to page 2. properties statue:- ta these es and mm)... It my be an W drag mmtsnmtagmmtemmemsimmmmsfmm ital. Its eg the use Maui». ‘ tht I at barbiturate panning m further in.» � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of changes in memory and learning to improvement in electroshock. Confinia Neurologica 1956;16(2-3):88-96. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-19-023 Date A point or period of time associated with an event in the lifecycle of the resource 1956 Creator An entity primarily responsible for making the resource Korin, H; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kwalwasser, s. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and publication. Confinia Neurologica. Proceedings of the Eleventh Annual Meeting of the Electroshock Research Association Atlantic City, New Jersey, May 8, 1955. From the Research Service of Hillside Hospital, Glen Oaks, New York. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Basel; New York: Confinia Neurologica Contributor An entity responsible for making contributions to the resource Spiegel, E. A. Published http://exhibits.library.stonybrook.edu/mfp/files/original/f7c87e4b8450f1ed2913d4dcd19d8101.pdf 28b2641c12bb8afccfb2c988034e1cc8 PDF Text Text Reprinted from the ISRAEL STRAUSS COMMEMORATIVE VOLUME Journal of the Hillside Hospital Volume V, Numbers 3 - 4 October, 1956 �DENIAL OF BLINDNESS FOLLOWING CEREBRAL ANGIOGRAPHY MAX FINK, M.D.1 In the fifty-eight years since the original report of Anton (1), there has been controversy in the literature as to whether denial of blindness is the result of a specific focal cerebral lesion or of a generalized disturbance of brain function without specific localizing significance.2 In reviewing the cases of denial of blindness, the majority of reports describe the patients as “confabulating,” “disoriented,” or “showing a Korsakoff psychosis.” Such descriptions lend support to the concept that denial occurs in a milieu of altered cerebral function. Studies of denial of hemiplegia, usually described under the term “anosognosia,” bring out identical arguments as to the significance of the phenomenon for localized dysfunction. Indeed, in many reports of denial of blindness, note is made of simultaneous denial of hemiplegia or of other defects. The literature of denial of illness, as well as clinical and experimental evidence to support their concepts, has been recently summarized by Weinstein and Kahn (23). They conclude that various forms of denial are a unitary phenomenon without cerebral localizing value, and that denial is an adaptation to a defect in the milieu of diffusely altered cerebral function. In this regard, most of the defects denied are of rapid onset, are not limited to one defect, are accompanied by confabulation, amnesia, changes in mood and absence of anxiety. The degree of altered cerebral function which provides the milieu for such adaptation is usually severe. Thus, their reports, as well as those of other authors cited (see footnote 2), Director, Research Service, Hillside Hospital, Glen Oaks, N. Y. 2The reviews of Critchley (6) and Weinstein and Kahn (23) present the two aspects of this problem. For specific reports ascribing the phenomena to focal cerebral disease see Barkman (2), Gerstmann (10), von Hagen and Ives (21, 22), Ives and Nielsen (l2), and Paul (16). Reports ascribing the phenomena to diffuse cerebral disturbances include Lunn (13), Redlich and Bonvicini (l7), Redlich and Dorsey (18), and Sandifer (19). 238 1 �DENIAL OF BLINDNESS 239 describe the phenomena of explicit denial of blindness and of hemiplegia as occurring in patients with brain tumors, subarachnoid hemorrhages and vascular disease. The following case history is presented as exemplifying various aspects of the syndrome of denial. The data support the thesis that the phenomenon is an adaptive response to a defect under the conditions of altered cerebral function, rather than the result of focal cerebral pathology. A patient, under observation for enlargement of the sella turcica presumably the result of pituitary adenomatous growth, was subjected to cerebral Iodopyracet (Diodrast) angiography. Before the procedure he was alert and oriented, but immediately following the second series of injections of Iodopyracet, he developed left hemiplegia, which gradually resolved. In the ensuing hours, blindness developed and was denied by the patient. The syndrome persisted for 48 hours, and then resolved. When the patient was seen in a follow-up visit eight months later there was an amnesia for the period of denial. Case Report:3 E. S., a 58-year-old right-handed male, was admitted for diagnostic study to the Montefiore Hospital with a sixmonths history of headaches and blurring of vision. Four months previously he had an episode of ptosis of the right lid associated with dilatation of the right pupil, which had persisted for a few weeks. Headaches became increasingly severe, and X—ray examination of the skull prior to admission demonstrated an enlarged sella turc1ca. He related his own history; appeared neither acutely nor chroni— cally ill; was alert, well oriented, and cooperative, with good memory and calculating ability. He was jovial, made friends readily, and was well liked. He denied previous severe illnesses, or persistent somatic complaints. He was fastidious about his personal belongings and was reluctant to intrude. The general examination was normal except for palpable enlargement of the right lobe of the thyroid gland. Neurological examination was normal except for the cranial nerve examination. His pupils were dilated, the right larger than the left. The reaction to light was sluggish on the right, and the pupils reacted well to near vision. The fundi showed well-outlined papillae with clear margins, definite temporal pallor, and normal vascularization. Visual acuity was 15/20 on the right, and 15/40 on the left. Visual fields to 1/2000 white test object demonstrated a relative bitemporal hemianopsia without macular sparing. The lumbar puncture and routine blood and urine studies were normal. Skull X-ray revealed enlargement of the sella turcica; atrophy of the anterior and posterior clinoids; and calcifications along 3 Patient studied through the courtesy of Dr. Nathan Savitsky at the Monte- fiore Hospital. �240 MAX FINK the lateral border of the sella. Pneumoencephalography demonstrated encroachment of the cisterna chiasmatis and pontis by a mass originating from the sella. An electroencephalogram showed a slight degree of electrical abnormality on the left side, mainly inferior and posterior. Alpha frequencies and amplitude were symmetric. For further clarification of the pathologic process, carotid angiography was recommended. Under local anesthesia, the right common carotid artery was exposed, and forty cc. of 35% Iodopyracet (Diodrast) was administered. Since the serial angiograms thus made were unsatisfactory, another injection of 15 cc. Iodopyracet was made. Immediately following this injection, the patient developed a complete left hemiparesis, including the face. He was restless, confused and irritable. He appeared drowsy; failed to obey commands and was irrelevant in speech. Vasodilators were administered, and the hemiparesis showed some improvement. That evening he was restless, directing his gaze most often to the right. When spoken to from his left side, he would turn his head to the right or backward, before finally localizing the voice correctly. He answered questions relevantly. Visual acuity was reduced to light perception, and pupillary reactions were present, though sluggish. He was unable to localize the position of a light nor identify fingers or objects; yet he denied his inability to see, confabulating seemingly appropriate responses. He was oriented for place but only approximately for time and date. Despite a large neck bandage, he denied the recent cutdown. A lumbar puncture was performed. The initial pressure was 140 mm. CSF, final pressure of 60mm. after the removal of 8 cc. of clear, colorless fluid which had no cells and a protein content of 43 mg%. Twelve hours later, now oriented in space and time on gross questioning, he was still unable correctly to localize light or perceive objects. There was a residual left hemiparesis. He denied both his weakness and his blindness. When walking about the room he stumbled over objects and bumped into the wall and the bed. He correctly identified the various examiners by their voices, and named a coin, key, pencil and comb by touch. There was no sensory loss on single stimulation; gait was hesitant; and the reflexes were increased on the left with bilateral Babinski responses and absent abdominal reflexes. Thirty-six hours later the hemiparesis had cleared except for a residual left Babinski response. He perceived light and localized it well in‘space, but image formation for reading or fine identification was impaired. Despite the partial nature of his vision, he still failed to recognize his impairment, confabulating many responses. An electroencephalogram at this time showed a change from the original record. There was bilateral asymmetry with high per cent time delta activity and a slowed, poorly organized alpha rhythm, mostly on the right. Forty-six hours later his vision had returned so that he was able �DENIAL OF BLINDNESS 241 to read. He was oriented, alert, affable and friendly. He maintained that he had been able to read and to see throughout the previous two days. He had an amnesia for the surgery, the hemiparesis and the blindness. During the ensuing weeks, visual acuity returned to normal; with visual fields manifesting minimal bitemporal hemianopic defect. An electroencephalogram one week later showed posterior voltages to be less depressed; per cent time delta activity had decreased; and there was desynchronization of the record on delta the of accentuation focal abnormality There was opening. eye in the right frontal leads. Three weeks later the electroencephalo— inwith abnormalities of the resolution increased showed gram creased and bilaterally equal per cent time alpha; decreased per cent time delta and resolution of the electrical asymmetry of the hemispheres. On examination eight months after this episode and after a course of radiation therapy for pituitary adenoma, this patient was alert, oriented and cooperative; with only occasional complaints of headache. The neurological examination was completely negative with normal visual acuity and a slight (10°) bitemporal hemianopic defect with 1/1000 white test objects. He denied any experience of blindness or weakness but did recall the neck dissection that preceded the angiography. When told of the experience, he jokingly denied the weakness and the blindness by saying that I was mistaking him for another patient. Discussion: Two aspects of this case report warrant amplification: the significance of the denial phenomenon and the cause of complications following cerebral angiography. The various aspects of denial of illness described by Weinstein and Kahn are well exemplified here. The acute onset of hemiplegia and blindness was followed by a period of restlessness, disorientation, and altered consciousness. Within a few hours, these gross symptoms were replaced by a calm, disinterested, smiling attitude in which the multiple defects of left-sided weakness and blindness were denied. He confabulated, was disoriented for time and date, and later was amnestic for this period. An electroencephalogram demonstrated bilateral diffuse slow wave activity of high voltage. Furthermore, despite the visual loss, the phenomenon of spatial inattention4 was observed. This complex of symptoms and signs is generally noted in diffuse cerebral disorders. While much effort has gone into localizing these defects, it is difficult to conceive a single focal lesion affecting the visual tracts bilaterally, the right hemisphere in an Various terms have been applied to the unawareness of one half of the body and the body space, such as imperception for one half of body (Schilder, 20), hemi-depersonalization (Ehrenwald, 7) and autosomatagnosia (Gerstmann, 10). See also Critchley (6, pp. 237-241), and Brain (4). 4 �242 MAX FINK area productive of hemiplegia and the frontal areas assumed to be productive of apathy, denial, and loss of anxiety. While the possibility of a focal lesion as the basis for this syndrome cannot be ruled out, it is more tenable to conclude that diffuse cerebral dys~ function was present. This conclusion is supported by the electroencephalogram, and also by experimental evidence noted below, demonstrating the effect of intra-arterial Iodopyracet as inducing severe vasospasm followed by generalized cerebral edema and increased permeability of the blood-brain barrier. The significance of the phenomenon of denial is to be seen in its defensive nature. While undergoing a test procedure, the patient suddenly suffers a catastrophic disability. His initial response of severe anxiety, manifested by restlessness, startle reaction, and irritability, is soon replaced by explicit denial. This primitive, “psychotic” defense is normally present only in childhood. But under the special conditions of cerebral dysfunction, with disturbances in spatial and temporal orientation and perception, denial of reality becomes tenable. It is maintained so long as the disability and the milieu of cerebral dysfunction persist. In this patient, as soon as visual perception was sufficient for reading, confabulation and explicit denial were no longer actively maintained for ongoing events. In the special situation of interviews with the staff during the period of visual and motor loss, the patient manifested no concern and confabulated responses readily. When visual acuity returned and his hemiparesis cleared, he maintained the same is imthis it In attitude. unconcerned regard affable, friendly, of denial in factor the explicit characterological to note portant illness. To the extent that the information is now available, this patient manifested a considerable number of the features described by Weinstein and Kahn (24). Special note should be made of the phenomenon of spatial inattention. The patient’s original visual complaint of blurred vision was accompanied by a minimal bitemporal hemianopia, apparent only on testing with 1/2000 white test objects. During the period of visual loss he was unable to locate a light and confabulated responses. One week later the bitemporal hemianopia was present to 3/2000 white test object, but in addition there was an irregular left homonymous upper temporal field defect to 5/2000 white. Evidence of a left homonymous field defect persisted in examinations for three weeks, after which only residual bitemporal defects were persistently reported. Left spatial inattention was prominent in the first 48 hours of this syndrome only, at the time when visual im- �DENIAL OF BLINDNESS 243 pairment was maximal, and when hemiparesis was present. When the hemiparesis receded, visual function returned, and orientation was intact, then spatial inattention disappeared. Thus, spatial inattention was an aspect of the total disturbance in function, possibly motivated by the left-sided defects, and was probably not dependent on a specific visual field defect. The syndrome of blindness and its denial following cerebral angiography is unique. Focal lesions producing transient hemiplegia, hemisensory defects, seizures, aphasia, and various cranial nerve syndromes have been described. In a series of 117 percutaneous carotid angiograms, Fink and Stein (9) noted an 8 per cent morbidity of such transient phenomena. Other series variously report such complications from 3 to 15 per cent of the cases.5 These figures do not include the few patients in whom the complications as hemiplegia, aphasia or exaggeration of their basic disease are permanent; or who succumb. In these studies of the complications of angiography, emphasis is placed on the relation of the concentration of the contrast medium, the rate and quantity of contrast substance injected and the time within which the injections are repeated. In experimental studies Olsson (14), Broman and Olsson (5) and Bloor et al. (3) demonstrated summation of toxic effects when the contrast substance was rapidly injected into animal arteries; and noted increased vascular permeability, cerebral edema and petechial hemorrhages not limited to the side of the injection. While it is possible that the complications of angiography are the result of thrombus formation at the needle site and focal embolization, it is more likely that diffuse toxic cerebral vascular changes are induced as seen experimentally. The diffuse character of the defects and the transient nature of the phenomena in this patient are readily understood in this context. Summary and Conclusions: In the course of carotid angiography in a patient with evidence of a pituitary adenoma, an acute transient episode of blindness and hemiplegia developed. Following a short period of restlessness and confusion, the patient became calm, denied his blindness and weakness, confabulated responses to questions, was disoriented, and manifested spatial inattention. The diffuse nature of the cerebral dysfunction underlying this syndrome is emphasized by noting the distribution of the presumed lesions, the bilateral, diffuse slowing of the electroencephalogram, 5For reviews of the complications of cerebral angiography, see Engeset Fink and Stein (9), Green and Arana (ll), (8), Perese et a1. (15) and Wickbom (25). �244 MAX FINK and the diffuse nature of the toxic sequellae of intra-carotid Iodopyracet (Diodrast). The defensive-adaptive significance of the syndrome of denial of blindness and hemiplegia is discussed, with emphasis on the development of this attitude under the special conditions of altered frames of temporal and spatial reference provided by altered cerebral function. REFERENCES (1) Anton, G.: Uber Herderkrankungen des Gehirnes welche von Patienten selbst nicht wahrgenommen werden. Wien. Klin. Wchnschr., 11:227-229, 1898. (2) Barkman, A.: De l’anosognosie dans l’hemiplegie cerebrale. Acta Med. Scand., 62:235-254, 1925. (3) Bloor, B. M.: Wrenn, F. R.; Margolis, 6.: Experimental Evaluation of Certain Contrast Media Used for Cerebral Angiography. ]. Neurosurg., 8:585—594, 1951. Brain, W.: Perception and Imperception. ]. Ment. Sci, 1022221-232, 1956. Broman, T. and Olsson, 0.: Tolerance of Cerebral Blood Vessels to a Contrast Medium of the Diodrast Group. Acta Radiol., 30:326-342. 1948. (6) Critchley, M.: The Parietal Labes. London: E. Arnold 8: Co., 1953 (see Chap. VIII, pp. 225-255; IX, pp. 258-263). (7) Ehrenwald, H.: Verandertes Erleben des Korperbildes mit konsekutiver Wahnbildung bei linksseitiger Hemiplegie. Mtschr. Psychiat. (2» Neural, (4) (5) 75:89-97, 1930. (8) Engeset, A.: Cerebral Angiography with Perabrodil. Acta Radial, Suppl, 56, 1944. (9) Fink, M. and Stein, J. M.: A Clinical Evaluation of Carotid Angiography. Confim'a Neural, 12:181-195, 1952. (10) Gerstmann, J.: Problem of Imperception of Disease and of Impaired Body Territories with Organic Lesions. Arch. Neural. (5' Psychiat, 48:890-913. 1942. J. R. and Arana, R.: Cerebral Angiography: A Clinical Evaluation Based on 107 Cases. Am. ]. Raentgenol., 59:617-650, 1948. Ives, E. R. and Nielsen, J. M.: Disturbances of Body Scheme. Bull. L. A. Neural. Soc., 22120-125, 1937. Lunn, V.: Uber mangelnde Wahrnehmung der eigenen Blindheit. Acta (11) Green, (12) (13) Psychiat. é} Neural, 16:191-242. 1941. (14) Olsson, 0.: Cerebral Angiography: Tolerance for Contrast Media of Diodrast Type. J. Neural, Neurosurg. é, Psychiat., 12:312-316, 1949. (15) Perese, D. M.: Kite, W. C.; Bedell, A. J.; Campbell, 12.: Complications Following Cerebral Angiography. A.M.A. Arch. Neurol. é} Psychiat., 712105-115, 1954. (16) Potzl, 0.: Uber Storungen der Selbstwahrnehmung bei linksseitiger Hemi- plegie. Ztschr. ges. Neural. (9 Psychiat., 93:117-168, 1924. (17) Redlich, E. and Bonvicini, G.: Uber das Fehlen der Wahrnehmung der eigenen Blindheit bei Hirnkrankheiten. Jahrb. f. Psychiat., 29:14.23, 1908. (18) Redlich, F. C. and Dorsey, J. F.: Denial of Blindness by Patients with Cerebral Disease. Arch. Neural. {‘7 Psychiat., 53:407-417, 1945. (19) Sandifer, P. H.: Anosognosia and Disorders of Body Scheme. Brain, 69:122137, 1946. (20) Schilder, P.: Localization of the Body Image. Assoc. Res. New. Dis., 13:466-484. 1932. {9'- Ment. �DENIAL OF BLINDNESS 245 (21) von Hagen, K. and Ives, E. R.: Anosognosia, Imperception of Hemiplegia. Bull. L. A. Neural. Soc., 2:95-103, 1937. (22) von Hagen, K. and Ives, E. R.: Two Autopsied Cases of Anosognosia. Bull. L. A. Neural. Soc., 4:41-44, 1939. (23) Weinstein, E. A. and Kahn, R. L.: Denial of Illness. Springfield, 111.: Charles C. Thomas, 1955. (24) Weinstein, E. A. and Kahn, R. L.: Personality Factors in Denial of Illness. A.M.A. Arch. Neurol. (5» Psychiat., 69:355-367, 1953. (25) Wickbom, I.: Angiography of the Carotid Artery. Acta Radiol., Suppl., 72,1948. �" Mamma: . mm. W W W6 63mm WWW mm,ljh9.* 3 Iran tau _.; a» V 1 3, Baum Sam», mill-ids Hospital, 61m Oaks, law mm ”imam, Rinaldo Hospital. W 1% 2’ A Luz/$4M“ [/m Mace rm éwm M429 Jaw / W1T �W a: Blindness removing Gombml 112310ng mm In an titty-.0131“; years since the apart or mm (1398); at than has Mon cmtroveuy 1n the litommm as to whether hunches; in tho result at a. specific fecal cembral lesion or at I. gua- «mum m1 disturbame or brain: Motion without specific localizing Moving the use: at initial or manna, tho majority of reports describo tho wasn‘t: an ’emfabulating,‘ “Manta maximums» (1). In ad,“ or ”shaving o lonakat‘f paychem.‘ Such satanptim lend support to tho meapt that denial com in a milieu of: almond heroism mum. studios of denial. of heniplagu, usually described under the term ”moon cantata", bring out Martina}. as to the significance at tho 1:: many topaz-ts of denial phenmm for lowland dysfunohim. W» of blinmhs, note ma, is undo of aimultmeun denial at haiplema or of other defects. Th: literature. at donul at 113m”, as imam evidence by to support 3013th and Kuhn ao 611111.081 and expert- ”may amazed They concludo that various farm of dam than (1955) a ten cmcaptn, has tea: m a mitary Monomer: without tantra}. Realising value, and that mm is an adaptstian to a Meet in tha milieu a: dummy alt-sud eembml function. In thin regard, mat of the defeat. mm are at 0:1.th (1953) and Museum and m (1955) prom the taro aspects of m: prom“. For mastic raparta “exiting the to fetal «am-um; disease as. Bum (1925). 9mm (19M), Hagan me 1m (1937. 1,939). I»: sue 3181301: (1937) and Pots}. (1921:). (1) the minus or y Reports aseribing tho phenomena to Mano mm disturbances mamas m (19M), Retinal: and mm (1911), Ramon and money (1916) and 8mm" (191:6). - ����*5and m “was mt m m m: hummus, than @13me the will mmm. K0 unnamed mr 915398“ earnestly iamutied them» 1m Wnbythoirwim, mamas. am, by, mailman}: by tmxch. Thus was no amou- W a: single: swam; gait. m mutant; mam mm»; mm inward an Babinski mama”: and album. thawing}. the ma um: mama reflexes. Minna” W mm 51ml Mt light napalm. W mater tho had cleaned mph for a nu it well in am... but. 1mg: {amnion tar reading or fine identification m mpaired. new“ the Be pameiveé and 106mm WWWW my reams.still mm: nature or his vision, he to An name him impairment, 319W flagmatthiamathamngofmfiuoflm remand. Wm may with high par mm; was @91th activity bilateral poem armined alpha rhythm mm an that» right. and a» slaved, Wan-six hours later his vision had returned «a that be we able to read. Ha an: omenmd, alert, affable and friendly. E maintained mthehadhemabhtomadmwmthmughoutmmmmu mail; far the surgery, the: hemipamm and tho Minn“. Baring the ensumg nah, visual wuw'm’mmd ta normal} with man. tieléa Wetting minim}. bimmpom Wop“ detect. in He had an: W caphnlow we we): later came! posterior manages to he lean dam-us:ed; per mt time delta activity had gamed; md than was Wehrmmm or the mom-d m syn .;,- Thor. m mm accantmmm at the claim 3.1930th in the right imam 1m. nurse weeks later the incmaad mwluum o: the swam-111m: with olectmemeqahahgm ma �am; dacmmd pa:- wt was clans. am! maeluum a: the chemical awn-y or the mmfimughtnmm mum apiaode Matter-a 3mm of radiation therapy £0: pituitary Wm, this patient was alert, orient-u ed and Wmum “weal: Wilma]. complaints of headache. m mmlom m mlately negatim with. normal visual acuity and a 311mm” amoral ammo. arm. with 1/1000 mu is» mama and 1311315911113 aqua). per cent the may. mm 9mm. Ra _ denied any experience a! 13mm“: or weakness but can an moi: dimatim that mama the Mummy. W did ran— m mm of my mm» and, tho blindness w mumums, he saw m we I m Blanking him tar mother mutant. the ��.3. «swung mmwmmmmnamm, m effact or mtmmm Wmt as inducing mam mam followed «Magma. ' by generalized 131006431913 W. «row-1 em Wand pamabili‘by at the and muwmuoxmmnmotmmnmummm ' mnwmm. miter: a. ontastmphia disability. Wily new of mm mm His Muted by mam-mu, aw mafia, 13w, ma ”placed by mum. is pm, initial a test Whil- m. chum. min punitive, normally prawn. mly in the and gamut irritability, in "Wm” Mme 3mm the special amdifimn of oembml. dysfuncfim. with MammGea in spatial and Wm]. estimation and panoptim, denial of minty bums tenable. It is mintamd so long as the disability and m mum at eembnl gym; china mint. But In this patient, an saw as visual pompmm m M!» fur reading, «Mahatma .ami explicit denial are no 1mm 3mm maintained for main wants; In the main). Inuktitut at interview with thy staff charm; the period or visual and mum- loan, the 14mm. pat—Lark Wound m mum and Mahmud vim acuity mtumd and hi: W readily. Mm alumni, he maintainad the same «farm, memeamd amimm In this regard it u mportant to note that chamtemlegim factor in upliait at 111mas. it: w extant mm. the momma: i.- naw available, this patient 11033119111931: mm, m1 Wasted a Widemble new of the reams download by and Kuhn (1953). special note should be made the patina“: original visual WW of the phenomena of spatial inattemfim. Wt of ma Man was mama �.9... by a W humeral manom, apparent any out team with 1/2900 white teat. obgews. During the pexied or visual loss be was unable to Meats a Mt and cmfubulated mums. later tho um. obfiaet, but in adfifim One week ' mu m pmmt m kW mmimmmlmhmmnmpertmpom madafoettOSflOw to 3/2009 mm“ of a lots; mm. A 1101:! mm persim in m ‘um for thm mm,- after which unity residual mammal. detect; mm persistently reporwd. Loft spatial inatmuon m prominent. in mam my, nun mmumw paiment m maximal, and m Mme!” m pram“. Hum tho mummmhahoam «this pares“ receded, visual function rammed, and orientation was intact, than spatial inattontim amppcmd. 21m:, spatial imthntion m an 3» Wm, 1:08“ny motivated by the aspect at the tow. Emit-aim Mac“, and w“ pro-mar Mt; 25¢th an a mafia visual field Moat. mm The grapm 1: 1:an of hunting“ am! its denial £91m osmium). anginmm. hum producing transient heuiplegia, new... «hum, «Ma, and various cranial nor" man-ms mm. mow Menu, have hm deans-Aha. In a. W’ of 317 pemtanwua carotid angiagrm. m and Stein (1952) now an What nation variaualy row-s as! much mama; at mm. transient Whammy: tram 3i W 15% of the such cases (3% when figure: do net inaluda the few patients in was: thin ammonium as Mplegu, aphasia or Manama: at their bum (3) Fur (191%), W: a! the «@11qu at «alum angiagraphy, sea mm. m and 3m {1953), emu and Anna (19w), (19514) and Him (191$). Fem-as a a. �diam m parliament; Imam a: Mommy, or m mm. In than studio: at tbs mm in phone! an the mutton of! the mun- cm mum: at 132m coma-alt man, we rat. and quantity or mtmst sub-n same wasted and the um vim which tho. indoctim an mpoam Wan]. studies 018m (19%, Em and 01m (19%) and Bloc: (1951} mum of Ma fist-mt. M the cantmt suntan“ in mm m mpddly instead in?» animal arteries; and noted Mama mam:pemammy, mmbral «dam aids of the macaw. 331111; ram“ an mm tom Wéum, it uh: and patéchial hemorrhages mt. 9:? it is 3303311311: that the maidens likely m durum We «mm. mm. um Mums am} the Walnut mm of; m phenomm in m indumd uxparimntauyg Th» wade-ram in this context of 0‘ W chamber at tho @2113, 11y I Wu: .famtim at. m: needle site and 5.. mar. {flanges mm to the patient an mad-n �WWW in I. mum: with Mama: 0: In the warm anarchic! a 19:1me mu transient walled. blmmMs m5Waving ashore patina at waflamw of an plagia developed. mum, thapamntbocm ma, mmtm. Wu and own mmbmmmwomu. can» tabulated responses to questions. ‘ and m 6180an and manifested spatial mm» nature, at the annual mum underlying thin «yaw arm in mum by mung an distribuum of the pramd mam. ‘ 5 [the mmm5 wmmwmmmmemmmw» fuss nature at that m defend“ We aoqmllae at inn-«mud (mm). 1W:mm of aiminam o: the uyndrm of blindness and Mylegia is flawed, with emu-t m m a! ma atfitudo mm the mam. mum' of alum at bupawl and spatial aroma provided by altered comm Manna. a; adapts.” Wt m �um:- fiarchrkmnmgm do: Eskimo: Velma Anton, a. (1893), nelbst niaht 2 .. 9,. .1. A. {1925): DI WW £2“; mm. m. w.- Hahnmgg" 3;: 9 * van limaegmsio clans Patienm 227-239. Planning“ combmlm .5331; 34. 23545!» mow, 3.14., “rum, LR. and litmus, G. (1951); Maximal Mum 03m Gmtmt Media Used tar cerebral lagiograpiv. 5. Human“. of E! 5354“? ‘ . am; (1955), Parcaptian and Wampum. g. m. w. m: Brain, w. W32. Rm; '2. and Men, '0. (19143), 2019mm at 60:10me Blood Vessels to Cmtrast Mun at Grimm 24. m1. (1.953), Pp. the Madmt Groups m Page“; 225—2553 11, 133:. “NE W Landau: n. 258—263.) 3: o. 326cm. Amid a no. (no chap. (1930),?omnaarm 3mm m mmmum nit maekutiwr ma, mm. wmnm 3. mm 393%. no: linkaaei’aigar Hemiplegio. 89497. , set, i A. (19111:); Gorabml $123me a. Rink, 2;. and sum, m. W 60mm. J. n an. Magnum with kmbmdil. $5.“; (1952), A clinical Evaluation or Carotid mummy. m: Immptinn of (19132), Problem remnants Gram, '12,. 15,: with Organic brim. 5%. and Arena, R. (191:8), Bum! an 107 Gaul. &- g.- of 91mm and at fl! w. W. i Mum 890.913. Eambm angiagraphy: Eoenm-1. Impaired Bow 52: 617-650. 611mm �7'93 Ham: :0 and IND, Edi. (193?). m‘ a. m m. a.» (1939), W3. O - Womeptiom a! a: 95403. Tim Autapsied Cases Wash. of Anoaognosia, ibid. 5: hum. mam, MI. (193?), 359$ 3.} W5... Ives, 3.22. and Disturbance of Bow schem« %‘ .13. 5 W. Vina». 1mm mm. am 191m. g gm. m. 613m; one (19w). comma. momma relax-am for 6mm mm a: 5. W“ mm“ 3: W. Puma, Bacall, Ad. (191a). Luna, . Hahmehmng der Eigam Echo)? ya: ‘ Type. Kenmsum.. nu, 16.0., 33.11., 10m. Paul, 6‘ (19%); Kamiplagia. Bedlam, E. and w. W. du 13mm. g... m. Pm... ("19%). 123-137. Egg. :9. 6. (1938). Helm mm. bed. 31 (1932). 53 W and mum of the Qt hMfih. Thoma. , ' i'ehlen do: 5,. Wahmalmmng W. as: g3: 1-9133. Blindness by Patients with 53} M’Hal'iu of Body 3m. fig Q: (.1953), W Body Image. 5. M“ b m. gm. Springfield. ma Pemmlity Factors in mm o: Mama. W& a Egghiuh Q3 355”367a new, 32. (19M); ingiomplv of mo emua Artery. W hwmt Eu I. Enid ‘36:}. l‘ 1;: _ charm 6. 7 m. a mutant. m. a: m. W. Magnesia Warden 5%. Manama, 3m and ham, 3.1.. {1955), , cmmum 213 117MB; and Barfly, mu. (191:5). Gembral 131mm. 3mm», (1951;), Haber Stet-tinge}: der selbumhmahmng bai unkemitigaw aim Blinéiwit fiendifer, 0mm; B. cambm Angina-am. 5.2%.» 9.9;. Renewing Web, me. and 312616.. g5 W � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Denial of blindness following cerebral angiography. J Hillside Hosp. 1956:5:238-245. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-20-024 Date A point or period of time associated with an event in the lifecycle of the resource 1956 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from the ISRAEL STRAUSS COMMEMORATIVE VOLUME Journal of the Hillside Hospital Volume V, Numbers 3-4 October,1956 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/83ab48a2c2deaa99207d2c9a9f5a4a5d.pdf 5d4afa38e2ad19bfcb3084fe8746be25 PDF Text Text 111: 9/55 Egbert I» Kuhn, mm. Hillside Raspiul, Glen Despite ”posted attomptn, wmlatiam am, my Ia‘rk between aim we activity dwed by «hammock and subsequent. therapeutic outcome haw ham Email, mrtain ahock therapy indum alterations in the sleetmncophalogm in all subjects. mamas voltage whim wmmuml. conclusions are wan-entree! Iran previous studies (1).- Electra:- Three pattema we generally dowribad: ‘1) slowing of tha 2) the in- may of mam, symtria awn {remiss} 51w wave activity, generality a: high appear as burnt nativity) and 3) didnu‘him cios in rate and amplitude. mm in din-act. a at beta rm;— relatim human 12m degree or Mg”, and the number and imam a! mama. In my subjoéts ”mum paint at change is daaeribod, which can be maintained by further those a. tmamnt, but which is apparently not increased. Such indueod oloatroenccpmlu ographic ehangaa are flux-aims. to the pretreatment lswls is number, frequency and Another area than type m ate at“ return at the: cem’bml generally 1 to h weeks, dcpending mhfimfihip between dagraa of manifest and authors is the the ha}: of direct wry loss and aonfusim and the degree of electroencephalogmphie abmmlity. wry changes with few tmamants and without. Cases are demribed of 3mm significant olaetmncaphalogmphic mm without manifest clinical flange; and also a: never: changes in cerebral emmnicn cf inpaimsnt. In these reports, ganic dimam an at tmtnen‘b. a! agreement ”mg the wry patterns it is? stated that Wim also correlates poorly with clinical results. Hammad at tbs Eastern me Society, Bethesda, September 30, 1955» mach or» ��Whfila and EEG these twa “mommy, atuéies dananatrute a ralatianship betwaen clininal ralult tho majority 91’ reports fail to do m. It 3.8 mt 11h]: that this diucrupanay is tha mosult a: diifarunt populatiana, but rather; tun dimer-macs in methods of evaluating Swami, than him at Matias; and diffexunaea in ontinnting change: in aarubrul runntian. In in» figurae at stufiias a! alfiarnd twain tunetian indueed by at elsatma— in SW Yak, further data m the mkfiiamhip betaaun EEG ahangea aaa clinical atfoeta of aluetrenhoek wars colleetcd. ’lhs genaral reaulta a: pruviaun investigatiena an the alteratienn in tho EEG with shank this 311137149 Hospital taro anniixnnd, but 313a, a fiatinite rmlatianahip betwaan.fiflfi effects and has clinical rasult was dnmnnstratod. Throa £661 are preaanted alaetmeshock today: (1) the m pattem mum electroshock and their “hum to in- pwavument. (2) The internorrelatianl at airfarant quantitieatians at ddlta acttvity. (3) m relation of these abaemtiam to a theary at abet whim. :'vzvfihgggggga§§§y Ihuntvmfaar aanaegutava patianta ratarrea for aleetre— 3 shock wart studied. Electruanczgu:.m¢~q us ' 5 warn nan: priar ta traatmant, at uaokly intsrvala flaring traatment aha grist treatment. In 8 ehanns1_flhdcra£t instrunsnt, uaodlo eloatrudus, and bipolar racording Hypervnntilaxdan was tha anly was unad. activatian tachnic utilixoé. truatnant, raaarda ware takna tbs day'attor; ganamully 25 to 31 hunts Datum: after traatmnnt. Th3 Baiter and the tmmnta wen administered by the staff paychia‘bris’m, 6 h? electrnatinulator. Treatment scheéulas namber of treatmants variad tram impruvemant, the 9 to 33. warm An thrae wing a. timma a'waek; patianta shaved alinical psychiatrist tended ta give raver treatments, and warn widely ��m5:- are mam of the diffieultiea in evaluating impmvmnm More might have «momma in the estimates of change in those patients. In any me, by E‘o wing this threefold clusifieatiem, the diffemooa between the groups will be distinct. 9E gag EVALUATIOX first and third W! A total. of 160 meow: were obtained in these who Following the suggestion of Strauss (h), the delta mm am determined for three: lead mmbinetiam (frontal—swam, anterior temporal - vertex, and lobe) for 180 ascends of Hoarding for not load. The delta index :13 on the pemont time woupiod by aerate. ”flame mm of '3 ops- or slower. Tho avenge delta-dude: for the thm loads,.’md the highest delta may: in my load were the 1mm: and in the final tabulation. waves Sinateneouoly, the record me mad for the almost frequency 1am» tifiea at least twioe in my load; the highs» voltage of any delta may and the duration of the longest beret. cm the basis of those were placed 160 mores in It rank fin indie” order from the of slow wave activity the meordu ngt abnormality to the lawn. The were then divided into 3 groups! a Met. upper thins? high degree abnormlfly, and lmat m were .. 1m demo mbmmlitm mum-*3: 1. 0m- nouns show a Mitim aomlntion human early out dugm m; okxomlity and improvement. Thane relationships are demonstrated 11: Slide 1. By utilising sleetroehock, we of troutmt is quantification of slow wave abnormality induced by conclude that snob EEG abnormality induced in the first 3 theme on “mental response. 2.. clinical mm minimums We, and than m clinical Mama for the short tom favorable mot bathroom met each of the eeeh other? indie”, first with the ‘ ��WWW £611.3ng ehetrashock mum is the mault of the emfim in the mtiant functim in winch new panama of adaptaum, part». Mae me “when amnamu 1mm thaw 6! dental, my be. of a inflame! brain as? WM. that: an. alts-rad milieu of eon-ohm}. a puma-equate for ~ 30W, :1: mmnt. mum as measured by delta abnormality is Ta @115 extent the first part. at the Mates».- ”WWI: many of quantitative far the duaidatian at ”Wm 51‘ 27mm mans studies paint. to the Em 5mm: �mm. 1.. than 39mm Lu Th0 Eleatmmeplulm in Thempim, J. Raw. 8: Kent. 131»... Egg 95.107, 3.9512. Jemph a. and Panelist, maetrie 311w]: 3., Harland, W... Kaufman, and Pincus, 6.: Changes in the 81qumafimlegm and in the ke-mtion at 17 {shoutemida [teeming Enam- 3. shmk mommy af Agitated Mpmvam, Payuhoaom. Had... Qt mm, mm: own in the me Mr Barbiturau Anesthesia mma by Elw£mcanwlsin Mama’s and mm SiWicanee for the Timmy (31‘ E01 3.. m and Olin. Rummy“, g; 26l—280, 1951. mum, h. 8km“; Km: Clinical - at mm. madmaophalogmphie Studies a eomhtim Elwtmmawralegmphie and Anatomic Ganges in Gases with m: 14260, 191th. Hammin, Eel” and him, Rd": Mastic U“ a! Mbafiihl 3mm! (“Mm Sodium“) in Ma Brain 31m”, Am. J. Wat" m: 12, m, 6. Fink, 3., Am. J. Psychnti, ' 1953. m,Rental Bead», flu H; and a! Qrmie 7. and Dimse, Org-mm Brain 5. Wfi; 19%. as n Diagnostia Sign Baum, at 246—58, 1952‘ W in now-y and Mauser, 3.: 33mm a: Impmmment in Wmhoak, cant. "euraloguu, 1‘? 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Three pltteme ere generally described as 1) the am ”3'“? am of high voltage which pregneeeee to burst activity; the 3) Mutation at but: 3 frequencies in rate and amplitude. There 1e e direct relation between the - of these changes, and the utmtien point of number and frequency ehmge 1e deeeriheé, which meat, but whieh, seemingly, frequeney and the type or is or treatments. In may an be maintained by eebjeeahe further ’6 ‘ treetmt, ship between degree of manifest M0113 memory the cited authors is lees and centueion maneephnlegnphio abnormality. Ceeee ere eited of severe the leek er and mm ‘ the degree of e memory We with significant electroencephalographic (flange; and fleece: afiWii..¢m”e in cerebral rhythm without. with“ clinical m Manet memory inpeimnt. In theee zeperte, aphasia in "month" he: on such organic ashram also earmletihg poorly we azmm rem! te , ., not inereeeed. Alec, such electmeneephalegmmw Another area of easement few treatments and without 6:3 7‘ g“3* �PM n2. awn”, homer. Two my be cited which mud n oomlatiem ham clinical improvemnt. Rowland, Halo mud, Kaufman and Peanut: in this 19% study of involutional woman ~( chums in the olectmncophalegm and in the accretion of 17 katostoroida new Electmncaphalognphic oranges wing alien-omen]: ens-251, 19M). and at agitated depreaeion, Paychoum. Hod. Q: a relation bunch changes in their clinical therapy roporbed activity as the disturbed be:havior boom now must, tho 13 cps activity incmaed. So treatment induced bohuviounl immanent, 13 ops activity diminished. with recurrent» of symptm, thorn m.- an increase in the 1 time 13 ops activity. rating scale and the per cent time manly, Mort Pmdnm by Theory of a Bath (changes Eloctroconmlaiw EGT action, we and ”no. of mums in which EEG 13 cps in the ma under Rumbas-ate Amsthaain and Their Significance for the hum cm. Hem-own. 1. 261-280, a relationship hottest: thiepontom manna We: and the recovery process “solicited. to inpmvomant. By that it Both noted that slow irregular in appuranm, could not be ntiatuctorily related mm antivity as new in a routine rcéord and be confirmed the reports 1951) described wan adminlltermg an intravenous aolutian of a barbituuto thmpentone, Roth elicited characteristic changes in the ma titer metroshock in mxy subjcct. Early than waé random irregular claw mu untidty, bilaterally which, with more treatment, increased to a highly We), synchronous, high amplitude delta runs and bursts. The” urn chiefly 2.3 cm, with voltages of 200.350 uv and cantlnuoua durations of 30.80 seconds. Winn the mating mcord cum“: rhythmic: Golta activity, umpontem increased its basic pm» its Imam. voltage and duration, spread Roth believed its urea, and decmuod that than chug" warn rehtod to the a! recovery, although, mo concluded: " Hanover, my development at a typical we cameo does slot ensure memory and 10 a! the 36 pntiontl who am men a mag. rams to me for longer m'tw wreaks. m M "Wu-v- 3‘ ' �~3¢ tmsicnt impmment in album). "lat-d. to tho EEG «mating EEG oondition mom to be pationto. .1: in are correct in W cm in thanmommue afloat it would ammo: with tho seem, 31mg mat. tho of tho patients develop typical changes, that the physiological basis for in- provmnt is acquired by the majority or one»; it. «man in promoting recovery.“ w or' my not pm In the course of studiea of altered brain function induced by electron at this mums. Hospital in New York, further day. on the ”Intimaships betmn EEG chanson and :31ch effects of electroshock were collected. shock The general remain of mum innoMga’oiom on the alterations in the elontmhook mm omflmd, but. also, I doflnito relationship between on“ attacks and tho clinical remit «immtmted. Throo fooi are presented today: £30 with - m (1) Tho EEG patterns following electroshock and their relation to mpmmt. (2) mo intercormlationl of nativity. mama; qmtifioaumo or down " (3) The rolotion of those obaomtiona to a theory of electroshock I . SUBJECTS ‘ action. w W: prior to treatment. 1 Twentyofour common“ portion“ referred for ehctm» shook were awaited. An 8 and bipolar moording was Elootmnoephalogms channel Madonna instrument , and. Hypomtiution mdlo electrodes, m the only activation technio mod. During ornament. records wore taken on the day treatment, generally 25 to 31 hours after worn don. trauma“ after a. . ��In this group in mt chum amiable or who moan change was transient immanent. 3m amt. impa‘md. of chm fluctuatians in behavior, at tins appearing. appeamd much as they did EV. diffsmd in tha third groups mmm or? 2 - Strauss (Clinical ham. Bruin that by tha and boron. Wu In w of the difficulties in evaluating impinmefi'o. aa’oimataa of w H111 be A in than patients. change cam, by using this thmefald classifimtim, firlt and sown pnuanu shaved only equivocal or But the ammo was not sua’oainod, no tm¢mnt, they We are “are might. have plum ware distinct. total at 160 thus 11001113 differences botmn the mm obtained in than manta. Following the maggostion or Dr. Rana me! mctmmphubgmc Studies Garrolations a! «.- Electmneophalogmphiu and Antonia chanson in Cases with Organic Dim. Al. J. Payout“... 3&1: hz—so. 19%); the delta ind»: :19th for thm lads (twahlupuriem. anterior tampon)... vortex. «comm of renaming for own land. The and purified-aunt love) for 180 don: mm is defined an the figment. slmr. 1m m tin maupiod by waves or 7 tsp: daluninéex for the three loads, and the: highest in my 1nd ware ten mm: and in the final tabulntiom The average or c1011» Simultmebunly, tho ruéorci was scanned for the slowest freqmncy m imufiod M. lean twice wlta Have; ed, but ivity, m in my load; the highest voltage of my and. the ruration 01’ the longest burst. %er aspect: recordwe! in m final Malawian, worn m mgulamy of ham act.- aim of Alpha activity“ and um degm fraqmciu and amplitude of fast activitiea. “than indie” ‘14 net land study; Qua Inn «mm diam not. by thumb": to statistical meow. Fat amounts." mm identifiablo in all tho the clinical administration of barbiturates. A: thin ' ��07‘! Similar mm» or the relation at nah or the: Macs and minim mm mm mm. be tho group cum than boron. Slide 2 mmmmlaumormauummmmwmt. 1‘1»me result. the much upmd group Jump! to cut-1y lam-wad and unimpmvod group: mm: a by tho 10-12 10—80% A 52:: by tho 7-9 m 1123mm tmtmntz mm gnaw, alum - the #0 tmamm. ‘ similar out or our”: is demonstrated in 511603 for the man um delta 1:: am 1nd. In tho nut. slide the man flaunt Imam in recorded, ma this ahm tho am aigniflunt nhflomhipl. Whiz. the mania imprond highest too ‘ pox-«em. patients than delta waves dam to 3 61:! or I.” by the «com! we]: or tmtmnt, th- at)»: two groups mm: man h 03:: by my fourth wok cf tutti-oat. and; The S and: improved group tho fourth the much new by show highar mm... by the not the elitism: Madly, slide 6 Vat «minim for tho mean highest amntndu chm the am are ”mam far :11 three groups. manta the mean aunties: of bursts. 111 (nu-flint}. In than ml: of Hot noted long bun-at” treatment. Burnt: m no less ”mg. m. wave neural more than 7 {remnant in W m significantly 9119er hen, the is the fact” or “gummy of hm“. £91m!- rmthntly mm more maul“ in troqmcy “plum!” than in the other We groups; than studio: my be interpmud u demonstrating that manure: of slow and The patient: lbw longer hunts, winging 1W tho third unimprmd and modes-«uh inpmvod groups and and mm: mm: and by activity aria from the «wk 01‘ than am myuological pm”, m «imam in ablation to the diaturbmoos in earn-bun. function induhd by elactmahock. �3. finally, can these alterations in npoets of «tubal function mid: In tho» undies, the myriad. 1mm: current-d with own:but been altered by olectroshaok? mama af «tubal function were assayed- tut or Weinstoin and m um 01' double stimulation and tom text showed a W test thus EEG. 013110? any m we ho of tan. In than ation of intuvumu memory and mum” sodium until. racing. 0: than threw indies», only correlation with the subject simultaneous is interviewed 1.21th and can and’ qmatiom of orient- mm, the quantum an reputed errors in orientation, mnfabuhuan, dank). at 3.11am: and rsduplicauon are mud n 'poaitiw' myul tut, and are indicatiw of cerebral wilful-mum; Comet roman to than qmstim after and an a ‘mgatiw' W'm “at. In the wt click, #7. the pox-0mm positivc mm tom are 4 , m wanna. botmn tn. cmpund for meat. me much in titanium. of the m1. gmupa, with the number or weeks ovary patient much improm and at trut- m other tam gram . in the and: improved group had u positive mm by the third weak a! mama, m m abnomaiity panama; in tho unimproved swaps only me patimm had a positive as tram-£19m «opus command mam-m. In 311d. high degree 8. the an relation between, 1‘ EEG abnomlity shows a maul? The“ . ’ tinntmaus tactile tom inclines alarm). maxim and tho distinct carnation which in autism tinny signifiemt. Hint of tho an m1 and thin ahmd no won-elation with mama’s, it. can be concluded that tutu of wry and impromt. In an: and the than are axiom! typo. of mmbml dam- m cannot. speak in gm tom 9! g hrk a! comhum batman m m and 00me dyarnncum or organic payment, function tad taut �‘9. this point I should like us muss m findings and mass thoughts as to thsir significance for s theory or electmshoak mm. At. m moss is 11m. doubt that eloctmshwk m. It 3.: all upmsds to almr, symwio, We. induces delta nbnomnty 1:: tbs may frontal, but with Mmamrtmmm, With immune trusmt thafisqmncios beam the smplitudu higher, tho bunt activity longer sad more regular. mile den: sbnomlity is pussnt in every mpord “fir olsctmhock, its Roth‘s mum‘s mammg Manning emu .mmw «gm 9.: with bat-bum“ are Digniflmt 1n pmfimg the 11m” emu Mum by «wk. furthsr slntroahwk. In sans subjects sanity is not. induced despite atoms.” Our aux-relations of Guam 0!." test, um s meeasary chm-"u fail to wear in the tram. delta ammlity with 13pm srs «:1»th thorium. significant far tbs ”amiss: o: alteration in cox-ohm function as mm War, a high dogma «hits smorAn early, autumn mm by the EEG, and (and in the m1 taut), also by m. ' pmummfiSiM for improvemt. when such EEG H u sign- nificmt clinical improvement V111 rail to wear in the patient' a hshs'dar. with wry loss, points Tbs rm. that than camlatiws mm not to the poasihiuty that. this is not a significant master in improvement. In conclusion, than studs.“ land uppers to s theory at E8? action mofintly unwanted by Gamma sud can at us (Kuhn). Thou “at ‘ authors postulstsd that wwwmt fanning olactroshoek is than malt of tbs amtion 1:: tbs patient 91' a min at altered brain function in much now puttéms or mputim, a-srtioulorly mm a! denial; my be main-- mm. mm m nudist Winn that :5 «land milieu of «avatar-J. museum u assured by mu abnormality is ,s pm~mu1s1u for improvisamt. ‘ro this extent the first. part. of fins unseen-am Wall is ’“PPGTst �% m W, mm «was: m- studs.» punt to fluaififlfiim of m “grammar of quantum" Wm at mum ' �Dr. Joseph S. A. Miller. To: From: Dr. Max Fink May I have your approval to submit this technical paper to the Eastern EEG Society for its October meeting in Bethesda ? ��mmmMmmwmtmmam mm m m mum as? (3) a» in mm. warm “at m m a: m mam a: mm mm: mwvm mmmmymmm mm,mzm �112:? My) Quantitative Studies 2;: Slow Wave I M 9/5"!» Activitz Following Electroshock Max Fink, HOD. Robert L. Kahn, PhoD. Hillside Hospital, Glen Oaks, New York Despite repeated attempts correlations between slow wave activity induced by electroshock and subsequent therapeutic outcasts have been unsuccessful. Howconclusions‘pfrom W; ”avg/a... rewart-m previous studies?“ "W Wm“ Ail—pam- over, certain mduuo are Electroshock therapy suffer alterations in the electroencephalogram«a»‘fiz 9%.- . 3m Three pattems are generally describedzu l) b slowing of the alpha frequen- cies; 2) the appearance of random, synmetxic slow wave activity, generally of; activity, and 3) diminution of beta frehigh voltage which Wfibwburst quencies in rate and amplitude. There is a direct relation between the degree of these changes, and the number and frequency of treatments. In many subjects a saturation point of change treatment, but the pretreatment levels mnnbe r, described, which can be maintained by further is which” are reversible. Qffldeef Mir. not increased. The ographic changes the is «he, we!“ c,at!” 5mm electroencephal- rate of return of the cerebral patterns to is generally l to b, weeksxgfl’ipending directly ugh- on frequency and the type of treatment. cited authors is the lack of direct relationship between degree of manifest memory loss and confusion and the degree Another area of agreement among the of electroencephalographic abnormality. Cases are describedgevere memory changes with few treatments and without significant electroencephalographic change; and also of severe changes in cerebral or memory impairment. In these reports, Weclinical is correlatgug poorly With organicconfusion also Presented at the Eastern E E W rhytlmls without manifest 0 Society, Bethedda) -~-- clinical confusion > Md “HA0? 8 such gM’Y’EJ results. - Septembee 30, ”0...... «.~.—.._._,___...~—-— 4...“ ._.... 195? �Two studies, however, may be cited as noting a correlation between ectro- u: encephalographic changes and clinical improvement. Hoagland, Malamud, Kaufman rt- fidand Pincus in their l9h6 study of involutional L’ women ‘1) - tonnage-MW: reported a =§W19§9+ relation between changes in their clinical rating scale and the per- cent time 4'40 W61 131, ‘ctivity. more than 3.2% activity increased. cw activity diminished. % A time 1301;: a More As treatment induced behaviojral improvement,—-B=eps tivity.C3,) Roth fl" there was an MK, increase in the . Mow-W .--__ , WWW-WBW‘UI relationship msngmmeWeWw5M— the Mby. ~. the disturbed behavior became more manifest, the With recurrence of symptoms, e WA recently, As . 1 described a between thiopentone induced EEG changes and recovery process. Roth noted that slow wave activity as seen in a routine post-shock record was irregular in appearance, and he confirmed the reports that it could not be satisfactorily m , related to improvement. the However, by administering an intravenous thiopefi‘tone, he elicited characteristic changes solution of in the EEG after electroshock in every subject. Early’there was random irregular slow wave act- ivity, whichyéith increased to a highly rhythmic, bilaterally more treatmen synchronous, high amplitude delta runs and M ILKoVol'PS bursts. These were with voltages of 200-350 is and continuous durations of 30-80 seconds. When its the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its believed that these changes were m F4» lemma; chiefly 2-3 area, and decreased its basic frequency. related to the process of recovery, and Both v �he concluded: “The development of a typical and 10 of the 36 patients who attained such a than two weeks. But transient improvement related to the ing the EEG EEG change does not ensure recovery failed torsmit for longer in clinical condition seemed tolae change in these patients. changes with the therapeutic effect it EEG change even If we are correct in connect- would seem, since most of the patients develop typical changes, that the physiological basis for improvement is acquired by the majority of cases; it may or may not prove effective in promoting recovery." Whileathesettwofistudiessdemonstrate a relationship between clinical result and EEG abnormality, the majority of reports fail to do so. It is not likely that this discrepancy is the result of different populations, but rather, the differences in methods of evaluating improvement, the time of evaluation, and differences in estimating changes in cerebral function. In the course ofestudies of altered brain function induced by electroshock at the Hillside Hespital in further data on the relationship! be~ tween EEG changes and clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the EEG with New York, electroshock were confirmed, but also, a definite relationship between effects and the clinical result was demonstrated. Three EEG foci are presented today: (1) The EEG (2) The patterns following electroshock and their relation to improvement. intercorrelations of different quantifications of delta activity. (3) Athe relation of these observations to a theory of electroshock action. SUBJECTS AND METHOD: Twenty~four consecutive patients referred for electroshock were studied. Electroencephalograms were done treatment, at weekly intervals during treatment and after treatment. prior to An 8 channel �.5‘ but the dramatic in the change so evident patient continued to first group was not apparent. Each noticable disturbance such as obsessional think- show some ing, paranoid ideas, or somatic preoccupation. C. whom Minimalyy or Unimproved: In this group were placed seven patients in change was not clearly noticable or who showed only equivocal or improvement. improved. Some showed transient fluctuations in behavior, at times appearing But the changes were not sustained, so that somewhat by the end of treatment, they appeared.much as they did before. we are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, using this threefold classification, the differences between the third groups will be by first and distinct. EVALUATION OF EEG RECORDS: A total of jects. Following the suggestion of LJ.aPsychiatemgggnehZ-Sewwl9hhd, w 160 records were obtained in these subStrauss the delta index was determined for three lead (frontal-parietal, anterior temporal - vertex, and parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined combinations as the perbcent time occupied by waves of 7 cps or slower. The average for the three leads, and the highest delta index in any lead indices used in the final tabulation. index Simultaneously, the record was scanned delta- were the for the slowest frequency identified at least twice in any lead; the highest voltage of any delta wave; and the durb ation of the longest burst. (V) �Ch. Medcrart instrument, needle electrodes, and bipolar recording was used. Hyperb ventilation was the only activation technic utilized. During treatment,:records were taken the day after, generally 25 to 31 hours The treatments were administered by the C h? electrostimulator. number of treatments after treatment. staff psychiatrists, using a Reiter Treatment schedules were three times a week; and the varied from 9 to 33. As patients Showed clinical improve- ment, the There psychiatrist tended to give fewer treatments, and more widelyfspaced. were 15 women and 9 men in the series, and ages ranged from.2h to 68 with a median of h7. EVALUATION QE CLINICAL RESPONSE: All the patients eight were observed for at least after termination of therapy. determined on the basis of the res- weeks patient's reaponse to electroshock was ident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervisor in charge of electroshock. The patients were The divided into three groups A. Markeglz ggproved: ~ markedly improved, moderately improved and unimproved. The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer showed the which brought them symptoms into the hOSpital; their doctors felt they were better; and the nurses' notes confirmed such aspects as being able to sleep without medic- ation, better appetite, and improved capacity to get along with the other patients and participate in hospital activities. six patients in this group showed some improvebut continued to manifest indications of mental illness. These patients B. iModerately ggprove : The ment typically Showed symptomatic relief, i§,, acute depressive features might be gone, �On the basis of these five indices of slow wave activity the records placed in a rank order from the greatestabnormality to the lowest. cords were then divided into 3 groups - g ufibr were The 160 third - high degree EEG re- abnorm- ality) and lowest third =£w degree abnormality. RESULTS:1.0ur results show a positive correlation between early high degree EEG abnormality and improvement. These relationships are demonstrated in Slide I. utilizing these quantifications of slow wave abnormality induced by electroshock, we conclude that such EEG abnormality induced in the first 3 weeks of ‘By is treatment an essential pre-requisite for the short term favorable clinical response. 2. What relationships exist between each of the indices, clinical response, and then / amongst each first with the other? Similar analyses of the relation of each of the indices and clinical result identical curves to the group curve shown before. Slide 2 shows the relation of the delta index to improvement. The mean index in the much im- showed proved group jumps to 52% by the 7-9 treatment; while the moderately improved and unimproved groups show a gradual, slow increase to 10-20% by the 10-12 treatment. A similar set of curves id demonstrated in slide 3 for the mean highest percent time delta in one lead. In the next shows the show delta other two Slide same slide the slowest frequency is recorded, significant relationships. While the and this) tbo/ much improved patients to 3 cps or less by the second week of treatment, groups Sarely reach )4 cps by the fourth week of treatment. waves down 5 shows the same much improved group show week the mean correlations for the mean and- *{e highest amplitude, the higher voltages by the second week and by the fourth differences are persistent for all three groups. �Finally, slide 6 shows the duration of bursts. mean The records of the much Improved patients third treatment. Bursts are less frequent in the unimproved and week of show longer bursts, averaging more than 7 seconds by the mod- erately improved groups and are significantly shorter in duration. not noted here, however, is the factor of regularity of bursts. In the longer bursts, wave forms frequently were more regular in frequency and amplitude, than in the other two groups. These studies may be interpreted as demonstrating of slow wave activity arise from the same that each of these measures physiological process, and assume the significance in relation to the disturbances in cerebral function induced by electroshock. same I 3. Finally, can these alterations in the pects of cerebral function which EEG may have been be correlated with other ap- altered by electroshock? In these studies, three other indices of cerebral function were assayed - the amytal test of Weinstein and Kahg? tests of double simultaneous tactile stim- ulatioaj and tests of amytal test showed a memory and recalfz) Of these three indices, only the positive correlation with improvement and.with the EEG. results were presented recently at the American Psychiatric Association we will forgo a discussion at this time. ‘93 __,wle These and It.;::; suffice demonstrates the correlation berel éF, tween the amytal eating and the high degreerhEG abnormality. n—v_ this iigfigLshows fib£ that the next slide, # 7 ' , distinct relationship between the two factors. At this point I should like to summarize our findings and express some thoughts as to their significance for a theory of electroshock action. There is little doubt that electroshock induces delta abnormality in the EEG. It is a symmetric, chiefly frontal, but with increasing treatment, spreads to all leads. With increasing treatment the frequencies became slower, the amplitudes higher, the burst activity longer and more regular. in every record after electroshock, its ‘While degree delta abnormality is present is variable. Roth's experiment's �~8- inducing increasing delta abnormality with barbiturate are significant in predicting the later changes induced by further electroshock. In some subjects however, a high degree delta abnormality is not induced despite extensive treatment. correlations of degree of delta abnormality with improvement are also significant for the theory of the mechanism of electroshock. An early, SusOur tained alteration in cerebral function as measured by the EEG, and also by the amytal test, appears to be a necessary pre-requisite for improvement. Where *- in the amytal test), the: the patient's behavior. €l%n ificant clinical improvement will fail to occur in fact that the correlations were not evident with memory loss, points to the possibility that this is not a significant factor in improvement. such changes fail to occur in the EEG (and The In conclusion, these studies lend support )to a theory of EST action recently (Kahn)(.r These authors postulated that enumerated by Weinstein and one of us improvement following electroshock is the result of a milieu of altered brain function in which of the creation in the patient new patterns of adaptation, part- icularly those of denial, may be maintained. These EEG studies demonstrate that an altered milieu of cerebral function as measured by delta abnormality is a pre-requisite for improvement. To this extent the first part of tbs Weinstein-Kahn hypothesis is supported. Secondly, these studies point to the validity or quantitative the elucidation of mechanisms of behavior. EEG studies for �1533 m a???" September 21, 1955 MEMORANDUM TO: FROM: Dr. Soseph S. A. Miller Dr. (1) Max Fink entitled "Quantitative Studies of Slow Wave Activity Following Electroshock" will be presented at the Eastem EEG meeting at Our paper Bethesda, Friday September 30th. (2) May I have permission for Dr. Kahn (the co-author) and myself to attend the sessions of the society? �(new? ' £5)“; saw» 21.. 1955 m! m1 Mamaahamr ”gum (1) our W amt-MM *mpmuu saw» a: 3m 1m Mtiviw (a) lily 1: MWMWflnbapWMWMMWmM at whim! is!» ma pammaa tear m». ”aim at the am m (m mama!) and W ta 357‘ �III: Quantitative Studies 2; Slow Wave 9/55 Activity Following'Electroshock Fink, Max MOD. Robert L. Kahn, Ph.D. Hillside Hospital, Glen Oaks, New York Despite repeated attempts, correlations between slow wave activity in- duced by electroshock and subsequent therapeutic outcome have been unsuccessful. However, certain conclusions are warranted from previous studies (1). Electro- shock therapy induces alterations in the electroencephalogram in all subjects. Three patterns are generally described: 1) slowing of the alpha frequencies; 2) the appearance of random, symmetric slow'wave voltage which cies in rate may activity, generally of high appear as burst activity; and 3) diminution of beta frequenThere and amplitude. is a direct relation between the degree of these changes, and the number and frequency of treatments. a saturation point of change is described, to the pretreatment levels The 1 to h weeks, depending directly on the treatment. relationship between degree of manifest memory degree of electroencephalographic abnormality. memory impairment. in cerebral loss and confusion of direct and the Cases are described of severe at the Eastern EEG rhythms without manifest In these reports, ganic confusion also correlates poorly with Evesented is the lack with few treatments and without significant electroencephalographic change; and also of severe changes confusion of further Such induced electroencephal- Another area of agreement among the cited authors memory changes subjects rate of return of the cerebral patterns is generally number, frequency and the type of many which can be maintained by treatment, but which is apparently not increaSed. ographic changes are reversible. In it is clinical stated that such or- clinical results. Society, Bethesda, September 30, 1955. �-2studies, however, Two cited as noting a correlation between may be electroencephalographic changes and clinical improvement. Hoagland, Malamud, in their l9h6 study of involutional Kaufman and Pincus women relation between changes in their clinical rating scale time more than 13 cycles per second activity. and the per-cent the disturbed behavior be- As manifest, the fast activity increased. came more (2) reported a treatment induced behavior- As al improvement, such fast activity diminished. With recurrence of there was an More induced increase in the Roth (3) described a recently, EEG time 13 cycles per second % provement. Roth noted it tone, he elicited characteristic changes in the was random irregular and bursts. w act- wave solution of the thicpen- EEG after electroshock in every slow wave activity, which increased bilaterally synchronous, high with mere treatment to a highly rhythmic, litude delta runs 51 was However, by administering an intravenous subject. Early, there that irregular in appearance, and could not be satisfactorily related to imr ivityas seen in a routine post-shock record reports that activity. relationship between thiopentone changes and the recovery process. he confirmed the symptoms, amp- chiefly 2-3 cycles per second, with These were voltages of 200-350 microvolts.and continuous durations of 30-80 seconds. the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its believed that these changes were patients than But two weeks. related to the ing the patients EEG EEG transient change even improvement change does not ensure recovery failed to remit for longer in clinical condition seemed to be change in these patients. If effect it we are correct in connect- would seem, since most of the typical changes, that the physiological basis for by the majority of cases; moting recove 1y." EEG attained such a changes with the therapeutic deveLOp is acquired who its area, and decreased its basic frequency. Roth related to the process of recovery, and he concluded: "The development of a typical and 10 of the 36 'When it may or may not prove improvement effective in pro- �.3While these two studies demonstrate a relationship between clinical result' and EEG abnormality, the majority of reports fail to do It is so. not likely that this discrepancy is the result of different populations, but rather, the differences in methods of evaluating improvement, the time of evaluation, and differences in estimating changes in cerebral function. In the course of studies of altered brain function induced by electro- at shock the Hillside Hospital in New York, further data on the relationship clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the EEG with between EEG changes and electroshock were confirmed, but also, a definite relationship between effects and the clinical result was EEG demonstrated. Three foci are presented today: (1) (The EEG patterns following electroshock and their relation to imp provement. (2) The (3) The SUBJECTS intercorrelations of different quantifications of delta activity. relation of these observations to a theory of electroshock acticn. AND METHOD: Twenty-four consecutive patients referred for electro- shock were studied. Electroencephalograms were done prior to treatment, at weekly intervals during treatment An 8 and after treatment. channel Medcraft instrument, needle electrodes, and bipolar recording was used. Hyperventilation was the only activation technic utilized. treatment, records were taken the day after, generally 25 to treatment. The Reiter C 31 hours During after treatments were administered by the staff psychiatrists, using a h? electrostimulator. Treatment schedules were three times a week; and the number of treatments varied from 9 to 33. improvement, the As patients psychiatrist tended to give fewer treatments, showed clinical and more widely �.u. There were 15 women and 9 men spaced. to 68 in the series, and ages ranged from 2h with a median of h7. g3 EVALUATION CLINICAL RESPONSE: All the patients were observed for at least eitht weeks after termination of therapy. patient‘s reSponse to electroshock'was determined on the basis of the resident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervisor in charge of electroshock. The patients The were divided into three groups - markedly improved, moderately improved and unimproved. A. Markedly Improved: The 11 cases in this group showing recovery or marked improvement. These symptoms which brought them into the beepital; patients were regarded as no longer showed the their doctor felt they were better; and the nurses' notes confirmed such aSpects as being able to sleep without medication, better appetite, and improved capacity to get along with the other patients and participate in hospital B. improvement activities. six patients in this group showed some but continued to manifest indications of mental illness. These Moderately,lmproved: patients typically The showed symptomatic relief, i:g;, acute depressive features might be gone, but the dramatic change so evident in the apparent. Each patient continued to show some first group was not noticable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally g£_unimproved: In this group were placed seven patients in whom change was not clearly noticable or who showed only equivocal or transient improvement. Some showed fluctuations in behavior, at times appearing somewhat improved. But the changes were not treatment, they appeared much sustained, so that by the as they did before. end of �.5are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, by we using this threefold classification, the differences between the groups first and third will be distinct. 93 EVALUATION delta index EEG RECORDS: was A total of 160 records were obtained in these sub- jects. Following the suggestion of Strauss (h), the determined for three lead combinations (frontal-parietal, anterior temporal - vertex, and parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined as the per-cent time occupied by waves of 7 ops or slower. delta-index for the three leads, and the highest delta index in any lead were the indices used in the final tabulation. The average for the slowest frequency idenp tified at least twice in any lead; the highest voltage of any delta wave; and the duration of the longest burst. Simultaneously, the record 0n the was scanned basis of these five indices of slow wave activity the records were placed in a rank order from the greatest abnormality to the lowest. 160 records were then divided into groups abnormality, and lowest third = RESULTS: in Slide 3 - i;g=_upper third= The high degree EEG low degree abnormality. l. Our EEG abnormality and improvement. These relationships are demonstrated results show a positive correlation between early high degree I. utilizing these quantifications of slow wave abnormality induced electroshock, we conclude that such EEG abnormality induced in the first 3 By of treatment is an.essential pre-requisite for the short term favorable by weeks clinical response. 2. What relationships exist between each of the indices, clinical response, and then amongst each other? first with the �~6- Similar analyses of the relation of each of the indices and clinical result identical curves to the group curve shown before. Slide 2 shows the relation of the delta index to improvement. The mean index in the much improved showed group jumps to 52% by the 7-9 treatment; while the moderately improved and un- improved groups show a gradual, slow increase to 10720% by similar set of curves is demonstrated in slide A 3 the 10-12 for the mean treatment. highest percent time delta in one lead. In the next slide the shows the same delta show other two groups to the same much improved group show week h cps by the much improved While the much improved fourth correlations for the week of mean all three 6 shows the mean duration of patients this, too, patients treatment. highest amplitude, the higher voltages by the second week and by the fourth the differences are persistent for Finally, slide and cps or less by the second week of treatment, the 3 rarely readh 5 shows is recorded, slowest frequency significant relationships. waves down Slide mean show groups. bursts. The longer bursts, averaging more than records of the 7 seconds by the third week of treatment. Bursts are less frequent in the unimproved and moderately improved groups and are significantly shorter in duration. Not noted here, however, is the factor of regularity of bursts. In the longer bursts, forms frequently were more regular wave in frequency and amplitude, than in the other two groups. These ures of the studies may be interpreted as demonstrating that each of these meas- activity arise from the same physiological process, and assume significance in relation to the disturbances in cerebral function in- 31 w wave same duced by electroshock. 3. Finally, can these alterations in the pects of cerebral function which may have been EEG be correlated with other as- altered by electroshock? In these studies, three other indices of cerebral function were assayed - the amytal �-7- test of Weinstein and Kahn (5), (6), and tests of memory and tal test showed a positive correlation with tests of double simultaneous tactile stimulation recall (7). Of these three indices, only the amyimprovement and with the EEG. These results were presented recently at the American Psychiatric Association and we will forgo a discussion at this time. It may suffice that the next slide, # 7, demonstrates the correlation between the responses on amytal of abnormality. This graph EEG tests and the degree distinct relationship between the shows a two I factors. this point I should like to summarize our findings and express thoughts as to their significance for a theory of electroshock action. At is little doubt that electroshock induces delta abnormality in the symmetric, chiefly There It is EEG. frontal, but with increasing treatment, spreads to all leads. increasing treatment the frequencies With some became slower, the amplitudes the burst activity longer and more regular. While delta abnormality in every record after electroshock, its higher, is present is variable. Roth's experiment's degree inducing increasing delta abnormality with barbiturate are significant in predicting the later changes induced by further electroshock. In some subjects however, a high degree delta abnormality is not induced despite extensive treat- ment. Our correlations of degree of delta abnormality with significant for the theory of the mechanism of electroShock. tained alteration in cerebral function as measured amytal test, such changes clinical improvement are also An early, sus- by the EEG, and also by the appears to be a necessary pre-requisite for improvement. Where fail to occur in the improvement in the amytal test), then significant will fail to occur in the patient's behavior. The fact that EEG the correlations were not ivident with (and memory loss, points to the possibility that this is not a significant factor in improvement. In conclusion, these studies lend support to‘a theory of enumerated by Weinstein and one of us (Kahn) (8). EST These authors action recently postulated.that �-8improvement following electroshock of a milieu of is the result of the creation in the patient altered brain function in which new patterns of adaptation, part- icularly those of denial, may be maintained. These EEG studies demonstrate that an altered milieu of cerebral function as measured by delta abnormality is a pre-requisite for improvement. To this extent the first part of the weinsteinKahn hypothesis is supported. Secondly, these studies point to the . for the elucidation of validity of quantitative mechanisms of behavior. EEG studies �REFERENCES l. Chusid, Joseph G. and Pacella, Bernard L.: the Electric Shock Therapies, J. Nerv. The Electroencephalogram & Dis., 11g: 95-107, 1952. Ment. Hoagland, H., Malamud, W., Kaufman, and Pincus, 6.: encephalogram and in the Excretion of 17 in Changes in the Electro- Ketosteroids Accompanying Electro- shock Therapy of Agitated Depression, Psychosom. Med., §; 2&6-251, 19h6. 3. Roth, Martin: Changes in the EEG Under Barbiturate Anesthesia Produced Electroconvulsive Treatment and Their Significance for the Theory of Action, EEG by ECT and Olin. Neurophys., 2; 261-280, 1951. Strauss, Hans: Clinical and Electroencephalographic Studies ~ Correlations of Mental, Electroencephalographic and Anatomic Changes in Cases with Organic Brain Disease, So Am. J. Psychiat., 191: and Kahn, R.L.: weinstein, E.A., ("Amytal Sodium") Diagnostic hZ-SO, l9hh. Use of Amobarbital Sodium in Organic Brain Disease, Am. J. Psychiat., 192: 12, 889-89h: 1953. 6. Fink, M., Green, M. and Bender, M.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology, 2: h6-58, 1952. 7. Karin, H., Fink, M. and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conf. “eurologica, 1Q: 88-96, 1956. Weinstein, E.A., Kahn, R.L. and Linn, L.: Peychosis During Electroshock Therapy: 19.9.: Its Relation to the 22-26, 1952. Theony of Shock Therapy, Am. J. Psychiat., �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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Archives of Neurology (“7 Psychiatry November 1957, Vol. 78, pp. 516—525 Copyright 1957, by American Medical Association Relation of Electroencephalographic Delta Activity to Behavioral Response in Electroshoek Quantitative Serial Studies MAX FINK, M.D., and ROBERT L KAHN, Ph.D., Glen Oaks, N. Recent theories of'electroshock therapy 1'3 have emphasized the role of neurophysiologic changes as. the basis for the therapeutic ac— tion of electroshock. Consistent with these theories, we have observed a relation between changes in certain measures of brain function and behavioral response. We have noted that evaluations of clinical improvement fol— lowing electroshock are related to changes in orientation and confabulation after intra— venous amobarbital,4 learning and recall,5 and syntactical aspects of language.6 In view of these observations, it could be expected that electroencephalographic studies would show a similar relationship. Numerous observers have reported consistent changes in the electroencephalogram after electrically induced convulsions. There is diffuse slowing with increased voltage and dysrhythmic activity?"12 Fast activity decreases, both in voltage and in percent time}3 and in patients who are intensively treated there is a slowing of persistent alpha frequencies.14 The degree, duration, and extent of delta activity are directly related to the frequency and number of grand mal convulsions?"14 Such activity is usually symmetric and appears maximal in anterior leads, and the electroencephalog— Received for publication June 18, 1957. From the Department of Experimental Psychia— try, Hillside Hospital. Presented at a meeting of the Eastern Associa— tion of Electroencephalographers, Washington, D. C., September, 1955. Aided, in part, by Grant M—927, National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Dalian Foundation for Medical Research, New York. Y. raphic effects usually disappear in the four to eight weeks following the last treatmentfgi9 In contrast to the consistency of these observations, studies of the relationship between the electroencephalographic and the clinical changes show conflicting results. Chusid and Pacella,15 after an extensive review of the literature, concluded that the number of treatments rather than the degree of induced delta activity, was the primary factor related to a favorable therapeutic re— sponse. On the other hand, Hoagland et al.16 reported a relation between changes in the percent time fast activity (more than 13 cps) and independent clinical ratings of be— havioral change._ Roth2 similarly reported a relationship between changes in the clinical state and alterations in the delta response induced by intravenous thiopental sodium. The divergent observations reflect variations in methodology. The present study is an attempt to apply quantitative methods of analysis of serial electroencephalographic records to this problem. The purpose of this study is to determine (1) the relation of changes in electroencephalographic delta activity to the behavioral response in electro— shock, and (2) if a relationship does exist, the significance it may have for an under-standing of the electroshock process. Subjects and Method 1. In the initial series, 24- consecutive patients referred for electroshock were studied. Electro— encephalograms were obtained prior to treatment and at weekly intervals during and after treatment, using an eight—channel Medcraft electroencephalograph and needle electrodes. Recording was bi— polar, and hyperventilation activation was utilized 516 ,. “(34.x �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE during each recording. During the treatment pe— riod, records were taken on the day following a treatment, generally 25 to 31 hours later. Grand mal electroshock therapy was administered by staff psychiatrists, using a Reiter C-47 electrostimulator. Treatment schedules were three times a week, and the number of treatments varied from 9 to 33. As patients showed a clinical response, the psychiatrist tended to give fewer and more widely spaced treatments. There were 15 women and 9 men in the series, and the ages ranged from 24 to 68, with a median of 47 years. Evaluation of EEG Records—A total of 160 records were obtained on these subjects. Following the suggestion of Strauss,17 the delta index was determined for three lead combinations (frontal— parietal, anterior temporal-vertex, and parietal-ear lobe) for 60 seconds of recording for each lead. The delta index is defined as the percent time occupied by waves of 7 cps or slower. The run of each selected lead combination was scanned, and 180 cm. (60 seconds) of recording that was artifact-free was noted. An additive map measure was run along the base of all waves of 7 cps or slower, determining the number of centi— meters occupied by such slow activity. The ratio of this figure to 180 was the delta index of that combination. ’ After these measurements were made, the rec— ord was scanned for the slowest frequency clearly The total record was also scanned for burst activity. The duration of burst activity, the regularity (modulation) of the waves in the burst, and average voltage were noted. In the final estimates of degree of delta activity, the average delta index for the three lead corn— binations, the highest delta index in any one lead, the slowest frequency, highest delta voltage, and duration of longest period of burst activity were listed for each record. The 160 records were ar— ranged in sequence for each index and the per— centile rank determined. The ranks were added and the records then arranged in rank order ac.— cording to this score. On the basis that the higher score reflected a greater degree of delta activity, the upper third of the records was classified as “high—degree delta”; the middle third, as “moderate-degree delta,” and the lowest third, as “lowdegree delta.” An example of each is shown in Figures 1, 2, and 3, respectively. High—degree delta records were characterized by an average delta index of at least 18%, a delta index of 21% or more in one of the three measured leads, a slowest frequency of less than 3% cps, a highest delta voltage of more than 100pv, and a burst duration of at least two and a half slow waves. LF-LO WWWAWWWNIWW WWW RF'RO LAT- LPT WWWVWWW RAT-RPT WWW/WWW PRE-EL seconds. Low-degree delta records were characterized by an average delta index of less than 2%, a highest delta index in one lead of 3% or less, frequencies no slower than 5% cps, voltages of less than 60pv, and burst duration of less than one—half second. W “WW W W identified at least twice in these selected lead combinations, and for the highest voltage of these R P‘E AMNVWWWNVW L F _ LO «wanjVMImWW-flm WMWMWMMW RF- RO awmwwm WW LC-LMT LC-LMT RC-RMT “WW RC-RMT LP-E WWW WW RP-E RP‘E WWWNAMMMMMWMW WWW WWW LAT' L PT LAT-LPT RAT-RPT PRE- ELECTROSHOCK ISECOND , 24 HOURS AFTER EST Fig. 1.—Low-degree delta activity. Fink—Kuhn I50 M, it l2 5-17 . ‘ WWW RAT-RPT WWW PRE-ELEC .mafi-” _,__._---_., __..-_t r-.- 518 �vs WWWWfi ., .v. h A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY LF LO WMWWWWWW WWWWWWWW LC-LMT WWW RC-RMT LP-E KEN-W LAT- LPT WWWWWNWWNWMNA W WWW»! I RAT RPT VWVWWNWWWWWWNwWV‘WWW/wm PRE-ELECTROSHOCK 24 HOURS SECOND 1:5on AFTER EST 4* IO Fig. 2.—Moderate-degree delta activity. L F “ LO WWEJVANWWWJWWWMk/‘W‘mgfaNJWW‘AMW R F - RO JVWMWWWWAW WWW LC'LMT RC-RMT LP-E WWW-”WW . RP-E WWW“ LAT- L PT WWW RAT-RPT PRE-EL ECTROSHOCK WW ISOMV WWW/meflwx 24 HOURS AFTER EST 4* M Fig. 3.—High-degree delta activity. 518 Vol. 78, N07J., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE I Moderate-degree delta records were between these two groups, with an average delta index between 2% and 18%, a highest delta index in one lead of 3% to 20%, a slowest frequency of 4-5 cps, high— est amplitude of between 60yv and 90,uv, and burst duration of one-half to two seconds. 2. In a second series, of 54 consecutive, unselected electroshock patients, electroencephalo— graphic records were obtained prior to treatment. during the second and third weeks of treatment, and two weeks after treatment. These records were analyzed using measures identical with those in the initial series. Using the original cut-off points, these records were classified as high-, moderate—, and low—degree—delta records, and the initial observations were tested in a predictive study of therapeutic response. Evaluation of Clinical Response—All patients were observed for at least eight weeks after termination of therapy. The patient’s response to electroshock was determined on the basis of the resident psychiatrist’s impression, the staff opinion, the nurse’s notes, and the clinical evaluation of the supervisor in charge of electroshock. The patients were divided into three groups—much improved, moderately improved, and unimproved—according to the following criteria: A. Much Improved: The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer presented the symptoms which brought them into the hospital; their doctors felt they were better, and the nurses’ notes confirmed such aspects as being able to sleep without medication, better appetite, and improved capacity to get along with others and participate in hospital activities. B. Moderately Improved: The six patients in this group showed some improvement but continued to manifest symptoms of mental illness. These patients typically showed symptomatic relief; i. e., acute depressive features might be gone, but the dramatic change, so evident in the first group, was not apparent. Each patient continued to show some noticeable disturbance, such as obsessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally or Unimproved: In this group were placed seven patients in whom change was not clearly noticeable, who showed equivocal or transient changes, or who became worse. They showed fluctuations in behavior, at times appearing less ill. The changes were not sustained, however, so that by the end of treatment they appeared much as before. activity and clinical ratings demonstrated a significant relationship between the early ap— pearance of high—degree delta activity and the “much-improved” clinical ratings. Of the records in patients who were rated as much improved, 80% were classified as high—de— gree delta in the second week, 91% in the third week, and 88% in the fourth week of treatment. Of the records in patients who were rated as unimproved, none showed high—degree delta in the second or third weeks of treatment, and only 20% were classified as high—degree delta in the fourth week. The data are expressed in Table 1 and graphically in Figure 4. TABLE 1.—Electroencephalographic Percentage of High-Degree Delta Records Degree of EEG Delta Activity and Clinical Ratings.——The initial analyses of the relation between the degree of induced delta F ink—Kahn 1. MUCH IMPRO +——Moo. IMPRO\ 50_ .---- UNIMPROVEI TIME A ‘13 A. 4‘“ PERCENT o: C? -.__~_ ,. m <.3 AVERAGE ...__.—_____.-._, c3 MEAN WAVES I50} .—- MUCH +——Moo. IMPROVI IMPROVI ---~ unmpnovso DELTA Treatment Period Much improved (11) OF 1-8 4—6 7—9 10—12 25 80 91 88 Moderately improved (6) 0 16 50 40 Unimproved (7) 0 O 0 20 IOOAv AMP(LITU)DE u- c.’ HIGHEST Indices and Clinical Ratings.——An analysis of the relation between each of the five indices used in the final estimate of the degree of delta activity and the clinical ratings also show significant correlations. In Figure 5A to E, each index is related to the number of convulsive treatments and the eventual therapeutic evaluation. The curves 2. Delta OOACTIVITY 90. 80- DELTA MUCH IMPROVED .—— M00. (III IMPROVE-10(6) ._-— UNIMPROVEDU) ‘ 70' 60‘ DEGREE 504 HIGH 40‘ 20I 0‘ o. O / '\. / 3O~ PERCENTAGE Results DELTA / I-3 / / ' / 4-6 __/' 7-9 NUMBER OF TREATMENTS MEAN L Fig. 5.—A-E, rt each index of delt: ' \\ /' / IO'IZ Fig. 4.—.Re1ation of clinical ratings to development of high—degree delta activity. 519 for the highest—am 5C) and the slow are most similar tc of delta activity ( The other three clearly differentia group from the p2 520 �/\ A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY f3 __J g . MUCH IMPROVEDUJ) IMPROVED (-6) 50_ pgmoo. o----UNIMPROVED(7) < 60’3 . w 2 40- E ,: PD 4 z as. 8 a: ling a: 30m a. aLu > ‘1 qz m 2 - lO- . _,e-’::.—// 0 "5' .V / U 3 :5 .J, Lu o a- //’ 53 a +— m u: I I9Z < g O 0 ________-_ . .......... _______ o 8 g 2 3 g 4§ E g. x «e —«' w D- W to 5 onZ I 4-6 ’ T 7-9 " IMPROVENS) .._.. UNIMPROVED(7) ' T IO-IZ ' -. ' —-—:—-—-"/ ,,«+ / / / {,x’ ”x” 5~ .t’ ----/’/ ,./ " /‘ ,xf “i3u Q (ll) MUCH IMPROVED o——MOD. Z 6-3 IL] +,.__._-,——‘ 0— 3- 6- a2 . 1—3 I 7-9 ----' C OK. 100- 50- ' 4—6 IO-‘IZ I50- ._Muc|-.1:|MPROVED(II) +——MOD. mpnovsom) ,_.- ummpaovso m 0 IL V" T I _. 7-9 A <>K //i1/ ------- °- -----MA’65... x 2 1m 5 NUMBER! OF TREATMENTS (I) . /// // i 2 . NUMBER OF TREATMENTS 4-6 1-3 3 ‘2 /+ ,, ........... ., -—-“"” ’4' , ‘ A -------2’ a: I l— // /" 20 o IMPROVED(II) 0--MO‘D. IMPROVED (6) °~--~U~NIMPROVED(7) LU p— {‘3 -— MUCH m D . o ‘‘‘‘‘ ———— -4fi‘” 415 1-3 719 NUMBER OF TREATMENTS 7 r D I0--I2‘ NUMBER OF TREATMENTS B .9. g 7‘ 3a: 6‘ m n: lL , .9 ,r—e ' -— MUCH IMPROVED (u) +——MOD.IMPROVED(6) o----UN‘IMPROVEO(7) l0-l2 '\. I A .m 5.. 22 9 8 4— .— Fig. 5.—A-E, relation of clinical ratings to each index of delta activity. 33. 3: 3o V 3-. z a 2 2a l _ . I” +’/” //’ “““ ---------- o-""" .fiu‘idifi“ , a _ O O ”_‘..—°V ° I ‘l ‘l l. l-3 4.96 7-9 IO‘IZ NUMBER OF TREATMENTS E for the highest—amplitudedelta activity (Fig. 5C) and the slowest frequency (Fig. 5D) are most similar to the curves for the degree of delta activity (Fig. 4). The other three indices (Fig. 5A, B, C) clearly differentiate the much improved group from the patients with the other two 520 ratings, but fail clearly to distinguish the moderate and unimproved groups. With in— creasing treatment, however, the separation of classes becomes clearer. Each index of delta activity, therefore, demonstrates a relation to the eventual short— term clinical rating which is much like that Val. 78, Nov., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE TABLE I i/ " . ” Average delta 2.—Interc0rrelati0ns of Individual I ndices and Degree of Delta Activity - - Average 63%qu Longest Dfifiiéi‘é“ 350831153 +0.72 +0.67 +0.80 +0.72 +0.68 +0.84 —0.78 —0.47 -—0.90 Delta One Lead FkZVJSEEy Afiié’fiiie - +0.98 —0.79 _ Degree Highest delta in one lead +0.98 _ —0.67 Lowest frequency Highest amplitude —0.79 —0.67 __ +0.72 +0.72 —0.78 -- +0.57 +0.88 Longest duration bursts +0.67 +0.68 —0.47 +0.57 __ +0.63 Degree of delta activity +0.80 +0.84 —0.90 +0.88 +0.63 -- demonstrated for the combined index of de— gree of delta activity. The intercorrelations of each of these in— dices are shown in Table 2. All correlations are significant at better than the 1% level of confidence, although the highest correlations with the degree of delta activity are noted for the frequency and amplitude measures. The lowest correlations are noted for the duration} of burst activity. These observa— tions indiCater that in future studies or in clinical application frequency response and amplitude changes may serve as criteria for the degree of induced delta activity. 3. EEG Delta Activity as Index of Clinical Outcome—Following these observations, a study was undertaken to determine whether the degree of delta response was predictive of the short—term therapeutic outcome. On the basis of the observation that the much improved patients had developed high—degree delta activity early and had sustained such activity, electroencephalograms were obtained during the second and third weeks of treatment 011 54 consecutive electroshock patients. The records were scored as to whether high—degreedelta activity was achieved dur— ing both, one, or neither of the four—six and seven-nine treatment periods, and the data TABLE were Both high (18) 12 (67%) One high (16) 4 (25%) None high (20) 6 (30%) * (Table 3). Of the patients who manifested high—degree delta activity during the second and third weeks of treatment, 67% were rated as much improved, while only 30% of patients with- . 1 out high—degree delta activity were so rated. Thus, the early induction and persistence of high-degree delta activity are seen to be re— lated to the short—term clinical evaluation. Comment The present study demonstrates a con— sistent relationship between the degree and duration of induced electroencephalographic delta activity and clinical evaluation of behavioral change. While it is conceivable that the difference between our results and previous reports may be due to a variation in population, it is more likely that methodo— logical aspects are important factors. Serial records were obtained during the course of therapy, so that the sequence of electro encephalographic change was evident. The records were obtained at a constant time in— terval following a treatment. Finally, quantitative analyses of the records were made instead of relying on clinical impressions. Of other investigators of this problem, both Moderately Improved 2 (11%) 8 (50%) 4 (25%) 7 (35%) 7 T ship between ind havioral respor therefore, perm changes in the o attendant alterat the physiologic process.* A simil. by Roth 23 on the *The Unimproved 4 (22%) ac’tivity.18’21’22 we. biochemical received limited stu on acetylcholine-chi tion in blood—brain and protein equilibri without definitive C( (35%) Significant at the 2% level of confidence. Fink—Kuhn the induced neu1 behavioral respoi these observation of action of elect 1. Relation ofi Behavior.—Beha accompaniment function. Chang tude, judgment, and insight atten tion, from what extensively docu literature. In this study, e consistently to alt in a fashion whic with states of altc studies of Davis Strauss,19 Ostow have affirmed the activity as an in< tion. Symmetric, has been interpre tion of midline centrencephalic s also indicative oi of consciousness being directly rel: tude, and freqi related to the clinical evaluations. Clinical Rating Much Improved 21 further elaboratii 3.—Patients with High-Delta Activity During Second and Third Weeks of Treatment* EEG Delta Roth 2 and Hoa out systematic E to demonstrate variables and be] Two aspects oi 521 522 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY Roth 2 and Hoagland et al.,16 who carried out systematic EEG analyses, were also able to demonstrate a relationship between EEG variables and behavioral changes. Two aspects of these observations warrant further elaboration: the relation and role of the induced neurophysiologic change to the behavioral response, and the significance of these observations for a theory of the mode of action of electroshock therapy. 1. Relation of Neurophysiologic Change to Behavior.—Behavioral change is a consistent accompaniment of alteration in cerebral function. Changes in mood, language, atti— tude, judgment, thought process, perception, and insight attend changes in cerebral function, from whatever cause, and-- have been extensively documented in the neurologic literature. In this study, electroshock has been shown consistently to alter the electroencephalogram' in a fashion which we have come to associate with states of altered cerebral function. The studies of Davis and Davis,18 Ostow and Strauss,19 Ostow and Ostow,2‘0 and Jung 21 have affirmed the significance of diffuse delta activity as an index of altered brain func— tion. Symmetric, dysrhythmic delta activity has been interpreted as evidence of dysfunc— tion of midline hypothalamic centers—the centrencephalic system?9 Such activity is also indicative of an alteration in the state of consciousness, more marked alteration being directly related to the duration, ampli— tude, and frequency of the slow—wave activity.18'21’22 The demonstrated relation— ship between induced delta activity and beafter electroshock, havioral response the conclusion that therefore, permits in the centrencephalic system with changes attendant alteration in consciousness are the physiologic basis of the electroshock process."< A similar conclusion was presented by Roth 23 on the basis of his studies of the *The biochemical substrate of this process has received limited study. Emphasis, has been placed on acetylcho-line-cholinesterase change,”25 altera— tion in blood-brain barrier,8 and changes in ionic and protein equilibria 26"” by different investigators, without definitive conclusions. 522 effect of thiopental on electroencephalo— graphic delta activity. Another example of the relation of the electroencephalographic delta activity to be— havior is seen in reports of epileptic patients. Landolt 28,29 describes a young epileptic who was ordinarily pleasant, friendly, and cooperative for his clinic visits. At these times, records were consistently dsyrhythmic. On one occasion he was surly, irritable, and withdrawn, and his EEG was without delta activity. On the subsequent visit, the EEG was again dysrhythmic, and a behavioral “improvement” was noted. Similar observations have been reported by Brockman .et £11.30 and Fabing.31 In a previous study4 we had applied the amobarbital test for brain disease 32 in a serial fashion to this group of patients and reported a relationship between changes in this index of cerebral function and be— havioral change. Were other tests of cerebral function to be applied in a similar fashion, it is anticipated that these, too, would demon— strate consistent changes during treatment and a relation to behavioral response, within the limits of the sensitivity of the test to reflect changes in cerebral function. In this context, electroshock may be said to be a method of inducing a state of altered brain function for extended periods, in order to achieve changes in behavior. From this point of view, the development of a significant degree of electroencephalo— graphic delta activity may be a readily determined guide in the rational management of electroshock therapy. In these studies we have examined various delta indices and/or the intercorrelations and have noted that the amplitude and the frequency of the induced slow waves are the best guide to the degree of delta'activity. In patients in whom the behavioral response to electroshock is inconsistent with the therapeutic expectation, examination of the electroencephalogram may provide a criterion for clarification. If the induced slow—wave activity is faster than 4 cps and lower than 100,u.v in anterior temporal—ear lobe or anterior temporal— frontal lead combinations, then there is Vol. 78, Nata; 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE presumptive evidence of inadequate electro— shock therapy. When frequencies less than 3% cps and voltages higher than lOOuv are maintained for a number of weeks, the assumption may be made that an adequate degree of altered brain function had been induced and that other factors (environ— mental, personality, pathophysiologic) were operating to preclude a favorable behavioral response to electroshock. A similar applica— tion can be made for amobarbital tests 4 or syntactic language after intravenous amobarbital.6 2. Theory of Electroshock Action—These studies of the electroshock process have demonstrated that alteration in brain func— tion is induced early and is sustained in patients in whom the greatest degree of behavioral change is noted. We have em— phasized high—degree EEG delta activity and positive amobarbital tests as indices of altered cerebral function, with the knowledge that other indices of altered brain function, applied in the same serial fashion, may also show significant alterations and a relation to behavioral change. We have been impressed that the ratings of improvement are value judgments of the behavioral response. All patients in whom cerebral changes are induced by electroshock manifest changes in behavior. The range of behavioral patterns induced under these conditions is wide. Only certain patterns are evaluated as improved, however, while others are regarded as “unimproved.” “Improvement” is a special case of behavioral response, being a subjective evaluation on the part of the observer that the patient is “better.” Electroshock does not induce “improvement”; it induces a milieu of cerebral activity in which behavior is different than before electroshock. To the extent that the induced behavior in depressed patients is perceived as less complaining, depressed, agitated, or anxious, or in schizophrenic patients as less delusional, hallucinatory, or excited, the patient is evaluated as “im— proved.” When behavior, however, is per— ceived as anxious, agitated, paranoid, complaining, or withdrawn, it is evaluated Fink—Kahn as “unimproved.” The particular type of behavioral pattern induced by electroshock is dependent on a number of factors, such as personality.33 Another aspect of the rating of improvement is the environmental response to the induced behavior. The modification of mutism, withdrawal, and negativism to excitement, overactivity, and irritability may be considered a positive movement by the therapist but a disorganization by the ward physician or family. The goals of the therapist and the family, and their expectations and tolerances, are significant factors in the behavioral response of the patient to therapy, and, also, in the ratings of improve— ment. These same factors are significant in the duration of the electroshock effect. The in— duced change in cerebral function persists for only two to eight weeks following even intensive courses of therapy. In many cases, the behavioral response is limited to this period of altered brain physiology. When in— duced changes in behavior are not adaptive in the milieu of the patient, the behavior reverts to pretreatment patterns. In other instances, the induced behavior is adaptive to the environment, and, we assume, sus— tained thereafter not by the initial change in brain function but by the newly developed interaction of ‘the subject with environment. That this is indeed true is seen by the fre— quent successful adaptation of the patient to the hospital milieu after electroshock, only to have a recurrence of symptoms when dis— charge planning is discussed or discharge is consummated. Altered brain function provides the physiologic milieu in which there is an altered interaction with the en— vironment—the doctor, family, or society. These observations lead to the conclusion that electroshock therapy is a nonspecific induction of persistent states of altered cerebral function. Such altered cerebral function provides the physiologic milieu for an alteration of the organism’s adaptive interpersonal behavior. Changes are in— duced in perception, language, mood, recall, and judgment which constitute a mode of 523 interaction with of behavior indu is dependent up subject, the envii action occurs, an of altered cerebrz A similar View was initially exp and Kahn,1 who tionship of neu: behavioral respor electroshock pr0( the observations Aird et al.3 The neurophys tion of electrosh( definition of the of further elabor: a hypothesis also standing of ther coma therapy, 1( agents. j Summary Serial electroe: weekly intervals referred for elect analyzed for the A significant tween the degrec delta activity an( behavioral chang firmed in a predi 54 patients. Differences bi those obtained It terms of differen A neurophysi tion of the electrt It is concluded t] specific inductio: altered cerebral physiologic miliei tive interpersona Improvement as a special case c these conditions. by an observer factors, including 1 r' 524 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY interaction with the environment. The type of behavior induced under these conditions is dependent upon the personality of the subject, the environment in which the inter— action occurs, and the duration of the state of altered cerebral function. A similar view of the electroshock process was initially expressed by Weinstein, Linn, and Kahn,1 who emphasized the interrela— tionship of neurophysiologic changes and behavioral response. This description of the electroshock process is also consistent with the observations of Ulett et al.,34 Roth,2 and Aird et al.3 The neurophysiologic—adaptive interpreta— tion of electroshock provides an operational definition of the process, which has promise of further elaboration and observation. Such a hypothesis also has application to an under— standing of therapeutic process in insulin coma therapy, lobotomy, and tranquilizing agents. Summary and Conclusions Serial electroencephalograms obtained at weekly intervals in 24 consecutive patients referred for electroshock were quantitatively analyzed for the degree of delta activity. A significant relationship was found be— tween the degree and duration of induced delta activity and the clinical evaluation of behavioral change. The results were confirmed in a predictive study in an additional 54 patients. Differences between these results and those obtained by others are explained in terms of differences in methodology. A neurophysiologic-adaptive interpreta— tion of the electroshock process is presented. It is concluded that electroshock is the non— specific induction of persistent states of altered cerebral function, providing the physiologic milieu in which changes in adaptive interpersonal behavior occur. Improvement after electroshock is seen as a special case of behavioral response under these conditions. The rating is an evaluation by an observer depending on numerous factors, including the type of adaptation, the 524 and expectation of the observer (therapist, family, or administrator), and the setting in which the behavior occurs. goal Mrs. Helen Donovan, Miss Gayle Wankel, and Mrs. Hannah Mosquera gave technical assistance in this study. Hillside Hospital. REFERENCES l. Weinstein, E. A.; Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat. 109 :22-26, 1952. 2. Roth, M.: Changes in the EEG Under Bar— biturate Anaesthesia Produced by Electro—Coxnvulsive Treatment and Their Significance for the Theory of ECT Action, Electroencephalog. & Clin. Neurophysiol 3 :2612-80, 1951. _ 3. Aird, R. B.; Strait, L. A.; Pace, A] W.; Hrenoff, M K. and Bowditch, S C.: Neurophysiologic Effects of Electrically Induced Con— vulsions, A. M. A. Arch Neurol. & Psychiatl- 75: 3371—3781956. 4. Kahn, R.L ; Fink, M., and Weinstein,,E. A.: Relation of Amobarbital Test to Clinical Improve— ment in Electroshock, A. M. A. Arch. Neurol. & Psychiat. 76 :23—29, 1956. 5. Korin, H.; Fink, M, and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Confinia neurol. 16: 88-96,1956. 6. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communications, edited by P. H. Hoch and I. Zubin, New York, Grune & Stratton, Inc., 1956. 7. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electro— shock, Electroencephalbgi&-Clin. Neurophysiol. 8: (abstract), 158 1956. Pacella, B. L.; Barrera, E. S., and Kalinowsky, L.: Variations in the'Electroencephalogram Associated with Electric Shock Therapy in Pa— tients with Mental Disorders, Arch. Neurol. & Psychiat. 47:367-384, 1942. 9. Proctor, L. D., and Goodwin, J. E.: Clinical and Electrophysiological Observations Following Electroshock, Am. J. Psychiat. 101:797-800, 1945. 10. Bagchi, B. K.; Howell, R. W., and Schmale, H. T.: The Electroencephalographic and Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders, Am. J. Psychiat. 8. 102 :49-61, 1945. Levy, N. A.; Serota, H. M., and Grinker, R.: Disturbances in Brain Function Following 11. R. Convulsive Shock Therapy, Arch. Neurol. & Psychiat. 47 :1009-1027, 1942. 12. Mosovich, A., and Katzenelbogen, S.: Elec— troshock Therapy, Clinical and ElectroencephaloVol. 78, N00,, 1957 ���mum m 3%: «u mmwgmwzum,mm muJ.MiMMfiW3MhWW m if mwmum. “ w. Mr maummwmmmmmd W. mam. mm W. ‘ ����Wfimmmamhmmuwmmuw (mfimumlmwmmumwmm MQ}WW#WWWMWW W“Nmmmuwmfiummxmwmmmmm Wan. 'meummmmm-umm m MW‘Mflqumemmuw-ua MW“ ' “- MWWW manna a) mxmmmmmmmwmm �������I ‘1“ A— �Wgwmmwmg MWMflmmmgw MWmmtmmum4h mwmm. wmmamm.mwm«mm* �����������. v ,9 M» fl..V 4%5.. ������..: 3 0%» .4 4L, “.4 .:‘ ».:4, J �����«flit WWMM. m twmnmmmm �����.14. u J, wring >,R �‘ ’ ,. "M :jfi" W; Walt ��W W M“ WWW!» mu?Wmmm mm: at W mm: in. {1. a» a) mum at *1?" mm in W WW; W m m at ��77 was“W r I €25” 0551: (”n-hum or Inn-I 4 -5«-r.:.5“......”"55. {/7 m mu “$17115: to Word mm. in Whack: wants." Serum. Studies . "v a» 5, g an m HDandRoborbL ma. 3.5.5» I: M. ' fl at mammal WW; Hillside Hospital, 01m Oaks, truths Want. lbw but. Aid-d, m m by gum. 14-927. mama mum. at Kent-.1 Health, mum). of find/m, v.3. mm Health San-1a.; and the mm mem mum for Mad. Ragnar-9h, nWJa-rlcM mt: , of mammeephalcmphoro, Won, Present!!! aththe mum Duct, WWI} 1955. m: M57» ‘ ' . ' “mm .— ; �Relation 5?? -.._.. a: _ Meet w {Mari-ea m, Delta Activiw to More}. mm in Wanna: antiutive Serial Studies; a: electroshock therapy m ( 1, 2,. 3) have emphasized the rule of neurophysiologic changes as the basis for the therapeutic .1 . mutant with these ,L theories, we have observed auction of a mutual: bum changes a: new means of brain function and behavioral name. We have noted an... $73 WW 40 electmsheek/‘afi- changes in orientation embarbital (2;), flaming and <6) . null and clinical hpmment following cmfabuletion after 111th (Shana syntactical aspects at ' 1% In view of these observations it. could be expected that. electroencephala ogrephie shudiee mld report-ad inflamed relationship. Nmaerous observers have eminent changes in the electmeneephelogm utter eleetzically Mime. rhyfiMc em 1 similar utivity There 18 6.1.th9 slewing with increased voltage and dye. (7 ~ 12). Feet percent—tum (13), and utivity decreases, both in voltage and in in patients we are intensively trauma, there is e naming of persistent alpha frequmcies (1h). The degree, mum and extent or éelte amenity is directly rented to the r'nquemy and amber of grand ml I Wane (8 -- 11;). Such activity is usually swede, appears maximal effects usually disappear 1:1meme in anterior leads, and the in ma mks renewing the 1m treatment-,3. 9). In contrast to the comiateney or them observations, studies of the relationship between the elmtmmephelogrephie and the dilated conflicting menus. ohmic: and mean: (15). after an mag” show mun review of the literature, £9011ch that the amber er treatments rather then the degree of named delta. activity we: the primry factor pantie response. 011 the other hand, rented to a fwomble there- 21qu 93 g}; (16) :0pr a relation how changes in the percent time feet eetivity (more than 13 cps) and ���.4... In the rim]. estimates or degree of deli: activity, the average delta index for the 3 load oombimtiono, the highest 3011:: index in any one load, the ulwest frequency, Most delta. voltago and out-aunt: of longest period of burst activity was listed for each macro. The 160 noorda were mangod in aoquemo for one): index and the percentile ram: dotemined. The ranks wen oddod and the the floor!!! than Imnged in rank order awarding to this score. a: that the higher score refloctod a. grotto; agree of delta activity, the upper third of the mom were classified as “high dogma the middle mm 58 "mm. degree delta“ and the lowest third as film dogmo‘ “main dolu:~, delta? . ohmotorizod by an flange delta index delta 1mm of ‘2135 armors in one o! the three High degree «sum record- wore of at. least. 18%; a mound 1m; voltage mm second», w slam“ frequency of loss than m madman; m: a Inn-at. 3 3/1; ops; highest mu mum of u least 2 1/2 ‘ Low degree dorm noords was characterised by an loss than 2%; slower than S meat. delta 1m in one lead of 1/2 ops; volt-.93 loss than 60 loss than 1/2 nomad. ’Hodornto degree delta groups with an 60-80 20%; Mormons; and 31m“ from Inn-at indoor or or 1am mquanom no naming and burst duration 3% room-do won Minoan ”lose two mugs delta index between 2% and 18%; no load of 3 to mugo delta ‘ mm finite 3mm in of h-S cpl; highest amplimdo bemoan duration of 1/2 to 2 seconds. fiftyafour omomtivo, unselected electroshock patients, oloctmonooplulogmphic records worn obtained prior to trustmne, during the We! and third weeks of treatment, and tam weeks after 13) In a. second aortas of mama‘s. mesa rooonin were mlyud using: the identical moms as in the initial ����W degree the” %%Ru.® was WW3 to datamine whether the at delta response was Mauve of the short bum theramutic cum. m the baéis of thfi observation that the much improved panama had dweloped high dtgrae delta #ctivity unfit-1y and had. sustained such activity, chew mamalogms ware obtained tinting; the second and third weak: of mutant in pltiants. The records- were Scored as ta whether high degree dolta actiut‘y was acldwed timing; both, on: or with: of the h—é and 7.9 treatmnt pariah, the data was muted to the clinical evaluatimm (Table III). Sh eonsecutiva electroshock and mm III ' ‘ EEG man Delta. _ (18) Both High One mgr; .. “Home High (16) (20) f who pntienta without. mm W 2 (113) 12 (67%) h (225‘) u (292:) a (sex) h (25;) 6 (30%) 7 (35%) 7 (355) // anwx‘uaummm,m M down delta activity?» rated. M, the surly 1n- ducbion and persisteme of mg; dogma delta the short mm. clinical 4» Moderatelx manifest high degree delta activity during tha second and onlgrBOSof attainment. or the patients 'mm - ma activity is seen to be related multim Meant at the m1 of cmm. 2% to_ ��J We “WWW“ 1111111111: delta activity has m integrate as evidence of dysfunction at manna centers {mtmmphmc systoml (19) . mpothalandc and Such activity is also indicatim of an alteratim in the cuts of consciousness, with more marked alteration being directly related to this duration, mum. activity (If, 21, 22). me dmstmted roala‘bianchip between induced delta activity and behavioral response after electric and tmquency of the slow wave hint- conclucion that. changes shock, themfom , permits the cephnlic 3513mm with attondant. alteration in conscimmnesa basis of the electroshock pmccas. m the basic cf his stwiea of the Another example of the behavior is tut-h seen £81 ~11 A ‘ 11.:1‘rect . M of me b visits. cooperativefar hie 01.111111 MW”. occaa11m be was 1153110111; mic 9.1213 :1 ported by we delta activity, belmvioral On At. an WW $133114. (23) '1'?—“1/1'54"? W 55130) reports of epileptic patients. Landon ordimrlly pleasant, ffiendly and them times, records the subsequent and 118 warn mimuy unit, Similar was mated. ram 111111 the EEG was again figsrhyth- obaomtionafi fire?” (31). applied the Maximal test 101» brain h nthembml serial fashian to this group of patients, and reporwd a mlatiomhip between changes in this index fwtion and behavioral changci. Herc Other tests of ccmbml {metion to be applied in a disease (32) an a 31:13:: 331131 fashion, 11'. is anticipated that thou, tab, would demonstrate bicchmcal substrate of this process has received 11mm: cm placed 011 acctyldlommholineatemse changes (2 ) (25), W818 has1nbean blooMrain barrier (3) and chasm in ionic and pmtoin nautical (£6) (2{) diffcmnt by aquilibria investigators, witho 1t definitive: con- it The 13111810113 . m surly, inflame and withdrawn, and his 1% ”13111101791331” In a prcvionl atudy (h) wwé‘gm relation Iof clactmcncefiulograpmc delta to (28) (29) describes a young synaptic: who was 011 the Gem-im- % the pigsiclcgic mansion similar 3.11 ���«18‘ {gnawing mu intents.“ name is courses of therapy. In limited to this 40f ,peziari many cases, the behavioral altemé! brain phys‘iolégz'f. When induued in behavior are net. afiaptive in fihe mien of the patient, £16: behavior be pwmamm patterns. In cther instances, the induced behavior is Idaptive to the environment, and, we assume, sustained thereafier not. by the changes" mm in brain function, but by the newly dmleed interaction at M2 subject with envirmmnt. Theft. miss is indeed true is sea: by the fremwnt suscaasm adamuon at the patient to we hospital milieu after electroshock. initial only change to We a marten-ea of symptoms when discharge planning is discussed or is mummied. Altered brag». function provides the Manage Mm: in which there is an altered hibernation with the environment -- the diIcharge doctor, famfily er society. I These ’ obm’cim lead to the canclusion that electroahack tirxerapy flfimum Such Wyenfific induction of persistent states of altered altemd mm; hid. rum um provides the physiologic milieu for m: altera- a -' tion of the organism‘: adaptygtexfgersoml behavior. in pemwp’oion. “a Changes WW3,W, mé‘m, and MW: which Max-scum with the ‘mirmn‘o. Mead ms:- than oonditim is deg-3mm I is The type of upon are induced m constitute 31 new behavior the personality of the 813123“, the environment in which the interaction occurs, and the duration of the stat. cf altered cerebral function. A similar View of the electroahock pmeesa fias initiélly expressed by rm and Kuhn Heimtein, Minibar: (1), who mfimaized the interrelationship of changes and behavioral msponse. This doseription of ma shock pmoess is also consistent with the observatians of Ulett Roth (2) and Aird (3). 533 new electro- $3; (31:): gig}. Th5 meioloMptim Mode. interpretation of electmmock pmviaiea m mutational definition of the pmaaa uhie‘n has promiaa of further 3mm ' 49’ �“on and wax-mum. _ Such a. a; Wilma ‘ standing of therapeutic procesa in quillizing agents. . also has appliuticn to 1mm coma therapy, lobobono' an man». ané tran- �«is. J ‘ , ‘ 1. Serial aloutmmoyhnlogmma Waive W ohm!“ at many intervals in patients Mama! for electroshock were quantitatively for the degree of delta activity. ’ 2. 215 W aimifioant relationahip was found between the degree and aux-afloat of induced delta activity and clinical ”elation of behavioral change. The results wen: confirmed in a meditative study in an additional 51: patients. A 3. Diffemnooa between them results and mono obtain-d by others are explained in toms of differences in m'modolow. h. A mmphyeiologic use is presented. It is duction - adaptive interpretation: of the elootmshock pro» concluded that electroshock is the non-Specific in- pomatantvatatea of altereri cerebral function, providing the ogic 31113:; in inch changes in adaptive interpersonal batman: occur. oi". 3. laymen)“. maponz—ze afar abotroshoch is under those conditions. " The seen u at 81300131 case of #133191“ botanical rating in an evolution by an observer (lemming on numerous faahora, including the type of adaptation. the goal and expectation of the observer (therapist, family or sminiatrator), ting in which the behavior mm. and the set- �4-43.6- Acknfledgemnt : We wish to Ranks]. and m. 31pm: our asppreciation to Mrs. Hahn Ewan, Miss Gayle Hannah fer their mammal assistance in this study. Wm �~17».- 1. Weimtein, E.A., Ling max-spy: Psychiat., z. MW 13., and Kuhn, R. .2 Psychosis During Its Rahtion ta the Log: 22.26, 1952. "zeory of Elan-maxed: J. Shank Thempy, Am. ‘ ' Bui‘biturato Anesthesia Produced by Changes in the m:m, wmm: Electra-convulsive Wmt and Their Significamo for the Theory EEG » act Action, Em. (315.11. Neurophys" 33 261-280, 1951. 3. Aim, R.B., Strait, LA" Pace, Jfi'q Hemoff, 14.x. ind Witch, 5.0.: of fie‘grophysialmc Effec'ta of Electrically Induced Gomulsions, Adidmam. a: Paychiat” 15.: 371-678, 1956. Arch. a; 3.5.: Relation a: mom-banal Test to Clinical Imgmemnt in mctmmack, AJLA. Arch. Neurol. Kahn, 3.1,... Pink, 5:. and Heinatein, 2;; chum... 163 23.29, 1956. S. Hg Fink, aR'Z'Efrim, M. to Legging 19 1o 6. Kahn, 3.1.. and Fink Wt and Fur-- 8.: Relation of Changes in Mmery and Nasser, in Electmahmk, Cont. Mauro]... ya: rm; Changes in 8M6, Language During Electmshoek Therapy, in “PSy‘chopathangy of Cmmication," Trumaaticns Amr. Psychopaflml. Lame” 1955, Gram: Stmttan, Raw York. 7. an», m. ané Hahn, Ram Quantimm Studies of Slaw wave Activity Faun£2 Elactmshock, 8. 1236.. 63.111. Haumpkys" Q: 1538 (Ethan), 1956. 13.1." Barrera, 31.8. ant-3 Kalinowslgr, 2...: Variations in the Elect» encephalogm Maociateé with Electric: Shack Theta: in Patients with fien’oal Eiisordern, Arch. neural. {é Psychiat” :1: 367-681;, 192:2. 9. Metar, Id)... and Goodwin, J.E.: Clinicnl and EleuhroMiologioal Observation! Following mammhmk, Am. J. Psychiat., 391.: $7.800, 1925.. 33336113., ' 3-“ 10. Bagahi, ' '11. My, 3.211., Ewell, 3.33., and Somalia, 8.1.: The Electreencepmlegrarphia Clinical Effecta of Elegtrically Induaegi Comnlsicms in the reament of Mental Disorders, Am. J. Paychiam, gag: 1&9~é1, 1915. HA... Beret... Km” and Grinker, R. Ru Disturbances in 3min Function I“ ComlsiVe Shock ’Faerapj. Arch. fieurol. Pay1914-2a MI 10094027, plain.” cum 12. Hamish A" and Katzenelbgen; 3.: Electmshock themm, 51mm. and 517'éacti‘ofigcehhalogmphic isms-Ems) J. Harv. ‘I Mani... Dis... 39, 9 we» m: ‘ 13. 24A. and “111mm 3.13.: Significance of Changes in Elect. mm, alogram Zhsults from Shock "therapy. J. chiat" 105 ,' 'va'hicit: 11045, 19%. Am. PB ��’19.. 29.’ Landau, Ru Uber )9 undw Vemer-‘mm W:- fur zguatwdsbilder be: PW3hmm$g 1?} 313‘331’ a 1mm,I' 19%50 schizophmxe Neurologio mu! Goo. 918178, W”, Related Type of TrutG.A.: to Thaw ‘3erE} 97-10%a1956. mnt, Confinia neurologica, 30» Bm:m,.fioJo Bmcm, 31.. Ming, IL: Personal cmmication, .3:»:. Veins’oein, ‘EJ... Kuhn, 1m... Sugaxman, Ink. and 1mm; 1“: The Diagmstic Use of murbital "Sedan (”Am-tel sodium“) in Brain Disease, Am. J. Psychiat" ngfisws’h, 1953. ngaa 1n JOC.’ Jaebbsm’ 1956. $16: U... ' Pemmuty raetor‘a 1n mum: Psapmae to m,a.s hilactroahock Tharapy, Gent. Kennel. (in prose). Kahn, R.L. and 833%, 8A., Smith, K. and thconvulsive 6 ham, (3.6.: Evaluation of Convulsive and Shock Therapies W‘.’ at 79m, 1956. Utiliniqg 2., Control. Group, Am. J. �~20- 136mm m 1. Lou Dogma Delta Activity . m Figure 1.1. Moderate Dogma Delta Activity “M 3.11. High Degree Delta Activity Figum 1?. Relation of Clinical Ratings to Development of High Degree Delta Activity. Figure v.0. - 6) Ralation Clinical Ratings to Delta Activity. (11' ill-Ia EAL-k M Index of �12.5553" ’53?! $3.4 vii. ‘ '3 �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263m: STREET GLEN OAKS. N. Y. Flaws-ran: 3-7800 s. A. MILLER. M. D. MEDICAL DIRECTOR JOSEPH MAURICE BAC‘HRIACH ADMINISTRATOR SHRON KWALWASSER- M. D. ASSOC. 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A WWW AW/MW“ mWngsUfiat/Lg, ‘4 M M MlefWWfl/L‘XW W Wséaz W M» Md WW +2637 '- AAA/M4 M-M.é"/.2£ Wot/(WA (WM mam. �(16) 3 5 flth, % Wk. MW ' - . 3 @3W Mr WM gge ,7 4% W A“ % W twé WK 77'W754’WW J calm/(P6,, (ii) Wot/7! MA: an 32AM“ a (6} W30 W A; 1 ¥ ‘— 6&3,“ A [fl/t “M” C, “5&7: I �LW 23m W (“’W 21%;.“ 2 W15— a. éd// /7// I . $5 (0) /4,' flair!“ M (W ‘-" (Axle—26‘) W/Wr d/flmfi/Wflwxw‘ W4”- (f) kn/WK A [OJ-W [6} gt/M W (4717 (02/2 @WV4 =1 loo-WM W2a.. 23% 26/? VFW A" ,2 Amt“ E �jW/MM/ r_ QawaQ/ducffi @fl )4) 1/) , 3) i W mgW W551” :M / H MM? ge/fsf? )krqu. fifth flaw“ AfiéflQ—m Mfle 2:. / M . - 5/3; ”a“, mgwk /W&”’V : �Bambi, B. It, Emil, R. m, and Schmidt, 3.13.8 inflated convulsions 1n the treatment of triaafily_1 1023‘ 1]7 9 ”The alwtroancaphalogmphia effects mad 3111113511 1:1li an! aim disordem.“ém. J. Pqnhigt. ' Barrera, St American J. Egg and P866118, B: In: “EEG finding! ”‘001amd With 31Wtfl¢ therapy in patients with mental 333.: 206119fl3. 3118.559}... GOldtarb, W" Laughlin, J3 Ma; 8336. Kiwfi’ H. Ea: ”P19163336. 1113111111 $193k dimm.“ Shafikdu VMO Gottlieb, J.S., Ashby, PLO", and Kimble; L.L.:'mamamlogi¢ study of schimphn min and depressim. IV. Ina fluence of electriu cenmlaiva them on, the aodium mm]. reapmua of the saleabmencephalcgrm.‘ Am. J. Psychiat. 10 : 6869696§ 1958:: » Harris, Roma, W.A.:"fisa of cur-are in mtraxol mnmlaant timer: with 15 3 5376 £1 19111“ observations.” maniatric Land 2mm, and Panama, E. Wt electmencephalografixiu England, Hr, whim, Mum, and Cinema, D.E.: " me electroencephalogram hypoglycemia and recovery." 7 J" Wigton, Hughes, Arena Neural. Ward, Am. 13., and at 13816111312. 14.11., and Rims, Jardon, F.:“Electmencephalogmphie studies on patimam meshing electm~shoek mamnt.” 19141. “SWiamm of L.F.: «hmgas in thy alecmenecphu flagram whichmsult from Each, ‘1'. 0., and autumn, Ed 251.13.. Arch. Neural. MO “The other effact of benmdrine and @2th ant: upon the (21mm Shank) EEGJIi'amatiun Pmc. 5:62“ 12%,. 8mm, mm, and Grinkar, 12.3.: Diaturbanaea in brain pastconvulsiw Levy, therapy." 53: shew}: W. ehiatu 50f 53§¥537g 12h3 8: 1mm, mm, 1' Payehnt. & m; J; Haul, B; H0; of schizophrenics curing insulin 1202 559‘5791 3.9;}; Gottlieb, J.S.: ”Chang” in. the eleetmeneephalogrm renewing insulin shack therapy." Neural. and Page and «1.12., J. $1131.01. as: figumg _ Jg.P§Fdhiflta 105‘,h0*h53 19h5v Knott, , mum refluxing wnmlsiw shack mummy.” 1:7: 1009402“: 192:2. Go»; Wu, { G; Rn, Pma‘bor, IN Dr; and 600%, J“ E03 "Parallel psychologisal, psychiatria and Whalesinn). findings: in sahimphmnie patieats undar insulin ahcmk treatment." Am. J... Psychiatr.» 933 1422-4129. 121:1... lbriafiy, LB... and Siam, 573 112*.»718‘ 1913!. maevich, A" nut. and, shoal: therapy.” Arch. Neural. g mint. Katzenelogen, 8.x “meatmslmck therapy, alibical and 10?: 517620. , J. 0.: “Ehctmmeemalogmphm study of electria 1214 8. encephalograpmga studiem J. 03.ch ant... Mex-v. 5: �«2. Pacena, B. Bax-rm, S. W" and Kalinawaw, I“: I“, elwtzic‘ shank therapy or ?: Hawk 1122 . V498— ’ ” Variatim in the 319nm.811661312310ng assaeiated with patina with mm mm". , 60 m .9341“; is _ _’ N. . Wt. . ; 13m. and Goodwin, v1.8.3 tit)” mm ‘. andfiliactmuflxyaiologiaal churnefanwm aleflmflhgakc M». J. ngaik‘bt :“x ilk H‘ \ Ibsen, 8. R5, Samaria, L., and Finlay, P3192» 11 (315.113.1331 101: 79%3094L 19kg; 111nm. ' J. Ea Camativq tlwtmeneemalogtmhia abs serrations / gnawing electroahaek therapy Am J.and alternating unidimctmm fluematmg m1: 5' using Proctor, trim 1 ' i 13.30.; and Goadwln, Proctor, Harold: VP: Arch. mm,i @533 . 1.7.; 617.6111, conservative approwh to fine 111% uhq of sneak therapy in 1M; ‘ mm arggi‘ijd Suthfirlmd’ Gt Fa: was experience with alwtric: aback treatment in mental (mama-35, with $963.91 regard to vamua psychowmtie 99: phenomena and to certain elcctmteahniaal “Worm”? Agni J. 531M, W5»; fillet-350:1, K. JV, 6111133511, Wk" " A eonsic‘haratim‘ M Mint; Pacella, La 'me aigmflicancegfinf abnormal elentmmfit$3ng; prior t6 electmmnmlsiva many. Taylor, R. 34., and Jr Nam. ‘8; Manta may 1073 2204.23.... Mar, . 51'. B. _ l , w. J”, Lewinger, L., and Wail, A. A“ manager, :4. C‘: l9 1‘ - F mdfleam, thorapwtic result in amiaophrmim ’ ‘ Am. J uW pmlecW» 3.2%}: eomlation or J3 'ghwk eleetmenaephalagmm and Win“ 1023 299‘ 1.9% ‘ ._ , '5 (,1 ”Elaatmmeephalq/{gmkfific studies renewing elwtrie 57-; 112" aback therapy; #13:). Wenml. s: mist.» .: 3 (I {V l l . \ I ‘ V 3 , ‘ 1‘ ‘2 l ‘ 1 "x \f.‘ 1 . ' ‘a I L ‘ ' 2%, ~ ‘ \ ‘ i : ; E ‘ i. ' J ‘ l‘ ‘* a ‘ l v 1,‘ 2‘ ‘2\ 1 E \ '1 . 6 w f ‘ / ‘ , , 4‘ ‘.\ .‘ , "V {3‘ ' w' l 4 i i 4/ e J L 5 ' -’ I“ "7 ,r _ ii e :y , fl ’1'! ,_ ‘ Y . , ‘, y . ' ��1 '___, Y? 3b CW #31 1416mm.) W 2’ 71ml afar}: JJngtu/zw: é/‘f M W .39“. 5““ ww—w—WWWT , {EM-fin. 7/ aux... GMM‘ ”£73 7;. 23/ , rfr3. MM WWW; flV/ZM (36¢ 3 —-—-— W7 " ., @// " " {If 557 nr— j ’7’7 Ik fer" (”a“) ’>’3 yum ¢7 i Lflflyl :7 94,}, ‘/f, 557 ' [5/ f7 l007-/¢v§ ’4’“ [7‘4“ ”3 ”7 - 9% 2/F/. ”I‘lfj " " 547+,4m7m «m 1‘- l7 [%’/&?Jflfl n/V‘é gédnw awn-£5:H " If” 415(fl/Ia 7"(K O’ermlw fif: 7" w 7 W 1 4 o2? 3v : ~———~r .1 £143de WI ,“d. _ L? ' ‘ I T) Q -1 F8 ‘ ,4, ,1, @1574”! Jflm '2 ’1 wri-ryn 334/ m ; "‘ “ :~ <- W V 3K3»: -;M " HJWAM �Levy, N.A. and Grinker, and 8.3., ”Electroencephalogranhic and ElectriC9llylln- Clinical Studies Following Metrazol . duced Convulsime herany of Affective Disorders", Archives of Neurology and Psychiatryh7, 19h2. 1009-1099. L., "Variations Pacella, g. L., Barrera,.3. E,, and Kalinowsky, Electroshock Therany with Associated ~in El’ectroencenhaloggram Archives of Neurology Disorders." Mental of Patients with and Psychiatry A7, 19h2, pp. 367-38hk Sflnon, A., Yeager, C.L., and Bowman, K. 5., "Studies in Electronarcosis Therapy IV EEG Investigationsfl' J. Nerv.and Mental' Dis., 118, on. 131-1M33 "Clinical and Electrophvsiological 3.. Following ileotroshock". Am. J. Psych. 101, Proctor, D., and Goodwind, Observations laué, pp. 7a7-8a0. of Electricéghock TreatKarliner, W.,A "Neurolowic Comnlications review." J. of Nerv. and Mental Dis. 107, on. 1-10. ments: Rosen, A. R,, Secunda, L., and Finley, K. H., "Conservative In— Mental ' of Shock Therapy in Illness, Tracings Before, Electroenoenhalographic of cluding Study Therapy". Quarterly r"sychiatric and After ghack , During Approach 17, 19h3, to Use pp.6l7-6hl. Turner, W.J., Lowinger, Lg, and_Huddleson, J. 3., "The Correlation of Pro Electroshock Electroencephalogram and Theraneutic Results in Schizonhrenics? Amer. J. of Psych. 102, lghg, I fia+41?1 r8}+d*uw~ CZ-2§ (hfiwt lqfii ; :ryfugzo a9m~fl¢3 _ _ ”—4“; «-4 �’5? [Evy—q“ .. x“. 7v , “aw—.77“ . ...,-._:$.. .1 , . fa?" Em: E». \‘a H :1 . .7 . , . . 1 ”way"- ,7 m ”V. '55: A“: - . Pup-<12: ‘ F.» 7“" ,s-n , Bagchi, B. K., Howell, R. W., and Schmale, H.T.: "The electroencephalographic clinical effects of elecmental disorders."Am. J. Psychiat. of treatment trically induced convulsions in the and 102: A9-61, 19A5. Barrera, S. E., and Pacella, B. L.: findings associated.with electric Shock therapy in patients with mental disorders." "EEG J. Physiol. 133.: 206,71951. Goldfarb, W., Laughlin, J. M., and Kiene, American H. E.:."Prolonged.insulin shock." Am. J. Psychiat. 101: 827, l9h5. Ashby, M.C., and Kinble, L.L.:"Pharmaoologic study of schizophrenia and depression. IV. Insodium the amytal response of the electfluence of electric convulsive therapy on 10h: l9h8. Am. 686-696, J. Psychiat. roencephalogram." Gottlieb, J.b., of curare in metrazol convulsant théerapy with electroencephalographic observations." Psychiatric Quart. 15: 537—5h3, 19h1. Hoagland, H., Rubin, M.A., and Cameron, D.E.: ” The electroencephalograms of schizophrenics during insulin 120: 559-570, 1937. Am. J. Physiol. hypoglycemia and recovery." Harris, M.M., and B. L.and Horwitz,‘w.A.:"Hse Pacella, 7 ‘ Wigton, R., and Jardon, F.:"Electroencephalographic studies on pat— J., Hughes, Arch. Neurol.& Psychiat. us: _ 7h8—7h9, ients receiving electro-shock treatment." l9hl. Kennard, M.A., and Nims, L.F.: "Significance of changes in the electroenceph- J. Psychiat. l9h8. 105: Ao—AS, alogram whichresult from.shock therapy." "'Am.“ Knott, J.R., and Gottlieb, J.S.: "Changes in the electroencephalogram following insulin shock therapy." Arch. Neurol. and P532 chiat. 50: 535-537, l9h3 a. Lennox, M.A., Ruch, T. C., and Guterman, B.: "The effect of benzedrine and Other chemical agents upon the postconvulsive (Electric Shock) EEG."Feraration Proc. 5:62, l9h6. Levy, N.A., Serota, H.M., and Grinker, R.R.: ‘Arch. Neurol. & Psychiat. D7: Disturbances in brain function following convulsive shock therapy." " 1009-1027, 19h2. Neel, B. H., Dswan, J. G., Myers, C. R., Proctor, L. D., and Goodwin, J- E.: "Parallel psychological, psychiatric and physiolog— ical findings in schizophrenic patients under insulin shock treatment." Am. J. Mo _ Psychiatr. 98: h22—h29, l9hl. Moriarty, J.D., and Siemens, J. 0.: "Electroencephalographic study &of electric shock therapy." Arch. Neurol. Psychiat. 57:712-718, l9h7. Nbsovich, A., and Katzenelogen, Dist. 107: 517-530, l9h8. 8.: "Electroshock therapy, clinical and &electroencephalographic studies. J. Nerv. lent. V �-2Pacella, B. L., Barrena, S. W., and Kalinowsky, L.: " Variations in the electro- encephalogram assbciated with electric shock therapy of patients with mental disorders. Arch. Neurol. & Psychiatric. h? 367-38h, (March) 19u2. Proctor, L.D., and Goodwin, J. E.: using raw 60 cycle alternating Egychiat. 99:525-530, 19h3. and Comparative electroencephalographic ob- serVations following electroshock therapy unidirectional fluctuating current. J. “““‘ Am. observaProctor, L.D. and Goodwin, J.E.: Clinical and electro-physiological Am. J. Psychiat. tions following electroshock. 101: 797—809, 19h51 Rosen, S. R., Secunda, L., and Finley, K.H.: conservative approach to the use of shock therapy in mental The illness. Psydhiatric Quart. 17: 617-6u1, 19h3. Sutherland, G. F.: experience with electric consideration of shock treatment in mental diSeases, withspecial regard to various psychosomatic phenomena and to certain electrotechnical factors." Am. J. Psychiat. 99: Sulzbach, W., Tillotson, K. J., " A Gullemin, V., and Jr.,some 519-52h, 19h3. Taylor, R. M., and Pacella, B. L.: . J. Nerv. _> & 1VLent. significance of abnormal electroencephalograms prior to electroconvulsive therapy. The Dis. 107: 220, l9h8. Lowinger, L., and Huddleson, J. H.: The correlation of pre-electro— shock electroencephalogram and therapeutic result in schizophrenia. .Am. J. Psychiat. 102: 299, l9h5. Turner, Neil, l9h7. W. J., A. A., Brinegar, W. 0.: "Electroencephalographic studies following electric Arch. Neurol. & Psychiat. 57: 719, shock therapy. �286.lfl§elation EEG Number Delta of Manuscript re: Activity ..." by Fink and Kahn Dear Doctor Fink: I am very pleased to inform you that your paper has been accepted by the Editorial Board for publica- NEUROLOGY AND PSYCHIATRY. tion in the of issue in an early article It is planned to use your A.M.A. ARCHIVES OF the ARCHIVES. Yours very truly, ROY R. GRINKER, M.D. Editor-in-Chief for Psychiatry P.S. It is necessary for publication that you forward an additional copy of your paper directly to Mr. G.S.Cooper, Managing Editor, A.M.A. Specialty Journals, 535 North Dearborn St., Thank you. Chicago 10, Illinois, as soon as possible. �L___E,, _, WW--. , , , , R. GRIEKEE, . DIRECTOR, P. a BOY MICHAEL REESE". 29th SIREET CHICAGO AND ,. pgmg's 2mg; E 16. ILLIIS|957 in %£;"3 Max Fink, Department M. DEdeEimental °f Hillside HOSPigg; 75 263rd Stfeéi “ ‘ Glen Oak§,3 c‘. NEWTYGRKE . -“ i V. - . I J .' --E EVE I ; . 3 i...' -_ .*-« . n a" Psychiatry l, ‘pja.'ff~xfiE=b . .4 -' . ', 3‘, . 2“” fl �C ' o Please return to r;’ MD Publications Inc., 30 East 60th St., New York, 22, by Jan. 2 1958. Relation of Electroencephalographic BeltavActiviiy to Behavioral Response in . Electroshock, Quantitative Serial Studies. EAX FENK Ali RDbnfiT L. AAHN. AMA-Archives of. e rology & Pegcniatry 78: 516-525, November, 1957 - I In a study of the neurophysioloch correlates of convulsive more”, serial electroencephalogram were obtained at weekly intervals in an consecutive patients referred for electrodzock. no records were quantitatively analysed for the degree of delta activity by moments of the per cent. tine delta, latest frequency and highest amplitude delta in the record, and daemon of burst activity. significant relationship was found batsmen the degree and duration of induced delta activity and clinical evaluation of behavioral change. The results were confined in a predictive study in m additional 9; patients. A Differences between these results and those obtained by others are ex’ plained in tonne of differences in methodology. A presented. It - adaptive interpretation or convulsive the repy is is concluded that convulsive therapy is the nonspecific induction neurophysiologic of persistent states of altered cerebral function, providing the physiologic milieu in which changes in sdaptive intezpersonel behavior occur. Ilprosrenen’c steer electrooonvulsive therapy . is seen es :1 special. case of behavioral response under these conditions. the rating is an evalmtion by an observer depending on annex-one teeters, including the type of adaptation, the goal and expectetim of the observer (therapist, family or adainistrstor), and the setting in which the behavior occurs. �In a-study of the neurophysiologic correlates of convulsive therapy, serial electroencephalograms were obtained at weekly intervals in 2h conseCutive patients referred for electroshock. The records were quantita- tively analyzed for the degree of delta activity by measurements of the per cent time delta, lowest frequency and highest amplitude delta in the record, and duration or burst activity. significant relationship was found between the degree and duration of induced delta activity and clinical evaluation of behavioral change. A The results were confirmed in a predictive study in an additional Sh patients. Differences between these results and those obtained by others are explained in terms of differences in methodology. A therapy ‘ neurophysiologic - adaptive interprdation of the-ele- convulsive is presented. It is concluded thataai-lil-convulsive therapy is the nonspecific induction of persistent states of altered cerebral function, providing the physiologic milieu in which changes in adaptive interpersonal behavior occur. Improvement after eledtrégggzfifliz’gfezwzz a special case of behavioral response under these conditions. The rating is factors, including the type of adaptation, the goal expectation of the observer (therapist, family or administrator), and depending on numerous and an evaluation by an observer the setting in which the behavior occurs. �v w a, z. K . .3 2.» w\ A Y; . 369 .36 N = W. ��EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE graphic Studies, J. Nerv. & Ment. Dis. 107 :517—530. 1948. 13. Kennard, M. A., and Willner, M. D.: Significance of Changes in Electroencephalogram Which Result from Shock Therapy, Am. J. Psychiat. 105:40—45, 1948. 14. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Electroencephalog. & Clin. Neurophysiol. 2 :157-162, 1950. 15. Chusid, J. G., and Pacella, B. L.: The Electroencephalogram in the Electric Shock Therapies, J. Nerv. & Ment. Dis. 116:95-107, 1952. 16. Hoagland, H.; Malamud, W.; Kaufman, I. C., and Pincus, G.: Changes in Electroencephalogram and in the Excretion of 17—Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. 8:246-251, 1946. 17. Strauss, H.: Clinical and Electroencephalo— graphic Studies: Correlations of Mental, Electro— encephalographic and Anatomic Changes in Cases with Organic Brain Disease, Am. J. Psychiat. 101: . 42-50, 1944. 18. Davis, H., and Davis, P. A.: The Electrical Activity of the Brain: Its Relation to Physiological States of Impaired Consciousness, A. Res. Nerv. & Ment. Dis, Proc. (1938) 19:50-80, 1939. 19. Ostow, M., and Strauss, H.: The Significance of Bilateral Abnormality in the Electroencephalogram, J. Mt. Sinai Hosp. 20:173-193, 1953. 20. Ostow, M., and Ostow, M.: Bilaterally Synchronous Paroxysmal Slow Activity in the Electroencephalograms of Non-Epileptics, J. Nerv. & Ment. Dis. 103 :346-358, 1946. 21. Jung, R.: Correlations of Bioelectrical and Autonomic Phenomena with Alterations of Con— sciousness and Arousal in Man, in Brain Mecha— nisms and Consciousness, edited by J. F. Delafresnaye, Springfield, 111., Charles C Thomas, Publisher, 1954, pp. 310-344. 22. Strauss, H.; Ostow, M., and Greenstein, L.: Diagnostic Electroencephalography, New York, Grune & Stratton, Inc., 1952. Fink—Kuhn 23. Roth, M.: A Theory of ECT Action and Its Bearing on the Biological Significance of Epilepsy, J. Ment. Sc. 98 244—59, 1952. 24. Bornstein, M. B.: Presence and Action of Acetylcholine in Experimental Brain Trauma, J. Neurophysiol. 9:349—366, 1946. 25. Tower,‘ D., and McEachern, D.: The Content and Characterization of Cholinesterases in Human Cerebrospinal Fluids, Canad. J. Research, Sect. E. 27:132-145, 1949. 26. Spiegel—Adolf, M.; Wilcox, P. H., and Spiegel, E. A.: Cerebrospinal Fluid Changes in Electroshock Treatment in Psychosis, Am. J. Psychiat. 104:697—706, 1948. and Spiegel-Adolf, M.: Physiological and Physiochemical Mechanisms in Electroshock Treatment, Confinia neurol. 13:38—63, 27. Spiegel, E. A., 1953. 28. Landolt, H.: Das EEG bei epileptischen Psychosen und schizophrenen Schiiben, Personal communication to the authors. 29. Landolt, H.: Uber Verstimmungen, Dam— merzustande und schizophrene Zustandsbilder bei Epilepsie, Schvveiz. Arch. Neurol. u. Psychiat. 76 1313—321, 1955. 30. Brockman, R. J.; Brockman, J. C.: Jacobsohn, U.; Gleser, G. C., and Ulett, G. A.: Changes in Convulsive Threshold as Related to Type of Treatment, Confinia neurol. 16:97—104, 1956. 31. Fabing, H.: Personal communication to the authors, 1956. 32. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: The Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Brain Disease, Am. J. Psychiat. 109:889—894, 1953. 33. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, Confinia neurol, to be published. 34. Ulett, G. A.; Smith, K., and Gleser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, Am. J. Psychiat. 112:795-802, 1956. Printed and Published in the United States of America 525 as �/ 4 I Tax A “fin? .A g. _ MW.» .15. __ O \Q « A A" 33 9% ~ ,. \a E , +3? “a . § mm“ ‘ g... .496 = a «a. .«F N . . my 3s \AVUFQV. . a SEN z «Kay pm“ Aw ‘ . fi 0. 3 qu$v g c. . E «7} Vi __ ramfljflaj~ a = Arsfiv xaxwrwmflu f» r «UN: :15. _ .n A an é it MW: a. N» “.3 M‘\ «R . R.“ A Mi 31.. A} _ “$me _ 3J3 .. mamme . .rrn: = h J H mfiuMMc «s V 4. NAQV � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of electroencephalographic delta activity to behavioral response in electroshock; quantitative serial studies. AMA Arch Neurol Psychiatry. 1957 Nov; 78(5):516-25. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-21b-026 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 7 items. 1: Reprint from the A.M.A. Archives of Neurology and Psychiatry November 1957, Vol.78, pp. 516—525. 2: Two final draft copies. 3: Several pages of handwritten notes. 4: Reference list (mix of typed and handwritten). 5: Postcard from Roy R. Grinker to Fink. 6: Copy of same page. 7: Scans of missing pages fromthe items listed above. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/4829a346731c642d4b009d69ede20ef4.pdf f52f80e5b4fabf3b53f885310a3d6354 PDF Text Text Clinical and electroencephalographic effects of Megimide in patients Without cerebral disease Martin A. Green, M.D., and Max Fink, M.D. the introduction of Megimide (beta, beta methylethylglutarimide) as an antagonist for barbiturate intoxication in 1955, considerable interest has been stimulated in its clinical applicability. Initial reports noted its efficacy in barbiturate poisoning,1—4 but subsequent studies failed to substantiate this applicationf)"8 In this laboratory, barbiturates are frequently administered under the standardized conditions of the “amobarbital test.”9 It was thus possible to assess the efficacy of Megimide in altering the behavioral response of human subjects to physiologic equivalent amounts of barbiturate. In addition to its suggested antagonism to barbiturate, Megimide induces both paroxys— mal discharges in the electroencephalogram and clinical grand mal seizures.10—14 The present report concerns our experience with both the behavioral and electroencephalographic effects of Megimide. FOLLOWIXG AIATERIAL AND METHODS Thirty-four hospitalized voluntary psychiatric patients with psychoneurosis, depression, or schizophrenia, ranging in age from 27 to 64 years, were studied. Megimide in a concentration of 5 mg. per cc. was administered intravenously at the rate of 0.5 mg. per kg. per minute, until definite changes were observed in the electroencephalogram and often beyond this point. The amount of Megimide varied from 45 mg. to 250 mg. In 15 subjects Megimide was administered without prior amobarbital. In 19 patients it was given following the administration of in— travenous amobarbital which was injected at 0.5 mg. per kg. every 40 seconds, in amounts necessary to induce nystagmus, slurred speech, and marked drowsiness or sleep. All experiments were undertaken in the elec- troencephalographic laboratory. An electroencephalogram was made prior to the injections and was run continuously during the administration of both drugs. The electrode placement consisted of frontal, motor—parietal, occipital, anterior temporal, posterior temporal, vertex, and earlobe'. Both scalp—to-earlobe and scalp-to-scalp combinations were used. RESULTS The electroencephalogram in all subjects prior to the administration of the drugs was “normal,” that is, symmetric and non-dysrhythmic. Electroencephalographic Response In the amount and rate of injection of Megimide employed, electroencephalographic changes occurred in every patient. The type of response and the amount of drug necessary to induce such a response were highly variable. The electroencephalographic changes included irregular low- and moderate-voltage slow ac— tivity, bursts of slow activity (usually of high voltage), single spike discharges, and spikewave forms (figure 1 A, B, and C). These ef— fects were diffuse and symmetric, with greatest prominence in the temporal leads. The sequence of these responses was inconstant. Irregular, low-voltage slow activity was the most frequent initial change in the record. In other instances, bursts of highvoltage slow activity or spike activity appeared initially. As the injection continued, the amplitude and per cent time delta activity inFrom the department of experimental psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. Read at the meeting of the Eastern Association of Electroencephalographers, New York, December 1956. Aided by Grant M 927, National Institute of Mental Health, National Institutes of Health, US. Public Health Service. Reprinted from NEUROLOGY, Minneapolis, September 1958, Vol. 8, N0. 9 Copyright 1958, by Lancet Publications, Inc. �EFFECTS OF MEGIMIDE "NV‘VV Mvw LP-RP *V‘JlWMAA/‘fr'rwm“MWHWIMS‘WWVWWMmeLMMA. L0‘ R 0 (memwwmewwWWW» WM WflM‘j(Ml/\rlY/‘Vr'j‘fluj'wwMWWWWWWJWMW VWLWMW WWW/wWWJMWW *WWWWWWW AT R P T I‘ 5A , ”v w. a WW1 '«M “-34x4“ MW‘WMMWW I ‘A ‘M’m‘rv‘v‘rfi‘w Jam.M’w’M—‘fi' draw; R “ij MW ® .I 50 35cc MEGIMIDE (5 cc/ MIN) mv lSEC, LP-RP @ 30 cc MEGIMIDE (Soc/MIN.) ' SEC' creased. Bursts of high—voltage slow activity were seen eventually in almost all patients. Spike discharges, however, were less frequent, even with relatively large doses of Megimide. For example, the tracings in one subject after receiving 220 mg. of Megimide and in another after receiving 250 mg. showed irregular diffuse slow activity without spike activity. Seizures Because of the nature of the population and the goals of our study, we specifically avoided administering Megimide in rates and amounts that would produce clinical grand mal seizures. Despite these precautions, a grand mal seizure was inadvertently induced in one patient. A 33 year old woman was given 200 mg. of Megimide at the rate of 50 mg. per minute. Up to 150 mg. there was only a decrease in the voltage of the alpha activity. After 200 mg. there was a sudden long run of diffuse, rhythmic 4 to 5% cycles per second high voltage activity, with intermixed spike activity which was immediately followed by the seizure. The electroencephalogram during injection and prior to the seizure showed minimal changes, and the seizure was not anticipated 35M: MEGIMIDE (Sac/MIN.) SE“ F IG. 1. Different types of electroencephalographic response to Megimide. A, delta activity, irregularly and in bursts, B, single spike activity, C, spike-wave activity Subjective Response The subjective reaction to Megimide was minimal, even when the induced changes in the electroencephalogram were severe. A few subjects complained of nausea, “dizziness,” “shakiness,” or a peculiar sensation in the abdomen. It was possible, however, to continue the injection without further increase in the symptoms. Two subjects became apprehensive, and in one of these the injection had to be discontinued. Myoclonic jerks occurred frequently. They were usually mild and confined to one extremity. Less frequently they were bilateral and more severe. The relationship between these movements and spike activity was inconstant. The myoclonic jerks usually preceded the appearance of spike activity, althOugh the reverse occurred occasionally. The simultaneous appearance of spike activity with myoclonic jerks was infrequent. The effect of Megimide was short-lived. There were no instances of seizures or other abnormal responses later in the day following its administration. However, since intravenous amobarbital followed in all patients, this may have prevented such occurrences. The clinical and electroencephalographic responses to intravenous amobarbital following Megimide appeared similar to those seen in subjects in whom amobarbital is administered without prior medication. The slow-wave or spike activity induced by Megimide disappeared and the usual patterns associated with barbiturates developed (figure 2). However, �NE UROLOGY 684 the well-modulated high per cent time beta activity usually noted after barbiturate administered was less prominent. M egz’mide Following Amobarbital One group of subjects received intravenous amobarbital prior to Megimide until drowsiness, slurred speech, and nystagmus were induced. The electroencephalogram showed the patterns commonly associated with barbiturates, that is, an increase in voltage and per cent time fast activity and a decrease in amount and voltage of alpha activity. The most prominent clinical change was the awakening of the subject. Within the few minutes necessary for the injection, the patient became more responsive, slurred speech disappeared, and drowsiness, both on subjective and objective evaluation, was minimal or absent. Nystagmus became inconstant, unsustained, or disappeared completely. Gait, including heel-totoe walking, was steady. However, the awakening effect was not uniform for all aspects of behavior altered by barbiturate. For ex— ample, if the subject became euphoric and more talkative with barbiturate, such behavior may have persisted in a milder form, even after the drowsiness of amobarbital was abolished by Megimide. These clinical changes were accompanied by alterations in the electroencephalogram (figure 3). Patterns of drowsy activity disappeared. Alpha activity increased both in amount and voltage. Fast activity induced by amobarbital usually persisted unchanged or was reduced only sightly. In some instances it increased in amount and voltage. The prior administration of amobarbital did not prevent the appearance of paroxysmal discharges. WW W LP-RP W WJMWW LO'RO LF-RF -om A mmwwwwwwvwvv WWW/”WWW AT-PT @RESTING RECORD W wa~VMMMWh~WMphfiwnw~ L AT-F R MMKWWWMMVWVJ @ UL ‘vr—WW‘W wabwuvmh1-vun~pa~h4qu WWW» 50!”?— 1 azsrmc RECORD 252 (28 mg. AIOBARBIYAL rug/40 SEC.) 40 c: IEGEIIDE (5 cc / III.) FIG. 2. Effect of amobarbital following administration of Megimide fiWWA/VWW 38cm MEGIMIDEHScc/MIN.) r. W WWW WWWWHW WWW WWW WVNMWMWWM o LO . R0 F: MNVWVWVWVW—M’NW’ Megimide is similar to pentalenetetrazol (Metrazol) in that it induces delta activity, spike and spike-wave activity in the electro— encephalogram, and clinical grand mal seizures. Such changes occur in nonepileptic subjects without brain disease, and considerable individual variability in the threshold for these changes exists. These discharges are nonspecific and cannot be used as evidence of the presence of a seizure disorder. The possibility of using Megimide in activating the electroencephalogram has received study.10—1‘-’ Several investigators have noted a more gradual onset of the electroencephalographic and clinical changes with Megimide than with Metrazol. For this reason, the opinion is expressed that Megimide may be more facile in reproducing both clinical and electro— encephalographic seizures in patients with seizure disorders. It should be emphasized, however, that in the one patient in the present study in whom a grand mal seizure occurred, the seizure began suddenly and was not anticipated either from the electroencephalogram or previous clinical responses. Megimide is effective in counteracting the clinical effects of small doses of intravenous amobarbital. This property has been previously demonstrated in animals3 and is being utilized LF-RF k WN-WINW‘MWMNWVM DISCUSSION 0%va6Wwaw'wwrwwqp'v LM-RM {-0 Bursts of high-voltage slow activity, spike activity, or spike-wave activity often appeared, usually during or after awakening. Such activity was not a necessary accompaniment of the awakening response, however, since other subjects in whom clinical drowsiness disappeared did not show such discharges. 500 mg.AMOBARBlTAL (50 mq./40 SEC.) Effect of Megimide following administration of amobarbital FIG. 3. SEC. �EFFECTS OF MEGIMIDE in anesthesiology to shorten the recovery period from barbiturate anesthesia postoperatively.15 It is questionable whether this action is specific for barbiturates or whether it also applies to states of altered consciousness due to other agents as well.16 CONCLUSIONS Thirty-four psychiatric patients without cerebral disease were given Megimide (beta, beta-methylethylglutarimide) before and after the administration of intravenous amobarbital. 2. Megimide produces irregular delta activ~ ity, bursts of delta activity, and spike and spike-wave activity in the electroencephalo1. 685 gram. Such effects are similar to those produced by pentalenetetrazol (Metrazol). 3. Considerable individual variability exists in the amount of drug necessary to produce these changes. 4. A grand mal seizure was inadvertently induced in one patient. The electroencephalogram during the injection and prior to the seizure showed minimal changes and the seizure was not anticipated. 5. Megimide counteracts the clinical and some of the electroencephalographic effects of small doses of intravenous amobarbital. Megimide supplied through the courtesy of A. las Ltd., Slough, Bucks, England. & I. Nicho- REFERENCES A., SHAW, F. H., CASS, N. M., and \Van, H. M.:M. A new treatment of barbiturate intoxication. Brit. J. 1:1238, 1955. 1. SCHULMAN, to . 3. 4. 5. 6. 1. 8. 9. F. H.: Further experiences with Megimide—a barbiturate antagonist. M. J. Australia 2:889, 1955. SHAW, F. H., SIMON, S. E., CAss, N., and SCHULMAN, .-\.: Barbiturate antagonism. Nature 174:402, 1954. HARRIS, T. A. 13.: A barbiturate antagonist. Lancet 1:268, 1955. L()U\V, A., and SONNE, L. M.: Megimide in the treatment of barbituric acid poisoning. Lancet 2:961, 1956. PEDERSEN, ].: Amusing effect of Megimide and Ami— phenazole in allypropymal poisoning. Lancet 2:965, 1956. PLUM, F., and SWANSON, A. G.: Barbiturate poisoning treated by physiological methods. J.A.M.A. 163:827, 1957. CERSHON, S., and SHAW, F. H.: Effects of Bemegridc on barbiturate overdosage in humans. Brit. M. J. 2: 1509, 1957. \VEINSTEIN, E. A., KAHN, R. L., SUGARMAN, L. A., and LINN, L.: The diagnostic use of amobarbital sodium (“Amytal sodium”) in brain disease. Am. J. Psychiat. 109:889, 1953. SHAW, 10. COURJON, 1., and BONNET, H.: Comparative effects of Metrazol and Megimide in activation of epileptic pa- tients. EEG 11. 12. 13. 14. 15. Clin. Neurophysiol. 8:710, 1956. DROSSOPOULO, G., GASTAUT, H., VERDEAUX, G. and J., and SCHULLER, E.: Comparison of EEG “activation” by pentamethylenetetrazol (Metrazol) and Bemegride (Megimide). EEG & Clin. Neurophysiol. 8:710, 1956. Room, E. A., RUTLEDGE, L. T., and CALHOUN, H. D.: Megimide and Metrazol (A comparison of their convulsant action in man and in the cat). EEG & Clin. Neurophysiol. 10:208, 1958. SOD‘TRBERG, U.: Eflect of Bemegride (Megimide) on cerebral blood flow and electrical activity of brain. Arch. Neurol. & Psychiat. 792239, 1958. PEACOCK, J. M.: An electroencephalographic examina— tion of the effects of Megimide and Daptazole in bar— biturate narcosis. EEG 8: Clin. Neurophysiol. 8:289, 1956. VVYKE, B. D., and FRAYVVORTH, E.: Use of Bemegride in terminating barbiturate anesthesia. Lancet 2:1025, & 1.957. 16. BOTTINGER, L. E., ENGSTEDT, L., and STRANDBERG, 0.: Is Bemegride a specific barbiturate antagonist? Lancet 1:932, 1957. �6mm and m We“: at Was in Patients WW?» 66”me Mum W m A. 11.3. ‘W-AMWI < I . the m Gala, Wt30!.of mm mm. mm swam. Glen 1mm... matting at the Max “manhunt: or m at thoMubor Elsemmm. 1956. Nam Yam-k, " Aiéadhy Grant Wham 3/58 65f I! 92?, Katina}. M‘W‘lfii at mm Kalil), 0.3. fibula Knuth 3031“. mm. 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Magma: as net 6.1119195.qu of men. dawn of tutu-amp“ maba'rhim. etfeete, �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical and electroencephalographic effects of megimide in patients without cerebral disease. Neurology. 1958 Sep; 8(9):682-5. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-22b-027 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from NEUROLOGY, Minneapolis, September 1958, Vol.8, N0.9 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/11575e68e7e18c8231219284212ca0ba.pdf 8597351b5fddeee289bccffd6b5c1c4f PDF Text Text 9Q J. Hillside Heapital, 1957 6: 197-206, A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMICTHERAPIES1 MAX FINK, MD.2 The proper role of the physiodynamic therapies (convulsive, insulin coma and lobotomy) in psychiatry remains poorly defined. In part, this results from the lack of an adequate formulation of their mode of action. In the past six years increasing evidence for a neuropllysiologic-adaptive view of electroconvulsive therapy has been presented (41, 32, 38, I). This view ascribes the therapeutic process in electroshock to a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. The type of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, an awareness of a similar mode of action in insulin coma (31) and lobotomy (40) has developed. During the past four years we have studied the relation between alteration in various indices of brain function and the behavioral response of psychiatric patients to therapy. The neurophysiologicadaptive view of electroshock has been supported and amplified (11, 12, 13, 19, 21); evidence for a similar view of insulin coma has been presented (22); and recently the concept has been extended to the newer “tranquilizers" (9). These studies provide the basis for a generalization concerning the efficacy of these therapies. It is our purpose in this report to examine the experimental evidence to determine whether or not the mode of action of each of these thera— 1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the. 2nd International Congress of Psychiatry, Zurich, September 6, 1957. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 2 Director, Department of Experimental Psychiatry, Hillside Hospital. 197 12-» �198 MAX FINK pies may result from their ability to induce sustained alteration in cerebral function; and the corollary question, whether measurable alteration in cerebral function is a necessary condition for the effi— cacy of these therapies, or a “complication" or "untoward effect." The indices of brain function used in these studies have varied. These include memory scales (2G), visual (20) and tactile (10) perceptual tasks, and changes in language patterns of orientation both clinically (19) and after intravenous amobarbital (21). In electroencephalographic studies of this problem, changes in the delta index, both in routine records (ll, 12) and after activation by intravenous thiopentone (32, 33), and in the beta index (16) have been applied Successfully. For this review, two indices will be stressed: changes in the delta index of the unactivated EEG, and clinical neurologic signs. These indices have been selected because of their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities. OBSERVATIONS (a) Electroshock 4.1 "1M The following notes summarize our experimental studies of the role of 'changes in EEG delta activity in the response of subjects to electroshock (11, 13). In these studies, electroencephalograms were obtained before treatment, and at weekly intervals on a day after a treatment in consecutive electroshock referrals. Grand mal treatments were administered three times a week, for twelve to twenty treatments. The EEG records were quantitatively analyzed for the amount of induced delta activity, and classified into categories of “high,” “moderate” and “low” degrees of delta activity. At the end of treatment, the patients were independently rated for their shortterm clinical response into the categories of “much improved," “moderately improved” and “unimproved." In the initial series of patients, a significant relationship between the early induction of high degrees of delta activity, and clinical ratings of “much improved” was observed. Eighty per cent of the records in the much improved group were high degree delta by the fourth to sixth treatment; and the percentage was sustained at 90 per cent in the third’ and fourth weeks. In contrast, none of the unimproved patients developed high degree delta records in the first three weeks, and only 20 per cent of the records in the fourth week were so classified. In a subsequent predictive study, the EEG records during the a wan-pow �THEORY OF PHYSIODYNAMIC THERAPIES 199 second and third weeks of treatment were analyzed. Of the patients who had high degree delta records on both occasions, 67 per cent were rated as much improved, while of the patients without such records, 70 per cent were in the unimproved and moderately improved categories. Roth (82, 33), studying the EEG delta activity evoked by intravenous thiopentone after electroshock, has related both the stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. He concluded that patients not attaining a specified delta activity level "have not acquired an adequate physiological basis for recovery,” and recommended measurement of delta activity levels after thiopentone as a guide to the clinical management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of delta activity that vary from low to high, subconvulsive therapy rarely alters EEG patterns or induces low degrees of delta activity (13). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Gleser (38) demonstrated a significantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (13) recently completed here, twenty-seven patients received a course of subconvulsive therapy. Electroencephalograms, taken at weekly intervals, demonstrated minimal changes—none of the records were scored as middle or high delta activity. Of the twenty-seven patients, no change in behavior was noted in twenty-three, and of these, nineteen were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed significant changes in behavior, while of the five who did not show the delta response, only two showed a behavioral change. Tranquilizing Drugs When the newer drug therapies are studied from the viewpoint of their electroencephalographic and clinical neurologic effects, a meaningful classification emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efficacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly definable electroencephalographic patterns. Based on observations made in chronic admin(b) �MAX FIN K 200 istration of drugs in adult psychiatric patients, the EEG changes may be classified according to predominant changes in the frequency spectrum. There are three broad types: Increased slow wave activity with hypersynchrony (“bursts")—“delta shift" II._ Desynchronization with voltage and frequency irregularity and irregular theta activity—“desynchronization” III. Increased high voltage fast activity—“beta shift.” Of the group of drugs inducing a delta shift, the phenothiazine derivatives chlorpromazine, promazine, and perphenazine are clear examples. Each drug induces seizures in nonepileptics or exaggerates seizures in epileptic patients (7, 8, 15, 29, 37). Each drug induces clinical parkinsonian neurologic patterns when given in adequate dosage. In our laboratories, we have induced parkinsonism in all patients receiving chlorpromazine (l4) and have observed seizures in 10 per cent of a group of psychotic patients without previous ltistnl'y of seizures. Induced delta activity, including burst activity, \ms nlm-ned in more than half the patients in this series. Rrxrxpiue also ernkes delta activity when given in large doses (3- \t liitth tlnugt‘ levels. it exaggerates seizures in epileptics and "I'lihrs wzmtes in animals (35). .-\t the usual clinical dosages, howr.:-:, ”supine imluu's desynrhronization of frequencies with a t; w-lrtxh‘ mitease in theta activity (28), without seizure induction in: mm definite motor rigidities. In a series of patients treated here ("T'H. parkiuwuism was induced in all patients. EEG Changes were limited to desynchronization only, without delta burst activity. The primary response of two other drugs, mepazine and benacty. . Ime. is the induction of EEG desynchronization. Mepazine, a phen()t‘ttLt/mt‘ derivative. induces desynchronization with small amounts; it n\n\ \ \ l‘h'lt'h .‘n‘H\'n\ has nx‘u t\\\‘ll 'li‘it‘l‘fik‘n. nor have .-' m: Immd reports either of seizures or parkinsonism in the clinical literature. Benactyzine, a potent anticholinergic compound, induces a blocking of alpha, flattening of the record and occasional theta activity (5, 17). Neither seizures nor parkinsonism have been described for this agent. Meprobamate is the clearest example of the group of drugs inducing a beta shift in the EEG (3). This agent further differs from the phenothiazines and reserpine in not producing parkinsonism and not only are clinical seizures not induced, but definite antiepileptic activity has been described (30). Habituation is readily 1. x a w �THEORY OF PHYSIODYNAMIC THERAPIES f 201 achieved, and withdrawal phenomena of agitation and seizures have been observed (42). In these actions, meprobamate is more like barbiturates than like the other new tranquilizers. If we determine the clinical efficacy of these agents, we note a parallel between the induced EEG effects and their potency in altering behavior. The drugs that most readily induce a delta shift in EEG frequencies—the phenothiazine compounds—are those with the greatest clinical efficacy in the therapy of psychoses. The compounds with lesser activity in this direction are less efficacious clinically. i f ,1 ,i / I/ ! Insulin Coma Therapy The effects of insulin coma therapy on the nervous system are well documented. During each coma, EEG delta activity is induced, which usually persists for minutes to a few hours after gavage. Not infrequently, in approximately one third of patients receiving deep coma therapy in this hospital, seizures, aphasia or prolonged coma results. After such events, EEG changes of delta activity persist for days, and in cases of prolonged coma, for weeks and months (43). The relation between prolonged coma, altered brain function and behavioral response has been discussed at length. Revitch (31) reported eight cases of prolonged coma and concluded that improvement may be attributed to the induction of organic brain damage, similar to lobotomy. Yaeger, Simon, Margolis and Burch (43), describing twelve cases of prolonged insulin coma, noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (34), emphasizing EEG data, and Kwalwasser and Caplan (27) presented individual cases to support the same conclusion. We reported a similar relationship between prolonged coma and behavioral response in a case study (22). A 34-year-old schizophrenic patient with paranoid ideation developed a left hemiplegia during insulin coma therapy. With the onset of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and spatial inattention, there was a marked change in speech and behavior. He became lucid, loquacious and denied his illness. His former paranoid-withdrawal type pattern was replaced by a friendly cooperative attitude. These changes were accompanied by delta changes in the EEG, as well as language changes after amobarbital indicative of altered brain function. The neurologic symptoms resolved, but the behavioral changes persisted so that he was discharged two months later as “much improved." , l 5, ' ‘ (c) m..- aunts..- 5 ’j 2 “ \lU, 5‘ r ' - �202 MAX FINK (d) Lobotomy to study lobotomy While we have not had the opportunity of of view of this summary, the reports the point from EEG patients a similar relationship. numerous observers clearly documentin all subjects postoperatively of changes of delta activity are present Walter et al. (40) in a study (6) and persist for varying periods. EEG persistence of abnormal 150 patients, found an 80 per cent be? relation noted a also authors activity after three years. These of postextent and and the degree tween clinical improvement operative slow wave activity. “complication," being variPostoperative seizures are a frequent (25). in up to 20 per cent of subjects ously reported as occurring of brain extent the between Furthermore, there is a relationship Circumscribed surgical tissue cut and the therapeutic outcome. improvement rate lower than lesions, regardless of locus, have an are frequently inadequate unilateral lobectomy; and these latter bilateral procedure (36). and are “improved” upon by a and i there havi Thfi tior the pa 5V 1,,“ F .'r' l s. l ‘_ DISCUSSION are essayed from the When the various physiodynamic therapies mode in brain function, a common point of view of an alteration which therapies represent devices of action becomes apparent. These function, with resultant change induce appreciable changes in brain and lobotomy induce measurable in behavior. Convulsive therapy directly; insulin coma primarily diffuse changes in brain function the phenothiazine and reserpine when complications ensue; and when given in adequate dosage. groups of tranquilizers function affect behavior is How persistent changes in cerebral“reversed" or “obliterated." is not not clear. Psychotic behavior the central nervous system milieu, in Rather, with an alteration of behavior including perception, there is an alteration in all aspects attitude. The specific adaptive mood, affect, memory, judgment and each subject and is dependent on numerous response is variable for Premorbid personality (18), historical and environmental factors. and the duration of environmental situation and expectations (13), have recently been discussed as the alteration in brain function (12) under these conditions. determinants of the behavioral response evaluated by the psychiaThe induced changes in behavior are the degree of “improvement." trist, administrator or family as to based the upon such factors as These ratings are value judgments, tolerance behavioral response, the environmental type of induced . JUN-laws �THEORY OF PHYSIODYNAMIC THERAPIES "Omy 0f ‘S E15G VC‘Iy } 'Of l EC ‘1 ’6 _ W . - . f . .-‘ i / / . ‘ y . “ (a 203 and the observer's expectations. In this context, the physiodynamic therapies do not induce “improvement"——-rather they induce behavioral change which is secondarily evaluated as improvement. The alteration of cerebral function is therefore not a “complication" or an "untoward effect" but the desired goal of these forms of therapy. Of the many “organic" therapies introduced during the past thirty years, none apparently has been a specific agent for the therapy of psychoses (in the sense that penicillin is specific for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efficacy in altering behavior by altering the cerebral milieu. In this context, the various physiodynamic therapies are not specific for a type of psychosis. The early enthusiasm that reserpine or chlorpromazine was specific for schizophrenia, or hypotheses that ascribe significance to an antagonism between these drugs and “psychosis" or "schizophrenia" are not tenable. Similar enthusiasm claiming a specificity of insulin coma for schizophrenia is also untenable, and support for this view is presented in a recent chlorpromazine-insulin coma control‘study (l4). EEG analysis of these therapies permits a more explicit definition of the induced alteration in brain function. Changes in cerebral function reflected by a shift in the spectrum of EEG frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as “bursts" or “hypersynchrony” provide the change in milieu that is more effective in altering behavior. The significance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the tranquilizers. That a delta shift has some specificity is seen in the analyses of the drug effects. Those drugs that induce the delta shift—the phenothiazines and reserpine—have been consistently reported as effective modifiers of psychotic behavior. Changes in brain function reflected by EEG desynchronization only, or a shift in frequency spectrum to the faster range, have a limited efficacy in altering psychotic behavior.3 The significance of a delta shift is further seen in the limited efficacy of subconvulsive electroshock when compared to convulsive electroshock in the management of psychoses. Another aspect of the alteration in brain function which may be defined is the change in seizure threshold. With the delta shift in 3 These observations suggest the application of EEG screening of new chemotherapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. �MAX FINK 204 the EEG, an increase in clinical seizures would be anticipated. This is indeed true. Seizures have been described following electroshock (4, 24); they are prominent after lobotomy (40) and a common “complication” during and occasionally following insulin coma therapy (23). With the tranquilizers, the parallel of clinical efficacy and seizure induction is most striking. Phenothiazine compounds induce seizures commonly; reserpine rarely; benactyzine not at all; and meprobamate is a potent anticonvulsant! The lowering of seizure threshold parallels the extent of the EEG delta shift induced by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism—both potent indices of an alteration in cerebral function. The neurologic basis for the delta shift and increase in seizure’ frequency is unclear. Whether this represents a persistent change in function of some specific brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a delta shift, with or without hypersynchrony, it appears more likely that the EEG changes reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of specific cellular masses. SUMMARY 1. The neurophysiologic and clinical neurologic aspects of con- vulsive therapy, “tranquilizers,” insulin coma and lobotomy, are reviewed. 2. The efficacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent change in cerebral function, of which a delta shift in the EEG spectrum and an increase in incidence of seizures are two indices. 3. Alteration in cerebral function is an essential prerequisite of behavioral change with each of these therapies. Such alteration is neither a “complication,” nor an “untoward effect," but is the sine qua non of the mode of action of these therapies. 4. No evidence has been educed in these studies that the physiodynamic therapies are specific agents for the relief of psychoses; nor do they affect a specific segment of the nervous system; nor do they induce specific behavioral'changes. 5. The therapeutic process of convulsive therapy, insulin coma, lobotomy and tranquilizers may be ascribed to the induction of a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. r.—-r,y.,.",,,, �THEORY OF PHYSIODYNAMIC THERAPIES 205 REFERENCES (1) (2 V i l l : Aird, R. B.: Strait, L. A.: Pace, J. “7.; Hernolf, M. K. 8: Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. A.M.A. Arch. Neural. (9 Psychiat., 75:371-378, 1956. Arellano, A. P. 8.- ]eri, R.: The Ellcct of Reserpine on the Scalp and Basal Electrocncephalogram. EEG. Clin. Neurophysiol., 8:150 (abst.), 1956. Berger, F. M.: The Chemistry and Mode of Action of Tranquilizing Drugs. Ann. N. Y. 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C. 8c Pincus, 0.: Changes in Electroencephalogram and in Excretion of l7-Ketosteroids Accompanying Electro-shock Therapy of Agitated Depression. Psychosom. Med., 8:246-251, �MAX FINK 206 and Other Hoch, P.: Shock Treatment, Psychosurgery 8c Stratton, 1952. Grune York: New Somatic Treatments in Psychiatry. This States Following Electroshock Therapy. (24) Karliner, W.: Epileptic Journal, 5:258-263, 1956. in Prefrontal Loof Seizures, with EEG Findings, (25) Klotz, M.: Incidence 1955. 74:144-148. 65' Psychiat, and botomy. A.M.A. Arch.8.- Neurol. Kwalwasser, 8.: Relation of Changes in Memory 1956. 16:88-96, (25) Korin, H.; Fink, M. Neurol., Electroshock. Conf. Learning to Improvement in A Case of Prolonged Insulin Coma: Treat8.- Caplan, M.: (27) Kwalwasser, S. 1952. ment. This Journal, 1:145-155, Drugs on EEG. EEG Clin. “Tranquilizing” of Effect T.: W. (23) Liberson, Neurophysiol., 8:523, 1956. Fits in LeuN.: The Occurrence of Epileptic (29) Liddell, D. W. 8: Retterstol, Neurol., Neuro]. Therapy. Chlorpromazine cotomized Patients Receiving 20:105-107, 1957. Disorders. surg, &» Psychiat., Miltown, Its Use in Convulsive and Related A.: M. (30) Perlstein, 1956. 161:1040, J. Am. Med. Assoc., ImproveOrganic Brain Damage and Clinical 28:79-92, 1954. (31) Revitch, E.: Observations on Quart., Coma. Psychiat. ment Following Protracted Insulin Produced by the EEG Under Barbiturate Anesthesia (32) Roth, M.: Changes in for the Theory of Significance Their and Treatment Electro-Convulsive 3:261-280, 1951. ECT Action. EEG Clin. Neurophysiol., and Pentothal K.; Shaw, J. 8: Green, ].: Prognosis W. D. M.: Kay, Roth, Treatment. (33) Electra-Convulsive in Induced Electroencephalographic Changes 1957. 9:225-238, EEG. Clin. Neurophysiol., and Clinical P. W.: Serial Electroencephalographic Neural. & (34) Shagass, C. 8: Rowsell, Arch. A.M.A. Coma. Insulin Studies in a Case of Prolonged Psychiat., 72:705-711, 1954. Interaction of A.: Mechanisms Involved in the (35) Sigg, E. B. 8: Schneider, J. Neurophysiol., 9: Clin. EEG. Reserpine. and Various Central Stimulants 419-426, 1957. M.: Unilateral and L. 11.; Adams, J. E. 8: Bowman, K. (35) Simon, A.; Margolis, A.M.A. Arch. Neurol. 6' Evaluation. Controlled A Bilateral Lobotomy: Psychiat., 66:494-503. 1951. Use to Activate Electroencephalographic (37) Stewart, L. F.: Chlorpromazine: 9:427-440, 1957. Neurophysiol., Clin. EEG Seizure Patterns. of Convulsive and SubEvaluation C.: 8c G. Gleser, K. (38) Ulett, G. A.; Smith, Am. J. Psychiat., Control Group. a convulsive Shock Therapies Utilizing (23) Kalinowsky, L. B. 8: . . 112:795-802, 1956. of A. G.; Fink, M. 8: Miller, J. S. A.: Evaluation (39) Wachspress, M.: Blumberg, Journal, 5:67-77, This of Anxiety. Relief for Reserpine Therapy High-Dose 1956. C. L.; Margolis, L. H. 8: Simon, A.: The EEG Changes 111:590(4°) Walter, R. D.; Yaeger, and Bilateral Frontal Lobotomy. Am. J. Psychiat., in Unilateral 594, 1955. and Physiologi8c Kahn, R. L.: Denial of Illness: Symbolic (41) Weinstein, E. A. 1955. cal Aspects. Springfield, Ill.: C. C. Thomas. Communication. (42) Wilder, A.: Personal L. H. 8: Burch, N. R.: Electroencephalo(43) Yaeger, C. L.; Simon, A.; Margolis, Ment. Dis., 118: Coma. ]. New. 6' graphic Studies in Posthypoglycemic 435-441, 1953. . 39W" _ . w . if �A Unified Theory of the Action of Physiodynamic Therapies Max Fink, M.D. From the Department of Experimental Psychiatry, Hillside Respital, Glen Oaks, Read at the 2nd International Congress of Psychiatry, Zurich, September 6, N.Y. 1957. of the National Institute of Mental Health, National Institutes of Health, U.S. Public acalth Service; and the Board of Directors' Research Fund of the Society of the Hillside Bbspital. Aided by 10-7-57 grant M-927 �Iv: unified A The 10/5/57 Theory of the Action of Physiodynamic Therapies proper role of the physiodynamic therapies (electroshock, insulin coma and lobotomy) in psychiatry remains poorly defined. In part, this results from the lack of an adequate formulation of their mode of action. In the past six years increasing evidence for a neurophysiologic-adaptive view of electro- (hl, 32, 38, 1). This view ascribes the there“ shock therapy has been presented peutic process in electroshock to a persistent alteration in cerebral function which provides the milieu environment. The for a change in adaptation of the subject to his type of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, of action in insulin coma (31) and lobotomy During the past four years we (MO) of psychiatric patients to therapy. The a similar view of insulin relation between and the behavioral response neurophysiologic-adaptive view of electroshock has been supported and amplified (9, 10, for mode has developed. have studied the alteration in various indices of brain function similar an awareness of a coma has been ll, 20, 21); evidence presented (19); and recently the concept has been extended to the newer "tranquillizers" (12). These studies provide the basis for a generalization concerning the efficacy of these therapies. It is our purpose in this report to examine the experimental evidence whether or not the mode of action of each of these therapies may to determine result their ability to induce sustained alteration in cerebral function; from and the coroln lary question, whether measurable alteration in cerebral function is a necessary �- - 2 condition for the efficacy of these therapies, or a "complication" or "untoward effect." The include indices of brain function used in these studies have varied. memory scales (26), visual (22) and tactile changes in language patterns of orientation both intravenous ambbarbital (20). changes in the clinically (21) and after In electroencephalographic studies of this problem, by intravenous thiopentone (32, 33), and successfully. For this review, have been (13) perceptual tasks, and delta index, both in routine records (9, delta index of the unactivated These and after activation in the beta index (16) have been applied two indices EEG, 10) and will be stressed: changes in the clinical neurologic signs. These indices selected because of their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities . �OBSERVATIONS: (a) Electroshock: The role of changes in following notes summarize our experimental studies of the EEG delta activity in the response of subjects to electro- In these studies, electroencephalograms were obtained before shock (9, 11). treatment, and at weekly intervals electroshock referrals. week, for after a treatment in consecutive Grand mal treatments were administered treatments. 12-20 on a day The EEG three times a records were quantitatively analyzed for the amount of induced delta activity, and classified into categories of "high", "moderate" and "low" degrees of delta patients were independently the categories of In the At the end of treatment, the activity. rated for their short term clinical response into "much improved”, "moderately improved" and "unimproved". initial series of patients, a significant relationship between the early induction of high degrees of delta activity, and clinical ratings of "much improved" was observed. Eighty percent of the records in the much improved group were high degree delta by the h-6 treatment; and the percentage was sus- tained at 90% In contrast, none of the unimproved in the third and fourth weeks. patients developed high degree delta records in the 20% third weeks of treatment were analyzed. delta records on both occasions, 67% were patients without such records, categories. 70% and only classified. of the records in the fourth week were so In a subsequent predictive study, the and first three weeks, EEG Of records during the second the patients rated as who had high degree much improved, while of the were in the unimproved and moderately improved �*“1 h Both (32, 33) studying the EEG - delta activity thiopentone after electroshock has related both the evoked by intravenous stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. activity level, He ...... " concluded that patients not attaining a specified delta have not acquired an adequate physiological basis for recovery," and recommended measurement of delta activity levels after thiopentone clinical as a guide to the management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of vary from low to high, subconvulsive therapy rarely alters duces low degrees of delta delta activity that EEG patterns or in- activity (11). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Gleser (38) demon- strated a significantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (11) recently completed here, twenty-seven patients received a course of subconvulsive therapy. weekly Electroencephalograms, taken at intervals, demonstrated minimal changes as middle or high delta activity. Of - none of the records were scored the 27 patients, no change in behavior was noted in 23, and of these, 19 were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed significant changes in behavior, while of the five who did not show the delta response, only two showed a behavioral change. (b) Tranquillizing Drugs: When the newer drug therapies are studied from the viewpoint of �-5their electroencephalographic and clinical neurologic effects, a meaningful classification emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efficacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly definable electro— encephalographic patterns. Based on observations made of drugs in adult psychiatric patients, the EEG in chronic administration changes may be according to predominant changes in the frequency spectrum. classified There are three broad types: I. Increased slow wave activity with hypersynchrony ("bursts") - "delta shift" II. Desynchronization with voltage and frequency irregularity and III. Of irregular theta activity - "desynchronization" shift." Increased high voltage fast activity - "beta the group of drugs inducing a delta derivatives chlorpromazine, promazine, Each drug induces shift, the phenothiazine and perphenazine are clear examples. seizures in non-epileptics or exaggerates seizures in epileptic patients (7, 8, neurologic patterns 15, 29, 37). when given Each drug induces in adequate dosage. clinical parkinsonian In our laboratories, have induced parkinsonism in all patients receiving chlorpromazine have observed seizures in 10% (1%) and of a group of psychotic patients without previous history of seizures. Induced delta activity, including burst activity, observed in more than we half the patients in this series. was �-5Reserpine also evokes delta At high dosage levels, it activity when given in large doses (2). exaggerates seizures in epileptics and induces seizures in animals (35). At the usual clinical dosages, however, reserpine induces desynchronization of frequencies with a moderate increase in theta activity (28), without seizure induction but with definite motor rigidities. In a series of patients treated here (39), parkinsonism was induced in patients. EEG all changes were limited to desynchronization only, without delta burst activity. The primary the induction of EEG response of two other drugs, mepazine and benactyzine, is desynchronization. Mepazine, a phenothiazine derivative, induces desynchronization with small amounts of theta activity has not been described, nor or parkinsonism in the have we found activity (7). Delta reports either of seizures clinical literature. Benactyzine, a potent anticholin- ergic compound, induces a blocking of alpha, flattening of the record and 17). Neither seizures nor parkinsonism have occasional theta activity (5, been described for this agent. Meprobamate beta shift in the and EEG is the clearest example of the group of drugs inducing a (3). This agent further differs reserpine in not producing parkinsonism from the phenothiazines and not only are clinical seizures not induced, hut definite anti-epileptic activity has been described (30). Habituation is readily achieved, and withdrawal phenomena of agitation and seizures have been observed (h2). barbiturates than like the other If we determine the In these actions, meprobamate new is more like tranquillizers. clinical efficacy of these agents, we note a parallel �-7between the induced drugs EEG effects and their potency in altering behavior. that most readily induce a delta shift in thiazine compounds - are those with the therapy of psychoses. The compounds EEG frequencies - the The pheno— greatest clinical efficacy in the with lesser activity in this direction are less efficacious clinically. (c) Insulin Coma The well documented. Therapy: effects of insulin During each coma, persists for minutes to a few hours EEG coma delta activity is induced, after gavage. imately one third of patients receiving deep seizures, aphasia or prolonged coma therapy on the nervous system are coma which usually infrequently, in Not approx— therapy in this hospital, results. After such events, of delta activity persist for days, and in cases of prolonged changes EEG coma, for weeks and months (h3). relation between prolonged The coma, altered brain function ioral response has been discussed at length. Revitch of prolonged coma and concluded tion of organic brain damage, that (31) reported improvement may be insulin eight cases attributed to the similar to lobotomy. Yaeger, Burch (#3), describing twelve cases of prolonged and behaVo induc— Simon, Margolis and coma, noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (3h), emphasizing and Kwalwasser and Caplan (27) presented EEG individual cases to support the data, same conclusion. We reported a similar relationship between prolonged response in a case study (19). A 3h coma and behavioral year old schizophrenic patient with paranoid �-8ideation developed a left hemiplegia during insulin coma therapy. With the onset spatial of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and inattention, there was a marked change in speech and behavior. loquacious and denied his illness. was by He ludic, became His former paranoid—withdrawal type pattern replaced by a friendly cooperative attitude. These changes were accompanied delta changes in the as well as language changes EEG, dicative of altered brain function. The neurologic after amobarbital symptoms in— resolved, but the behavioral changes persisted so that he was discharged two months later as "much improved." (d) Lobotomy: While we have not had the opportunity from the point of view of document a this summary, similar relationship. all subjects postoperatively (#0) in a study of 150 after three years. EEG (6) and to study patients lobotomy the reports of numerous observers clearly changes of delta activity are present in persist for varying periods. Walter et al., patients, found an 80% persistence of abnormal These authors also noted a EEG relation between clinical ment and the degree and extent of postoperative slow wave activity improve— activity. Postoperative seizures are a frequent "complication," being variously reported as occurring up to relationship between the 20% of subjects (25). Furthermore, there extent of brain tissue cut and the is therapeutic Circumscribed surgical lesions, regardless of locus, have an improvement lower than unilateral lobectomy; are "improved" upon by a and these a outcome. rate latter are frequently inadequate bilateral procedure (36). and �DISCUSSION: When view of an These the various physiodynamic therapies are assayed from the point of alteration in brain function, a therapies represent devices of action becomes apparent. common mode which induce appreciable changes in brain function, with resultant change in behavior. Electroshock and lobotomy induce measurable diffuse changes in brain function when directly; insulin coma primarily complications ensue; and the phenothiazine and reserpine groups of quillizers when given How tran— in adequate dosage. persistent changes in cerebral function affect behavior is not clear. Psychotic dehavior is not "reversed" or "obliterated". Rather, with an alteration in the central nervous system milieu, there is all aspects of behavior including perception, and attitude. is dependent The affect, alteration in memory, Judgment specific adaptive response is variable for each subject on numerous historical and environmental sonality (18), environmental situation of the mood, an alteration in brain function factors. and expectations (10) have (ll), and Pre-morbid perand the duration recently been discussed as determinants of the behavioral response under these conditions. The induced changes in behavior are evaluated by the administrator or family as to the degree of "improvement." psychiatrist, These ratings are value judgments, based upon such factors as the type of induced behavioral response, the environmental tolerance and the observer's expectations. In this context, the physiodynamic therapies do not induce "improvement" - rather they induce behavioral change which is secondarily evaluated as improvement. alteration of cerebral function is therefore not a "complication" or The an "untoward �-10.. effect" but the desired goal of these forms of therapy. therapies introduced during the past thirty years, Of the many "organic" none apparently, has been a specific agent for the therapy of psychoses (in the sense that penicillin is specific for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efficacy in altering behavior by altering the cerebral milieu. In this context, the various physiodynamic therapies are not specific for a type of psychosis. was The early enthusiasm that reserpine or chlorpromazine specific for schizophrenia, or hypotheses that ascribe significane to an antagonism between these drugs and "psychosis" or "schizophrenia" are not tenable. Similar enthusiasm claiming a specificity of insulin coma for schizophrenia is also untenable, and support for this view is presented in a recent chlorpromazine— insulin coma EEG control study (1h). analysis of these therapies permits a the induced alteration in brain function. by a shift in the spectrum of EEG Changes more explicit definition of in cerebral function reflected frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as "bursts" or "hypersynchrony" provide the change in milieu behavior. The that is more effective in altering significance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the That a delta drug effects. reserpine tranquillizers. shift has Those drugs - have been some specificity is seen in the analyses of the that induce the delta shift - the phenothiazines and consistently reported as effective modifiers of psychotic �- 11 - of psychotic behavior. Changes in brain function reflected by EEG desynchroniza- tion only, or a shift in frequency spectrum to the faster range, have a limited efficacy in altering psychotic behavior. * The significance of a delta shift is further seen in the limited efficacy of subconvulsive electroshock when com- pared to convulsive electroshock in the management of psychoses. Another aspect of the is the change alteration in brain function in seizure threshold. delta shift in the With the in clinical seizures would be anticipated. which may be defined This been described following electroshock (h, 2h), EEG, an increase is indeed true. Seizures have are prominent after lobotomy (ho) and a common ”complication" during and occasionally following insulin coma therapy (23). With the tranquillizers, the parallel of clinical efficacy and seizure induction is most striking. commonly; reserpine rarely; benactyzine not at all; anticonvulsant! EEG Phenothiazine compounds induce seizures The lowering of delta shift induced and meprobamate is a potent seizure threshold parallels the extent of the by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism - both potent indices of an alteration in cerebral function. The quency some neurologic basis for the delta shift and increase in seizure is unclear. Whether fre— this represents a persistent change in function of specific brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a screening of new chemo— therapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. * These observations suggest the application of EEG �- 12 - delta shift, with or without hypersynchrony, EEG changes it appears more likely that the reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of specific cellular masses. �- 13 SUMMARY: 1. shock, The neurophysiologic and clinical neurologic aspects of electro- "tranquillizers, insulin H 2. The coma and lobotomy, efficacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent of which a delta shift in the seizures are 3. two EEG change in cerebral function, spectrum and an increase in incidence of indices. Alteration in cerebral function is behavioral change with each of these therapies. a "complication," nor an "untoward mode of are reviewed. an essential prerequisite of Such alteration is neither effect," but is the sine 92a action of these therapies. h. No evidence has been educed in these studies that the physiodynamic therapies are specific agents for the relief of psychoses; nor specific non of the segment of the nervous system; nor do they induce do they affect a specific behavioral changes. 5. and The therapeutic process of electroshock, insulin tranquillizers may be in cerebral function coma, lobotomy ascribed to the induction of a persistent alteration which provides the milieu the subject to his environment. for a change in adaptation of �L.A., Pace, J.W., Hernoff, M.K. and Bowditch, S.C. (1956): Neurophysiologic Effects of Electrically Induced Convulsions, A.M.A. Arch. Neurol. & Psychiat. 15: 371-378. Aird, R.B., Strait, Jeri, R. (1956): The Effect of Reserpine on the and Basal Electroencephalogram, EEG. Clin. Neurophysiol. Scalp Arellano, A.P. and g: 150 (abet). Berger, F.M. (1957): The Chemistry and Mode of Action of Tranquillizing Drugs, Ann. N.Y. Acad. Sci. é]: 685-699. I.J. Spontaneous Seizures and Related Electroencephalographic Findings Following Shock Therapy, J. Nerv. Ment. Dis. 122: 581~588. Blumenthal, (1955): Coady, A. and Jewesbury, E.C.O. (1956): A Clinical Trial of Benactyzine Hydrochloride ("Suavital") as a Physical Relaxant, Brit. Med. Journ. Mar. 3, pp. ABS-#87. Cohn, R. (l9h5): & EEG Psychiat. Study of Prefrontal Lobotomy, Arch. Neurol. 5;: 351—357. Denber, H.C.B. (1957): Discussion, Symposium on the Psychopharmacologic Approach to Schizophrenia, Second Int'l Congress of Psychiatry, Zurich. Fabisch, Effect of Chlorpromazine on the Electroencephalogram of Epileptic Patients, J. Neurol. Neurosurg;_& Psychiat. 29: W. (1957): 185—190. 10. Fink, M. Fink, M. Quantitative Studies of Slow Wave Activity Following Electroshock, EEG Clin. Neurophysiol. §: 158 (abst). and Kahn, R.L. (1956): Delta Activity to Quantitative Serial Psychiat. (in press). and Kahn, R.L. (1957): Relation of Behavioral Response in Electroshock: Studies, ll. . A.M.A. Arch. Neurol. & EEG Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the Electroshock Process, J. Nerv. Ment. Dis. (in press). Fink, M. (1957): Therapy of Schizophrenia: Role of Alteration of Brain Function in Behavior, Presented 2nd Int. Congress of Psychiatry, Zurich. �- 15 REFERENCES 13. Fink, M., Green, M.A. and Bender, M.B. (1952). The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology' 2: h6—58. 14. Fink, M., Shaw, R., Gross, G. and Coleman, F.S.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis, J. Amer. Med. Assoc. (in press). 15. Hankoff, L.D., Kaye, E., Engelhardt, D.M. and Freedman, N. (1957): Convulsions Complicating Ataractic Therapy, Their Incidence and Theoretical Implications, N.Y. State J. Med. 51: 2967-2972. l6. Hoagland, H., Malamnd, w., Kaufman, 1.0. and Pincus, G. (l9h6): Changes in Electroencephalogram and in Excretion of 17 Ketosteroids Accompanying Electro-shock Therapy of Agitated — Depression, Psychom. Med. Q: 2h6~251. 17. Jacobson, E. (1955): Suavitil, et Nyt Stof Med Specifik Virkning pa Centralnervesystemet, Ugeskrift for Laeger, 117: 1147—1151. 18. Khhn, R.L. and 19. Kahn, R.L., Graubert, D. and Fink, 20. Kahn, R.L., Fink, Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol. (in press). (1955): of Parts of the Body After Insulin Hospital. '3: 13h-1h8. Coma Delusional Reduplication Therapy, J. Hillside and Weinstein, E.A. (1956): Relation of Amobarbital Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. M. Test to Psychiat. & 21. M. 1g: 23-29. (1957): Changes in Languages During Electroshock Therapy, in Psychopathology of Communication, Grune & Stratton, Kahn, R.L. and Fink, M. (in press). (1957): Perception of Embedded Figures After Induced Altered Brain Function, Am. Psychol. 12: 361 (abst.). 22. Kahn, R.L. and Fink, 23. Kalinowsky, L.B. and Koch, P. (1952): Shock Treatment, Psychosurgery and Other Somatic Treatments in Psychiatry, New York: Grune & 2h. Karliner, M. Stratton. W. (1956): J. Hillside Epileptic States Following Electroshock Therapy, HOSp. 2: 258—263. �- 16 REFERENCES 25. Klotz, Incidence of Seizures, with (1955): M. Prefrontal Findings, in Psychiat. 1E: EEG Lobotomy, A.M.A. Arch. Neurol & Ink—1&8. 26. and Kwalwasser, S. (1956): Relation of Changes in Memory and Learning to Improvement in Electroshock, Korin, H., Fink, M. Conf. Neurol. 16: 88-96. 27. Kwalwasser, S. and Caplan, M. (1952): A Case of Prolonged Insulin Coma: Treatment, J. Hillside Hosp. 1: Ins-155. 28. Liberson, W. EEG T. (1956): Effect of "Tranquillizing" Clin. Neurophysiol. Drugs on EEG, 8: 523. (1957): The Occurrence of Epileptic Fits in Leucotomized Patients Receiving Chlorpromazine Therapy, J. Neurol., Neurosurg., & Psychiat. 29: 105-107. 29. Liddell, 30. Perlstein, D.w. and Retterstol, M.A. (1956): Disorders, J. Revitch, E. (l95h): Clinical N. Miltown, Its Use in Convulsive and Related Assoc. 161: thO. Am. med. Observations on Organic Improvement Following Psychiat. Quart. 28: 79-92. Brain Protracted Damage and Insulin Coma, (1951): Changes in the EEG Under Barbiturate Anesthesia Produced by Electro Convulsive Treatment and Their Significance for the Theory of ECT Action, EEG Clin. Neurophysiol. g: 261-280. 32. Roth, 33- Roth, M., Kay, D.W.K., Shaw, J. and Green, J. (1957): Prognosis and Pentothal Induced Electroencephalographic Changes in ElectroConvulsive Treatment, EEG. Clin. Neurophysiol. 2: 225-238. 3h. Shagass, C. and Rowsell, P.W. (195k): Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma, A.M.A. Arch. Neurol. & Psychiat. 12: 705—711. 35- Sigg, E.B. and Schneider, J.A. (1957): Mechanisms Involved in the Interaction of Various Central Stimulants and Reserpine, EEG. Clin. Neurophysiol. 2: h19-h26. 36. Simon, A., Margolis, L.H., Adams, J.E. and Bowman, K.M. (1951): Unilateral and Bilateral Ldbotomy: A Controlled Evaluation. M. A.M.A. Arch. Neurol. & Psychiat. gg; ugh—503. �- 17 REFERENCES Chlorpromazine: Use to Activate Electroencephalographic Seizure Patterns, EEG Clin. Neurophysiol. 2: #27-hh0. 37- Stewart, L.F. (1957): 38. Ulett, G.A., Smith, K. Convulsive and Control Group, 6.0. (1956): Evaluation of Subconvulsive Shock Therapies Utilizing a and Glesser, Am. J. Psychiat. 112: 795-802. Wachspress, M., Blumberg, A.G., Fink, M. and Miller, J.S.A. (L956): Evaluation of High—Dose Reserpine Therapy for Relief of Anxiety, J. Hillside Hosg. 2: 67-77. #0. Walter, R.D., Yaeger, C.L., Margolis, L.H. and Simon, A. (1955): The EEG Changes in Unilateral and Bilateral Frontal Lobotomy, 111: 590-59h. Am. J. Psychiat. hi. Symbolic Weinstein, E.A. and Kahn, R.L. (1955): Denial of Illness: Thomas. C.C. and Physiological Aspects. Springfield, 111.: he. Wikler, A.: Personal Communication. (1953): Yaeger, C.L., Simon, A., fiargolis, L.H. and Burch, N.R.: Electroencephalographic Studies in Posthypoglycemic Coma, J. Nerv. & Ment. Dis. 118: h35—hhl. �A Unified Theory of the Action of Physiodynamic Therapies Max Fink, M.D. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Read at the 2nd International Congress of Psychiatry, Zurich, September 6, N.Y. 1957. Institute of Mental Health, National Institutes of Health, U.S. Public Health Service; and the Board of Directors' Research Fund of the Society of the Hillside Hospital. Aided by grant M-927 of the National 10-7-57 �Iv: A The 10/5/57 Unified Theory of the Action of Physiodynamic Therapies proper role of the physiodynamic therapies (electroshock, insulin coma and lobotomy) in psychiatry remains poorly defined. In part, this results from the lack of an adequate formulation of their of action. In the past mode six years increasing evidence for a neurophysiologic-adaptive shock therapy has been presented (hl, 32, 38, 1). view of electro- This view ascribes the thera- peutic precess in electroshock to a persistent alteration in cerebral function which provides the milieu environment. The type for a change in adaptation of the subject to his of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, of action in insulin mode coma (31) and lobotomy (ho) has developed. During the past four years we have studied the alteration in various indices of brain function of psychiatric patients to therapy. The view of insulin relation between and the behavioral response neurophysiologic-adaptive view of electrhshock has been supported and amplified (9, 10, for a similar similar an awareness of a coma has been ll, 20, 21); evidence presented (19); and recently the concept has been extended to the newer "tranquillizers" (12). These studies provide the basis for a generalization concerning the efficacy of these therapies. It is our purpose in this report to examine the exPerimental evidence whether or not the mode of action of each of these therapies may to determine result their ability to induce sustained alteration in cerebral function; from and the corol- lary question, whether measurable alteration in cerebral function is a necessary �-2condition for the efficacy of these therapies, or a "complication" or "untoward effect." The include indices of brain function used in these studies have varied. These memory scales (26), visual (22) and tactile changes in language patterns of orientation both (13) perceptual tasks, and clinically (21) changes in the delta index, both in routine records (9, 10) and by intravenous thiopentone (32, 33), and successfully. For this review, have been selected because of after In electroencephalographic studies of this problem, intravenous amobarbital (20). delta index of the unactivated and in the beta index (16) have been applied two indices EEG, and after activation will be stressed: changes in the clinical neurologic signs. These indices their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities . �OBSERVATIONS: (a) Electroshock: The role of changes in ll). shock (9, following notes summarize our experimental studies of the EEG delta activity in the response of subjects to electro- In these studies, electroencephalograms were obtained before treatment, and at weekly intervals on a day after a treatment in consecutive electroshock referrals. week, Grand mal treatments were administered for 12-20 treatments. The EEG three times a records were quantitatively analyzed for the amount of induced delta activity, and classified into categories of "high", "moderate" and "low" degrees of delta patients were independently the categories of In the activity. At the end of treatment, the rated for their short term clinical reaponse into "much improved", "moderately improved" and "unimproved”. initial series of patients, a significant relationship between the early induction of high degrees of delta activity, and clinical ratings of Eighty percent of the records in the "much improved" was observed. much improved group were high degree delta by the h-6 treatment; and the percentage was sus- tained at 90% in the third and fourth weeks. In contrast, none of the unimproved patients developed high degree delta records in the 20% three weeks, and only of the records in the fourth week were so classified. In a subsequent predictive study, the and first third weeks of treatment delta records were analyzed. on both occasions, 67% were patients without such records, categories. 70% EEG records during the second 0f the patients rated as who had much improved, high degree while of the were in the unimproved and moderately improved �Roth (32, 33) studying the EEG h . delta activity thiopentone after electroshock has related both the evoked by intravenous stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. activity level, " He ...... concluded that patients not attaining a specified delta have not acquired an adequate physiological basis for recovery," and recommended measurement of delta activity levels after thiopentone as a guide to the clinical management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of vary from low to high, subconvulsive therapy rarely alters duces low degrees of delta delta activity that EEG patterns or in- activity (11). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Glaser (38) demon- strated a significantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (11) recently completed here, twenty-seven patients received a course of subconvulsive therapy. weekly Electroencephalograms, taken at intervals, demonstrated minimal changes ~ none of the records were scored as middle or high delta activity. 0f the 27 patients, no change in behavior was noted in 23, and of these, 19 were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed significant changes in behavior, while of the five who did not show the delta response, only two showed a behavioral change. (b) Tranguillizing Drugs: When the newer drug therapies are studied from the viewpoint of �-5. their electroencephalographic and clinical neurologic effects, a meaningful classification emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efficacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly definable electroencephalographic patterns. Based on observations made of drugs in adult psychiatric patients, the EEG in chronic administration changes may be according to predominant changes in the frequency spectrum. classified There are three broad types: I. Increased slow wave activity with hypersynchrony ("bursts") - "delta shift" II. Desynchronization with voltage and frequency and III. irregular theta activity — "desynchronization" shift." Increased high voltage fast activity - "beta Of the group of drugs inducing a derivatives chlorpromazine, promazine, Each drug induces irregularity delta shift, the phenothiazine and perphenazine are clear examples. seizures in non—epileptice or exaggerates seizures in epileptic patients (7, 8, 15, 29, 37). neurologic patterns when given have induced parkinsonism in have observed seizures in 10% Each drug induces in adequate dosage. clinical parkinsonian In our laboratories, all patients receiving chlorpromazine (1k) and of a group of psychotic patients without previous history of seizures. Induced delta activity, including burst activity, observed in more than we half the patients in this series. was �- 6 - Reserpine also evokes delta activity At high dosage levels, it exaggerates when given in large doses (2). seizures in epileptics and induces seizures in animals (35). At the usual clinical dosages, however, reserpine induces desynchronization of frequencies with a moderate increase in theta activity (28), without seizure induction but with definite motor rigidities. In a series of patients treated here (39), parkinsonism was induced in patients. EEG changes were limited to desynchronization only, without all delta burst activity. The primary the induction of EEG response of two other drugs, mepazine and benactyzine, is desynchronization. Mepnzine, a phenothiazine derivative, induces desynchronization with small amounts of theta activity has not been described, nor or parkinsonism in the have we found activity (7). Delta reports either of seizures clinical literature. Benactyzine, a potent anticholin— ergic compound, induces a blocking of alpha, flattening of the record and 1?). Neither seizures nor parkinsonism have occasional theta activity (5, been described for this agent. Meprobamate beta and shift in the EEG is the clearest example of the group of drugs inducing a (3). This agent further differs from the phenothiazines reserpine in not producing parkinsonism and not only are clinical seizures not induced, but definite anti—epileptic activity has been described (30). Habituation is readily achieved, seizures have been observed (ha). barbiturates than like the other If we determine the and withdrawal phenomena of agitation In these actions, meprobamate new is and more like tranquillizers. clinical efficacy of these agents, we note a parallel �- 7 between the induced drugs that thiazine most EEG effects their potency in altering behavior. and readily induce a delta shift in frequencies - the pheno- the greatest clinical efficacy in the compounds - are those with therapy of psychoses. EEG The The compounds with lesser activity in this direction are less efficacious clinically. (c) Insulin Coma The well documented. Therapy: effects of insulin During each coma, persists for minutes to a EEG coma delta activity is induced, after gavage. few hours imately one third of patients receiving deep seizures, aphasia or prolonged coma therapy on the nervous system are coma which usually infrequently, in approx- Not therapy in this hospital, results. After such events, changes EEG of delta activity persist for days, and in cases of prolonged coma, for weeks and months (h3). relation between prolonged The coma, altered brain function ioral response has been discussed at length. Revitch of prolonged coma and concluded tion of organic brain damage, that (31) reported improvement may be insulin eight cases attributed to the induc- similar to lobotomy. Yaeger, Burch (h3), describing twelve cases of prolonged and behav- Simon, Margolis and correlation coma, noted a between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (3h), emphasizing and Kwalwasser and Caplan (27) presented EEG individual cases to support the data, same conclusion. we reported a similar relationship between prolonged response in a case study (19). A 3h coma and behavioral year old schizophrenic patient with paranoid �- 8 - ideation developed a left hemiplegia during insulin coma therapy. With the onset of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and spatial inattention, there was a marked change in speech and behavior. loquacious and denied his illness. was by became He ludic, His former paranoidowithdrawal type pattern replaced by a friendly cooperative attitude. These changes were accompanied delta changes in the as well as language changes EEG, dicative of altered brain function. The behavioral changes persisted so that he neurologic was after amobarbital in- symptoms resolved, but the discharged two months later as "much improved." (d) Lobotomy: While we have not had the opportunity from the point of view of document a this summary, similar relationship. all subjects postoperatively (to) in a study of after three years. 150 EEG to study lobotomy patients the reports of numerous observers clearly changes of delta activity are present in persist for varying periods. Walter et al., patients, found an 80% persistence of abnormal EEG activity (6) and These authors ment and the degree and also noted a relation between clinical improve- extent of postoperative slow wave activity. Postoperative seizures are a frequent "complication," being variously reported as occurring up to 20% of subjects (25). Furthermore, there is a relationship between the extent of brain tissue cut and the therapeutic Circumscribed surgical lesions, regardless of locus, have an improvement lower than unilateral lobectomy; are "improved" upon by a and these outcome. rate latter are frequently inadequate bilateral procedure (36). and �DISCUSSION: When view of an the various physiodynamic therapies are essayed from the point of alteration in brain function, a therapies represent devices These of action becomes apparent. common mode brain which induce appreciable changes in function, with resultant change in behavior. Electroshock and lobotomy induce measurable diffuse changes in brain function when when given How clear. is primarily tran— in adequate dosage. persistent changes in cerebral function affect behavior is not Psychotic dehavior is not "reversed" or "obliterated". Rather, with alteration in the central nervous system milieu, there is all aspects of behavior including perception, and coma complications ensue; and the phenothiazine and reserpine groups of quillizers an directly; insulin attitude. The mood, affect, an alteration in memory, Judgment specific adaptive response is variable for each subject dependent on numerous historical and environmental sonality (18), environmental situation factors. and Pre-morbid per- and expectations (11), and the duration of the alteration in brain fUnction (10) have recently been discussed as determinants of the behavioral response under these conditions. The induced changes in behavior are evaluated by the psychiatrist, administrator or family as to the degree of "improvement." These ratings are value judgments, based upon such factors as the type of induced behavioral response, the environmental tolerance and the observer's expectations. context, the physiodynamic therapies induce behavioral change which do not induce "improvement" - is secondarily evaluated as In this rather they improvement. alteration of cerebral function is therefore not a "complication" or The an "untoward �- lo - effect" but the desired goal of these forms of therapy. therapies introduced during the past thirty years, Of the many "organic" none apparently, has been a specific agent for the therapy of psychoses (in the sense that penicillin is specific for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efficacy in altering behavior by altering the cerebral milieu. this context, the various physiodynamic therapies are not specific In for a type of psychosis. was The early enthusiasm that reserpine or chlorpromazine Specific for schizOphrenia, or hypotheses that ascribe significane to an antagonism between these drugs and "psychosis" or "schizophrenia" are not tenable. Similar enthusiasm claiming a specificity of insulin also untenable, insulin coma EEG and support control study for this view coma for schizophrenia is is presented in a recent chlorpromazine- (1’4). analysis of these therapies permits a more explicit definition of the induced alteration in brain function. Changes in cerebral function reflected by a shift in the spectrum of EEG frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as "bursts" or "hypersynchrony" provide the change in milieu behavior. The that is more effective in altering significance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the That a delta drug effects. tranquillizers. shift has Those drugs some Specificity is seen in the analyses of the that induce the delta shift - the phenothiazines and reserpine - have been consistently reported as effective modifiers of psychotic �-11... of psychotic behavior. Changes in brain function reflected by tion only, or a shift in frequency Spectrum efficacy in altering psychotic behavior. is further to the faster range, have a limited * The significance of a delta shift seen in the limited efficacy of subconvulsive electroshock when Another aspect of the alteration in brain function in seizure threshold. change With the which may be defined delta shift in the in clinical seizures would be anticipated. This is indeed true. been described following electroshock (h, 2%), are prominent (to) and a common comp ‘ pared to convulsive electroshock in the management of psychoses. is the desynchroniza— EEG EEG, an increase Seizures have after lobotomy "complication" during and occasionally following insulin coma therapy (23). With the tranquillizers, the parallel of clinical efficacy and seizure induction is most striking. reserpine rarely; benactyzine not at all; commonly; anticonvulsant! EEG Phenothiazine compounds induce seizures The lowering delta shift induced and meprobamate is a potent of seizure threshold parallels the extent of the by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism - both potent indices of an The quency some alteration in cerebral function. neurologic basis for the delta shift and increase in seizure fre- is unclear. Whether this represents a persistent change in function of specific brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a * These observations suggest the application of EEG screening of new chemo~ therapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. �- 13 SUMMARY: 1. shock, The neurophysiologic and clinical neurologic aspects of electro- "tranquillizers," insulin 2. The coma and lobotomy, are reviewed. efficacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent change in cerebral function, of which a delta shift in the seizures are indices. 3. two EEG spectrum and an increase in incidence of Alteration in cerebral function is behavioral change with each of these therapies. a "complication," nor an "untoward mode an essential prerequisite of Such alteration is neither effect," but is the gigs 333 299 of the of action of these therapies. M. No evidence has been educed in these studies that the physiodynamic therapies are Specific agents for the relief of psychoses; nor specific do they affect a segment of the nervous system; nor do they induce Specific behavioral changes. 5. and The therapeutic process of electroshock, insulin tranquillizers may be in cerebral function coma, lobotomy ascribed to the induction of a persistent alteration which provides the milieu the subject to his environment. for a change in adaptation of �- 1a - REFERENCBS Pace, J.w., Esrnoff, M.K. and Bowditch, 8.0. (1956): Neurophysiologic Effects of Electrically Induced Convulsions, A.M.A. Arch. Neurol. & Psychiat. 12: 371-378. Aird, R.B., Strait, L.A., Jeri, Arellano, A.P. and R. (1956): The Effect of Reserpine on the EEG. Clin. Neurophysiol. Scalp and Basal Electroencephalogram, §: (abet). 150 The Chemistry and Mode of Action of Drugs, Ann. N.Y. Acad. Sci. é]: 685—699. F.M. (1957): Berger, lizing I.J. 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K. and Miller, J.S.A. (L956): Reserpine Therapy for Relief of M. and Evaluation of High-Dose Anxiety, J. Hillside Hosp. E: 67~77. Personal Communication. �- 12 _ delta shift, with or without hypersynchrony, EEG changes it appears more likely that the reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of specific cellular masses. �gfiéW W ¢ mA/LWWW“??? flflmw ”fl 0 WA; .Wbfl' WV WW/W» Wfiwé W erflc/ééé/‘nggg WW Wan/Raw ,5, wage; 4* ”Jaw“ £5149 MM 55¢?” 44%“ €40» MW + mama 5-an we 9 MA 401: é’U—k , é1w%(b Wdyk 7" «anlwn/em r 6 MW Www MAM/:2 WAMWMmM ”acacia/77¢“ M 0.4.2. 407973 WWMMWM MWMA Wfl’wwvéob (law w W MfM 3k- (WALK-MW —~ c w mQa—éflaec. "1426 7'":wa flow szC 2’ , VM’bgek-«tk’ fl/Lf/wa «6% Egg kw Mgr , LWwaCA/I wwafl/VL/e .Z 9744M /,’_5._ J 1(HMWA‘QWW CWc/QW'OA‘: /\ ("‘1‘ fyék" W W “FM W (aw/WWW wa» W/MW W»! 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' ”i'QUq \ qi‘fi-«x;.¢'\§§\r "ix ‘3 ,, 3 F—J-n , r) ,, ., -- M A v = ‘\ - | J) J} \3_ } 9531‘wNAQDQ s;- "(f‘ LJ) ' l . 3 r k1\ J _ ‘53 x 1- 2' 743. \3: - 4344;- 3‘*‘ AV‘JJQ.» ’ ‘2‘J&\ I a “432.35 «3513:; )vaia r"3-1-3 51,5r ‘ *7 \ , ._3 ~ \ , . 3 (\x ,‘ .3-.M—vx;“* f T . . 3 \I-J‘IJL‘J ‘ ,3 3.3\J -\_)\r§ 3 Q [11-43) " j J—‘~f'\' {t ’3‘ .3. 3 3, u r “331,-. ‘ is m N3 a . v �QFURTHER OBSERVATIONS MADE SINCE THE ARTICLE "Electro-cncephalo- graphic Evidence of Bersonality Changes by Ataraxic Drugs in Mentally Disturbed Patients." WAS WRITTEN. l) A number of mistakes due to faulty or non-standardized technique in the assessment of alpha a) Duration of the recording: It was found that some activity for the first stability patients had were made. little alpha five to ten minutes of the who recording deve10ped a more stable alpha activity, later it is on. therefore suggested that samples of alpha activity should be taken at least ten minutes after the beginning of the E.E.G. recording. b) Period of the day: Slight differences of habitual alpha activity were observed in one and the same patient according to the time of the day when the E.E.G. recording was taken. applies also to the period of the last meal. It is therefore suggested that the E.E.G. tracings The same should be taken at the same time of the day and at the same intervals after the last mealhad been taken. c) Waiting of the patient before the E.E.G. recording. It observed that if patients had to wait for long periods in the waiting room before his E.E.G. recordwas ings were taken the alpha activity was poorer than on d) Noises. The effect of any noises, particularly of any talk, during the E.E.G. recording changed thexalpha E.E.G. pattern imedia-telyss It seems therefore that the total absence of any noise is necessary to produce a valid E.E.G. recording for the assessment of alpha 0) A stability. Special alpha run, allowing the simultaneous trac-' ing of temporal and parietal occipital alpha was found to be useful. �2) The alpha stabilizing effect of Largactil and Serpasil. a) Single administration: intravenous and intramuscular administration of a single large dose of Largactil (100 mg.) or Serpasil (5 mg.) often had little or no effect on the 1. The alpha stability. ii. The period of administration of the 3 days to 2 same drugs, over a weeks, did produce an alpha stabilization. b) Age groups: effect of these two drugs, in sufficient quantities, was observed in all children whose habitual alpha activity was poor. ii. In adults there were some exceptions to the rule, particularly elderly people suffering from depression. 0) Quantitl: The effect of alpha stabilization, even after a long period of administration, was sometimes only observed when large quantities of the drugs were given. It is therefore suggested that in case of a negative E.E.G. effect the test should be repeated after in1. The creasing the dosage of the drug. d) Temporal Alpha: It is observed that in sons cases the alpha stabilization occurred equally in the temporal and parietal occipital regions. Most often however, the alpha stabilization was more marked in the temporal regions, infrequently the alpha stabilization occurred in the temporal regions only. and not e) An experiment was conducted on 30 schizophrenic pmients, 10 patients received Serpasil 3 grs. daily, 10 patients received a new drug to be tested and 10 patients received a placebo. E.E.G. tracings were taken before the 'administration of the drugs and on one occasion after the course of drugs was started. Psychological tests were made to assess the clinical improvement. �It that the patients who had received Serpasil showed a statistically significant improvement of their alpha-stability. The ten patients who had received the new drug that was to be tested showed a significant diminution was found of alpha-stability in the temporal regions. The patients who received the placebo showed a random distribution of improvement or deterioration of their temporal alpha rhythm. The correlation between improvement of alpha-stability int.- the temporal region and clinical improvement was about +0.45 only, in all 30 cases, whether this was due to the effect of drugs or not. The Doctor who was conducting the experiment, the statistician of the Mental Hygiene Department and our own observations in our E.E.G. Department showed that many relevant factors during the psychological testing (in which unfortunately "socialis- ation“ was not a part) suggesting improvement were not controle' led. f) It is that alpha-stability may be correlated with relaxation and alpha-blocking with tension, though this is certainly not the full story, probably a reasonable hypothesis to assume only an approximation. About 80% of true melancholics, who are certainly not relaxed, have an exceptionally high alpha index. Ostow's suggestion thatwalpha activity generally respons to a preparation for constructive thinking and the disappearance of the alpha activity when the constructive process was put into action, probably, is nearer to the truth. The more correct hypothesis would seem to be that relaxed patients generally ruminate less than tense subjects. 3) Further references bearing on the subject of alpha stabilization: a) "By hypnotic suggestion to relax, Ford and Yeager reported the induction of "good" alpha patterns in several patients with anxiety states, whose previous E.E.G.'s showed little or no alpha-rhythm.' Relaxation suggestions were not followed by EE.G. changes in subjects whose E.E.G.'s rhythm." naturally showed "good" �- 4 _ Ford, W.L. and Yeager, C.L. "changes in the electroencephalogram in subjects under hypnosis. "Dis.nerv. systo 1948, 9, 190—192. H a) There are several references in the literature to the fact that short courses of electro-shock-treatment tend to increase the E.E.G. alpha activity. 4) W: quoting a reference of Ellingson a mistake occurred in my article which should be corrected. When Should read - preposition by Saul and Davis that passive indiv— iduals tend to have regular persistent alpha rhythms of high index has been often cited in the literature and “The appears to have been accepted as fact. Sisson and E11ingson reviewed the evidence upon which that preposition was based and found it unconvincing.” uni?“ �/ g , §n\3\ L. @ 6 W Q wwwwwsméo WfipfloA Ni Nf \\ WWUWMNW . w glwfig ENK :xWng W . (GMWECQMV wmim 3% 13mm v Eé . IVSNEPSNxMPIQXB \m\§§£§§w\% ‘ gmxmigg §§\ W I \KQ‘PVGV \um m EQ® “Sag V � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A unified theory of the action of physiodynamic therapies. J Hillside Hosp., 6: 197-206. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-23-028 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 5 items. 1: Xerox copy. 2: Two presentation copies. 3: Handwritten manuscript.4: Draft copy. 5: Chart. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/31ade8ace56aaea325e0c1b5774137fb.pdf 34c1dccec8167a1f1d6a23f225341ecc PDF Text Text F , Perception of Eknbedded Figures after Induced Cerebral Trauma Robert L. Kahn, Ph.D. and Max Fink, M.D. 1/? "a From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, M—927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Aided by grant Presented 11—27-57 at American Psychological Association, New York, August, 1957. NJ. �Perception of Embedded Figures after Induced Cerebral.Trauma Studies of complex visual perception man are not always clear or consistent. after cerebral The damage in disagreements may be due, in part, to difficulties in evaluating the extent of the disease process or the degree of alteration in cerebral function. In contrast, conditions in'Which there is control of the degree of brain damage, as in electroconvulsive therapy (ECT), provide a unique opportunity for studying this problem. While investigations of brain-injured populations have focused an the role of location of lesion on behavior, current studies of emphasized the been shown to EDT. have factor of individual differences. marked.variability has for perceptual (l), behavioral (2) and physiological reSPonses In addition, various personality (h) and social factors (5) have 1. C. Landis, D. Dillon and S. Leopold, Changes 2. M. 3. R.L. Kahn, ' ECT in flicker-fusion threShold are in choice reaction time induced by electroconvulsive therapy, J. Psychol., bl, 1956, 61-80. Fink, R.L. Kahn and M. A. Green, Experimental studies of the Electroshock process, J. Nerv. & Ment. Dis. (in press). M. Fink and E.A. weinstein, Relation of amobarbital test to clinical improvement in electroshock, A.M.A. Arab. Neurol. & PWChiato, 76’ 1956, 23-29; Fink and R.L. Kahn, Relation of EEG delta activity to behavioral in electroshock; quantitative serial studies, A.M.A. Arch. response M. Neurol. & Psychiat. 78, 1957, 516-525. h. R. L. Kahn and M. Fink, Personality 5. R. L. Kahn, M. Pollack ahd factors in behavioral response to Electroshock, Conf. Neural. in press). F. Fink, Social factors in.the selection of therapy in a voluntary mental hospital, J. Hillside Hosp., 6, 1957, 216-228. �-2been related to differences In the course of an in reSponse to treatment. investigation of the perceptual and behavioral changes with ECT, a convulsive-subconvulsive control study was undertaken. In this report, performance on complex visual tasks is presented. Specific- ally, the aim.was to determine whether perceptual change induced by ECT is related to the degree of altered brain function and clinical behavioral change; and whether the pretreatment perceptual pattern was related to physiologic changes with treatment. The method used in the study was the perception of embedded geometric figures - a technique which has been Widely studies of perceptual changes accompanying in recent years in cerebral dysfunction (6). employed Lethe: 1) Population: were 22 Fifty-three consecutive patients referred for studied. These included 16 men and 37 women, with ages ranging_fran to 66 with a median of h9 years. into ECT The patients two groups. An experimental group of 29 were divided at patients (Convulsive random A) received grand.mal electrotherapy with pentothal premedication three times a week, using C—h? either a Medcraft alternating current instrument or a Reiter electrostimulator. A minimum of 12 treatments were given. of treatments was determined by the supervising The number psychiatrist in charge of clinical criteria. A control group of treated in similar faShion, except that only subconvulsive the treatment unit on the basis of 2h 6. patients was 5. Battersby, H.P. Krieger, M. Pollack and M. B. Bender, Figure ground discrimination and the "abstract attitude" in patients with cerebral neoplasms, A.M.A. Arch. Neurol. & Psychiat., 76, 1956, 369-379; H. L. Teuber and S. Weinstein, Ability to discover hidden figures after cerebral lesions, A.M.A. Arch. Neurol. & Psychiat., 763 1956, 369-379; F. Pollack, W.S. Battereby and M. B. Bender, Figure-ground discrimination in patients with cerebral tumor, presented at Eastern Psychological Association, 1957. W. �"1 -3stimulation was given following the pentothal. Fourteen patients in the control group were subsequently given a regular course of convulsive therapy (Convulsive B). 2) Perceptual task: In the week prior to treatment and on the day following the 12th treatment each patient was tested with a modifica- tion of Gottschaldt's hidden figures developed The by Battersby subject is presented with a page containing geometric figure, figure is embedded it and below (fig. 1). -a simple a complex figure in which the simple The patient is asked to trace a Specific by geometric figure from the background/outlining ~The two fonns gt 2;.(7). it with a colored pencil. discriminations ranged in complexity from relatively simple to more complex. There were 25 such discriminations. was allowed for each. Performance of errors. To minimize a was A maximum of two minutes scored in terms of total number practice effect two equivalent forms of the test were used. 3) Evaluation of physiologic change: Two the electroencephalogram and the amobarbital tests of brain function - test (8) - were given to at weekly intervals during treatment. each patient prior to, 7. Battersby, Krieger, Pollack and Bender, op. 8. E. A. weinstein, R.L. Kahn, L.A. Sugarman and L. Linn, Diagnostic use of amobarbital sodium ("amytal sodium") in organic brain disease, Am. J. Peychiat., 112, 1953, 889-89h. and cit., The 703-712. �.uelectroencephalogram was evaluated as to the degree of delta activity induced according to criteria previously published (9)° ’The amobarbital test for brain disease was noted as positive or negative according to the standardized criteria (10). The results of these tests obtained during the second, third and fourth weeks of treaunent furnished the criteria for physiological change. A combined physiological index was obtained by ascribing to each high degree delta barbital test a score of one. ranged from zero to six. h) EEG record and each positive amo- The range of Behavior ratings: Each physiological alteration thus patient's behavior was evaluated at weekly intervals. After the 12th treatment, a rating for the degree of behavioral change was made according to »..none. These ratings of four classes: marked, moderate, change were minimal or not value judgments as to the quality of change, but rather quantitative estimates of differences in behavior patterns under similar conditions of observation. vpatterns as euphoria, paranoia or withdrawal might [Thus such behavior all be rated as equivalent degrees of quantitative change, although the implications of each for qual- itative evaluation of 9. 10. improvement were Fink and Kahn, op. cit., quite different. éin~pressl. 37$-5§fin. 'Weinstein, Kahn, Sugarman and Linn, op. cit., 889-89h. �Results: pre-treatment and treatment scores The number of errors with treatment is intragroup analysis shows shown and the mean change for each group that the subconvulsive group in the in Table I. made The significantly fewer errors during treatment, while the combined convulsive patients made significantly more. TABLE I Intragroup Comparisons for Number Before and During ECT Mean No. Type of Treatment Subconvulsive Convulsive A Convulsive B Before E} ECT of Errors Errors During EDT Difference p_* 2h 9.96 7.67 -2.29 4:1.02 29 10.59 12.62 +2.03 NS 7.36 10.1h +2.79 ‘=1.05 +2.28 “=1.02 ** 1h Combined Convulsive h3 ‘ * Intragroup analyses in this and subsequent tables based on Wilcoxon's method of paired replicates. ** Patients originally in control group, then placed on convulsive treatment. group is period. The score obtained during treatment used here as the pretreatment score Prior to treatment. subcgnvulsive patients made in the control for the convulsive approximately the same number of errors as the original convulsive group. During treatment, however, subconvulsive subjects made fewer errors (7.67), while the errors in convulsive patients increased to 12.62 errors - a difference significant at better than the 1% level of confidence. �-6When the data is analyzed with respeCt to physiologic change, significant increases in errors are found only in those patients with the greater degrees of physiologic change. This relationship is present in analysis of the amobarbital tests are test and the combined (Table EEG as separate indices, and when the two II). TABLE II Intragroup Comparisons for Number of Errors Before and After ECT in Relation to Degree of Physiological Change . Physiological Index N Mean Difference in Number of Errors during Treatment Amobarbital Test. or None positive one 13 -O.23 NS 28 +3.714 .01 23 +1.73 NS 18 +3.33 .05 3 21 +1.00 h to 6 us 20 +3.90 .01 Two or three positive Electroencephalogram or None one High Delta Two or three High Delta . . Combined Physiological 0 to The in relationship between number of flue degree errors during treatment is of behavioral change shown with no, minimal or moderate behavior changes difference in made number of errors. in Table III. do not show an and the change Those patients appreciable Those with marked behavior changes, however, significantly more errors during treatment. �TABLE III Intragroup Comparisons for Number of Errors Before and During ECT in Relation to Degree of Behavioral Change Degree of Behavioral Change Difference Nnmber Errors During Treatment Mean N _ marked 2h Moderate 1h p <1.0l +3.58 +1.00 NS -0.h0 NS l Minimal or 5 None Analysis of the pretreatment error scores in relation to the degree of physiological change is shown in Table IV. The results show that subjects with large pretreatment error scores manifest greater degrees of physiolog- ical change during treatment. Patients with little physiological change during convulsive therapy had a mean pretreatment score of 7.88, while physiological effects, had a mean pretreatment score of 13.25 errors. The triserial correlation the .05 level of confidence. is +.3h, significant at those who developed marked TABLE IV Relation of Pretreatment errors to Eventual Degree of Physiological Change During Treatment N Mean Number Errors Prestreatment Physiologic Change: o to 211’ 3/ and my 16 7.88 19 11.21 �Qualitative Data: Alterations in size of figure or in minor aspects of form were common types of error during both testing periods. Certain qualitative patterns were frequently noted during treatment, however, which occurred only or to a lesser extent in the pretreatment period. patients to .was make no It was common attempt to trace the more complex figures. rarely for This response often associated with a generalized withdrawal reaction in which the patient was unreSponsive to any stimulus or procedure. Others became hostile and negativistic toward the testing. l i Patients wifln the greatest amount of physiological change seemed to difficulty following instructions. They would trace the lines indiscriminately without regard for the Specific figure to be outlined, repeated have ‘ a previous figure despite changes in the actually existed, the more complex and impulsively, and showed Such little drew lines where none trace the stimulus figure while ignoring and attempted to test figure. test figure, patients were likely to respond quickly concern about making an error even they might spontaneously comment, "I know that's not right." when ‘ �Discussion: results of this study clearly danonstrate a relationship between the degree of cerebral dysfunction and perceptual alteration. Patients ‘The with subconvulsive stimulation make fewer errors on retesting. A slight decrease or no change in errors occurred in those patients receiving vulsive therapy who showed only minimal physiological changes. vulsive patients, however, with the showed a significant increase in alteration, of errors. This interrelation- number is in accord with studies of patients with altered brain function due to head injury and brain tumor. (ll), The con- most marked physiological ship of brain fUnction and perception and Weinstein con— Teuber applying a similar technique in cases with penetrating ’brain,wounds, concluded that performance was unrelated to locus of lesion but that aphasic patients made significantly more errors than a non- aphasic brain-injured group. Pollack gt §l3(12), using the identical in this study, reported relationship between perceptual errors as no test and the location of lesion in tumor patients. They reported, instead, that defective perception related to the severity of other rental changes, was ‘ such as It disorientation. Should'be pointed out that the all patients referred for to that found by Pollack ECT was 10.35 total pretreatment cit., Teuber and Weinstein, op. 12. Pbllack, Battersby and Bender, op. 13. Ibid. score for errors, a score almost identical gt §l5(13) in thefi‘brain 11. mean 369-379. cit. tumor patients. Since �the two populations are comparable in terms of other parameters as age The and education. defects in figure ground discrimination cannot be ’regarded as reflective of cerebral dysfunction as an isolated entity abstracted from the totality of behavior. Rather than being in a to one relationship, poor performance on such tasks interaction of many there are cases with cerebral many may be due to the factors, brain dysfunction; being only one. not damage who do show one Thus defects. Con- versely, the present findings indicate that the inability to perceive embedded as it is The figures may be related as much to certain types of mental illness to brain disease. ! relationship of perceptual alteration to behavioral is clearly demonstrated. treatment The patients increase in errors during treatment were those pronounced change in clinical behavior. who showed also who change during the greatest showed the most They manifested such behavior patterns as euphoria, hypomania, withdrawal, somatization or paranoia. Comparable to these are the embedded figures test during treatment. related to paranoid was qualitative aspects of performance an evasion The some may as well be was cases, and to a lack of concern in correcting errors associated with clinical patterns of euphoria increase in errors the Failure to attempt the task or withdrawal reaction in hostility in orders. on attributed to and hypomania. change The in motivation or attitude toward the task or examiner as it is to any Specific aSpect of the altered brain function. Changes in performance on this complex perceptual task can thus be understood as one manifestation of changes in the patterns of interaction with the environment. The relation between behavioral this type of task, has been noted and perceptual by Witkin to be patterns, using true of persons without 9 �-11.. demonstrable cerebral dysfunction as well. He individual differences in the perception of embedded be related to personality factors (15). The found that the wide figures (1h) may finding in the present study of the prognostic significance of the pretreatment score to the eventual physiological reaponse is in accord with his observations. 7 Personality factors may thus be related to the degree of changes in In a previous study (16) certain person- brain function.with trauma. ality patterns were associated with the ment following ECT. short term behavioral improve- basic characteristics of persons with a favorable prognosis defined in that study were an inability to think critically The or sensitively about their own or other's needs or feelings, patterns characterized by oversimplified generalizations, ,stereotypy and conventionality. The present data that persons with greater difficulty in making the necessary analysis and figure-ground and response discriminations on embedded figures show a greater alteration in behavior with treatment, is consistent with the previous observations. Witkin,.Individual differences in case of perception of figures, J. Pers., 19: 1950, 1-15. 15. H. A. Witkin, Nature and importance of individual differences in perception, J. Pers., 18, l9h9, 1&5-170. 1h. 16. H. A. embedded Kahn and Fink, op. cit. �.12Summary and Conclusion: 1. Fifty-three consecutive patients referred for electrotherapy were studied before and embedded geometric after treatment figures. An on their ability to perceive experimental group of 29 patients received A. regular grand mal therapy wifla pentothal premedication. control group of 2h patients received subconvulsive stimulation only. 2. The experimental group made significantly more errors following treatment than did the controls. I 3. 'Within the experimental group, however, there was considerable I variability. Increase in errors was found to be significantly related to the degree of altered brain function, and the degree of behavioral change. h. The pretreatment error scores were significantly related to the degree of altered brain function developed during treatment. The significance in terms of personality factors is indicated. 5. Performance in this complex visual task mirrors the pattern of of this behavioral change observed clinically. 6. one It is concluded that performance on a complex visual task is manifestation of a generalized pattern of interaction with the environ- ment. ,4 Lu... �.13- Legend Illustrations of test figures. Fig. 1. used to acquaint the subjects with the task the task is The is preliminary sample shown in a. In d complicated by having the subject determine which of the two simple figures can be found in the complex figure. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Perception of embedded figures after induced altered brain function. American Psychologist, 12: 36, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-24-029 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/2e0c07f8713070c07cedfceccd13935e.pdf f963256ba3adedd04d38ff5d4403fc1f PDF Text Text Social Factors in the Selection of Therapy in a Voluntary Mantel Hospital Robert L. Kahn, Ph.D. Max Pollack, Ph.D. Max From Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Grant Me927 of the National Health Service. 10-8-57 N.Y. Institute of Mantel Health, U.S. Public j M M 3:) �Social Factors in the Selection of Therapy in a Voluntary Mental Hospital Recent investigations have indicated a relationship between social class and illness (3, 5, 6, and and incidence of mental psychiatric disorder with respect to type therapeutic selection 13, 1h), outcome (10). The and maintenance of treatment (2, 6, 15), present study is concerned with social factors in the selection of therapy in a voluntary mental hospital. In the studies reported by Bollingshead, Redlich and their co—workers (3, 5, 6, 13, 15), the population of classes New Haven was divided into five social basis of weighted criteria of education, occupation on the of residence. Of the residents who were under and place psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care Of was more common among the psychotherapies, psychoanalysis groups. was entirely restricted to the two upper Social class was the predominant determinant of the type of treatment selected even as follows: when the diagnosis "..... it is found was held constant. They summarize their results that treatment does not and medical determinants alone, but on the well. the lower classes. depend on psychological status position of the patient as degree Psychotherapeutic methods are applied in disproportionately high to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the �- 2 - extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting therapeutic techniques and services are available to where the same This requirement is met all patients. at Hillside Hospital. It is a non-profit, sectarian institution for the treatment of voluntary patients with "early curable mental symptoms" (h), pay. are admitted regardless of their and ability to criteria for accepting patients is their "ability to of the main One who non- participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy available is regarded as the when needed. primary method of treatment with organic therapies The average length of hospital stay is six months, al- though some patients remain for as long as a year. The present investigation is of electroshock therapy. an outgrowth of In previous work several years of study it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose patients differ of the present study from those was to determine whether electroshock receiving other forms of treatment in regard to cultural background, including such factors as education and personality as measured by the California F and place of birth, scale (1); secondly, whether these factors were also related to referral for adjunctive hoSpital services. �m: Population: as of March 7, The 1957 was entire in-patient adult population of Hillside Hbspital studied. This constituted a total of ranging in age from 16 to 68 with a mean 172 of 3h.6, and including patients, 58 men and 11h women. 1) The population was subdivided Procedure: into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only. * 2) The groups were compared for age, education and place of birth. I 3) of the California naire (see F All patients were tested scale suggested by Levinson (9). Appendix) which has been The F scale The patient reads ten statements indicates whether he agrees or disagrees with each statement tent. The and score given for each item ranges from one to seven and the score range is tained. is a question- related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). and ** with a ten-item.modification The 10 to 70. The to what ex- total greater the agreement the higher the score ob— statements themselves are extreme, uncritical or stereotyped expressions. patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data was included in both groups. In the results this makes a total of 179 subJects. * All patients were tested with the F scale prior to treatment. In the case of those patients who were actually on EST on march 7th their pre-treatment scores were used in the statistical compar- ** As part of ison since treatment. an ongoing study all the EST it had been found that EST significantly affects the score during �-uh) The population was subdivided in regard of certain adjunctive services in the hospital. Among to utilization such services available are group activities, occupational therapy, psychological testing therapy. The latter is a diagnostic and and creative therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psychological testing and creative therapy were selected for this study because both require a specific referral from the therapist. �RESULTS: data The 1) comparison of the treatment was analyzed as follows: scores and place of groups for age, education, F scale where diagnosis is held constant, prior to treatment, birth, 2) comparison significance of length of hospitalization 3) and h) comparison between groups referred for adjunctive hospital services. I. Comparison of Treatment Groups: For each of the three treatment groups the means and standard devia- -tions for the Table I. F scale scores, The EST group had age and years of schooling are presented in higher P scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These differences reach were statistically significant for statistical significance for education. cation to differentiate the groups electroshock group contained many was due, F score and age but failed to The failure of years of edu- in part, to the fact that the foreign born patients whose education was treatment groups were subdivided into difficult to evaluate accurately. When number of eight years of education, the difference was patients above and below significant at the .01 level. not differ statistically for The insulin any of these and psychotherapy groups did factors. �Hague uwumuom auom $5 $5 nMfimnom m mo 2 $3 Agooav muwam awamuom .nuom no modem m>fiuaz nvuwm amousm a m m 383 “somv 33$ mm mfl 8 $8 Afloav no qmfiwuom $8 anon a nowpwoscm um anon can muaam wkfid .ummm 3me nuhum o nahwm m $fi>u% ma once $8 .mw< H 6m- .cm no auhoom we 0 b made» How 0 8H $5 Ammv :5 m H .~ m; w.m *Réudx .cm am Ho unmanamua ma aonm mqmdg masono a. $8 Afimmv mummy cams 8.3 «a 0.3 H.ma 8;: m.: can: mi m.mm 3m am 93 m.ma 9.: gums 3: am p ***om.w dfia m.w N.H a ***mm.a ***ww.m m:.~ mm.” H.H m>.H pnmnwuhan mw¢ can: .33 ~.m o.m >.:H mo nomwnmmsoo a **Aa.m mm. m>.m Hm>ofi amped Hm>ma no. do. «a pa pa pauu««Hanm aguofiqumfiw endowmfinwam macaw m can: 9.3 9% m.Hm ado: .&B ~.m o.ma so: ”om“ G3 nonu naasmnu 9% Hoe. uonuhmmanwaamnm madamnH.amm nacho m.m Rama» mm -onohnm.emm mgauon» ammumnp * ** K *** �- - 7 Both somatic groups had a higher percentage of foreign born patients than the psychotherapy group, with the electroshock group being highest of Among the foreign born patients, those who came from all. Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe reneived psychotherapy alone. II. Comparison of Treatment Groups in Relation The to Diagnosis: diagnostic categories of the patients in this study are comparable to those reported in previous studies of the hospital population (12). Of the fl72 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and two with other diagnoses. portion of the depressed patients with other diagnoses. To (52%) As expected, a larger pro- received electroshock than did those control for the factor of diagnosis in choice or treatment, the psychotic depression patients were subdivided into those received electroshock and those are shown who were given psychotherapy alone. .02 The results in Table II. While the two groups were comparable shock who patients had a much level of confidence. higher It is mean F for age and education, the electro- score, a difference significant at the also demonstrated that a significantly higher proportion of the electroshock patients were born in Eastern Europe. �‘hmavo afimv as: a a Agmmv :83 nunwm no nnmpmmm muonsm ma unusuauua m #moi madam Afimmv mo m>apaz 333 u, whom ma NN mm mumwa 0903 $8 anoumhuwn Aaawv.wm .usdm no w Mo cwbaoumm mm Pm...” m Ammmv mama» soamm 3?: u m a NN 3.: a p cams. m.o~ 0.2 am :.mH .92 spas gum: 0.0: 9S mpnuupdm am 0a: HH .ust IQ- mm mama noummohmmn no uuaow $03 .MHS p canonohmm mad omd mN.o mmm. m.ma {3 m.om 0.3 9602 33.3 v No.0 *m:.m muoom mo m can: 502 .935 0N6 Hm>oH nomuhdmaco mo. pa as pnwowgfiamum namv 3203393 -ongmmm.amm hmdhmfi. 9mm b it; * �-9. III. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment: While the electroshock from those receiving insulin or psychotherapy, there intra-group differences. postulated that the To account While most of the less than three months for some were who EST scores and were older were treated Place of birth h0% months were born earlier than the is also a significant factor. cance, although 28% in the U.S. The were also compared according Patients who had on higher younger and lower F scale While hh% of those all patients referred after data was referred after a period were III the patients are within three months were foreign born, six it were placed on treatment to the period of hospitalization prior to electroshock. groups. considerable of these differences received after admission, about In Table to differ patient was referred for electro- which a given patients of three to twelve months. F still shown factors involved in selection of treatment same related to the readiness with shock. patients, as a group, have been education Just treated a period of fails of signifi- of those treated earlier had less than eight years of edu— cation. IV. Use of Adignctive Hospital Services: Comparison of the logical testing is shown patients referred for creative therapy in Table IV. It is clear that of these procedures had significantly lower more education and more were for these services. F and psycho~ those referred for either scores, were younger_in age, had native born than patients who were not referred �.350 Agmv m Agmmv nuHHm cumwmmm 0935 Mo NH o o haemv o m *ma.m pamapmmne madam 0p “away Afiowv ma w AgooHv u m>wuwz anon Ha N x nownm 933 Ammuv Afiomv mm m no m mo nofipduwawpwmmom Aaooav HH mafipwuscm made» w mm.: 0 Agmmv Agoav m H an >.m m.m o.m gm: m.m ».ad m.mH 333 mo a N x HHH nnwan '0‘"- no mqm¢9 on p aw.” mm.o mm.o aoavmosu mama» cams mm.H .Muaa Hm.a Po.nw*wm.m mnwcnoou< am m.ma m.ma m.oa 30E m.m; w.mm H.om u FH.H Hw.H mm¢ Hp.m mpqmwgwm m~.m swag».meg ‘ ~:.mnwrmw.m mm 9mm o.:a w.HH a m.~H mm.a mm.a , _ macaw mo m new: H.a: ~.N: m.mm mama .Mqu m:.m m~.m ma.ma nomwuwmaco ncwpcufiawpunmom .moa Hmpmfl mo. Ho. pa 96 AHHV Ammv angdwha Hm>oH Aoflv .mos : u .moa .woa .noa .moa n m mo nvmumq m m .moa on nova gang swap mama w m 0p m mama can» pnaowwflnmfim pqaofimfinmfim nun» can» m on mama m m .moa on mnoz mama mm .moa whoa «nos m * ** �nmnpo hmmnmna $8 Away m m Asmav m Aamv m npuwm a3 Amwmv Afimv cnmpmdm # muonsm m>wpwmuo A mo mm Afimav ma *mm.m *mm.® $3 mqwam cam hfimwv Agapv Afimpv u u m>w¢dz upon mwfipmme 3 a» flame Amway Aapmv “*pmv 8 mm my mm MN am H» «x whoa no Haowwoaonommm m mo *mm.: mowpmosum *mm.m mndow m mo soamm :5 Awmav Afimv a A$MHV n H ma mtm H.: Nx m «x ma >H p mwuw>hmm am IHHI mgm¢H m.m mm.m mo ***>.m m».H aowpwuscm mama; can; 3; aw v.0“ «.mH m.HH m>fiponmmd¢ m.mw**om.: mm no“ O.H h%fi add m.ma 5mm m.mm m.HH p :.ma mm.m om¢ o.> cams. p.0m p.»m mam: .men H.oa***mm.m a dmunmwmm am 3: m.m~ cum: 9mm p.m: w.:~ m.ma r*wm.m choom mgqmwpwm m H.mm $.H: can: .umfin m.w m.:a rm>¢r amped Ho>oa mo mo. Ho. :8 pa pa pa amoavhmanona Appv newwnwmabo 3239 mumua «CC. Ammv .a.o pnmUHuHamHm pacuHMwumHm * ** HQNUfiMHanm oz mmsouo .Hoaohmm m>wpmmuo mummy :.Honommm 8385 .Honoamm oz oz .a.o oz *** �DISCUSSlON: results indicate that the factors of education, age, place of birth The and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients better educated, native born and had lower F scores. Such who were younger, patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated were most likely to be and foreign born, referred for EST. particularly in Eastern Europe, These patients infrequently were referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hbllingshead, Redlich and their co-workers (3, 5, 6, 13, 15) who demonstrated related to the type of therapy received in a community. that social factors are The present study demonstrates that such factors are also significant in a hospital setting where ability to pay is not a criteria of therapeutic selection and of therapy are equally available to the With financial aspects and the where all forms entire population. availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations factors may of therapy. may be considered. The social relate directly to the empirically established criteria for choice On this basis a patient is referred for electroshock because older, poorly educated or foreign born, clinical experience having shown he that is �such persons respond best to adequate since 13 - this type of treatment. This explanation is in- half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to ‘choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communi- cation. Thus, a patient is not referred for electroshock because he is foreign born or poorly educated, but rather, these factors provide the difference in cultural background between patient and therapist which makes successful communi» cation less likely in the psychotherapeutic relationship. Robinson 33 EE' (15) in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic rela- tionship. In the present study, similarly, the patients who received psycho- therapy alone were more like the therapists with regard to the factors studied.* Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have score of 21.8 and a mean age of 33.9. Sixteen percent were born in Eastern Europe. Their mean years of education was over 20. * The 18 therapists had a mean F �-1ushown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are patterns appear to be likely to receive electroshock (7, 8). more frequent Such language in persons with poorer socio-cultural back- grounds. Social and cultural factors, in addition to their effect on cation patterns, that, has noted may communi~ also determine the manifest symptomatology. Opler (11) patients diagnosed as schizophrenic, differences in among symptoms are related to differences in cultural background. Frank gg'gl. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those mained had ideational shock patients (8) we In a study of personality factors in electro- have noted that certain patterns of symbolic value The F scale and likely to be associated with the development of a The indicates that symptoms re- symptoms. communication were more depressive psychosis. who relationship between communication pattern symptoms themselves are a mode and of communication. furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. study the F scale was In the present the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. �- 15 - Preliminary observations from a study in progress indicate that lowbscorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing closely for age and place of necessity for developing new their social differences, by matching them more birth. 0f possible greater importance is the modes of communication when treating patients who are refractory to conventional psychotherapeutic approaches.* While epidemiological studies have clearly structured some of the problems involved in selection of treatment, and have indicated the direction of further study, it still remains for more process~oriented definitive answers. * See Esecover's presentation of this topic in this issue. research to provide �- 16 - SUMMARY: 1. In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth and score on the California F scale were significantly related to the type of therapy received and to the utilization of adJunctive hospital services. 2. Patients and were be who were older, poorly educated, had higher foreign born, particularly in Eastern Europe, referred for electroshock. those patients who most were most F scores likely to Psychotherapy was the treatment of choice for closely resembled the therapist in these aspects. were present even when diagnosis was held 3. These relationships h. Among the electroshock patients the constant. significant in choice of therapy which a patient 5. was It is were same factors found to be also related to the readiness with referred for electroshock. postulated that treatment selection is the result of the communicative interaction between patient and be important insofar as they are therapist. Social factors may related to different modes of communication. �- 17 - REFERENCES Adorno, T.W., FrankeloBrunswik, (1950): & The E., Levinson, D.J. and Sanford, Authoritarian Personality, New R.N. York: Harper Brothers. Frank, J.D., Gliedman, L.H., Imber, S.D., Nash, E.H. and Stone, A.R. (1957): Why Neurol. Am. Leave Psychotherapy, A.M.A. Arch. Psychiat., 11; 283-299. & Freedman, L.Z. and Patients Hollingsheadfij. (1957): Neurosis J. Psychiat., Hillside Hospital, 29th 113: 769-775. Annual Report, 1956. Schizophrenia and Social Hollingshead,A.B. and Redlich, F.C. (l95h): Structure, Am. and Social Class, J. Psychiat., 110: 695-701. Social Class and Psychiatric Ecllingshead,A.B. and Redlich, F.C. (l95h): Disorders, in Interrelations Between the Social Environment and Psychiatric Disorders, New York: Milbank MEmorial Fund, pp. 195-208. -3 Kahn, R.L. and Fink, Therapy. Zubin, M. (1957): Changes in Language During Electroshock In Psychopathology of Communication (Roch, P. and J. Eds.), Kahn, R.L. and Fink, M.: New York: Grune & Stratton. Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol., in press. Levinson, D.J.: 10. Personal Communication. Morgan, N.C. and Johnson, N.A. (1957): Chronic Hospital Patient, Am. Failures in Psychiatry: J. Psychiat., The 113: 82h-830. �-18. REIFEEENCES ll. Opler, Schizophrenia and Culture, Scientific American, M.K. (1957): .. 191: 103-110. 12. Rachlin, H.L., Goldman, 6.8., Gurvitz, (1956): ll}. Redlich, F.C., Hollingshead, A.B., Roberts, 33., Robinson, H.A., KJ. (1953): Social Structure and Psychiatric Disorders, Am. J. Psychiat., fl: 729-73h. Rennie, T.A.C., Srole, L., Opler, M.K. and Langner, T.S. (1957): Am. Titus, Psychiatric Treatment, Am. H.E. and Hollander, E.P. (1957): Tougas, R.R. (19511): Urban J. Psxghia‘b” 3.3;: 831-837. Robinson, H.A., Redlich, F.C. and Myers, J .K. (195M: Psychological Research: 17. Rachlin, L. Freedman, L.Z. and Meyers, and 16. A. and J. Hillside Hospital, 2: 17-40. 1950, Life and Mental Health, 15. Lurie, Follow-up Study of 317 Patients Discharged from Hillside Hospital in 13. 14., Social Structure J. Orthopsychiat., g5: 307-316. The California F Scale 1950—1955, P331301. Bu11., Ethnocentrism as 8. it: in 147-64. Limiting Factor in Verbal Therapy, In Psychotheragy and Personality Change, C.R. Rogers and R.F. Dymond, 18. Zierer, E. and eds., Chicago: University of Chicago Press, pp. l96-21h. Zierer, E. (1956): of Creative Activity, Am. Structure and Therapeutic J. Psychotherapy, i3: Utilization 11833519. �- 19 - APPENDIX F SCALE FORM Below are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I DISAGREE A LITTLE AGREE PRETTY MUCH I DISAGREE PRETTY AGREE VERY MUCH I DISAGREE VERY I AGREE A I I LITTLE 1. No MUCH MUCH sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. h. think about 5. ation, When it, 6. the youth needs most is will to wOrk and is best for strict discipline, fight for family Nowadays when so many much, a person has an it him not to but to keep busy with more cheerful things. What and the a person has a problem or worry, rugged determin- and country. different kinds of people mix together so to protect himself especially carefully against catching infection or disease from them. 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. �-20.. 8. is to The best teacher or boss is the be done and how 9. the strong. go about to get over them and tells us exactly what it. Young people sometimes up they ought 10. to one who get rebellious ideas, but as they settle grow down. People can be divided into two distinct classes: the weak and �Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital Duration of Hospitalization. Discharge Ratings. and Diagnosis ROBERT L. KAHN. Ph.D.; MAX POLLACK. Ph.D.. AND MAX FINK. M.D. GLEN OAKS. N. Y. �Reprinted from the A. M. A. Archives of General Psychiatry December 1959, Vol. I, pp. 565—574 Copyright 1959, by American Medical Association Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital Duration of Hospitalization, Discharge Ratings, and Diagnosis ROBERT L. KAHN, Ph.D.; MAX POLLACK, Ph.D., and MAX FINK, M.D., Glen Oaks, N.Y. The increasing studies of the sociopsy— chological aspects of psychiatric treatment in recent years have primarily been concerned with treatment patterns in the community,12 private practice,29 and outpatient clinics.24'2” In the studies reported by Hollingshead, Redlich, and their co—work— ers ”'27 it was found that social class was a major determinant of the type of psy— chiatric treatment in the New Haven com— munity. Patients from the upper classes were more frequently treated with psycho— therapy, while somatic or custodial care was commoner among the lower classes. They summarized their results by noting: “It was found that treatment does not depend on psychological and medical determinants alone, but on the status position of the pa27 well.” tient as Weinstock,29 reporting the results of a poll of the American Psycho— analytic Association, observed that the pa— tients being treated by their members in private practice came disproportionately from the better—educated, high-income pop— ulation. Similar findings have been noted in studies of outpatient facilities. Myers and Schaffer 2" showed that the higher a per— son’s social class the more likely he was to be accepted for psychotherapy, treated by more highly trained personnel, and treated intensively over a long period of time. In another study Rosenthal and Frank 28 Submitted for publication April 16, 1959. From the Department of Experimental Psychia— try, Hillside Hospital. Aided, in part, by Grants M-927 and MY-2092, National Institute of Mental Health, National In~ stitutes of Health, US. Public Health Service. found almost a linear relationship between educational level and frequency of referral for psychotherapy. A more critical test of the importance of sociopsychologic factors in relation to psychiatric treatment would be in a setting where the same therapeutic techniques and services were equally available to all patients. This requirement is met at Hillside Hospital, which is a nonprofit institution for the treatment of voluntary patients with “early and curable symptoms,” 11 who are admitted regardless of their ability to pay. One of the main criteria for accepting pa— tients is their “ability to participate profit— ably in psychotherapy.” 11 Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment, with physiodynamic therapies available when needed. The average length of hospital stay is seven months, although some patients stay for more than a year. In a previous study of the Hillside Hos— pital population,“ it was shown that the factors of age, education, place of birth, and degree of stereotypy, as measured by the California F Scale,1 were related to the selection of therapy. Those patients who were older, had less education, were foreign-born, and had high scores on the F Scale were more likely to receive convulsive therapy. In contrast, patients who were younger, better—educated, and native—born and obtained low scores on the F Scale re— ceived psychotherapy as their sole form of treatment. The purpose of the present study was to determine the relation of sociopsychological 27/565 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY factors to (1) the duration of hospitaliza— tion, (2) the clinical evaluations at time of discharge, and (3) the final diagnosis. Population Method Population—The entire inpatient adult population of Hillside Hospital on March 7, 1957, was studied. This consisted of 171 patients, 57 male and 114 female, ranging in age from 16 to 68 years, with a mean of 35 years. Procedura—The patients were divided according to the duration of hospitalization, clinical response to treatment, and diagnosis. The duration was de— termined by the number of complete months in the hospital. The clinical response and the diagnosis were determined by the medical director at a staff evaluation conference, usually held just prior to the patient’s discharge. Each patient was rated as recovered, much improved, improved, or unim— proved on the basis of the reports of the therapist, supervising psychiatrist, and milieu staff. The discharge diagnoses were divided into four major groups: involutional psychosis, manic—depressive psychosis, schizophrenia, and psychoneurosis. These diagnostic categories included all but three patients in the population. Each patient was tested with a lO—item modification of the California F Scale.20 The F Scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism, and rigidity.1 The subject reads 10 statements and indicates to what extent he agrees or disagrees with each, i.e., “a little,” “pretty much,” or “very much.” The score for each item ranges from 1 to 7, and the total score range is 10 to 70. High scores indicate greater agreement with the statements. These are extreme, uncritical, or stereotyped expressions. For example, one state— ment is this: “If people would talk less and work more, everybody would be better off.” 1. Results Length of Hospitalization—In this population the duration of hospitalization ranged from 1 to 16 months, With a median of 7 months. For the purpose of analysis, the population was divided into three groups: 49 patients who were hospitalized for 1 to 5 months; 64, for 6 to 9 months, and 58 for 10 or more months. The relation of sociopsychological factors to the length of hospitalization is shown in Table l. The group of patients who were hospitalized for the shortest period had 28/566 1.—Dnration of Hospitalization: Total TABLE Months in Hospital No. to 5 to 9 or more 49 04 58 1 6 10 F Score. Mean 43.9 Age, Mean Yr. 45.5 32.5 27.9 40.1 31.0 Education. Mean Yr. ForeignBorn 10.0 11.9 12.8 41% 19% 10% x’=l5.0 I Moan Mean Difi'i r- Difi‘eiences Differences 13.0 § 1.9 T § ences to 1‘s. l to 5 vs. more 6 to 9 vs. more 1 0 lo 10 10 9 3.4 Mean or 12.9 § 17.6 § 2.8 9.5 § 4.6 * 0.9 or P<0.05. t P<0.02. I P<0.01. § P<0.001. * the highest mean F scores, were oldest, and had the least education and the largest per— centage of foreign—born. Conversely, the group in the hospital for 10 months or more had the lowest F scores, were youngest, and had the most education and the smallest percentage of foreign births. Patients who were hospitalized for an intermediate period fell in beLween these two groups for each of the factors. When the data for those patients who re— ceived convulsive therapy (Table 2) and those who received psychotherapy (Table .3) as their only form of treatment were analyzed separately, similar relationships between sociopsychological factors and length of hospitalization were found within each group. In the psychotherapy group there was an increase in mean years of education with greater months of hospitalization, but the differences fail of significance. It may be noted, however, that many of the patients who were in the hospital for 10 months or more were under 19 years of age and were thus unable to achieve more than a limited number of years of schooling. These same relationships of sociopsychological factors to length of hospitalization were found when the patients were classiVol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 2.—Dnration of Hospitalization: Patients Receiving Convnlswe Therapy Months in Hospital F Score, No. Mean to 5 6 to 9 10 or more 15 1 to 5 vs. 1 to 5 vs. more 6 to 9 vs. more 1 “ T 1 § 17 25 to 9 10 or 6 58.2 45.6 34.9 . Mean Yr. 51.7 42.2 32.1 Yr. Born 6.5 12.3 13.2 67% 24% 16% x2=12.0 I Mean Difier- ences ences ences 12.61 9.5 ‘ 5.81 1 of Hospitalization: Patients Receiving Psychotherapy Only Education, Mean Foreign- Mean Difier- Months in _ 1 6 10 or § 19.6 § * 10.1 t NO- t0 5 to 9 or more 33 43 6.7 to 5 (is. to 5 vs. more to 9123. more 1 * 11-4 11.7 12.4 30% 16% 8% Mean to 9 10 or 6 1.6 12,4 10 * Difl‘er- Differ— ences ences 14.1 * 0.3 18.4 * 1.0 or 10.8 Mean 4.3 0.7 . . almost definlte, a hnear, relat1onsh1p be— tween the ratings of improvement and these factors. Patients in the recovered group had the highest F scores, were oldest, least educated, and showed the highest incidence of foreign birth. In contrast, patients in the unimproved group had the lowest F scores, were younger, better educated, and were mostly native—born. Because of the wide variability within each group, however, only the factor of age reached a level of statistical significance. Education also sig— nificantly differentiated the groups when dichotomized according to those who had less than eight years of education and those who had eight years or more. Of the re— covered patients, 29% had less than eight IS TABLE 43-2 29.1 24-8 ForeignBorn P=0.001. . fied according to four major diagnostic groups (Table 4). For each diagnostic class, the lowest F scores, youngest mean ages, most years of education, and least percentages of foreign—born were characteristic of patients hospitalized for the longest periods. As a group, patients diagnosed as schizophrenic were the most homoge— neous in relation to time in the hospital, showing major differences only in the F score, without a consistent trend for the factors of education or place of birth. 2. Results of Treatment—The relation of sociopsychological factors to evaluation on discharge is shown in Table 5. There 40-2 38-6 27-8 Differences 0.9 p<omL Mean Yr. Mean § P<0.05. P<0.02. P<0.01. F Score, Mean Education, Mean Yr. 26 Mean Difler- 6 10.7 HOSDltal Age, x’=5.4 1 23.3 10 Age, TABLE 3.——Dui*a_tion _ _ 4.—Duration of Hospitalization in Patients Classified According to Diagnosis Diagnosis Months in Hospital F Score, Mean Mean Yr. Involutional psychosis ___________________ 1-5 58.2 50.9 35.0 58.8 54.5 52.3 9.6 16.0 40.0 46.1 33.1 46.8 39.1 35.5 11.0 11.7 12.3 39% 23% 40.1 36.6 36.1 41.0 27.1 27.1 8.7 12.5 12.5 50% 19% 13% 36.3 38.5 27.6 27.8 27.8 24.1 13.3 12.3 12.9 10% ‘ 6—9 10+ Manic-depressive psychosis .............. 1-5 6-9 10+ Psychoneurosis ........................... 1-5 6—9 10+ Schizophrenia ............................ 1-5 6—9 10+ Kahn et al. Age, Education, Mean Yr. 7.1 Foreign-Born 57% 43% 0 0 8% 12% 39/ 567 �M a? A. M. A. ARCHIVES OF GENERAL PSYCHIATRY TABLE Evaluation ............................... .......................... ................................ ............................. Recovered Much improved Improved Unimproved 5.—Discharge Evaluation No. 17 82 63 9 F Score, Mean 42.9 39.0 36.1 31.1 Age, Mean Yr. Education, Mean Yr. Foreign-Born 44.5 35.6 31.2 31.1 10.7 11.2 11.2 13.2 41% 22% 16% 11 % x 2=6.1 Mean Differences Recovered vs. Much Improved Recovered vs. Improved Recovered vs. Unimproved ............................. .................................... ................................. Much Improved 08. Improved ............................. Much Improved vs. Unimproved ........................... Improved vs. Unimproved ................................. 3.9 6.8 11.8 2.9 7.9 5.0 Mean Differences 8.9 * 13.3 I 13.4 4.4 4.5 0.1 * T Mean Difl'erences 0.5 0.5 2.5 0.0 2.0 2.0 ' P<0.05. P<0.02. t P<0.01. 1‘ years’ education, while all of the unimproved patients had more than eight years’ educa— tion; the much improved and improved pa— tients were in between. By X2—analysis these results were significant at the 5% level of confidence. When the data were analyzed for the patients treated with convulsive therapy, the trends noted for the population as a whole were intensified (Table 6). Analysis of the patients who received psychotherapy as their only form of treatment (Table 7), however, failed to show any statistically significant pattern. The recovered patients were oldest and had the highest percentage of foreign births, but education and F score did not show any clear trend. TABLE 3. Diagnosis.~—The relation of sociopsy- chological factors to diagnosis is shown in Table 8. Those patients classified as show— ing involutional reactions had the highest F scores, the oldest mean age, the least years of education, and the highest inci— dence of foreign birth. In contrast, pa— tients classified as schizophrenic had the lowest F scores, the youngest mean age, the most years of education, and the least num— ber of foreign—born. Patients classed in manic—depressive psychosis and psycho— neurosis categories were in between with regard to these social factors. Comment The present study has demonstrated that sociopsychological factors, in addition to 6.—Discharge Evaluation in Patients Receiving Convnlsive Therapy Evaluation N 0. F Score, Mean Recovered _______________________________ Much improved __________________________ Improved and unimproved _______________ 8 26 23 53.1 41.8 39.7 Mean Differences Recovered vs. much improved ______________________________ Recovered vs. improved and unimproved___________________ Much improved vs. improved and unimproved _____________ 11.3 13.4 ‘ 2.1 Age, Mean Yr. Education, Mean Yr. 51.6 43.8 32.3 9.4 10.6 12.3 Mean Foreign-Born 50% 35% 17% x *=3.5 Differences Mean Difierences 7.8 19.3 I 11.5 t 1.2 2.9 1.7 * ’ P<0.05. P<0.02. I P<0.001. ’r 30/568 Vol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 7.——Discharge Evaluation in Patients Receiving Psychotherapy Only F Score, Mean N 0. Evaluation ............................... .......................... Recovered Much improved Improved and unimproved ............... 54 32-6 38.1 39 33.5 9 Age, Mean Yr. Education, Mean Yr. Foreign-Born 38.2 32.2 31.9 12.3 12.0 12.2 33% 15% 18% x '= 1.8 Mean Differences .............................. ................... ............. Recovered us. much improved Recovered vs. improved and unimproved Much improved vs. improved and unimproved 5.5 0.9 4.6 their previously determined importance in the selection of treatment, are also significantly related to the duration of treatment, the evaluation of the results of treatment, and the psychiatric diagnosis. If such results were obtained in a survey of private practitioners, as in the Weinstock report,29 it could be concluded that the limitation of the number of practitioners and the expense of treatment served to select preferred persons from the upper social classes who could afford the treatment in terms of time and money. The present results, however, were obtained in an institution where the various kinds of'treatment were equally available to all patients and where the ability to pay was not a factor in the management of the patient. We postulate, therefore, that TABLE Mean Differences Mean Differences 6.0 6.3 0.3 0.3 0.1 0.2 the observed relationships are not due merely to mechanically selective aspects, such as income or the prestige status of the patient. Social factors are important because they are also related to psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. We shall attempt to evaluate these processes and their effect on the psychiatric relationships studied in terms of the influence of sociopsychological factors on the attitude and behavior of the therapist, the patient, and the therapist-patient interaction. Current data both from this laboratory 14 and from others 12'24’27'28 have demon— strated that psychotherapy is most likely to be sustained with those persons who most 8,—Diagnosis Diagnosis N 0. F Score, Mean Involutional psychosis ___________________ Manic-Depressive psychosis ______________ Psychoneurosis ___________________________ Schizophrenia ____________________________ 24 39 37 68 52.3 40.8 36.9 32.8 Age, Mean Yr. 56.7 41.9 29.4 26.1 Education, Mean Yr. 8.9 , 11.5 11.9 12.7 Foreign~Born 46% 26% 22% 10% x’=14.2 I Mean Involutional vs. Manic-depressive psychosis ................ Involutional psychosis vs. psychoneurosis __________________ Involutional as. schizophrenia ______________________________ Manic-depressive psychosis vs. psychoneurosis _____________ Manic-depressive psychosis vs. schizophrenia_______________ Psychoneurosis vs. schizophrenia ___________________________ Mean Mean Differences Differences Differences 11.5 I 15.4 I 19.5 § 14.8 27.3 § 30.6 § 3.9 8.0 4.1 12.5 15.8 3.1 § 2.0 ‘ 3.0 I 4.5 § 0.4 1.6 0.8 T § § P<0.05. T P<0.02. 1 P<0.01. § P<0.001. * Kahn et al 31/569 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY closely resemble the therapists with regard to cultural' background, systems of value, and communication patterns. With stress at Hillside Hospital on psychoanalytically oriented psychotherapy, it is consistent that those patients who are most like the therapists with regard to these factors would be kept in the hospital for the longest period. This was true for patients receiving convulsive therapy or psychotherapy and for all diagnostic groups. The length of time a patient remains in a psychiatric facility is related to the par— ticular function and philosophy of the insti— tution. In studies of outpatient clinics which have a psychoanalytic orientation 24,28 it has been observed that persons from the higher social classes, determined by educa— tion or income, are treated for a longer period. In contrast, in state mental hospitals, patients with the least education are kept longer and form a higher proportion of the chronically hospitalized groupfi'l'fi23 The state—hospital therapist, viewing the in— stitution primarily as a custodial facility,12 is evidently oriented toward the more rapid discharge of those patients who come from a background most like his own. The observation of the relation between sociopsychological factors and improvement rating, particularly in those patients receiving convulsive therapy, may also be related to differences in communication patterns between therapist and patient that result in referral for convulsive therapy. The therapist may set different criteria for im— provement for theolder, less educated pa— tients than he does for the younger, more sophisticated ones. In the patient with littl/ education and with modes of expression different from his own, he may regard, for example, the manifestation of denial or minimization of symptoms as improvement.15 But in patients culturally like him— self, the expression of denial is regarded as a defensive operation, and the patient is considered unimproved. Ratings of improvement are also related to the base line of premorbid functioning. 32/570 . Thus, the rating of recovered is defined at Hillside Hospital as “the reasonable ex— pectation that the patient will be able to return to his community and function as well, or better, than he did before he became ill.” 11 The therapist’s perception of the patient’s premorbid functioning may be influenced by the distance between his value system and that of the patient’s. The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change may be. For ex— ample, for older, lower—class patients the ability to resume work may be the major criterion of improvement. For bettereducated patients work adjustment may be one of many criteria, including such intangible aspects of behavior as insight, work gratification, and ease of sociability. The patient’s expectancy not only of the type of psychiatric treatment but of improvement is also dependent upon social back— ground.12 While the same trends were shown in the psychotherapy patients, the results did not reach the level of statistical significance. This may have been due to the greater homogeneity of these patients for the factors studied, in contrast to the convul— sive group. The outpatient study by Rosenthal and Frank 28 also failed to find a relation between social factors and improve— ment rating in the patients who received psychotherapy. This observation, also, was obtained in a population that was more homogeneous after the initial admission selection process and after the spontaneous screening effected by the patient’s willing— ness to attend treatment after he had been accepted. The marked relationship between socio— psychological factors and diagnosis is not surprising. Certainly, the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and in dementia precox the names themselves have a chronological connota— tion. Landis and Page,19 in 1938, stated that age was the “most important single deter— Vol. 1, Dec., 1959 . �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT mining factor that we can know about men— tal disease.” They asserted that, given the age distribution of a group of patients, they could accurately predict the number in each diagnostic group, as well as the probable outcome with respect to recovery and the length of hospital residence. More recently, Frumkin,8 reporting the median ages of first admissions to a mental hospital in Ohio, observed data similar to our own with re— gard to the ages for the various diagnostic groups. In the .present study, however, we have also shown that education, place of birth, and F score significantly differentiate the major diagnostic groups in the hospital. In View of these findings, we have postulated that a psychiatric diagnosis is not just a one—to—one reflection of a specific type of behavior pattern but is also a value judgment in terms of social interaction. Thus, both in our own studies and in the work of 12 it has been noted that patients others with similar symptoms will receive different diagnoses, depending on their social background. An additional hypothesis relating socio~ psychologic factors to diagnosis may be based on the concept that persons from dif— ferent social backgrounds acquire different habitual modes of adaptation, communica— tion, and expression. Accordingly, under conditions of stress, altered brain function, or states associated with the onset of mental illness, a person will show those behavior patterns or symptoms which are similar to his habitual patterns. Thus, persons from a lower-class social background are more apt to communicate in nonverbal, physical terms, while upper—class people are more likely to do so in ideational and verbal modes. Thus, anger may be expressed by lower—class people by physical violence, while persons from the upper classes are more likely to resort to exhortation or argu— ment. Opler and Singer,25 studying schizo— phrenic Irish and Italian patients in a Veteran’s facility, found significant difKahn et al. ferences in the types of symptoms related to cultural differences in the family backgrounds. Patients from Irish families in which the active expression of emotions were frowned upon and who had dominant, overprotective mothers, were passive, compliant, and withdrawn, and were fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of emotion and who were ruled by a dominant father, showed as— saultive and destructive behavior, were diffi— cult to manage, and were rebellious against authority. In a comparable study, Miller and Swan22 noted that hospitalized schizophrenic son patients exhibited significant social—class difference in symptomatology. Lower-class patients showed a predominance of “motoric themes,” while middle—class patients exhibited “conceptual or r u m i n a t i v e themes.” Hollingshead and Redlich12 found a marked difference in the type of neuroses shown by persons from different social classes. While hysterical reactions were found predominantly at the lowest social levels, obsessive—compulsive patterns were characteristic of the upper classes. They felt thatthe lower—class patient expresses his neurosis by acting out, whereas the upper—class neurotic shows his symptoms in ideational dissatisfaction with himself. According to our hypothesis, then, we should expect that persons from lower social levels would show symptoms that are nonverbal, and are expressed predominantly in sensory or motor patterns. Among such types of symptoms Would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness, and paral— ysis. In this connection it is noteworthy that both hysteria and manic—depressive psychosis have been reported on the wane in the general populatio-n.2v4'8'10 This de— crease, in our view, is related to the general increase in educational level of the country as a whole. One cannot, of course, ascribe 33/571 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY the decrease in hysteria to a greater freedom in sexual matters; hysteria is commonest in more poorly educated people, who are least 26 has Rees inhibited sexually.”6 reported that those British soldiers who had hysterical symptoms in World War II were mainly the mental defectives. He noted that hysterical symptoms were related to intelli— 7 indi— has education. and Freyhan gence cated not only that the present clinical patterns of hysteria are different from those shown at the turn of the century but that such schizophrenic manifestations as “cataleptic stupors, stereotypical motor peculiar— ities, grandiose excitement, and violent behavior” are difficult to find today. These observations suggest that a sociopsycho— logical framework can lead to the prediction of future patterns of mental illness. In our investigations of persons with de— pressive psychoses, we have frequently noted a pattern of premorbid behavior characterized by lack of imagination, creativity, and introspective capacity, and by conven— tionality and general rigidity.13 Similar patterns have been reported by other authors.3'5""21 We believe that a deprived cultural background, such as that involving little or no education, with the early years spent in an illiterate environment with meager cultural resources, is conducive to the development of such a personality pat— tern. When mentally disordered, such per— sons react with the repertoire of behavior patterns that we term “depression.” It is important to keep in mind that while the relationship between social factors and the psychiatric aspects described is probably applicable as a general principle, the specific findings may vary in different settings or institutions. For example, Hollingshead and Redlich12 found that schizophrenia was a diagnosis proportionately commoner among the lower than among the upper classes, while at Hillside Hospital the schizophrenic patients had the highest education. This discrepancy may be related to differences in composition of the two populations, the Hillside patients being drawn largely from 34/572 the middle-class groups, with relatively few from the upper or lower social classes. In Hillside Hospital the diagnosis of schizo— phrenia may indicate an “interesting” pa— tient, while in a state hospital population the same diagnosis may represent a patient who is “hopeless.” From the perspectives developed in this report, observations which are commonly explained in motivational and “dynamic” terms may also be understood in other ways. Thus, some situations where a pa— tient is said to be “hostile” or “resisting psychotherapy” may reflect a problem in communication between patient and ther— apist, related to their differences in social background. It also is apparent that the social back— ground of the majority of the mentally ill paients is such as to make the current prac— tice of universally employing a verbal, in— sightful-oriented therapeutic approach a difficult, if not inappropriate, procedure. The answer to the problem of how to treat the vast number of mentally ill may be not to train more and more psychother— apists, but, rather, to develop therapeutic techniques more suitable to the patient’s own systems of value and communication. Summary and Conclusions Significant relationships were found be— tween sociopsychological factors and dura— tion of hospitalization, discharge evaluation, and diagnosis in a voluntary mental hos— pital. Patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign—born, and had the highest scores on the California F Scale. Younger, native—born, more edu— cated, and lower F—score patients were hos— pitalized the longest. The same relationship of these factors to length of hospitalization was found when analyses were made according to type of treatment (convulsive therapy or psycho— therapy) and diagnosis. Discharge evaluations of improvement were significantly related to age, the older ' . Vol. 1, Dec., 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT patients having the more favorable ratings. Analysis of the data by type of treatment demonstrated that patients rated as recovered or much improved after convulsive therapy had the highest F scores, the least education, and were most likely to be foreign-born. Diagnoses of schizophrenia or psychoneurosis were associated with lower F scores, younger ages, more education, and native birth. The older, less educated, foreign—born, high-F-score patients were most frequently classified under involutional or manic—depressive psychosis. It is postulated that these relationships reflect the influence of social background on psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. These not only contribute to the pattern of mental ill— ness but affect all aspects of the patient— therapist interaction. Hillside Hospital, 75-59 263d St. (Dr. Fink). REFERENCES Adorno, T. W.; Frenkel-Brunswik, E.; Levinson, D. J., and Sanford, R. N.: The Authoritarian Personality, New York, Harper & Brothers, 1950. 2. Arieti, S.: The Decline of Manic—Depressive Psychosis: Its Significance in the Light of Dynamic and Social Psychiatry, paper read at 113th Annual Meeting of American Psychiatric Association, Chicago, 1957. 3. Arnot, R.: The Predepressed Personality, A.M.A. Arch. Neurol. & Psychiat. 76 :617-618, 1. 1956. 4. Chodoff, P.: A Re-examination of Some Aspects of Conversion Hysteria, Psychiatry 17: 75—81, 1954. Cohen, M. B.; Baker, R; Cohen, R. A.; Fromm—Reichmann, F., and Weigert, E.: An Intensive Study of 12 Cases of Manic—Depressive Psychosis, Psychiatry 17:103-137, 1954. S. H. W., and Meltzer, B. N.: Predicting Length of Hospitalization of Mental Patients, Am. J. Sociol. 52:123—131, 1946. 7. Freyhan, F. A.: The Impact of Somatic Therapies on Course and Clinical Profile of the Schizophrenias, J. Clin. & Exper. Psychopath. 19: 6. Dunham, 195-201, 1958. Frumkin, R. M.: Occupation and Major Mental Disorders, in Mental Health and Mental 8. Kahn et al. Disorder, prepared by a committee of the Society for Study of Social Problems, edited by A. M. Rose, New York, W. W. Norton & Company, Inc., 1955, pp. 136—160. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression, Proceeding 42d Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1952, pp. 199—209. 10. Harvey, W. A.: Changing Syndrome and Culture: Recent Studies in Comparative Psychiatry, Internat. J. Soc. Psychiat. 2:165—171, 1956. 11. Hillside Hospital: Twenty-Ninth Annual Report, 1956. 12. Hollingshead, A. B., and Redlich, F. C.: Social Class and Mental Illness: A Community Study, New York, John Wiley & Sons, Inc., 1958. 13. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. Neuropsychiatry, to be published. 14. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside Hosp. 6: 9. 216-228, 1957. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Proceedings of 46th Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958. 16. Kinsey, A. C.; Pomeroy, W. B., and Martin, C. 13.: Sexual Behavior in the Human Male, Philadelphia, W. B. Saunders Company, 1948. 17. Kramer, M.; Goldstein, 11.; Israel, R. H., and Johnson, N. A.: A Historical Study of the Disposition of First Admissions to a State Mental Hospital, Public Health Monograph No. 32, Government Printing Office, 1955. 18. Kramer, K.; Pollack, E. S., and Redick, R. W.; Studies of Incidence and Prevalence of Hospitalized Mental Disorders in the United States: Current Status and Future Goals, paper read at the 49th Annual Meeting of the American Psychopathological Association, New York, 1959. 19. Landis, C., and Page, J. D.: Modern Society and Mental Disease, New York, Farrar & Rinehart, Inc., 1938. 20. Gallagher, E. B.; Levinson, D. J., and Erlich, I.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hospital, edited by M. Greenblatt, D. J. Levinson, and R. H. Williams, Chicago, Free Press, 1957. 21. Malamud, W.; Sands, S. L., and Malamud, I.: The Involutional Psychoses: A Socio—Psychiatric Study, Psychosom. Med. 3:410—426, 1941. 22. Miller, D. R., and Swanson, G.: Defense Against Conflict and Social Background, paper 15. 35/573 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY read as part of a symposium at the meeting of the American Psychological Association, September, Disorder, New York, Milbank Memorial Fund, 1953. 23. A.; Redlich, F. C., and Myers, J. K.: Social Structure and Psychiatric Morgan, N. C., and Johnson, N. A.: Failures in Psychiatry: The Chronic Hospital Patient. Am. J. Psychiat. 113 :824-830, 1957. 24. Myers, J. K., and Schaffer, L.: Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic, Am. Sociol. Rev. 19: 307-310, 1954. 25. Opler, M. K., and Singer, J. L.: Ethnic in Behavior and Psychopathology, Internat. J. Soc. Psychiat 2:11-22, 1956. 26. Rees, J. R.: in discussion on paper by Gruenberg, E. M., in Epidemiology of Mental Differences 36/574 1950, pp. 51—52. 27. Robinson, H. Treatment, Am. J. Orthopsychiat. 24:307—316, 1954. 28. Rosenthal, D., and Frank, J. D.: The Fate of Psychiatric Clinic Outpatients Assigned to Psychotherapy, J. Nerv. & Ment. Dis. 127 :330343, 1958. 29. Weinstock, H. 1.: Report of the Central Fact—Gathering Committee of the American Psychoanalytic Association, paper read at the 48th Annual Meeting of the American Psychopathological Association, New York, 1958. Prénted and Published in the United States of America ��J. Hillside Hospital, 6: 216-228, 1957. SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL1 ROBERT L. KAHN, PH.D.,2 MAX POLLACK, PH.D.,3 and MAX FINK, M.D.4 Recent investigations have indicated a relationship between social class and psychiatric disorder with respect to type and incidence of mental illness (3, 5, 6, l3, l4), selection and maintenance of treatment (2, 6, 15), and therapeutic outcome (10). The present study is concerned with social factors in the selection of therapy in voluntary mental hospital. In the studies reported by Hollingshead, Redlich, and their coworkers (3, 5, 6, 13, 15), the population of New Haven was divided into five social classes on the basis of weighted criteria of education, occupation and place of residence. Of the residents who were under psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care was more common among the lower classes. Of the psychotherapies, psychoanalysis was entirely restricted to the two upper groups. Social class was the predominant determinant of the type of treatment selected even when the diagnosis was held constant. They summarize their results as follows: ". . . it is found that treatment does not depend on psychological and medical determinants alone, but on the status position of the patient as well. Psychotherapeutic methods are applied in disproportionately high a 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, U. 8. Public Health Service. 2Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3Scnior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 4 Director, Department of Experimental Psychiatry, Hillside Hospital. ‘ 216 �SOCIAL FACTORS IN SELECTING THERAPY 217 ‘ degree to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient’s financial resources or the extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques and services are available to all patients. This requirement is met at Hillside Hospital. It is a nonprofit, k, h . ....-_.._...-.,...v..... nonsectarian institution for the treatment of voluntary patients with “early and curable mental symptoms" (4), who are admitted regardless of their ability to pay. One of the main criteria for accepting patients is their “ability to participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment with organic therapies available when needed. The average length of hospital stay is six months, although some patients remain for as long as a year. The present investigation is an outgrowth of several years of study of electroshock therapy. In previous work it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose of the present study was to determine whether electroshock patients differ from those receiving other forms of treatment in, regard to cultural background, including such factors as education and place of birth, and personality as measured by the California F scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. mum METHOD Population: The entire inpatient adult population of Hillside Hospital as of March 7, 1957 was studied. This constituted a total of 172 patients, ranging in age from 16 to 68 with a mean of 34.6, and including 58 men and 114 women. Procedure: (1) The population was subdivided into three groups, according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only.‘5 5All patients are seen in psychotherapeutic sessions during ’hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data were included in both groups. In the results this makes a total of 179 subjects. .... “.4. na. ._‘....-..—._4.,_....—««... . gbnyw. C) �KAHN—POLLACK—FINK 218 (2) birth. The groups were compared for age, education and place of (3) All patients were tested6 with a ten-item modification of the California F scale suggested by Levinson (9). The F scale is a questionnaire (see Appendix) which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to what extent. The score given for each item ranges from one to seven and the total score range is 10 to 70. The greater the agreement the higher the score obtained. The statements themselves are extreme, uncritical or stereotyped expressions. (4) The population was subdivided in regard to utilization of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing and creative therapy. The latter is a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psychological testing and creative therapy were selected for this study because both require a specific referral from the therapist. RESULTS The data were analyzed as follows: (1) comparison of the treatment groups for age, education, F scale scores, and place of birth; (2) comparison where diagnosis is held constant; (3) significance of length of hospitalization prior to treatment; and (4) comparison between groups referred for adjunctive hospital services. Comparison of Treatment Groups For each of the three treatment groups the means and standard deviations for the F scale scores, age and years of schooling are presented in Table l. The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These differences were statistically significant for F score and age but failed to reach statistical significance for education. The failure of years of education to differentiate the groups was due, in part, to the fact that the electroshock 1. 6As part of an ongoing study all the EST patients were tested with the F In the case of those patients who were actually on EST on March 7 their pretreatment scores were used in the statistical comparison since it had been found that EST significantly affects the score during treatment. scale prior to treatment. �SOCIAL FACTORS IN SELECTING THERAPY .850 :wmuuom Eon $5“ 82m 39.7114? $.32 o ammokoh we 219 55 ..fi.:namo cwMuSh .ummmfiuom omen”.— fiamr: $.85“ $83 :25 .PEaZ x0 3:: 3:: Eom $.8va $532 fivawm 55m mo .minamo 82m -fimuuoh Eon @EE $3“ fimmIv $.32 Agar: :otugfim 985 .me .3— $.8va now .«o 0 .Ssnamo .Eeum 988w fl ”55H. K $5; ax? 3?: Gm 3. ea mm 532 2: 2: qfi wzofiom ‘8.“ $336 6m mow—mo? “2253‘; a 532 .59 ...23 3 2, N.— o o . ~23»me «I m5.— Gm q: 3 2;. n: gm 3” a :32. .8.” mi ed 3 ow< x0 532 :82 a5 n: a a tantamwficc Gm 92 ”.2 a: mi. 3» 3m . :2.» tmhd £5 E2 BE 3:: 38mm 532 :82 .En 3: 3 hm any .3. 8. So. a an 3 38%?2.85:»; Esscma .o&u>m&.::=n=— aozéemfi 335-5“ 585-98— -OH—U smvhmm $5.19 r7305 .53.: uh .382: . .. 2.. �220 KAHN—POLLACK—FINK group contained many foreign-born patients whose education was difficult to evaluate accurately. When treatment groups were subdivided into number of patients above and below eight years of education, the difference was significant at the .01 level. The insulin and psychotherapy groups did not differ statistically for any of these factors. Both somatic groups had a higher percentage of foreign-born patients than the psychotherapy group, with the electroshock group being highest of all. Among the foreign-born patients, those who came from Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe received psychotherapy alone. Comparison of Treatment Groups in Relation to Diagnosis The diagnostic categories of the patients in this study are comparable to those reported in previous studies of the hospital popution (12). Of the 172 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and 2 with other diagnoses. As expected, a larger proportion of the depressed patients (52%) received electroshock than did those with other diagnoses. To control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those who received electroshock and those who were given psychotherapy alone. The results are shown in Table 2. While the two groups were comparable for age and education, the electroshock patients had a much higher mean F score, a difference significant at the .02 level of confidence. It is also demonstrated that a significantly higher proportion of the electroshock patients were born in Eastern Europe. 2. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment While the electroshock patients, as a group, have been shown to differ from those receiving insulin or psychotherapy, there were still considerable intragroup differences. To account for some of these differences it was postulated that the same factors involved in selection of treatment were also related to the readiness with which a given patient was referred for electroshock. While most of the patients who received EST were placed on treatment less than three months after admission, about 40 per cent were referred after a period of three to twelve months. In Table 3 the patients are compared according to the period of hospitalization prior to electro3. �SOCIAL FACTORS IN SELECTING THERAPY .550 $.23. ax”: 5.3m 538mm jigli‘l EuEEEh we “Egan $53” «Rana— .Sauamu REE Kc .0332 50m §$§ $53“ EOENN §£Vmw awash 208 39$me a; How no con—8.6m 938» name Bwamwunfi exam; 15.3. Gm 3. 3 532 3: 3: Gm wfi n2 :32 3:. 9:. Ga 3: «.2 h :32 new q: wzogum 0:3 N .vm 38C. somnufifium we mama? :32 . 86 £5 85 utofibfi 5.3» a mud ow< 582 a3 and 3:»..qu kc . é.“ 38m :ontfiwEoU :32 ea BE 3m 8. «liq. a $6 . ‘ . :3 Hammama .ofirmémm -onuwnm ha. , . 2!!!!) .. , ‘ W 7 832: . ,1" w 322: , 221 �KAHN—POLLACK—FIN K 222 ., .550 @va c o sin uo .£6 . 33mg 583m uncuzm $53 m o $53 figs: a : Mano cum—m 2.25355 -0322 50m 3 @932 3.2% 308 $.83 $5me : mm new “o :otuggxwmom QUE :oumusvm wweflamo “26> w Afiwua 32:: c 3015 kc m Ewnud 45 55H. S a 85 :2 85 £5 a: 8.... a; 9 :4 :3.” 3» :82 .En E...“ 2.2 N: ms: a 8; :3.“ 5* 3... Gm 5.. am 3.. 38> 582 am hi 3.; Gm 3: mfi 2: 532 93 mg Gm q: 582 2:. mo can: mEEouuV Szuzcm 8.. uw< :3 Sam \0 . m3 38m zowtuiEeU h mo as 3 .88 him -mNSSEmo: 52: Susannah. sum—SA €3.88... no: 4 w. $04 ,w ‘ 8 e5 $6 kwoa :2: o m 532 c: m Gan—u .85 0.82 c 33 o2 2.2 e 2 » .22 me. 8. aa -608 .88 ~22 m Ema—u 30..— 288 :2: 308 .85. 3 n 285:? 385:”; 52: o 308 88¢ . 2. . �SOCIAL FACTORS IN SELECTING THERAPY 223 Shock. Patients who had higher F scores and were older were treated earlier than the younger and lower F scale groups. Place of birth is also a significant factor. \Vhile 44 per cent of those treated within three months were foreign-born, all patients referred after a period of six months were born in the U. S. The data on education just fails of significance, although 28 per cent of those treated earlier had less than eight years of education. .,,. ,, . mug-r; Adjunctive Hospital Services Comparison of the patients referred for creative therapy and psychological testing is shown in Table 4. It is clear that those referred for either of these procedures had Significantly lower F scores, were younger in age, had more education and more were nativeborn than patients who were not referred for these services. 4. Use of DISCUSSION .. "155' . , The results indicate that the factors of education, age, place of birth, and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services‘ in this hospital. Psychotherapy was the treatment of choice for those patients who were younger, better educated, native-born and had lower F scores. Such patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated and foreign-born, particularly in Eastern Europe, were most likely to be referred for EST. These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich, and their co-workers (3, 5, 6, 13, 15) who demonstrated that social factors are related to the type of therapy received in a community. The present study demonstrates that such factors are also significant in a hospital setting where ability to pay is not a criterion of therapeutic selection and where all forms of therapy are equally available to the entire population. With financial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations maybe considered. The social factors may relate directly to the empirically established criteria for choice of therapy. On this basis a patient is ' �KAHN—POLLACK—FINK 224 .850 fin“; $me Amwutch 35:30 533mm «@055 A03: Afimwvmw H 1%: 35:2 @33 @3: @8va §§8 .mwmuamo «50 853 .25“ «:8 $63 .23 2:5 go ARE; 50m aways $95: $.38 138% Z MFGSK. 805 1%» 3w .uo H ~838va PfimSafibfi .Nmenamu mud“; «Eu 3?: $.27: 33“ $.32 Gm fl. 3 a.» 38> 582 3: 2: 3“ N: mic—om kc v 8.938% .Um 35? we 8.“ :82 a octhd £5 QN m5 3 , uptuzzbuv. . .Sx 2: we a: E: 532 SN 3». 5.8 5.3 Gm 2: ”.2 a: 2: 3w 5.3 3» ASV 32v Gm .tnowJ. ....ewm "A: S. vw< Vutfiwm :8: . 2:».zum Kc a5 tooomd :8.” ~22 3,2 no. 8. 38m h 582 532 £5 Nfiu «.3. 2 :32 so. a3a :ofluEwEoU st 333.5 3380 u>tmuu0 332:. REEF oz 285:?“ 285:»; ..H..U .._oau>mm .355 38.“. Saucmcmmm .355 Amaze... oz uhu OZ 0z . .3 2. �,amr»: . “ ‘ .. SOCIAL FACTORS IN SELECTING THERAPY 225 , .. new... 4.. ,wu referred for electroshock because he is older, poorly educated or foreign-born, clinical experience having shown that such persons respond best to this type of treatment. This explanation is inadequate since half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communication. Thus, a patient is not referred for electroshock because he is foreign-born or poorly educated, but rather these factors provide the difference in cultural background between patient and therapist which makes successful communication less likely in the psychotherapeutic relationship. Robinson et al. (15), in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic relationship. In the present study, similarly, the patients who received psychotherapy alone were more like the therapists with regard to the factors studied.7 . Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have shown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are likely to receive electroshock (7, 8). Such language patterns appear to be more frequent in persons with poorer sociocultural backgrounds. Social and cultural factors, in addition to their effect on communication patterns, may also determine the manifest symptomatology. Opler (11) has noted that, among patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank et a1. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those, who remained had ideational symptoms. In a study of personality 7 The 18 therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen per cent were born in Eastern Europe. Their mean years of education was over 20. , .vr" �KAHN—POLLACK—FINK 226 factors‘in electroshock patients (8) we have noted that certain patterns of symbolic value and communication were more likely to be associated with the development of a depressive psychosis. The relationship between communication pattern and symptoms indicates that symptoms themselves are a mode of communication. The F scale furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an etlmocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. In the present study the F scale was the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. Preliminary observations from a study in progress indicate that lowscorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing their social differences, by matching them more closely for age and place of birth. Of possible greater importance is the necessity for developing new modes of communication when treating patients who are refractory to conventional psychotherapeutic ap1 proaches. While epidemiological studies have clearly structured some of the problems involved in selection of treatment,‘and have indicated the direction of further. study, it still remains for more processoriented research to provide definitive answers. SUMMARY In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth, and score on the California F scale were significantly related to the type of therapy received and to the utilization of adjunctive hospital 1. servrces. ’ Patients who were older, poorly educated, had higher F scores and were foreign-born, particularly in Eastern Europe, were most likely to be referred for electroshock. Psychotherapy was the treat2. �. . p *Wflg g “A 4““ .. )WA-W.~»‘,.I_~HWW‘W« "r .t. SOCIAL FACTORS IN SELECTING THERAPY 227 ment of choice for those patients who most closely resembled the therapist in these aspects. 3. These relationships were present even when diagnosis 'was held constant. 4. Among the electroshock patients the same factors found to be significant in choice of therapy were also related to the readiness With which a patient was referred for electroshock. 5. It is postulated that treatment selection is the result of the communicative interaction between patient and therapist. Social factors may be important in so far as they are related to different modes of communication. APPENDIX “Wadwfl a F SCALE FORM . Below are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I AGREE A LITTLE I AGREE PRETTY MUCH I AGREE VERY MUCH 3),." glue»: ‘. 1. No sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. 4. When a person has a problem or worry, it is best for him not think about it, but to keep busy with more cheerful things. to 5. What the youth needs most is strict discipline, rugged determination, and the will to work and fight for family and country. 6. Nowadays when so many different kinds of people mix together so much, a person has to protect himself especially carefully against catching an infection or disease from them. 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. 8. The best teacher or boss is the one who tells us exactly what is to be done and how to go about it. 9. Young people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down.‘ . \4 I DISAGREE A LITTLE I DISAGREE PRETTY MUCH I DISAGREE VERY MUCH �\‘ KAHN—POLLACK—FINK 228 People can be divided into two distinct classes: the weak the and strong. 10. REFERENCES (1) (2) (3) (4) (5) (5) (7) Adorno, T. W.; Frenkcl-Brunswik, E.; Levinson, D. J. 8c Sanford, R. N.: The Authoritarian Personality. New York: Harper 8.: Brothers, 1950. Frank, J. D.; Gliedman, L. H.; Imber, S. D.; Nash, E. H. 8: Stone, A. R.: Why Patients Leave Psychotherapy. A.M.A. Arch. Neurol. (9' Psychiat., 77: 283-299, 1957. Freedman, L. Z. 8: Hollingshead, A. B.; Neurosis and Social Class. Am. J. Psychiat., 113:769-775, 1957. Hillside Hospital: 29th Annual Report, 1956. Hollingshead, A. B. 8: Redlich, F. C.; Schizophrenia and Social Structure. Am. ]. Psychiat., 1102695-701, 1954. Hollingshead, A. B. Fe Redlich, F. C.: Social Class and Psychiatric Disorders. In: Interrelations Between the Social Environment and Psychiatric Disorders. New York: Milbank Memorial Fund, pp. 195-208, 1954. Kalm, R. L. 8: Fink, M.: Changes in Language During Electroshock Therapy. In: Psychopathology of Communication, ed. P. Hoch 8: J. Zubin. New York: Grune 8: Stratton, 1957. Kahn, R. L. 8: Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy. Conf. Neural. (in press). (9) Levinson, D. J.: Personal Communication. (10) Morgan, N. C. 8.: Johnson, N. A.: Failures in Psychiatry: The Chronic Hospital Patient. Am. J. Psychiat., 113:824-830, 1957. (11) Opler, M. R.: Schizophrenia and Culture. Scientific American, 197:103-110, - (8) 1957. Rachlin, H. L.; Goldman, G. S.; Gurvitz, M.; Lurie, A. 8: Rachlin, L.: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950. This Journal, 5:17-40, 1956. (13) Rcdlich, F. C.; Hollingshcad, A. B.; Roberts, B. H.; Robinson, H. A.: Freedman, L. Z. 8c Meyers, J. K.: Social Structure and Psychiatric Disorders. Am. ]. Psychiat., [09:729-734, 1953. (14) Rennie, T. A. C.; Srolc, L.; Opler, M. K. 8: Langner, T. 8.: Urban Life and Mental Health. Am. J. Psychiat., 113:831-837, 1957. (15) Robinson, H. A.: Redlich, F. C. 8: Myers, J. K.: Social Structure and Psychiatric Treatment. Am. ]. Orthopsychiat., 24:307-316, 1954. (15) Titus, H. E. 8c Hollander, E. P.: The California F Scale in Psychological Research: 1950-1955. Psychol. Bull., 54:47-64, 1957. (17) Tougas, R. R.: Ethnocentrism as a Limiting Factor in Verbal Therapy. In: Psychotherapy and Personality Change, ed. C. R. Rogers 8: R. F. Dymond. Chicago: University of Chicago Press, pp. 196-214, 1954. (13) Zierer, E. 8: Zierer, E.: Structure and Therapeutic Utilization of Creative Activity. Am. ]. Psychother., 10:481-519. 1956. (12) . �Social Factors in the Selection of Therapy in a Voluntary Mantal Hospital Robert L. Kahn, Ph.D. Max Pollack, Ph.D. Max Fink, M.D. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Grant M-927 of the National Health Service. 10-8-57 Institute of mental Health, U.S. Public N.Y¢ �Social Factors in the Selection of Therapy in a Voluntary Mental Hospital Recent investigations have indicated a relationship between social class and psychiatric disorder with respect to type illness (3, 5, 6, and therapeutic and incidence of mental selection and.maintenance of treatment (2, 6, 15), 13, 1h), outcome (10). The present study is concerned with social factors in the selection of therapy in.a voluntary mental hospital. In the studies reported by Hollingshead, Redlich and (3, 5, 6, 13, 15), the population of classes on the of residence. New Haven was their co-workers divided into five social basis of weighted criteria of education, occupation Of the residents who were under and place psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care Of was more common among the psychotherapies, psychoanalysis groups. Social class selected even as follows: when " was was held constant. They summarize is found that treatment does not and medical determinants alone, but on the well. entirely restricted to the two upper the predominant determinant of the type of treatment the diagnosis ..... it was the lower classes. their results depend on psychological status position of the patient as Psychotherapeutic methods are applied in disproportionately high degree to the upper social levels. The data of this study would most psychotherapy takes place in a setting seem to indicate that where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the �extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques This requirement is met and services are available to all patients. at Hillside HoSpital. It is a non-profit, sectarian institution for the treatment of voluntary patients with "early curable mental symptoms" (h), pay. of the main One who non— and are admitted regardless of their ability to criteria for accepting patients is their "ability to participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy available is regarded as the primary when needed. The average method of treatment with organic therapies length of hospital stay is six months, al- though some patients remain for as long as a year. The present investigation is of electroshock therapy. an outgrowth of several years of study In previous work it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose patients differ of the present study was to determine whether electroshock from those receiving other forms of treatment in regard cultural background, including_such factors as education and personality as measured by the California F and place of to birth, scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. �Mame: Population: as of March 7, 16 entire in-patient adult population of Hillside Hospital studied. 1957 was ranging in age from llh The This constituted a to 68 with a mean total of 172 of 3h.6, and including patients, 58 men and women. Procedure: 1) The population was subdivided into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only. * 2) The groups were compared for age, education and place of birth. 3) of the California naire (see F All patients were tested scale suggested by Levinson (9). Appendix) which has been indicates whether tent. The scale is a question- The patient reads ten statements he agrees or disagrees with each statement and to what ex- score given for each item ranges from one to seven and the total score range is tained. The F related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). and ** with a ten-item modification The 10 to 70. The greater the agreement the higher the score obs statements themselves are extreme, uncritical or stereotyped expressions. patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data was included in both groups. In the results this makes a total of 179 subjects. * All part of an ongoing study all the EST patients were tested with the F scale prior to treatment. In the case of those patients who were actually on EST on march 7th their pre-treatment scores were used in the statistical comparison since it had been found that EST significantly affects the score during ** As treatment. �- h h) The population was subdivided in regard to of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing therapy. The latter is and be analogies life experience (18). Psychological testing and creative therapy selected for this study because both require a specific referral therapist. creative a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to of utilization were from the �RESULTS: data The was analyzed as follows: 1) comparison of the treatment groups for age, education, F scale scores and place of where diagnosis is held constant, prior to treatment, birth, 2) comparison significance of length of hospitalization 3) and h) comparison between groups referred for adjunctive hospital services. I. Comparison of Treatment Groups: For each of the three treatment groups the means and standard devia— tions for the Table I. F scale scores, age and years of schooling are presented in The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. differences reach were statistically significant for statistical significance for education. cation to differentiate the groups electroshock group contained many was due, F These score and age but failed to The failure of years of edu- in part, to the fact that the foreign born patients whose education was difficult to evaluate accurately. When number of eight years of education, the difference was patients above and below significant at the .01 level. not differ statistically for The treatment groups were subdivided into insulin any of these and psychotherapy groups did factors. �*** ** fig * $3qu dumumww 33mg. menwmwowOa mmwnwOu macaw mmeanmcpwn Humcfiuamov Hamcwwuawmwoan mnmunHnmUd md .oow mumbwwwomsw 309 mwmuwwwomud ma ma .OH .ow 38 w.w ma Hw.o 83.. Emma wrm flaw ES. 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Place of birth is also a significant factor. within three months were foreign born, six months were born cance, although 28% in the U.S. The While hh% of those all patients referred after data education just on F fails scale treated a period of of signifi- of those treated earlier had less than eight years of edu— cation. IV. Use of Adjunctive Hospital Services: Comparison of the logical testing is shown patients referred for creative therapy in Table IV. It is of these procedures had significantly lower clear that those referred for either F more education and more were native born than for these services. and psycho- scores, were younger in age, had patients who were not referred �** * w Beam Bowm bmmm fio m Em: «was dams mumuwwwomba m 3 w Hmmm 308m m ma mw w 0 gem. Bow. Bow. 80m. o n ma Hm<mw mHMou bmmmaw do 38. ow w $8 38. awwmdamua momvwdmwwumawon 32 “Hwy .OH 5% arms wsmu u Bow. 3 m dumb 38. 80m. mwmbHWHomUd w .Om Hm<mw ooswmwwmos m.4m 3.5 95 Emma UH%H. ww.m 5.4 SL Ewan w ow macaw Ema H.Mm H4.w d Fm tro ww.m Sam mme mu m.mm**.wm.5 mu} $.4H Tme UMWfi. wo.H .zmmu mmwwmbam bmm v.5 H.mw d Ho.w Hm.“ 53 mu >ooowawum wamxwmbu v.8 H.mw UHHH. Kama Hm.m fl; mb Emma Mmmwm ao mocnmawou o.wm PS 0.3 ebwfiw om d m.o Pm “.4 mb u Ho Hammaw HHH N m H H 0 m ow waves 323 333 m :.mm ammwm manomdwoa HP AHOO$V m mw 60ch SR3 momvwdmwwnmawou m ow on Baum wHHow xm PH n AHOO$V a Hm 393 3&3 wows do zmdw<m wwmom m.wm* Hammdams¢ w o 383 0 0 pm ow mcuowm mmmdmus 395 wwuwu m R§ oawmu u �zo *** ** * ac n.e. zo 593. wanWOH.u - oummdw<m ammflm wmwauou. mammaw<m zo mwmuwwwnmbfi mHmuwanmbd owocwm mumswwwombd Awmv o.e. Sea gamumww mw 2.: m» ma oosvaumOb ewmuquawomv Amqv .ow .Om ow .OOH‘Hmamu wm<mw wm<mw m.w up.» uwww. Emma :H.: w: :w.4 mm.“ Saws w wmdeUdm mooam Hm.w a w.wm*4 arm Hm.w po.m mu wmwmwuma m.wm***po.w cwww. Emma w&.4 we; Wm.m mm.a Emma 4.0 bmm % m.mm**.w.o Hw.: a 5.» Hm.m 5.» Ho.a wow Ho.p mu :.mo**wm.w >aucundwdo fiuww smmu Hp.m rw.m Emma wmmwm wacnmdwou H.4w m.<*** & m.wm ow E p.» w.“ Bbmbm mu mmH<Hnmm H< N» u Hm prwv m 33 mm ww p mmwot ow u Awmfiv Am$v m «mmdm m.mw* macomduon r.mm* mw d mm Am4$v 3.33 Ammfiv mm m ow mmRnwowomwoww 0% Amway Beam ammfiwmm xm 4H mp u N» Q: my moan zmdu<m u Aqmav 8% A4H$V “mpgv mum wwmnm m.wm* m.mm* Hm v mw H ow mcuowm owmmaw<m mmmdmwu prfiv Q: “MN$V Amfiv wwudw m m m m Amfiv :3: Amfiv Ammv akumnm OdWmH �-12.. DISCUSSION: results indicate that the factors of education, age, place of birth The and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients better educated, native born and had lower F scores. Such were younger, who patients were also referred more frequently for the auxiliary hospital services of psychological testing creative therapy. Conversely, those patients were older, poorly educated likely to were most be and foreign born, referred for EST. who and had higher F scale scores, particularly in Eastern Europe, These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich and their co—workers (3, 5, 6, 13, 15) who demonstrated related to the type of therapy received in a community. The present study that such factors are also significant in a hospital setting demonstrates ability to that social factors are is not a criteria of therapeutic selection pay and where all where forms of therapy are equally available to the entire population. With financial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, factors may of therapy. two alternative interpretations may be considered. The social relate directly to the empirically established criteria for choice On this basis a patient is referred for electroshock because older, poorly educated or foreign born, clinical experience having shown he that is �- 13 such persons respond best to adequate since this type of treatment. This explanation is in- half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional cation. Thus, a modes of therapy, such as mode of communi- patient is not referred for electroshock because he is foreign born or poorly educated, but rather, these factors provide the difference in cultural background between patient and therapist which makes successful communi» cation less likely in the psychotherapeutic relationship. Robinson 33 Ei' (15) in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic tionship. In the present study, similarly, the patients who rela— received psycho- therapy alone were more like the therapists with regard to the factors studied.* Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations haVe therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen percent were born in Eastern Europe. Their mean years of education * The 18 was over 20. �-11).shown that verbally and use of uncommunicative persons, prone to denial, evasion, stereotypy cliches are likely to receive electroshock (7, 8). patterns appear to be more frequent in persons with poorer Such language socio-cultural back- grounds. Social and cultural factors, in addition to their effect cation patterns, that, has noted may among on communi- also determine the manifest symptomatology. Opler (11) patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank 33 a}. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those mained had shock ideational patients (8) we symptoms. symptoms likely to The indicates that The F In a study of personality factors in electro~ hare noted that certain patterns of symbolic value and communication were more depressive psychosis. re~ who be associated with the development of a relationship between communication pattern symptoms themselves are a mode and of communication. scale furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital lation, Levinson (9) found that high—scorers were popuu less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. study the F scale was In the present the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. �Preliminary observations from a study in progress indicate that low—scorers the scale have a poor response to electroshock, and that those with high F on F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing closely for age and place of necessity for developing their social differences, by matching birth. new modes Of them more possible greater importance is the of communication when treating patients who are refractory to conventional psychotherapeutic approaches.* While epidemiological studies have clearly structured some of the problems involved in selection of treatment, and have indicated the direction of further study, it still remains for more process-oriented research to provide definitive answers. * See Esecover's presentation of this topic in this issue. �_ 16 - SUMMARY: 1. In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth and score F on the California scale were significantly related to the type of therapy received and to the utilization of adjunctive hospital services. 2. who were older, poorly educated, had higher F scores foreign born, particularly in Eastern Europe, were most likely to and were be Patients referred for electroshock. those patients who most Psychotherapy was the treatment of choice for closely resembled the therapist in these aspects. were present even when diagnosis was held 3. These relationships h. Among the electroshock patients the constant. significant in choice of therapy which a patient S. was were factors found to be also related to the readiness with referred for electroshock. It is postulated that treatment selection is the result of the communicative interaction between patient and be important same therapist. Social factors may insofar as they are related to different modes of communication. �m 17 - REFERENCES Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, R.N. (1950): & The Authoritarian Personality, New York: Harper Brothers. Frank, J.D., Gliedman, L.H., Imber, S.D., Nash, E.H. and Stone, A.R. (1957): Why Neurol. & Patients Leave Psychotherapy, A.M.A. Arch. Psychiat., 11: 283—299. Neurosis and Social Class, Freedman, L.Z. and Rollin gsheadfifi. (1957): Am. J. Psychiat., Hillside Hospital, 29th 113: 769-775. Annual Report, 1956. Schizophrenia and Social Hollingshead,A.B. and Redlich, F.C. (l95h): Structure, Am. J. Psychiat., 110: 695-701. Social Class and Psychiatric Hollingshead,A.B. and Redlich, F.C. (l95h): Disorders, in Interrelations Between the Social Environment and Psychiatric Disorders, New York: Milbank Memorial Fund, pp. 195-208. Kahn, R.L. and Fink, Therapy. Zubin, M. (1957): Changes in Language During Electroshock In Psychopathology of Communication (Hoch, P. and J. Eds.), Kahn, R.L. and Fink, M.: New York: Grune & Stratton. Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol., in press. Levinson, D.J.: 10. Personal Communication. Morgan, N.C. and Johnson, N.A. (1957): Chronic Hospital Patient, Am. Failures in Psychiatry: J. Psychiat., The 113: Sen-830. �_ 18 _ REFERENCES 11. Schizophrenia and Culture, Scientific American, Opler, M.K. (1957): £91: 103» 110. 12. Rachlin, H.L., Goldman, G.S., Gurvitz, M., Lurie, (1956): J. Hillside Hospital, 2: 1950, and Psychiatric Disorders, Am. Social Structure J. Psychiat., Am. J. Psychiat., 109: 729-73h. Titus, Psychiatric Treatment, Am. H.E. and Hollander, E.P. (1957): Urban 113: 831—837. Robinson, H.A., Redlich, F.C. and Myers, J.K. (l95h): and 16. l7—h0. Rennie, T.A.C., Srole, L., Opler, M.K. and Langner, T.S. (1957): Life and Mental Health, 15. L. Redlich, F.C., Hollingshead, A.B., Roberts, B.H., Robinson, H.A., Freedman, L.Z. and Meyers, K.J. (1953): 1h. Rachlin, Follow-up Study of 317 Patients Discharged from Hillside Hospital in 13. A. and Social Structure J. Orthopsychiat., g3: 307-316. The California F Scale in Psychological Research: 1950-1955, Psychol. Bull., 53: h7-6h. 17. Tougas, R.R. (195%): Ethnocentrism as a Limiting Factor in Verbal Therapy, In Psychotherapy and Personality Change, 0.3. Rogers and R.F. Dymond, 16, Zierer, E. and eds., Chicago: University of Chicago Press, pp. l96-21h. Zierer, E. (l956): of Creative Activity, Am. Structure and Therapeutic Utilization J. Psychotherapy, lg: h81-519. �- 19 - APPENDIX F SCALE FORM Below are a number of statements. For each statement we give us your personal opinion of whether you agree or disagree. want you to Answer each statement according to one of the following: I AGREE A I I I DISAGREE A LITTLE AGREE PRETTY MUCH I DISAGREE PRETTY AGREE VERY MUCH I DISAGREE VERY LITTLE 1. No MUCH MUCH sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. h. think about 5. ation, an it, a person has a problem or worry, it is best for him not to but to keep busy with more cheerful things. What and the 6. much, a When the youth needs most is will to work and strict discipline, fight for family Nowadays when so many rugged determin- and country. different kinds of people mix together so person has to protect himself especially carefully against catching infection or disease 7. from them. Sex crimes, such as rape and mere imprisonment; such criminals ought to attack be on children, deserve more than publicly whipped, or worse. �”"1 ‘ -20.. 8. is to The best teacher or boss is the be done and how 9. to go about 10. the strong. tells us exactly what it. Young people sometimes up they ought to get over them and one who get rebellious ideas, but as they settle grow down. People can be divided into two distinct classes: the weak and � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Social factors in selection of therapy in a voluntary mental hospital. J Hillside Hosp., 6: 216-228, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-25-030 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Kahn, Robert L.; Pollack, Max; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 4 items. 1: [Preprint]. 2: Reprint from the A. M. A. Archives of General Psychiatry December 1959, Vol. I, pp. 565—574; title: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital. 3: Xerox of J. Hillside Hospital publication. 4: Another [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/a0dd669fe6ef80d3f920fa82ad004579.pdf 922f3407ada0d1bf7f975f2fcd3d0f5a PDF Text Text From the Journal of the Hillside Vol. VI October, 1957. I1oslojfoait, ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI1 HYMAN KORIN, PH.D.2 and MAX FINK, M.D.3 In the course of extensive investigations (1, 2, 3) into the perception of multiple simultaneous stimuli, the pattern of failure of subjects accurately to report one of two stimuli led to a concept of an “order of dominance” in cutaneous perception. Since then, the relationship of the observed pattern of dominance to biologic and psychiatric concepts of body image and body scheme has been the subject of considerable speculation (4, 7, 8, 14). The interrelationship of body areas was initially clearly demonstrated in simultaneous tactile tests of face and hand (2), in which it was noted that the stimuli to the hand were frequently not reported or mislocalized. These phenomena of “extinction” and “displacement” led to the inference that cheek area stimuli were “dominant” to hand stimuli. In subsequent reports (3, 10, ll, 12) a pattern of dominance for tactile stimuli was described in which the face and the primary genital areas were the most perceptive or dominant areas; the hand was the least dominant; and the shoulder, foot, buttock, breast, back, thigh and abdomen fell between these extremes in a mild gradient. These observations were made in normal adults and children and psychiatric patients, but were most clearly discerned in patients with brain disease. Indeed, the major portion of the data relates to a group of patients with severe diffuse brain dysfunction under observation in a general psychiatric hospital. 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M—927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. 2Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3 Director, Department of Experimental Psychiatry, Hillside Hospital. 241 �242 KORIN—FINK unclear. In a review of the problem (3) consideration was given to hypotheses ascribing significance to anatomic, psychophysical, genetic, environmental and neurophysiologic factors. In their conclusions, Bender, Green and Fink of the organization “no explains that adequately theory one note this pattern. Learning and maturation are probably factors, but it brain with of studies In inherent.” be patients to mostly appears disease and normal young children, Cohn (4, 5) emphasized the rostral order of dominance and ascribed significance to “an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain.” He also noted specifically that this pattern was primarily associated with “the over-all sentient function of the brain.” A more extensive elaboration of a maturational and developmental explanation of the order of dominance has been proposed (14). Taking the infantile patterns of sucking and feeding as a model, Linn ascribes dominance to the face as it is the oldest element in the body image; the dominant role of the genital area to the intensity of pleasurable sensation that the infant elicits from masturbation; and the subordinate position of the hand to its role as an second holds it wherein and appendage tension-relieving exploring place in awareness to its stimulation of the more exciting mouth and genitalia. A neurophysiologic view was advanced by Critchley (6, 7), who, after expressing a preference for the term “tactile inattention” instead of “extinction,” emphasized the rostral order of dominance. He stated that “strong stimulation of the healthy side suppresses the attenuated sensations on the impaired side,” and concluded that “tactile inattention in parietal patients is probably no more than an instance of local neglect or disregard, which may be demonstrated at times in many other spheres of consciousness besides the tactile—whether motor, visual or spatial.” A psychophysical explanation was eschewed by Bender, Fink and Green (3, 10, 11), who found no relation between the order of dominance and the tactile threshold for touch or pin prick. DennyBrown, Meyer and Horenstein (8), however, insisted that these patloss of alteration there when or was an only terns were apparent the that demonstrated exfurther discrimination. They two-point tinction of the hand stimulus by a stimulus to the leg could be cheek the of dominance hand. The the stimuli four to overcome by the stimuli altered to be ten by however, could hand the not, to hand in their subject. The basis for these phenomena is” �STIMULUS INTENSITY IN PERCEPTION 243 The following data further emphasize psychophysical factors in perception under the conditions of multiple simultaneous stimulation. These studies represent the initial report of an investigation into the application of simultaneous tactile stimulation tests to the problem of measurement of the alteration in brain function induced by electroshock therapy. In the course of this study electrical stimuli were applied to the cheek and hand of psychiatric patients. Stimuli were either at threshold or suprathreshold levels. Two aspects of the data are presented: (a) the effect of alteration of relative strength of stimulus in the order of dominance on facehand tests; and (b) relation of perceptual thresholds to the order of dominance. SUBJECTS AND METHOD The subjects were thirty-four consecutive psychiatric patients referred for electroshock therapy. The range of their ages was between 21 and 65 and the mean age was 45. Eleven patients were diagnosed as involutional melancholia, thirteen as manic-depressive, depressed, eight as schizophrenia, and two as psychoneurosis mixed type. All testing was done prior to a course of electroshock therapy and no patient had clinical or EEG evidence of altered brain function. Each patient was tested in one session for the purposes of this report. Two model S-4B Grass square wave stimulators were synchronized to deliver either single or two simultaneous electrical stimuli. An isolation unit was connected to each stimulator to eliminate artifacts and the output was monitored visually by an oscilloscope. A switch box inserted in the circuit permitted independent selection of the various body parts. An active and an indifferent electrode, required for each body part, were small 3%; inch steel discs placed 1 inch apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. The electrodes remained affixed to the selected body parts throughout the period of testing. The patient was placed on a couch in a relaxed and supine position. To alleviate undue anxiety the nature of the testing was described. It was emphasized that only a slight tap-like sensation would be felt. The electrodes were then placed on (I) the dorsum of the hands, (2) the mandibular area of both cheeks, and (3) the medial calf area of the legs. In the testing procedure, thresholds for the various body parts were first determined. At a frequency of .3 cycles /second, and a pulse �244 KORIN—FINK duration of 50 milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, until the subject perceived 100 per cent of the stimuli. Increments of 5 volts were applied to the hand and increments of 1 volt to the cheeks. After a ten-second interval, the voltage was decreased until sensation disappeared. Following another ten-second interval, the voltage was gradually increased by 1 volt each six seconds until the patient again reported 100 per cent of the stimuli. This reading was considered the minimal voltage required to produce threshold sensation. Such stimuli, at threshold and 10 per cent above the threshold, are reported by the subjects as a “tap,” a “prick” or a “sting.” Complaints of painful perception were not elicited at these levels of stimulation. After the thresholds were determined, testing with a series of single and double simultaneous stimuli followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and left cheek (homologous stimulation). Both parts were stimulated simultaneously, or one part singly, in a mixed order for ten trials for each of the following conditions: (1) threshold, (2) suprathreshold (10 per cent above the threshold), (3) one body part at suprathreshold and the other at threshold, and (4) the reverse of (3). The order of presentation of conditions (1) and (2) was alternated for different subjects and the same was done for conditions (3) and (4). Similarly the order of presentation of the heterologous and homologous stimulation was alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. When this change occurred, stimulation was increased until a new threshold was determined and ten trials were started anew. RESULTS Threshold Values The threshold stimulation for perception was determined for the hands, cheeks and legs (Table I). The threshold values for the hands and legs are three to four times higher than the thresholds for the cheeks. While the threshold values in the legs are less than in the hands, these differences lack statistical significance. Variability of the threshold is considerably greater in the hands and legs than in the cheeks. There is virtually no overlapping of thresholds, however, Where the cheeks and the hands are concerned. A. �STIMULUS INTENSITY IN PERCEPTION 245 I Mean Thresholds and Standard Deviations of Body Parts TABLE Mean Thresholds (volts) Standard Deviation Right Cheek Left Cheek Right Hand Left Hand Right Leg Left Leg 6.76 7.85 29.25 22.35 24.50 19.52 4.47 4.86 14.88 13.60 13.99 13.64 Extinction Patterns The difference between the number of extinctions of the right hand or the left cheek on stimulation of both parts with either threshold or suprathreshold stimuli was not significant (Table II). Also, when both cheeks were stimulated with either threshold or suprathreshold stimuli, there were no differences in the number of extinctions in each cheek (Table III). In contrast to these observations, stimulating one body part with a suprathreshold stimulus and the other at threshold resulted in a significant increase in the failure to report the body part stimulated at threshold. Thus the cheek was dominant over the hand, or the hand was dominant over the cheek depending on the body part to which the stronger stimulus was applied (Table II). Altering the relative strength of the stimuli applied to the cheeks resulted in a similar predictable change in the pattern of dominance (Table III). Further analysis of the data in Table II indicates that the hand B. TABLE II Mean Extinctions of Cheek and Hand for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Mean Extinctions Extinctions of Hand of Cheek Hand and Cheek at Threshold Hand and Cheek at Suprathreshold Hand at Suprathreshold and Cheek at Threshold Cheek at Suprathreshold and Hand at Threshold Difference Significance 1.55 1.56 .01 NS. 1.02 .59 .57 NS. 2.30 .22 2.08 p<.01 .32 1.36 1.04 p<.01 �KORIN—FINK 246 was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.04) for the thresholdsuprathreshold condition. This tendency is also evident when both parts were simulated at suprathreshold. If it is considered that the mean threshold for the hands is approximately 30 volts, while for the cheeks the threshold is 7 volts, the difference in incidence of extinction may be explained. Suprathreshold stimulation was set at 10 per cent above the threshold value. The hand stimulus was TABLE 111 Mean Extinctions of Both Cheeks for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Extinctions of Left Cheek Mean Extinctions of Right Cheek Difference Significance Threshold .39 .45 .06 N.S. Both Cheeks at Suprathreshold Right Cheek at .18 .37 .19 NS. .96 .14 .82 p<.05 .03 1.28 1.25 p<.01 Both Cheeks at Suprathreshold and Left Cheek at Threshold Left Cheek at Suprathreshold and Right Cheek at Threshold therefore increased by 3 volts and the face stimulus by only 1 volt above the threshold value. Such an increase, although proportionately equivalent, appears to have given greater relative strength to the hand stimulus. Extinction Regardless of pattern, the mean total of the number of extinctions was greater when heterologous body parts were stimulated at threshold than when these parts were stimulated with suprathreshold stimuli (Table IV). For these same conditions of stimulation the dilferences between the mean number of extinctions obtained on homologous stimulation of the cheeks lack statistical significance, but the results are in the direction which indicate that a greater number of extinctions occur when two body parts are stimulated at threshold (Table IV). The failure to obtain a significant difference in the latter instance is partly due to the fact that relatively few C. Incidence of �STIMULUS INTENSITY IN PERCEPTION TABLE 247 IV Mean of Combined Number of Extinctions For Varying Conditions of Threshold and Suprathreshold“ Stimuli Both Parts at Both Parts at A-Suprathreshold A-Threshold Threshold Suprathreshold B-Threshold B-Suprathreshold A-Cheek B-Hand 3.11 1.63 1.68 2.43 .85 .56 1.31 1.10 A-Left Cheek B-Right Cheek * Differences between the mean number of extinctions at threshold and the other three conditions of stimulation are significant for the cheek and hand but are insignificant for both cheeks. extinctions are elicited when homologous parts are stimulated. These findings on the total number of extinctions are in agreement with previous observations (2). DISCUSSION The pattern of extinction followingelectrical stimulation of the skin with threshold and suprathreshold stimuli has been determined. In contrast to the findings of investigators (3) who used clinical (tactile) stimulation, the face stimuli were not reported more frequently than the hand stimuli. Under the conditions of the method of testing in this investigation, nevertheless, it is clear that the pattern of extinction for any two body parts can be readily altered by varying the relative strength of the stimuli. Thus a suprathreshold stimulus applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimulus intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand, in Simultaneous tactile testing, is due to an inherent factor, perceived body image, rostral dominance, developmental principle or a learned factor, are not supported by these observations under our conditions of testing. If any of these factors were involved, a pattern of face dominance should have been elicited when the hand and cheeks were stimulated with equivalent electrical stimuli at threshold and suprathreshold intensities, despite the methodological dif- �248 KORIN—FINK ference introduced by the procedure of affixing electrodes to the skin. The findings in this study, namely that differences in the strength of the simultaneous stimuli can alter the pattern of extinction, supin differences inference, By hypothesis. stimulus-intensity a ports threshold also play a significant role. That an intense stimulus elsewhere can raise the pain threshold and Wolf demonstrated been has by Hardy, 35 much cent as as per Goodell (13). This effect of a relatively intense stimulus on the threshold of another stimulus has also been found by investigators how however, still remains, The stimuli 9). problem (8, other using it is that a pattern of dominance may be elicited when presumably stimuli. touch stimuli by are applied equivalent The results of this study suggest an explanation. Stimuli of for sensation threshold elicit a to intensities are required differing various body parts. When these stimuli are increased 10 per cent, the resultant stimuli are proportional and are perceived as equivastimuli the two body in parts, touching clinically lent. In contrast, are disproportionate relative to the threshold value although apthe of Because their in of application. intensity equal proximately differences in threshold for the hand and cheek, the tactile stimulus the than threshold the above is more cheek the proportionately to stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and has been considered “dominant.” A threshold hypothesis was rejected (3) on the basis that the thresholds obtained by von Frey (16) for pressure and pain do not double the elicited order by dominance the to strictly correspond simultaneous stimulation tests. Most difficult to reconcile is von which the of threshold penis, glans the that Frey’s finding pressure is second in dominance rank only to the cheek in a group of ten the while millimeter; 111 is tested, grams per square body parts 12 is is least dominant, only which at the grams of hand, threshold per square millimeter. feand male for the in area thresholds genital Unfortunately, thresholds of list Von determined. Frey’s been seldom have male (16) is based on a single subject. His more detailed observations (17), however, indicate that there is virtually no pressure sense in the and warmth of the pain, perception clitoris, although or penis glans cold is well developed. It is quite possible that the punctate presthe where touch with genital area correlate does threshold not sure is concerned but that instead some other sense or combination of senses is involved. �STIMULUS INTENSITY IN PERCEPTION 249 Thresholds for the dorsum of the hand and the cheek obtained by von Frey and other investigators indicate that the cheek is considerably more sensitive than the hand. These findings are in agreement with the thresholds obtained in this study. In a recent study of electrical thresholds at various body sites Sigel (15) reported that “leg areas including thigh and ankle, also dorsum of the hands and the palm showed a definite tendency for higher thresholds. Scalp, temple, forehead and face tended to have lower thresholds. The anterior chest and upper arm and anterior wrist areas showed a tendency for lower thresholds. Neck areas, abdomen and upper back showed no definite trend.” In this statement there is no disagreement with the clinically observed order of dominance. From the experimental results obtained here, it is proposed that the dominance hierarchy elicited under the conditions of simultaneous testing may be explained on the basis of the relative strength of the stimuli and the stimulus threshold. SUMMARY Using square wave electrical stimuli, the threshold for perception in the hands, cheeks and calves were determined in thirtyfour psychiatric patients. Simultaneous stimuli were applied in random sequence to combinations of cheek and hand and both cheeks, at threshold, suprathreshold and combinations of threshold and suprathreshold intensities. With simultaneous threshold, or simultaneous suprathreshold stimulation, the differences between the number of extinctions in either part were not significant. With stimuli of unequal intensity (one stimulus at threshold and one suprathreshold), however, there was a significant increase in the failure to report the threshold stimulus. The total number of extinctions is greater with threshold than with suprathreshold stimuli; and greater in heterologous than in homologous patterns of stimulation. It is concluded that the observed order of dominance in simultaneous cutaneous tests may be explained by psychophysical relationships. REFERENCES (1) Bender, M. B.: Disorders in Perception. Springfield, 1952. (2) 111.: Charles Thomas, Bender, M. B.; Fink, M. 8c Green, M. A.: Patterns in Perception on Simultaneous Tests of Face and Hand. A.M.A. Arch. Neurol. é» Psychiat., 66: 855-362, 1951. �KORIN—FINK 250 (3) Bender, M. B.; Green, M. A. 8c Fink, M.: Patterns of Perceptual Organization with Simultaneous Stimuli. A.M.A. Arch. Neurol. (5" Psychiat., 72:233-255, 1954. (4) (5) (5) (7) (8) (9) (10) (11) Cohn, R.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation. 1. Nero. (5. Ment. Dis., 113:471-484, 1951. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: II—A Study in Rostral Dominance in Children. Neurology, 1:119-122, 1951. Critchley, M.: The Parietal Lobes. London: Edward Arnold 8c Co., 1953. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions. Brain, 72:538-561, 1949. Denny-Brown, D.; Meyer, J. S. 8c Horenstein, S.: The Significance of Perceptual Rivalry Resulting from Parietal Lesion. Brain, 75:433-471, 1952. Duncker, K.: Some Preliminary Experiments on the Mutual Influence of Pains. Psychol. Forseh, 21:311-326, 1937. Fink, M. Sc Bender, M. B.: Perception of Simultaneous Tactile Stimuli in Normal Children. Neurology, 3:27-34, 1953. Fink, M.; Green, M. A. 8: Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects. ]. Nerv. 63'» Ment. Dis., 117:43-49, 1953. (12) Fink, M.; Green, M. A. 8: Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46—58, 1952. (13) Hardy, J. D.; Wolf, H. S. 8: Goodell, H.: Studies on Pain. A New Method for Measuring Pain Threshold: Observations on Spatial Summation of Pain. 1. Clin. Invest., 19:649-658, 1940. (14) Linn, L.: Some Developmental Aspects of the Body Image. Int. ]. Psychoanal., 3621-7, 1955. (15) Sigel, H.: Cutaneous Sensory Threshold Stimulation with High Frequency Square-Wave Current: 11. The Relationship of Body Site and Skin Diseases to the Sensory Threshold. ]. Invest. Derm., 18:447-451, 1952. (15) von Frey, M.: Beitrage zur Physiologic des Schmerzsinns. Ber. Sdchs. Ges. Wiss., 462185-196, 283-296, 1894. (17) von Frey, M.: Beitrage zur Sinnesphysiologie der Haut. Ber. Siichs. Ges. Wiss., 47:166-184, 1895. �JOURNAL of the HILLSIDE HOSPITAL VOL. VI, No. 4 l . l OCTOBER, 1957' * . . CONTENTS Papers» from the Department of Experimental Psychiatry A UNIFIED THEORY: OF THE ACTION‘OF- PHXSIODYNAMIC- THERAPIEs—‘——Max Fink - ’ A 19.7 AN OBJECTIVE STUDY OF COMMUNICATION .IN‘ PSYCHIATRIC, INmRyIEws—Jbseph Iafle 207‘ SOCIAL FACTORS IN THE SELECTION OF THERAPY IN TA—RY MENTAL HOSPITAL—Robert and Max Fink L Kahn, Max Pollack SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN TO ELECTRosHOC'x—Martin A. Green A VOLUN- EEG .216 RESPONSE 229 ROLE OF STIMULUS INTENSITY IN PERCEPTION 0F SIMULTAN'EOUS‘ ELECTRICAL CUTANEOUS STIMULI—Hy‘mqn Max Fink Korzn and "241 ‘ NEWS AND NOTES -- "I ' ' I " " —— ——-——————_—. V , , V Published quarterly for the Hillside HOspit-al, Glen Oaks,- N. Y., by 7 ‘ 251 ' THESOCIETY 0F HILLSIDE HOSPITAL Copyfight_1957, The Society OE Hillside HOSpital, Inc. v” "V ' �Hillside Hospital is a nonsectarlan, nonprofit mental hospital for the treatment Of voluntary patlents sufferlng from early and curable mental illne-SS; regardless o'E the1r ability to pay. A special department for adolescents1's 1ncluded:1n the Hospital program. The Hospital teaches and trains" phys1c1ans ‘;in‘ psychiatry and psychotherapy, and also prOVidEs graduate training to graduate students1n psychology, social service and psych1atr1c nursing. Research programs are in progress in psychiatry, med1c1ne and1n the laboratories. The teaching and training program carefully organized and integrated with the clinical serv1ces and 1nvolves the participation of the administrative staff, a staif of superv1sors and the cooperation of a large psychiatric attendmg staff almost entirely psychoanalyti— cally trained. In addition to all the usual inpatient adjunctive therapies, the Hospital condiu‘cts anact’e extramural program including an aftercare clinic, an outpat1et1c11n1c affiliation with Adelphi College for the tralnmg'of’ psychologists, nurses and social workers, an organization of formerpatients; lectures to the general public, and a close affiliation with the LongIsland Jewish Hospital. The Hospital traces itsbegmmngsto orgamzatlonal meetings in 1917 held under the sponsorsh1p of Dr Israel Strauss which led to the formation of the Committee for Menta 'iI-Iealth among Jews, in 11919. Hillside Hospital was opened anddedlcated in 1927. Its original location was in Hastings-on-Hudson, mQVing' to its present location in 1941. It is an afliliate of Federatlon ofi Jewish Philanthropies of New York, and has been growmg stead1lyin bed capacity, the present size being 200 beds. is " ' �JOUBNAL of the HILLSIDE HGSPITAL Published as a function of the Publications Committee of the Medical Board. The Hospital is an agency of The Federation of Jewish Philanthropies of New York. VOL. VI, No. 4 OCTOBER, 1957 Editorial Advisory Board MORRIS B. BENDER, M.D. DUDLEY SANDOR LORAND, D. SHOENFELD, M.D. MD. Editor SIDNEY TARACHOW, MD. Associate Editors M.D. JOSEPH S. A. MILLER, M.D. ABRAHAM S. LENZNER, M.D. M. DAVID EPSTEIN, M.D. SYLVAN KEISER, M.D. EMANUEL KLEIN, Distributed by INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street, New York 11, N. Y. �Information to Contributors Manuscripts—Original manuscripts should be sent to Sidney Tarachow, M.D., 123 East 80 Street, New York 21, N. Y. All parts of the manuscripts should be typewritten, double-spaced, on one side of bond paper. References should conform to the style of this Journal. Reprints—Orders for reprints should be addressed to International Universities Press, 227 West 13 Street, New York 11, N. Y. ANNUAL SUBSCRIPTION, $3.00, SINGLE ISSUES, $1.00 Editorial communications should be addressed to Sidney Tarachow, M.D., Editor, Journal of the Hillside HosPital, 123 East 80 Street, New York 21, N. Y. Business communications, remittances, subscriptions and advertising material should be addressed to the Administrator’s Office, Hillside Hospital, Glen Oaks, N. Y. �EDITORIAL NOTE The Editors are happy to devote this issue to the work of one of the Hillside Hospital research departments, the Department of Experimental Psychiatry. While from time to time the pages of this Journal have carried reports of the various research activities within the Hospital, this is the first time that an entire issue of the Journal has been given over to presenting a comprehensive picture of the activities of a single department. Future issues will carry reports of our other research activities, in different spheres and carried on with varying methodologies. In our next issue we expect to present a large report on the many activities of the in-Hospital and attending staffs in professional and public education. We turn this issue over to the Department of Experimental Psychiatry. It is a young department, its workers are searching for scientific measurable factors in psychiatry, and hope by their findings to contribute to the multidisciplinary approach in psychiatry. 195 �PREFACE The reports in this issue of the Journal are representative of studies now in progress in the Department of Experimental Psychiatry. The Department was established in September 1954 upon the initiative of the late Dr. Israel Strauss. The goal of its full-time research personnel was defined as the study of psychologic and physiologic aspects of behavior. In establishing the operational, experimental principles of the Service we have leaned heavily on our previous experiences with Drs. M. B. Bender and E. A. Weinstein at the Bellevue and Mount Sinai Hospitals of New York. These studies are supported financially by the Board of Direc. tors of the Society of the Hillside Hospital. In 1954 the United States Public Health Service, National Institute of Mental Health established their support of the program, which has continued. Funds have also been obtained from the Dazian and Kaufmann Foundations, and recently from the Foundations’ Fund for Research in Psychiatry. The Staff has shown rapid growth, and at the present time includes: Martin A. Green, M.D. Joseph Jaf‘fe, M.D. Robert L. Kahn, Ph.D. ' Hyman Korin, Ph.D. Max Pollack, Ph.D. Assistant in Neurophysiology Assistant in Psychiatry Senior Assistant in Psychology Assistant in Psychology Senior Assistant in Psychology —— —- — — — Technical assistants include Mrs. Hannah Mosquera (EEG), Mrs. Jean Kolodny (Psycholinguistics) and Mrs. Janet Bowie (Secretary). During the past year Dr. Harold Esecover, Senior Resident in Psychiatry, has been associated with the Department on a half-time basis. October 10, 1957 Max Fink, M.D., Director Department of Experimental Psychiatry 196 �A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMIC THERAPIES1 MAX FINK, MD.2 The proper role of the physiodynamic therapies (convulsive, insulin coma and lobotomy) in psychiatry remains poorly defined. In part, this results from the lack of an adequate formulation of their mode of action. In the past six years increasing evidence for a neurophysiologic-adaptive View of electroconvulsive therapy has been presented (41, 32, 38, 1). This view ascribes the therapeutic process in electroshock to a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. The type of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, an awareness of a similar mode of action in insulin coma (31) and lobotomy (40) has developed. During the past four years we have studied the relation between alteration in various indices of brain function and the behavioral response of psychiatric patients to therapy. The neurophysiologicadaptive view of electroshock has been supported and amplified (1 l, 12, 13, 19, 21); evidence for a similar view of insulin coma has been presented (22); and recently the concept has been extended to the newer “tranquilizers” (9). These studies provide the basis for a generalization concerning the efficacy of these therapies. It is our purpose in this report to examine the experimental evidence to determine whether or not the mode of action of each of these thera1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the 2nd International Congress of Psychiatry, Zurich, September 6, 1957. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 2Director, Department of Experimental Psychiatry, Hillside Hospital. 197 �MAX FINK 198 pies may result from their ability to induce sustained alteration in cerebral function; and the corollary question, whether measurable alteration in cerebral function is a necessary condition for the effi— cacy of these therapies, or a “complication” or “untoward effect.” The indices of brain function used in these studies have varied. These include memory scales (26), visual (20) and tactile (10) perceptual tasks, and changes in language patterns of orientation both clinically (19‘) and after intravenous amobarbital (21). In electroencephalographic studies of this problem, changes in the delta index, both in routine records (11, 12) and after activation by intravenous thiopentone (32, 33), and in the beta index (16) have been applied successfully. For this review, two indices will be stressed: changes in the delta index of the unactivated EEG, and clinical neurologic signs. These indices have been selected because of their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities. OBSERVATIONS (a) E lectrosh ock The following notes summarize our experimental studies of the role of changes in EEG delta activity in the response of subjects to electroshock (11, 13). In these studies, electroencephalograms were obtained before treatment, and at weekly intervals on a day after a treatment in consecutive electroshock referrals. Grand mal treatments were administered three times a week, for twelve to twenty treatments. The EEG records were quantitatively analyzed for the amount of induced delta activity, and classified into categories of “high,” “moderate” and “low” degrees of delta activity. At the end of treatment, the patients were independently rated for their shortterm clinical response into the categories of “much improved,” “moderately improved” and “unimproved.” In the initial series of patients, a significant relationship between the early induction of high degrees of delta activity, and clinical ratings of “much improved” was observed. Eighty per cent of the records in the much improved group were high degree delta by the fourth to sixth treatment; and the percentage was sustained at 90 per cent in the third and fourth weeks. In contrast, none of the unimproved patients developed high degree delta records in the first three weeks, and only 20 per cent of the records in the fourth week were so classified. In a subsequent predictive study, the EEG records during the �THEORY OF PHYSIODYNAMIC THERAPIES 199 second and third weeks of treatment were analyzed. Of the patients who had high degree delta records on both occasions, 67 per cent were rated as much improved, while of the patients without such records, 70 per cent were in the unimproved and moderately improved categories. Roth (32, 38), studying the EEG delta activity evoked by intravenous thiopentone after electroshock, has related both the stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. He concluded that patients not attaining a specified delta activity level “have not acquired an adequate physiological basis for recovery,” and recommended measurement of delta activity levels after thiopentone as a guide to the clinical management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of delta activity that vary from low to high, subconvulsive therapy rarely alters EEG patterns or induces low degrees of delta activity (13). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Gleser (38) demonstrated a significantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (13) recently completed here, twenty-seven patients received a course of subconvulsive therapy. Electroencephalograms, taken at weekly intervals, demonstrated minimal changes—none of the records were scored as middle or high delta activity. Of the twenty-seven patients, no change in behavior was noted in twenty-three, and of these, nineteen were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed significant changes in behavior, while of the five who did not show the delta response, only two showed a behavioral change. (b) Tranquilizing Drugs When the newer drug therapies are studied from the viewpoint of their electroencephalographic and clinical neurologic effects, a meaningful classification emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efficacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly definable electroencephalographic patterns. Based on observations made in chronic admin- �200 MAX FINK istration of drugs in adult psychiatric patients, the EEG changes may be classified according to predominant changes in the frequency spectrum. There are three broad types: 1. Increased slow wave activity with hypersynchrony (“bursts”)——“delta shift” 11. Desynchronization with voltage and frequency irregularity and irregular theta activity—“desynchronization” III. Increased high voltage fast activity—“beta shift.” Of the group of drugs inducing a delta shift, the phenothiazine derivatives chlorpromazine, promazine, and perphenazine are clear examples. Each drug induces seizures in nonepileptics or exaggerates seizures in epileptic patients (7, 8, 15, 29, 37). Each drug induces clinical parkinsonian neurologic patterns when given in adequate dosage. In our laboratories, we have induced parkinsonism in all patients receiving chlorpromazine (14) and have observed seizures in 10 per cent of a group of psychotic patients without previous history of seizures. Induced delta activity, including burst activity, was observed in more than half the patients in this series. Reserpine also evokes delta activity when given in large doses (2). At high dosage levels, it exaggerates seizures in epileptics and induces seizures in animals (35). At the usual clinical dosages, however, reserpine induces desynchronization of frequencies with a moderate increase in theta activity (28), without seizure induction but with definite motor rigidities. In a series of patients treated here (39), parkinsonism was induced in all patients. EEG changes were limited to desynchronization only, without delta burst activity. The primary response of two other drugs, mepazine and benactyzine, is the induction of EEG desynchronization. Mepazine, a phenothiazine derivative, induces desynchronization with small amounts of theta activity (7). Delta activity has not been described, nor have we found reports either of seizures or parkinsonism in the clinical literature. Benactyzine, a potent anticholinergic compound, induces a blocking of alpha, flattening of the record and occasional theta activity (5, 17). Neither seizures nor parkinsonism have been described for this agent. Meprobamate is the clearest example of the group of drugs inducing a beta shift in the EEG (3). This agent further differs from the phenothiazines and reserpine in not producing parkinsonism and not only are clinical seizures not induced, but definite antiepileptic activity has been described (30). Habituation is readily �THEORY OF PHYSIODYNAMIC THERAPIES 201 achieved, and withdrawal phenomena of agitation and seizures have been observed (42). In these actions, meprobamate is more like barbiturates than like the other new tranquilizers. If we determine the clinical efficacy of these agents, we note a parallel between the induced EEG effects and their potency in altering behavior. The drugs that most readily induce a delta shift in EEG frequencies—the phenothiazine compounds—are those with the greatest clinical efficacy in the therapy of psychoses. The compounds with lesser activity in this direction are less efficacious clinically. Insulin Coma Therapy The effects of insulin coma therapy on the nervous system are well documented. During each coma, EEG delta activity is induced, which usually persists for minutes to a few hours after gavage. Not infrequently, in approximately one third of patients receiving deep coma therapy in this hospital, seizures, aphasia or prolonged coma results. After such events, EEG changes of delta activity persist for days, and in cases of prolonged coma, for weeks and months (43). The relation between prolonged coma, altered brain function and behavioral response has been discussed at length. Revitch (31) reported eight cases of prolonged coma and concluded that improvement may be attributed to the induction of organic brain damage, similar to lobotomy. Yaeger, Simon, Margolis and Burch (43), describing twelve cases of prolonged insulin coma, noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (34), emphasizing EEG data, and Kwalwasser and Caplan (27) presented individual cases to support the same conclusion. We reported a similar relationship between prolonged coma and behavioral response in a case study (22). A 34—year-old schizophrenic patient with paranoid ideation developed a left hemiplegia during insulin coma therapy. With the onset of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and spatial inattention, there was a marked change in speech and behavior. He became lucid, loquacious and denied his illness. His former paranoid-withdrawal type pattern was replaced by a friendly cooperative attitude. These changes were accompanied by delta changes in the EEG, as well as language changes after amobarbital indicative of altered brain function. The neurologic symptoms resolved, but the behavioral changes persisted so that he was discharged two months later as “much improved.” (c) �202 MAX FINK (d) Lobotomy While we have not had the opportunity to study lobotomy patients from the point of view of this summary, the reports of numerous observers clearly document a similar relationship. EEG changes of delta activity are present in all subjects postoperatively (6) and persist for varying periods. Walter et a1. (40) in a study of 150 patients, found an 80 per cent persistence of abnormal EEG activity after three years. These authors also noted a relation between clinical improvement and the degree and extent of postoperative Slow wave activity. Postoperative seizures are a frequent “complication,” being variously reported as occurring in up to 20 per cent of subjects (25). Furthermore, there is a relationship between the extent of brain tissue cut and the therapeutic outcome. Circumscribed surgical lesions, regardless of locus, have an improvement rate lower than unilateral lobectomy; and these latter are frequently inadequate and are “improved” upon by a bilateral procedure (36). DISCUSSION When the various physiodynamic therapies are essayed from the point of View of an alteration in brain function, a common mode of action becomes apparent. These therapies represent devices which induce appreciable changes in brain function, with resultant change in behavior. Convulsive therapy and lobotomy induce measurable diffuse changes in brain function directly; insulin coma primarily when complications ensue; and the phenothiazine and reserpine groups of tranquilizers when given in adequate dosage. How persistent changes in cerebral function affect behavior is not clear. Psychotic behavior is not “reversed” or “obliterated.” Rather, with an alteration in the central nervous system milieu, there is an alteration in all aspects of behavior including perception, mood, affect, memory, judgment and attitude. The specific adaptive is and is each for variable dependent on numerous subject response historical and environmental factors. Premorbid personality (18), environmental situation and expectations (13), and the duration of the alteration in brain function (12) have recently been discussed as determinants of the behavioral response under these conditions. The induced changes in behavior are evaluated by the psychiatrist, administrator or family as to the degree of “improvement.” These ratings are value judgments, based upon such factors as the tolerance environmental the behavioral of induced response, type �THEORY OF PHYSIODYNAMIC THERAPIES 203 and the observer’s expectations. In this context, the physiodynamic therapies do not induce “improvement”-—rather they induce behavioral change which is secondarily evaluated as improvement. The alteration of cerebral function is therefore not a “complication” or an “untoward effect” but the desired goal of these forms of therapy. Of the many “organic" therapies introduced during the past thirty years, none apparently has been a specific agent for the therapy of psychoses (in the sense that penicillin is specific for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efficacy in altering behavior by altering the cerebral milieu. In this context, the various physiodynamic therapies are not spe— cific for a type of psychosis. The early enthusiasm that reserpine or chlorpromazine was specific for schizophrenia, or hypotheses that ascribe significance to an antagonism between these drugs and “psychosis” or “schizophrenia” are not tenable. Similar enthusiasm claiming a specificity of insulin coma for schizophrenia is also untenable, and support for this view is presented in a recent chlorpromazine-insulin coma control study (14). EEG analysis of these therapies permits a more explicit definition of the induced alteration in brain function. Changes in cerebral function reflected by a shift in the spectrum of EEG frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as “bursts” or “hypersynchrony” provide the change in milieu that is more effective in altering behavior. The significance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the tranquilizers. That a delta shift has some specificity is seen in the analyses of the drug effects. Those drugs that induce the delta shift—the phenothiazines and reserpine—have been consistently reported as effective modifiers of psychotic behavior. Changes in brain function reflected by EEG desynchronization only, or a shift in frequency spectrum to the faster range, have a limited efficacy in altering psychotic behavior.3 The significance of a delta shift is further seen in the limited efficacy of subconvulsive electroshock when compared to convulsive electroshock in the management of psychoses. Another aspect of the alteration in brain function which may be defined is the change in seizure threshold. With the delta shift in These observations suggest the application of EEG screening of new chemotherapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. 3 �MAX FINK 204 the EEG, an increase in clinical seizures would be anticipated. This is indeed true. Seizures have been described following electroshock (4, 24); they are prominent after lobotomy (40) and a common “complication” during and occasionally following insulin coma therapy (23). With the tranquilizers, the parallel of clinical efficacy and seizure induction is most striking. Phenothiazine compounds induce seizures commonly; reserpine rarely; benactyzine not at all; and meprobamate is a potent anticonvulsant! The lowering of seizure threshold parallels the extent of the EEG delta shift induced by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism—both potent indices of an alteration in cerebral function. The neurologic basis for the delta shift and increase in seizure frequency is unclear. Whether this represents a persistent change in function of some specific brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a delta shift, with or without hypersynchrony, it appears more likely that the EEG changes reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of specific cellular masses. SUMMARY The neurophysiologic and clinical neurologic aspects of convulsive therapy, “tranquilizers,” insulin coma and lobotomy, are 1. reviewed. The efficacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent change in cerebral function, of which a delta shift in the EEG spectrum and an increase in 2. incidence of seizures are two indices. 3. Alteration in cerebral function is an essential prerequisite of behavioral change with each of these therapies. Such alteration is neither a “complication,” nor an “untoward effect,” but is the sine qua non of the mode of action of these therapies. 4. No evidence has been educed in these studies that the physiodynamic therapies are specific agents for the relief of psychoses; nor do they affect a specific segment of the nervous system; nor do they induce specific behavioral changes. 5. The therapeutic process of convulsive therapy, insulin coma, lobotomy and tranquilizers may be ascribed to the induction of a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. ' �THEORY OF PHYSIODYNAMIC THERAPIES 205 REFERENCES Aird, R. B.; Strait, L. A.; Pace, J. W.; Hernoff, M. K. 8c Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. A.M.A. Arch. Neural. (9 Psychiat., 75:371-378, 1956. (2) Arellano, A. P. 8: Jeri, R.: The Effect of Reserpine on the Scalp and Basal Electroencephalogram. EEG. Clin. Neurophysiol., 8:150 (abst.), 1956. (3) Berger, F. M.: The Chemistry and Mode of Action of Tranquilizing Drugs. (1) Arm. N. Y. Acad. Sci., 67:685-699, 1957. (4) Blumenthal, I. J.: Spontaneous Seizures and Related Electroencephalographic Findings Following Shock Therapy. J. Nerv. é» Ment. Dis., 122:581-588, 1955. (5) Coady, A. 8: Jewesbury, E. C. 0.: A Clinical Trial of Benactyzine Hydrochloride (“Suavital”) as a Physical Relaxant. Brit. Med. J., Mar. 3, pp. 485487, 1956. (5) Cohn, R.: EEG Study of Prefrontal Lobotomy. Arch. Neural. & Psychiat., 53:351-357, 1945. (7) Denber, H. C. B.: Discussion, Symposium on the Psychopharmacologic Approach to Schizophrenia. Second Int. Congress of Psychiatry, Zurich, 1957. (8) Fabisch, W.; Effect of Chlorpromazine on the Electroencephalogram of Epileptic Patients. J. Neurol., Neurasurg., (5» Psychiat., 20:185-190, 1957. (9) Fink, M.: Therapy of Schizophrenia: Role of Alteration of Brain Function in Behavior. Presented Second Int. Congress of Psychiatry, Zurich, 1957. (10) Fink, M.; Green, M. A. 8c Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. (11) Fink, M. 8: Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Clin. Neurophysiol, 8:158 (abst.), 1956. (12) Fink, M. 8: Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neural. (5» Psychiat., 78:516-525, 1957. (13) Fink, M.; Kahn, R. L. 8: Green, M. A.: Experimental Studies of the Electroshock Process. J. Nerv. 6} Ment. Dis. (in press). (14) Fink, M.; Shaw, R.; Gross, G. 8c Coleman, F. 8.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis. J. Am. Med. Assoc. (in press). (15) Hankofi', L. D.; Kaye, E.; Engelhardt, D. M. 8c Freedman, N.: Convulsions <16) Complicating Ataractic Therapy, Their Incidence and Theoretical Implications. N. Y. State J. Med., 57:2967-2972, 1957. Hoagland, H.; Malamud, W.; Kaufman, I. C. 8c Pincus, G.: Changes in Electroencephalogram and in Excretion of 17-Ketosteroids Accompanying Electro-shock Therapy of Agitated Depression. Psychosom. Med., 8:246-251, 1946. (17) Jacobson, E.: Suavitil, et Nyt Stof Med Specifik Virkning pa Centralnervesystemet. Ugeskrift for Laeger, 117:1147-1151, 1955. (18) Kahn, R. L. 8: Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy. Conf. Neural. (in press). (19) Kahn, R. L. 8c Fink, M.: Changes in Languages During Electroshock Therapy. In: Psychopathology of Communication. New York: Grune 8c Stratton, (in press), 1957. (20) Kahn, R. L. 8c Fink, M.: Perception of Embedded Figures After Induced Altered Brain Function. Am. Psychol., 12:361 (abst.), 1957. (21) Kahn, R. L.; Fink, M. Sc Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. A.M.A. Arch. Neurol. (5- Psychiat., 76:23-29, 1956. (22) Kahn, R. L.; Graubert, D. Fink, M.: Delusional Reduplication of Parts of the Body After Insulin Coma Therapy. This Journal, 4 :134-148, 1955. 8: �MAX FINK 206 (23) Kalinowsky, L. B. 8: Hoch, P.: Shock Treatment, Psychosurgery and Other Somatic Treatments in Psychiatry. New York: Grune 8c Stratton, 1952. (24) Karliner, W.: Epileptic States Following Electroshock Therapy. This Journal, 5:258-263, 1956. (25) Klotz, M.: Incidence of Seizures, with EEG Findings, in Prefrontal Lobotomy. A.M.A. Arch. Neurol. 65- Psychiat., 742144-148, 1955. (26) Korin, H.; Fink, M. 8: Kwalwasser, S.: Relation of Changes in Memory and Learning to Improvement in Electroshock. Conf. Neurol., 16:88-96, 1956. (27) Kwalwasser, S. 8c Caplan, M.: A Case of Prolonged Insulin Coma: Treatment. This Journal, 1:145-155, 1952. (28) Liberson, W. T.: Effect of “Tranquilizing” Drugs on EEG. EEG Clin. Neurophysiol., 8:523, 1956. (29) Liddell, D. W. 8c Retterstol, N.: The Occurrence of Epileptic Fits in Leucotomized Patients Receiving Chlorpromazine Therapy. J. Neurol., Neuro(30) (31) (32) (33) (34) (35) surg., (g. Psychiat., 20:105-107, 1957. Perlstein, M. A.: Miltown, Its Use in Convulsive and Related Disorders. ]. Am. Med. Assoc., 161:1040, 1956. Revitch, E.: Observations on Organic Brain Damage and Clinical Improvement Following Protracted Insulin Coma. Psychiat. Quart., 28:79-92, 1954. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive Treatment and Their Significance for the Theory of ECT Action. EEG Clin. Neurophysiol., 3:261-280, 1951. Roth, M.; Kay, D. W. K.; Shaw, J. 8c Green, 1.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electro-Convulsive Treatment. EEG. Clin. Neurophysiol., 9:225-238, 1957. Shagass, C. St Rowsell, P. W.: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma. A.M.A. Arch. Neurol. 65Psychiat., 72:705-711, 1954. Sigg, E. B. 8c Schneider, J. A.: Mechanisms Involved in the Interaction of Various Central Stimulants and Reserpine. EEG. Clin. Neurophysiol., 9: 419-426, 1957. (35) Simon, A.; Margolis, L. H.; Adams, J. E. 8c Bowman, K. M.: Unilateral and Bilateral Lobotomy: A Controlled Evaluation. A.M.A. Arch. Neurol. (‘5' Psychiat., 66:494-503, 1951. (37) Stewart, L. F.: Chlorpromazine: Use to Activate Electroencephalographic Seizure Patterns. EEG Clin. Neurophysiol., 9:427-440, 1957. (38) Ulett, G. A.; Smith, K. 8c Gleser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group. Am. ]. Psychiat., 112:795-802, 1956. (39) Wachspress, M.: Blumberg, A. G.; Fink, M. 8: Miller, J. S. A.: Evaluation of High—Dose Reserpine Therapy for Relief of Anxiety. This Journal, 5 :67-77, 1956. (40) Walter, R. D.; Yaeger, C. L.; Margolis, L. H. Simon, A.: The EEG Changes in Unilateral and Bilateral Frontal Lobotomy. Am. J. Psychiat., 111:5908c 594, 1955. (41) Weinstein, E. A. 8: Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. Springfield, Ill.: C. C. Thomas, 1955. (42) Wikler, A.: Personal Communication. (43) Yaeger, C. L.; Simon, A.; Margolis, L. H. 8: Burch, N. R.: Electroencephalographic Studies in Posthypoglycemic Coma. ]. New. 6’ Ment. Dis., 118: 435-441, 1953. �AN OBJECTIVE STUDY OF COMMUNICATION IN PSYCHIATRIC INTERVIEWS1 JOSEPH JAFFE, The clinical interview MD.2 is the psychiatrist’s primary tool for diagnosis of psychopathology, the modification of behavior, and collection of research data. Only in recent years, however, have actual transactions which comprise the interview been studied the the the ob- jectively. Investigators of the interview have usually employed systems of content analysis (1), which are based upon various theories of psychodynamics. Currently, there is increasing emphasis upon formal aspects of interaction such as temporal patterns of speech (14), drastic change of subject (3), physiological relationships of the participants (2), grammatical patterns of language (5, 6, 9), and speech disturbances and silences (10). These aspects, in contrast to content categories, are relatively independent of theoretical preconceptions, and are more readily quantified and studied statistically. In many investigations of these formal variables, however, the patient’s communications are abstracted from the total context of the interview. These approaches neglect the fact that the psychiatrist is a participant observer, i.e., a significant variable in the interaction (ll). Others have attempted to control this variable by means of structured interviews in which the doctor’s contribution is standardized according to a predetermined experimental design (6, 7, 14). These structured situations delete the very quality of living relationship that is the ultimate concern of the psychotherapist (7). 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the New York Divisional Meeting, A.P.A. November, 1957. Supported by Grant 56-151 of the Foundations’ Fund for Research in Psychiatry. 2Assistant in Psychiatry, Department of Experimental Psychiatry, Hillside Hospital. 207 �208 JOSEPH JAFFE We are in need of methods of verbal interaction analysis that neither preclude nor prescribe the doctor’s clinical responses. The purpose of this paper is to present a method of interview analysis which (a) is objective and quantitative, (b) preserves the natural patient-therapist relationship, and (c) treats the interview as an integrated system of interpersonal communication. This is accomplished by including the doctor’s usual clinical behavior in the data to be studied. The raw material is not the patient’s speech, but rather the total verbal output of the “two person” or “dyadic” group (8). METHOD The tape-recorded interview transcribed, without regard to the speaker of the words. Careful attention is given to subtle repetitions such as “I—I mean,” “Well as—as I say,” and to (i i, such “so as “you know,” to speak, interpolated expressions as I said,” etc. These have a tendency not to be heard since they are irrelevant to the content. The transcript is then arbitrarily divided into consecutive units of 100, 50 or 25 words, depending on the discreteness of the phenomena to be investigated. Thus a unit contains contributions of words from either doctor or patient alone, or from both in varying proportions. The measurement applied to these units of dyadic speech is the type-token-ratio (TTR). This is an index of the balance between repetition and variety of words (12). The TTR is the ratio of the number of diflerent words (types), to the total number of words (tokens), in a sample of language. For example, in a lOO-word sample the repetition of the identical word 100 times in succession would produce the lowest possible ratio of .01 (1 type/ 100 tokens). The highest possible ratio of 1.0 would result if every one of the 100 successive words were different (100 types/ 100 tokens). These extremes of stereotypy and diversity are rarely encountered, and then only in grossly pathological situations (8). The “word-type,” i.e., the numerator of the TTR, is arbitrarily defined. All words are different which are pronounced or spelled differently. Thus, give, gives, gave, given and giving are considered different types, as are know and no. Vocalizations not clearly identifiable as words are omitted, with the major exception of “mmhmm” which is a frequent utterance of the interviewer in our records. Contractions are retained as single words, but vulgarisms such as “I dunno” are edited to read “I don’t know.” is precisely �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 209 The TTR is calculated for each unit and the pattern of consecutive scores is graphically plotted, as illustrated in Figures 1 and 2. For additional precision, the units may be overlapped; e.g., 50word units may be advanced 25 words at a time, so that each unit is composed of the last half of the preceding and the first half of the subsequent unit. This often smoothes the resultant curve. The overlapping technique is illustrated in Figure 3. Previous studies of the TTR have dealt with the over-all average in a single person’s language (12). The present method studies the sequential pattern in dyadic language. OBSERVATIONS In the last eighteen months approximately sixty recorded interviews have been investigated by this method. The material includes forty patients in all diagnostic categories. The dyadic TTR patterns have been found to be sensitive to a variety of clinical phenomena (8). This report illustrates the changes in language interaction occurring during the course of hospitalization and therapy, as well as changes in rapport and defensive operations within individual interviews. TTR Pattern in Clinical Change Figure 1 shows the pattern of the first 1500 words of three separate interviews during the clinical course of one patient. The doctor (a) Dyadic DYADIC TTR PATTERN WITH CLINICAL CHANGE (CONSECUTIVE PRE-TREATMENT T53 I. 25 WORD UNITS) POST-TREATMENT# I2 0N DISCHARGE .92 .84 .76 M M .68 ."-' — ‘ .60 I lo 20 30 40 UNIT NUMBER 5060 I I0 20 30 40 UNIT NUMBER FIGURE 1 5060 I I0 20 30 4O 50 60 UNIT NUMBER #40 #49 #59 I957 �210 JOSEPH JAFFE in each. This case was selected as an unequivocal example of gross clinical change. In the first interview the patient was agitated and depressed. She refused to be seated and paced about the room, reiterating stereotyped self-recriminations, crying hysterically, with marked pressure of speech. At the time of the second interview, following a course of grand mal electroshock, the clinical picture was grossly altered. She was less agitated and more cooperative, although withdrawn and complaining of a memory deficit. On discharge two months later, she appeared alert, poised, conversational and, at times, surprisingly insightful. She had been rated is the same clinically as “recovered.” The TTR of consecutive 25-word units of interaction, for each of the three periods described, is graphically represented in Figure 1. Consecutive points are connected by lines so that the fluctuations in the graph reflect the difference between successive scores. The mean TTR for the complete interview from which these samples were taken is represented by a horizontal line through each graph. The pattern of scores demonstrates a fluctuating equilibrium about the mean. ' The interviews at these three successive stages show a sequence of changes. The mean level of the interaction is seen to increase as the clinical status changes from psychosis to “recovery.” There is a concomitant restriction in the amplitude of the pattern, i.e., a decrease in variation about the mean. Comment: The sequence of change in the TTR pattern parallels the progressive improvement in interpersonal communication that was apparent clinically. This suggests an approach to the quantification of clinical change, defined as an altered pattern of verbal interaction in the interview. (b) Changes in Communication Within the Interview Figure 2 is an enlargement of the first of the three interactions shown in Figure 1. Here the sequence of changes within a single interview is examined rather than comparing the patterns of successive interviews. As described before, the patient was speaking continuously in a disorganized affective outburst. The lower line indicates the 25-Word units in which the interviewer participated. Following the doctor’s introductory remarks, units 3-12 represent the patient’s uninterrupted speech. Wide oscillations of the pattern are prominent. From samples 13 onwards the doctor made repeated efforts to communicate with the patient. Two independent judges reviewed the transcribed protocol, and both identified three areas �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 211 in which there seemed to be an understandable, rational interchange between the participants. These periods are labeled “rapport” in the upper line. During these three periods the oscillations of the pattern are much constricted. Compare other nonrapport periods such as 23-24 and 39—41, in which the doctor’s participation amplified the oscillations. DYADIC TTR PATTERN (CONSECUTIVE 25 WORD UNITS) —— 'RAPPORT" TTR 36 DOCTOR'S PARTICIPATION l 5 l0 IS 3035 4045 20 25 UNIT NUMBER FIGURE 2 50 #40 I957 Comment: This illustrates a method of quantifying interpersonal phenomena, such as the degree of “contact” with a severely disturbed patient. The affective pattern in this patient represents the psychotic integration, and for this reason, the occasional occurrences of conventional, rational conversation are described as periods of “rapport.” The restriction in the amplitude which characterizes these periods is similar to the over-all pattern at the time of “recovery.” Complete Interview Figure 3 demonstrates the initial dyadic TTR analysis of a complete interview. This interview is the discharge evaluation of a patient who had been hospitalized following a bizarre suicide at(c) Analysis of a �JOSEPH JAFFE 212 tempt. After seven months of hospitalization, she had “improved” clinically. This took the form of a hypomanic mood and a gross denial of her severe emotional conflicts. The interview is scored by the method of successive 50-word units advancing by 25-word steps. The mean TTR for the interview is shown by the horizontal line drawn through the graph. The pattern falls into several natural segments. There are two areas in which ten consecutive points fall below the mean (areas 4 and 7). These are unusual in this interDYADIC TTR ANALYSIS TTR OFA PSYCHIATRIC INTERVIEW (OVERLAPPING so woao UNITS) .98 .94 .90 :3: ::2 I.I—'i—'.I—'Ij== .70 .r. III -. v. 255- -/1-’1 I II ~ JUL—I- ---.r I 4I—I—I—I----I----—I——-—I-—I—|*I—---|—I—I I 3 4 7 5 9 8 l0 II I2 it 54 |957 FIGURE 3 There are also areas of gross deviation from the mean (such as area 2). Thus we allow the objective pattern to determine our criteria for phenomena to be studied. In general, we look for per- View. sistent changes in the TTR level, gross trends or sudden shifts. Several of the deviant areas are described to illustrate the method. The interview begins with a hypomanic monologue in which the patient describes her successful visit home, her euphoric outlook and plans for a rosy future. Area 2 has been delineated because of gross deviation from the mean. The beginning of this period coincides with a change of topic to her plans for going back to her job two days hence. Her optimism is’interrupted by a period of confusion as she tries, with some difficulty, to recall one of the details of the job. The end of the gross fluctuation coincides with the rationalization “I don’t think I’ll have too much trouble.” ‘ �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 213 Area 4 was delineated as one of the two sections in which ten consecutive scores fall below the mean. Its beginning coincides with a statement about her depression on admission to the hospital. This area ends with the lowest score of the interview, which precedes by only a few words a spontaneous reference to her suicide attempt. This large deviation at the end of area 4 embodies the main characteristics of the following area. Area 5 is characterized by large fluctuations above and below the mean. The content of this area is completely on the theme of suicide. She attempts to prove how much she now wants to live. The doctor’s queries at the end of the period meet with increasing resistance. In the beginning of the next segment (area 6) she stubbornly refuses to discuss the subject of suicide further, at which point she changes the subject abruptly. Area 7 was delineated on the basis of two criteria. It begins with a precipitous drop in the TTR, followed by ten consecutive scores below the mean, and ends with an equally abrupt rise. Its beginning coincides with a change of subject by the doctor in the form of a question about her feelings at that moment in the interview. This content area, i.e., the “you-me” relationship, is pursued at a very repetitive level. The period ends when she abruptly changes the Area 9 is delineated because of an extremely low score enclosed by two large deviations. It coincides with a brief mention of a meeting with a young man who told her how well she looked. It ends with an embarrassed r'emark and her statement “I decided to get him off the topic.” These examples illustrate areas of disturbance or disequilibrium in the verbal interaction pattern. In contrast, 3, 6, 8 and 10 are areas of relative stability or equilibrium in the record. These periods are marked by a different quality of communication. They consist either of a euphoric, hypomanic monologue which avoids all stressful subjects, or of evasion of the doctor’s probing questions by superficial rationalization and conventional cliches. Comment: Recent reports of objective interview studies using other techniques (10) have noted that the interaction goes through a series of definable phases, which may correspond to periods of stressful disorganization and successful defense respectively. The phases demonstrated here, and the events that delineate them, suggest an analogous formulation. The content areas that disturbed the pattern in this final interview also did so on the initial interview seven months earlier. We anticipate that the discussion of a subject �214 JOSEPH JAFFE that had resulted in disequilibrium, but now no longer does so, may constitute an operational definition of “resolution of an area of conflict.” DISCUSSION AND CONCLUSIONS Diverse and highly personal interpretations of interview data limit the growth of psychiatry as a science. Systematic study of the actual transactions may lead to operational definitions of hitherto subjective phenomena. For example, it is likely that the patterns of verbal diversification presented here constitute part of the subliminal cues to which therapists respond when making clinical judgments of anxiety, affect, etc. Objective investigations of the interview must encompass the behavior of both participants since the events observed are interpersonal processes. Gill, Newman and Redlich (4) define even the initial interview as the “diagnostic evaluation of an interpersonal relationship.” Ruesch (13) has recently stated that “observations made in social situations do not have the characteristics of a scientific procedure in which one aspect is studied in detail while all other variables are held constant.” The method presented here is an attempt to convert these concepts into practical research methodology. It permits a quantitative statement of various clinical phenomena occurring either within single interviews or in the course of therapy. Disturbances of verbal interaction are defined operationally in terms of the configuration of the TTR pattern. Applications to the definition of clinical change and transactions within the interview have been presented. The TTR is only one of many quantifiable aspects of dyadic speech. Pace of interaction, time reference, and relative amounts of participation by doctor and patient are also being measured. Further applications of these techniques are under investigation. REFERENCES (l) Auld, F. 8c Murray, E. J.: Content-Analysis Studies of Psychotherapy. Psychol. Bull., 52:377-395, 1955. (2) Coleman, R.; Greenblatt, M. 8: Solomon, H. C.: Physiological Evidence of Rapport During Psychotherapeutic Interviews. Dis. New. System, 17:2-8, 1956. H.; Hamburg, D. A.; Inwood, E. R.; Salzman, L.; Meyersburg, H. A. 8c Goodrich, G.: A Procedure for the Systematic Analysis of Psychotherapeutic Interviews. Psychiatry, 17:337-345, 1954. (4) Gill, M.; Newman, R. 8c Redlich, F. C.: The Initial Interview in Psychiatric Practice. New York: International Universities Press, 1954. (3) Eldred, S. �COMMUNICATION IN PSYCHIATRIC INTERVIEWS (5) 215 Goldman-Eisler, F.: A Study of Individual Differences and of Interaction in the Behavior of Some Aspects of Language in Interviews. ]. Ment. Sci., 100:177-197, 1954. (6) Gottschalk, L. A.; Gleser, G. C. 8c Hambidge, G.: Verbal Behavior Analysis. A.M.A. Arch. Neural. 63'» Psychiat., 77:300-311, 1957. (7) Grinker, R. R.; Sabshin, M.; Hamburg, D. A.; Board, F. A.; Basowitz, H.; Korchin, S. J.; Persky, H. 8c Chevalier, J. A.; The Use of an AnxietyProducing Interview and Its Meaning to the Subject. A.M.A. Arch. Neural. (5* Psychiat., 77:406-419, 1957. (3) Jaffe, 1.: Language of the Dyad: A Method of Interaction Analysis in (9) (10) (11) (12) (13) (14) Psychiatric Interviews. Psychiatry (in press). Lorenz, M. 8c Cobb, 8.: Language Patterns in Psychotic and Psychoneurotic Subjects. A.M.A. Arch. Neurol. (5. Psychiat., 72:665-673, 1954. Mahl, G. F.: Disturbances and Silences in the Patient’s Speech in Psychotherapy. ]. Abn. é» Soc. Psychol., 53:1-15, 1956. Mandler, G. 8c Kaplan, W. K.: Subjective Evaluation and Re-enforcing Effect of a Verbal Stimulus. Science, 124:582-583, 1956. Mowrer, O. H.; Verbal Behavior in Psychotherapy. In: Psychotherapy: Theory and Research, ed. 0. H. Mowrer. New York: Ronald Press, 1953. Ruesch, 1.: Disturbed Communication. New York: W. W. Norton, 1957. Saslow, G.; Matarozzo, J. D. 8: Guze, S. B.: The Stability of Interaction Chronograph Patterns in Psychiatric Interviews. J. Consult. Psychol., 19: 417-430, 1955. �SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL1 ROBERT L. KAHN, PH.D.,2 MAX POLLACK, PH.D.,3 and MAX FINK, M.D.4 Recent investigations have indicated a relationship between inci— and with to disorder class and type social respect psychiatric dence of mental illness (3, 5, 6, 13, 14), selection and maintenance of treatment (2, 6, 15), and therapeutic outcome (10). The present in of selection the in factors social therapy is with concerned study a voluntary mental hospital. In the studies reported by Hollingshead, Redlich, and their coworkers (3, 5, 6, 13, 15), the population of New Haven was divided into five social classes on the basis of weighted criteria of education, under who residents the Of were residence. of and place occupation freclasses social more were the from those upper psychiatric care, quently treated with psychotherapy, while organic treatment or custodial care was more common among the lower classes. Of the the restricted two to was entirely psychoanalysis psychotherapies, of the determinant the class Social was predominant upper groups. held conthe when was diagnosis selected even of treatment type is that “. found it follows: results . . as their summarize stant. They determedical and psychological does on not depend treatment well. the of as the patient status but position minants alone, on Psychotherapeutic methods are applied in disproportionately high 1 Glen Hillside Hospital, of Psychiatry, Experimental the From Department Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, U. S. Public Health Service. 2Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 4Director, Department of Experimental Psychiatry, Hillside Hospital. 216 �SOCIAL FACTORS IN SELECTING THERAPY 217 degree to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist” (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques and services are available to all patients. This requirement is met at Hillside Hospital. It is a nonprofit, nonsectarian institution for the treatment of voluntary patients with “early and curable mental symptoms” (4), who are admitted regardless of their ability to pay. One of the main criteria for accepting patients is their ”ability to participate profitably in psychotherapy.” Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment with organic therapies available when needed. The average length of hospital stay is six months, although some patients remain for as long as a year. The present investigation is an outgrowth of several years of study of electroshock therapy. In previous work it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose of the present study was to determine whether electroshock patients differ from those receiving other forms of treatment in regard to cultural background, including such factors as education and place of birth, and personality as measured by the California F scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. METHOD Population: The entire inpatient adult population of Hillside Hospital as of March 7, 1957 was studied. This constituted a total of 172 patients, ranging in age from 16 to 68 with a mean of 34.6, and including 58 men and 114 women. Procedure: (1) The population was subdivided into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only.5 5All patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data were included in both groups. In the results this makes a total of 179 subjects. �KAHN—POLLACK—FINK 218 (2) birth. The groups were compared for age, education and place of (3) All patients were tested6 with a ten-item modification of the California F scale suggested by Levinson (9). The F scale is a questionnaire (see Appendix) which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to What extent. The score given for each item ranges from one to seven and the total score range is 10 to 70. The greater the agreement the higher the score obtained. The statements themselves are extreme, uncritical or stereotyped expressions. (4) The population was subdivided in regard to utilization of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing and creative therapy. The latter is a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psycho— logical testing and creative therapy were selected for this study because both require a specific referral from the therapist. RESULTS The data were analyzed as follows: comparison of the treatment groups for age, education, F scale scores, and place of birth; (2) comparison where diagnosis is held constant; (3) significance of length of hospitalization prior to treatment; and (4) comparison between groups referred for adjunctive hospital services. (1) Comparison of Treatment Groups For each of the three treatment groups the means and standard deviations for the F scale scores, age and years of schooling are presented in Table l. The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These difierences were statistically significant for F score and age but failed to reach statistical significance for education. The failure of years of education to differentiate the groups was due, in part, to the fact that the electroshock 1. 6As part of an ongoing study all the EST patients were tested with the F scale prior to treatment. In the case of‘ those patients who were actually on EST on March 7 their pretreatment scores were used in the statistical comparison since it had been found that EST significantly affects the score during treatment. �SOCIAL FACTORS IN SELECTING THERAPY 219 - .550 ammvaom §3« 50m $.32 o ammuuoh mo REE 55 :Eduamo fiwmouom onesm .ummm.50m $32 Afioozw fivwwvm £me 50m -0332 «a fivgvmm $592 fiaéww :25 83m mo .Esnamo 8m: 35 -Gwmuuom Son $52 $55“ fimwvvv $392 $82 “Staggm 088 .vm GMV @8va How mo .Ssflamo 658% 98on H 53H. h mBOBm J/ SK $2; $5: fix: l/i If!!! 3320 6M Gm «0 28> 582 EwEuufih 3 3 g NM 2: 2: OS "~on .qu :53 9: «E MN S 2 :33. 1&3 fill!!! “59$th Qm q: 3 3; n: 3w mum u w? um< x0 :82 Gav: £5 .2: 3w a 3%...“ 3 :oflkfificu Gm 92 3; 2: ::.m m2. :32 E2 28m h 582 3% fine: 2m we”. a5 3 3: mm mo. 8. 32 So. 3 a a so: 8% 385:me 285:? 385:3 t 1 .onoxmmézsmcu £35me 339% @380 532: -onuwmm Saga -935-.me 38% 3&2: 1:. �220 KAHN—POLLACK—FINK group contained many foreign-born patients whose education was difficult to evaluate accurately. When treatment groups were subdivided into number of patients above and below eight years of education, the difference was significant at the .01 level. The insulin and psychotherapy groups did not differ statistically for any of these factors. Both somatic groups had a higher percentage of foreign-born patients than the psychotherapy group, with the electroshock group being highest of all. Among the foreign-born patients, those who came from Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe received psychotherapy alone. Comparison of Treatment Groups in Relation to Diagnosis The diagnostic categories of the patients in this study are com— parable to those reported in previous studies of the hospital popution (12). Of the 172 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and 2 with other diagnoses. As expected, a larger proportion of the depressed patients (52%) received electroshock than did those with other diagnoses. To control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those who received electroshock and those who were given psychotherapy alone. The results are shown in Table 2. While the two groups were comparable for age and education, the electroshock patients had a much higher mean F score, a difference significant at the .02 level of confidence. It is also demonstrated that a significantly higher proportion of the electroshock patients were born in Eastern Europe. 2. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment While the electroshock patients, as a group, have been shown to differ from those receiving insulin or psychotherapy, there were still considerable intragroup differences. To account for some of these differences it was postulated that the same factors involved in selection of treatment were also related to the readiness with which a given patient was referred for electroshock. While most of the patients who received EST were placed on treatment less than three months after admission, about 40 per cent were referred after a period of three to twelve months. In Table 3 the patients are compared according to the period of hospitalization prior to electro3. �SOCIAL FACTORS IN SELECTING THERAPY .830 ax”: $.va vacuum 133$ $2; fihm “225355 «0 583m ainamo 83m «so .033 50m $32 @5th $.ng @8va Z ”REE 208 23$th a; how «0 comumuswm Envy. Mano Sign“ waofium N fig; @E: 23 .vm HEM—NH =32»:qu Qm 3 can: 3: mo $3on 3 2: GNU: a $5 a5 86 a mg umucxuafim Gm mi «NH 3.2; vm< 582 3:“ Gm 32 3* Que: mg £5 fitubum kc a fl: *Nwm 88m goutumwficu h 532 3* non 5N0: Em: a5 8d me. a as 3% 285:? -ofiwmmémm -oauwmm 322: 382: Ha a. 221 �KAHN—POLLACK——FINK 222 fié .850 N a o .83 5.85 $me mo 583m @888 uneasm 8 8me H o m «Eu EuEEush -0332 3 58m $88 $85 $8: 2 5 2 fig $89 $83 mm a : BER 988 How we tetanacfifiwem 8.8 H 8098sz any? «Eu 183 wBBom x0 $2: a m m SMEVN 6mm 559 3 Qm E :82 3 «o 928% 3 ca 5.: 8.8 8 88 :2 8.8 :82 .85 cm: Sn a; fill!!! Mfifikouuvx Gm 8.2 25.36% 98 8.2 a :4 :88 gm :82 .85 83. $4: 8...: a 8.8 :8.“ :2 %< 8.8 582 8% :3 Ram 88 Qm Q: w: mm; 38m :ofltificu BE :52 :8 rm :32 Sim -mNzflmmmom “cued—88H. 622.: aa dawned .88 :05 8.8 a; 9 mo E« $va .88 m m .85 $8 288 EMS“ 2c m 52: o 3 :82 88 who: 8 $04 a; 2.2 8 288 .88 8 8 m 8. S. 8. m 52: 80A .89: 5:: 988 885.85 88:88.,” Gmflu .888 c 8 m UHOE .888 a.“ I �SOCIAL FACTORS IN SELECTING THERAPY 223 shock. Patients who had higher F scores and were older were treated earlier than the younger and lower F scale groups. Place of birth is also a significant factor. While 44 per cent of those treated within three months were foreign-born, all patients referred after a period of six months were born in the U. S. The data on education just fails of significance, although 28 per cent of those treated earlier had less than eight years of education. 4. Use of Adjunctz've Hospital Sewices Comparison of the patients referred for creative therapy and psychological testing is shown in Table 4. It is clear that those referred for either of these procedures had significantly lower F scores, were younger in age, had more education and more were nativeborn than patients who were not referred for these services. DISCUSSION The results indicate that the factors of education, age, place of birth, and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients who were younger, better educated, native-born and had lower F scores. Such patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated and foreign-born, particularly in Eastern Europe, were most likely to be referred for EST. These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich, and their co-workers (3, 5, 6, l3, 15) who demonstrated that social factors are related to the type of therapy received in a community. The present study demonstrates that such factors are also significant in a hospital setting where ability to pay is not a criterion of therapeutic selection and where all forms of therapy are equally available to the entire population. With financial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations be conmay sidered. The social factors may relate directly to the empirically established criteria for choice of therapy. On this basis a patient is �KAHN—POLLACK—FIN K 224 550 .35an «REE $5; $5.: @2va $5: 153$ $3: Axwwvwa $.8va @583 $.me @me $3 5me «0 532%.“ vacasm fiw: fivfivmw H awwuamu «Eu 82m 323.5 -0332 3:3 1E3 Eom a wumtuh EOE $38 kg How «0 N £038st *Nmenamo man“; ~e£m£o£uaam «Eu . 33:5 ARR“: waofium fiéw fiévfi u8 w. 8.9.5wa it’ll; .wm 539 if} 3. m.» Qm a.» a 8N ***h.w mm: mo 28> 2: 3: :82 wfi w: :82 a5 A: AWN 233::va .8“ Qm 2: 3: «.2 :82 EN 3m Sun «.2 a mg :52 .Em ***©N.m fwawowé om< wmtukum 0.“. fioa Scwtek it$©m6 Gm kc 2: QB inomfi H as 2: :32 :32 28m h :82 982 3w 5.3 soy 32V 3.» iv 55 m.w mg: A5 s. so. a a a 23.23%:80 O>UNQHU mo. :52 Esme? 385:? $3389 385:? Aonuwmm 3:80 .rH.U 03330 322? 3225 Oz Jonowmm .Hoaowmm and. oz -Hd OZ * oZ i I; �SOCIAL FACTORS IN SELECTING THERAPY 225 referred for electroshock because he is older, poorly educated or foreign-born, clinical experience having shown that such persons respond best to this type of treatment. This explanation is inadequate since half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communication. Thus, a patient is not referred for electroshock because he is foreign-born or poorly educated, but rather these factors provide the difference in cultural background between patient and therapist which makes successful communication less likely in the psychotherapeutic relationship. Robinson et al. (15), in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic relationship. In the present study, similarly, the patients who received psychotherapy alone were more like the therapists with regard to the factors studied.7 Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have shown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are likely to receive electroshock (7, 8). Such language patterns appear to be more frequent in persons with poorer sociocultural backgrounds. Social and cultural factors, in addition to their effect on com— munication patterns, may also determine the manifest symptomatology. Opler (11) has noted that, among patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank et al. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those who remained had ideational symptoms. In a study of personality The therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen per cent were born in Eastern Europe. Their mean years of education was 7 20. 18 over �KAHN—POLLACK—FINK 226 factors in electroshock patients (8) we have noted that certain patterns of symbolic value and communication were more likely to be associated with the development of a depressive psychosis. The relationship between communication pattern and symptoms indicates that symptoms themselves are a mode of communication. The F scale furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethnocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. In the present study the F scale was the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. lowthat indicate in from observations study a progress Preliminary scorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing their social differences, by matching them more closely for age and place of birth. Of possible greater importance is the necessity for developing new modes of communication when treating conventional psychotherapeutic apwho to refractory are patients proaches. While epidemiological studies have clearly structured some of the indicated have and of selection in involved treatment, problems the direction of further study, it still remains for more processoriented research to provide definitive answers. / SUMMARY In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of and of birth, education, place available, age, were equally therapy score on the California F scale were significantly related to the type of therapy received and to the utilization of adjunctive hospital 1. services. Patients who were older, poorly educated, had higher F scores and were foreign-born, particularly in Eastern Europe, were most likely to be referred for electroshock. Psychotherapy was the treat2. �held constant. 4. Among the electroshock patients the same factors found to be significant in choice of therapy were also related to the readiness with which a patient was referred for electroshock. 5. It is postulated that treatment selection is the result of the communicative interaction between patient and therapist. Social factors may be important in so far as they are related to different modes of communication. APPENDIX F SCALE FORM Below are a number of statements. For each statement we want you to give us your personal opinion of whether disyou or agree agree. Answer each statement accordi ng to one of the following: I AGREE A LITTLE I DISAGREE A LITTLE I AGREE PRETTY MUCH I DISAGREE PRETTY MUCH I AGREE VERY MUCH I DISAGREE VERY MUCH I. No sane, normal, decent close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and wor k more, everybody would be better off. pe and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. 8. The best teacher or boss is the one wh 0 tells us exactly what is to be done and how to go about it. 9. Young people sometimes up they ought to get over them and settle down �KAHN—POLLACK—FINK 228 weak the classes: distinct into divided two be 10. People can and the strong. REFERENCES 8c Sanford, R. N.: D. Levinson, J. E.; Frenkel-Brunswik, (1) Adorno, T. W.; 8: Brothers, 1950. York: New Harper The Authoritarian Personality. St: Stone, A. R.: E. H. S. Nash, D.; L. Imber, H.; (2) Frank, J. D.; Gliedman, (33» 77: Neurol. Arch. Psychiat., A.M.A. Leave Psychotherapy. Why Patients 283-299, 1957. (3) Freedman, L. Z. 8c Hollingshead, A. B.: Neurosis and Social Class. Am. ]. Psychiat, [13:769-775, (4) (5) (5) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) 1957. Hillside Hospital: 29th Annual Report, 1956. 8c Redlich, F. C.: Schizophrenia and Social Structure. A. B. Hollingshead, Am. ]. Psychiat., 110:695-701, 1954. Disorders. Class and Social Psychiatric 8: C.: F. A. B. Redlich, Hollingshead, Disand Psychiatric Environment Social the Between In: Interrelations orders. New York: Milbank Memorial Fund, pp. 195-208, 1954. Kahn, R. L. 8c Fink, M.: Changes in Language During Electroshock Therapy. 8c J. Zubin. New York: P. Hoch ed. Communication, In: Psychopathology of Grune 8c Stratton, 1957. to Behavioral in 8c Response Factors M.: Personality L. Fink, R. Kahn, Electroshock Therapy. Conf. Neurol. (in press). Levinson, D. J.: Personal Communication. 8c Johnson, N. A.: Failures in Psychiatry: The Chronic HosC. N. Morgan, 1957. 113:824-830, Am. Patient. ]. Psychiat, pital 197:103—110, American, Scientific Culture. and K.: M. Schizophrenia Opler, 1957. 8: Rachlin, L.: A. Lurie, M.; Gurvitz, G. S.; Goldman, Rachlin, H. L.; 1950. in Hillside from Hospital 317 Patients Discharged of Follow-up Study This Journal, 5:17-40, 1956. Redlich, F. C.; Hollingshead, A. B.; Roberts, B. H.; Robinson, H. A.; Disorders. and 8: Social K.: Structure Psychiatric Z. L. J. Meyers, Freedman, Am. J. Psychiat., 109:729-734, 1953. Rennie, T. A. C.; Srole, L.; Opler, M. K. 8: Langner, T. 8.: Urban Life and Mental Health. Am. J. Psychiat., 113:831-837, 1957. Robinson, H. A.; Redlich, F. C. 8c Myers, J. K.: Social Structure and Psychiatric Treatment. Am. ]. Orthopsychiat., 242307-316, 1954. Titus, H. E. 8: Hollander, E. P.: The California F Scale in Psychological Research: 1950-1955. Psychol. Bull., 54:47-64, 1957. In: Verbal in Factor Therapy. Ethnocentrism as Limiting a R.: R. Tougas, 8c R. F. Dymond. C. ed. R. Rogers and Change, Personality Psychotherapy 1954. 196-214, Press, of Chicago pp. University Chicago: Creative of Utilization 8c and E.: Therapeutic Structure E. Zierer, Zierer, Activity. Am. ]. Psychother., 10:481-519, 1956. �SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN EEG RESPONSE TO ELECTROSHOCK1 MARTIN A. GREEN, MD.2 The assumption is often tacitly made in studies of nervous system function that the capacity for neurophysiological change is similar for animals or humans in the groups under study. Differ- ences in response are ascribed to different parameters of the stimulus or to differences in the location and extent of lesions, either spontaneous or experimentally produced. Such an assumption may not be warranted, however. Perhaps another factor in the variability of response under these conditions is an individual variability in neurophysiological reactivity or responsiveness. The initial “base line” may not be similar in all individuals. The possibility of different inherent patterns of reactivity has been suggested by the studies of the alterations in the EEG during electroshock. We have been impressed by the high degree of variability in such alterations both in their quantitative and qualitative aspects. Although this variability has been described by previous investigators, it has not been stressed sufficiently; nor have possible explanations been advanced or systematically investigated. The present report concerns a description of the changes in the EEG during electroshock in the Hillside Hospital material. The concept of neurophysiological reactivity is presented and studies that may clarify this problem are suggested. MATERIAL AND METHODS Eighty-nine patients who received electroshock for psychiatric illness were studied. The patients were voluntary admissions to 1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. 2Assistant in Neurophysiology, Department of Experimental Psychiatry, Hillside Hospital. 229 �230 MARTIN A. GREEN Hillside Hospital and the majority had not received electroshock previously. The diagnostic groups included psychotic depression, manic-depressive psychosis and schizophrenia. The largest group was patients with depression. Ages ranged from 20 to 68 years with a median of 47 years. Treatments were given three times weekly, each patient receiving at least twelve treatments. The Medcraft instrument (alternating current) was used for twenty-eight patients and the Reiter instrument (unidirectional current) for sixty-one patients. Electro— encephalograms were taken prior to, at weekly intervals during, and two weeks following the course of treatment. Patients Whose pretreatment EEG was abnormal were specifically excluded from study. Tracings were done on a nontreatment day (from 24 to 36 hours following the previous treatment) with an eight channel Medcraft machine using needle electrodes. Frontal, motor, parietal, occipital, anterior temporal, posterior temporal, vertex and earlobe placements were employed with scalp to scalp and scalp to earlobe combinations. RESULTS Delta Activity A. Quantitative Difierences: The delta activity was analyzed according to the method described by Fink and Kahn (7). The duration of burst activity, the lowest frequency, the average delta index in several leads, the highest amplitude, and the highest per cent time delta in one lead were measured. Records were classified as showing a low, middle or high degree of delta activity (Fig. 1) according to criteria previously described (7). All patients developed delta activity during the course of twelve treatments, but differences in the amount of the slow activity and its rate of development were very apparent (Table I). Some patients developed “high delta activity” early in treatment, whereas other patients showed only “low” or “middle” changes even after twelve treatments. These latter patients were followed further with serial EEGs. As treatment was continued, a high degree of delta activity did not develop in some of these patients until twenty or more treatments, or until treatments were given on a daily basis. They were resistant to neurophysiologic change. This individual variability in EEG response was independent of the type of electroshock current employed, being present both with alternating and with unidirectional current applications. 1. �INDIVIDUAL VARIABILITY IN EEG UPON ECT 231 WWW WWW WWW’VW’WW WWW WWW WWW "WWW WWW-«MW WWW WWW LF-LO RF-RO .,, LC-LMT RC-RMT RP-E LAT-LPT WWWWWWWVW ”W ISECOND RAT-RPT PRE- ELECTROSHOCK FIGURE la 24 HOURS AFTER EST 150 W 4%: l2 Degree of Delta Activity—Low From Fink and Kahn (7) Qualitative Diflerences: Although the total amount of delta activity may be similar, records differ as to type, frequency and voltage of delta activity. One prominent qualitative difference is the ratio of irregular delta activity to bursts of slow activity. Nearly all B. W WW LF‘ LO WWWMWMWW LC-LMT R C -R MT L P-E RmANWMMW-E LAT- LPT ' WNW/“WWW WWW/MW Ison "WWW WWW WWIMMMMMMWNVWMMWWMMMMMHM £59932. RAT-RPT PRE-ELECTROSHOCK FIGURE 1b 24 HOURS AFTER EST #10 Degree of Delta Activity—Middle From Fink and Kuhn (7) �MARTIN A. GREEN W W W mm 232 LWW WWW «WWW - L MT T ELEM“ Mwmwwaw MR LP'E RP-E ”WWW “H” WWW lSECOND RAT- RPT' PRE-ELECTROSHOCK 24 FIGURE 1c {5,on HOURS AFTER EST =11:” Degree of Delta Activity—High From Fink and Kuhn (7) records show burst activity during a course of twelve treatments. In some patients the initial delta change is in the form of bursts which become more frequent, slower and of higher voltage as treatments are continued. The irregular delta activity in such records is much less prominent and usually occurs at faster frequencies. In other patients the reverse occurs. Delta activity appears chiefly in an irregular and scattered form. Although burst activity is also present, it is not conspicuous. In a third group of patients the amounts of irregular delta activity and bursts are approximately equal (Fig. 2). These differences in the form that the delta activity assumes are usually constant during the course of treatment. At times, TABLE I Degree of Delta Activity in Serial Electroencephalograms during Electroshock (2-4 records were taken for each patient) No. of Records in Each Treatment Period EEG Activity No change Low delta activity Middle delta activity High delta activity EST 1-3 4-6 7-9 10-12 5 l 1 37 0 21 7 20 28 22 45 10 25 16 3 1 �INDIVIDUAL VARIABILITY IN EEG UPON ECT 233 however, burst activity will become more prominent than the irregular delta only during the latter part of the course of treatment; or burst activity which appears prominent early in treatment may be overshadowed and obscured in later records by a large amount of continuous irregular delta activity. WWWW A HH I486 WWW AT‘VERTEX R 5 HH F-VERTEX 1392 WWWNWWVWWW R WWWWWWWWW ‘3 HH l599 AWWWWWWWMMMMWNWWW D HH 50 mv. I572 |____ SEC. l FIGURE 2 Qualitative Changes in Delta Activity A—Irregular Delta C—Rhythmic Runs B—Delta Bursts D—Asymmetry The slow activity is maximal at the anterior temporal and frontal electrodes and less pronounced at the more posterior electrodes. Often it is asymmetric, being of higher voltage, slower, and in greater amounts at the left anterior temporal and frontal electrodes as compared to the right (Fig. 2). Only rarely is the reverse true, i.e., accentuation on the right side. This asymmetry occurs during treatment both with alternating and with unidirectional currents. Another type of abnormality is the appearance of rhythmic runs of delta activity which may continue for 10 to 20 seconds (Fig. 2). �MARTIN A. GREEN 234 The regularity of the frequency and voltage of the slow waves in these runs is very striking. These runs are usually infrequent, but may be the most prominent alteration in the record. In many records the amount of delta activity fluctuates during the tracing. At times, some portions of a record may appear nearly normal, while in other parts of the same record the delta activity may be quite pronounced. This variation is independent of the electrode combinations employed. or Spike-Wave Activity A large number of records show single spike activity of low, moderate or high voltage. Most often such spikes are slower and not as prominent as those present in patients with seizure disorders. A small number of records show spike—wave activity. This is usually at irregular, mixed frequencies and, again, does not resemble the regular rhythmic bursts commonly seen in patients with seizure disorders (Fig. 3). 2. Spike 3. A lpha Activity The alpha activity shows changes both in amount and frequency. As the amount of delta activity increases the amount of alpha activity usually decreases. Changes in frequency occur but are not proHH A F I40! a ~wvv~uu~vv*1qJJWV’V‘r 0 W “H 3‘ WWW AT-VERTEX TO EARLOBES AT VERTEX '5“ P-EARLOB ”PT 50 mv.| I SEC. FIGURE 3 Spike and Spike-wave Activity �INDIVIDUAL VARIABILITY IN EEG UPON ECT 235 nounced. The frequency will be slowed by 1-2 cps but at times will remain the same as in the preelectroshock tracing. In a small number of patients the amount and voltage of alpha activity increases during treatment. This change persists during the posttreatment period after the slow-wave activity subsides (Fig. 4). F-O HHI484 L R WW PRE-EST HH |597 WWW’WWWWWMMWWWWMAMWMWW L F-O 2 wxs. POST-EST FIGURE 4 50 mv.|_ l SEC. Change in Alpha Activity Beta Activity The fact that many sedatives, particularly barbiturates, induce fast activity in the EEG and the difficulty in controlling the administration of these drugs in the population studied makes it difficult to evaluate changes during the course of treatment. In most instances changes in fast activity are minimal. The most frequent change, when present, is a decrease in the activity. 4. DISCUSSION The problem being raised is that of the individual variability in the type and degree of EEG alteration during electroshock therapy. AS described, this is manifested in: (1) the amount of slowwave activity and its rate of development; (2) qualitative differences in the slow-wave activity (amount of burst activity vs. irregular delta activity, symmetry, fluctuating appearance of slow activity, runs of rhythmic Slow activity); (3) presence of Spike or spike-wave activity; and (4) changes in alpha and beta activity. Previous investigations (2, 4, 5, 10, ll, l2, l4, 17, 18, 19, 20, 25) have stressed possible correlations with age, sex, frequency of treatment, type of current employed, psychiatric diagnosis, and clinical �236 MARTIN A. GREEN change. Increasing the frequency of treatment, for example, will increase the degree of alteration in the EEG. However, when patients of similar sex, age and psychiatric diagnosis are given treatments at the same frequency with the same type of electroshock current, variability in the rate of development of changes in the EEG and their type and degree are still very prominent. One explanation for this variability might be the distribution of the electroshock current in the brain. Perhaps minor differences in the resistance of the skull, in the distribution of blood vessels and their permeability or in the arrangement of nerve tracts create differences in the pathways taken by the current. Under such circumstances, different portions of the brain may receive more or less current in one patient as compared to another. Differences in the type of electrical activity generated by these variously affected areas might account for variability in the EEG. Available studies employing direct intracerebral measurements indicate considerable diffusion of current throughout the brain (6, 9, 16, 21). However, a concentration of current anteriorly and along large neuronal pathways, such as the corpus callosum, has been demonstrated. No further information is available as to amounts of current received by more specific cerebral areas. Due to the high resistance of the skull only a small portion of the applied current actually reaches the brain. The amount of current entering different portions of the brain is said to be determined by the resistance of the skull overlying these areas, the anterior concentration of current being the result‘of the thinness of the temporal bone with its consequent lower resistance as compared to other parts of the skull (9, 21). Several considerations, however, indicate that individual differences in these factors of resistance and amount of current reaching different areas of the brain are of minor, if any, importance in the EEG response during electroshock. It is the occurrence of the generalized seizure per se, rather than the passage of electricity, which is the primary factor. During a course of grand mal therapy induced by nonelectrical means such as metrazol, EEG changes occur which are similar, in general, to those seen with electroshock (13, 14). Diffuse slow-wave activity, accentuated anteriorly, and spike or spike-wave activity are described. The amount of slow-wave activity increases during treatment'but shows individual variability unrelated to the number of treatments. Another observation is that electroshock therapy which induces petit mal (8, 18) or focal (3) seizures rather than grand mal does not produce the characteristic �INDIVIDUAL VARIABILITY IN EEG UPON ECT 237 build-up of slow-wave activity. In addition, there is no increase in the degree of delta activity in our patients in whom mal grand therapy is given with high suprathreshold stimuli as compared to those in whom threshold stimuli are used. Factors of current cannot be entirely dismissed, however. Even with grand mal therapy, the type of current employed may influence the EEG change. We have confirmed a previous study (20) showing that the rate of increase of delta activity is slower in therapy with unidirectional current than in that with alternating current. Similarly, brief stimulus therapy is said to produce smaller degrees of alteration in the EEG as compared to alternating current therapy (15). The other theory to be considered in explaining the variability in EEG responsiveness, and the one which is probably more decisive, involves inherent differences in neurophysiological reactivity. By this is meant both the quantitative and qualitative aspects of the inherent capacity of the nervous system to respond to stimuli or injury. Not only the degree of response, but also the type of response, may have these determinants. The type and degree of EEG abnormalities developed during electroshock therapy to be appear the reflection of such inherent individual differences in neurophysiological reactivity. Several types of investigation may serve to test this hypothesis. Methods other than electroshock known to produce EEG alterations could be applied prior to treatment. These might include lowering the blood sugar by parenteral insulin, intravenous administration of convulsants such as metrazol or Megimide, photic stimulation, or the intravenous administration of drugs such as barbiturate. In addition, perhaps the actual electroshock seizure threshold or the pattern or severity of the seizures may be a measure of nervous system responsiveness. Data from such investigations could be correlated with the degree and types of EEG change during electroshock. In this manner it might be possible to demonstrate different patterns of neurophysiological reactivity and to classify individuals accord- ingly. Such studies may not only help in understanding the variability in the EEG alterations during electroshock but would have wider application to other problems in clinical electroencephalography and neurology. For example, the basis for the development of spontaneous seizures secondary to traumatic, vascular, or neoplastic lesions of the nervous system is not known. Patients with lesions �238 MARTIN A. GREEN comparable in type, size and location may or may not develop seizures. As previously described, some subjects show spike or spikewave activity during electroshock. This suggests an inherent difference in the capacity to develop clinical seizures or EEG seizure activity following “injury” to the nervous system, whether the injury is spontaneous or induced. Differences in this capacity may be reflected in varying patterns of neurophysiological reactivity. Differences in neurophysiological reactivity may also be manifested in the pretreatment EEG. Patients in whom the pretreatment record is abnormal (ll), “instabile” (22), or shows a predominant alpha rhythm (5) are said to develop the greatest alteration in the EEG during electroshock. Other investigators have not confirmed these observations (2, 23). Actually, such correlations depend on the method of analysis of the pretreatment record employed and the criteria used for “abnormality.” Further investigation of this relationship is necessary. Suggesting that neurophysiological reactivity is an inherent process does not imply that a physiological basis does not exist or cannot be investigated. This may reside in the central nervous system itself, consisting of individual differences in neurochemical systems or in the permeability of cells or blood vessels; or it may be outside the nervous system. Individual differences in hormonal or other humoral substances produced during the stress of electroshock may serve to “sensitize” or “desensitize” the cerebrum with regard to developing different amounts and types of electrical activity. That such factors may be operative is suggested by the following studies. Trypan red injected intraperitoneally in cats before a course of electroshock decreased the permeability of the blood-brain barrier and reduced the degree of EEG changes as compared to control animals (1). Atropine and scopolamine administered during a course of electroshock in man blocked the development of the usual slow-wave activity (24). Electroshock therapy affords an excellent opportunity for the experimental investigation of the problem of an inherent neurophysiological reactivity. One is able to apply studies directly to man rather than animals. The stimulus to the central nervous system can be standardized and the degree of neurophysiological change controlled, within limits, by changing different parameters. Tests of EEG responsivity can be given before such changes are induced as well as during and after treatment. Restudy of patients is often possible when subsequent courses of treatment are necessary. I ‘ �INDIVIDUAL VARIABILITY IN EEG UPON ECT 239 SUMMARY Individual differences, both quantitative and qualitative, in the EEG changes during a course of electroshock treatment in eighty-nine patients are described. 2. These differences are pronounced and are not explainable by age, sex, type of shock current, frequency of treatment, psychiatric diagnosis, or clinical change. 3. An inherent capacity for neurophysiological change that has both quantitative and qualitative aspects may be the primary determinant of these differences. 4. Variation in skull resistance and in the amount of current reaching the brain appear to be minor factors. 5. Investigations that might serve to test the hypothesis presented are described. Such studies may lead eventually to a classification of individuals as to different patterns of neurophysiological reactivity and clarify other problems in clinical neurology and electroencephalography. 1. REFERENCES Aird, R. B.; Strait, L. A.; Pace, J. W.; Hrenoff, M. K. 8: Bowditch, S. C.: Current Pathway and Neurophysiological Effects of Electrically Induced Convulsions. J. Nerv. (‘5' Ment. Dis., 123:505-512, 1956. (2) Bagchi, B. K.; Howell, R. W. 8: Schmale, H. T.: The Electroencephalographic and Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders. Am. ]. Psychiat, 102:49-61, 1945. (3) Bergman, P. S.; Impastato, D. J.; Berg, S. 8c Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Focal Seizures. Conf. Neurol., 13:271-277, 1953. (4) Callaway, E. 8c Boucher, F.: Slow Wave Phenomena in Intensive Electroshock. EEG. Clin. Neurophysiol., 2:157-162, 1950. (5) Chusid, J. G. 8c Pacella, B. L.: The Electroencephalogram in Electric Shock Therapies. ]. Nerv. €7- Ment. Dis., 116:95-107, 1952. (6) Delgado, J. M. R.; Alexander, L..& Hamlin, H.: Effects of Electroshock on the Cortical and Intracerebral Electroactivity of the Brain in Schizophrenic Patients. Conf. Neurol., 13:287-294, 1953. (7) Fink, M. Sc Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Re» spouse in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neurol. (‘3‘Psychiat., 78:516—525, 1957. (8) Fink, M.; Kahn, R. L. 8c Green, M. A.: Experimental Studies of the Electroshock Process. J. Nerv. &- Ment. Dis. (in press). (9) Hayes, K. J.: The Current Path in Electric Convulsion Shock. Arch. Neurol. é} Psychiat., 63:102-109, 1950. (10) Hoagland, H.; Malamud, W.; Kaufman, I. C. 8c Pincus, 0.: Changes in the Electroencephalogram and in the Excretion of 17-Ketosteroids AccompanyElectroshock ing Therapy of Agitated Depression. Psychosom. Med., 8:246251, 1946. (1) �MARTIN A. GREEN 240 Willner, M. D.: Significance of Changes in the Electroencephalogram Which Results from Shock Therapy. Am. ]. Psychiat., 105: (11) Kennard, M. A. 8: 40-45, 1948. ' (12) Klotz, M.: Serial Changes Due to Electrotherapy. Dis. Nerv. Sys., 16:120-122, 1955. (13) Knott, G. R.; Gottlieb, J. S.; Leet, H. H. 8c Hadley, H. D., Jr.: Changes in the Electroencephalogram Following Metrazol Shock Therapy: A Quantitative Study. Arch. Neural. (5" Psychiat., 50:529-534, 1943. (14) Levy, N. A.; Serota, H. M. Sc Grinker, R. R.: Disturbance in Brain Function Following Convulsive Shock Therapy. Arch. Neurol. 1027, 1942. (‘5' Psychiatu 47:1009- (15) Liberson, W. T.: Current Evaluation of Electric Convulsive Therapy. Res. Publ. Ass. Nerv. Ment. Dis., 31:199-231, 1951. (16) Lorimer, F. M.: Sega], M. M. Sc Stein, S. A.: Path of Current Distribution in Brain During Electroconvulsive Therapy. EEG. Clin. Neurophysiol., 1: 343-348, 1949. (17) Moriarity, J. D. 8c Siemens, J. C.: Electroencephalographic Study of Electric Shock Therapy. Arch. Neurol. é» Psychiat., 57:712—718, 1947. (18) Pacella, B. L.; Barrera, S. W. 8c Kali'nowsky, L.: Variations in the Electro- encephalogram Associated with Electric Shock Therapy of Patients with Mental Disorders. Arch. Neural. E} Psychiat., 47 :367-384, 1942. (19) Proctor, L. D. 8c Goodwin, J. E.: Clinical and Electra-physiological Observations Following Electroshock. Am. J. Psychiat., 101 :707-800, 1945. (20) Proctor, L. D. 8: Goodwin, J. E.: Comparative Electroencephalographic Observations Following Electroshock Therapy Using Raw 60 Cycle Alternating and Unidirectional Fluctuating Current. Am. ]. Psychiat., 99:525530, 1943. Wegener, C. F .: On Electric Convulsive Therapy with Particular Regard to a Parietal Application of Electrodes Controlled by Intracerebral Voltage Measurements. Acta Psychiat. et Neural, 19:529-549, 1944. (22) Sulzbach, W.; Tillotson, K. J.; Guillemin, V., Jr. 8: Sutherland, G. F.: A Consideration of Some Experience with Electric Shock Treatment in Mental Diseases, with Special Regard to Various Psychosomatic Phenomena and to Certain Electra-technical Factors. Am. J. Psychiat., 99:519-524, 1943. (23) Taylor, R. M. Sc Pacella, B. L.: The Significance of Abnormal Electroencephalograms Prior to Electroconvulsive Therapy. J. Nerv. (S; Ment. Dis., (21) Smith, J. W. 8c 107:220—227, 1948. - Johnson, M. W.: Effect of Atropine and Scopolamine Upon Electroencephalographic Changes Induced by Electro-convulsive Therapy. (24) Ulett, G. A. 8c EEG. Clin. Neurophysiol, 9:217-224, 1957. (25) Weil, A. A. 8c Brinegar, W. C.: Electroencephalographic Studies Following Electric Shock Therapy. Arch. Neural. é" Psychiat., 57 2719-729, 1947. �ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI1 HYMAN KORIN, PH.D.2 and MAX FINK, M.D.3 In the course of extensive investigations (1, 2, 3) into the perception of multiple simultaneous stimuli, the pattern of failure of subjects accurately to report one of two stimuli led to a concept of an “order of dominance” in cutaneous perception. Since then, the relationship of the observed pattern of dominance to biologic and psychiatric concepts of body image and body scheme has been the subject of considerable speculation (4, 7, 8, 14). The interrelationship of body areas was initially clearly demonstrated in simultaneous tactile tests of face and hand (2), in which it was noted that the stimuli to the hand were frequently not reported or mislocalized. These phenomena of “extinction” and “displacement” led to the inference that cheek area stimuli were “dominant” to hand stimuli. In subsequent reports (3, 10, ll, 12) a pattern of dominance for tactile stimuli was described in which the face and the primary genital areas were the most perceptive or dominant areas; the hand was the least dominant; and the shoulder, foot, buttock, breast, back, thigh and abdomen fell between these extremes in a mild gradient. These observations were made in normal adults and children and psychiatric patients, but were most clearly discerned in patients with brain disease. Indeed, the major portion of the data relates to a group of patients with severe diffuse brain dysfunction under observation in a general psychiatric hospital. 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. 2Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3 Director, Department of Experimental Psychiatry, Hillside Hospital. 241 �242 KORIN—FINK The basis for these phenomena is unclear. In a review of the problem (3) consideration was given to hypotheses ascribing significance to anatomic, psychophysical, genetic, environmental and neurophysiologic factors. In their conclusions, Bender, Green and Fink note that “no one theory adequately explains the organization of this pattern. Learning and maturation are probably factors, but it appears to be mostly inherent.” In studies of patients with brain disease and normal young children, Cohn (4, 5) emphasized the rostral order of dominance and ascribed significance to “an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain.” He also noted specifically that this pattern was primarily associated with “the over-all sentient function of the brain.” A more extensive elaboration of a maturational and developmental explanation of the order of dominance has been proposed (14). Taking the infantile patterns of sutking and feeding as a model, Linn ascribes dominance to the face as it is the oldest element in the body image; the dominant role of the genital area to the intensity of pleasurable sensation that the infant elicits from masturbation; and the subordinate position of the hand to its role as an exploring and tension-relieving appendage wherein it holds second place in awareness to its stimulation of the more exciting mouth and genitalia. A neurophysiologic View was advanced by Critchley (6, 7), who, after expressing a preference for the term “tactile inattention” instead of “extinction,” emphasized the rostral order of dominance. He stated that “strong stimulation of the healthy side suppresses the attenuated sensations on the impaired side,” and concluded that “tactile inattention in parietal patients is probably no more than an instance of local neglect or disregard, which may be demonstrated at times in many other spheres of consciousness besides the tactile—whether motor, visual or spatial.” A psychophysical explanation was eschewed by Bender, Fink and Green (3, 10, 11), who found no relation between the order of dominance and the tactile threshold for touch or pin prick. DennyBrown, Meyer and Horenstein (8), however, insisted that these patterns were only apparent when there was an alteration or loss of twopoint discrimination. They further demonstrated that the extinction of the hand stimulus by a stimulus to the leg could be overcome by four stimuli to the hand. The dominance of the cheek to the hand could not, however, be altered by ten stimuli to the hand in their subject. �STIMULUS INTENSITY IN PERCEPTION 243 The following data further emphasize psychophysical factors in perception under the conditions of multiple simultaneous stimulation. These studies represent the initial report of an investigation into the application of simultaneous tactile stimulation tests to the problem of measurement of the alteration in brain function induced by electroshock therapy. In the course of this study electrical stimuli were applied to the cheek and hand of psychiatric patients. Stimuli were either at threshold or suprathreshold levels. Two aspects of the data are presented: (a) the effect of alteration of relative strength of stimulus in the order of dominance on facehand tests; and (b) relation of perceptual thresholds to the order of dominance. SUBJECTS AND METHOD The subjects were thirty-four consecutive psychiatric patients referred for electroshock therapy. The range of their ages was between 21 and 65 and the mean age was 45. Eleven patients were diagnosed as involutional melancholia, thirteen as manic-depressive, depressed, eight as schizophrenia, and two as psychoneurosis mixed type. All testing was done prior to a course of electroshock therapy and no patient had clinical or EEG evidence of altered brain function. Each patient was tested in one session for the purposes of this report. Two model S-4B Grass square wave stimulators were synchronized to deliver either single or two simultaneous electrical stimuli. An isolation unit was connected to each stimulator to eliminate artifacts and the output was monitored visually by an oscilloscope. A switch box inserted in the circuit permitted independent selection of the various body parts. An active and an indifferent electrode, required for each body part, were small 5%; inch steel discs placed 1 inch apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. The electrodes remained affixed to the selected body parts throughout the period of testing. The patient was placed on a couch in a relaxed and supine position. To alleviate undue anxiety the nature of the testing was described. It was emphasized that only a slight tap-like sensation would be felt. The electrodes were then placed on (1) the dorsum of the hands, (2) the mandibular area of both cheeks, and (3) the medial calf area of the legs. In the testing procedure, thresholds for the various body parts were first determined. At a frequency of .3 cycles/second, and a pulse I �244 KORIN—FINK duration of 50 milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, until the subject perceived 100 per cent of the stimuli. Incre1 volt of increments and the 5 hand volts to of were applied ments to the cheeks. After a ten-second interval, the voltage was decreased until sensation disappeared. Following another ten-second interval, the voltage was gradually increased by 1 volt each six seconds until the patient again reported 100 per cent of the stimuli. This reading was considered the minimal voltage required to produce threshold sensation. Such stimuli, at threshold and 10 per cent above the threshold, are reported by the subjects as a “tap,” a “prick” or a “sting.” Complaints of painful perception were not elicited at these levels of stimulation. After the thresholds were determined, testing with a series of single and double simultaneous stimuli followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and left cheek (homologous stimulation). Both in mixed singly, a one stimulated or simultaneously, were part parts order for ten trials for each of the following conditions: (1) threshold, (2) suprathreshold (10 per cent above the threshold), (3) one body part at suprathreshold and the other at threshold, and (4) the reverse of (3). The order of presentation of conditions (1) and (2) was alternated for different subjects and the same was done for conditions (3) and (4). Similarly the order of presentation of the heterologous and homologous stimulation was alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. When this change occurred, stimulation was increased until a new threshold was determined and ten trials were started anew. RESULTS A. Threshold Values The threshold stimulation for perception was determined for the hands, cheeks and legs (Table I). The threshold values for the hands and legs are three to four times higher than the thresholds for the cheeks. While the threshold values in the legs are less than in the hands, these differences lack statistical significance. Variabiland hands the in legs is threshold considerably the of greater ity than in the cheeks. There is virtually no overlapping of thresholds, however, where the cheeks and the hands are concerned. �STIMULUS INTENSITY IN PERCEPTION TABLE 245 I Mean Thresholds and Standard Deviations of Body Parts Mean Thresholds (volts) Standard Deviation Right Cheek Left Cheek Right Hand Left Hand Right Leg Left Leg 6.76 7.85 29.25 22.35 24.50 19.52 4.47 4.86 14.88 13.60 13.99 13.64 Extinction Patterns The difference between the number of extinctions of the right hand or the left cheek on stimulation of both parts with either threshold or suprathreshold stimuli was not significant (Table 11). Also, when both cheeks were stimulated with either threshold or suprathreshold stimuli, there were no differences in the number of extinctions in each cheek (Table III). In contrast to these observations, stimulating one body part with a suprathreshold stimulus and the other at threshold resulted in a significant increase in the failure to report the body part stimulated at threshold. Thus the cheek was dominant over the hand, or the hand was dominant over the cheek depending on the body part to which the stronger stimulus was applied (Table II). Altering the relative strength of the stimuli applied to the cheeks resulted in a similar predictable change in the pattern of dominance (Table III). Further analysis of the data in Table II indicates that the hand B. TABLE 11 Mean Extinctions of Cheek and Hand for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Mean Extinctions Extinctions of Hand of Cheek Hand and Cheek at Threshold Hand and Cheek at Suprathreshold Hand at Suprathreshold and Cheek at Threshold Cheek at Suprathreshold and Hand at Threshold Difference Significance 1.55 1.56 .01 NS. 1.02 .59 .57 NS. 2.30 .22 2.08 p<.01 .32 1.36 1.04 p<.01 �KORIN—FINK 246 was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.04) for the thresholdsuprathreshold condition. This tendency is also evident when both parts were simulated at suprathreshold. If it is considered that the mean threshold for the hands is approximately 30 volts, while for the cheeks the threshold is 7 volts, the difference in incidence of extinction may be explained. Suprathreshold stimulation was set at 10 per cent above the threshold value. The hand stimulus was TABLE 111 Mean Extinctions of Both Cheeks for Varying Conditions of Threshold and Suprathreshold Stimulation Both Cheeks at Threshold Both Cheeks at Mean Extinctions of Left Cheek Mean Extinctions of Right Cheek .39 .45 .06 N.S. Difference Significance Suprathreshold Right Cheek at Suprathreshold and Left Cheek at Threshold .18 .37 .19 N.S. .96 .14 .82 p<.05 Left Cheek at Suprathreshold and Right Cheek at Threshold .03 1.28 1.25 p<.01 therefore increased by 3 volts and the face stimulus by only 1 volt above the threshold value. Such an increase, although proportionately equivalent, appears to have given greater relative strength to the hand stimulus. Extinction Regardless of pattern, the mean total of the number of extinctions was greater when heterologous body parts were stimulated at threshold than when these parts were stimulated with suprathreshold stimuli (Table IV). For these same conditions of stimulation the diflerences between the mean number of extinctions obtained on homologous stimulation of the cheeks lack statistical significance, but the results are in the direction which indicate that a greater number of extinctions occur when two body parts are stimulated at threshold (Table IV). The failure to obtain a. significant difference in the latter instance is partly due to the fact that relatively few C. Incidence of �STIMULUS INTENSITY IN PERCEPTION 247 TABLE IV Mean of Combined Number of Extinctions For Varying Conditions of Threshold and Suprathreshold‘ Stimuli Both Parts at Both Parts at A-Suprathreshold A-Threshold Threshold Suprathreshold B-Threshold B-Suprathreshold A-Cheek 3.11 1.63 1.68 2.43 .85 .56 1.31 1.10 B-Hand A-Left Cheek B—Right Cheek Differences between the mean number of extinctions at threshold and the other three conditions of stimulation are significant for the cheek and hand but are insignificant for both cheeks. * extinctions are elicited when homologous parts are stimulated. These findings on the total number of extinctions are in agreement with previous observations (2). DISCUSSION The pattern of extinction following electrical stimulation of the skin with threshold and suprathreshold stimuli has been determined. In contrast to the findings of investigators (3) who used clinical (tactile) stimulation, the face stimuli were not reported more frequently than the hand Stimuli. Under the conditions of the method of testing in this investigation, nevertheless, it is clear that the pattern of extinction for any two body parts can be readily altered by varying the relative strength of the stimuli. Thus a suprathreshold stimulus applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimulus intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand, in simultaneous tactile testing, is due to an inherent factor, perceived body image, rostral dominance, developmental principle or a learned factor, are not supported by these observations under our conditions of testing. If any of these factors were involved, a pattern of face dominance should have been elicited when the hand and cheeks were stimulated with equivalent electrical stimuli at threshold and suprathreshold intensities, despite the methodological dif- �248 KORIN—FINK ference introduced by the procedure of affixing electrodes to the skin. The findings in this study, namely that differences in the strength of the simultaneous stimuli can alter the pattern of extinction, supports a stimulus-intensity hypothesis. By inference, differences in threshold also play a significant role. That an intense stimulus elsewhere can raise the pain threshold as much as 35 per cent has been demonstrated by Hardy, Wolf and Goodell (13). This effect of a relatively intense stimulus on the threshold of another stimulus has also been found by investigators using other stimuli (8, 9). The problem still remains, however, how it is that a pattern of dominance may be elicited when presumably equivalent stimuli are applied by touch stimuli. The results of this study suggest an explanation. Stimuli of differing intensities are required to elicit a threshold sensation for various body parts. When these stimuli are increased 10 per cent, the resultant stimuli are proportional and are perceived as equivalent. In contrast, in clinically touching two body parts, the stimuli are disproportionate relative to the threshold value although approximately of equal intensity in their application. Because of the differences in threshold for the hand and cheek, the tactile stimulus to the cheek is proportionately more above the threshold than the stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and has been considered “dominant.” A threshold hypothesis was rejected (3) on the basis that the thresholds obtained by von Frey (16) for pressure and pain do not strictly correspond to the dominance order elicited by the double simultaneous stimulation tests. Most difficult to reconcile is von Frey’s finding that the pressure threshold of the glans penis, which is second in dominance rank only to the cheek in a group of ten body parts tested, is 111 grams per square millimeter; while the threshold of the hand, which is at least dominant, is only 12 grams per square millimeter. Unfortunately, thresholds in the genital area for male and female have seldom been determined. Von Frey’s list of thresholds (16) is based on a single subject. His more detailed observations (17), however, indicate that there is virtually no pressure sense in the glans penis or clitoris, although the perception of pain, warmth and cold is well developed. It is quite possible that the punctate pressure threshold does not correlate with touch where the genital area is concerned but that instead some other sense or combination of senses is involved. �STIMULUS INTENSITY IN PERCEPTION 249 Thresholds for the dorsum of the hand and the cheek obtained by von Frey and other investigators indicate that the cheek is considerably more sensitive than the hand. These findings are in agreement with the thresholds obtained in this study. In a recent study of electrical thresholds at various body sites Sigel (15) reported that “leg areas including thigh and ankle, also dorsum of the hands and the palm showed a definite tendency for higher thresholds. Scalp, temple, forehead and face tended to have lower thresholds. The anterior chest and upper arm and anterior wrist areas showed a tendency for lower thresholds. Neck areas, abdomen and upper back showed no definite trend.” In this statement there is no disagreement with the clinically observed order of dominance. From the experimental results obtained here, it is proposed that the dominance hierarchy elicited under the conditions of simultane— ous testing may be explained on the basis of the relative strength of the stimuli and the stimulus threshold. SUMMARY Using square wave electrical stimuli, the threshold for perception in the hands, cheeks and calves were determined in thirtyfour psychiatric patients. Simultaneous stimuli were applied in random sequence to combinations of cheek and hand and both cheeks, at threshold, suprathreshold and combinations of threshold and suprathreshold intensities. With simultaneous threshold, or simultaneous suprathreshold stimulation, the differences between the number of extinctions in either part were not significant. With stimuli of unequal intensity (one stimulus at threshold and one suprathreshold), however, there was a significant increase in the failure to report the threshold stimulus. The total number of extinctions is greater with threshold than with suprathreshold stimuli; and greater in heterologous than in homologous patterns of stimulation. It is concluded that the observed order of dominance in simultaneous cutaneous tests may be explained by psychophysical relationships. REFERENCES (1) Bender, M. B.: Disorders in Perception. Springfield, Ill.: Charles Thomas, (2) Bender, M. B.; Fink, M. 8c Green, M. A.: Patterns in Perception on Simultaneous Tests of Face and Hand. A.M.A. Arch. Neurol. (9 Psychiat., 66: 1952. 355-362, 1951. �250 (3) KORIN—FINK Bender, M. B.; Green, M. A. 8: Fink, M.: Patterns of Perceptual Organization with Simultaneous Stimuli. A.M.A. Arch. Neurol. 67- Psychiat., 72:233-255 , 1954. (4) (5) (5) (7) (8) (9) (10) (11) Cohn, R.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation. J. New. 6» Ment. Dis., 113:471-484, 1951. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: II—A Study in Rostral Dominance in Children. Neurology, 1:119-122, 1951. Critchley, M.: The Parietal Lobes. London: Edward Arnold 8c Co., 1953. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions. Brain, 72:538-561, 1949. Denny-Brown, D.; Meyer, J. S. 8c Horenstein, S.: The Significance of Perceptual Rivalry Resulting from Parietal Lesion. Brain, 75:433-471, 1952. Duncker, K.: Some Preliminary Experiments on the Mutual Influence of Pains. Psychol. Forsch, 21:311-326, 1937. Fink, M. Sc Bender, M. B.: Perception of Simultaneous Tactile Stimuli in Normal Children. Neurology, 3:27-34, 1953. Fink, M.; Green, M. A. 8c Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects. J. Nerv. 69'» Ment. Dis., 117:43-49, 1953. (12) Fink, M.; Green, M. A. (13) (14) (15) (15) Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. Hardy, J. D.; Wolf, H. S. 8c Goodell, H.: Studies on Pain. A New Method for Measuring Pain Threshold: Observations on Spatial Summation of Pain. J. Clin. Invest., 19:649-658, 1940. Linn, L.: Some Developmental Aspects of the Body Image. Int. J. Psychoanal., 36:1—7, 1955. Sigel, H.: Cutaneous Sensory Threshold Stimulation with High Frequency Square-Wave Current: 11. The Relationship of Body Site and Skin Diseases to the Sensory Threshold. J. Invest. Derm., 18:447-451, 1952. von Frey, M.: Beitréige zur Physiologic des Schmerzsinns. Ber. Siichs. Ges. 8c Wiss., 46:185-196, 283-296, 1894. (17) von Frey, M.: Beitrage zur Sinnesphysiologie der Haut. Ber. Siichs. Ges. Wiss., 47: 166-184, 1895. �NEWS AND NOTES DR. MILLER ANNOUNCES APPOINTMENT OF DIRECTOR OF PROFESSIONAL SERVICES Dr. Joseph S. A. Miller, Medical Director of Hillside Hospital, has announced the appointment of Dr. Lewis L. Robbins of Topeka, Kansas as Director of Professional Services at Hillside Hospital, starting July 1, 1958. Dr. Robbins has been connected for many years with the Menninger Foundation, and has held many senior positions at the Foundation, including the Directorship of the Outpatient Depart ment, and up to about a year ago, the Directorship of the Department of Adult Psychiatry. During the past year, he has been Senior Psychiatric Consultant and Chairman of the Psychotherapy Research Project at Menninger’s. Born in Chicago, Dr. Robbins was graduated from the University of Chicago and received his medical training at the Rush Medical School. He interned at the Michael Reese Hospital, Chicago; and had his psychiatric residency training at the latter hospital as well as at the Menninger Sanitarium. He graduated from the Topeka Institute for Psychoanalysis. He is a Diplomate of the American Board of Psychiatry and Neurology and also holds the American Psychiatric Association’s Certificate as a Mental Hospital Administrator. Dr. Robbins has been an instructor in psychiatry at the Washington School of Medicine and a lecturer in psychiatry at the University of Kansas Medical School, the Menninger School of Psychiatry as well as a training analyst at the Topeka Institute for Psychoanalysis. He is a member of numerous national and regional societies, including fellowship in the American College of Physicians, the American Psychiatric Association, American Orthopsychiatric Association, the Group for the Advancement of Psychiatry; and he also holds important offices on the executive and other committees of the American Psychiatric and American Psychoanalytic Associations, and is currently the Secretary of the American Psychoanalytic Association. Hillside welcomes Dr. Robbins to its staff. The position of Directorship of Professional Services will include the general direction of the Hospital’s treatment, teaching, and some of the important research programs of the Hospital. 251 �252 NEWS AND NOTES SPECIAL INSTRUCTION FOR RESIDENTS DURING 1957—1958 We are pleased to announce that we have engaged the teaching services of three prominent psychiatrists and psychoanalysts for the special instruction of our Residents during the 1957-1958 season. These are: (1) Dr. Robert C. Bak, whose course will be on “The Psychopathology of the Psychoses, with Special Reference to the Schizophrenias.” The lectures will be given at the Hospital on Wednesdays from October 1957 through May 1958, from 12:00 to 1:00 P.M. (2)Dr. Paul Goolker, who will be giving the course on “Principles and Practice of Dynamic Psychotherapy for Hospitalized Patients.” This course will be given during the same period on Fridays from 12:00 to 1:00 RM. (3) Dr. I. Peter Glauber will be in charge of the course on “Important Readings in Psychoanalytic Psychiatry.” This will be given at the Hospital on Thursdays from 11:45 A.M. to 12:45 P.M. As has been the custom, these lectures to the total Resident staff will be preceded by three hours of special conferences including group preceptorship of a number of Residents and their particular Supervisor. A SPECIAL COURSE OF LECTURES ON GROUP PSYCHOTHERAPY We have the pleasure of announcing that Dr. Aaron Stein, the Director of the Group Psychotherapy Program at the Hospital, will be giving an introductory course of lectures to our Resident staff; and that all members of the psychiatric Attending Staffs and the Clinical Assistants of both the Manhattan and Queens Clinics are cordially invited to attend. The lectures will be held at the Hospital in Glen Oaks on Saturday mornings from 9:00 to 10:15 A.M., beginning Saturday, September 28 and up to Saturday, December 21. Dr. Stein is an Associate Attending Psychiatrist at the Hospital and an authority in group psychotherapy. He plans to cover the important practical aspects of the subject, including general principles, selection of patients, group psychodynamics. the role of the group therapist, relationship between group and individual psychotherapy, etc. J.S.A.M. �Recent and Forthcoming Publications INSTINCTIVE BEHAVIOR The Development of a Modern Concept Translated and edited by CLAIRE H. SCHILLER Introduction by KARL S. LASHLEY With contributions by Konrad Lorenz, Paul H. Schiller, Nicholas Tinbergen, Jakob von Uexkiill 120 illustrations, $7.50 EROGENEITY AND LIBIDO Some Addenda to the Theory of the Psychosexual Development of the Human Psychoanalytic Series, Volume I By ROBERT FLIEss $7.50 YOUTH AND CRIME Proceedings of the Law Enforcement Institute Held at New York University Edited by FRANK J. COHEN $6.00 ON THE UTILITY OF MEDICAL HISTORY Institute on Social and Historical Medicine, Monograph I The New York Academy of Medicine Edited by IAGO GALDSTON $2.00 ON NOT BEING ABLE TO PAINT New Revised Edition By MARION MILNER Foreword by illustrated, $4.50 ANNA FREUD or order directly from INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street New York 11, N. Y. At your bookstore 1] �THE INDEX OF PSYCHOANALYTIC WRITINGS ALEXANDER GRINSTEIN, M .D. 5 Volumes, sold as set only, $75.00 Volumes I and II, now available Volume III, Fall, 1957 The Index covers the entire psychoanalytic literature through 1952. Every book, article, review or abstract is listed in alphabetical sequence according to authors and titles. There are approximately 37,500 listings drawn from 25 psychoanalytic publications and some 75 journals containing articles by psychoanalysts or about psychoanalysis and closely related subjects. Psychoanalytic books and articles, published in 21 languages, have been included, and foreign-language titles have been translated into English. The most invaluable feature is a separate subject index with some 30,000 topical entries. In addition, there are a number of appendices. One of them lists nonanalytic books reviewed in psychoanalytic journals. The others are devoted to a chronological listing of the writings of psychoanalytic pioneers. Among them is the first complete bibliography of Sigmund Freud’s writings and published letters. Dr. Heinz Hartmann says: “Psychoanalysis has reached a stage at which a truly comprehensive index of analytical literature has become a necessity. Many questions of principle had to be decided, on the methods of listing, on the degrees of inclusiveness, etc., in order to make this Index a valuable tool for research workers in psychoanalysis and related fields. Dr. Grinstein made these decisions with considerable wisdom and objectivity, guided by a lucid understanding of all the rather complex problems inherent in his tremendous task. This task might well have looked forbidding and frightened off many a less courageous man. Having become accustomed to using Volume I of The Index of Psychoanalytic Writings (other volumes are to follow soon), I can say that the obvious difficulties of this comprehensive venture have been successfully overcome and that this imposing work has proved of the greatest value to me, and without doubt to very many others.” At your book store or order directly from INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street New York 11, N. Y. . 1] �JOURNAL of the HILLSIDE HOSPITAL VOLUME VI 1957 NUMBERS 1-4 CONTENTS Scientific Papers Blane, Howard T. and Glad, Erik—THE PSYCHOLOGIST AND THE PSYCHIATRIC TEAM IN A RESPIRATOR CENTER . Boyer, L. Bryce—THE MEANING SCHIZOPHRENIC PATIENT Desmonde, William H.—THE ANIMAL SACRIFICE . . OF INSULIN THERAPY TO A . . 24 . . . . . . ORIGIN OF MONEY IN THE . . . . . . . . Devereux, George—THE CRITERIA OF DUAL CO‘MPETENCE IN PSYCHIATRIC-ANTHROPOLOGICAL STUDIES . 87 Fink, Max—A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMIC THERAPIES . . . . . . . . . Glynn, Eugene—THE THERAPEUTIC USE ADOLESCENT PAVILION . . . OF SECLUSION IN AN . . Green, Martin A.—SIGNIFICANCE OF INDIVIDUAL IN EEG RESPONSE TO ELECTROSHOCK . . Jafie, Joseph—AN OBJECTIVE 1 9‘7 . . . . 156 VARIABLIITY . 229 . STUDY OF COMMUNICATION IN . 207 FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL . . . . . . . . . . 216 PSYCHIATRIC INTERVIEWS . . . . . . . Kakn, Robert L.; Pollack, Max; and Fink, Max—SOCIAL Karin, Hyman and Fink Max—ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI. . . . . . . . . . . . . 241 �Locke, N orman—REMARKS PSYCHOLOGY AND THE ON THE GROUP PSYCHOTHERAPY OF THE HARD OF HEARING 100 . M eerloo, ]oost A. M .—Kos AGAINST KNIDOS: AMBIVALENCE AS THE PSYCHIATRIC OUTLOOK ON MAN . . . . . 67 M ullan, H ugh—GROUP PSYCHOTHERAPY IN PRIVATE PRACTICE: PRACTICAL CONSIDERATIONS 34 Nz'ederland, William G.——THE SYMBOLIC RIVER-SISTER EQUATION IN POETRY AND FOLKLORE Reider, N OTman—TRANSFERENCE PSYCHOSIS Slap, Joseph William—PSYCHOTHERAPY 91 131 . WITH A CASE OF 43 MALADIE DES TICS Slap, [oseph William—SOME CLINICAL AND THEORETICAL 150 REMARKS ON CHESS Clinical Symposium OUTPATIENT TREATMENT VIA PSYCHOTHERAPY OF A CHARACTER NEUROTIC WITH IMPOTENCE Part 1: Case presentation by Lionel Blackmcm Part II: Discussion Book Review News and Notes 107 160 180 . . . . . . . . 55,121,182,251 �NO and YES on the genesis of human communication By RENE A. SPITZ $4.00 Dr. Spitz, well known for his original studies of the psychological ‘ i development of infants, devote-s a monograph to the beginnings of com~ munication. He tackles this most important problem from a broad basis, using the theoretical framework of pSychoanalysis; direct ob’servations of infants, both normal and abnormal; and the newest findings of animal ethology, experimental psychology, embryology and physiology. Skillfully integrating the dataiobtained by thesescience'sr Dr. .Spitz presents a most fascinating and thought-provoking theory of, the roots of communication, both verbal and nonverbal. Dr. Spitz eXa-mines the inherited or preformed motor behavior patterns whiCh have a function in the earl1est nursing situation. Both negatiOn as well as affirmation have such early motor prototypes, which in the Course of deve10pment undergo a change of' function. Divorced, fromthe behavior they originally subserved, these motor patterns can now be utilized exclusively as signals of communication. Later, endowed with semantic meaning which the child acquires through identification with the adult’s “No” gesture, they are used for communication proper. Though drawing upon the data and theories of other sciences, the framework of this monograph rests upon Freud's fundamental insights into human pSychological development. Its, major contribution is the minute examination of some of; the building blocks of‘Freud’s theory. This proc'edUre permits the author to throw light on hitherto unexplored interrelations between speCIfic aspects of behaviOr1n infants. these findings emerges the generally applicable concepts of From ‘ “organizers of psychic development" as well as a description of the origins of the Selfin infancy. These findings have the widest implications for clinical psychoanalysis as well as the study of human relations in general. . . ‘ .< .. .1 2...: .J _ ‘ ’ —.—___‘_____________________ At your bookstore. or order directly from ‘ 1] INTERNATIONAL UNIVERSITIES PRESS, INC. 227. West 13 Street 'New York 11, N. Y. . , ' �M THE PS’YCHOANALYTIC STUDY OF THE CHILD Volume XII, $8.50 Contents. of the Newest Volume ERNST KRIS, 1.9004957 Contributions to Psychoanalytic Theory Nature and Development of the Concept of Repression in Freud's Writings PHYLLIS GREENAcRE—The Childhood of the Artist EDITH JACOBSON—On Normal and Pathological Moods Pathoand Normal JEANNE LAMPL—-DE GRoor—On Defense and Development: ‘CHARLES BRENNER—The logical RUDOLPH M. LOE-WENSTEIM—eSomt} Thoughts on Interpretation in the Theory and Practice of Psychoanalysis SEYMOUR L. LUSTMAN—Psychic Energy and Mechanisms. of Defense ’ Aspects of Early Development CAsusoe-Anxiety Related to the Discovery of the‘Penis': An Observation. With an Introduction by ANNA FREUD MARIANNE KRIS—The Use of Prediction in :1 Longitudinal Study WILLIAM G. NIEDERLAND—The Earliest Dreams of a Young Child GABRIEL _ ‘ ANNEMARIE SANDLER, ELIZABETH DAUNTON and ANNELIESE SCHNURMANN— Inconsistency in the Mother as a. Factor in Character Development: A Comparative Study. With an Introduction by ANNA FREUD V Clinical Contributions PETER BLos—Preoedipal Factors in the Etiology of Female Delinquency ERNA FURMAN—Treatment of UndefiFiV'es by Way of Parents ELISABETH GELEERD—Some' ASPects cents of Psychoanalytic Technique in Adoles- BELA MITrELMANN—‘Motility in the Therapy of Children NATHAN N. ROOT—A Neurosis in Adolescence MARGARETE and Adults RUBEN—Delinquency; A Defense Against Loss of ObjeCts and Reality LISBETH J. SACHS—On Changes in Identification frOm Machine to Cripple ‘ Applied Psychoanalysis the Salamander’ StanislaVsk-i PHILIP WEISSMAN—The Childhood and Legacy of ROBERT PLANK—On ‘fSeeing ______—__‘_____._______———————————or- order directly from {I At your bookstore INTERNATIONAL UNIVERSITIES PRESS, INC. 0 New York 11, ‘N. Y. 227 West 13 Street, . . �jam; Rah at smug/1n Pox-caption of Simultaneous mm. swam Pub}! m 2 Karin $.13. and 3"!“ Fink Kenn ”amt at emu“ in “armament until. puma“: ha m been the object at midst-able discussion was. it: «napalm by Bender and common and matron: wlmtim hm bun errand. Ema: 12h. threshold for perception 9150mm maand “mm, 3!; mm w psychiatric putienta. «in: mm, simianeoua stimuli are applied in madam nqumo to lamination: o! cheek md hand and both check: at 111mm, mthruhold and mama” cf throdwld and mmthruhold human. Bung aqua-o in ’01:. hands, Results: 40de 3mm: cinnamon” or supnthromold «imam, wmw, the differences between the number of “auctions in aither part. were not. nigaifiunt. Him «ml: or mummy (m sum“ at thmhold and one supmthmshold), Mater; then m a significant meme in the £13,1an ta «part tho thruhom. with W Cancyuam Thou data suppert tho 1:: simultaneous cutaneous ‘o‘ono " ”Ix/57 mmnm: tint the obnmd nrdor of Wm mm are pmd upon paydmfiysieal anaemia“. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Role of stimulus intensity in perception of simultaneous cutaneous electrical stimuli. J Hillside Hosp., 6: 241-250, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-26-001 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Korin, Hyman; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint From the Journal of the Hillside Hospital,Vol. VI October, 1957. Full copy of the Journal of The Hillside Hospital, Vol VI, No. 4, October 1957, Table of contents: A UNIFIED THEORY: OF THE ACTION OF PHYSIODYNAMIC- THERAPIEs by Max Fink; AN OBJECTIVE STUDY OF COMMUNICATION IN PSYCHIATRIC INTERVIEWS by Joseph Jaffe; SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL by Robert L Kahn, Max Pollack and Max Fink; SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN EEG RESPONSE TO ELECTROSHOCK by Martin A. Green; ROLE OF STIMULUS INTENSITY IN PERCEPTION 0F SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI by Hyman Korin and Max Fink; NEWS AND NOTES. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/7bd07b6cfa28408a13dfb7a2b134ee43.pdf 7a8e9dcb7ef041dbb63226e8de460992 PDF Text Text �Reprinted from Psychopathology of Communication Grime & Strstton. Inc., 1958 Printed in. (1.5.4. 9 CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY By ROBERT L. KAHN, PH.D., I AND MAX FINK, M.D.* Weinstein and his associates have described patterns of symbolic adaptation in patients with cerebral dysfunction.l The main emphasis in their work has been placed on altered language patterns. Their observations have shown the similarity and relationship between various kinds of behavior which were previously regarded as disparate phenomena. Instead of being isolated defects due to focal brain lesions, these phenomena can be understood as unified aspects of an altered pattern of adaptation under the conditions of a diffuse disturbance in brain function. Some of the factors which determine the particular type of adaptation shown include the premorbid personality and the nature of the environmental stresses. This emphasis on language has been shown to be a useful method of study. For example, the presence of certain characteristic changes in language under the influence of amobarbital sodium, such as disorienta— tion for time and place, denial of illness, and reduplication, has been standardized as a diagnostic test of brain disease in neurological patients?! 3 This technique has application in the study of other conditions of altered brain function, as in the somatic therapies. The electroshock population is of interest for two reasons. It is possible in these patients, as it is not in those with neurological diseases, to manipulate experimentally the stimulus causing changes in brain function. Secondly, the mode of action and the psychological changes associated with electroshock treatment remain poorly understood. In a previous study we have shown that a favorable clinical response to electroshock treatment is related to early and persistent manifestations of language changes with amobarbiN RECENT YEARS * Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. Prepared with assistance from the National Institute of Mental Health, Public Health Service and the Dazian Foundation for Medical Research. 126 �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 127 tal sodium characteristic of altered brain function} This finding was considered to support the hypothesis advanced by Weinstein and Kahnl’ 5 that the mechanism of therapeutic action of electrically induced convulsions lay in the creation of a condition of altered brain function in which the patient might express his problems in a new symbolic fashion, particularly in the form of denial. The present investigation is a further attempt to test this hypothesis by studying changes in language that occur with treatment. The following questions specifically were studied: 1. Are there characteristic identifiable changes in language which develop in the course of electroshock treatment? 2. Are these changes related to the clinical response? 3. Are these changes related to the degree of alteration of brain function? 4. Does the administration of amobarbital sodium prior to treatment produce any changes in language which have prognostic value for the eventual clinical response to treatment, the development of altered brain function, and the development of language changes during treatment? METHOD Population: Sixty-five consecutive referrals for electroshock treatment at the Hillside Hospital were studied. The Reiter electrostimulator was used on 49 patients, while 16 were treated with the Medcraft. There were 20 men in the series and 45 women and ages ranged from 21 to 68. Each patient was tested prior to treatment and retested during the second week of treatment after having received 4-6 convulsions, and during the third week after having received 7-9 convulsions. On each of these occasions the patient was first tested clinically and then after amobarbital sodium had been administered at the rate of .05 grams per minute until nystagmus, slurred speech, drowsiness, and errors in counting backward were noted.2 The test consisted of a standardized series of questions concerning orientation and awareness of illness. This study is based, however, on the response to only three of the questions used: (1) What is your main trouble? (2) Why did you come to this place? (3) If you could have one wish, what would you wish for? All responses were recorded verbatim. Observations were also made on such nonverbal aspects as smiling, laughing, gestures, and other bodily movements. �128 PSYCHOPATHOLOGY or COMMUNICATION RESULTS Patterns of Language Change Noted Clinically During Treatment In evaluating the changes in language, the original responses to the three questions given clinically prior to treatment were used as the baseline. The evaluation of what constituted a change was based on explicit objective changes in grammar rather than on subjective or interpretative changes as to affect, mood, feeling, pitch, voice quality, etc. In this manner the following types of language change were noted clinically during the course of treatment: (1) alteration in the syntactical use of person, (2) evasion, (3) verbal denial, (4) qualification, (5) change in tense, (6) displacement, (7) stereotyped expressions and cliches, and (8) smiling and laughing. Alteration in the syntactical use of person. Instead of using the first person singular as in the pretreatment period, 28 patients used the second or third person and, occasionally, the first person plural. To the question concerning main trouble such responses were given as, “It’s what they call a depression,” “They told me I was emotionally and mentally sick,” “We’re having a lot of trouble with my mother-in-law,” “My cousin brought me; she said I was nervous,” “What’s your main trouble, or don’t you know?” and “My Mrs. is sick and I would appreciate it if they would let her in here as soon as possible.” The reason for coming to the hospital was variously given as, “My wife brought me,” “My father told me to come here,” or “My doctor said this was a good hospital.” The wish was given as “Perfect health for my family,” “My children, my husband, and all my good friends should be healthy and happy,” and “There should be peace in the world.” Evasion. Evasion in answering the question about their illness was shown by 27 patients. This commonly took the form of answering this question with another, as, “What do you mean by my main trouble?,” “What do you expect me to say?,” “Well, what it it?,” and “What did I say last time?” Other language patterns considered evasive included such responses as, “I don’t know how to tell you,” “I don’t get what you mean,” “Let me think,” “It’s hard to say,” and “I just don’t know how to express it.’ One patient asked the examiner to give her a hint. Verbal denial. Explicit verbal denial of illness was shown by 23 patients. They either said they had no main trouble, were well or else, after giving evasive ‘I don’t know” responses, denied their illness and symptoms when specifically questioned about them. �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 129 Qualification. Qualification of a response in the direction of less commitment was shown by 19 patients. This language pattern was characterized by the use of such words as “guess,” “kind of,” “sort of,” “think,” “apparently,” “probably,” “possibly,” “might be,” “seem,” “assumed,” 9, and “perhaps. Thus such responses were given as, “I guess I have been jittery,” “I seem to be very much depressed,” “Probably that I’m nervous,” “I suffer from anxieties, apparently,” “Possibly worry about the future,” “I have sort of gotten frightened,” “Mentally upset, I assume,” and “I think I’m a little insecure.” Change in tense. In 18 patients there was a change in tense in describing their illness. In most cases the patient used the past tense: “I was depressed when I came here” or “I had been nervous.” In other cases the patient answered the question about his main trouble by putting it in the future tense as a wish. Displacement. In 20 cases there was a displacement of the complaint to something other than originally given prior to treatment. This was invariably less serious than the original complaint. Sometimes the displacement was in the form of a somatic complaint, as saying the main trouble was “diarrhea,” “headaches,” “pain in the feet,” “I slammed the finger in the door,” and “I’ve got an itch.” In other cases the displacement was to some concrete aspect of the hospital situation, as “My main trouble is getting these treatments,” or “I’m upset because I was transferred to another ward.” Stereotyped expressions and cliches. The use of stereotyped expressions and cliches was shown by 11 patients. They gave such responses as “It seems to me under the proper circumstances I’d be all right,” “ [My trouble is] monetary problems with people that are honorary and sincere,” “That’s the root of the whole thing,” “The only thing certain is death and taxes,” “Learn my lesson and be a good boy,” “To be a person of pep and reliability,” and “I just want to stop being a lazy lout.” One woman responded to a question of her one wish with, “I think I should consult my husband before I make a wish because he’s a lawyer and the father of my children.” Smiling and laughing. In 20 cases the patient was noted to smile or laugh either immediately preceding or following his response to the question concerning his illness. Language Changes Shown with Amobarbital Sodium During Treatment The language patterns after amobarbital sodium during the second �130 PSYCHOPATHOLOGY OF COMMUNICATION and third weeks of treatment were similar to those noted clinically. With the drug, however, the changes appeared earlier in the course of treatment. A given language pattern might be noted in the second week of treatment with the drug, but would not occur clinically until the third week. In addition, the reactions to the drug took more extreme forms, which are described as (l) cryptic responses, and (2) withdrawal reactions. Cryptic responses. These were shown by 23 patients. Responses were classed as cryptic when they had no obvious relevance to the test question or when their meaning was obscure, representing a very personalized expression. Thus one patient, when asked his main trouble, said, “Nightmare of the afternoon of the evening of the nightmare.” Others do the know the didn’t “I such problems—couldn’t as responses gave problems,” “Getting my husband to write down what he does,” or “What could I say—you don’t get the crossword.” Withdrawal reactions. Some pattern of withdrawal was noted in 33 patients. This behavior was characterized by incomplete sentences, incoherent mumbling, neologisms, perseveration, the use of a foreign language by bilingual patients, and delay or failure to respond to the questions. These patients would characteristically lie with their eyes open, would smile or turn their heads when the examiner spoke, and would speak clearly and promptly and in English when asked questions not pertaining to their illness. Other Changes in Language Other changes in language were noted both clinically and with amobarbital sodium in response to the other questions of the test battery but not as a part of this study. There was frequent misnaming of the examiner or reference to him as “Mister.” With the drug those patients who had a “positive reaction,” i.e., one characteristic of altered brain function, showed the characteristic patterns of disorientation for place and time and confabulation described in previous communications. (2) Relation of Language Changes to Clinical Response The evaluation of clinical response to treatment was made independently of this study. The patients were rated by the supervising psychiatrist in charge of the treatments, by the patient’s own therapist and supervising psychiatrist, and by the medical director. On the basis of these ratings the patients were classified into three groups: 28 patients were �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 13]. considered much improved, no longer showing the symptoms which had brought them into the hospital; 22 patients were rated as moderately improved, showing some symptomatic relief but still showing disturbing features; and 15 were regarded as unimproved, having shown only equivocal or transient changes at best. The ratings were short term evaluations, being made within two months after completion of treatment. For quantitative purposes the language changes shown during both the second and third weeks of treatment have been grouped together as though the patients had been tested only once. If a particular pattern was shown during both periods, the item was scored only once. Altogether, 89 per cent of the patients showed at least one of these patterns of language change clinically during treatment. Such changes were found in all of the much improved patients but in only 73 per cent of the unimproved group. It was apparent that there was a relation between the degree of clinical improvement and the number of changes in language patterns. When the data are analyzed for the patients who showed three or more language pattern changes, there is a significant difference between the groups (table 1). While 68 per cent of the much improved patients showed three or more language changes, only 20 per cent of the unimproved patients showed this degree of language change. Using Chi-square, the over-all difference is significant at better than the 1 per cent level of confidence. TABLE 1.—Relation of Language Changes Shown Clinically to Response to Treatment Three or more * patterns Fewer than three Change No. Much improved Moderately improved Unimproved 28 19 22 7 32 15 68 15 3 20 12 80 65 29 45 per cent 36 55 per cent Total *X’ = 11.26; P < 68 per cent patterns 9 * 32 per cent .01 When each language pattern is analyzed individually (as shown in fig. 1) it becomes apparent that not all patterns discriminated equally �132 PSYCHOPATHOLOGY OF COMMUNICATION between the groups. In all but one case, a greater percentage of the much improved group was most likely to show denial, use of the second or third person, evasion, and displacement of complaint. The only lanmuch the between found difierence which little was on pattern guage improved and unimproved patients was the incidence of smiling and laughing. Analysis of the changes shown by the difierent groups under amytal is shown for the cryptic and withdrawal reactions only in figure 1. While the crytic responses did not vary much with the different groups, the showing of a withdrawal reaction differentiated the three groups significantlyfi‘ occurring in 71 per cent of the much improved, 45 per cent of the moderately improved, and only 20 per cent of the unimproved patients. Relation of Language Changes to Electroencephalographic Response In a previous communication a method of quantitatively evaluating electroencephalographic records was described.6 Criteoria were established for rating records as showing relatively high, middle or low degree of slowing according to five criteria: average per cent time delta waves (waves of six or fewer cycles per second), the highest per cent time delta waves at any one lead, the lowest frequency in the record, the highest amplitude of delta waves, and the longest duration of a burst of delta waves. In the present study, an electroencephalogram was obtained prior to treatment and in the second and third weeks of treatment. Each record was evaluated according to the dichotomy of showing a relatively high degree of delta activity or not, using these criteria. In table 2 the relationship is shown between electroencephalographic slowing and changes in language. Those patients with the highest degree of cerebral dysfunction, having high degree delta in both the second and third weeks of treatment, show a greater number of language changes both clinically and with amobarbital sodium. Using the withdrawal reaction as an index of the drug effect, however, the difference just fails to be statistically significant. Pretreatment Language Patterns The language patterns described in this study were considered as changes only when they occurred after the original pretreatment clinical test which was used as a baseline. Seven patients, however, showed some " X2 = 10.72, significant at better than the 1 per cent level of confidence. �133 CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY TABLE 2.—Relation of Language Change to High Degree Delta on the Electroencephalogram During the Second and Third Weeks of Treatment Withdrawal reactions with amobarhital sodium T Change No. Three or more changes clinically Both weeks high Delta Activity One week high Delta Activity No high Delta Activity 25 16 16 8 50 9 56 24 6 25 8 33 = 7.62; P < TX” = 4.87; P < * X2 * 64 per cent 15 60 per cent .05 .10 M form of these language patterns in the initial clinical test. The manifestation of these same patterns by these patients at any other time was accordingly not scored as a change. When given amobarhital sodium prior to treatment, however, 30 patients (or 46 per cent of the total) showed some language change comparable to that noted during treatment. Table 3 shows the relation between such changes at this time and the eventual clinical response. These changes were found in 68 per cent of the much improved patients, in 36 per cent of the moderately improved, and in 20 per cent of the unimproved groups. TABLE 3.—-—Relation of Pretreatment Language Changes with Amobarbital Sodium to Eventual Clinical Response Change No. Much improved Moderately improved Unimproved 28 19 22 8 36 15 3 20 “ X2 = 10.30; P < .01 Change with amobarhital sodium 68 per cent * �134 PSYCHOPATHOLOGY OF COMMUNICATION In table 4 it is demonstrated that the pretreatment change with the drug was also prognostic of the eventual physiological response to treatment as measured by the degree of electroencephalographic slowing. The over-all distribution just falls short of statistical significance, although when those who showed high delta activity in both periods are compared with all the other cases as a group, the difference is significant at the 5 per cent level of confidence. of Pretreatment Changes with Amobarbital Sodium to High Degree EEG Delta Activity During the Second and Third Weeks of Treatment TABLE 4.———Relation Both weeks high Delta Activity One week high Delta Activity No high Delta Activity "‘X2 = 5.27; Change with amobarbital sodium No. Change P < * 64 per cent 25 16 16 6 38 24 8 33 .10 Finally, the initial response to amobarhital sodium was also prognostic of the degree of language change shown clinically and to the manifestation of withdrawal reactions with the drug during treatment (table 5). Between Pretreatment Language Response to Amobarbital Sodium and Clinical Changes and Withdrawal During Treatment TABLE 5.——Relati0n No. Pretreatment Three or more clinical lan* guage patterns barbital sodium = 4.26; P < 'l'X2 = 6.88; P < "‘X2 .05 .01 tions to amobarbital sodium '1‘ 30 18 60 per cent 21 70 per cent 35 11 31 12 34 response to amobarhital sodium N0 pretreatment response to amo- Withdrawal reac- �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 135 DISCUSSION The relationship of the language changes to the development of altered brain function and to the clinical response is consistent with our original hypothesis concerning the mode of action of electroshock treatment. In 6 studies4’ we have shown that the clinical outcome is related previous to the presence and degree of alteration in cerebral function. Using the “amytal test”2 and the EEG as indices, it has been found that those patients with the earliest and most persistent manifestations of cerebral dysfunction were most likely to have a favorable response. Such physiological changes create the milieu which facilitates behavioral change. The present study, analyzing language patterns, clarifies the nature of the behavioral changes that occur with treatment. The language shown originally (prior to treatment) may be summarized in the statement, “I have this particular illness.” The subject of this sentence answers the question “who,” the predicate refers to “what,” and the verb describes the relationship, including the temporal and intensity aspects. During treatment the subject of the sentence may be modified by changes in the use of person, so that the sentence might read, “You [or he, she, or they] have this particular illness.” Changes in the predicate are shown by such patterns as displacement or evasion. In displacement the sentence might read, “I have some other kind of illness,” while, with evasion, it would be, “I have something, but I don’t know what.” Changes in the verb are shown by denial, qualification, or alteration of tense. In denial the statement would be, “I don’t have this particular illness;” a qualified sentence would read, “I might have this particular illnessg” while with alteration of tense the sentence would be, “I had this particular illness.” Some language patterns modify the sentence as a whole. If the patient smiles, or if he introduces his statement by saying, “The doctors tell me that . . . ,” any part or all of the sentence may be modified. In other reactions, particularly those noted under amytal, the patient avoids giving any meaningful statement at all. In the withdrawal reaction he says nothing or omits part of the sentence. In the use of cliches or cryptic expressions no specific referential meaning can be drawn from the language. It is evident from this analysis that the language changes are not random or bizarre, but form a patterned reorganization of communica- �136 PSYCHOPATHOLOGY OF COMMUNICATION tion characterized by an alteration in the patient’s attitudes to his problems and his illness. The patient either says he is not now and never has been ill, displaces his illness temporally, spatially, or personally, is less committed to his awareness of his illness by the use of qualifications, or avoids the whole problem by evasion and noncommunication. These patterns are comparable to those noted previously by Weinstein and Kahn:l in patients with cerebral disorders, and referred to by these authors as the “language of denial.” Similar language changes have also been described following other somatic therapies. Frank“ 8 reports that lobotomized patients avoid talking about the operation, and he states that “the facility and glibness with which they say ‘well I had an operation for my nerves, I guess’ contain the quality of unconscious denial.” Legault,9 working intensively with post-lobotomy patients, found persistent attitudes of denial. One patient, when asked why she came to see the doctor, said it was her relatives’ idea. Many gave qualified responses, saying they “supposed” they had had an operation. Others doubted that the operation was on the brain, or used an evasive, stereotyped expression as “some nerve in there,” or displaced the procedure as in, “Oh, yes, I went to the hospital and got two black eyes.” When asked about the symtoms that led up to the operation, patients gave such response as, “It seems to have gone.” In studying patients who showed clinical improvement following prolonged coma reactions in insulin coma therapy, we have noted similar changes in language. In a case report10 we noted the appearance of reduplicative phenomena, evasion, verbal denial, displacement, increased use of stereotyped expressions and cliches, cryptic responses, and much smiling and laughing, at a time when clinical improvement was most marked. Since these language changes occur most frequently in patients who are clinically evaluated as improved, may not the language patterns themselves be the critical cues that give a favorable clinical impression? There is traditionally much difficulty in rating patients after treatment. Such evaluations are highly variable because of the lack of suitable objective criteria. While there are other objective cues which can be used, such as the amount of sedation required or the quantity of food eaten, the appearance of these language patterns may constitute an operational basis for clinical evaluation in the psychiatric interview. Not all patients, however, who showed at least three of the language changes were regarded as much improved, and not all of the much im- �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 137 proved patients showed this degree of change. There may be other aspects of language and communication not covered by this study which are significant. Another explanation is that the use of these language patterns may vary in time or in different situations. On the basis of our previous observations of the “Amytal test” and the electroencephalogram in electroshock patients, we should predict that unimproved patients would show these language changes only transiently, while improved patients would show them persistently. Future work should also be directed toward comparison of language patterns shown when the patient is speaking to a physician with those used when he is with his family or friends. The degree to which members of the patient’s family are made more comfortable by the changed language, and even their inclination to use similar language, may explain the variability in the duration of 11 and Both Kahnl' Weinstein and improvement following treatment. Legault9 have indicated a relationship between the patterns of communication of the patient and those of his family. Finally, our results demonstrate the prognostic usefulness of amobarbital sodium administered prior to treatment. The prognostic value of the drug in the somatic therapies has been noted previously by Hoch12 and others,““14 who felt that patients who became more normal in speech, ideation, and behavior under the influence of barbiturates were most likely to improve with treatment. In the present study the manifestation of a change in language with the drug was related not only to the development of altered brain function and to the clinical outcome, but to the eventual manifestation of these language patterns clinically. On this basis, an operational definition of the goal of electroshock therapy might be described as enduring clinical manifestation of those language patterns which occur initially only with amobarbital sodium. SUMMARY AND CONCLUSIONS consecutive patients referred for electroshock treatment were studied prior to and during the second and third weeks of treatment. Each patient was tested at these times both clinically and with amobarbital sodium with a standard series of questions concerning attitude toward illness. 2. The results showed that characteristic changes in language occurred both clinically and with amobarbital sodium during treatment. These changes were significantly related to the clinical response to treatment 1. Sixty-five �138 PSYCHOPATHOLOGY OF COMMUNICATION M and to the degree of alteration of brain function as measured by the electroencephalogram. 3. The presence of these language patterns with amobarbital sodium prior to treatment was related to the eventual clinical response, the development of altered brain function, and the development of language changes clinically during treatment. 70 a 6050 40 'lo 30 FIG. 1. CLINICAL WITH AMOBARBITAL r-——| I uucu Imovso- Ei Ionmovw Cl ‘ummovso Relation of each language pattern to response to treatment. 4. It is felt that these language changes constitute an operational basis for the evaluation of the clinical response. 5. The results support the hypothesis that the therapeutic mechanism of electroshock treatment is the development of different patterns of symbolic adaptation to the patient’s problems and illness under the conditions of altered brain function. REFERENCES 1. WEINSTEIN, E. A., AND KAHN, R. 2. L.: Denial of Illness: Symbolic and Physiological Aspects. Springfield, III., Charles C. Thomas, 1955. SUGARMAN, L. A., AND LINN, L.: Diagnostic use of amobarhital sodium (“Amytal Sodium”) in organic brain disease. Am. J. Psychiat. —, —, 112: 889-894, 1953. 3. —-~, , AND MALITZ, 5.: Serial administration of the “Amytal test” for brain disease: its diagnostic and prognostic value. Arch. Neurol. & Psychiat. 71 : 217-226, 1954. �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 139 Relation between altered brain function and denial in electroshock therapy. Arch. Neurol. & Psychiat. KAHN, R. L., FINK, M., AND WEINSTEIN, E. A.: 76: 23-29, 1956. WEINSTEIN, E. A., LINN, L., AND KAHN, R. L.: Psychosis during electroshock therapy: its relation to the theory of shock therapy. Am. J. Psychiat. 109: 22-26, 1952. FINK, M., AND KAHN, R. L.: Quantitative studies of slow wave activity following electroshock, Electroencephalog. Clin. Neurophysiol. 8: 158, 1956. FRANK, J .: Clinical survey and results of 200 cases of prefrontal leucotomy. J. Ment. Sci. 92: 497-508, 1946. —: Some aspects of lobotomy (prefrontal leucotomy) under psychoanalytic scrutiny. Psychiatry 13: 35-42, 1950. LEGAULT, 0.: Denial as a complex process in post lobotomy. Psychiatry 17: 153-161, 1954. 10. KAHN, R. L., GRAUBERT, D., ll. FINK, M.: Delusional reduplication of parts of the body after insulin coma therapy. J. Hillside Hosp. 4: 134-137, 1955. WEINSTEIN, E. A., AND KAHN, R. L.: Personality factors in denial of illness. AND Arch. Neurol. & Psychiat. 69: 355-367, 1953. 12. HOCH, P. H.: The present status of narcodiagnosis and therapy. J. Nerv. Ment. Dis. 103: 248-259, 1946. 13. HARRIS, M. M., Honwn‘z, W. A., AND MILCH, E. A.: Regarding Sodium Amytal as a prognostic aid in insulin and metrozol shock therapy of mental patients (dementia praecox). Am. J. Psychiat. 96: 327, 1939. 14. GOTTLIEB, J. 5., AND HOPE, J. M.: Prognostic value of intravenous administration of Sodium Amytal in cases of schizophrenia. Arch. Neurol. & Psychiat. 46: 86-100, 1941. ��r i , ‘ 4‘ __ W g 1" ' 3 m' 13 1956 ‘ L g 0 cm In meme: mama wrmsnocx mm! Robert L. mm, mm. (1) m m; 3.9. (2) x a 3 E m the Roman Service, Rama 303mm, f 610:: om, In Ion-k Research Assistant (Psychology). (1) (2) Inmmumrtufflmumrdn : um,upon,bymtmavrmmhmmmmeumwmmum l hum). Instant-a We quiz . .____.,_T f 3 32 I m M“ 7 , , , ‘ of Heath, Public Health Service, and tin mm mum :m' W/we‘bé , . I ��.————n.~— um w-w—w, m , c121: ll‘ynbolié rum“, gamma: in we tan a: mu. m pal-amt imadglfim 1- 5 mm»: «mm t0 tut this Methods by studying changes in 1mm: um. ocetu' wfih transom. speculum, in: quantum war. ”mad: 1) he then numb-nun 1631153113131. chug“ in language in the a: 93.00th tmmu 2) An thug changes routed tn the clinical rum? cm 3) 1;) tho Imm- which develop ‘ mmwmmmadummrmumz 1:.an m <3th no» mum-mum at amour-him swim prior to mm mane pm «no any chaugu Salaam mu tax-tho mutual 611M681 “spams t0 tmtmnt, tho Moment 6:! ahead brain mum, and the m1»- mt of language We! during treatment? �www.— mm Pbpflatim 8mm.” «causative mun-.1- for 0103th mama 3W. n: tho 3:11.146. Hoopim were ha ma Rutter mootmtimlator was used an puma, m: 16 mm trhud with m Index-art. mm was 20 m m that nflaoanthm,andthoagaamngofifm21t068o 1361th mudprbrto What, and nuuuddurxng tbs soc. nadmok o: tmhent arm-hum medMM amen... and man; the third Each Mattel-havingmiv'ud'l-‘P convulsions. am was first team clinically, m and muchatthcnoemiona tbsp“- that after Win]. ”dim had bun mun- mm, slurred speech, dram intend at the at. of .05 Per mm mm sine” and awn 1n counting hackurd was We! (2). m tut consist-d of a. “1m and ”mane” at 111m". a» standardised an» of Question concerning orient» nu stumr in band, hammer, on thg mm” to was a.) flaw in your Iain troublo? 2) Why am you com to this 131100? 3)Ifmcon1dhnve mum, whutwofldmwinhfar? 111 responses was mom 19mm. Mmum am: also on such mam}. only three or . aspects as questions mum, laughing, gestural: and cum- bodily m mu. �._. m- WW.Mmmmmm.m W —...— , "Hwy—n warm munmmgtmmsmmmemom nmaeatothathm questions gm clinically prior to treatment. were and at tho Malina. ufimofwhat mfiWaWmewut a: chug-l, 1) as to affect, mod, um mm: m. mum Amen a: mg. mum m. nag. change wars noud oval- objoeuva changaain gm author than mm” or infierprouuw In mung, pitch, vein. The clinical): during the saw at {amen-at: alumna in ma tynucuml m a: pox-on, 2) 0mm. 3) «M ma. h) Mama, 5) ohms. mu, 6) amt, 7) stereotyped 11: oxpzésum and cliches, and a) 1. Album first pom singular is wing and 12mm. , in tho pmtmttmt Warmingtha patient. used the second or third pom and occasionally the first. person plural. to me question anoaming min trouble such reopen.” ward given us ”It's what they call a depress- 10a.”- 17823.64, 28 Whaytoldmlmmfiomuyandmmliuck,‘ We'mhavingalatef trouble with w mflme-lm,“ my cousinbrnght no; she said I was mus,“ mam troublo, er mm mm,“ and my lira. it sick and I tram tppmciato it bar in how u soon a pas-ibis.” thq mum team for coming to the heapiul m anomaly given a W wife hm: no," "W "What‘s 11‘ tamortaldm to m hora! oriwdeow mid mama mumm.‘ will: an: grim as “Part-rat ' The 3.0% mu: for w M13," W alumna.- my Tho husband and anwgoodfm uhauldbelnnlflvandhappy' mfimmaummmm m Md.“ �“”1 ‘ ~5i I LAW Men Wiring m. m M 2. w 1:: 21 patients. rm- with a question, as ”What. do. mm; m Wm momma the queetioh about their tea: the tom of you new by m main trouble?,' “that do you «poet mo; won, what 1:: m,“ and "What «he 1 may last than?“ Gum-1W patterns considered and" included such responses as ”I don't know how to tell you,“ ”I don’t get what you mean," "Let ale think,“ um hard to any,“ ad “I no to m Just don‘t hint. how to expanse 11:." One patient asked the «minor to give her a W. mutwmmammummwzspu an,” Wm W. 1mm. they either math-y had no um «am or an axing evasive “I don't mow” reapeneeo, denied specifically questioned about. him. ' eomltmont the use their illness and a... arm- mention a: a meme in the dimtion a: 1»- m ohm by 19 patients. a: were. as ”31103:," ably, " "possibly,“ ”man. be,“ were given no '1 gun: I have ”pmbably that I'm This lulguago pattern was characterised by ”kind of, “an,“ been ' , “sort at " ”think " “apparentlyfl "prob- “assumed," and “perhape." That such Jittery,” “I seen to he very ream mammaed,“ mom,” “I suffer from emotion, apparently,“ ”Poenbly early about the fume," ”I have sort or! gotten momma,“ upset, I and ”I think I'a a little inseam..." W. ”W ‘ Inlapntiente therewaeaohangein um,” mum» in; their 1111:)“. In most cane the patient used the past tense, as "I wan depressed when I one here” or 'I had been mm.” In other canoe the patient answered the question about his main trmzble by ' 131%(2mg. In 20 cases mung it in the future there no a diamamnt tense as 3 Huh. of the Wt ‘ W to something other than originally given prior to treatment. This was mummy lest Bonan- than the original comm. Sometimes the dilplacamnt was in the tom of a emetic complaint, as laying the main trouble was ”diarrhea," “headaches,“ �WWWWMI—Fr‘ .6. ' ”pm in the tests," “I slams the rings;- in the door,“ stair case: the displacemnt as ‘33: main form»! m to some mores. aspect or the: itch.” In hospital situation, trauma in getting those treatments," or “I'm upset because I to another 7.} and "I‘vs got. an was trans- wand.” Sufism mania and 011mg. Tho use of stereotyped sxpmssim andsliohumaambyupltisntl. Thsygan-uehnnponauunltmtam undo:- the proper circumstance: Igd be alright," with pupils than. are honorary and sinners,“ “The only '1‘0 be thing «mm is “(my tmblo in) monetary "Tut’- the root of the (bath and taxes,“ "Loam my pmblou whole thing,“ lesson and be a good boy,” person a! pep Ind nhtbility,” and “I just want to stop being a hly lent.“ Muhammlpmbdto‘aqusstimothsrmwishuth, 'Imnkllhmaoonsultw a. W. husband borers 8. laugh I make a wish became ho'a a lawn: and the {nth-r or InfiOcaauthopatimtmmtodtoamoor 01m manuly wounding or following his coming xv childish." suspense to the question can- nu 111m". to. language ”zoom um:- ambarbitsl mom during to. mono and tom: units of treatment. were 11min:- to those noted clmenlly. with the drug, haunt, the changes 5mm earlier in the sour» or treatment. A given Imguags pattern might be noted in the second was]: at insistent with tho drug, but. would not occur annually until the third mt. In Audition, the motions to the drug took more extreme forms, which are ascribed cryptic responses and withdrawal remnants. 1. W. u patients. 3031mm” wars class-sdas cmtiswhmthsyhndmobfim relevance to the testqueetion ormthsir 31118 was shown by 23 m obscure, 1'31)an a very momma-d «pr-union. Thu: ms patient, MWMsMntmnble, ma'mghmoftmuumomofmmmgattm naming night-am.” Others gave such msponsoa an to. problem," ”gutting no husband to you duo‘s get. the naturism." '1 MN. know the pmblsm - cm‘t do ma dm mo he does,“ or firm oouu I uy .. �M_W~«W.“hm... ,Wfir—yyw'V‘amn"WW—wzmw. wm-u.www‘wex"w\’murvxl'ww’byum—lam. 7, am....-.. We. .: . ~ . , V . ... 7 or Wham-x“... .3». > my- a. ~u..r-_..L-r.-‘~w flaw. ,‘m,r__ wry", “Tee ‘11ng reaction. 8m pattern or withdrawal was noted in 33 patients. 2. m: behavior we: ohenoteriled by ineomlete egim, pomemtdon, the use or failure to eve-pond of e totem Manage by bilingual patients, and delay to the questions. meet; patiente would cheruoterietioelly lie m1. with their eyes open, would or turn their heed clearly end promptly and in would speak eentencee, incoherent mumbling, mela- when the miner epoke, and Well when asked motions not pertaining to their illness. comm sodium My endwith ambarbitel oom- changes in hnguege were newborn in neponee to the other qua-time of the tut battery but not part of thie more use frequent dimming of the manner, or uteri-mg to hm :- .‘Eflater.’ with the drug these Intimate who had e “punitive reaction,“ my one characteristic characteristic patterns of acclimation for place and time and contebuhtion deeorlbed in preview! communion! (2) . of altered man Motion, showed the the evaluation of clinioel memo to treatment we mede independently of thie may. The Intimate were mted by the supervising peyohietnet in charge of the teammate, the patient‘fl om therapist end eupenieing peydxiatflat, anaby the director. 0:: the beeie of these ratings the petiente were unsealed “eel into three gmpa: W turned, 28 pmenu um widened much which brought then aiming em into the hoepitel; eynptometio 22 improved, no longer showing the petiente were rated as moderately relief, but still ehowing dimming restore" 15 were ragweed ee mmproved, having elbow: on]: equivocal or trmeient and We at beet. me rating: were abort term evaluations, being ude within two loathe after coupletim of them. �PERCENTAGE SHOWING EACH LANGUAGE PATTERN ACCORDING TO RESPONSE TO TREATMENT 70 60 CLINICAL I—————————-‘ WITH AMOBARBITAL l———_I I MUCH IMPROVED El UNIMPROVED I400. IMPROVED �*8. For quantitative purposes the language change: diam during both the mead third week: of tmtaent have been grouped together“ as though the patient: had been tested only once. If e particular pattern we chm during both periods, the the: me scored only wee. ntegether, 895 of the petiente enabled at least one at and then patterns of We manually dining treatment. Such changes were fomdinullthemch mpmvoepauembntinonly7motuuunmpmdm. It as nmt. and the amber [the patients a: chengee who showed mungmgo patterns. three or more leaguege language change. em a.“ is analysed for Wed petm enlyZOSottbeunimpmedpaflenu ienteehmdthmotmnlmgugechangee, this degree of When We- petum changes, there is a signifi- I). ‘gieent differ-wee between the groups (Table shaved clinieel apparent that. there me e relation between the degru of 681 of the much Bung cm! the menu dietdbufidnie lim- mMatbetmtnmth-uwaercmnm. Relatian of. W m 1mm (28) WW MW (22) W (15) 1‘0“!- (65) Chang" W Shawn 3. Wally to Ream“ to Treatment. lie. lo. 5 1 19 685 9 32: 7 )2! 15 681 3 201 12 895 29 ' W 36 551 :2 - 11.25 1! <m Hheneachlengmge pettemiemelyeedmdivimm,um1nfl¢m1, itbecaneeeppemtthetnotenpe‘btem wcmmequmymmw. Infilbntoaeem,emmmtmeftmmmmdpeumuwmmn ’ �Y «my v m. n.“ .-‘ nmxw “gamma. — yawn , v mama-gm m w“... n- ,.—., »1—0” —W -.~.- - V , , n «Fur run...“ .- - . 17,1,» - . , men-1mm, mottheeecmdormmpeum, Wanda-Newt o! ambush; The afly 1111311130 petum on While}: little airtime was found between mmmmmmmdmmamemdmmmum. .Anuymatmmemwmwrmmmup-meumm termerypueandwithdmel mam anlyinrigun 1. mmaypuc reepeneee did mtnrymeh with the afferent groups, the withdml, moving of e mum differentiated the three gmupe eigfifimm: occurring in 711 of the mach Whfldthemdenflhhpmndmdmmzfiottbmnpmdpauwu. x. : mu.“ Mum of In a e to ., vs; mea new M of qumtitafivm Mam electro- Mama pm ducribed (6). emeMgraphic ' a resend: records an m inning relatively high, middle ,a; criteria 62‘ ~ were established low degree for rating of abnonnliia according to five agitating avenge percent. time delta. wee (waves at :11 cycles per mood or lees), the highest percent time delta. mm at my one low. the lowest tremmney lathe moord,thehigheetamplitudeofdelteme, burst. of delta me. mummumote In the present study, an electroencephelogm wee obtained priortotmmntandm the ”Windmirdmk a: treatment. Each ”comm «alum mending to the dichom at showing eliw er m, using the-e axe-Lurk. In Table ality V and changes the relation-hip 2 in animation, Wag show a 1mm. am reletively h1g1 demo at ebnon'e- mm mm abetroonaeplulognphtc linem. Tho: patients with the in Why of high mate; mm: 18 I. greatest degree at cerebral both the «can! I2 a 10.72, thinner:- at mmt, hmge change- both clinicallyxand with Waite]. and“... the mama. mum at! mime-u: at the drug effect. ' m, was the 3m. ran- to be statistically significant. I» end. Wimt 1% better than the ' 11 level or comm. �fl‘rfiwwwme—wmm. . ‘ermmmfimvfimimmw' TABLE Relation of Language Ghana. ’60 High 3 WW (25) OnMunimzé) ‘ lo 315: Ahnamauw (2h) mm withdrawal Motion! with W191}. Seem: i lo. 1 15 as a 50% 6 255 - 15 601 _ 9 5“ ‘ B 335 . Yoa P < 0°, :2 12 Language when they ._._.r,._r. Eloctmmmalom Dunne , m1: < ‘ Both Weeks 31g: 2h: , of Treatment clinical]: lo. may “at on the or Kan changes m._.—r.m~. 2. 83m and Third flecks the , P pat-Mm «termed in that: stuck wan manned afar tho original ’ has? .19 < midsmd a: change: mmmm clinical test which an and u a. baseline. Bum patients, 11mm, .Ihmd can form of than 1mm puttem in the initial 91.1mm test. me minimum or thus same pattern! bythaeepnuenuatmomrtimmmonnnmnatuconduachmgo. mm gum Wits). actual prior to tmtmt, War, 30 patients", at Wot‘flwmu,mmdmhngmgammnbhmmntnommtmh neat. In‘hbh3thonhumbomahmgamhchmguat mamumhm m'mmmeumm mm». Manfmdméfifidmmw pmdpmmnu, thwzyséiutlmnoammynwdwamozmmmd W. . ‘ , par" .— .V �w :u—v-r—wwxv—mww: Relatim of W W3 Pn-tmmt Language Ghangon autumnal Mun with mm and clinical Mona cm. with Ambarbital mu 1 Ho. Knob Impravod (28) Hodomtely MIMI: W 68$ 19 (28) 8 36% 3 W 30 It“ (15) Tom (65) l :3 - 10.30 P< In Tab}. was I; .01 it 1. “infiltrated that the pm-vtmtmnt change with the also prognostic of tho eventual drug Widow anionic to tmtment as mound ouctmcaphalogmmc abnomanw. Tho mun distribution 3m; tall: chart at statistical lawman, although than who my: almonby m. magic. 01' m mlityinboflpeuoda an conpnrodwiflzall’ehsothor crence is significant at th- 51 1m]. 91‘ canfldonoo. Relation of ma mnuam, thaw:- Pwtmmt Languag- Ghanges with manual. Sodium and High Basra Em Abnomliw Drug the Second and Third Weeks of Tmman‘b Both Wuks High One week mmty (25) M Announnw (16) Chung: With Amobarbital Sodium Ho. 1 16 6&1 6 . 38$ ’ la High Abnormality (2h) 8 335 - 5.27 P<olO 1a �many, the initial degru a! Ianguagl clung. I‘hm cunicamand "actions with the drug during twat-ant (km: S). tho m hcpom to 5 . human at Pro-tantalum sodium.an pregnant?“ at to tho Mutation otirithdmnl response to ambarbital Language . NW mm mm: 5041mm . 1': 011mm Chang“ and Withdrawal Remuom 3 Clinical PatternLeague. 03' Hora lo. Pmtmmm Respom to max-mm Sodium (30) In l’ru—treatment Response to Mammal Soditm (35) 18 , 11 :2 aims 9‘00; Withdrawal Reaction! fio Amour-Mu]. Sodium 1 30. i 601 21 705 311 12 3M - 6.38 P<ll°1 x2 _ �'Iwwa‘v-rI—Ku,WM wc-v— ~33- w".— «my. qzwrr * Discussim the relationship or the language changes to the development of sltsred brain function and to the clinicsl reepcnee is cmistent with our original vaethesie cenceming the nude have shown ct action or electmehock treatment. In previous stmnee that the clinical outcome is related to the (hfié) we presence and degree of alter- ”mm test" (2) and the we as indicse, it has been fomd that those patients with the earliest and most persistent Mutations were met likely to have a favorable response. Such physioof cerebral aticn in cerebral function. Using the mm logical changes create the milieu which facilitates behavioral change. present study, analysing language petteme, clezii’ies the nature a: the beheviorel changes that occur with treatment. the language chem criginelly, mic:- tc. treatment, my be amused in the The statement, "I have this particular illness.” The subject or this sentence answers the questicn 'Who,’the predicate refers to What,‘ and the verb describes the relationship, including the femoral and intensity aspects. During treatment the sub- dectoi’thesentencemybenofltiedbycmngesinthemotpereon, eothntthe sentence night read "You (or he, she or they) have this particular illness." Changes in the predicate are shown by such. fiettem as displacement or evasion. In displncs- nent the eentencc night tied “I have ecu other kind of illness," em... with evasion, whet.” Change: in the verb are it would be, "I have something, but I don't m qualification or alteration of tones. In denial the statement would be, “I don‘t have this particular illnessg' a. qualified sentence would read, “I light have this particular illneseg“ while with alteration or tense the sentence would be, "I as this particular illness,” flown by deniel, Sons language psttems- modify the sentence as a whole. " If the patient mice, or 1: n. introduces his etstewent by saying. "no doctors tell me theta...“ any, pert or all of the sentence my be emailed. Other reactions, particularly those noted under mytcl amid giving any meaningful statemt at ell. In the withdrawal reaction w”... �W, wwcww—mw '-—-—'- ..r.-_m..—w., ”fir .,,,,.:.._._‘,._.. r_.‘-“‘1KvW“fiW——r—W‘w‘wwflwmwwi'w ,_,. WWW .Vw—ya-awwmwnmr an... Wpemsaysnoflfingormiupertottlnsen’om. Intheuseotoliohesot cryptic expxessions no specific referential meshing can be dram free the language. or numemm-WumtwmoW-mmom bot rose mourned him, mrzaniutim a of omioeuon Motorised by so alteration in the petient's attitudes to his problems and his illness. The patient either says he is not now and never has ill, displaces his illness temporslly, or parsmslly, in less committed to his or his illness by the use of quelifioeums, or avoids the whole problem by evasion and These pettems en oonpereble to these noted previously by Weinstein end Kahn (1) in patients with cerebral disorders, and who Memo to than as the "m3. w spam use of detain." Sinus: lsngusge mm” Manon. changes have also been described following other emetic therapies. Frank (7,8) reported that lebotonised ptiente avoid talking sheet the operation, end he states that " the teoility and glibness with which they say Well 1 had so operation for nerves, I guess' contain the quality a! moon-:' scion!» q denial." Benoit (9), working mummy with postnlobotouy patients, some ‘ persistent attitudes a: denial. the patient. when asked why she ems to see the doot-or, said it was her, relatives' idea. new game qulii'ied responses, saying they owned the operation was on the brain, or used an evasive, stereotyped «passion as "sou nerve in there,” or aispleoed the procedure es in “oh, yes, I went to the hospital and got one black eyes.“ when asked “suppose“ they had an operation. Others ' about the symptoms that led up to the eperstioo suoh responses were given as ”it seems to have gone." In stucbring patients who showed clinical improvemt following prelooged om reactions in insulin eons thin-em, we have noted sinilsr changes in lengoege. In a ease report (.10) we noted the sppeerenoe of nduplicetive phenomena, evasion, verbal dermal, displacement, incmsed use or stereotype expressions and cliches, eryptio responses and moh mung and laughing at pmemt was most marked. s. time than clinical ile- �wmmmemMMp‘mmm mmmamuwmmmmpmmmum mmmum nugtammmmmr ‘mmumm mmwuumpmmmm MWmm mmammammwmwmm ultimatum awn'mmamhMMuMdemwmm utyotrmdummwdmmpmmwmututamw mmmrormmumummm um. mapm,m,mmummumwmu unwumwwmmammwpflmm mommd'm mummommdhwudmmmm . mmwmsmméhmummt. 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It. in $311: mm. mum to the pntiont'u problem and 111m” talcum. am. _ War the conditions a: slum brain .w-wm. __..,‘ ’n’rr' 2-}— �1o “sustain, E. A. and Kuhn, R. L. AW, Springticld, 2. , 1111mm, 8mm, , . W cum: of L. A. and Man, ("mm Sodium") 39am. I maul! Evacuated. mm, 1955. L. : Dwain Us. at Ambaxbitul 6. argma Brain 1n Symbolic and maul, Ann-1m J. meant... $183943?!» 1953.. ”J 3. _____, and mm, Psychintg, E: Serial Administration at the for ”Am/ta]. Test." “mm, MILL. Arch. 217.226, 1951;. 1!. and Yul-match, E. A. s h. mm, R. 1... Pink, cation and x It: Diagnostic and Prognostic Vila, Brain 131mm: a: 3. mm in Ebotroflxock Therapy, 361.31% Between Alum: Bran rm- L114. Arch. ”enrol. G: ' Pageant... in press. 5. Renown, E. It: am: 1., L. and Kuhn, B. Linn.» Kantian be the of Timmy La Psychosis During Electmhock Shock Ehex'npy, Am. J. Paychiatu ' 14. and mm, 3. Lu Quantitative Studies mammm. m. cm 7. Frank, J. I clinical Survey J. fluent. 301., 8. 23! 1;th, 0.: Dani-.1 161. 1994. 10. ram, R. Body at 1956. , 7 (Putnam mom) Under Psychoanalytic u a comma m” in Post know, yummy, u: 1531 1mm 0m 11.: morally. a. 11. Hem-tan, E. A. and Kuhn, R. In: Arch. Activity Founding 354:3. 1950. I... Gmubert, n. and Fink, Am:- - mm o: 200 Cm: or Putnam Macaw, of lobotomy Scrutiny, Psychiatry. 9. (mm). Heumphysiol. g: 158 and Slow wave ”7-508. 13%. Some Aspects I 01‘ mt ' 22-26, 1952. 6. Pink, Burk» mm. a: Pawn»... éi‘ Delusional Redupliaation of Parts at th- mum. Wm, Personality Eastern b; ”Iv-1&7. 1955. 1:: Denial of ’ 355-367, 1953. Inna”, �"fl..- v.w-m,.__wWR—v~.....,1,..e..r.»-w.q.w,__ v7 Koch, P. 313., n. : no Prognostic n W “F" _~—,w .— Mm vunw H.‘ r u-vn ~..»u-,Ww—~wwwwnw~. WVWVWW ,wuwyfl—w ”Maw—v.4. 1911.6: Roma, 3. A. and men, n. 4.: lid in Insulin and Home]. Shock mgammg ‘I‘hompy (was Pmeox), m. a. Paychitt" 2g: 327. 3.939. 11;. ‘swa ant. Status as Memo-1- and Thoupy, J. Harv. Mont, m8 W59; 13. Harris, :4. a... , scum was. as a of Inantal Patients Mm», a. s. and Hop-,4. u. ! Pragmatic van; ,0! 1:11.va amusmum at Mm W]. in ease: of Schisommin, Arch. 3mm}... & Wt.f 5g: 86400. ' 191.1. ' um" , l u, ,, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Changes in language during electroshock therapy. In P.H. Hoch and J. Zubin (eds.), Psychopathology of Communication. Grune and Stratton, New York, 1958: 126-139. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-27-002 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and reprint. Reprint from Psychopathology of Communication Grime & Stratton. Inc., 1958 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/73f23282cc67af28739fea856ee770e8.pdf e300a093a9da17b1283d89c0561639fc PDF Text Text Reprinted from ”Electroencephalography and Clinical NeurOphysiology Iournal" Vol. 10, No. 1, February 1958. LATERAL GAZE NYSTAGMUS AS AN INDEX OF THE SEDATION THRESHOLD 1 MAx FINK, M.D. With the technical assistance of HANNAH MOSQUERA Department 0] Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. (Received for publication: October 17, 1957) On reading the report of Thorpe and Barker (1957) in the recent issue of the Archives, we were moved to assess our own experiences with the sedation threshold, and to report a clinical guide to the “inflection point” that we have found useful. Following the initial description of the technique by Shagass (1954), we modified our tests which included the administration of the amobarbital test for brain dysfunction (Weinstein et al. 1953) to obtain a measurement of the sedation threshold as well. Our technique was identical to that of Shagass, with the addition of the measurement of nystagmus on lateral gaze which the latter test required. The change in beta amplitude in the EEG was measured visually in consecutive samples of record, using the additive ruler described by Shagass. In the initial group of patients, two observers were unable to identify the onset of slurred speech with consistency. Disagreement led to administration of amounts of amobarbital greater than was required, with the frequent induction of sleep. As we were also obtaining a record of the induction of nystagmus on lateral gaze, we became aware that this index was reliably agreed upon by the two observers, and a correlation with the sedation threshold was sought. We, therefore, omitted the instructions regarding counting and substituted the following instructions. Subjects were told that at periodic intervals they would be requested to open their eyes and to look first to one side and then to the other at pre-arranged tion period. The administration of barbiturates con— tinued until nystagmus was observed, and then an additional 2 cc. were given. RESULTS To date, we have 91 measurements. The following table notes the difference between the number of milli- grams of amobarbital per kilogram body weight for the EEG measure (the sedation threshold) and for the onset of nystagmus. Differences greater than one unit did not occur in this series. The two measurements are seen to be reliably related by a unit of 0.5 or less in more than 90 per cent of the observations. M TABLE I Frequency Distribution of Difference in Amount of Amobarbital Necessary to Induce EEG Change and Nystagmus (mg. amobarbital/kg. body weight) No. Tests (91) 1 47 12 +0.5 +1.0 27 4 Test-Retest Reliability: During these studies we have also had the opportunity to repeat the sedation threshold measurement three to five times in the same patient at weekly intervals. These measurements were done in randomly selected patients receiving subconvulsive doses of elec- TABLE II Absolute Range of ST. Values Range 0 0.5 1.0 1.5 2.0 No. Subjects (16) 0 2 6 2 4 fixation points. This was repeated twice in each direction, usually within ten seconds, while the observer noted the development of sustained regular nystagmus on lateral gaze. Such observation was repeated after each injection of 1 cc. of amobarbital solution, between the 25th and 40th sec. of the injecSupported by the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 1 2 tric current under barbiturate premedication as part of a study of convulsive-subconvulsive electroshock. The behavioral changes in this group were small 14 of the 16 were referred for grand mal electroshock within 4 weeks after the subconvulsive treatment -—— period. The range of sedation threshold measurements under these conditions is noted in table II. [162] �LATERAL GAZE NYSTAGMUS OF THE SEDATION THRESHOLD Being unable to ascribe greater validity to one reading than to any other, we determined the mean sedation threshold for each subject, and the range of variability about the mean. In table III we have listed the subjects in each range of variability about the individual mean value. Thus, the intra-patient inter-test variability for this test in this series is considerable. The test reliability of nystagmus as an index of the electroencephalographic change is well within the retest variability of the test in these subjects. 163 lographique mesuré chez ces malades et dont la validité a été démontrée. Il est recommandé d’utiliser cette méthode en remplacement de celle qui est basée sur l’apparence de troubles dysarthriques. ZUSAMMENFASSUNG Das Auftreten von Nystagmus mit lateralem Blick ist ein klinisches Mass fiir die Sedationsschwelle, welche gut mit dem gemessenen EEG-Index iibereinstimmt und dessen Verlasslichkeit nachgewiesen werden konnte. Gebrauch dieser Methode wird daher TABLE III Range of ST. Values from the Mean Range No. Subjects (16) 0.1—— 0.6—— 0 0.5 1.0 0 6 4 CONCLUSION The appearance of nystagmus on lateral gaze is a clinical guide to the sedation threshold, with a variability from the measured EEG index well within the test-retest reliability of the test itself. It is recommended as a substitute, therefore, for the onset of slurred speech. Further studies of the retest reliability of the sedation threshold are necessary. RESUME L’apparition d’un nystagmus dans le regard latéral est une mesure clinique de la sedation qui montre une bonne correlation avec l’index electroencepha- 1.1— 1.6— 2.0 >2.0 4 1 1 1.5 empfohlen als Ersatz fiir diejenige basiert auf dem Auftreten von verwischter Sprache. REFERENCES The sedation threshold. A method for estimating tension in psychiatric patients. EEG Clin. Neurophysiol, 1954, 6: 221-233. THORPE, J. G. and BARKER, J. C. Objectivity of the sedation threshold. A.M.A. Arch. Neurol. Psychiat, 1957, 78: 194-196. WEINSTEIN, E. A., KAHN, R. L., SUGARMAN, L. and LINN, L. The diagnostic use of amobarbital sodium (“Amytal Sodium”) in brain disease. Amer. J. Psychiat, 1953, 109: 889-895. SHAGASS, C. threshold. sedation the of index M. Lateral as an FINK, nystagmus Reference: gaze physiol, 1958, 10: 162-163. EEG Olin. Neuro- 63:3 �‘ “W 9.13.5? W W ma w Mai mm 0 �mmmmtwmwmmmmmeum MWW,wmnwummmmflm-uwm amummm,mmmauammmmumfimaummv Wtwmfmm. wmvmpumwmmmwmmtz), Wm ”memmwzmmmmumdmmml *mt Warm. {fiwo‘hWtWt 92mm“ wwwmxmmmwmtamm.nw mmumwmetummmummmm fifiwmmm. mmmmwnmmmmmww mmawmmmumm,mmwawmwwm WW: hwqmmefiMgMWWWth mmmmawmeapmmmmm. MW“ aim “Wamflmdmuaf mammmmotdw. uwmduobmmtmmdw fiWmumlmgwmmmtthm numwummmmmmwnWMvmmmm ‘ V “.mm,mimmmmmummmmm MW m 3mm mmmfi mm um um am it mom mummymmummmwmmmawwmnmw mramquWWamrmWWflanummu. Mm MMMmmmmum,ummymm£-nmm.mum mmmmzflmmwwnwamuum we. mmwmmmmatmmmmwxma mummmm,hommzmwmwwmmmm mm. m mumm WWW Mme mm mm m «1’ �mammammmzmmam. mammmflmm. thmmm wwmbmwem(wmmmum)mmrmwt Wmummrmmthnwmmwmh ”W; m Mmummwwfipmf- mmwammtmfiu Wmmwmmumtwmmw mmmm«mhmammmwmwwma mmmmmthmwtmmmmmumuu mm Wu awn w We: m: m WW“ Mum umwamwmmmwmmmmm mm mmmwmmmmmwmmt �«2w «mum 11. W m mm (as) mmmmuwmmwummmmmmow,m humammmuwmmmmwmwwwa wwwmmm. hmmwmmwmmmuum M,WWM$WWW£W wumtmmm ummm. MMW‘Wflanmmwmnm W‘s-mm“ �mwas-mmmummsummmw ummmmwwmmuw. “MW unmm, Wm,mmmwfiww. WW �' 1_ W ' ”W «mummy MW “mm.“ wmmm.muwg mm Wigwam m3. é» 3n & 199:. W”; WW 4: ’ “ ' �W WWW Emmtxy WM? 13' 1957‘ W9; Miter, Section or Awhim Baumlm 5:. , AM. 29th a mu ham, W Wm, DP. Roy W mum. 0mm. 7 of ‘ ‘\ \ 16,, Dear Dr. Grimmer: W Inmadmzhoramtmmloafmmdmrmm pmblem. undead short 45an my am vb» m nth-mung an ”gamut of tho «mum tgnsumtofl this that. cmMahala," we are md to “(nativity at w M15192: than 111th this tout, u an as our solution to pufllol mama “the be of help to note W this note is I: the taunt. at pinned to follow your momma. would be for the Archives, I m Fink, 1w. K3563 �PUBLICATION OFFICE AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET CHICAGO IO. ILLINOIS AUSTIN SMITH, EDITOR, A. M A. SCIENTIFIC PUBLICATIONS A. M. A. ArChives Of NEUROLOGY and PSYCHIATRY GILBERT s. COOPER, MANAGING EDITOR A. M. A. SPECIALTY JOURNALS SECTION ON PSYCHIATRY DR. EDITORIAL BOARD RCY R. GRINKER $R., M.D. CHIEF EDITOR. CHICAGO STANLEY COBB, M.D.. BOSTON GEORGE E. GARDNER, M.D.. BOSTON ““353?st JOHN WHITEHORN, M.D., BALTIMORE Institute for Psychosomatic and Psychiatric Research 29th Street and Ellis Avenue, Chicago 16 September 20, 1957 Max Fink, M.D. Department of Experimental Psychiatry Hillside HOSpital 75-59 263rd Street Glen Oaks, New York Dear Doctor Fink: it will not be possible to publish and we like to backlog, large have a wide selection of papers on many subjects and feel that we have published already all that seems important on the sedation threshold test as devised by Shagass.. I the in your paper am very sorry, but ARCHIVES. We have a Regretfully yours, Roy R. Grin er, M.D. Editor~in-Chief for Psychiatry RRszm enclosure �3.er Dr. Mort 3. Sam, General Putnamtu Boa: (7&3 {’4’ BOWEN, ah. 1957. Hospital, Mt Du:- Dr. Scarab: In vnading : recent. article on the ”mmuvity of the Station Threshold" in the Archives or Barclay and Paychntx-y, we were mud to parallel «panama with we test, as well as our 301an to the problm. I would appreciate your enumeration of this short clinical not» for the Section of 61mm. uni laboratory Notes of the mm m EEG hum]... Simon]: you", mm, 130th HE‘BJB or menu-m1 Paychutry; “on. �3-8200 EXT. 380 TEL. LAFAYETTE ROBERT s. SCHWAB. M.D. MASSACHUSETTS GENERAL HOSPITAL BOSTON 14 September 27, 1957 Dr. Max Fink 75-59 263rd Street Hillside Hospital Glen Oaks, New York _ C.N. #61 Dear Dr. Fink: received and I would like to conditionally accept for Clinical Notes in the EEG Journal as it stands subject to the approval Your manuscript has been it of the Bditor—in—Chief, Herbert Jasper. MW Yours very RSS:mc sincerely, Robert S. Schwab, M.D. �1g 33 ‘12, McGILL UNIVERSITY MONTREAL Department of Electrophysiology Allan Memorial Institute, 1025 Pine Avenue'West, Montreal. September 30 1957 Dr.Max Fink, Hillside Hospital, 75-59 263rd Street, Glen Oaks, New York. Dear Max, to see you for your note on the nystagmus. It was nice at Zurich, and I hope that we shall be able to meet Thank you again soon. My best regards. Sincerely, Cw CS/ef % , C. Shagass, M.D. �12/3/58 Discussion: Dr. Shagass Dr. H. Fink - Hillside HOSpital Dr. Thompson, Members and Guests: It is always a pleasure to read another chapter in the unfolding saga of sedative tolerance tests as they have been developed by Dr. Shagass.‘ This study, like its predecessors, relates neurophysiologic indices to behavioral measures this area of psychiatry, reflects a welcome application science to clinical problems. a and in of basic appropriate to examine this report in the perspective of recent concepts in experimental psychiatry. During the 1930's, when electroencephalography was a new science considerable effort It seems in relating EEG patterns to "personality types" or ”diagnoses,” without success. With more refined instrumentation, there have been sporadic re-assessments without noticeable success. In the sedation threshold, however, Dr. Shagass, did succeed in achieving such a relationship. In these earlier studies, he was expended related the amount of barbiturate necessary, under standard conditions of rate of administration and concentration, to induce a specific EEG voltage and frequency change, to the personality profiles of the Handsley-Eysenchian school. It is important to note that the relationship was not between any fixed aspect or index of the EEG and behavior but between a measure of reactivity or responsivity of clinical behavior. We may carry this description a bit-further. The electroencephalogram is a reflection of central or brain neurochenistry, and the reactivity of the electroencephalogram to any chemical stress, a measure of the reactivity, or reSponsivity, or bufibring the EEG and �of the biochemical enzymatic systems flat make up the nervOus system. It is in this organisnic biochemistry that much activity is now directed in experimental psychiatry. The wide variety of phrenotrOpic agents, the new and more potent hallucinogens, and the expanding technics of enzyme and steroid chemistry are providing experimental psychiatry with research tools of considerafle adaptability. One application of these technics highlighted yesterday by Dr. Gottlieb and his co-workers at the Lafayette Clinic,who reported their ihitial observations on the significant relationships between schizophrenic behavior was and the reactivity of insulin. These of the glucose-enzyme systems to the authors carefully noted that there stress was no relationship between the initial levels of their biochemical measures and behavior. Dr. Shagass' earlier studies of the sedation threshold - end-point - are clearly within this tradition. His report today is also in this general tradition, but instead of a neurophysiologic index of clear definition has utilized a clinical index ~ lack of a verbal motor response to a verbal command - as the end-point. In the report today, he has related the amount of pentothal necessary to induce this state of lack of response (which is defined as "sleep") with the affective state of the individual at the time of the experiment. He has observed that the more fearful,disturbed, tense, angry and worried a subject is, the more barbiturate is necessary to induce using an EEG �-3- quieter, more indifferent, inactive and retarded patient is, the less barbiturate is necessary for sleep. He sleep. a Ehe titration is thus achieving a biochemical titratinn, and is, in essence, measuring the subject's responsivity or reactivity to barbiturate. By repeating the studies seriatim, he is able to report shifts in this state of reactivity. In his desire to extend the sedation threshold technic to situations in which the EEG was not available, and provide for greater clinical applicability, some of the precision of the earlier studies has been forfeited. It is not unexpected, considering the lack of precise definition of behavior as well as the endpoint of titration, that the reactivity-clinical relationships I have noted two puzzling relationships. Increasing sleep thresholds are associated, on the one hand, with excitement, worry, restlessness and anger; but also, with clinical improvement in a course of convulsive therapy. Also, in one are somewhat cloudy. patient, transient induced psychosis sharp drop in threshold, while in the same a LSD is associated with patient, fear of a treatment, restlessness and increased tension are associated with rising thresholds. I would snapect that these apparent discrepancies arise frOm the non-Specific nature of behavioral reaponse to neuro— physiologic change and to the poverty of our descriptive language for behavioral change. I would wonder what shape the curves would take if the change in sleep threshold were plotted against other indices of brain function as predominant EEG frequency pattern or degree of synchronization; or such psychologig indices of brain function as the perception of embedded figures or OFF; or such behavioral indices as dyadic or syntactic linguistic �-hanalyses. Alternatively, more precise,— operational measures of the behaviorll subsumed under "anger," restlessness,¥ "worry” may proiido, again, the relationships indicated earlier by the sedation threshold studies. Lest these comments be misconstrued, let me say, in closing, that Dr. Shagass is to be warmly congratulated in these studies basis for the developing neurOphysiologicadaptive hypothesis of behavior. His demonstrations of central neurophysiologic reactivity in the sedation threshold are in the best exPerimental traditions. We are eagerly looking forward to further experimental neurophysiologic studies from his new which are providing a firm laboratories in Iowa. �12/3/58 Discussion: Dr. Shagass Dr. H. rink — Hillside Hospital Dr. Thompson, Henbers and Guests: It is always a pleasure to read another chapter in the unfolding saga of sedative tolerance tests as they have been developed by Dr. Shagass. This study, like its predecessors, relates neurophysiologic indices to behavioral measures and in /‘this area of psychiatry, reflects a welcone application or basic science to clinical problems. It seaas appropriate to examine this report in the perspective — of recent concepts in experimental psychiatry. During the 1930's, electroencephalography was a new science considerable effort was expended in relating EEG patterns to ”personality types" or "diagnoses," without success. With more refined instrumentation, there have been sporadic re-assessnents without noticeable success. In the sedation threshold, however, Dr. Shagass, did succeed in achieving such a relationship. In these earlier studies, he related the amount of barbiturate necessary, under standard conditions or rate of administration-and concentration, to induce a specific EEG voltage and frequency change, to the personality profiles of the Handsley-Eysenchian school. It is important to note that the relationship was not between any fixed aspect or index of the EEG when and behavior but between a measure of reactivity or resphnsivity of clinical behavior. The e1ectro~ We may carry this description a bit further. encephalogran is a reflection of central or brain neurochenistry, and the reactivity of the electroencephalogram to any chemical stress, a measure or the reactivity, or responsivity, or buflhring the EEG and �«2e- of the_biochenica1 ensynatic systems fiat make up the nervous system. It is in this organisnic biochemistry that much activity is now directed in experimental psychiatry. The wide variety or phrenotropic agents, the new and more potent hallucinogens, and the expanding technics of enzyme and steroid chemistry are providing experimental psychiatry with research tools of considerafls adaptability. One application or these technics was highlighted yesterday by Dr. Gottlieb and his co-workers at the Lafayette Clinic,vho reported their initial observations the significant refationships between schizophrenic behavior and the reactivity of the glucose-enzyme systems to the stress of insulin. These authors carefully noted that there was no on relationship between the initial levels of their biochemical measures and behavior. earlier studies of the sedation threshold using an EEG endspoint ~ are clearly within this tradition. Bis report today is also in this general tradition, but instead or a neurophysiologic index of clear definition has utilized a clinical index - lack of a verbal notor response to a verbal Dr. Shagass' - as the endnpoint.' In the report today, he has related the amount of pentothal necessary to induce this state of lack of response (which is defined as asleep“) with the affective state or the individual at the tins of the experiment. He has command observed that the more feartn1,distnrbed, tense, angry and worried a subject is, the more barbiturate is necessary to induce �-3sleep. the quieter, gore indifferent, inactive and retarded a patient is, the last barbiturate is necessary for sleep. He titration is/thna achieving a biochemicat titration, and is, in essence, measuring the subject's responsivity or reactivity to barbiturate. By repeating the studies seriatin, he is able to report shifts in this state of reactivity. In his desire to extend the sedation threshold technic to situations in which the EEG was not available, and provide for greater clinical applicability, eons of the precision of the earlier studies has been forfeited. It is not unexpected, considering the lack of precise definition of behavior as well as the endpoint of titration, that the reactivity-clinical relationships are somewhat cloudy. I have noted two finssling relationships. Increasing sleep thresholds are associated, on the one hand, with excitenent, worry, restlessness also, with clinical improvement in a course of convulsive therapy. also, in one patient, a transient LSD induced psychosis is associated with a sharp drop in threshold, while in the sane patient, tear of treatment, restlessness and increased tension are associated with rising thresholds. I would suspect that these apparent discrepancies and anger; but arise from the nonnspecific nature of behavioral response to neuro~ physiologic changa and to the poverty of our descriptive language for behavioral change. I would wonder what shape the curves would take if the change in sleep threshold were plotted against other indices of brain function as predominant EEG frequency pattern or degree of synchronisation; or such-psychologtg indices of brain function as the perception of embedded figures or 61?; or such behavioral indicee as dyadic or syntactic linguistic �l-h‘ analyses. Alternatively, more precise,~ ofierstionsl measures of the behavioral subsumed under ”anger,“ restlessness,1 “worry" hey provide, again, the relationships indiohted esrlier by the sedation threshold studies. Lest these comments he misconstrued, let me say, in closing, that Dr. Shegsss is to be warmly congratulated in those studies which are providing o firm basis for the developing neurophysiologica adsptive hypothesis of behavior. his demonstrations of central neurophysiologio reactivity in the sedation threshold are in the best experimental traditions. we are eagerly looking forward to further experimental neurophysiologic studies from his new laboratories in Iowa. �qt- I ZIN’EIQAL. 614245 ' ‘ QM r r; m Marlyn»; #ng /% 4n Z/{[ 5/ ’f/e. /3~f7 Ska/177m Amt gnaw; E u, . . 7:va E Wu” E :1va E I . m,“ 1W 1W" ‘ quwr—rrw—nw—v /M /W flaw @524: // M" am/ZEWW/éwu Lb 7%“ @43’ W WM &%M/w/’ Aruéda 54% E E E E M7424 - . �W we moved reading the report of Thorpe and ' in the to assess our own W5 /Q1(LLAAjr Barke%ajm issue of the Archives, we were experiences with the sedation threshold, and to (2 report anether clinical guide to the "inflection point" that useful. ' ‘ ’“ n U Following the initial description the adninistration of the amobarbital W / )1 "# WWW Our ’ ' / ' “‘ '* have found, we ,, I _ / " fir of the technique by Shagass we modified flat: is: iifi— our seaside which included test for brain dysfunction (-Weéna-teim, to obtain a measurement of the sedation threshold as well. technique was identical to that of Shagass, with the addition of the measurement of nystagmus on 775: lateral q change gaze which the latter test required. 7h4¢4ww¢16f EEG was done- visually ‘ ‘ in beta amplitude in the in consecutive samples of record, using the additive ruler described by Shagass. In the initial group of patients, two observers were unable to the onset of slurred speech with consistency. identify Disagreement led to administration of amounts of amobarbital greater than was required, with the frequent induction �-2l?!‘ sleep. gaze, As we were also We, ML. Wis-of :_ reliably that this index was we became aware observers, and w/umd 9/ obtaining /“45“¢’7"" nystagmus on ?/ lateral agreed upon by the slur-e W..a.correla.tion withthe sedation thresholdwv W/{Z‘ therefore, omitted the instructions. regarding counting stituted the following instructions. Subjects intervals they would one side and then be requested to were their open and sub- told that at periodic eyes and to look first to the other at pre-arranged fixation points. This to was repeated twice in each direction, usually within ten seconds, while the observer noted the development of Sustained regular nystagmus gaze. Such observation was repeated after The injection of lateral 1 cc of amo— N, ~: ‘ . “42" barbital solution, each on between the 25 and ho seconds of the injection period. administration of barbiturates continued until nystagmus was observed, and. MW ’00 (Lou and then ?WU°: ——————-—_ To more were given. date, we have 91 measurements. ,, difference between the number of thes926an threshold and W W . MW) not!“ the : milligramkl (/19 m7... of ambbarbitaljfo/r Mafia,” for the Onset of nystagmus, reflects-enemi- Differences greater than one unit did not occur in this series. The two measurements 7,2 79/1; following table 4 The arenreliably related by a unit of 0.5 or lessxw Wamflm~ Z... ‘ ' �-3I TABLE Frequency Distribution of Difference in Amount of Amobarbital Necessary to Induce EEG Change and Nystagmus (mg Amobarbital/Kilogram Body Weight) No. Tests .100 .005 0 +0.5 +1.0 l 12 h? 27 h \ ?// ; Test-Retest Reliability: During these studies all» we ' havenhad the opportunity to repeat the sedation threshold measurement three to five times in the intervals.- weekly These measurements were done patient at same in randomly selected patients receiving subconvulsive doses of electrnc current under barbiturate premedicationqi as part of a study of convulsive-subconvulsive electroshock. changes in this group were small - fourteen of the sixteen The were behavioral referred for /z~n/¢‘¢A{4”~*¢¢ég«~0 ' grand mal electroshock within four weeksye7/ngr . ‘ (fl/$4,224. The range of sedation threshold meaSurement?under these conditions noted in Table II. TABLE II Absolute Range of S.T. Values' Range My, Subjects (/4) 0 0.5 1.0 1.5 2.0 o 2 6 2 h >2.S 2 ff’a./§L»«# is �-hBeing unable to ascribe greater é validity . the we determined we have mean sedation threshold for each subject, subjects in the-m mdmadud MM. value. the listed WE: W W one reading than fies any each range of M basis variability ’ mean III TABLE Range Range /o. fiubjects (/5) other, of S.T. Values from the e 0.10.5 0.61.0 o 6 h 1.6- 101'- 1.5 ’ “N‘r‘m-wrv .,.m 52.0 2.0 7 h J Mi."- Mean 1 1 , . ., K.,.fim’WhfiW-am~w-.w:122-w 7 Wat, {is mus-patient;inter-test variability for this test in this series is considerable. test reliability of The electroencephalograpmzhc change is well within the retest variability of test in these subjects. Qéz: the adapted the appearance of nystagmus on m a ; / J1/ J 1/}, C- i ’ / A A f" is / / /z€—— "/5 I I , [KI-A ,5 - ,v clinical guide to a ‘4’; my: M , fl» gray 1.47! /’L! CW/m4‘4flt (331’; fi{ I, ;’(f fl ,Cy «a, ' M; gaze WWK .ma- Asa/2w ,Aaé .4 // My 4 Wfiffeéé: fr!» WI mat?» lateral WRfi—WW the sedation threshold, a; nystagmus as an index of the AA“: iséwtu/MA‘I (2: 7! /)/”/»£¢A/L.( M #63“e/ Ca” we '1’ .11“ fl¢»%flw//L{u¢{304?“:{3’ a? / ,. 3 if '4" ”17’2“" r , _.;__.‘ 4’ "I; a: A" {fi’flg‘t . ,, ,4? Ayifi ”(:4'5‘ Alt—‘3 / A’Jik �, ..‘ )- I *’ Wv .1. C . ya $407M Mann}; 4 M4, /:7 a4“!!- C . 74V galvauE/Zw/ I £44373; 59:7. Z—f: M4. 41% ’7sz /f4/A/75, (”fif) W77er?“ ' #1 %@‘*’5‘“ g CL .‘ «9-9/-'.?33, ‘ /7f¥, M . ‘ / $42M” ~ i ) fltm NA /‘J3, /flf: ff7~ff~c '/ $4,441,, V . flu d {7 . /% (1;.1'5 7. �THE LONG ISLAND JEWISH HOSPITAL 270-05 76th AVENUE Department of MEDICINE 0 NEW HYDE PARK, LONG ISLAND, N. Y. - TELEPHONE: Fleldstone 3-6700 �Suptonbar 21, 1961 ntrtin H. rats, Ph.n. Reiuurch Piyuholosint Paychophurnnaoloxy surviuc Cantu: o: nautnl Bonita lation:1 Institutg Md. Buthnldn 1h, Dcar _ flirtin, tour lattqr regarding 1 r0110! o: it: Iodaiitn thrcihold attack a oynpsthcsia chord, and I an caconr:god to share my Vitus with rat, Buvavcr, tin probla: in acuu plax tad perhaps no as: not anido tan. tin. in Huntington fur a dutuiled diacunuion. Hy interest in tho sedation thronhaid van cooulionnd onrlicr intarout in tho at. 0: intravoaonn snibirhitll an a fast tar brain dynrunation. Hoinltciu and Ichni Donitl at Illa-an c c. ThOIIl, 19 S) In tn. court. of ofcoifiucfioci 05:310., we curriod out many out13¢tau at tho 8.2. .36 can. to it. eontlalion taut sh. inst was phyliylogically and itchnically Hound. Finding dylgrthriu I difficult ondnpoiut, I lubntitnicd nyutccnuu; but in raulity, thin can b: dilponlod wish, ninco tn. acnlurod and-puini in to. EEO tbs 3.3995: by ny aarpud nhoui drunrthrin, corroct ll tar an int: hlvo (out, but thin dittiauliy intr.not inlnrunuBStblo, uni boar: no aigaitiaing rolgtion to the valet at $8. tout. the critic: who have The quantiann It inane trot II it. tlli stunt. in in: can. individual .v-rtiuo? 2. In thuro a charteturiltio tcapanao which boar: a oiguir10§nt1y high corroliticn with n bchnvioral Vlriibli - ntnnly, sh. oililifiottion by psychiatriltl a! tangent: iuia uolclogic (racy-9 1. �0-2- 3. Thirdlr, your quclhiou, “it true, it (8.1.) ahvioualy can b. very alarm! in trtttnaut firodiotion nhndicl'. 1. Out Inn uxp.richou indiohtUI that : high intrh~ individual variabiliir; a limited ran 0 at vuluon tar thc halt (tvclvc point. from 1-6 in half than. and an oqnivocnl EEG 0nd»point in 10-20! a: test: lit?! to nuko tha rnlihbla duturu ainntion if tho 8.!. difficult.’ that. vurinblcn soon inhurout in th. taut danish, and Ira not, in :1 opinion, I luck or know-haw by uh. ohlurvcrl. 2. no. Hy nogahiva unuwar to thin question is partly hhoad on (1); Ind partly on tho uuucl dittioaltios at nonology. in somewhat limplowmiadod to uspuat a high corrolntion It betwocn a 'uinplt’ phyiinloxic rotativity naulurc had a “90:91.3” hypnthctie clhatrnat with '0 Inch inhtront unhigui» 3 hy Ind variability. in: 3.2. may hat bu rnlutcd in diagnosis; aha the 3.T. h. unoful in truttacnt prediction? I think it uh: ha, ~~ not for hhc losicul raglan: anuuily IiVOI, but blcinll of the value of tha tout an I .anctivity” nth-urn. In the pulh tow ybnrn variouu indict: huvo blln nhaua to huar IOll rolatiou to trontnont or to diacnnlis ~hnd ouch influx it halt huh-ulna under tho hgru or a 'ruautivio influx”. HO utatod hhht pationth vhe chowod two or nor. tr laughing «hangs. utter intrtvonoun uncharhitnl war. nor. likely to thaw curly EEO ehnnsun httnr uloetrouhock, had to 3. Evan ihough aha: gruntor dncrucn or hohnviortl church and iuprovonnnt of Cenaunieatign, 126 - 139, 1958). Goldntn pantothnl burnt. tr. 010' ’3'; a o thin in uppchrsaoo in achiIOphronic nnhjocta, and ht! unod tout protnouticclly. Siuilhr mittencutl hart bath midi, in £36 Ctt‘uli nor. quantitttivo Itudinu, by Itil (Erlungun) (Milan), why havu rclntod thn changod EEO putt-run to corehrnl ltrophy on pucnnaoneophulozrtphy. In hnothcr type of studios, tho bland prolhnro rcupan-au to nocholyl and to harshnlin have bath roptahcdly Incgnutod an a dilflnflltic had prognontic 136.3. A cannon bhaiu in thcnc Ithdiou in that u link of reactivity or a alow ranchivihy in zanornlly taunted vith schiloyhruni: 0» brain atrophy ~~ a poor proxnoutic high to: the artillhlo thsrtpiol; whil. high rtnotivity in aquutnd with écprcauivc syndronon ~~10w: [and tauntivprognostic sign with awnilhblh thnrapitu. Than, invoked indux or but hi an high any your prtgnoling a: it: ruaahivity will bchr A high wurrulation with hshhvioral chaugu, had a varinhlo In. with inprOthont rutinzs. (3.0 �.3our views of beteviorel change and inpreveuent ratings, Arch. Gen. Feloniet. g; 259, end 5; 30, 1961) Thus, there is much merit in Shannen 8.1. -- not, in .my View as e diegnoetic index (for age is much more relieble and easier to ascertain), but ea one guide to neurophyeielegic reeetivity -- e eubaect that needs {nether study as e preg- noetic and as]: noeelogicel teal! I trust this in reeponeive to your inquiry. I would 16-1? ?) like to disease it acre fully in doWashington (October the 8.1., in end wenld recommend that if yen get interested on veriene reactivity that you consider 3 eeriee or aeetinge ueeeuree in plyehietry .. the neehelyl test, the 8.2. end the coldnen ee exemplee at the more explicit. My regerde. sincerely yours, Hrcdte ex n , “.5. �I1 I. I. I $5 I [3 EE P1 (3 55 F’ I'T'l\ I. FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263RD A. MILLER, M. D. , , Medical Director JOSEPH S. SIMON KWALWASSER, FIELDSTONE LEON LOWENSTEIN 8-7800 Department Of Experimental Psychiatry M. D. Assoc. Medical Director MAURICE STREET. GLEN OAKS. NEw YORK BACHRACH Honorary Chairman Board of Directors ROY .FOSTER Chairman Board Of DWWOH ALVIN E. COLEMAN Administrator President September 12, 1957. Dr. Roy Grinker, Editor, Section of Psychiatry, A.M.A. Archives Neurology & Psychiatry, 29th Street & Ellis Avenue, Chicago, 16, Illinois. Dear Br. Grinker: In reading the report of issue of the Archives, the sedation threshold, Thorpe and Barker in the latest (August) to assess our own experiences with and to report another clinical guide to the we were moved "inflection point" that we have found useful. During the past two years we have included a measurement of the sedation threshold in our tests of brain function. we initially followed the technique described by Shagass (EEG Clin. Neurophysiol. é: 221-233, l95h). Measurement of the beta amplitude reaponse is done visually in several samples of record using the additive ruler described by Shagass. initial group of patients, two observers were unable to onset of slurred Speech with any consistency. 'We, therefore, the identify omitted this step, and continued drug administration until gradually drowsiness was clearly manifest, combined by a statement by the technician that an increase in beta amplitude in the record had occurred at least 1% In the minutes before. that occasionally amounts of amoreach an inflection point were administered. We, barbital inadequate to therefore, began to note'the onset of nystagmus on lateral gaze as a guide to the sedation threshold. This technique had the drawback Subjects were told that at periodic intervals they would be requested to open their eyes and to look first to one side and then to the other at pre-arranged fixation points. This was repeated twice in each direction, usually within ten seconds, while the observer noted the development of sustained regular nystagmus on lateral gaze. The administration of barbiturates continued until nystagmus was observed, and then 2 cc more were given. The EEG records were then measured for the inflection point by the visual method. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �Dr. Roy Grinker (Contd) -2— To date, we have 91 such.measurements. In the following table, the difference between the point of onset of nystagmns (nystagmus index) and the inflection point of beta amplitude change (EEG index) is reported. Difference .100 1 EEG Index s-Nystagmns Index .005 0 +05 +1.0 12 h? 27 h Differences greater than 1.0 unit did not occur. It is apparent that the nystagmus end point for the sedation threshold is reliably related to the EEG end point by a unit of % in more than 90% of the trials. Since the error of the sedation threshold under test - retest conditions is between 0.5 and 1.0 units, this nystagmus index is a satisfactory guide to the sedation threshold, as defined by Shagass. W In our continuing studies of the sedation threshold, we have, therefore, ceased measurement of slurred speech or drowsiness, but have relied on the onset of nystagmns as the clinical guide to this index. I trust that this data may be helpful to other investigators. Sincerely'yours, v ,4 a’V‘wflwc has: MF:JB _ Fink, mm. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Lateral gaze nystagmus as an index of the sedation threshold. Electroencephalogr Clin Neurophysiol. 1958 Feb;10(1):162-3. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-28-003 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 12 items. 1: [Preprint]. 2: Reprint from Electroencephalography and Clinical Neurophysiology Journal Vol.10, No.1, February 1958. 3: Letter to Dr. Roy Grinker form Fink. 4: Letter from Grinker to Fink. 5: Letter to Dr. Robert S. Schwab from Fink. 6: Letter to Fink from Schwab. 7: Letter to Fink from C[harlie] Shagass. 8: [preprint] to Dr. Thompson, members and guests discussing Dr. Shagass (2 copies). 9: Handwritten notes. 10: Draft with edits. 11:Letter to Martin M. Katz from Fink. 12: Letter to Roy Grinker from Fink. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Mosquera, Hannah Published http://exhibits.library.stonybrook.edu/mfp/files/original/f8b5cf3cf6b847561379d21a8181ceef.pdf 550c4683b921dafa008583e1e9dd5aff PDF Text Text ��COPY Clinical Release PRODUCT Combination of 'Thorazine' and Diparcol (SKF #1026-A) Diparcol alone 'Thorazine' mg/cag. ca . FORMULAS 50.0 mg. H01 2.0 Magnesium.Stearate Lactose 200.0 -__- ---- mg. mg. 300.0 mg. is. Restricted Medical Utility Studies - Dr. Herman Denber TOXICITY Acute Intravenous Toxicity The intravenous acute toxicity of a combination of SKF #1026—A ('Diparcol') and 'Thorazine' in the ratio of 5:1 was determined. Intravenous LD50'S in male mice (CFl) were determined for SKF #1026-A, 'Thorazine' and a combination of SKF #1026-A and ‘Thorazine' in the ratio of 5:1. The mice were observed for a 2h hour period, at which time all surviving mice appeared — normal. Combination significantly more toxic than SKF #1026-A (T.R. = 1.2) 'Thorazine' ngt_significantly'more toxic than combination. (T.R. 'Thorazine' significantly more toxic than - 1.36) SKF #1026-A (T.R. = 1.13) acute intravenous toxicity in mice of a combination of 'Thorazine' and ‘Diparcol', in the ratio of 1 part of 'Thorazine' to 5 parts of 'Diparcol', did not differ significantly from that of 'Thorazine' alone. Such a comparison is valid since the slopes of the toxicity curves are parallel. The combination is significantly more toxic than 'Diparcol' alone, but the comparison is subject to criticism.that the slopes of the toxicity curves are not parallel. The December 9, 1955 �DIPARCOL In answer to your request an attempt has been made to find data comparing the anticonvulsant activity of Diparcol (Diethazine, SKF #1026) with.that of other phenothiazine derivatives: Phenergan (SKF 1&98), 'Thorazine‘ (SKF 2601), Promazine (SKF 3h06), 'Compazine' (SKF h657), SKF 5277 and SKF 5116. No such studies have been done in our laboratory. The only SKF lab report on Diparcol gives its toxicity as LDSO * 31.2 mg/Kg I.V. as compared with 22.9 mg/Kg I.V. for 'Thorazine'. Balestrieri (1955) compared Diethazine, Phenergan, Parsidol and chlorpromazine with respect to their protective action against electroshock and Metrazol seizures in rabbits. Phenergan and chlorpromazine showed no anticonvulsant action against electroshock seizures; Diethazine, 5 mg/Kg I.V. protected 2/5 animals and at 10 mg/Kg I.V. 3/5 animals. Parsidol protected 2/5 animals at both doses. These results confirm SKF data obtained using maximal electroshock seizures in mice which showed no anticonvulsant activity for SKF lh98, 2601, h657 or 5116. SKF 3h06 did protect mice against seizures; the ED§Q was 155 mg/Kg p.o. SKF 5277 also demonstrated anticonvulsant activity with an oral ED50 of 71.0 mg/Kg. , Balestrieri snowed chlorpromazine to be Metrazol seizures. Phenergan was inactive inactive in protecting at 5 mg/Kg I.V. rabbits against but a 10 mg/kg I.V. protected h/5 animals. Diethazine protected h/5 animals at 5 mg/Kg and 5/5 at 10 mg/kg. ParSidol protected 5/5 animals at both doses. ’No similar SKF data are available. The experiments of Anticonvulsant action and molecular structure of phenothiazine derivatives. .krch. Int. Pharmacodynam. 103:1-11, 1955 Balestrieri, HLM:pz hc A. �COPY- PHARMACOLOGY REPORT November 8, 1956 10-(2'-Diethy1aminoethyl)-Phenothiazine Hydrochloride 0R (Diparcol) SKF No. 1026-A Compound: Code No. Lot No. 99 Structure: )W ii /” '\\ K\//h\§v/\ EV 1 9H2 l c H2.N-( 02H37~2 mignzim.R.T.Cmma' Tested for: Dose Range - .HCl Mmda Studies in mice after intravenous administration (11/10/55) Observations Dose rug/kg side effects 2.5 No 5.0 2/2 slight depression, loss of pinnal reflex 2/2 ataxia, sl. depression, loss of pinnal reflex, 'Thorazine' walk. 2/2 ataxia, marked depression, dyspnea, 'Thorazine' walk, loss of pinnal reflex. 10.0 15.0 6/6 clonic convulsions, apnea, prostration, ataxia after recovery, hypotonicity, 3/6 dead 2/2 clonic convulsions, apnea, prostration, ataxia after re- 20.0 25.0 . cover h otonicit Note-—all animals recovered from.prostration within 60 minutes.. Summary: exhibited 'Thorazine'-like side effects after intravenous administration in mice. Slightly higher doses were required to produce depression than with 'Thorazine' and the depression produced was of shorter duration. SKF #1026—A 'Thorazine'-like Activity: Charge: Biological screening GW/IB/m/mh �LILLY LABORATORY FOR CLINICAL RESEARCH INDIANAPOLIS GENERAL HOSPITAL INDIANAPOLIS 7, U. S.A. December 29, 1955 Max Fink, MOD. Hillside Hospital 75-59 263rd Street Glen Cake, New York Dear Dr. Fink: In answer to your recent request, Storey et a1. (Antibiotic Med. & Clin. Therapy, 2c258, September, I§§STI though they do not report electroencephalogram findings, do discuss the behavioral effects of cycloserine. There have been no publications, to my knowledge, reporting EEG findings in patients receiving 'Seromycin' (Cycloserine, Lilly). Veterans Administration hospitals have been doing EEG tracings but their reports have not yet been published. They will probably present their data at the Veterans Administration Conference on the Chemotherapy of Tuberculosis to be held in St. Louis in February. do be not we of further please may assistance, any If hesitate to w rite us. The Very truly yours, f th, M.D. ri Clinical esearch Division R. mlw 18760EIGHTIETH ANNIVERSARY-1956 �TELEPHONE: LEHIBH Form 90a-Adm. 4-1300 State of New York Department of Mental Hygiene MANHATTAN STATE HOSPITAL JOHN H. TRAVIS, M. D. DIRECTOR IN Ward’s Island, New York City 35, N. Y. ANSWERING REFER To ______.______._____ Dr. Max Fink June 20, 1957 Hillside Hospital 75-59 263rd Street Glen Oaks, N. Y. Dear Max: your findings on I should like very much to include Chloram on I that writing the final in paper the 'Diparcol' me send Could of you Treatment Depression. promazine-Diethazine diethazine I.V. of the effects in general, note indicating, a brief on the EEG? Were there any concomitant psychological effects? of "personal reference under the of note I will course, this, communication." Many thanks. Sincerely yours, [/7 HD:SS Herman C. B. Denber, M. D. Director of Psychiatric Research �4;:- x} June a?) 1957. Dr. Hem 6. B. Ember, Dimmr of Payehiatma Bsmmh, Mahatma; State ammm, ”55W"! 1818M, ”at. f: , Dear Hm Itwaaaplmto Atlantic city. I am aomr that mm we We withyouandymwfiein mum could not. get. smother for "mucus“ much. Johanna and cmvisit. I social enjoyed bht very Mb: 5.3 who: moth with a wry Might. boy, But this yw' almdy may: Mahala, Ina 1mm. A9 fer our “parlance with your suggestion in 1 obtained some intmous manual from SKI. In the last 1w ‘mths we hm given it. to six ”news intmmly. Evin subject and tt. {um at" electroshock therapy and the trim of the I. of much. In sank instance high height. of m: mo 1n In: an the premix "mag abatmmphdogm u’mrity tam. the but situation, in which I and an we qmamm 3 and than remand after the parlour M the Watt-attests cf the d 50 2 of the The rate was mm. dosage drug gvmat smnmum. and than abuut for thirty ”cording a at. of the air. rate mast how the to for eight Manama unplug :pprmntnly mm hour. mm. mm mm, W 93.03th m m mm W» 6!me We: m. mum WW m W m ma Way m hiring the ministmtion, each patient Moped, batman the coma um fourth cc. m epdseda of waging. mare m macaw in breathing which an trunnion. This was the mat untoward attach a: m m alaotromcophnlosnphia ohms pared gradually but was mt. M: the: tho of minutes n injection. within tan 150 ace mm apparent. to thin tin mm veto mead rm a may a! than mansions 70 rum rmmyms toammcf in mm» Wt.- mmumm. tamper-u MWalimdzm;wnwegemmWoffimSma cent. tin 691th, however, mad about the sum. Mb 3:: «that peanut! far one to an hours and in :1]. WWW 1n the maples “loan about four to time: hours liter the Gilt: activity at at the pro-injection m1. In an. “outpatient:mdauutifltymmotthaomrofhto66330.3“ caplofion of the Winn in value” of he to 70 UN. mm the delta activity am: ”My ma in pomnt tiny and in voltage u: that. m an: amount! mam- him he Waits. nun appeand stupor-impound film �Dr» new at Bar mr, #2 a clearly defined 25 cpl. nativity... Tlmm records the the was an ”alerting? following. report Warmly animated by an incmaad methane” ai‘ we patient and a crust. “ibis greater difficulty in having the patient maintain his eyes gazed, ma tbs change in hm patients from: a "Home for this alerting phenm effect to a mgative am)... The changes in language after positive were the reverse of the changes in language which we have axperlmcod 131ml 1n the past after tho amatmtion a! mama-him. Since we use the identical w scone the changes in 11am in an Mammal fashion. In maimaim, three Mamas the questions prior to the of Dime}. wen 11-. and therefore to ovum.“ the changes in Imam. negative Waible & “manure" In one manna tha max-d changed in to an 1mm. mama clung» of the kind tkmt we see: with mbarbim. This dinmponcy I. cannot explain. m m m1 m 1mm W10 rm manna; am eontinning this study and I would 11m to pmmt the behavioral and electroeneephalog‘aphia effects My in the £111 to the Eastern EEG Association. Thaw observations are, of eourse, migratory and I am not 8m 8 UT the next batch or patients may not shot-7 us some other patterns. To tho flat extent. that. this inmatigation has confirmed the observations of Leann”, I an moat yieased. Ha I have no objection to war reporting some of this itfl'omtian in outline. If is of any help ta you, I will be pleased to see the paragraph: as yen intend to report, them and give you my reaction as to how they reflect. it our axpoziemaa, Sincerely yours,Kn: Fink, Dani-haunt at MFtJB mammal Pnyuhiatry. H.130 �“,f ‘i? ziirect i v . i of Diethazine on EEG ’5‘ 0+3 qt I for and Significance Theory of Convulsive Therapy Mauougflwk.fldb Previous studies of the role of EEG changes in convulsive therapy delta activity for have demonstrated the significance of the induced the behavioral re3ponse. Investigations concerning the biochemical substrate of delta in electroShock and convulsions EEG have indicated significance for the cholinesterase - acetylcholine system. reports on by Ulett concerning the effects of atropine and Recent 00’ scogfilflhine the delta response-effihe-EEE-showed a reversal of the-induced patterns. Boncurrent iswmvafi. reports by r and of diethazine on normal EEG and that following Lechner on the EEQ effects trauma provided the stimulus for the study of the effects of this drug in electroshock. Subjects: Twenty voluntary psychiatric patient in an openyward/psychiatric hospital have been tested to date. d " £5? During recording, at various maturing (Biparcol) is administred intravenously at per minuteI Maw “'5’57- £155; xi treatmen . rmi 94°" " the rate of 25 milligrams ‘1 250 milligrams, {My diethazime 70.,qu * �Observations : a) by the of All dryness cmgling, respond subjects Behavioral“ mouth and thickness of speech. Feelings of weakness of extremities illusory sensations are and There common. is an increase in rest- lessness and difficulty in maintaining eyes closed. In patients who have had sufficient electroshock to manifest syntactic and orientation language changes indicative of altered cerebral function, is there ‘ b) EEGSq a reversal of language patterns. . In all subjects there is desynchronization of frequencies \ and decrease in voltage. Alpha rhythms are less prominent. ! low Occasionally, \ -—-a c" In voltage “ILA 577’ frequencies appear. \ voltages-a25of delta with degrees varying activity, patients in decrease‘, frequencies decrease and burst activity disappears. Irregular alpha and beta frequencies of low voltage become c) The EEE and persist clinical effects consist for gradually disappear. one mmminent. to three hours, and �Discussion: The pharmacologic effects of diethazine are described as "anti- cholinergic" and "atropine-like," and in patients with altered brain function may be h described as "allert‘ electroshock induced m (Ulett). EEG delta is P The action of diethazine an 0 . scopfll ine similar to atropine and eeelpalemine (Zinc floss observations era‘similar to those in subjects with head injury (Jeéhker and Lechner). Conclusion: ‘1'“ Based on this data, as well as the cerebr¢{:§pinal fluid cholin- esterase studies of Bornstein) and Tower and McEachern, . fuedJLb£1 diethazine hes-e ready that: (l) ' ' it is .: enter the central axrhnL; and trauma induced electroshock by by delta system3(2) a . concluded nervous 4' may similar A have biochemical substrate;(3) electroshock may be looked upon as a controlled 6F Alana; method tc.indnge ce ebral dysfunction for The its induced behavioral significance of these observations for EEG studies of head trauma and the mode of action of gin-ilpconvulsiVe therapy discussed. effects. will be �//— £3th at Diethuine on 3%: and Significance for Theory at Germanium mm Previous studies of the rule of have demtrnted EEG changes in convulsive thenpy the eigmfieam or the induced delta activity for the behwioral response. Imeatigetions containing the substrate of EEG 1:10ch delte 1n electroshock and convulsions have inflated significance for the eholinestemae - mtwlchonne system. reports Ulatt concerning the «treats a! atropine and by anthedalta patterns, response otheEEGshemdamml of napalm theinducedm Goncurrent reports by Jemkner and Lochner an the offliethum «1110;14:11me Recent. effects mtrmmmmmmm atimelua for the study of the effects or this drug in electmahock. Subagetet Twenty voluntary psychiatric patimte in en upward/psychiatric hospital have been tested to date. Electroencephalogm have been obtained mutant. During the recording, at. various fines during (limit) is administer! intmemualy per me until at. the 250 Milligrams have been rate of Metered. diethume 25 milligrams a an �¢2~ mumations: a.) Behavioral - 51]. subjects respand by coming, dryness (J the math and thickness of speech. Feelings of weakness of extremities and mm. illusory sensations are Mamas is news in mt. an difficulty in maintaining eyes closed. In pgtients 3nd who have had There Mficient ehctmhwk to manifest syntactic and onentation language changes indicative of altamd cerebral function, them in a reversal of language pattern» b) EEG ~ In all subjects than in Voltage. and decrease Damionflly, 10w is «synchronization Alpha W of Inqueneies are less prominent. tnqmncies appear. voltnga In pstinnta with varying dogma of delta activity, voltaga is deemed, tmquemiea in “cram am} burst wtivity disappears; Irregular alpha and but: fmqmnoioa of law voltage become more a) Tho W and liy clinical eflwta diuppnr. . pox-stat mm gamut. for om to than hours, and �A! mammalian The phnmaeolog'ic effects of diethuine are described as ”anti- cholinergia“ and “atmpimlflm,” and in patients with altered brain function may be doacribod an ”martini." The action of electroshock induced (Butt). EEG delta is 3min:- to atropine Also, than. observations with hast! 11131211 («bunker and m diothum 8nd n W napalm 51:11” to than in subdue“ Mr). 091191113th Band on this data, us all 0 as the carom spinal fluid wanna «tea-am swarms of Bernstein and Tower and IicEnchem, it is minded that: (1) diothuine has a randy ability to enter the central nervous system (2) delta induud by electroshock and by trauma my have similar Mommioal substrate (3) electroshock my be loolwd upon as a controlled m’chod to induce cerebral dysfunction for Ema tm its induced behavim'al effects. hand for'EEG of atxfiias of these obsamtiona significant: and the mode of discussed. act-.1031 of electmcomluvo therapy will. be �MM or blow swam m and Gmmlaim Therapy on m m, for 1119on of 24.13. me changes in wmulsive therapy have the signifiam of the induced delta actdxiw for the biochemm umoarning the Invasfigatlans tome. have EEG and indicated electroshock emulsions of delta in mutate nignfimm tor the ahonmuem - mmdcholine system mm. Pruvioua studies Wand 1:6de at the rails of. otatropdmandaoopolmo Wbymttcommmgmeflw EEG induced showed EEG or cloctrashook a moral in an pattom. am: Comm-rent reparts by Janka»: and Lechner an the: extent: of on mm]. EEG and that. following tram provided this stimulus far the study of the effects at this drug in electroshock. mm Salaam” treatment various during ht stages patina“ puma-lo in an open—ward voluntary psychiatric hospital have been tested to (Dimmol) is manicured date. "During EEG recording, int-.mwaly at the rate of 25 milligrams- por minute, for a total at 2% Twenty diam W0 Mmtionu ' : a) %: b) m m All subjects respond by coughing, dryness of the thickness of mach. Feelings of weakness of emu-mitten mm and illusory marathons are cam. more is an immune 1h restless. mas and mamty 1n maintaimng eyes clued. In patients who have had sufficient. electroshock to manila“ syntactic and orientation language changes indicative of album earabral function, there is a reversal of language patterns. more 13a doaynchrmiuuon of rmmdes down» in voltage. Alpha rhythms are less lament. Occasionally, 1m? voltage theta frequencies appear. In all subjects In patients with varying demos of delta activity, voltageand burnt increase frequencies activity disappears. Irregular decmo, alpha and beta Imumcies of low voltage become prominent. c) The EEG and clinical effects persist for one to three hours, and gradually disappear. Fm Department of men Oaks, ELY. than 1.1-6.5? - EAEEG mmm Psychiatry, Hillside Hospital, �‘5 of downbeat afloat: dawn» m Wohgie u ”antiwhonmtgie" and 'ttropine‘uka," and in patina“ With slated brain imam any be 6030de as ”wrung.” the mum at on ahctroshack induced EEG delta is amm to atropine 610mm um! £39me (010%). mm ebmmfiom an aim similar to firm in aubjccta with bud injury (Janina: and helmet). The cmcluaiam Mac! on this duh, as «11 as this cerebmspinal fluid cholimatamso studios of Ben-MW, and Tower and Wuhan, is wmludod that: (1) damn» mam entm the «antral nervous system; (2) delta nativity inducod kw alwtrodmck and and by tram may ham: 3 similar (3) mutate: mm be lookad upon an o. watt-0119c! ”that! of naming «mural to: its behaviaral affaa‘w. it mmwu m Wanna The «:1ng the or action of convulsive: therapy will trauma and node of thew than mamtiom for m ”adieu or had be animated. �v -r:‘V?\'(‘r.uv' w--w—ILW|>L‘»V‘V'~B—w"y:mm w—r-mw-vwn»vww.,u—A » v —.-.r. -- .vr. w—y ~ w — "av/\— <7 r ,rw-I'IWK . aw u 'mwl' - - - "a.“ AM'HV'Wwv _,,, A was �wan-my r'm ��Form 90-Adm. éhhft$nk jfluh fisgrlfiatrit gustitute 722 WEST 188'"! STREET. LAWRENCE B. KDLI, M. D. nlnlm'run NEW YORK December 4, 1957 Dr. Max Fink Dept. of Experimental PSychiatry Hillside Hospital 75—59 263rd Street Glen Oaks, New York Dear Max: feelings about Saturday night are reciprocal. Weihoroughly enjoyed the gracious company of you and Martha. With the intuitive perceptiveness of the female, Yetta informed me of a forthcoming event in your family, and we Wish you the best of everything. I indeed look forward to the reprints on your Work which you described in your letter and our discussing them together. The next edition of the Kalinowsky and Hoch will be expanded to include tranquilizers, and I would also appreciate any reprints of yours in this area. I have enclosed my own reprint on the clinical effects of Win-2299 and the basic paper by Luduena and Lands. As you will note, the compound is a peripheral anticholinergic and produces a "disorientative" reaction in cats by central action. Its psychotomimetic action in man appears basically to be an acute toxic reaction type. I would imagine that its central mech~ anism of action is similar to that of atropine (which also produces acute confusional states in high doses). Win—2299 is effective at much lower dosages than atro— pine. Possibly both atropine and Win—2299 both produce central effects by an anticholinergic action but, as far as I know, this modus operandi has not been pinned down crucially as far as the C.N.S. is concerned. I would not expect all anticholinergic agents to be psychotomimetic, of course. Win-2299 is a tertiary amine. Monodral is a closely related drug, differing only by quaternization of the terminal nitrogen in Win—2299. It is Win~4369 in the paper of Luduena and Lands (p.283), i.e. the methobromide form. According to Winthrop-Sterling, it is a peripheral anticholinergic in man in doses of 5-40 mg. per day. Central or psychic actions are not mentioned in their account. Presumably, quaternization reduces central activity by reducing permeability. Our �Dr. Max Fink (cont'd) ’ -2— I imagine that other agents in the Win series with central effects in cats might also be active as psychotomimetics in man. I am not familiar with the formula of diparcol and if you have it available would appreciate learning where to look it up. The drug is not covered by Goodman and Gilman. I would appreciate return of the Luduena and Lands paper when it has served your needs. We gave the Win—2299 the orally, The compound being drug was supplied as the supplied in tablet form. racemic mixture, the asymmetric carbon atom being terminal in the aliphatic chain. Sterling—Winthrop may have it for intravenous use and I suggest that you write M. L. Tainter, M.D., Director, Sterling-Winthrop Research Institute, Rensselaer, N.Y. about it. Our oral supply was used up in the study. As you know, all psychotomimetics not only create new symptoms in mental patients but also intensify or revive pre-existent symptoms. Best of luck. Cordially, ”2a Harry Pennes, H. HHP/ys Encl. M.D. �PA if .. _ * (on 1M5? I Effect of Diethazine on EEG and we Significance for Theory of Convulsh M Therapy MD Mow In a previous report to-this society we noted the relationship between the degree of induced delta activity during the course of therapy and the behavioral reSponse to electroshock. Those patients, in delta activity were induced early, and were degrees of behavioral change, as well as a significantly greater percentage W gm vial £64414a Law In. Box} EH: acetylcholine and in whom only low degrees were induced (Fink and Kahn, 1957). activity 1, (ii; '1.) high degrees of sustained, manifested the greatest of improvement and recovery than those patients of delta whom ,hML-wQA‘O‘ . a, W" , ‘Jawc‘z MM L Mkfil‘g‘f‘” ’M‘Af‘z‘ mv’efrff " in!“ (.4 Mfianges infree” ' a variety é‘fu‘reports, cholinesterase in the Spinal fluids of patients (Sachs, 9. Ward) and animals (Bdrnstein, Tower and McEachern) following head Wig; . . I the observations that by trauma M o (Bfrnstein, flue/4% In 1956 .c‘ E agents liq—alter the EEG patterns induced Ward, Jenkner-Lechner) and by electroshock ( “knew“at?mp (Ulett)pu_l Ulett reported that atropine g’scbpolaminerwhea-aéiénéstered— / W, blocked the appearance of the delta wea»...have come to associate with - _,-.,..«-'V'F-r -v~ WWW ahaaul,” "‘4“qu w. traumalawfl electroshock therapy. A!” 791’] am’LlLJ/g/J M ’L “‘2‘“ 4“““4/ié’MWrrW ”“an“ j?” activity {lama/Wye? v» �-ebeervetions~ Previously, ward (193) following the suggestion of Bornsteiny (19h6) had noted that atropine altered both the EEG patterns and the neurologic signs induced in.man by head trauma. afiereT-tee, the side ZZ,AQA7V ~effects were marked. In 1955: Jenkner and Lechner reported that EEG behavioral effects similar to atropine were achieved by diethazine istered in patients with head trauma.‘ They and admin— also reported the effect‘of diethazine in normal subjects. It is the purpose of this report to describe the effects of intravenous diethazine on the EEG of patients during electroshock therapy; and to relate their these findings to the present neurophysiologic-adaptive hypothesis of the ndde of~action of convulsive therapy. w ‘flwmwmflmwwwfl_fl____.imm 3" Diethazine is a soluble phenothiazine compound with phamacologic properties similar to atropine. In experimental animals, (19h?) have noted that diethazine blocks vagal slowing of the heart‘) M suppresses the bradycardia, bronchospasm, salivation, and fasciculation and seizures induced by acetylcholine, DFP ‘‘‘‘‘ ‘wywwflfimgimww‘fizoxsum-“:- w' ”mm—«MA..- and pilocaxxfixg and induces dry mouth, mydriasis and hypotension. L/——' / Heymans EE.E£ a“: nevus-aw» 4.: '2‘ YW',‘47"’~"5‘W1‘-05 Emma-gwhz - .— ' .~_4~:_MD~J �93" ”w W Subjects: Twenty-two psychiatric 42‘ patients,” various stages of electro- shock treatment in an open-ward, voluntary psychiatric hOSpital have been studied. the laboratory. Following a routine EEG administered intravenously at the rate of of 2630 to 250 mgm, the i Tl’br.‘ EEG 25 mgm per minute, for a total effects. Prior to the historical interview and a structured questionnaire period were tape-recorded. EEG recording, diethazine was depending upon the behavioral drug administration, an unstructured both EEG gubjects were tested in Following drug administration, recording‘ and recorded interview periods were continued until record again manifested.the pre-injection patterns on visual inspection. Mm New. ‘>IIVW~.. Qbservations: in Le ,, (a) Clinical: AH su jects manifesm Spontaneous coughing mutual-i33- @ followed by a dryness of the mouth and a thickness of speech. flgrtrf They note‘, ' 3'37 a feeling of lassitude and weakness of the extremities? soon followed by increased restlessness and difficulty in maintaining eyelid closure. phenomena were PSymW/clearly between 15 and 30 minutes . manifested in after some subjects. In the rest period drug administration, six subjects spontan- ..,. _‘ ... _ A �4,. eously voiced feelings of unreality, visual and haptic illusions, and delusional thoughts about their illness, the setting of the test procedures or our identity. Such patterns were transient and had disappeared In by the termination of the experiment,-asaallyhiééfifiurdfinnxrdnmzns. three subjects, increasing agitation . and panic led to a cessafion of the recording. éHere7-tccy—restétation_a£—pme—énjenfifinnrdnfiuufiuuaauua I 'li' g“, , I! i . fiilliwuwfi (b) In previous studies, the intimate relationship we had noted between changes in syntactic language patterns with alteration in cerebral function induced by electroshock. In subjects tested prior to electroshock, diethazine induced changes in syntactic pattern of an "alerting" variety. I - gal [5% In subjects with elta activity‘ with clinical syntactic patterns indicative of an alteration in cerebral function, diethazine induced a transient dis- appearance or minimzation of Such language in language (c) was concurrent with changes EEG Patterns: In all patterns. The period of changes in electroencephalogram. records, there is a decrease in voltage and desynchronization of frequencies. There is a decrease in prominence of prevailing rhythms. In patients without delta activity (pre-electrodhock)’ �-s5‘ 4/ this deéhronization and voltage decrease is occasionally accompanied by the appearance of small amounts of low voltage These are demonstrated in Slides 1, not appear to be altered. The and 2. The 5’7 '5' cps activity. basic alpha rate does build-up in voltages and appearance of thm slower frequencies with hyperventilation is blocked. In patients with varying degrees of induced high voltage activity voltage”, both random and 4 This change It and 3 dub is a decrease in burst delta activity disappears; and irregular, / low voltage alpha and beta frequencies become prominent. are noted in Slides delta These changes LL. 5W in is manifest in appears during drug administration, and all electroshock subjects. persists for awe. [WM filwwx 13% 2/1. floncurren WithAelectroencephalographic hours vtwv ‘ ”fly to three age MM» Wrens-em fiith the 8&3 17TH 770 n moustita—tion— of the pre-injectionEl'I} patterns, the pre-injection behavioral and language patterns again appeared. �DISCUSSION: report of Jenkner and Lechner of the t”t.¥£~£ dikd/“4lz‘ijzz7' effects of diethazine in"normal" subjects. 'Wa.alsa—nnta_tha§21iethazine These observations confirm the alters records-snd-fiith electroshock induced delta activity in‘a fashion similar to atropine and scopolamine, as described by Ulett, A Mada» W was. . 1%,. is apparent, therefore, thatngfi readily affects the central nervous and.é53 duration system, ofiactivity is most useful for experimental purposes. The-previeusiy—eitnd studies by numerous Observers of nervous system effects of head trauma point to an intimate relationship between the degree of neurologic dysfunction, the degree of EEG alterationjgand the level of free acetylcholine in the spinal fluid. The effect of atropine both the Echand ill on concomitantly on behavior in subjects with head trauma lends further support to the significance of figs: acetylcholine as the biochemical basis for the observed EEG patterns. In these studies of diethazine electroshock, the intimate relationship between EEG patterns and and behavior �-7have been reported. We note the parallel to the observations in head \ trauma. On the basfis of these observations, as well as studies of Spinal fluid Woholinesterase levels; (Tower we would and HoEachern, Fink and Goldenberg)‘ suggest that the biochemical substrate of the electroshock process. is isimilar to that of head controlled trauma.9 method of inducing ectroshock hLauri. may be looked upon cerebral dysfunction for its as a behavioral effects. Previous studies have demonstrated that alteration in cerebral function provides the physiologic basis for the behavioral changes in electroshock (Fink and Kahn, 1957). Such alteration in cerebral function provides the milieu for a change in the organism's adaptation to his environment. aSpects of behavior, as perception, language, mood, recall, memory, All affect, undergo change, and provide the basis for the therapist's evaluation of improvement. The studies of diethazine amplify this neurophysiologic 9.39.9. adaptive hypothesis of electroshock by suggesting the type of biochemical substrate that underlies both the physiologic and the behavioral changes. �Mm= 0 Diethazine, a pftent anti-cholinergic compound, u was experimentally introduced intravenously in psychiatric subjects,;fi various stages of convulsive therapy. Electroencephalograms manifested a desynchmnization of frequenciesfue («C decrease in voltage records without prior delta activity. Records with delta activity showed similar changes with disappearance of delta burst activity. Concomitant with the electrographic patterns indicative of It is concluded a effects, behavioral reversal of the electroshock effect enters the central nervous System upon intravenous (b) The biodemical basis for that of head trauma; (c) therapy The may EEG compound that readily adninistration. changes in electroshock is similar and biochemical basis of the lie in were observed. that: (a) Diethazine is a Bitent anti-cholinergic to and language mode of action of convulsive the acetylcholine-cholinesterase system. a, �@ Research and Development Division SMITH, KLINE & FRENCH LABORATORIES PHILADELPHIA - I ESTABLISHED I84| December 11, 1956 Max Fink, M.D. Director of Research Hillside Hospital 75—59 263rd Glen Oaks, Street New York Dear Doctor Fink: associate, Mr. C. W, French, has referred your letter of November 12 requesting a supply of diethazine to me for reply. It has taken me a little While to uncover-sufficient supplies for the short clinical trial you want to conduct since our interest in diethazine alone and in come bination with 'Thorazine' isn't too great at this time. My not have this compound available in 500 mg. capsules as you requested. It is only available in 250 mg. tablets. A supply of this strength has been sent to you together with a supply of the intravenous we do material so that you is all the literature we this will be of some help. Enclosed hope the may Observe EEG effects on 10 have available on Sincerely yours, .\ to 15 patients. diethazine. I , J”, Meagan? Ms (,7 . John F. Buckley a Research Associate / ’ ' Medical Department JFB:hc Enclosures P.S. Will you kindly sign the enclosed FDA card and return so that we may keep our files up-to-date. it to us � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effects of Diethazine on EEG and significance for theory of convulsive therapy. Electroencephalogr Clin Neurophysiol. 10 207-208. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-29a-004 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 13 items. 1: Handwritten notes. 2: Clinical Release. 3: Diparcol. 4: Pharmacology Report. 5: Letter to Fink from R. S. Griffith. 6: Letter to Fink from Herman C. B. Denber. 7: Letter to Denber from Fink. 8: Draft with edits. 9: Two drafts. 10: Handwritten notes. 11: Letter to Fink from Harry H. Pennes. 12: Draft with edits. 13: Letter to Fink from John F. Buckley Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/78017191476d8e778612e5c61eff422b.pdf 82ede86cdae7bcc77cb09f6c0bbd0389 PDF Text Text Mammal in studios of Germain find Drug max-span mun-ya Theofitio Imitation! In swans a: aonvnluivo, payohophumcmgic and inaulin a» therapist, msalon of "idem tar a mmphysiolozimpuve W011! or the and. of these flux-apt!» has wwmhtod. This hypotmsia “crib“ the officwy 01' each therapy in the trantaont of wohma to their ability to induae a persistent alternates: in cerebral function. mien provides the am“: for u changa in adaptation of the subject to his anviroment. In those studies, in Em have been and as indie» of uttered brain tumuom In convulsive thong, the shift in EEG tmuoneias to the delta range has been directly rented to the behavioral changa (AMA, Arch, Emmi. and analyses at r3;chiat. (J: com be (n) «hangs: 16;: 516, 1957). A maid. H292. 5: “1&1;in has been observed 31:11.: Bk. 1955). classified ascending to their EEG From flat fnqucncios, with in- (mpmbmu, barbiturates); and (c) (domains, bemctysine and asp-nine). then analyses, a shirt in unused synchronisation tnnquiliutim m EEG mggasmd sedation. 1.957): mums». pruning, perphenaame, reserpine); (b) indueo a ahifl. to crewod synchronization frequencies Viviana psychophameologe uganta can offsets: (J. Hillside Ham. 9; 197, mum a mm to delta frequenciu and high dose to insulin «mama frequencies to delta range and in» u the nmrophysiologic concomitanta mmphyaiologimdaptim hypothoais hm applicatim to the ammonia of physiodymmic mempiee, acmning or psychoplumeologic agents and as a trans of refemnce for the study a: bmior arid of and The mmphyaiology. From L010, the Dayna-meat “at; or Workman. rm. Hemlogical Society, MAR 2 6‘85 Why, Hillaido Hospital, Glen mks, March 11, 3.958. �«W W WWW AFTER 225 mg. PRE-DRUG LF-LO RF-RO WIN/WWW SOyvl _ #I64IHH �PRE- DRUG AFTER 150 mg �W WW ”“va W W W WW WW WW + PRE-DRUG + 25 mm 200 mg. LF-LO WWWNVMMJVW RF R0 NWvaw-AAW “T'RWWJWMM H ”fin. MM LF-RFNWWN WWW” LPT'LO WWWM 50 )Lvl I $|631 NH �PRE-DRUG @. AFTER 250 mg. W W W W W W W W W W WW 50pvl_ SEC. 1 #IZQS NH �Effect of Anti-Cholinergic Agent, Diethazine, Significance for Theory of Max From the Department of Experimental L015, NJ. Fink, on EEG and Behavior: lesive Therapy 14.1). Psychiatry, Hillside Hospital, Glen Oaks, in part, by grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Aided, (in part) at the meeting of the Eastern Association of Electroencephalographers, N.Y., December 1957,‘ 4.7444417 Jazz; Read 33?: 3-58 /“ a M 14/11.” 050,?wa �3.3-58 Effect of Anti-Cholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy Recent investigations of convulsive therapy have emphasized EEG delta activity as the neurophysiologic basis for the induced behavioral change (1,2,3,h,5). Little study, however, has been given to the biochemical effects of this therapy, except in the course of investigations of head injuries. In investigations of head trauma significance has been ascribed to in the acetylcholine-cholinesterase systems both for the behavioral and the electroencephalographic effects. An increase in free acetylcholine (6) and an alteration of the ratio of cholinesterases (7) in the spinal fluid have been positively correlated with the degree of EEG abnormality changes and degree of heurologic improvement deficit. in clinical status The EEG patterns were "blocked," and was reported following atropine (7,8). In convulsive therapy, atropine observed to block the appearance of delta some the administration of and scopolamine were activity, (9) although the systemic effects of the large doses of these agents were marked. Recent reports (10) noted that EEG and behavioral effects similar to atropine {were achieved in patients with head trauma by intravenous diethazine a phenothiazine compound systemic effects. with anticholinergic properties - with minimal In our continuing studies of the role of delta activity in electroshock (3), the effect of diethazine was studied. It is the purpose of this report to describe the effects of diethasine on EEG patterns and on behavior of patients during electreconvulsive therapy; and to relate these observations to the present neurophysiologic-adaptive hypothesis of the mode of action of convulsive therapy. �SUBJECTS AND METHODS: Forty psychiatric patients, at various stages of electroshock therapy in an open-ward, voluntary psychiatric hospital have been studied. All observations have been Following a routine at the rate of EEG made in acute experiments in the laboratory. recording, diethazine was administered intravenously 25 ngm per minute, upon the behavioral EEG effect. for a total of Dosage varied from to 250 mgn, depending 2.8 to h.0 mgm per kilogram 175 body weight. Diethazine is a soluble phenothiazine compound with pharmacologic properties similar to atropine. In experimental animals, diethazine blocks the bradycardia, bronchospasm, salivation, fasciculation and seizures induced by acetylcholine, di-isopropyl fluorophosphate and pilocarpine. suppresses salivation, and induces mydriasis and hypotensicn EEG It (ll). Anilxses: Recording was continuous for the duration of the observation period, except during interview periods. Needle electrodes, and an Moderaft instrument were used. All records were analyzed delta activity (3); the per cent time the relative amount of fast activity. measured in anterior temporaldvertex, and The and 8 channel for the degree of principal alpha frequency; and alpha and delta activity were parietal-ear ldbe lead coMbinations. Behavior measures: Prior to drug administration an unstructured psychiatric historical interview and a structured questionnaire period (12) were tape recorded. Following drug administration, periods of recorded interview were alternated �~3- with EEG recording periods, until the me had again manifested the pre- injection pattern on visual inspectioné Two estimates of behavioral effects were used: clinical descriptions subject, interviewer and technician - of the changes occurring during the drug period, and language analyses of the recorded interviews. Changes in language were evaluated by a syntactic analysis (12) and an analysis of the variability in verbal interaction in the dyad (13,1h).* by the participants ~ Both measures have been shown to be sensitive to induced by changes in the central nervous system. * Detailed analyses of these observations DPS. J. Jaffe alterations in behavior and Re In Kahn. will be reported separately by �OEERVATIONS: (a) Clinical: Within two to five minutes of the start of the injection, subjects manifested spontaneous coughing follow ed by a dryness of the of speech. and a thickness They reported a feeling of lassitude, mouth and a heaviness and weakness of extremities which was soon succeeded by increased difficulty in maintaining eyelid closure. Reports of visual and haptic illusory sensations, feelings of unreality distance, and delusional thoughts about their illness, the setting of restlessness and and test procedures or identity were voiced Spontaneously in eighteen subjects in the period between 15 and 60 minutes after drug adninistration. the our In three instances, increasing agitation and panic led to a cessation of the In two subjects withdrawal and negativism was the prominent recording. behavioral response. Such patterns of behavior were transient and had disappeared in (b) EEG 1% - h hours in all subjects. Patterns: Alteration in the EEG patterns was concurrent with the behavioral effects. In all records, changes occurred during drug administration and were sustained, with gradual diminution and restitution of the pre-injection patterns, in one to five hours. The initial response was a decrease in voltage and desynchronization of all frequencies. There prominence of prevailing rhythms. was a decrease in In patients without delta activity (pm-electroshock), desynchronization and voltage decrease was occasionally activity, symmetric and prominent in frontal and anterior temporal leads (Figure l, 2). The alpha frequency was not altered. accompanied by low voltage 5-? cps �~5The build-up in voltage and appearance of slower frequencies with hyper- ventilation was blocked. In patients with varying degrees of high voltage delta activity there was a prominent decrease in voltage and desynchronization of the record. burst delta activity diminished or disappeared, and irregular voltage alpha and beta frequencies became prominent (Fig. 3, h). The Both random and low hyperventilation response was no longer apparent. (c) Language Patterns: In previous studies, an intimate relationship between changes in syntactic language patterns and the behavioral response in electroshock had been reported (12). With alteration in brain function, increased use of third person, veroal denial, qualification, displacement and cliches became prominent. These effects could be enhanced by the administration of intravenous amobarbital (1h). In the subjects in the present study, syntactic analyses demonstrated a reversal of the patterns noted in electroshock. Use of third person, qualification and displacement decreased. Explicit verbal denial was modified and replaced by minimization and displacement, or by a reiteration of complaints of illness. In dyadic analyses, the verbal interaction was characterized by a greater diversity of vocabulary and less variability in the diversity scores for 25 word units. qualitative nature of these changes in the language patterns is opposite to that of amobarbital and electroshock. The duration of language changes was concurrent with the changes in the electroencephalogram. The �DISCUSSION: These observations confirm the report of Jenkner and Lechner of the effects of diethazine in "nonmal" subjects (10). Diethazine also alters electroshock induced delta activity in a fashion similar to atropine and sncpolamine, as described by Ulett and Johnson (9), with minimal unpleasant symptoms. EEG The effects of intravenous diethazine are immediate, both and behavior, and thus provides a cholinergic" properties. Two on the useful experimental agent with "anti- aSpects of these experimental observations warrant discussion: the role of acetylcholine-choldnesterase in the electroconvulsive therapy progress, and the significance of die thazine "alerting" for concepts of hallucinogenic activity. 1. Biochemical Basis of the Convulsive Therapy‘l’rocess: While there has been considerable study of the psychologic neurophysiologic aspects of convulsive therapy, biochemical processes is available. The little and infomation concerning studies of biochemical changes following head trauma and spontaneous seizures provide some analogic data. Bernstein (6), in a classical experimental study of head trauma in cats, that within a few minutes after trauma, free acetylcholine appeared in the Spinal fluid and persisted for periods up to 148 hours. He further demonstrated a positive relation between the severity of head trauma demonstrates and the quantity of free acetylcholine, degree of electroencephalographic the severity of the behavioral changes. The electroencephalographic records initially showed short periods cf high voltage fast activity, alteration and transient period of flattening of electrical activity, followed by prolonged periods of high amplitude sharp waves in the delta frequencies. Concomitantly, a �-7alteration in consciousness, changes in reflexes seizures EEG change. Tower and HbEachern (7) confirmed studies in man. In post-traumatic highest concentrationSOf free acetylcholine were most prominent with and greatest degree of and 112 neurologic these observations in clinical patients, free acetylcholine was found in the cerebrospinal fluid only in patients following head trauma and recent grand mal seizures; and the level of free acetylcholine varied directly with the degree of cerebral damage. In addition, these authors assayed the cholin- esterase activity of the spinal fluid, (7, 16). In patients following head trauma, they noted a sharp rise in non-specific cholinesterase (benzqylcholine- in.the specific cholinesterase (meoholyl-splitting) activity of the spinal fluid. No such inversion was noted in fluids containing splitting) and a drop free acetylcholine following spontaneous seizures. Electroencephalograms were taken at varying intervals following correlation of the extent of EEG trauma, and demonstrated a direct abnormality and the appearance of free acetylcholine in the spinal fluid. Tower and MhEachern also reported observations in six patients In patients after 3-7 induced convulsions, they noted free acetylcholine in the spinal fluid in two, and an increase in non-Specific cholinesterase with reversal of the cholinesterase ratio in five receiving electroconvulsive therapy. of the six. They concluded that the spinal fluid changes in electroshock are more like those of craniocerebral trauma than those found in epilepsy. * patient of the six who failed to show either free acetylcholine or a reversal of the cholinesterase ratio, they noted: “It is interesting that this patient was the only one of the six to show no * Regarding the one response to treatment." �-8recently, Sachs (17) confirmed the reports of free acetylcholine in the spinal fluid after head trauma and after electroshock. In his studies, Bornstein (6) administered 0.5-1.0 lug/kg atropine Mcre effects, and a modification of the behavioral and neurologic signs. Atropine also blocked the EEG and clinical signs induced by intracisternal acetylcholine. and demonstrated a reversal or a blocking of the Ward (8) applied these observations with varying degrees of head trauma. atropine induced both clinical EEG to the treatment of Subcutaneous doses of 0.1 mg/kg of improvement and reversal of These observations were recently confirmed by Sachs Hughes (19). Based on subjects human these observations, Ulett (l7), EEG effects. Rugs (16) and and Johnson (9) noted the effect of atropine and scopolamine in blocking the Em changes of electroshock tharapy, without noting the effect on clinical behavior. Concurrently, Jenkner and Lechner (10) reported effects similar to those of Ward, in studies of diethazine in cases of head injury. Another group of investigations complete the available data. Studies of anticholinesterases, as DFP (di-isopropyl fluorophosphate) and (tetraetlwl-pyrophosphate), which block the enzymatic TEPP breakdcvm of acetyl- choline, demonstrate the development of high amplitude rapid frequency mac patterns similar to status epilepticus as well as lesser degrees of abnormality as noted in post-tramnatic states (20, 21, 22, 23). In these studies, atropine blocked both the electroencephalographic and the clinical toxic effects. Thus, both from experimental and trauma we may assume clinical studies of craniccerebral that (a) the acetylcholine activity of the spinal �-9- fluid increases; (b) pseudo-cholinesterase activity increases with a reversal of the ratio of cholinesterases; (c) slowing agents From parallel these biochemical alterations; may EEG tamer-synchrony and and (d) anticholinergic block both the electroencephalographic and the clinical effects. it is probable that the biochemical basis the data available convulsive therapy is similar to that of craniocerebral trauma. of Convulsive therapy results in free aoetylcholine in the spinal fluid (7, l7) and a reversal of cholinesterase ratios (7, 16). The electroencephalographic effects of repeated induced convulsions is the developnent of high voltage, activity, occasionally with spike activity (3, 2h, 25), which is similar to that observed in severe head trauma (26, 27). In symmetric slow wave previous studies we have reported the relationship between the degree of activity and behavioral reaponse (3). The studies reported here and that of Ulett and Johnson (9) demonstrate a reversal of the EEG and the behavioral effects of convulsive therapy by antiinduced slow wave cholinergic In each characteristic, convulsive therapy is thus compounds. similar to cerebral trauma. While the acetylcholine-cholinesterase system is highlighted (17). These studies, other enzyme systems may also be altered studies also suggest that convulsive therapy provides an by these excellent experimental method for studies of craniocerebral trauma. Studies of the brain stem activating system by Jasper and DroogleverFortuyn (28) and Lindsley gt a}, (29) had laid the foundation for the prevailing conclusion that symetric EEG slow wave activity has its origin in mesencephalic structures, and that these structures intimately affect the states of "alerting" and "drowsiness." More recently, Rinaldi and �-10- site of action of atropine and cholinergic to this mesodiencephalic activating system. It is also probable that Himwich drugs (30, 31) have related the these structures may be selectively affected by the convulsive therapy process, and that both the clinical and electrographic effects may be intimately related to changes in this systan. 2. Diethazine "Alerting" The and Hallucinogenic Activity: behavioral effects of diethazine provide information regarding another aspect of the convulsive therapy processxs. In patients without prior convulsive therapy, illusory phenomena and feelings of unreality were observed. These were similar to the hallucinogenic effects of and mescaline (33). Again analogic data about the of these agents may provide some no change, (31;) clinical and EG effects noted that the intermittent or continuous increase in alpha frequency. (32) information about convulsive therapy. In studies of mescaline, Wikler either LSD low voltage EEG danonstrated fast activity or Denber and Merlis (35) noted a similar acceleration of alpha frequency, decrease in per cent tine alpha including its disappearance, and non-specific random beta activity. Delta activity did not occur. In patients with delta activity induced by electroshock, Merlis and Hunter (38) noted that intravenous mesoaline markedly diminished the amplitude and per cent time delta activity with an increase in per cent time alpha activity. The effects of LSD on EEG are similar. Gastaut at g. (36) noted an acceleration of alpha frequency of 0.5 to of beta rhythms. Rinkel gt 9;... 14.0 (37) confirmed cps with an aocentuation this observation and noted, �-11- in addition, a reduced reaponsivity to hyperventilation.* In summarizing his studies Wikler (3h) concluded that " . . . regardless of the drug administered, shifts in the pattern of electroencephalogram in the direction of desynchnonization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness." This generalization provides a meaningful construct may be assessed. Agents that in which these agents evoke EEG desynchronization tend to be are clear examples. Agents that synchronize frequencies, such as barbiturate and meprobamate in the beta delta frequency range, and chlorpromazine, promazine and hallucinogenic, and mesoaline and LSD Wainthe frequency range (39) tend to be sedatives, euphoriants and relaxants. 'Ihe observations on diethazine reported here are consistent with this hypothesis. In patients without delta activity, the EEG demonstrated desynchronization of frequencies, and this was associated with clinical illusory phenomena. In patients with delta activity desynchronieation occurred, and alerting and reversal of the speech patterns induced by electroshock were observed. Electroconvulsive therapy We *- have previously noted a may also be understood in this framework. direct relationship between clinical evaluations Studies are now in progress of the effects of LSD, Win-2299, benactyzine and other anticholinergic compounds on post-convul sive EEG delta activity. Initial experiments m. ah intravenous ISD (50-100 gamma) demonstrated marked diminution in per cent time and amplitude of delta activity. �of improvement and the degree of conditions, sedation Under these EEG slowing induced by electroshock (3). and euphoria are most prominent and hallucinatory activity diminished. In patients in not induced, behavioral change is limited whom hypersynchrony and 'improvement' does is not occur (in) . Previously that the we have concluded therapies is based on the mode of action of convulsive induction of a state of altered cerebral function, in which changes in adaptive interpersonal behavior occur, preted as 'improvement' (3, h, 39). The inter- present studies amplify two aspects of. this neurophysiologc-adaptive hypothesis. substrate of the behavioral change and are is reflected by an The biochemical alteration in the acetylcholine-cholinesterase relationships of the central nervous system. It is also probable that EEG basis of the milieu change euphoria and mpersynchrony provides the neurophysiologic which is evaluated as is clinically manifest as sedation and 'imprcvement.‘ The neuropklysiologi.C-adaptive hypothesis of convulsive therapy has provided a meaningful basis for studies of other physiodynamic therapies (39) . In this study, it has been possible to amplify our understanding of neurophysiologic aspects of hallucinogens as well. �SUMMARY: effect of an anticholinergic agent, diethazine, on the behavior and language patterns was observed in to psychiatric patients, 1. EEG, The at various stages in the course of electrooonvulsive treatment. (a) Behavior: Increased restlessness and agitation, haptic and visual illusory sensations, and delusional thoughts about their illness or examiner's identity were observed. (b) Egg; Alteration in There was a decrease in voltage EEG was concurrent with behavioral changes. and desynchronization of In patients with delta activity, the per cent time all frequencies. and voltage of delta activity decreased. (c) Language: Syntactic patterns described for convulsive therapy were reversed. Use of third person, qualification and displacement decreased. In dyadic analyses, there was a decrease in the coefficient of variation. 2. These observations are discussed in the framework of the neuro— physiologic-adaptive hypothesis of the action of convulsive therapy; and it is concluded that: (a) the biochemical basis for convulsive therapy is similar to that of craniocerebral trauma; (b) changes in acetylcholine-cholinesterase metabolism are intimately related to the behavioral effects; (c) EEG desynchronization may be and a physiologic concomitant of hallucinogenic activity; and EEG-hypersynchrony associated with euphoria and sedation. �.m. W 1. Weinstein, E. and Kahn, R.L.: Denial of Illness, 0.0. Thomas, Springfield, I110, 1955. 2. Roth, M., Kay, D.W.K., Shaw, J. and Green, J.: Prognosis and Peutdzhal Induced Electroencephalographic Changes in Electroconvuleive Treatment, EEG 225‘237’ 1957. Clin. Neurophxsiol. 2: and Kahn, R.L.: Relation of Electroenecephalographic Delta Activity to Behavioral Response in Electromock, A.M.A. Arch. Neurol. and Psychiat. 1Q: 516-525.. 1957. 3. Fink, h. Fink, 24., Green, M.A. and Kahn, R.L.: Experimental Studies of the Electroehock Pracess, Dis, Nerv. SE . (in press). 5. Ulett, G.A., Smith, 6. Bornstein, M.: Presence and Action of Acetylcholine in Experimental Brain Trauma, J. Newcphzsiol. 2: 3113-366, 191:6. 7. Tower, 13.3. and McEachern, D.: Acetylcholine and Neuronal Canad. J. Research, 3.1: 105-131, 191:9. 8. Ward, A.: Atropine 9. Ulett, M. K. and Glaser, G.C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, Am. Jo Pszghia‘b. gala-3 795’802, 1956c in the Treatment of Closed Neurosurg., 1: 398—102, 1950. G.A. and Johnson, M.W.: Head Effect of Atropine Injury, Activity, ,1. and Scopelamlne Electroencephalographic Changes Induced by Beetroconvulsive Therapy, EEG Olin. Neurophlsiol. 2: 217-2224, 1957. Upon 10 . Jenkner, F.L. and Lechner, H.: The Effect of Diparcol on the Electroencephalogram in the Normal Subject and in Those with Cerebral Trauma, EEG Olin. Neuromzsio . _7_: 303-305, 1955. 11. Heyman, Sur la 0., Estable, J.J. and de Bonneveaux, 8.0.: de la menothiazinyl-Etlnrldiethylandne (2987 R.P.) , Pharmac 12. in Language During Electroshock in {exchomthologg of Communication, pp. 126-139, Stratton’ NoYo 9 o Kahn, R.L. and Fink, 11.: Changes Therapy, Gr‘me 13. . 12: 123-138, 1919. Pharmacologie Arch. Int. Jafi‘e, 8C Objective Study of Comuufication in Psychiatric Interviews, J. Hillside Hospital, é: 207-215, 1957. J.: An �.15.. Jaffe, J.: Language of the Dyed: A Method of Interaction Analyses in Psychiatric Interviews, mchiatgy, (in press). 15. 16. Weinstein, E.A., Kehn, R.L., Sugarman, L.A. and Linn, 1...: Diagnostic Use of Amobarbital Sodium in Organic Brain Disease, Am.J. mchia . 1-}.2.‘ 889-8911, 1953. Tower, D.B. and McEechern, D.: The Content and Characterization of Cholinesterases in Human Cerebrospinal Fluids, Canad, J . Research, 21: 132-115, 19349. 17. Sachs, E.: Acetylcholine and Serotonin in the Spinal Fluid, Neurosurg., 11*: 22-27, 1957. 18. Rugs, D.: The Use of Cholinergic Blocking Agents Cranio-Cerebral Injuries, J. Neurosurg., ,1. in the Treatment of I_l._1_: 77-83, 19514. Injury, J. Neural. of Acetylcholine in Head 1957. chia . g9; p.70, 19. Hughes, B.: The Role Neurosur . and 20. Freedman, A.M., Bales, P.D., Willis, A. and Himwich, H.E.: Experimental Production of Electrical Major Convulsive Patterns, 21. Am. J. @8101” fig: 117-1214, 19149. GrOb, Do, Harvey, A.M., Iangworthy, 00R. and Lilienthal, Jolie 3 The Adminis tration of Di-Isopropyl Fluorophosphate (DFP) 257.266, 19,47. Man, B11110 Jo H0215. Hogan, to a: 22. McCauley, A. and Hinmich, H.: Effects of Di-Isopropyl Fluorophosphate (DFP) on mectroencephalogram Hampson, J., Essig, C.F., EEG 23. 01in. 3: 141448, Neuropflsio . Activity, angocmlinesterase 19 . Himwich, H.E., Essig, C.F., Hampson, J.L., Bales, P.D. and Friedman, A.M.: Effect of Trimethadione (Tridone) and Other Drugs on Convulsions Caused by Di-Isopropyl Fluorophosphate (DFP), J. Psychiat., 106: 816-820, 1950. Am. 2h. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Egg. Clin. Neurophysiol., g: 157-162, 1950. 25. Green, 26. Jasper, H.H. , Kershman, J. and Elvidge, A.: Electroencephalographic Studies of Injury to the Head, Arch. Neural“: Psychiat” 1A: Significance of Individual Variability in EEG Reaponse to Electroshock, J. Hillside Hosp” _6_: 229-2ho, 1957. M. : 328~3h8’ 19,400 �~16~ W Ostow, M. and Greenstein, L.: Dia Gmne 8: Stratton, N.I., ostic $35. Electro- 27. Strauss, H., 28. Jasper, H.H. and Droaglever-Fortuyn, J .: Experimental Studies on the Functional Anatonw of Petit Mal Epilepsy, Res. Publ. A. Nerv. Mt. Dis. 2-6-3 272-298’ 19117. Lindsley, 1)., ‘Schreiner, L.H., Knowles, W.B. and Magoun, H.W.: Behavioral and EG Changes Following Chronic Brain Stem Lesion in the Cat, EEG Olin. Neuropmsiolu 2: 1:83-1:98, 1950. Rinaldi, F. and Him-rich, H.H.: Alerting Responses and Actions of Atropine and Cholinergic Drugs, A.M.A. Arch. Neural. and 29. - PfizChiate, 123 387-395) 19530 31. Himwich, H. and Rinaldi, F.I:'The Effect of Drugs on Reticular System, in Brain Mechanism and Dru Action, 15-4411, C.C. Thomas, Springfie d, 19 7. 32. Stall, W.: Lysergsaure Phantaetikum aus der Arch. Neurol. PsEhiat. , §_Q: diethylamid, ein -Schweiz Mutterkomgruppe, 1-h7, 19m. ' Neural. Psychiat., 1-315, 33. Beringer, K.: Der 'Meskalinrausch Springer, Berlin, 1927. 3h. Wikler, A.: Clinical and Electrencephalographic Studies on the Effects of Mescaline, N-allylnarmorphine and Morphine in Man, J. Nerv. Wilt. 1318., 120: 157-175, 19%. i Monog. on Mescaline I: Action in Schizo~ Psychiat. Quart., g2: 1.21-1.29, 1955. 3.: Studies 35. Denber, H. and Merlis, 36. Gastaut, H., Ferrer, S. and Castello, 0.: Action de la diethylamide de l'acide d-lysergique (LSD 25) sur lee fonctions psychiques at l'electroencephelograxme, Conf. Neuro1., 12: 102-120, 1953. 37- Rinkel, H., DeShon, H.J., Hyde, R.W. and Solomon, H.C.: Experimental Schizophrenia-Like Symptoms, Am. J. Psychiat., 108: 572-578, 1953. 38. Merlis, S. and Hunter, W.: Studies on Mesaaline II: nectroencephalogram in Schizophrenics, Psychiat. Quart. , g2: 1:30-4:32, 1955. 39. Fink, M.: ha. Fink, phrenic Patients, A Unified Theory of the Action of Physiotbmamic Therapies, J. Hillside Hosp. , {3: 197—206, 1957. and Green, M.A.: Electroencephalographic Correlates of the Electroshock Process (in proparation). M. ‘ ��~24... 1m 1955. mm:- and WM )mpwm that EEG and human-n oflam swim to abopinn were achieved by mm mama in pafienta with head trauma. Fran thaw report in mute“. the ayatemic attacks of We at ( am- theme and diam nppamd mam. intamt in the nativity 1n enmeshed: r613 of 6311;: ), an immigauon a: the «that of dint-hum, in patients manning eomlain therapy wmsuport to describe the oft-hats bazwiw sf pitienta mm in was both m EEG and behavior, mama. It in the puma «mm mthexmmdm aux-lag olwhmflmek’ therapy; and to unto the” obsomtiom to the meant neurapbyaioloac adaptive hypothesis a! the mode of widow: of convulaive them. Wamwthodg: mum pitta cuts, at. “nuns sagas or electroshock flmmpy in an awn-mad, volmtu'y psychiatric haepital have been studiad. All mum hm ham EEG and. Mot-ding, diafhuine 25 mm per minute, in the me laboratory. 3‘an a mum m amateur! intravenously at. the for a total of 175 to .200 mm, depending upon rate of the �uh Wm: «that. Ins/k8 1» wording to m ram, (SW mm mm 2.8 b0 Int/ks. mum is a column Wino W: with am to “reprint. “perineum the Wen. bmnehm, Wmtim, rummum lawman «mm by mfiylmolm, «1»:meth 15W “Maiden, M and «1 and ‘ A mum: in» (DFP and plum-pins. new Wis 1nd momma (Raymu- 19189): All records were unlisted the por car animals, 22:: We mi: time and fast nativity. far the: dams of dolta aébiviw principal 31pm “fluency; Drug errata were emailed find the relative meant as synchronising (I) or Warning (n) «@0ng to the mam mama by um» ( In In W, mm, tapers]. both and 81m parietal and )3 ( ). mu nativity was mum in natal-ion» m m m mum. War Wm: Prim to drug twain-rattan an mmzmmd psychiatric historical �.3;- intern“ and a structmd Wm 1?ng drug achinistmtian, pat-1363 altamted with ma EEG mm. period 1mm tape 31’ taps new 13me m ”cording parieda, until the again. manifested EEG 1236 Macaw pattern 0213131231 inspection. 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Sadness! the spinal fluid in m, in non-specific ohelineatamo with reversal of the abounin five 91‘ the six patients. They concluded that {m apinal I 6W3 flute! than are in electroshock and than row in opium} more like those of nraflnworebml trauma many, Sachs ( ) cuiflmd tbs a? the. six who max in show gum fm “It. 13 Mare patient WW at cholimatem mun, they note: an mum). at a. Em one this patient was the only one of the 31:: to mm interesting that tmtmant.” show no response to ��‘ YEP? («mun/1 the ensyutie , mien bleak pyraphoaphate). 13:9an 91' tmtyloholim, demonstrate the cf high amplitude rapid frequemy mm Malawi. similar to status epileptmug u “11 as lessor demos of abmmality noted in postutramtio status ( , , ). In those swam, ntmpina blocked both the algatm mauphalmsphic and clinical talc “feats. m, both in maximum and clinical studies of cmmbnl we my mum that (a) the mtylehulim nativity of the spinal fluid increases, (b) pundwhounestamae nativity 231' the: ratea of mung"; ad chommflseu; (6) that (6) me change: with a mama]. 13.111101 than bioehoflcal mtigholimgm «wounds my block both the shown- whalomphic mad the clinica stints. proth memes From the data available it. that the Mechanical basis of the eonvulsive therapy process in am to that of nth amowmbml trauma. infrae mtylcholine inthe spimlflnid£ imatamae mum ( ). g. Gmlaivc Manny results )m amenal of chol-v m alanimcaphuomphic affects of ”pasted manned convulaims is tha amazement of high voltago, slaw is ma activity, mmimlly with spike activity ( -. , mimic ), �awe» mid'xiemtosmmhoadhrAWC , studies-we have reported the relationship hem the degree of WW fit»! me utivity and behavioral respme (i). thbe a moml of the 61W my ‘ The studies method here. new «feet: at cumin“ the Marion). In each ehmeterietie, emuisive Wheemimmbni tnm.imhthemmm1im~ system is Weave by those studies, other animals mm am be altered provides In and cm. therapy by antichoiinergie Wrapyisthul EEG L Inpmim g ). ( Theta «mam suggest that mum mm «comet experimental maxed fer studios of emioeembni ensue Baum mains of the brain stem activating system by Jasper and mmmrem ( fer the wailing nomination its erigln 1n the mtraymm at and mm ( ) and Waleyw. ( ”macaw that “matures, Morning? and , ) have ehoiinergic drugs to this ”mute ) bed “We! thmfom, that. the» structures are Here may, Rama. ream: the hits of nation masodiWMg4.,mnung ”M prohehie, we nativity hm ma aim and that. than stmehm’ec may be we the feundntion at umpim m6 We It is 3130 selectively affected! �hr; the Wire therapy pm”, and that. both the clinical and electrou angina streets my be intimately muted to shanghai in thin mm. �m um *13- «mu of mm mm wax-nation ”mmmammammym.mw patients without may Wu and findings WW thorny or mm mm, 111nm at many um mmmmWemmotm( W. Thane were ).uaennm( mum human“ mm£2dcmm1omammwmmmm “Imumu-WwWWMWm about mm. them. Inatndiunfum,mkhr( )wmmmma Mata-um am no m, mumm an- em 1a values :mmntywmmmamtm.‘mma&mn( ) Wammmmotmrmm,mmmnmtm aw infinding its diam, and We w W. mmwmmammmm. Belt: «mum did random bots nativity. wunJ )nm 11130003.th dfm1Wfi0aSWhuflmuihmteaMflm wmum.m1otn( ) WWnpm'hmmd, in mm, 3 mm aspen-131w to mus-mam». ), �.31... In punish with 601k mdfiutaW W «adv by dwhromok, mm.- )ammtmmmmmmmwmmm mummmmmmumuuw uthanimminpmm ammuwy EWWWIMI‘( )mnaludedthat“... mammmmm,m1nmepmmdmam memmumw ”9061an m, ddsmhrmtutimommd in m, W Winona nth 9W3, similar: W." MmMnWanmehmmw mmmwmtwwmummmwn with hallucination... a! in the manna. mums or m: or mdmm,MaMMmfimm.Wthh mm” Wamfiummuwuwmuumum rang“, and Wine, lira-um dem in the an: mean an manymmmmmm. Jthe mm on ammm mm hire am also amine-at War. In 3W without we: mum the m Wham mmmumqums, andthismmociaud umamm with this illusory Momma In gamma with ma mama dammit-am mmwamwmmoxmwpmmmmw �~65- WW ( ) mm Wwwmamhmmmmrw. MmemmaWnuumummmmfim «Wmmamormummwamm( )a mm, mm upland: are mt Wat. In puma“ mmammwummmwmumm ma Radar than and ‘mmat‘dmwtm. WmWWflWtWMfiwfimdflm «mnwmmasrmmwmioaatamanumm Man, in mm W. in mm” inmm We: cam, MWWM'W'C , , )Jhemmtm wmmwwummmmwmm. Thu mmmmmofflwbmmmwh,orwha mm by, an aluminum in the mwlahelmmehonmsm mum” at the mm: muons man. It in also probable that. mmmmmmummmmimmmmamwm momwaammnwmummmmmmummm u ’Wflt’ ., �WWW at cm“ thirty form mWanu blathuamdnitmmlmufihtonwxym flmmdodynnue thanpfiu( mammamotmmmsunn. �Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior Significance for Theory of Convulsive Therapy MAX FINK. M.D.. GLEN OAKS. N. Y. �Reprinted from the A. Ill. A. Archives of Neurology 6“ Psychiatry September 1958, Vol. 80, pp. 380—387 Copyright 1958, by American fliedical Association Effect of Antieholinergic Agent, Diethazine, on EEG and Behavior Significance for Theory of Convalsive Therapy MAX FINK, M.D., Glen Oaks, N. Y. Recent investigations of convulsive therapy have emphasized EEG delta activity as the neurophysiologic basis for the induced behavioral Changel"5 Little study, however, has been given to the biochemical effects of this therapy, except in the course of investi— gations of head injuries. In investigations of head trauma signifi— cance has been ascribed to» changes in the acetylcholine—cholinesterase systems both for the behavioral and for the electroencephalo— graphic effects. An increase in free acetyl‘6 choline and an alteration of the ratio of cholinesterases 7 in the spinal fluid have been positively correlated with the degree of EEG abnormality and degree of neurologic defi— cit. The EEG patterns were “blocked,” and some improvement in clinical status was reported following the administration. of atropine.“8 In convulsive therapy, atropine and scopolamine were observed to block the appearance of delta activity,9 although the systemic effects of the large doses of these agents were marked. Recent reports 10 noted that EEG and behavioral effects similar to atropine were achieved in patients with head trauma by intravenous diethazine—a phenothiazine compound with anticholinergic properties— Submitted for publication March 24, 1958. From the Department of Experimental Psy— chiatry, Hillside Hospital. Aided, in part, by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. Read (in part) at the meeting of the Eastern Association of Electroencephalographers, New York, December, 1957. Awarded A. E. Bennett Psychiatric Research Award of the Society of Biologic Psychiatry, May, 1958. 380 with minimal systemic effects. In our con— tinuing studies of the role of delta activity in electroshock,3 the effect of diethazine: was studied. It is the purpose of this report to describe the effects of diethazine on EEG patterns and on behavior of patients during electroconvulsive therapy, and to relate these observations to the present neurophysiologic— adaptive hypothesis of the mode of action of convulsive therapy. Subjects and Methods Forty psychiatric patients, at various stages of electroshock therapy in an open-ward, voluntary psychiatric hospital were studied. All observations were made in acute experiments in the EEG lab— oratory. After a routine EEG recording, diemhazine was administered intravenously at the rate of 25 mg. per minute, for a total of 175 to 250 mg, depending upon the behavioral effect. The dosage varied from 2.8 to 4.0 mg. per kilogram of body weight. Diethazine is a soluble phenothiazine compound with pharmacologic properties similar to those of atropine. In experimental animals, diethazine blocks the bradycardia, bronchospasm, salivation, fasciculatio-n, and seizures induced by acetylcholine, fluorophosphate, and pilocarpine. It suppresses salivation and induces mydr‘iasis and hypotension.11 EEG Analyses.~—Recording was continuous for the duration of the observation period, except dur— ing interview periods. Needle electrodes, and an eight—channel Medcraft instrument were used. All records. were analyzed for the degree of delta activity,3 the per cent time and principal alpha frequency, and the relative amount of fast activity. The alpha and delta activities. were measured in anterior temporal—vertex, parietal-ear lobe, and frontal-occipital lead combinations. Behavior Mensures—Prior to drug administra— tion an unstructured psychiatric historical interview and a structured questionnaire period” were tape-recorded. Following drug administration, �EFFECT OF ANTICHOLINERGIC AGENT ON EEG periods of recorded interview were alternated with EEG recording periods, until the EEG had again manifested the preinjection pattern on. visual inspection. Two estimates of behavioral effects were used: clinical descriptions by the participants—subject, interviewer, and technician—of the changes oc— curring during the drug period, and language analyses of the recorded interviews. Changes in 1“ evaluated by a syntactic analysis language were and an analysis of the variability in verbal interaction in the dyad?"14 * Both measures have been shown to be sensitive to alterations in behavior induced by changes in the central nervous system. W W W W WW W WW AFTER I50 mg. PRE-DRUG LF-LO RF.“ LAT‘LF RAT-RF LF-RF LPT-LO 0-0 RPT-RO WWW-MN WWW“ MWVVUWVV’WMWM 50va___ SEC. l Observations (a) C1inicwl.—Within two to five minutes of the start of the injection, subjects mani— fested spontaneous coughing followed by a dryness of the mouth and a thickness of speech. They reported a feeling of lassi— tude and a heaviness and weakness of the extremities, soon succeeded by increased restlessness and difficulty in maintaining eye— lid closure. Reports of visual and haptic illusory sen— sations, feelings of unreality and distance, and delusional thoughts about their illness, the setting of the test procedures, or our identity were voiced spontaneously by 18 subjects in the period between 15 and 60 minutes after drug administration. In three instances increasing agitation and panic led Detailed analyses of these observations will be reported separately by Dr. J. Jaffe and Dr. R. L. Kahn. * AFTER 225 mg. PRE-DRUGI 0-0 W {Wyn-— SEC. =0? IGQI HH 1 Fig. 1.—Effect of intravenous diethazine prior to electroshock in a man aged 27. Fin/e #1125 NH Fig. 2.——Effect of intravenous diethazine prior to electroshock in a woman aged 57. to a cessation of the recording. In two subjects withdrawal and negativism were the prominent behavioral response. Such patterns of behavior were transient and had disappeared in one and one~half to four hours in all subjects. (I?) EEG Potterns.——Alteration in. the EEG patterns was concurrent with the be— havioral effects. In all records, changes oc— curred during drug administration and were sustained, with gradual diminution and resti— tution of the preinjection patterns, in one to five hours. The initial response was a decrease in voltage and desynchronization of all frequencies. There was a decrease in prominence of prevailing rhythms. In patients without delta activity (preelectro— shock), desynchronization and voltage decrease were occasionally accompanied by low—voltage 5—7 cps activity, symmetric and prominent in frontal and anterior temporal leads (Figs. 1 and 2). The alpha frequency was not altered. The build—up in voltage and appearance of slower frequencies with hyperventilation were blocked. In patients with varying degrees of high— voltage delta activity, desynchronization of the records became prominent, with a sig— nificant decrease both in voltage and in per cent time of slow wave activity. From an average per cent time delta of 45% in frontal—occipital leads, there was a reduction to a mean of 20%. Both random and burst delta activity diminished or disap‘ 381 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY PRE-DRUG AFTER 250 mg. W W ”W W W W W WW W W WW WW W LAT-LF/W RAT WWWW‘ WWWW RPM/MW LF- +5HRS. +|.HR WVJMWWVV' LPT'LQ’W’W‘VWW 0 ° ”WNW RPT—RW WMw/V *1249 SOpv [TEE—C HH Fig. 3.—Effect of intravenous diethazine on delta activity after electroshock. peared, and irregular low—voltage alpha and beta frequencies became prominent (Figs. 3 and 4). The hyperventilation response was no longer apparent. (c) Language Patterns.——In previous studies, an intimate relationship between changes in syntactic language patterns and the behavioral response in electroshock had been reported.” With alteration in brain function, increased use of the third person, verbal denial, qualification, displacement, and cliches became prominent. These: ef— fects could be enhanced by the administra— tion of intravenous amobarbital.15 In the subjects in the present study, syntactic analyses demonstrated a reversal of the patterns noted in electroshock. Use of the third person, qualification, and dis— placement decreased. Explicit verbal denial was modified and replaced by minimization and displacement, or by a reiteration of complaints of illness. In dyadic analyses, the verbal interaction was characterized by a greater diversity of vocabulary and less variability in the diversity scores for 25 word units. The qualitative nature of these changes in the language patterns is opposite that of amobarbuital and electroshock. The duration of language changes was concurrent with the changes in the electroencephalogram. Comment These observations confirm the report of Jenkner and Lechner of the effects of di— ethazine in “normal” subjects.10 Diethazine also alters electroshock—induced delta activity in a fashion similar to atropine and scopolamine, as described by Ulett and Johnson,9 with minimal unpleasant symptoms. The effects of intravenous diethazine are immediate, both on the EEG and on W W “MW MN “$wa W W WM W W W W “”wa PRE-DRUG + 200 mg. +25 min. + 70min. LF-LO Rm MWWW st UT'LWMW ”NM-«MW WVMW“ LF-RF LPT~LO °'° WWW WWW/“M 5°}‘VL._. ISEC. WWW/WWW #l637 HH Fig. 4.—Effect of intravenous diethazine on delta activity after electroshock. 382 Vol. 80, Sept, 1958 �EFFECT OF ANTICHOLINERGIC AGENT ON EEG behavior, and thus provide a useful experi— mental agent With “anticholinergic” proper— ties. Two aspects of these experimental observations warrant discussion: the role of acetylcholine-cholinest‘erase- in the electroconvulsive therapy process, and the signifi— cance of diethazine “alerting” for concepts of hallucinogenic activity. 1. Biochemical Basis of the Convulsive Therapy Process.——While there has been considerable study of the psychologic and neurophysiologic aspects of convulsive therbiochemi— information little concerning apy, cal processes is available. The studies of biochemical changes following head trauma and spontaneous seizures provide some analogic data. Bornstein,‘6 in a classical experi— mental study of head trauma in cats, demonstrated that within a few minutes after trauma free acetylcholine appeared in the spinal fluid and persisted for periods up to 48 hours. He further demonstrated a posi— tive relation between the severity of head trauma and the quantity of free acetylcholine, the degree of electroencephalo— graphic alteration, and the severity of the behavioral changes. The electroencephalographic records initially showed short peri— ods of high—voltage fast activity, and a transient period of flattening of electrical activity, followed by prolonged periods of high—amplitude sharp waves in the delta frequencies. Concomitantly, alteration in consciousness, changes in reflexes, and post— traumatic seizures were most prominent with highest concentrations of free acetylcholine and greatest degree of EEG change. 7 Tower and McEachern confirmed these observations in clinical studies in man. In 112 neurologic patients, free acetylcholine was found in the cerebrospinal fluid only in patients following head trauma and re— cent grand mal seizures, and the level of free acetylcholine varied directly with the degree of cerebral damage. In addition, these authors assayed the cholinesterase activity of the spinal fluid.7’1‘6 In patients following head trauma, they noted a sharp rise in. nonspecific cholinesterase (benzoylcholine— Fink splitting) and a drop in the specific cholin— esterase (methacholine—splitting) activity of the spinal fluid. No such inversion was noted in fluids containing free acetylcholine following spontaneous seizures. Electroen— cephalograms were taken at varying inter— vals following trauma and demonstrated a direct correlation of the extent of EEG abnormality with the appearance of free acetylcholine in the spinal fluid. Tower and McEachern also reported ob— servations in six patients receiving electro— convulsive therapy. In patients after three to seven induced convulsions, they noted free acetylcholine in the spinal fluid in two pa— tients and an increase in nonspecific cholinesterase with reversal of the cholinesterase ratio in five of the six. They concluded that the spinal fluid changes in electroshock are more like those of craniocerebral trauma than those found in epilepsyj' More re17 Sachs confirmed the reports of cently, free acetylcholine in the spinal fluid after head trauma and after electroshock. In his studies, Bornstein6 administered 0.5—1.0 mg/kg. of atropine and demonstrated a reversal or a blocking of the EEG effects and a modification of the behavioral and neurologic signs. Atropine also blocked the EEG and clinical signs induced by intra— cisternal acetylcholine. Ward8 applied these observations to the treatment of human subjects with varying degrees of head trauma. Subcutaneous doses of 0.1 mg/kg. of atropine induced both clinical improvement and reversal of EEG effects. These observations were recently confirmed by Sachs,17 Ruge,18 and Hughes}9 On the basis of these observations, Ulett and Johnson 9 noted the effect of atropine and scopolamine in blocking the EEG changes of electroshock therapy. Con— 10 currently, ]enkner and Lechner reported ' Regarding the one patient of the six who failed to show either free acetylcholine or a re— versal of the cholinesterase ratio, they noted: “It is interesting that this patient was the only one of the six to show no response to treatment.” 1‘ 383 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY effects similar to those of Ward, in studies provides an excellent experimental method for studies of craniocerebral trauma. of diethazine in cases of head injury. Studies of the brain—stem—activating sys— Another group of investigations complete the available data. Studies of anticholines— tem by Jasper and Droogleever-Fortuyn 28 terases, such as fluorophosphate, and tetra— and Lindsley et al.2‘9 had laid the founda— ethylpyrophosphate (TEPP), which block tion for the prevailing conclusion that sym— the enzymatic breakdown of acetylcholine, metric EEG slow—wave activity has its demonstrate the development of high-ampli— origin in mesencephalic structures, and that tude rapid—frequency EEG patterns similar these structures intimately affect the states to those of status epilepticus, as well as of “alerting” and “drowsiness.” More reslighter degrees of abnormality, as noted in cently, Rinaldi and Hivaich 30"” have re— post—traumatic states.”23 In these studies, lated the site of action. of atropine and atropine blocked both the electroencephalo— cholinergic drugs to this mesodiencephalic activating system. It is also probable that graphic and the clinicaltoxic effects. these be structures may selectively affected clinical and both from experimental Thus, studies of craniocerebral trauma we may by the convulsive therapy process, and that both ef— clinical the and the of electrographic the that acetylcholine activity (a) assume the spinal fluid increases, ([9) pseudo- fects may be intimately related to changes in cholinesterase activity increases, with a re— this system. 2. Diethazine “Alerting” and Hallucinoversal of the ratio of cholinesterases, (c) EEG hypersynchrony and slowing parallel gem'c Activity—The behavioral effects of these biochemical alterations, and (d) anti— diethazine provide information. regarding cholinergic agents may block both the elec— another aspect of the convulsive therapy troencephalographic and the clinical effects. process. In patients Without prior convul— From the data available, it is probable that sive therapy, illusory phenomena and feelthe biochemical basis of convulsive therapy ings of unreality were observed. These is similar to that of craniocerebral trauma. were similar to the hallucinogenic effects of Convulsive therapy results in free acetylcho— lysergic acid diethylamide (LSD32) and line in the spinal fluid 7'17 and a reversal of mescalinef“3 Again, analogic data about the clinical and EEG effects of these agents cholinesterase ratios.”6 The electroencepha— information provide about some con— may induced effects of con— repeated lographic vulsive therapy. is the development of high—voltage, vulsions 34 noted In studies of Wikler mescaline, symmetric, slow—wave activity, occasionally that the EEG demonstrated no change, or is which similar to with spike: activity,3"24’25 intermittent continuous low—voltage fast or trauma..2627 that observed in severe head increase in activity, or alpha frequency. In previous studies we have reported the Denber and Merlis 3'5 noted a similar accel— relationship between the degree of induced eration of decrease in per alpha frequency, slow—wave activity and behavioral response.3 cent time alpha, including its disappearance, The studies reported here and, the work of and random beta nonspecific activity. Delta 9 Ulett and Johnson demonstrate a reversal activity did not occur. In patients with of the EEG and the behavioral effects of delta activity induced by electroshock, Mer— convulsive therapy by anticholiner‘gic com— lis and Hunter 38 noted that intravenous pounds. In. each characteristic, convulsive mescaline markedly diminished the ampli— therapy is thus similar to- cerebral trauma. tude and per cent time delta activity with While the acetylcholine—cholinesterase sys— an increase in per cent time alpha. activity. tem is highlighted by these studies, other The effects of LSD on EEG are similar. enzyme systems may also be altered.17 These Gastaut et al.3‘6 noted an acceleration of studies also suggest that convulsive therapy alpha frequency of 0.5 to 4.0 cps, with an 384 Vol. 80, Sept, 1958 �EFFECT OF ANTICHOLINERGIC AGENT ON EEG accentuation of beta rhythms. Rinkel et al.3‘7 confirmed this observation and noted, in addition, a reduced responsivity to hyper— ventilation: In summarizing his studies, Wikler 34 concluded that “regardless of the . . drug administered, shifts on. the pattern of elec— troencephalogram in the direction of de— . synchronization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness.” This generalization. provides a meaningful construct in, which these agents may be assessed. Agents that evoke EEG desynchronization tend to be hallucinogenic, and mescaline and LSD are clear examples. Agents that synchronize frequencies, such as barbiturate and meprobamate in the beta frequency range, and chlorpromazine, pro— mazine, and perphenazine in the delta fre— 39 tend to be sedatives, quency range euphoriants, and relaxants. The observations on diethazine reported here are consistent with this hypothesis. In patients without delta activity, the EEG demonstrated desynchronization of f requen— cies, and this was associated with clinical illusory phenomena. In patients with delta activity desynchronization occurred, and alerting and reversal of the speech patterns induced by electroshock were observed. Electroconvulsive therapy may also be understood in this framework. We have previously noted a direct relationship be— tween Clinical evaluations of improvement and the degree of EEG slowing induced by electroshock.3 Under these conditions, seda— tion and euphoria are most prominent, and hallucinatory activity diminished. In, pa— tients in whom hypersynchrony is not in— of iStudies are now in progress on the effects LSD, Win—2299 (2~diethylarminoethy1-cyclo— pentylhydroxy—Z-thienylacetate), benactyzine, and other anticholinergic compounds on postconvulsive EEG delta activity. Initial experiments with these compounds have demonstrated marked diminution in per cent time and amplitude of delta activity associated with behavioral changes similar to those seen with diethazine. Fin/a duced, behavioral change is limited, and “improvement” does not occur.4 Previously we have concluded that the mode of action of convulsive therapies is based on the induction of a state: of altered cerebral function, in which changes in adap— tive interpersonal behavior occur, and are interpreted as “improvement.” 3'4'39 The present studies amplify two aspects of this neurophysiologic-adaptive hypothesis. The biochemical substrate of the behavioral change is reflected by an alteration in the acetylcholine—cholinesterase relationships of the central nervous system. It is also prob— able that EEG hypersynchrony provides the neur‘ophysiologic basis of the milieu change, which is clinically manifest as sedation and euphoria and is evaluated as “improvement.” The neurophysiologic-adaptive hypothesis of convulsive therapy has provided a meaningful basis for studies of other physiody— namic therapies.39 In this study, it has. been possible to amplify our understanding of neurophysiologic aspects of hallucinogens as well. Summary and Conclusions The: effect of an anticholinergic agent, diethazine, on the EEG, behavior, and lan— guage patterns was observed in 40 psychiat— ric patients, at various stages in the course of electroconvulsive treatment. (0) Behavior: Increased restlessness and agitation, haptic and visual illusory sensa— tions, and delusional thoughts about their illness or the examiner’s identity were ob— served. (b) EEG: Alteration in EEG were con— current with behavioral changes. There were a decrease in voltage and desynchroni— zation of all frequencies. In patients with delta activity, the per cent time and voltage of delta activity decreased. (c) Language: Syntactic patterns de— scribed for convulsive therapy were re— versed. Use of third person, qualification, and displacement decreased. In dyadic analyses there was a decrease in the coeffi— cient of variation. 385 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY These observations are discusSed in the framework of the neurophysiologic—adap— tive hypothesis of the action of convulsive therapy, and it is concluded that (at) the biochemical basis for convulsive therapy is similar to that of craniocerebral trauma; (1)) changes in acetylcholine-—cholinesterase metabolism are intimately related to the be— havioral effects, and (c) EEG desynchroni— zation may be a physiologic concomitant of hallucinogenic activity, and EEG hyper— synchrony, associated with euphoria and sedation. Mrs. Hannah Mosquera gave technical assistance in the EEG recordings, and Dr. Joseph Jaffe and Dr. Robert L. Kahn made the analyses of the tape recordings. Diethazine was made available through the courtesy of Smith, Kline & French Laboratories, Philadelphia. Hillside Hospital, 75—59 263d St. REFERENCES Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects, Springfield, 111., Charles C Thomas, Publisher, 1. 1955. 2. Roth, M.; Kay, D. W. K.; Shaw, J., and Green, J.: Prognosis and Pentothal Induced Elec— troencephalographic Changes in Electroconvulsive Treatment, Electroencephalog. & Clin. Neuro— physiol. 9:225—237, 1957. 3. Fink, M., and Kahn, R. L.: Relation of Electroencephalographic Delta Activity to Be— havioral Response in Electroshock, A. M. A. Arch. Neurol. & Psychiat. 78:516—525, 1957. 4. Fink, M.; Green, M. A., and Kahn R. L.: Experimental Studies of the Electroshock Process, Dis. Nerv. System, 19:113—118, 1958. 5. Ulett, G. A.; Smith, K, and Gleser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, Am. J. Psychiat. 112:795—802, 1956. 6. Bornstein, M.: Presence and Action of Acetylcholine in Experimental Brain Trauma, J. Neurophysiol. 9:349—366, 1946. 7. Tower, D. B., and McEachern, D.: Acetyl— choline and Neuronal Activity, Canad. J. Res. 27: 105-131, 1949. Ward, A.; Atropine in the Treatment of Closed Head Injury, J. Neurosurg. 7 :39‘8-402, 1950. 9. Ulett, G. A., and Johnson, M. W.: Effect of Atropine and Scopolamine upon Electroencephalo— graphic Changes Induced by Electroconvulsive 8. 3.86 - 7 Therapy, Electroencephalog. & Clin. Neurophysiol. 92217—224, 1957. 10. Jenkner, F. L., and Lechner, H.: Effect of Diparcol on the Electroencephalograim in the N ormal Subject and in Those with Cerebral Trauma, Electroencephalog. & Clin. Neurophysiol. 7:303- 305, 1955. 11. Heymans, C.; Estable, J. J., and de Bonne— veaux, S. C.: Sur la Pharmacologie de la phénothiazinyl-éthyldiéthylamine (2987 R. P.), Arch. internat. Pharmacodyn. 792123438, 1949. 12. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psy— chopathology of Communication, edited by P. H. Hoch and J. Zubin,.New York, Grune: & Stratton, Inc, 1958, pp. 126-139. Jaffe, J.: An Objective Study of Communication in Psychiatric Interviews, J. Hillside Hosp. 13. 6:207—215, 1957. 14. Jaffe, J.: Language of the Dyad: A Method of Interaction Analysis in Psychiatric Interviews, Psychiatry, to be published. 15. Weinstein, E. A.; Kahn, R. L.; Sugariman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium in Organic Brain Disease, Am. J. Psychiat. 112:889—894, 1953. 16. Tower, D. B., and McEachern, D.: The Content and Characterization of Cholinesterases in Human Cerebrospinal Fluids, Canad. J. Res, Sect. E. 27:132—145, 1949. 17. Sachs, E., Jr.: Acetylcholine and Serotonin in the Spinal Fluid, J. Neurosurg. 14:22-27, 1957. 18. Ruge, D.: Use of Cholinergic Blocking Agents in the Treatment of Cranio—Cerebral Injuries, J. Neurosurg. 11:77—83, 1954. 19. Hughes, B.: Role of Acetylcholine in Head Injury, J. Neurol. Neurosurg. & Psychiat. 20:70, 1957. 20. Freedman, A. M.; Bales, P. D; Willis, A., and Himwich, H. E.: Experimental Production of Electrical Major Convulsive Patterns, Am. J. Physiol. 146:117-124, 1949. 21. Grob, D.; Harvey, A. M.; Langworthy, O. R., and Lilienthal, J. L.: The Administration of Di-Isopropyl Fluorophosphate (D‘FP) to Man, Bull. Johns Hopkins Hosp. 81 :257—266, 1947. 22. Hampson, J. L. ; Essig, C. F.; McCauley, A., and Himwich, H.: Effects of Di—Isopropyl Fluorophosphate (DFP) on Electroencephalogram and Cholinesterase Activity, Electroencephalog. & Clin. Neurophysiol. 2:41—48, 1950. 23. Himwich, H. E.; Essig, C. F.; Hampson, J. L.; Bales, P. D., and Friedman, A. M.: Effect of Trimethadione (Tridone) and Other Drugs on Convulsions Caused by Di—Isopropyl Fluorophosphate (DFP), Am. J. Psychiat. 106:816—820, 1950. 24. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Electroencephalog. & Clin. Neurophysiol. 2:157-162, 1950. Vol. 80, Sept, 1958 �EFFECT OF ANTICHOLINERGIC AGENT ON EEG M.: Significance of Individual Variability in EEG Response to Electroshock, J. Hillside 25. Green, Hosp. 6:229-240, 1957. 26. Jasper, H. H.; Kershman, J., and Elvidge, A.: Electroencephalographic Studies of Injury to the Head, Arch. Neurol. & Psychiat. 44:328-348, 1940. 27. Strauss, H.; Ostow, M., and Greenstein, L.: Diagnostic Electroencephalography, New York, Grune & Stratton, Inc, 1952. 28. Jasper, H. H., and Droogleever—Fortuyn, J.: Experimental Studies on the Functional Anatomy of Petit Mal Epilepsy, A. Res. Nerv. & Ment. Dis., Proc. 26 :272-298, 1947. 29. Lindsley, D. B.: Schreiner, L. H.; Knowles, W. B., and Magoun, H. W.: Behavioral and EEG Changes Following Chronic Brain Stem Lesion in the Cat, Electroencephalog. & Clin. Neurophysiol. 2 :483-498, 1950. 30. Rinaldi, F., and Himwich, H. H.: Alerting Responses and Actions of Atropine and Cholinergic Drugs, A. M. A. Arch. Neurol. & Psychiat. 73 :387395, 1953. 31. Himwich, H., and Rinaldi, F.: Effect of Drugs on Reticular System, in Brain Mechanism and Drug Action, edited by W. S. Fields, Springfield, Ill., Charles C Thomas, Publisher, 1957. Fink 32. Stoll, 'W. A.: Lysergsaure—Diathylamid, ein Phantastikum aus der Mutterkorngruppe, Schweiz. Arch. Neurol. u. Psychiat. 60:279—323, 1947. 33. Beringer, K.: Der Meskalinrausch, Seine Geschichte und Berlin, Erscheinungsweise, Springer—Verlag, 1927. 34. Wikler, A.: Clinical and Electroencephalographic Studies on the Effects of Mescaline, N— Allylnormorphine and Morphine in Man, J. Nerv. & Ment. Dis. 120:157—175, 1954. 35. D‘enber, H., and Merlis, S.: Studies on Mescaline: I. Action in Schizophrenic Patients, Psychiat. Quart. 29:421-429, 1955. 36. Gastaut, H.; Ferrer, S., and Castells, C.: Action de la diéthylamide de l’acide d—lysergique (LSD 25) sur les fonctions psychiques et l’électroencéplhalogramme, Confinia neurol. 13:102— 120, 1953. 37. Rinkel, M.; DeShon, H. J.; Hyde, R. W., and Solomon, H. C.: Experimental Schizophrenialike Symptoms, Am. J. Psychiat. 108:572—578, 1953. 38. Merlis, S., and Hunter, W.: Studies on Merscaline: II. Electro—Encephalogram in Schizophr‘enics, Psychiat. Quart. 29:430—432, 1955. 39. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp. 6: 197—206, 1957. 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They also noted that the dose of atropine necessary to affect the EEG-was such as to be associated with unpleasant systemic effects. The reports describing diethazine as an anticholinergic by Jenkner and Lechner (2) compound with potent neurologic but minimal systemic effects led us to undertake studies similar to those of Ulett and Jehnson; and these observations, in turn led to an investigation of other similar agents. clinical and EEG It is correlations the purpose of this report to describe the on the intravenous administration of various hallucinogens and anticholinergic agents in psychiatric patients it various stages of convulsive therapy; and to relate these observations to the recently expressed neurophysiologic-adaptive hypothesis of the mode of action of convulsive therapy and of hallucinogens. Subject and Mathod: Our subjects were consecutive referrals for convulsive therapy in an open ward voluntary psychiatric hospital. Patients have various stages of therapy, with observations being in the 17 EEG laboratory. Following a standard leads using needle electrodes, the intravenously at a made been studied in acute experiments 8 channel EEG compound under at recording from study was administered set rate per minute, until clinical behavioral or �electrographic changes diethazine, were observed. Win 2299*, LSD-25, benactyzine, Diethazine was administered at 25 mgm;'Win-2299 and benactyzine at 10 gamma per minute per minute for 1.2-3.6 mgm. at 0.5 for 50-150 studied The compounds JB—318* and JB-336.* per minute, for a mgm gamma; have been total per minute for 2-5 of 175-250 mgm; LSD-25 and JB~318 and JB-336 at 0.h mgm mgm. Observations: the administration of diethazine, in 15 patients prior to convulsive therapy, there was a decrease in voltage and a desynchronization of all On frequencies. Prevailing rhythmic patterns some instances, symmetric prominent in the was not hy frontal altered, but the became low voltage 6-? cps and less prominent. In activity appeared, most anterior temporal leads. in voltage build—up The alpha frequency and slower frequencies induced hyperventilation was blocked (Fig. 1, 2). In 17 patients during convulsive therapy, with varying degrees of induced high voltage delta activity, there was a significant decrease both in voltage and in per cent time of slow wave activity. From an average per cent time delta of h5% in the fronto-occipital leads, there was a reduction to a mean of 20%. Both random and burst delta activity diminished voltage alpha and beta frequencies became prominent. response was no longer apparent. hyperventilation electrographic effects persisted for is 2-diethy1aminoethyl cyclopentyl (2-thienyl) ggycolateg is n-ethyl-B-piperidylbenzilateg JB-336 is memethyl-3-piperidy1benzilate. ”'Win-2299 JB-313 These The and low �one to five hours (Fig. 3, h). Concurrent with these Patients changes. EEG became more effects, we observed irritable and distinctive behavioral restless and complained of sensations of unreality with dysesthesias of the extremities. Visual illusory phenomena and delusional thoughts about their illness, the setting of the test procedure or the examiner's identity were described. Their language patterns were characteristically altered in a fashion opposite to that previously described for amobarbital (3), so that verbal denial, minimization, cliches, third person mode and past tense became less prominent. The These changes were concurrent with maximum electrographic change. behavioral observations with diethazine led to a review of the effects of hallucinogens on EEG activity. In 1955 Denber and Merlis (h) had reported that mescaline altered EEG delta activity induced by electroshock, in a fashion similar to diethazine. They described a marked reduction in amplitude and per cent time of high voltage symmetric slow wave bursts with an increase in alpha per cent time and in low voltage, random leW'wave activity. Reports by fennes (5) that an experimental compound, Win-2299 manifested both potent anticholinergic activity and induced hallucinations in to our study of this compound. The effects were (Fig. 5). led similar to that observed in the diethazine group. In patients pre-convulsive therapy, desynchronization and decrease in voltages of man all frequencies EEG were induced In eleven patients with high voltage delta activity there was a decrease in amplitude and per cent time of slow wave activity with an increase in alpha and beta frequencies. activity dropped from 50% to 23% The mean per cent time delta in these subjects. Associated with these �-helectrographic effects and hallucinatory and clinical patterns of restlessness, excitement, illusory activity (Fig. 6). As the hallucinogenic were activity of LSD-25 was well established, these studies were next repeated with this compound. Here, too, the behavioral and electroencephalogrgphic effects, was a administration, on intravenous were similar to diethazine. There difference in the time constant in that the behavioral effects occurred 1% to 2 after hours drug administration, but the electrographic changes were concurrent with the behavioral change. While there was desynchronization with Mean LSD, less the delta activity was significantly repressed. fell per cent time delta activity in five subjects from h7% to 16% (Fie- 7, 8, 9). Recalling reports that benactyzine, a potent anticholinergic compound, induced EEG desynchronization next administered this we compound intravenously in eleven subjects, and again observed similar clinical and electrographic patterns. Both in the well modulated alpha record and in the record with high voltage delta activity, desynchronization was prompt. Delta activity decreased from a subjects (Fig. 10, ll).’ clinical restlessness same per cent time of electrographic patterns 39% to 17% we in 8 were accompanied by and excitement. While we did not observe hallucinatory activity, in the These mean illusory or did note that the language patterns were altered fashion as with the other agents tested. Lately, following reports by Abood (6) that various piperidylbenzilates had potent anticholinergic properties and induced activity, we patterns were tested two of these, clinical hallucinogenic JB~318 and JB-336. identical to those of Win-2299 and The electrographic in each instance in which desynchronization was observed, clinical restlessness and hallucinatory �~5- activity for l to (Fig. 12, 13). was noted 3 The hallucinatory activity persisted hours, and during this period, electrcgraphic alteration was prominent. Thus, six compounds have been shown to have similar electrographic and behavioral effects. Each has definitive anticholinergic activity. Each induces hallucinogenic or excitatory activity; and these behavioral changes are accompanied by desynchronizaticn. compounds have a vamine EEG Furthermore, these similar chemical structure (Fig. 1h). The tertiary in a substituted diethylaminethanol is prominent, corroborating the recent reports by Denber (7) on the hallucinogenic activity of tertiary amines, and amplifying his studies by the common concurrent electrographic patterns. These observations amplify our understanding of the convulsive therapy process. In earlier studies high voltage slow wave activity we indicated that the development of was the neurophysiologic correlate of behavioral change in convulsive therapy, and a necessary, though not sufficient, condition for clinical years, studies improvement (8). During the past ten by Bernstein, Tower and MeEachern, ward, Sachs, Bugs and others have noted similarities in the biochemical changes in convulsive therapy to craniocerebral trauma (9). They reported an elevation of free acetylcholine and pseudonholinesterase in the spinal fluid during convulsive therapy. In addition, topical administration of acetylcholine induces high voltage bursts uni spike activity. Ulett and Johnson emphasized the blocking of these cholinergic effects by the anticholinergic activity of atropine and scopolamine. The obsumvaticns on this report on �~6- diethazine, Win-2299, benactyzine and the piperidylbenzilates ISDbZS, support their observations. Each of these compounds has potent anticholinergic clinical behavioral and language effects areqpposite to those described for convulsive therapy. we may thus amplify the earlier conclusion that the neurophysiolegic basis for behavioral change in activity and the convulsive therapy by noting is that this the development of high.voltage slow wave EEG change activity reflects an alteration in the acetylcholine- cholinesterase relations of the nervous system, probably in the direction of increased cholinergic activity. These observations lend themselves to application in studies of craniocerebral trauma. .ward's (10) reports of the efficacy of high doses of atropine in altering the clinical manifestations of head trauma also indicated that effective doses brought with It would more them severe systemic be advisable to repeat these studies, neurologically specific anticholinergic utilizing such effects. more compounds as used potent, in these experiments. Finally, these observations, and our earlier reports significance of EEG on the delta activity in convulsive therapy, support the his report on mescaline, morphine with the comment that: "... regardless observation of Wikler (11) n-allylnormorphine and who concluded of the drug administered, shifts in the pattern of the electroencephalogram in the direction of desynchronization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness." This conclusion, supported by our observations, permit a more meaningful �.7- ._ generalization of the recently expressed neurophysiologicuadaptive twpothesis of the mode of action of somatic therapies in psychiatry. We may infer that agents that synchronize EEG in the beta frequency range frequencies, like barbiturate and and chlorpromazine, promazine and perphenazine in the delta frequency range, tend to while agents that evoke hallucinogenic, as EEG meprobamate be sedative, euphoriant and relaxant; desynchronization tend to be excitant and was noted for diethaaine, mescaline, and the piperidylbenzilates. LSD-25, Win-2299, benactyzine, �~8~ In summary, and the effects of various hallucinogenic we have observed anticholinergic compounds on the electroencephalogram and behavior in psychiatric patients at various stages of convulsive therapy. Behaviorally, these compounds induced increased restlessness, haptic and visual illusory sensations and delusional thoughts about the illness or the examiner's identity. The subject's syntactic language patterns described for convulsive therapy and barbiturate were reversed. Concurrent with these changes were a decrease in voltage and a desynchronization of all freQuencies in the In patients with high voltage delta EEG. activity, the per cent time and voltage of the delta activity were markedly decreased. These observations have been discussed common in the framework of the biochemical structure and anticholinergic properties of these agents with the conclusion that: (a) The biochemical basis for convulsive therapy and for>high alteration in the acetylcholinecholinesterase relation of the nervous system, probably in the direction voltage EEG delta activity may be an of increased cholinergic activity. (b) of the mode The recently expressed neurophysiologic-adaptive hypothesis of action of somatic therapies in psychiatry is amplified to encompass the action of hallucinogens. It is cholinergic more recommended compounds that further studies of the effects of anti- in creniocerebral trauma to neurologically specific Win-2299. compounds be undertaken, utilizing as diethazine, benactyzine and �REFERENCES 1. .2. Ulett, Effect of Atropine and Scopolamine Electroencephalographic Changes Induced by ElectroOlin. Neuro aio . 2; 217-22h, 1957. convulsive Therapy, G.A. and Jehnson,1MJfl.: Upon Jenkner, F.L. and Lechner, H.: wig; 19 3. 5. ,6. Effect of Diparcol on the . in Kahn, R.L. and Fink, M.: Changes Therapy, In Grune ,h. The Electroencephalogram in the Normal subject and in Those Cerebral Trauma, EEG Olin. ' NeuropQXSiol. I; 303-305, & EEZOhOEEthOlOEY Stratton, Denber, H. and marlis, N.Y. 19 8. 8.: Studies Language During Eleotroshook of Communication, pp. 126-139, on Nescaline I: Action in Schizophrenic Patients. Efiychiat. Quart., g2; h21-h29, 1955. Pennes, H. and Koch, P.: Paychotomimetics, Clinical and Theoretical Considerations, Amer. J. Psychiat. _1_1_;: 887-892, 1957. Abood, L.G., Catfield, A.M. and Biel, J.: A New Group of Psychotomimetic Agents, Proc. Soc. Exp. Biol. Mad. 21: h83‘h861 1958 o 7. Denber, H.C.B.: Drug-Induced States Resembling Naturally Occurring Paychosee, in ggzchotrogic DEEES: eds. Garattini, S. and .8. - , l9 7. Fink, M. and Kahn, R.L.: Relation of EEG Delta Activity to Behavioral Response in Electroehock: Quantitative Serial Studies, A.M.A, Arch. Neurol. & Psychiat. 1Q} 516-525, 1957. Ghetti, V., Elaevier, 9. Fink, M.: Effect of Anti-Cholinergio Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy, A.M.A. Arch. Neurol. a Psychiat. §Qr W88, 1958. 10. Ward, A.: Atropine in the ”heatinent of Closed 398.).‘02’ 1950. 7: Neurosurg., Head Injury, ,1. Clinical and Electaoencephalographic Studies on the Effects of Mescaline, Nealkylnormorphine and Morphine in ‘Wikler, A.: Man, J. Nerv. Ment. 1318., 120: 157.175, 195h. �Effect of Anti-Cholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Omleive merepy Max From LOI.’ Fink, 14.1). the Department of Experimental Psychiatry, Hillside Hospital, NOYI Glen Oaks, in part, by grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Aided, Read (in part) at the meeting of the Eastern Association of Electroenceplmlo- graphers, N.Y., December 1957. SBP: 3-58 �3-3-58 Effect of Anti-Cholinergic Agent, Diethazine, Significance for Theory on EEG-and Behavior: oi Convulsive Therapy Recent investigations of convulsive therapy have emphasized EEG delta activity as the neuroprxyaaoiogic basis for: the induced behavioral change (l,2,3,h,5). Little study, however, has been given to the biochemical effects of this therapy, except in the course of investigations of head injuries. In investigations of head trauma significance has been ascribed to in the acetylcholine-cholinesterase systems both for the behavioral and the electroencephalographic effects. An increase in free acetylcholine (6) and an alteration of the ratio of cholinesterases (7) in the spinal fluid have been positively correlated with the degree of EEG abnormality changes and degree of neurologic improvement deficit. in clinical status The EEG patterns were "blocked," and was reported following some the administration of atropine (7,8). In convulsive therapy, atropine and scopolamine were observed to block the appearance of delta activity, (9) although the effects of the large doses of these agents were marked. Recent reports (10) noted that EEG and behavioral effects similar to systemic atropine were achieved in patients with head trauma by intravenous diethazine a phenothiazine compound with anticholinergic properties - with minimal systemic effects. In our continuing studies of the role of delta activity in electroshock (3), the effect of diethazine was studied. It is the purpose of this report to describe the effects of diethazine on EEG patterns and on behavior of patients during electroconvulsive therapy; and to relate these observations to the present neurophysiologic-adaptive hypothesis of thexnode of action of convulsive therapy. �SUBJECTS AND METHODS: Forty psychiatric patients, at various stages of electroshock therapy in an open-ward, voluntary psychiatric hospital have been studied. All observations have been made in acute experiments in the EEG laboratory. Following a routine recording, diethazine was administered intravenously per minute, for a total of 175 to 250 mgm, depending the behavioral effect. Dosage varied from 2.8 to h.0 mgm per kilogram at the rate of upon EEG 25 mgm body weight. Diethazine is a soluble phenothiazine compound with pharmacologic properties similar to atropine. In experimental animals, diethazine blocks the bradycardia, bronchospasm, salivatim, fasciculation and seizures induced by acetylcholine, di-isopropyl fluorophosphate and pilocarpine. It suppresses salivation, and induces nwdriasis and hypotension (11). me An ses: Recording was continuous for the duration of the observation period, except during interview periods. Needle electrodes, and an Medcraft instnnnent were used. All records were analyzed delta activity (3) 5 the per cent time the relative amount of fast activity. measured in anterior temporal-vertex, and The and 8 channel for the degree of principal alpha frequency; and alpha and delta activity were parietal-ear lobe lead combinations. Behavior Measures: Prior to drug administration an unstructured psychiatric historical interview and a structured questionnaire period (12) were tape recorded. Following drug administration, periods of recorded interview were alternated �+3- with EEG recording periods, injection pattern on until the EEG had again manifested the pres visual inspection; No estimates sf behavioral effects were used: clinical descriptions by the participants - subject, interviewer and technician - of the changes occurring during the drug period, and language analyses of the recorded interevaluated by a syntactic analysis (12) views, Guanges in language were .* and an analysis of the variability in Verbal interaction in the dyad (13.11:) Both measures have been shown induced by changes in the to be sensitive to alterations in behavior central nervous system. * Detailed analyses of these observations Drs. J. Jaffe and R. L. Kahn. will be reported separately by I �OBSERVATIONS: (a) Clinical: Within two to five minutes of the start of the injection, subjects manifested spontaneous coughing followed by a dryness of the anzl a thickness of speech. They reported a feeling of lassitude, mouth and a heaviness and weakness of extremities which was soon succeeded by increased difficulty in mintan eyelid closure. Reports of visual and haptic illusory sensations, feelings of unreality distance, and delusional thoughts about their illness, the setting of restlessness and and test procedures or identity were voiced Spontaneously in eighteen subjects in the period between 15 and 60 minutes after drug aduinistration. the our In three instances, increasing agitation and panic led to a cessation of the recording. In two subjects withdrawal and negativism was the prominent behavioral response. Such patterns of behavior were transient and had disappeared in (b) EEG 1% - 14 all subjects. hours in Patterns: Alteration in the EEG patterns was concurrent with the behavioral effects. In all records, changes occurred during drug administration and were sustained, with gradual diminution and restitution of the pre-injection patterns, in one to five hours. The voltage and desynchronization of initial response was a decrease in all frequencies. praninence of prevailing rhytlms. There was a decrease in In patients without delta activity (pm-electroshock), desynchronization and voltage decrease was occasionally activity, symmetric and prominent in frontal and anterior temporal leads (Figure l, 2). The alpha frequency was not altered. accompanied by low voltage 5—7 cps �~5The build-up in voltage and appearance of slower frequencies with hyper- ventilation was blocked. In patients with varying degrees of high voltage delta activity there was a prominent decrease in voltage and desynchronization of the record. burst delta activity diminished or disappeared, and irregular voltage alpha and beta frequencies became prominent (Fig. 3, h). The Both random and low hyperventilation response was no longer apparent. (c) Language Patterns: In previous studies, an intimate relationship betwaen changes in syntactic language patterns and the behavioral response in electroshock had been reported (12). With alteration in brain function, increased use of third person, verbal denial, qualification, displacement and cliches became prominent. These effects could be enhanced by the admirfistration of intravenous anobarbital (1h) . In the subjects in the present study, syntactic analyses demonstrated a reversal of the patterns noted in electroshock. Use of third person, qualification and displacement decreased. Explicit verbal denial was modified and replaced by minimization and displacement, or by a complaints of illness. In dyadic analyses, the verbal characterized by a greater diversity of vocabulary and reiteration of interaction was less variability in the diversity scores for 25 word units. qualitative nature of these changes in the language patterns is opposite to that of amobarbital and electroshock. The duration of language changes was concurrent with the changes in the electroencephalogram. The �DISCUSSION: report of Jenkner and Lechner of the effects of diethazine in "normal" subjects (10). Diethazine also alters electroshock induced delta activity in a fashion similar to atropine and These observations confirm.the s cpolamine, as described by Ulett and Johnson (9), with minimal unpleasant symptoms. EEG The effects of intravenous diethszine are immediate, both and behavior, and thus provides a on the useful experimental agent with "anti- aspects of these experimental observations warrant discussion: the role of acetylcholine-cholinesterase in the electrocholinergic" properties. The convulsive therapy progress, and the significance of diethasine "alerting" for concepts of hallucinogenic activity. 1. Biochemical Basis of the Convulsive Therapy Process: While there has been considerable study of the psychologic neurophysiologic aSpects of convulsive therapy, biochemical processes is available. The little and information concerning studies of biochemical changes following head trauma and spontaneous seizures provide some analogic data. Bernstein (6), in a classical experimental study of head trauma in cats, demonstratadthat within a few minutes appeared in the Spinal fluid and after trauma, free acetylcholine persisted for periods up to h8 hours. He further demonstrated a positive relation between the severity of head trauma and the quantity of free acetylcholine, degree of electroencephalographic alteration and graphic records the severity of the behavioral changes. initially showed short periods The electroencephalo- of high voltage fast activity, transient period of flattening of electrical activity, followed by prolonged periods of high amplitude sharp waves in the delta frequencies. Concomitantly, a �.7 - alteration in consciousness, changes in reflexes and post-traumatic seizures were most prominent with highest concentrationsof free acetylcholine and greatest degree of EEG change. Tower and HbEachern (7) confirmed studies in man. In 112 neurologic these observations in clinical patients, free acetylcholine was found in the cerebrospinal fluid only in patients following head trauma grand mal seizures; and the level of free acetylcholine varied the degree of cerebral damage. and recent directly with In addition, these authors assayed the cholin- esterase activity of the spinal fluid, (7, 16). In patients following head trauma, they noted a sharp splitting) and a drop rise in non-specific cholinesterase (benzoylcholine- in the specific cholinesterase (mecholyl-splitting) activity of the spinal fluid. No such inversion was noted in fluids containing free acetylcholine following spontaneous seizures. Electroencephalograms were taken at varying intervals following correlation of the extent of EEG trauma, and demonstrated a direct abnormality and the appearance of free acetylcholine in the spinal fluid. Tower and MbEachern also reported observations in six patients receiving electroconvulsive therapy. In patients after 3-7 induced convulsions, they noted free acetylcholine in the spinal fluid in two, and an increase in non-specific cholinesterase with reversal of the cholinesterase ratio in five of the six. They concluded that the spinal fluid changes in electroshock are more like those of craniocerebral trauma than those found in epilepsy. * patient of the six who failed to show either free acetylcholine or a reversal of the cholinesterase ratio, they noted: "It is interesting that this patient was the only one of the six to Show no response to treatment." * Regarding the one �-8recently, Sachs (17) confirmed the reports of free acetylcholine in the spinal fluid after head trauma and after electroshock. In his studies, Bernstein (6) administered 0.5-1.0 mg/kg atropine More and demonstrated a reversal or a blocking of the EEG effects, and a modification of the behavioral and neurologic signs. Atropine also blocked the EEG and clinical signs induced by intracisternal acetylcholine. Ward (8) applied these observations with varying degrees of head trauma. atropine induced both clinical to the treatment of subjects human Subcutaneous doses of 0.1 mg/kg of improvement and reversal of EEG effects. recently confirmed by Sachs (1?), Huge (18) and these observations, Ulett and Johnson (9) noted the These observations were Hughes (19). Based on in blocking the Em changes of electroshock therapy, without noting the effect on clinical behavior. Concurrently, Jenkner and Lechner (10) reported effects similar to those of Ward, in effect of atropine and scopolamine studies of diethazine in cases of head injury. Another group of investigations complete the available of anticholinesterases, as DFP data. Studies (di-isopropyl fluorophosphate) and (tetraethyl-pyrophosphate), which block the enzymatic TEPP breakdown of acetyl- choline, demonstrate the development of high amplitude rapid frequency EEG patterns similar to status epilepticus as well as lesser degrees of abnormality as noted in post-traumatic states (20, 21, 22, 23). In these studies, atropine blocked both the electroencephalographic and the clinical toxic effects. Thus, both from experimental and trauma we may assume clinical studies of craniocerebral that (a) the acetylcholine activity of the Spinal �-9- fluid increases; (b) pseudo-cholinesterase activity increases with a reversal of the ratio of cholinesterases; (c) EEG hypersynchrony and slowing agents From parallel these biochemical alterations; may and (d) anticholinergic block both the electroencephalographic and the clinical effects. the data available convulsive therapy it is probable that the biochemical basis is similar to that of craniocerebral trauma. of Convulsive therapy results in free acetylcholine in the spinal fluid (7, 17) and a reversal of cholinesterase ratios (7, 16). The electroencephalographic effects of repeated induced convulsions is the development of high voltage, symmetric Slow wave activity, occasionally with spike activity (3, 2h, 25), which is similar to that previous studies we have observed in severe head trauma (26, 27). In reported the relationship between the degree of activity and behavioral response (3). The studies reported here and that of Ulett and Johnson (9) demonstrate a reversal of the EEG and the behavioral effects of convulsive therapy by anti- induced slow wave cholinergic compounds. In each characteristic, convulsive therapy is thus similar to cerebral trauma. While the acetyloholine-cholinesterase system studies, other enzyme systems may also be altered studies also suggest that convulsive therapy provides an is highlighted (17). These by these excellent experimental method for studies of craniocerebral trauma. Studies of the brain stem activating system by Jasper and DroogleverFortuyn (28) and Lindsley gt|§l. (29) had laid the foundation for the activity has its origin in mesencephalic structures, and that these structures intimately affect the states of "alerting" and "drowsiness." More recently, Rinaldi and prevailing conclusion that symmetric EEG slow'nave �-mrelated the site of action of atropine and cholinergic drugs to this mesodiencephalic activating system. It is also probable that Himwich (30, 31) have these structures may be selectively affected by the convulsive therapy process, and that both the clinical and electrographic effects may be intimately related to changes in this system. 2. Diethazine "Alerting The and Hallucinggenic Activity: behavioral effects of diethazine provide information regarding another aSpect of the convulsive therapy processt. prior convulsive therapy, illusory phenomena and In patients without feelings of unreality were observed. These were similar to the hallucinogenic effects of and mescaline (33). Again analogic data about the of these agents may provide some no change, (31;) noted that the intermittent or continuous increase in alpha frequency. (32) and EG effects information abmt convulsive therapy. In studies of mescaline, Wikler either clinical LSD low voltage EEG demonstrated fast activity or Denber and Merlis (35) noted a similar acceleration of alpha frequency, decrease in per cent time alpha including its disappearance, and non-specific random beta activity. Delta activity did not occur. In patients with delta activity induced by electroshock, Merlis and Hunter (38) noted that in travenous mescaline markedly diminished the amplitude and per cent time delta activity with an increase in per cent time alpha activity. similar. Gastaut gt g. (36) noted an acceleration of alpha frequency of 0.5 to h.0 cps with an accentuatim of beta rhythms. Rinkel 33 al. (37) confirmed this observation and noted, The effects of 151) on EEG are �4L1- in addition, a reduced responsivity to hyperventil‘afion.* In smnmariaing his studies Wikler (3h) concluded that " . . . regardless of the drug administered, shifts in the pattern of electroencephalogram in the direction of desynchnonization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness.“ This generalization provides a meaningful construct may be assessed. Agents that hallucinogenic, and mascaline in which these agents evoke EEG desynchronization tend and 1813 to be are clear examples. Agents that synchronize frequencies, such as barbiturate and meprobamate in the beta frequency range, and chlorpromazine, promazine and pezfimaz‘mainthe delta frequency range (39) tend to be sedatives, euphoriants and relaxants. The observations on diethazine reported here are consistent with this hypothesis. In patients without delta activity, the EEG demonstrated desynchronization of frequencies, and this was associated with clinical illusory phenomena. In patients with delta activity desynchronisati.on occurred, and alerting and reversal of the speech patterns induced by electroshock were observed. Electroconvulsive therapy We ~31- have previously noted a Studies are now may also be understood in this framework. direct relationship between clinical evaluations in progress of the effects of LSD, Win-2299, benactyzine other anticholinergic compounds on post-convul sive EEG delta activity. Initial experiments w- ah intravenous LSD (SO-100 gamma) demonstrated marked dinfinution in per cent time and amplitude of delta activity. and �of improvement and the degree of Under these conditions, sedation EEG slowing induced by electroshock (3). and euphoria are most prominent and hallucinatory activity diminished. In patients in whom hypersynchrcny is not induced, behayicral change is limited and 'imprcvement' does not occur (hO) . Previously we have concluded therapies is based on the that the mode of action of conVulsive induction of a state of altered cerebral function, in which changes in adaptive interpersonal behavior occur, and are inter» preted as 'hmprovement' (3, h, 39). The present studies amplify two aspects of this neurcphysiologic—adaptive hypothesis. The biochemical substrate of the behavioral change is reflected by an alteration in the acetylchcline-cholinesterase relationships of the central.nervous system. It is also probable that EEG basis of the milieu change hypersynchrony provides the neurophysiologic which is clinically manifest as sedation and euphoria and is evaluated as 'imprcvement.‘ The neurophysiologic-adaptive hypothesis of convulsive therapy has provided a meaningful basis for studies of other physiodynamic therapies (39). In this study, it has been possible to amplify our understanding of neurophysiologic aspects of hallucinogens as well. �SUMMARY: effect of an anticholinergic agent, diethazine, on the behavior and language patterns was observed in to psychiatric patients, 1. EEG, The at various stages in the course of’electroconvulsive treatment. (a) Behavior: Increased restlessness and agitation, haptic and visual illusory sensations, and delusional thoughts about their illness or examiner's identity were observed. (b) pg: Alteration in There was a decrease EEG was concurrent with behavioral changes. in voltage and desynchronization of all frequencies. In patients with delta activity, the per cent time and voltage of delta activity decreased. (c) Language: Syntactic patterns described for convulsive of third person, qualification and displacement decreased. In dyadic analyses, there was a decrease in the coefficient therapy were reversed. Use of variatian. 2. These observations are discussed in the framework of the neuro- physiologic-adaptive hypothesis of the action of convulsive therapy; and it is concluded that: (a) the biochemical basis for convulsive therapy is similar to that of craniocerebral trauma; (b) changes in acetylcholine-cholinesterase metabolism are intimately related to the behavioral effects; (c) EEG desynchronization of hallucinogenic activity; and and sedatidn. EEG may be a and physiologic concomitant hypersynchrony associated with euphoria �.Ih~ REFERENCES 1. Weinstein, E. and Kahn, R.L.: Denial of Illness, C.C. Thomas, Springfield, 111., 1955. 2. Roth, M., Kay, D.W.K., Shaw, J. and Green, J.: Prognosis and Pentcthal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG 225-237. 1957. Clin. Neurophysiol. 2: R.L.: Relation of Electroenecephalographic Delta Activity to Behavioral Response in Electromock, AMA. Arch. Neurol. and Psychiat. '_?_8_: 516-525, 1957. 3. Fink, h. 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Gastaut, H. , Ferrer, S. and Castello, 0.: Action de la diethylamide de l'acide d-lysergique (LSD 25) sur lee fonctions psychiques at l'electroencephalogranme, Conf. Neum1., 3;: 102-120, 1953. 36. Pslchiat. , Arch. Mutterkomgruppe, 1-h7, 19m. Monog. §_Q: Neural. Psychiat., 1-315, 37. Rinkel, M., DeShon, H.J., Hyde, R.W. and Solomon, H.C.: Experimental Schizophrenia-Like Symptoms, Am. J. Pszchiat" 108: 572-578, 1953. 38. Merlis, S. and Hunter, W.: Studies on Mescaline II: Electroencephalogram in schizophrenics, Psychiat. Quart., g2: 1.30-1.32, 1955. 39. Fink, M.: ho. Fink, A Unified Theory of the Action of mysiodynamic Therapies, J. Hillside M. Hosp. , é: 197-206, 1957. and Green, M.A.: Electroencephalographic Electroshock Process (in preparation). Correlates of the ��j: q-»-\’X mm or mumma manganese» w Panama“ m and Behavior 4" tho abmfim at W Fm;black-d the W mek, m mathem- diam!” induced «synchronization of ma fmquamisa and in ”mums. In ptfient! with dais: activity, voltage flowed, nativity diuppeumd. mufims, m, amt mm mm function. ath an was amt alpha and beta and bdnvioral changes Wynn in mm“ therapy. the behavioral wager? airflow}: 11:01:16.6 mm o! the language patterns indicative psychotonmotio nativity nf 2299, um mm frame“: increased WV Mutton and withdrawal, immaod asthma, in maintaining eyelid closure, of 1115”“ and W muuhdmrgic comm, amine. tine of delta nativity and burnt. “W that «It: w’dflty .méucad by convulsiw mum, studies mm max-tutu: with a and Jamie»: 419mm led 1» may of Mme sum or cmlsive for ml: of mu W: In recordings of compounds 1:: tbs dons matreutmt, each MOW. m amt induced memmauon at can record with momma in beta “unity, mm, par-1103.06 mm md 1n fmuemy and per-cent time at alpha. m nativity, both the mug. and ppm meat. was “at Imam" mm, nativity. In ”cards with 01w was of thin: activity and film alpha Wan}. Bombwnt of mm: W58 APR 2 :5: tummy immacd. (many: new concurrent with than ehctmgnphic manages, use both mm inhibited by Pram the mm, mtmm WW mummsim. Psychiatry, Hillside Kama, Cam Oaks, LL, NJ“. �nfia‘ m alumna” are Mar ta thwa of Dunbar a}. 3;. tor Winn. Wt Michalimmio prawn", and significanaa structurally, each contain: 1 mm nitrogen linkage. Each of theme compounds have The 01’ than fianrapy of amatima far the theazy of film made of nation at convulsiw mama‘s. as will u tor the wommbmr and Wing $.13 1:311qu 1:111 b0 discusud. K �new cat Antichollnergle Game at mmmm me and Bob-71w * 3mm the observations 2: 217, 1957) by cumin ergie (W. file“ and Johnson um. atropine and 309130le blocked the delta wtiuty induced than”, dMlar studies were undemken with another madmanof diet-henna. Prenloe’oroehock, dietbuine induced demahrmiution tuuuaned.“ end a decrease/1n voltages. In peasants with delta. activity, compound, of ER; voltage md pennant time of delta emvity hemmed, frequencies increased and burst activity diuppeared. dam all” end beta . Concurrent behavioral mum, illusory maid ideetion and withdrawal, increased restlessness, difficulty in maintaining eyelid closure, and reversal of the language patterns «scouted with altered eerebml function after canvulsive changes included therapy (m amt. tholog 9; Gomniggtion, _ The Gram a: Sure/atom, pg. 126, 1958) psychotoulmtle aunt}; of diethuim led to the study at hear-ac and diethyhflde, Win 2299 and bemtysim in voluntary momma patients at venous stages of convulsive firm-aw. These antichaunerglo compounds were Metered intmenously in amounts! of 50-150 gm, 2 to S m and 1.5 m respectively, dung“ mder continuous and language mum-es mutmtmt, nah compound EEG mm. ‘For «ch compound the behavioral peremled those of diethuine. In ma meanings induced EEG demchmieeuon with an increase in beta activity and in the alpha fmqueney. In renews with slow wave activity, both the voltage and pop-neat time of this activity decreased, pement time feet rmuemlea manned, and the alpha frequency increased. Behavioral ahmgea mm concurrent with these ehctrographlc changes, and both were inhibited by intravenous uhlorpmmine. A it Fm: the 61.1}. m. Amos Mia/SB fluent of Experimnbal Psychiatry, Hillside Hospital, .1. NW York. �«a. 3mm ahauntim for muslin. we boon reported by Dunbar. We and (W. W want]. the 33: m. 1955). of postoonvulain Em and bah-uric: pattoma by these potent “mallow «unwound: “was“ a naumphyuiologic but: for comma“ thorupy. Purim 39mm acted that. the clinical ropoma to manned comm m «peach; m the dmlemfit af Wain hiya voltnga aim: we nativity (W. my than be 19,: 516.. mmiaud with ma 1957). An 1mm in ahalinorgic nativity Wchrazv and clinical sedation and whom. SWy. a decrease in choumrgia activity may bu associated with EEG «syncing-am mum and 6111:1031 psychotmuc nativity. as therapy or the mad. or whim of amulaiu ”exam and tho mou- phyamlogic «float: of mfiebalmergic command- will be dismantled. �\\ "v Mint: of Ant-1011mm: W311: Minimums on Wm E39 and neopolmim blocked the dclta activity induced by convulsive therapy, studies are Wart-ken with moflar mama“ 0136th dinthuim «cram in voltages. induced compound, diothuine. m. «mm-m on of frequencioa and In putianta with delta activity, volfige and pen-mt m of delta nativity acct-cu», tramway immune and law“ activity disappears. Concurrent behavioral chanson: 11:01am imam and withdrawal, illusory sensations, paranoid incmaod ”flatleusnass, difficulty in maintaining mud. of the ham patterns indicative of altered The apparent. hallucinogenic activity m to any of eyelid cio'sum, and «mm. flirtation. various Wu inoluang The of hmetysim LSD. Win 2299, bohuvionl changes in the dam dawns. In m6 Hoarding intizm at the record with an employed were mutmhaant, «eh mousse in '58" parallel to those agent indmd «manom- an fmuemiu, max-cue in alpha Inquency, and alpha voltaga tad para-mt 601%: and masculine. tins. In records mm activity, both the valtagc md pox-«mt tins of delta. activity duel-sand, �duh 4..., par-43m tine fut {maintains Manama, Behavioral (changes were ugd both wm inhibited by and. alpha Inquancy increased. emmnt with than electramphie mung», intramm «human-um. 00de hm patent mticholimrgic properties a wall as n W tertiary W W... Wm“ or them absent»Each at then The um 29:: thus timery :5 of thg an“ a: nation or combs.” therapy in payments, all «a fur the mumphysialogy and pinmcology of hallumogana 61mm. 11.111 be �Effect of Anticholinergic * Compounds an Post—Convulsive EEG and Behavior Following the observations of Ulett and Johnson (EEG Clin. Neurophysiol. 2; 217, 1957) that atropine and scopolamine blocked the delta by convulsive therapy, similar studies were undertaken with ergic of compound, EEG activity induced snail-l anticholin- diethazine. Pre-electroShock, diethazine induced desynchronization frequencies and a decrease in voltages. In patients with delta activity, voltage and per-cent time of delta activity decreased, donfinant alpha and beta frequencies increased and burst activity disappeared. Concurrent behavioral illusory sensations, paranoid ideation and withdrawal, increased restlessness, difficulty in maintaining eyelid closure, and reversal of the language patterns associated with altered cerebral function after convulsive changes included therapy. The apparent psychotomimetic activity of diethazine led to the study of lysergicl;:dudiethylamide, benactyzine in voluntary psychiatric Win 2299 and patients at various stages of convulsive therapy. were administered intravenously mgm in reSpectively, under continuous These anticholinergic amounts of 50-150 gamma, EEG recording. 2 EEG 5 mgm and 1:5 For each compound the behavioral changes and language measures paralleled those of diethazine. pre—treatment, each compound induced to compounds In EEG recordings desynchronization with an increase in in the alpha frequency. In records with slow wave activity, both the voltage and per—cent time of this activity decreased, per~cent time fast frequencies increased, and the alpha frequency increased. Behavioral beta activity and changes were concurrent with these electrographic changes, and both were inhibited by intravenous chlorpromazine. % From the Department Glen Oaks, AEEG: L.I. u/3/58 New of Experimental Peychiatry, Hillside Hospital, York. ' . H.“ as... �a-2-n Similar observations for mscaline have been reported by Denber, Merlis and Hunter . w» “inhuman“. fiJ/A‘revious reportstzgoted that the clinical response to induced convulsions the development of extensive high voltage was dependent upon slow wave,activity.QAaH7k7~Aznh.aNauroi7v9SyChtat?"j§7"516?“t959}n The reversal of postconvulsive cholinergic compounds suggcrests and euphoria ’ WC fies G The EEG and behavior “patterns thatEEmersynchrony by these potent and anti- [clinical sedation {increase in cholinergic acti@ desynchronization and clinical psvchotomimetic activity,ere 4:. decrease in cholinergic activl$291 5M7 Wild relation of these observations to studies of head trauma, and to the neurophysiologic-adaptive hypothesis of the convulsive therapy will be discussed. mode of action of �Effect of Anti cholingeric Compounds on Post Convulsive EEG and Behavior , In 1956 Ulett and Johnsgon repcrted to this society that large doses (jig of atropine erscopolamine blocked the appearance of high voltage delta ,. Its-their—smdyzhey noted 6? activity usually induced by convulsive therapy. that the dose! of atropine necessary to affect the W" ' with“ carried m unpleasant W5 mic ”We effects. ‘ ' Jenkner and Lechner M compound. It is m were these-sthet—else— Following. £23 reports by Modiethazine 4 a—peten-‘t (Mf‘iam facts aw cw. anticholinergic compound with minimal systemic 9 those of Ulett and Johnson EEG W. 1' Mi! W XMMA‘.‘ ”fir/félcm studies to similar W Our observations with led to an investigation of other anticholinergic this. the purpose of this report to describe the clinical and EG correlations on intravenous A administration of LSD-25, Win-2299, benactyzine and diethazine . n Z; in pSychiatric patients at various stages of convulsive therapy; and relate and these observations to thekneurophysiolog'c-adapative hypothesis of the mode of action of convulsive therapy and of hallucinogens. Subject and Method: Our km subjects ass consecutive referrals for convulsive therapy in an open ward voluntary I psychiatric hospital. Patients have been studied at �.2— [ll observations mg: made in acute is? laborah'y. Following a standardfirecording from experimnts in the W 17 leads, the compound under study #8 administered intravenously at a W various stages of therapy, EEG 1-: rate per minute , until clinical behavioral or electrographic changes m I observed. The compounds studied have been diethazine, Win-2299, LSD-25 p and benactyzine . Fig. I- Diethazine was administered at Win-2299 and benactyzine mgm; 10 gamma Chemistry structure 25 mgn. per minute, at 0.5 per minute for 50-150 mgm for a total of 175-250 per mimte for 2—; men; and )5atI LSD gamna. Observations: ‘ low If; patients (Q Wm ' there decrease in voltage and a desynchronization of rhythmic patterns became less prominent. In all frequencies. Prevailing some voltage 6-7 cps activity appeared, most prominent temporal leads. m The alpha frequency was not 993 $9321; Wm was a instances, symmetric in low the frontal and anterior a; altered, and? the build-up an by hyperventilation was blocked, �-u-u— -- .— --- —-.— --—--- Fig. 2’ \‘V 93 \. W; Diethazine - EEG - g Pre-Cenvulsive Treatment vi; .........._.-- __ W , /7 “I at! 3 InApatients during convulsive therapy, with varying degrees offlhigh ,5 (V significant decreaseA in voltage and in We}? ‘1‘! a W K%W W aways... Flusucu/ISlow per-cent time of delta activity. Both random and burst delta activity is voltage delta activity, there M a M 4 V - ~ I 0’3 diminished and low voltage alpha and beta frequencies The hyperventilation respoxaewas — no Fig. Diethazine --—---- .- EEG - Patients ’4, S Convulsive Treatment EEG effects, “wwwwww for irritable Mdysesthesias 1:3» and patterns were ‘ ,m to five hours. I Me dest-tive restless behavioral and complained of of the extremities. W. Visual illusory their illness, the setting of the test W1 46M! procedure; or the examiner's identity were MAM Myopposite one we observed phenomena and delusional thoughts about ‘ / #‘X became more sensations of unreality prominent. longer apparent. @hctrographic effects persisted changes. been .— Concurrent with these . l4» "— ' Their language L w to that previously described for amobarbital) 5 �- 80 W thatkdehial, minimization, cliches, third person were of 4:mode and less prominent. These behaVioral changes were pun-at. during the period 46W W W W W M maximum EG- chani gs. We: led to i. :qs's’ diethazine of other-imam hallucinogens Aru— m Denber and Merlis had W W mmdhfimmndm They WAWWM t-L similar to diethazine. «mt fiche-high voltage symmetric slow wave time and in w ”Mutant low voltage, ‘9” WW W wand M ”ma,”led to ‘x ’ril' ‘ ~ MWMJ MIM‘M? - MAM“? Ffiffiw' W this compound. study ELIZA; —— 51/ bursts were-diminished WW activity. random slow wave //{/,{r_,,"" fa. etagrm with an increase in alpha per/cent ”.WMM @ports by Pennes and anticholinergic altered mescaline . it: EEG changes“induced by electroshock in a fashion The past tense M. ‘ x-Jyx'yfl effects were similar to that: in the diethazine group. Inpatients pres convulsive therapy, 4,.v‘. I EEG .4 ‘ '7 .“-' ’ ' , I desynchronizationéwas induced. Fig. Win 2299 - 6 Pm-Cpnvulsive Treatment .I‘.\ In patients with high voltage slow wave activity induced by convulsive therapy, �.5. P, . \B ‘2‘ 9 \C . there was of slow wave adecrease in amplitude and per-cent time " OLE, & WA. LC— "1L” . ”I , ‘ r '1‘.“ I activity ' with an increase in alpha and beta frequencies. AA‘ssociated with these electrographic effects were clinical patterns of restlessness, excitement, / _.__ , Win 2299 and hallucinatory and - Post Fig. 7 Convulsive Treatment We firemefikwawAfl illusory activity. . I, Th? studies yore7/"repeated with intravenous -' 4 LSD {if/(MW isWM inMcbwLW W MAL/”3‘ W. l /.I ( V W A’M/[F There m behavioral effects] W €265 a difference In the time constant bee—names In line/- M electrographio changes-.flkhh 144. ’1» A—‘nfilvj 5—6796 mi there me less desynchronization 2-bit the delta activity WrepressedmMkw M “(p/7L “79% M7 mifllméw} __ (5‘; a I/L-v ‘ I, . Wfi‘fi’Wxfii Mose-Al} Recalling the- reports that benactyzine induced l . “Mflx I)?“ ‘ EEG W '3 desy‘nchmnization 5 we / adninistered the- ccmpound intravenously: and again! observed similar clinical and is electrographic patterns. In the well modulated alpha record, desynchronization prcmpt. In the record with high voltage delta activity, desynchronization �~6- ' MWMKL Wdelta I790: V13. activity 3903+} __ Fig. 11,’ 12 Bemctyzine WWW These pattems were accompanied by While we did not observe - EEG clinical restlessness and excitement. illusory or hallucinatory activity, mguagew m and Mo diethazine, ‘éu-e ”,ij Cl w w IL: cc te-theé-r EEG M M M3 a: W desmchrmizWeWw, thficue M compounds , an, Malt/71,) aaflwf/‘04 WM have In: W11 chemical structure W Jaw/554m these did note the Am to have similar electrographictand behavioral effects. minced I”) we Win-2299 and LSD. Thus, four compounds shown M awffiijfj d‘u a M M “by; have been {m W’MM 0’}; Ag,“ écfmmnmé’ é; 444-“ my 1“.” “In diethyl-anfino-ethyl organization. ' 7544.. (5y --------m-- ---~Repeat Fig __________________ WM”; WWWtK’L/océeufiflfinféawhhmva\ «a �. ' I I I These observations therapy process. In high voltage slow a; i Ii . site amplify our understanding of the convulsive earlier studies wave activity was . we indicated that the development of the neurophysiologic correlate of behavioral change in convulsive therapy, and a necessary, though not sufficient, condition for clinical improvement. During the past ten years, studies by Bornstein, Tower and McEachern, Ward, Sachs, Bugs and I“.— of convulsive therapy have noted similarities in the biochemical to craniocerebral trauma. acetylcholins They reported thatqguring convu Sl and pseudocholinesterase others erap free are-eiouated in the Spinal fluid. In addition, topical administration of acetyicholine induces high voltage burst and Spike activity. Ulstt and cholinergic effects ‘ The by the Johnson emphasized anticholinergic the blocking of these i::;::§§s;7:;ropine and 5v . . observation in this report on dietha21ne,‘Win-2299, support their observations. Each of these activity and the clinical behavioral 6 AldAbév‘ that the neurophvsiologic eerreiate compounds has and language thfse described for convulsive therapy. LSD-25 and thus scopolamine. benactyzine potent anticholinergic effects are apposite to we may/amplify the earlier conclusion behavioral changes in convulsive therapy �.5- is the development of high voltage slow wave activity, by this EEG tag—ion that reflects an alteration.in the acetylcholine-cholinesterase change "L”! J‘ relation of the basin, probably in the direction of increased cholinergic activity} [Tl' These observations lend themselves to application in studies of cranio- h9,41;r17§ cerebral trauma. The-repeat—ef Ward ll“ e clinical efficacy of high doses of atropine in altering the clinical manifestations of head trauma/also noted that effective doses brought with be advisable them severe peripheral effects. to repeat these studies, utilizing such neurologically Specific anticholinergic more potent, It would more compounds as Win-2299, diethazine or benactyzine. Finally, these observations, of EEG (l95h) and our earlier reports on the significance delta activity in convulsive therapy, support the observation of Wikler who concluded with the comment his report that: ".... on mascaline, n-allylnormorphine and morphine regardless of the drug administered, shifts in m the pattern.ofnelectroencephalogram.in the direction of desynchronization occurred in association with anxiety, hallucinations, fantasies, illusions or �tremors, and in the direction of synchronization with euphoria, relaxation M or drowsiness." This conclusion, supported by these observations, permit a more near meaningful generalization of the recently expressed neurophysiologic - adaptive hypothesis of the We may mode of action of somatic therapies in psychiatry. infer that agents that Synchronize frequencies, like barbiturate ”fl . and meprobamate phenazine EEG in the in the be r ge and chlorpromazine , promazine and deltm; tend to be sedativel, while agents that evoke EEG euphoriant and relaxantl; desynchmnization tend to be excitant and halluc- inogenic, as was noted for diethazine, In smmnary, per- we have observed pf 161), Win- 2299, benactyzine and meccaline. the effects of various compounds as diethazine, ,x/ Win~2299, LSD, benactyzine and mescaline on the electroencephalogran and behavior? in psychiatric patients at various stages of convulsive therapy. Behaviorally, these compounds induced increased restlessness, haptic and visual illusory sensations and delusional thoughts about the subject's illness or the examiner' 5 identity. The syntactic language patterns described for Wham/C convulsive therapy were reversed. Concurrent with these changes were a decrease in voltage and a desynchronization of all frequencies in the EEG. In patients with high voltage delta activity, the per-cent time and voltage �.10.. of the delta activity were marhedly decreased. These observations have been discussed in the framework of the common biochemical structure - that of a substituted diethylanimoethanol thééIanticholinergic properties with the conclusion that: (a) The // - and £74kfzitiég‘ biochemical basis for convulsive therapy;may be an alteration in the acetylcholine-dholinesterase relation of the nyrvous system, probably in the direction of increased cholinergic (b) The (Z? encompass the activity. recently expressed neurophysiologic adaptive hypothesis of the mode of action of somatic therapies action of hallucinogens; studies of the effects of anticholinergic trauma be undertaken, utilizing more in psychiatry is amplified to t is recommended that further compounds in craniocerebral neurologically Specific as diethazine, benactyzine and Winr2299. lfiffig’ compounds �Effect of Antichelinergic Hallucinogen: on Post Convaleive EEG _and Behavior * tron the Department of Experimental Psychiatry, Hillside Hospital, GlQn OIkB, L010, 3.1. part, by grant H—927 and HI~2092 of the National Institute of Hental Health, National Institutes of Health, 0.8. Public Health Aided, in Service. Read at the v1: 1/59 ~ American EEG. EEG Society neeting, Atlantic City, June, 1958, �Effect of Anticholinergic Hellocinogens on Poet Convnleive EEG and Behavior In 1956 Ulett and Johnson ( ) reported that atropine and ecopolanino blocked the appearance of the high voltage delta activity usually induced by convulsive therapy. They that the dose of atropine necessary to affect the also noted EEG was each as to be associated with unpleasant systemic effects. Reports by Jenkner conponnd us 90 this J Leehner (r) describing diethaeine as an antioholinergic bet minimal eyatenic effects led vith potent neurologic endertake studies similar to those of Ulett and Johnson using compound ( )y and these observations, in turn, led to an investigation of other experiaental enticholinergic agents. is the purpose of this report to describe clinical and It electro~ encephalographic observations on the intravenous administration of various anticholinergic agents in psychiatric patients at various stages of convulsive therapy and to relate these obeervationa to hypotheses concerning the node of action of convulsive therapy and the physiology o: hallucinogens ( ). ( ) �-2SUBJECTS AND METHOD: Our subjects were consecutive referrals for convulsive therapy in an open ward voluntary psychiatric hospital. numbers of While varying subjects have been studied for each compound, Ages ranged from 18 in 10k eXperinents have been assayed. subjects 86 to 67 years, and diagnoses include schizophrenic reactions, manic-depressive and involutional depressive psychoses. Patients have been studied at various stages of the treatment process. observations were The laboratory. 1 standard 8 made channel EEG in acute experiments in the EEG recorder and needle electrodes applied in 17 lead placements following Strauss 22.2; ( ) were In each experiment, the compound under study was edninistered used. intravenously at a set rate per minute, until clinical behavioral or electrographic changes were observed. The compounds studied have been diethasine, Win-2299, benaetyaine, Each is a potent JB~318, JB-336, and atropine. anticholinergic agent in vitrc. Diethasine (diethylaaineethyl~n~dibensoparathiasine), for example, induces mydriesis and hypotension, suppresses salivatien and blocks the �-5. bradycardia, aalivation and soizuros cf acctylchcline and fluorophosphatc ). ( Win-2299 (2-diotylaminoothy1 cycloponty1—2-thieny1~ 1 (2-diethy1aninoathyl benzilato) are similar to atropine pcgflLt central offocts synthetic anticholinorgic agents/but with glycolatc) and minimal and benactyzino : peripheral effects ( , ). JBo318 and JB-336 (N~ethy1o3-piperidy1bensilate, H-nethyl~3-piperidy1bonsilato) , . are two at a rccant series or synthetic anticholinergic 33:3: coupounda of high ( ). Diathazino total or minute central potency was 2 to 5 hallucinogenic activity adminiatcrod at 25 ngn. per minute for a 175—250 ngn; Win—2299 for and high ngn.3 and anqbonactynine at 0.5 nan. par JB—BIB) ngnt per minute for 1.2 to h.o ngn. JB-336, and atropine at O.h �OBSERVATIOHS: (a) Diethezine: A: previously reported administration or diethezine in 15 ), the ( patients prior to convulsive ron therepy resulted in a decrease ib volteges and a deeychnnnization or all frequencies. Prevailing rhythmic patterns became lees In some inetences, symmetric low voltage 6-7 ope prominent. activity appeared, nest proninent in the frontal temporal leads. The and anterior elphe frequency was not altered, but the build-up in voltage and the slower frequencies induced by hyper- ventilation vere blocked (fig. 1). acetone-ounces- In 25 petiente during convulsive therapy, with varying degrees of induced high voltage delta activity significant decrease both in voltage slow wave activity. From an and in ( ) there was a per cent time or everage per cent tine delta or hSI in the £ronte~occipita1 lends, there was 1 reduction to e neen per cent tine of 201. Both random and burnt delte �-5- activity diminished became proninent. and low increase in degree of slow The hyperventilation was on effects persisted for voltage alpha and bets frequencies longer apparent. no one activity wave These electrographic to five hours (Fig. 2). fi-‘-¢’---‘ Fig. 2 --‘------Concurrent with these electrographic effects, distinctive behavioral changes. Patients and restless and conplained of we observed irritable became more sensations of unreality and or dysthesias of the extremities; Visual illusory phenomena and delusional thoughts about their illness, the setting or the test procedure or the examiner’s identity were reported. syntactic language patterns a ( were Their . characteristically altered in fashion opposite to that previously described for snobarbital ), so that verbal denial, minimisation, cliches, third person node and past tense hsaanaflhax becane less prominent. changes were concurrent with maximum These electrographic change. �«6» (b) Win-2299: Reports by Pennee compound, Win 229?, manifested both and induced compound. excitetory etatee in The ( ) that an eXperimental potent anticholinergic actiity nan led to our study or this observations were einilar to those observed with diethazino. In five patients without slow wave activity, deeynchronisation of frequencies and decrease in voltages of all frequencies were noted in tour (Fig. 3). noofiflfl‘vw Pig. 3 ”------In 11 patients with high voltage delta activity there was a decrease in amplitude and per cent tine of slow wave activity with an increaee in alpha and beta frequencieec The mean per cent tine delta activity dropped from 50% to 23% (Fig. h). Fiz.\h -‘-‘---“ Associated with these electrographio effects were clinical patterne of reatleaeneea and and excitenent. Patients became fearful tenee. Visual seneatione were reported and in three subjects, delusional elaboraticne about their hospital experience were �-7. proninentdheee behavioral changee appeared during drug administrau tion or within ten minutes, ' levels, within to Reports that benactycine induced (c) Benactzaine: diethazine and disappeared, at these dosage tea three hours. two deeynchronization and ( its structural similarity both to and ) Win~2299 EEG led to our testing of this coupoond. Intravenous administration in 12 oubjecto elicited oiuilar clinical and electrographic patterns. Both in the well modulated alpha record and in the record with high voltage delta activity, deeynchroniaation was prompt. Delta activity decreaeed from a mean per cent tire of to 171 in 391 ‘--“‘-C“--“ PigS. 5’ 8 cuhjecte (Figs. 5, 6). 6 fi“-~--‘---These electrographic patterns were accompanied by clinical reetleeeoeee, irritability was more difficult. dittaanxt The thoughts econ with the dosage levels. In and excitement. Artifact-free recording illusory sensations initial compounds were and delusional not noted at these patients with manifest dieorientation language changee associated with convulsive therapy ( and ), however, �‘8‘ there wee en alerting and e revereal or the language patterns. (d) Piperiqzibenziletee: Abood ( ) that various piperidylbenziletea both manifested entioholinergic activity subjects, The Following recent reports by we tested and induced two or these, hallucinations in psychiatric JB-318 and JB—336 in 2b subjects. electrographio patterne were identicel to those other deeynohronination was during - Onset of inaynshxlaxxntx experimental oonponnde. injection or within 15 ninntee and persisted for one to four hours (Fig. 7, 8). -“Q.*.‘..--‘U.Figs. 7, 8 -nfl-~fi--.‘-‘--animation was observed, In each instance in whioh deeynchrntxixx clinical restlessness activity changes. were and exoitenent, illusory and hallucinatory noted, and were concurrent with the electrographio In two inetanoee the behavioral changes were halted by the subsequent intravenous adninietration of chlorpronaaine. �(e) Atrozine: Continuing our etudy or enticholinergic compounds, we edniuietered atropine intraveneuely in 12 subjects, in dosages of 0.8 to h.0ngn. Systemic erreeta were prenineut during the injection with increased respiratory rate, puller, dial dry akin and dry mouth, preeorttxxx cenpleinte and eerked teehy~ eerdie (Figs. 9, 10). und.~¢...mnd.¢Figs. 9, 10 ‘b.-’~.fi-‘----Subjects beenne reetleee end feertul (as did the obeervergp) end Seekxxxnptenxxunxnxpxenixentxlxxte recording became difficult. Within ten minutes these symptoms subsided and the subjects became drowsy and relaxed. In subjects without delta activity in the initial record, to leeeitude by decreased slowing (Fig. little be followed during change was seen the period at voltages, desychrenization and increased 9). Fig. 9 In subject: with delte activity, there wee en initial decreeee in voltage and per eent time or such activity during the period or �~10... reatlonancaa, following by an increaao during tho period of quiotudc (Fig. 10). --fi---.-‘&-flw Fig. 10 “.Q‘....‘.‘.‘ �-11DISGUSSIOH: i Various compound: with measurable anticholinorgic activity have that been effects. Thoco shown to have similar oloctrographic and bohovioralw oxporinontal compounds oxhibiting the greater facility in altoring cloctrcgraphic patterns structure oach containing a have a cannon tortiory nitrogen with linkage to varying roota (Fig. ll); a diothyl whilo atropine, rolativoly inpotont in altering oloctrcgraphic patterns contains a quaternary nitrogen. Bohaviorolly each compound induces stimulating, excitatcry and illusory and hallucinatory activity. Electro- graphically each induces dcaynchronication of frequencioa, and docroaac in voltages, most prominent in anhycta with delta activity c 7 following thoropcntically induced convulsions. (a) Convulsive theragy process: Those observations amplify our understanding of the convulsive therapy process and at the induced activity. In earlier studios or high voltoho slow wave ccrroloto or bohoviordl we slow wave indicated that the development activitr chango EEG woo tho nonraphyaiologic in convulsive therapy, and a �-12- - heceslary, though not sufficient, condition for clinical improvement ( ). During the past ten years, .1ncluding Bernstein, have reported numerous Tower and HoEachern, Ward, similarities in the biochednicsl authors Sachs, Rugs changes or the central nervous system in convulsive therapy to that seen in craniocerebral trauma ( ). They observed an inorease in cholnerzic activity as manifest by an elevation of tree acetylcholine and pseudocholinestereses in the spinal fluid. In addition, the direct increase in central nervous system acetyloholine activity by topical administration or eoetyloholine induced high voltage bursts and spike activity. Ulett and Johnson ( enphesised the blocking of the behevioral and electrographic effects by the antioholinergic activity of strapine The observations in this report on end scopolenine. dietheziue, Win-2299, benectysine and the piperidylbenziletes support their observations. The potent enticholinergic activity of such of these compounds (with apparent predoninant locus of activity in the central nervous system) expliries the suggestion that the beechenical basis for the induced slow wave activity of oonvulsivei therapy results from �an increased lova4tf control acetylcholine-cho1inesterase activity. Support for such a hypothesis considerable degrees of slow adniniotrotion of DE? wave is also seen in the activity observed after the (di-ioopropylrlnorophoophote) - a potent oholinootoraoo blocking agent. Uhilo these observations demonstrate that anticholinorgic compounds or. affective in reducing slow wovo activity,.roporto of othor compounds with similar effectihavo also appeared. ‘Anphotanino (Bonaodrino) ( acid diothylonido and diphenhydronino (Bonodryl) ( ) ), moocalino ), lyoorgic ( ( have been reported as rodncing post-convulsive slow wave These compounds ) activity. are primarily described as oymphthominotio and ontihiatoninio in phornncologio activity, yet each has exoitotory ond stimulating effofioto on bahnvior ( , , , ). The relations or those observations to than. soon in this report are possibly boat assessed in relation to synaptic activity. In t study of tho effects or vorioua agonta on the EEG and behavior of unanosthotizod cats with chronic inpltnted electrodes, �-1hBradley and Elkee ( ) postulated the exietence of two, or pcesibly three, types of interacting chemoreaponeive receptors within the central nervous system: cholinergic, non~cholinergie eheeeptible to amphetamine, and nonecholinergic susceptible to LSD and tryptaminie derivatives. Marezei and Hart ( ) exploring intercortical-(transcollosel) partwaye in the cat, described the effects of various compounds on direct electrical stimulation. They on the evoked potentials postulated the presence of two chenoreeeptive potentialities of the synapse - cholinergic and adrenergic ~ with Opposing stimulatory and inhibitory aetien. In both constructs, the administration at antifcholinergie agents, or at eympatheniaetic agenta, results in equivalent eynaptic .electrieal effects. LSD Thus adrenaiine, amphetamine, meecaline inhibit the electrical activity recorded afcreee and a synapse. in ddentieal effect is achieved with atropine. In the light or these suggestions, the present experiments permit a.mere specific hypothesis regarding the pharmacologic baeie of the convulsive therapy preceee. Repeated induced convulsions leads to an increase in synaptic eheliaergie activity with an �-15- increase in the level at electrical activity of the central nerveue system, which 1e recorded by surface electrodes es augmented high voltage slow wave activity. Adainietratien of entieholinergic agents reduces the leveflef synaptic activity, resulting in a decrease in tbe manifest cortical electrical activity to pre-convulsive levels. The administration of ayapathomimetic agente, however, also achieve: the seme etiolate, not by altering the by increasing the aloe EEG uni“ chelinergic ectivity but level of adrenergic activity. activity, wave so preninent and so or the poet-seizure state electrical ( The manifest persistent in the ) may waking thus be related to a pereiatent alteration in synaptic transmission activity of large numbers of The delicate thin balance is seen in the ready reversibility with a! Venture or alerting calls at the centre‘rerveee system. ( ), tine agents neted hare. ( ) and the wide variety or pharmacologie Repeated induced convuleione nay thus be described an a device to creete bioeheaieal changes in the brain �.16. for their resulting behavioral effects. fornuletion is Such a consistent with the view that convulsive therapy is therapeutic process non~apecitic ). ( initial suggestion The a ( ) for the convulsive therapy process may that the pharmacologio basis lie in alteration in an acetylcholine-cholinaeteraeo relationships, can, thus on be focused the alteration in the level of synaptic activity. 11:? regard, the observation that diphonkydranine anti~hystaninic agent, also reduces slow convulciono amount of ), ( and wave Innzyknhni In this primarily an , activity of induced the observations by Sacha ( ) that increased cerotinin appear in the spinal fluid otter convulsion: cuggeet that this image of synaptic activity in convulsive therapy is oversimplified. Nevertheless, further animal studies or the effects of various drugs on the poat~seizure electrical activity are warranted. (b) Neurophysiologz;pf hallucinogenic activitz: These observations of anticholinergic compounds delta activity also nay activity. be on EEG related to concepts of hallucinogenic Each of the compounds studied induced excitatory �-17behavior including illusory and hallucinatory phenomena.* Here, - too, synaptic models nescaline, may be useful. Sympathomimetie agetts, as amphetamine, and LSD, and entieholinergie agents es those described here, are equally potent hellucinogene, The neurophermacologic basis for such behavior may be characterized ee en alteration in synaptic balance in the direction of increased inhibition (decreeeed.trenenieeion) of stimuli. clinical efficacy of convulsive therapy in The hallucinatory ectivity.ney the: lie in biochemical level. known alteration at this Equally eignifieent are the effects of other cin entiehellunuiogene, ee chlorpromezine end reserpine, electrical activity. in an modifying men ( nedceline ), block the ( ), and Both compounds induce EEG EEG on hypersynohrony deeynehronieing effects of LSC.end in animal studies, block behavioral and electrogrephic effects ( ,). LSD and mesoeline The nonospecific nature of the neurophysiologic basis of orperimental hallucinatory activity ia thus emphasized. In the doses need, hellucinetory phenomene were not observed for benectyeine. A report of such activity was reported at higher doeege ( ). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effect of anticholinergic agent, diethazine, on EEG and behavior; significance for theory of convulsive therapy. AMA Arch Neurol Psychiatry. 1958 Sep;80(3):380-7 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-29b-005 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 6 items. 1: Experimental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretic Implications (one page). 2: Small graphs. 3: [preprint]. 4: Draft. 5: Reprint from the A. M. A. Archives of Neurology and Psychiatry September 1958, Vol. 80, pp. 380—387. 3: File copy. 4: Handwritten notes. 5: 8 drafts. 6: [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/41d2ce5a639c29832746c6ec9a762f69.pdf be29ea3cfc0ebd057d49979acc6884d6 PDF Text Text �Reprinted from Biological Psychiatry Grunt & Stratton, Inn, 1959 Printed in (1.8.4. CHAPTER 14 Effect of An Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy By MAX FINK, M.D. of convulsive have therapy emphasized EEG RECENT delta activity as the neurophysiologic basis for the induced behavioral change.“5 In investigations of head trauma significance has been ascribed to changes in the acetylcholine-cholinesterase systems both for the behavioral and the electroencephalographic effects. An increase in free acetylcholine6 and an alteration of the ratio of cholinesterases7 in the spinal fluid have been positively correlated with the degree of EEG abnormality and degree of neurologic deficit. The EEG patterns were “blocked,” and some improvement in clinical status was reported following the administration of atro8 pine.“ In convulsive therapy, atropine and scopolamine were observed to block the appearance of delta activity,9 although the systemic effects of the large doses of these agents were marked. Recent reports10 noted that EEG and behavioral effects similar to those produced by atropine were achieved in patients with head trauma by intravenous diethazine—a phenothiazine compound with anticholinergic properties—with minimal systemic effects. The effect of diethazine was studied in the course of our continuing studies of the role of delta activity in electroshock.3 It is the purpose of this report to describe the effects of diethazine on EEG patterns and on the behavior of patients during electroconvulsive therapy, and to relate these observations to the present neurophysiologicadaptive hypothesis of the mode of action of convulsive therapy. INVESTIGATIONS From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, N. Y. Aided, in part, by grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S.P.H.S. Co-recipient of the 1958 A. E. Bennett Foundation Award for research in biological psychiatry. Reprinted by permission from the A. M. A. Arch. Neurol. & Psychiat. 8: 38 (Sept) 1958. I am indebted to Mrs. Hannah Mosquera for her technical assistance in the EEG recordings, and to Drs. Joseph Jafl'e and Robert L. Kahn for their analyses of the tape recordings. Diethazine was made available through the courtesy of Smith, Kline and French Laboratories, Philadelphia, Pa. 184 �EFFECT OF AN ANTICHOLINERGIC AGENT 185 SUBJECTS AND METHODS Forty psychiatric patients, at various stages of electroshock therapy in an openward, voluntary psychiatric hospital have been studied. All observations have been made in acute experiments in the EEG laboratory. Following a routine EEG recording, diethazine* was administered intravenously at the rate of 25 mg. per minute, for a total of 175 to 250 mg., depending upon the behavioral efi'ect. Dosage varied from 2.8 to 4.0 mg. per Kg. body weight. EEG Analyses: Recording was continuous for the duration of the observation period, except during interview periods. Needle electrodes and an 8 channel Medcraft instrument were used. All records were analyzed for the degree of delta activity,3 the of fast relative and the amount time and frequency, alpha principal cent per activity. The alpha and delta activity were measured in anterior temporal-vertex, and parietal-ear lobe lead combinations. Behavior Measures: Prior to drug administration an unstructured psychiatric historical interview and a structured questionnaire period12 were tape-recorded. Following drug administration, periods of recorded interview were alternated with EEG recording periods, until the EEG had again manifested the preinjection pattern on visual inspection. Two estimates of behavioral effects were used: clinical descriptions by the particithe drug of the during occurring and changes interviewer technician) (subject, pants period, and analyses of the language of the recorded interviews. Changes in language were evaluated by a syntactic analysis12 and an analysis of the variability in verbal interaction in the dyad 1" “1' Both measures have been shown to be sensitive to alterations in behavior induced by changes in the central nervous system. OBSERVATIONS Clinical: Within two to five minutes after the start of the injection, subjects manifested spontaneous coughing followed by dryness of the mouth and thickness of speech. They reported feelings of lassitude and heaviness and weakness of extremities, soon succeeded by increased restlessness and difficulty in maintaing eyelid closure. Reports of visual and haptic illusory sensations, feelings of unreality and distance and delusional thoughts about their illness, the setting of the test procedures or our identity were voiced spontaneously in 18 subjects in the period between 15 and 60 minutes after drug administration. In three instances, increasing agitation and panic led to a cessation of the recording. In two subjects withdrawal and negativism were the prominent behavioral had and transient of behavior disappeared Such were patterns responses. in one and one-half to four hours in all subjects. *Diethazine is a soluble phenothiazine compound with pharmacologic properties similar to those of atropine. In experimental animals, diethazine blocks the bradycardia, bronchospasm, salivation, fasciculation and seizures induced by acetylcholine, di-isopropyl fluorophosphate and pilocarpine. It suppresses salivation, and induces mydriasis and hypotension.11 'j'Detailed analyses of these observations will be reported separately by Drs. J. J affe and R. L. Kahn. �186 BIOLOGICAL PSYCHIATRY WWW Wm mm PRE-DRUG LF-LO RF-RO 0-0 RPT-RO AFTER 225 mg. WWW/«WNW WWW WW 50flVl—— l FIG. l.—-EHect SEC. of intravenous diethazine, pre-electroshock (male, age 27). PRE-DRUG 0-0 1r I64l HH AFTER I50 mg. WW 5°)‘VL— SEC. I FIG. 2.—Efi'ect of we I725 HH intravenous diethazine, pre-electroshock (female, age 57). �187 EFFECT OF AN ANTICHOLINERGIC AGENT PRE-DRUG W W ”W W W W W W W W W W W WW + 200 mg. + 25 min. 4- 70min. “WWW- 50 )‘VI I SEC. #l637 HH 3.—Eflect of intravenous diethazine after electroshock (note especially effect on delta) . FIG. PRE-DRUG +|HR AFTER 250 mg. W W W W W W W W W W WW SGML...— I FIG. 4.——-Effect of on delta) . SEC. + 5 HRS. WwL/M *l249 HH intravenous diethazine after electroshock (note especially effect EEG Patterns: Alteration in the EEG patterns was concurrent with the behavioral effects. In all records, changes occurred during drug administration and were sustained, with gradual diminution and restitution of the preinjection patterns in one to five hours. The initial response was a decrease in voltage and desynchronization of all frequencies. There was a decrease in prominence of prevailing rhythms. In patients without delta activity (pre- �188 BIOLOGICAL PSYCHIATRY electroshock), desynchronization and voltage decrease were occasionally accompanied by low voltage 5 to 7 cps activity, symmetric and prominent in frontal and anterior temporal leads (FIGS. 1 and 2). The alpha frequency was not altered. The build-up in voltage and appearance Of slower frequencies with hyperventilation were blocked. In patients with varying degrees of high voltage delta activity there was a prominent decrease in voltage and desynchronization of the record. Both random and burst delta activity diminished or disappeared, and irregular low voltage alpha and beta frequencies became prominent (FIGS. 3 and 4) . The hyperventilation response was no longer apparent. Language Patterns: In previous studies, an intimate relationship between changes in syntactic language patterns and the behavioral response to electroshock had been reported.12 With alteration in brain function, increased use Of third person, verbal denial, qualification, displacement and clichés became prominent. These effects could be enhanced by the administration of intravenous amobarbital.“ In the subjects in the present study, syntactic analyses demonstrated a reversal of the patterns noted in electroshock. Use of third person, qualification and displacement decreased. Explicit verbal denial was modified and replaced by minimization and displacement, or by a reiteration of complaints of illness. In dyadic analyses, the verbal interaction was characterized by a greater diversity Of vocabulary and less variability in the diversity scores for 25 word units. The qualitative nature of these changes in the language patterns is Opposite to that of amobarbital and electroshock. The duration of language changes was concurrent with the changes in the electroencephalogram. DISCUSSION These Observations confirm the report of Jenkner and Lechner of the effects Of diethazine in “normal” subjects.10 Diethazine also alters electroshock-induced delta activity in a fashion similar to atropine and scopolamine, as described by Ulett and Johnson,” with minimal unpleasant symptoms. The effects of intravenous diethazine are immediate, both on the EEG and behavior, and it is thus a useful experimental agent with “anticholinergic” prOperties. Two aspects Of these experimental Observations warrant discussion: the role of acetylcholine-cholinesterase in the process of electroconvulsive therapy, and the significance Of diethazine “alerting” for concepts of hallucinogenic activity. Biochemical Basis of the Convulsive Therapy Process: Bornstein,6 in a classic experimental study of head trauma in cats, demonstrated that within a few minutes after trauma free acetylcholine appeared in the spinal fluid �EFFECT OF AN ANTICHOLINERGIC AGENT 189 and persisted for periods up to 48 hours. He further demonstrated a positive relation between the severity of head trauma and the quantity of free acetylcholine, degree of electroencephalographic alteration and the severity of the behavioral changes. The electroencephalographic records initially showed short periods of high voltage fast activity and a transient period of flattening of electrical activity, followed by prolonged periods of high amplitude sharp waves in the delta frequencies. Concomitantly, alteration in consciousness, changes in reflexes and post-traumatic seizures were most prominent with highest concentrations of free acetylcholine and greatest degree of EEG change. Tower and McEachern7 confirmed these observations in clinical studies. In 112 neurologic patients, free acetylcholine was found in the cerebrospinal fluid only in patients following head trauma and recent grand mal seizures; and the level of free acetylcholine varied directly with the degree of cerebral damage. In addition, these authors assayed the cholinesterase activity of the 16 fluid.“ spinal They noted a sharp rise in nonspecific cholinesterase (benzoylcholine-splitting) and a drop in the specific cholinesterase (mecholylsplitting) activity of the spinal fluid in patients following head trauma. No such inversion was noted in fluids containing free acetylcholine following spontaneous seizures. Electroencephalograms were taken at varying intervals following trauma, and demonstrated a direct correlation of the extent of EEG abnormality and the appearance of free acetylcholine in the spinal fluid. Tower and McEachern also reported observations in six patients receiving electroconvulsive therapy. ’In patients after three to seven induced convulsions, they noted free acetylcholine in the spinal fluid in two, and an increase in nonspecific cholinesterase with reversal of the cholinesterase ratio in five of the six. They concluded that the spinal fluid changes in electroshock are more like those of craniocerebral trauma than those found in epilepsy.* More recently, Sachs17 confirmed the reports of free acetylcholine in the spinal fluid after head trauma and after electroshock. In his studies, Bornstein6 administered 0.5 to 1.0 mg./ Kg. atropine and demonstrated a reversal or a blocking of the EEG effects, and a modification of the behavioral and neurologic signs. Atropine also blocked the EEG and clinical signs induced by intracisternal acetylcholine. Ward8 applied these observations to the treatment of human subjects with varying degrees of head trauma. Subcutaneous doses of 0.1 mg./Kg. of atropine induced both clinical improvement and reversal of EEG effects. These observations were recently confirmed by Sachs,17 Ruge,18 and *Regarding the one patient of the six who failed to show either free acetylcholine or a reversal of the cholinesterase ratio, they noted: “It is interesting that this patient was the only one of the six to show no response to treatment.” �190 BIOLOGICAL PSYCHIATRY Hughes.19 Basing their study on these observations, Ulett and Johnson" noted the effect of atropine and scopolamine in blocking the EEG changes of electroshock therapy. Concurrently, Jenkner and Lechner10 reported effects similar to those of Ward, in studies of diethazine in cases of head injury. Another group of investigations complete the available data. Studies of anticholinesterases, such as DF P (di-isopropyl fluorophosphate) and TEPP (tetraethyl-pyrophosphate) , which block the enzymatic breakdown of acetylcholine, demonstrate the development of high amplitude rapid frequency EEG patterns similar to status epilepticus as well as lesser degrees of abnormality as noted in post-traumatic states.”23 In these studies, atropine blocked both the electroencephalographic and the clinical toxic effects. Thus, both from experimental and clinical studies of craniocerebral trauma we may assume that (a): the acetylcholine activity of the spinal fluid increases; (b) that pseudo-cholinesterase activity increases with a reversal of the ratio of cholinesterases; (c) that EEG hypersynchrony and slowing parallel these biochemical alterations; and (d) that anticholinergic agents may block both the electroencephalographic and the clinical effects. From the data available it is probable that the biochemical basis of convulsive therapy is similar to that of craniocerebral trauma. Convulsive therapy results in free acetylcholine in the spinal fluid“ 17 and a reversal of cholinesterase ratios.“ 16 The electroencephalographic effects of repeated induced convulsions is the development of high voltage, symmetric slow wave activity, occasionally with spike activity,3' 24’ 25 which is similar to that observed in severe head trauma.” 27 In previous studies we have reported the relationship between the degree of induced slow wave activity and behavioral response.3 The studies reported here and that of Ulett and Johnson" demonstrate a reversal of the EEG and the behavioral effects of convulsive therapy by anticholinergic compounds. In each characteristic, convulsive therapy is thus similar to cerebral trauma. While the acetylcholine-cholinesterase system is highlighted by these studies, other enzyme systems may also be altered.17 These studies also suggest that convulsive therapy provides an excellent experimental method for studies of craniocerebral trauma. Studies of the brain stem-activating system by Jasper and DroogleverFortuyn28 and Lindsley et al.29 had laid the foundation for prevailing conclusion that symmetric EEG slow wave activity has its origin in mesencephalic structures, and that these structures intimately affect the states of “alerting” and “drowsiness.” More recently, Rinaldi and Himwich30’ 31 have related the site of action of atropine and cholinergic drugs to this mesodiencephalic activating system. It is also probable that these structures may be selectively affected by the process of convulsive therapy, and that �EFFECT OF AN ANTICHOLINERGIC AGENT 191 both the clinical and electrographic effects may be intimately related to changes in this system. Diethazine “Alerting” and Hallucinogenic Activity: The behavioral effects of diethazine provide information regarding another aspect of the convulsive therapy process. In patients without prior convulsive therapy, illusory phenomena and feelings of unreality were observed. These were similar to the hallucinogenic effects of LSD32 and mescaline.33 Again, analogic data about the clinical and EEG effects of these agents may provide some information about convulsive therapy. In studies of mescaline, Wikler34 noted that the EEG demonstrated either no change, intermittent or continuous low voltage fast activity or increase in alpha frequency. Denber and Merlis35 noted a similar acceleration of alpha frequency, decrease in per cent time alpha including its disappearance, and nonspecific random beta activity. Delta activity did not occur. In patients with delta activity induced by electroshock, Merlis and Hunter38 noted that intravenous mescaline markedly diminished the amplitude and per cent time delta activity with an increase in per cent time alpha activity. The effects of LSD on the EEG are similar. Gastaut et a136 noted an acceleration of alpha frequency of 0.5 to 4.0 cps with an accentuation of beta rhythms. Rinkel et a1.37 confirmed this observation and noted, in addition, a reduced responsiveness to hyperventilation.* In summarizing his studies Wikler34 concluded that “ . . . regardless of the drug administered, shifts in the pattern of electroencephalogram in the direction of desynchronization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness.” This generalization provides a meaningful construct in which these agents may be assessed. Agents that evoke EEG desynchronization tend to be hallucinogenic, and mescaline and LSD are clear examples. Agents that synchronize frequencies, such as barbiturate and meprobamate in the beta frequency range, and chlorpromazine, promazine and perphenazine in the delta frequency range89 tend to be sedatives, euphoriants and relaxants. The observations on diethazine reported here are consistent with this hypothesis. In patients without delta activity, the EEG demonstrated desynchronization of frequencies, and this was associated with clinical illusory phenomena. In patients with delta activity desynchronization occurred, and alerting and reversal of the Speech patterns induced by electroshock were observed. *Studies on the effects of LSD and such anticholinergic compounds as Win-2299, benactyzine, and hallucinogenic piperidyl benzilates (JB-318, 336) demonstrated marked diminution in per cent time and amplitudes of delta activity, associated with behavioral changes similar to those seen with diethazine.“ �192 BIOLOGICAL PSYCHIATRY Electroconvulsive therapy may also be understood in this framework. We have previously noted a direct relationship between clinical evaluations of improvement and the degree of EEG slowing induced by electroshock.3 Under these conditions, sedation and euphoria are most prominent and hallucinatory activity diminished. In patients in whom hypersynchrony is not induced, behavioral change is limited and ‘improvement’ does not occur.‘1 Previously we concluded that the mode of action of convulsive therapies is based on the induction of a state of altered cerebral function, in which changes in adaptive interpersonal behavior occur, and are interpreted as 4’ 39 ‘improvement’F" The present studies amplify two aspects of this neurophysiologic-adaptive hypothesis. The biochemical substrate of the behavioral change is reflected by an alteration in the acetylcholine-cholinesterase relationships of the central nervous system. It is also probable that EEG hypersynchrony provides the neurophysiologic basis of the milieu change which is clinically manifest as sedation and euphoria and is evaluated as ‘irnprovement.’ The neurophysiologic-adaptive hypothesis of convulsive therapy has provided a meaningful basis for studies of other physiodynamic therapies.39 In this study, it has been possible to amplify our understanding of neurophysiologic aspects of hallucinogens as well. SUMMARY The effect of an anticholinergic agent, diethazine, on the EEG, behavior and language patterns was observed in 40 psychiatric patients, at various stages in the course of electroconvulsive treatment. Behavior: Increased restlessness and agitation, haptic and visual illusory sensations, and delusional thoughts about their illness or examiner’s identity were observed. EEG: Alteration in the EEG was concurrent with behavioral changes. There was a decrease in voltage and desynchronization of all frequencies. In patients with delta activity, the per cent time and voltage of delta activity decreased. Language: Syntactic patterns described for convulsive therapy were reversed. Use of third person, qualification and displacement decreased. In dyadic analyses, there was a decrease in the coefficient of variation. 2. These observations are discussed in the framework of the neurophysiologic-adaptive hypothesis of the action of convulsive therapy; it is concluded that: (a) the biochemical basis for convulsive therapy is similar to that of craniocerebral trauma; (b) changes in acetylcholine-cholinesterase metabolism are intimately related to the behavioral effects; and (c) EEG desynchronization may be a physiologic concomitant of hallucinogenic activity; and EEG hypersynchrony may be associated with euphoria and 1. sedation. �EFFECT OF AN ANTICHOLINERGIC AGENT 193 REFERENCES . Weinstein, E. A., and Kahn, R. L.: Denial of Illness, Illness: Symbolic and Physiologic Aspects, Springfield, Ill., C. C. Thomas, 1955. Roth, M., Kay, D. W. K., Shaw, J. and Green, J.: Prognosis and pentothalinduced electroencephalographic changes in electroconvulsive treatment. EEG & Clin. Neurophysiol. 9: 225-237, 1957. Fink, M. and Kahn, R. L.: Relation of electroenecephalographic delta activity to behavioral response in electroshock. A.M.A. Arch. Neurol. & Psychiat. 78: 516—525, 1957. Green, M. A. and Kahn, R. L.: Experimental studies of the electroshock, process. Dis. Nerv. Sys. 19: 113-118, 1958. Ulett, G. A., Smith, K. and Gleser, G. C.: Evaluation of convulsive and subconvulsive shock therapies utilizing a control group. Am. J. Psychiat. 112: 795-802, 1956. Bornstein, M.: Presence and action of acetylcholine in experimental brain trauma. J. Neurophysiol. 9: 349-366, 1946. Tower, D. B. and McEachern, D.: Acetylcholine and neuronal activity. Canad. J. Research. 27: 105-131, 1949. Ward, A.: Atropine in the treatment of closed head injury. J. Neurosurg. 7: 398-402, 1950. Ulett, G. A. and Johnson, M. W.: Effect of atropine and scopolamine upon electroencephalographic changes induced by electroconvulsive therapy. EEG & Clin. Neurophysiol. 9: 217-224, 1957. Jenkner, F. L. and Lechner, H.: The effect of Diparcol on the electroencephalogram in the normal subject and in those with cerebral trauma. EEG & Clin. Neurophysiol. 7: 303-305, 1955. Heymans, CL, Estable, J. J. and de Bonneveaux, S. 0.: Sur la pharmacologie de la phenothiazinyl—ethyldiethylamine (2987 R. P.). Arch Int. Pharmacodyn. 79: 123-138, 1949. Kahn, R. L. and Fink, M.: Changes in language during electroshock therapy. In Hoch, P. and Zubin, J. Eds: Psychopathology of Communication. New York, Grune & Stratton, 1958, pp. 126—139. J affe, J.: An objective study of communication in psychiatric interviews. J. Hillside Hospital. 6: 207-215, 1957. : Language of the dyad: A method of interaction analyses in psychiatric interview. Psychiatry. 21: 249-258, 1958. Weinstein, E. A., Kahn, R. L., Sugarman, L. A. and Linn, L.: Diagnostic use of amobarbital sodium in organic brain disease. Am. J. Psychiat. 112: 889-894, 1953. Tower, D. B. and McEachern, D.: The content and characterization of Cholinesterases in human cerebrospinal fluids. Canad. J. Research. 27: 132-145, , 10. 11. 12. 13. 14. 15. 16. 1949. 17. Sachs, E.: Acetylcholine and serotonin in the spinal fluid. J. Neurosurg. 14: 22-27, 1957. 18. Ruge, D.: The use of cholinergic blocking agents in the treatment of craniocerebral injuries. J. Neurosurg. 11: 77-83, 1954. 19. Hughes, B.: The role of acetylcholine in head injury. J. Neurol. Neurosurg. and Psychiat. 20: p. 70, 1957. 20. Freedman, A. M., Bales, P. D., Willis, A. and Himwich, H. E.: Experimental production of electrical major convulsive patterns. Am. J. Physiol. 146: 117124, 1949. �194 BIOLOGICAL PSYCHIATRY 21. Grob. D., Harvey, A. M., Langworthy, O. R. and Lilienthal, J. L.: The administration of di-isopropyl fluorophosphate (DFP) to man. Bull. the Johns Hopkins Hosp. 8]: 257-266, 1947. 22. Hampson, J. L., Essig, C. F ., McCauley, A. and Himwich, H. E.: Effects of diisopropyl fluorophosphate (DF P) on electroencephalogram and cholinesterase activity. EEG & Clin. Neurophysiol. 2: 41-48, 1950. 23. Himwich, H. E., Essig, C. F., Hampson, J. L., Bales, P. D. and Friedman, A. M.: Effect of trimethadione (tridone) and other drugs on convulsions caused by di-isopropyl fluorophosphate (DFP). Am. J. Psychiat. 106: 816-820, 1950. 24. Callaway, E.: Slow wave phenomena in intensive electroshock. EEG. & Clin. Neurophysiol. 2: 157-162, 1950. 25. Green, M.: Significance of individual variability in EEG response to electroshock. J. Hillside Hosp. 6: 229-240, 1957. 26. Jasper, H. H., Kershman, J. and Elvidge, A.: Electroencephalographic studies of injury to the head. Arch. Neurol. & Psychiat. 44: 328-348, 1940. 27. Strauss, H., Ostow, M. and Greenstein, L.: Diagnostic Electroencephalography. New York, Grune & Stratton, 1952. 28. Jasper, H. H. and Drooglever-Fortuyn, J.: Experimental studies on the functional anatomy of petit mal epilepsy. Res. Publ. A. Nerv. Ment. Dis. 26: 272-298, 1947. 29. Lindsley, D., Schreiner, L. H., Knowles, W. B., and Magoun, H. W.: Behavioral and EEG changes following chronic brain stem lesion in the cat. EEG & Clin. Neurophysiol. 2: 483-498, 1950. 30. Rinaldi, F. and Himwich, H. E.: Alerting responses and actions of atropine and cholinergic drugs. A.M.A. Arch. Neurol. & Psychiat. 73: 387-395, 1953. 31. Himwich, H. and Rinaldi, F.: The effect of drugs on reticular system. In Brain Mechanism and Drug Action. Springfield, 111., C. C Thomas, 1957. 32. Stoll, W.: Lysergsaure—diethylamid, ein Phantastikum aus der Mutterkorngruppe. Schweiz Arch. Neurol. Psychiat. 60: 1-47, 1947. 33. Beringer, K.: Der Meskalinrausch, Monog. Neurol. Psychiat. Berlin, Springer, 1927. 34. Wikler, A.: Clinical and electroencephalographic studies on the effects of mes35. 36. 37. 38. 39. 40. caline, N-allylnormorphine and morphine in man. J. Nerv. Ment. Dis. 120: 157-175, 1954. Denber, H. and Merlis, 8.: Studies on mescaline. I: Action in schizophrenic patients. Psychiat. Quart. 29: 421-429, 1955. Gastaut, H., Ferrer, S. and Castello, 0.: Action de la diethylamide de l’acide d-lysergique (LSD 25) sur les fonctions psychiques at l’electroencephalogramme. Conf. Neurol. 13: 102-120, 1953. Rinkel, M., DeShon, H. J., Hyde, R. W. and Solomon, H. 0.: Experimental schizophrenia-like symptoms. Am. J. Psychiat. 108: 572-578, 1953. Merlis, S. and Hunter, W.: Studies on mescaline. II: Electroencephalogram in schizophrenics. Psychiat. Quart. 29: 430-432, 1955. Fink, M.: A unified theory of the action of physiodynamic therapies. J. Hillside Hosp. 6: 197-206, 1957. Effect of Anticholinergic Compounds on Post-convulsive EEG and . Behavior, EEG and Clin. Neurophysiol. 10: 776 (Abst.) 1958. #3....” � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effect of anticholinergic agent, diethazine, on EEG and behavior; significance for theory of convulsive therapy., In JH Masserman (ed.), Biological Psychiatry. Grune and Stratton, New York, 1959, 1:184194. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-29c-006 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from Biological Psychiatry Grune & Stratton, Inc., 1959 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/b574305356446714449f347eaa71e515.pdf 4bf163bfe85fee82b5e7d9be3ad5c243 PDF Text Text Experimental Studies of the Electroshock Process MAX FINK, M.D., ROBERT L. KAHN, In the last seven years, increasing study by various authors“5 of the neurophysiologic alterations occurring in electroshock has resulted in a re-assessment of the mode of action of this form of therapy. The present neurophysiologic-adaptive hypothesisly2 states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in the continuing evaluation of the electroshock process in this laboratory. These include: The relation of changes in neurophysiolog‘ic indices to behavioral change; 2. Types of psychologic response expressed and factors in the evaluation of “improvement;” 1. 3. and The role of personality in the behavioral response. and Method: The studies have been carried out in groups of consecutive, unselected electroshock referrals. The subjects are voluntary patients in an open ward psychiatric hospital. All patients are treated by resident psychiatrists, who make the referral to the elec— troshock therapy unit. The duration and type of therapy, however, are determined by the supervising psychiatrists in charge of the treatment unit. Patients varied in age from 20 to 66, and have been diagnosed as suffering from depressive and schiz0phrenic I. Subjects illnesses. (a) Tests of Brain Function: Two indices of cerebral function have been stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,6 and changes in orientation and aware— ness of illness after amobarbital sodium.7 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided, in part, by grant M-927, National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Read at the Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N. J ., June, 1957. PH.D., and MARTIN A. GREEN, M.D. 1) EEG: Electroencephalograms were done weekly prior to treatment, and on a day following a treatment. Bipolar recording was used, and selected leads were measured fOr the degree of delta activity. The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and slowest frequency of delta, and, the longest duration of bursts were the measures utilized in the classification of the recOrds into “high degree]? "‘mod— erate degree” and “low degree delta activity.”6 Amobarbital Test: This is a structured interview, in which the patient is asked a standard set of questions pertaining to ori— entation and awareness of illness. Amobarbital is then administered intravenously, in a concentration based upon body weight, at a rate of 1 cc to every 40 seconds, until nystagmus and slurred speech are induced. In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold} the procedure was modified to allow for weight differences of subjects. The same questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called “positive” and are indicative of states of altered cerebral function.7 Tests were carried out before electroshock, and at weekly intervals during elestroshock on the day following treatment. (b) Evaluation of Behavior: In addition to the notes of the patient’s therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and 2-4 weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these descriptions. Ratings of improvement 'Were based on the behavioral response two to three weeks after the last treatment, and reflect a short term clinical rating. The patients were divided into three groups: much improved, moderately improved and unimproved, based on criteria 2)_ described.2 Reprinted from Diseases of the Nervous System, Vol. XIX, No. 3, March 1958. �(0) Evaluation of Personality .' The initial method of personality assessment employed has been a structured family interview. In their original observations, Weinstein and Kahn described the characteristics of the maintenance of high degree delta activity and short term clinical ratings.6 Of the pa— tients who were rated much improved, 90% had high degree delta EEG records in the 3rd and 4th weeks of treatment, While of the unimproved patients, only 20% had such records. The relationship between delta activity and clinical ratings is seen in Figure 1. “explicit verbal denial personality.”9 To determine the significance of this personality type for behavioral response, a structured questionnaire was developed. In interviews OO .— MUCH IMPROVED (u) with two members of the family, the patient’s usual attitudes and interests in 15 90 .-—— moo. IMPROVENG) UNIMPROVEDW) .-.— characEach specific areas were explored. 80 teristic was rated as being absent, moderately present or markedly present. Scores 7O of 0, 1 and 2, respectively, were assigned, '60 and added—the resulting score being termed 50 the “denial personality score.”1° (d) Treatment: Electroshock was admin- 4o istered on a schedule of three treatments 3. 30 12 week. A minimum of treatments was given, except in a few cases where a. severe 20 confusional state appeared earlier. The course of treatment was determined by the supervising psychiatrist in charge of the lO-lZ electroshock unit, based upon clinical criteria. Treatments were grand mal, using either a Medcraft alternating current instruobservations In these series, subsequent ment or a Reiter C-47 electrostimulator. Pain Based extended predictive were study. a tients were generally premedicated with inthe earlier it on was suggested observations, travenous Pentothal prior to the treatment. those the much that were improved patients In the past year, a subconvulsive therapy been in had whom delta high activity degree group was instituted. Randomly selected induced in and the of treatment course early electroshock referrals received 12-42 suband Records second sustained. the during convulsive treatments, under Pentothal preweeks of third treatment, therefore, were medication. These patients were subjected in 54 consecutive The results assessed. pato the same test procedures and the same bein Table Of I. the noted tients patients are therevaluations mal havioral as the grand delta who degree developed activity high makthe Neither psychiatrist apy subjects. weeks of third second the and treatduring ing the evaluation, the patient’s therapist, while much rated 67% improved, were ment, nor the patient was cognizant of which pawithout the such of 30% aconly patients tients received which form of therapy. The rated. so were tivity data for this series of patients is now being evaluated, and reference will be made only TABLE I to the general observations. Patients With High Delta Activity During II. Observations: Second, Third Weeks of Treatment RATING CLINICAL in Cerebral Role Function of Altered (a) '8 >. Behavior: i’ 75w: a: Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and a 1. .c: EEG Delta Both High (18) One High (16) None High (20) S E to. E 5 8 a 5 12 (67%) 4 (25%) 6 (30%) a; 8 ’5‘ Q sE (22%) 8 (50%) 7 (35%) 4 a D 2 4 7 (11%) (25%) (35%) . �Amobarbital Test In the initial series of 24 patients, ‘previ: ously reported,‘-’ eleven patients were rated as much improved,,andall had positive aniobarbital test reactions after 7 to 9 treatments and sustained this response. Of the unimproved patients, 15% had positive amobarbital responses in the third week and 28% in the fourth week, but these were not Sustained. A comparison of both the EEG observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. In 77 patients tested to date, observations during the second and third weeks of treatment were examined for the presence of high degree delta activity and positive amobarbital test results. Of the much improved patients, 75% had both positive amobarbital tests and high EEG delta activity during this period. Of the unimproved patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a significant one; and equally significant is the cluster of negative amobarbital tests, low and moderate EEG delta activity and clinical rating of unimproved. TABLE II EEG and Amobarbital Test Results During Second, Third Weeks of Treatmenfit 2. :, .c: 8 2 8 Total .................................................... 33 .01 E 3 8 E e s E Both Positive Amobarbital and High EEG Delta Activity ........................ 25 Either Positive Amobarbital or High EEG Delta Activity .......................... 8 Neither Positive Amobarbital nor High EEG Delta Activity .............. O *Significant at better than 2 2 Q E sD 10 3 12 5 3 11 25 19 level of confidence. (b) Clinical Patterns of Behavior: In these patients, we have observed varied responses to electroshock including the absence of noticeable symptoms with a return of pre-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic com.plaints and pre-occupations, states of in— creased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of’behavioral change is seen to be related to the degree of alter'a} tion in the neurophysiologic indices. During electroshock, with the gradual induction of states of altered brain function, and their restitution in the weeks following cessation of therapy, behavior shows characteristic patterns. The following are but a few of the gross patterns that are observed during the period of increasing and waning states of altered brain function. An early change in behavior in retarded subjects, for example, may be a change in the degree of participation in ward activities and increased neatness and interest in personal care. This is succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial of illness, and insistence upon going home. At this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest in the future becomes prominent. Premorbid patterns of behavior are in evidence, and the EEG returns to normal and the amobarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed during treatment, withdraw from participation in hospital activities, and complain increasingly of memory loss, physical distress and insomnia. Amobarbital tests and electroencephalograms may show the same degree of change as in the first group. With cessation of treatment, there is either a return to the depressed state, or a persistent emphasis on the memory loss and physical complaints of the treatment. Another pattern, seen in hostile, negativistic and withdrawn patients, is the development of hyperactive, hypomanic, and impulsive behavior. Memory loss is marked, and clinical disorientation and confusion may be noted at the height of neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional for.3 �mation become prominent, to be followed by withdrawal and mutism. (c) Efiect of Subconvulsive Therapy: The interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by obser— vations in the subconvulsive group. TWentyseven subjects received subconvulsive therapy instead of grand mal. Minimal changes in the electroencephalogram and in amobarbital tests were induced, and the changes in clinical behavior were limited. The electroencephalograms demonstrated either no delta or a minimal amount of such activity. In no patient were moderate or high degree delta activity records observed. In the amobarbital tests, only three patients had positive tests during treatment, and in each instance it occurred only once. No change in symptoms or behavior was noted in twenty—three. Nineteen were referred for a second course of treatment. Grand mal electroshock in— duced changes in brain function of high de— gree delta activity and/or repeated positive amobarbital tests in fourteen of these. All fourteen showed significant changes in behavior; While of the five patients in whom the physiologic indices showed only minor changes, only two patients showed a definite behavioral change. (d) Role of Personality in the Adaptive Respouse: Another variable in the adaptive response of the patients is the personality—the habitual attitudes, patterns of perception and behavior and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients showing denial mechanisms to the clinical result. The relatives of 47 patients were interviewed, and denial personality scores assessed. Scores ranged from 0 to 25, with a median of 11. The scores were divided into two groups: scores from 11 to 25 were classed as the “high denial group” and those from 0-10 as the “low denial group.” Of the patients with high denial personality scores (Table III), 58% were in the much improved group, and only one patient (4%) was in the unimproved group. The ratings of improvement for the patients with low denial personality scores were random—'4 about one third appearing in each rating category. TABLE III Relation of Denial Personality Scores to Clinical Response to Electroshock Personality Score 11-25 0-10 Total Much Improved 14 Moderately Unimproved Improved 7 9 9 1 7 21 18 8 Total 24 23 47 The difference in the denial scores between the much or the moderately improved patients, when compared to the unimproved patients, is statistically significant. That the personality ratings were indeed reflective of the patients’ adaptive response under the conditions of altered brain function is noted in the correlation of these scores with actual changes in language patterns which had been described11 as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classified according to whether he showed three or more explicit language changes. The group of patients With high denial personality scores showed a significantly greater number of language changes than patients with low personality scores. The coefficient of correlation is +.71, which is significant at better than the 1% level of confidence. Discussion: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn,1 and again by Kahn, Fink and Weinstein,2 and the observations of Roth,3 Aird,4 and Ulett.5av Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. We have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital as indices of altered brain function. Other measures, applied in the same serial fashion, will, we believe, demonstrate the same relation to changes in behavior or alteration in brain function. Under the conditions of the induced 111. ‘0 �change in brain function, altered patterns of adaptation are expressed.» The type of adaptation varies, apparently dependent upon the personality organization. In these studies we have noted the relationship of an “explicit verbal denial” personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews.11 We have observed that patients with high denial scores are those who are more likely to be evaluated as “much improved” (Table III). The type of adaptation is varied, however, as we have described here. In this context, therefore, the conclusion is affirmed that electroshock is a means of inducing change in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. We have emphasized “change in behavior” in this report. In previous studies, we related our observation to “improvement.” “Improvement” is a derivative evaluation of the induced behavioral change, which is dependent upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, who had been withdrawn, crying, and had expressed suicidal thoughts, no longer is seclusive, and is jovial, friendly and euphoric, denies his prob— lems and sees his previous thoughts of suicide as “silly,” a rating of “much improved” is made. To the extent that a schizophrenic patient is perceived as less delusional, less excited, and less Withdrawn, he is rated as “improved.” When, however, the induced behavior is one of increased anxiety and fear— fulness, or persistent complaints about memory loss, pain or other physical symptoms, or excitement and delusional thoughts, a rating of “unimproved” will be made. These studies amplify the present neurophysiologic-adaptive hypothesis of electroshock action. Further studies, defining the significant aspects of personality and of the expectations of the environment on the patterns of behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquilizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. IV. Summary and Conclusions: 1. This report summarizes continuing experimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an alteration in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The pattern of behavioral alteration is shown to vary markedly, depending upon the degree of induced cerebral dysfunction, the personality of the subject and the environmental situation. 4. “Improvement” ratings are seen as a special case of behavioral change dependent upon the type of adaptation elicited, the expectation of the therapist, administrator and family, and the tolerance of the milieu. 5. The extension of this neurophysiologicadaptive hypothesis of electroshock action to other forms of somatic therapies is suggested. 1. REFERENCES Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat, 109: 22-26, 1952. 2. Kahn, R. L., Fink, M., and Weinstein, E. A.: Re- lation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. and Psychiat., 76: 23-29, 1956. 3. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive Treatment and Their Significance for the Theory of EST Action. EEG 01m. Neurophysiol., 3: 261-280, 1951. 4. Aird, R. N., Strait, L. A., Pace, J. W., Hernoff, M. K., and Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. Arch. Neurol. and Psychiat, 75: 371-378, 1956. 5 a. Ulett, G. A., Smith, K., and Glesser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group. Am. J. Psychiat, 112: 795-802, 1956. 5 b. Ulett, G. A., Glesser, G. C., Caldwell, B. M., and Smith, K.: The Use of Matched Groups in the Evaluation of Convulsive and Subconvulsive Photoshock. Bull. Merm. Olin, 18: 138-146, 1954. 6 a. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Olin. Neurophysiol., 8: 158 (Abst.) 1956. �6’ b. . . Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. Arch. Neurol. and P31chiat, 78: 516-525, 1957. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112: 889-894, 1953. Shagass, C.: The Sedation Threshold. A Method for Estimating Tension in Psychiatric Patients. EEG Clin. Neurophysiol., 6: 221-233, 1954. : . Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol.» and Psychiat, 69: 355-367, 1953. . Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock. Therapy. Conf. Neural. (In Press.) 11. Kahn, ;R. L., "and Fink, M.: Changes in Language During Electroshock Therapy in Psycho~ pathology of Communication (Hoch, P., and Zubin, J ., Eds.). Grune and Stratton, N. Y., 1957. (In press.) 10. _ ��.thv- AyiAuu. .gypZZILu Experimental Studies of the Electrcshock Process Max Fink, 14.13., Robert L. Kahn, 31.1). and Martin A. Green, M.D. From the Department of Experimental Psychiatry, Hillside HOSpital, Glen Oaks, N.Yo of Mental Health, part, by grant M—927, National Institute Service. Health Public U.S. of Health, National Institutes Aided, in Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N.J., June, 1957. Read Vo at the 6‘27-S7 �-2Experimental Studies of the Electroshock Process In the last seven years, increasing study by various authors (1-5) of the neurophysiologic alterations occurring in electroshock has re- sulted in a re-assessment of the The mode of action of this fcnm of therapy. present neurophysiologic-adaptive hypothesis (1,2) states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in this laboratory. in the continuing evaluation of the electroshock process These include: relation of changes in neurophysiologic indices in behavioral change; 1) The 2) types of psychologic response expressed and evaluation of "improvement;" and 3) the role of personality factors in the in the behavioral response. �II. -3“ Subjects and Method: studies have been carried out in groups of consecutive, unselected The electroshock referrals. ward subjects are voluntary patients in an The open psychiatric hospital. All patients are treated. by resident psychiatrists, who make the referral to the electroshock therapy unit. type of therapy, however, are determined by the supervising unit. Patients varied in age from charge of the treatment have been diagnosed as sufferina from depressive (a) Tests of Brain Function: have been Two duration and The psychiatrist in 20 to 66, and and schizophrenic illnesses. indices of the cerebral function stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,(6) and changes in orientation awareness of illness after amobarbital sodium (7). 1) Egg: Electroencephalograms were done.weekly ment, and on a day following a treatment. selected leads were measured and prior to treat- Bipolar recording was for the degree of delta activity. used, and The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and Slowest frequency of delta, and the longest duration of bursts were the measares utilized in the class- ification of the records into "high degree," "moderate degree" and "low degree delta activity" (7). 2) Amobarbital Test: This the patient is and awareness asked a standard set of questions pertaining to orientation of illness. Amobarbital is then administered intravenously, in a concentration based seconds,% is a structured interview, in which upon body weight, until nystagmus and at a rate of 1 cc slurred speech are induced. to every ho The same 1"“.% In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold (8), the procedure was modified to allow for weight differences of subjects. �~12.- questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called "positive" and are indicative of states of altered cerebral ftnction (7). Tests were carried at weekly intervals during.electroshock out before electrodiock, and day on a after a treatment. (b) Evaluation of Behavior: In addition to the notes of the patient's therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and Z-h weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these on descriptions. Ratings of the behavioral response reflect a short term groups: much improved, described ( two to three clinical rating. weeks The improvement were based after the last treatment, patients were divided and into three moderately improved and unimproved, based on criteria ). (c) Evaluation of Personality: The initial method of personality assessnent employed has been a structured family interview. In their orig- inal observations, Weinstein and Kahn described the characteristics of the "explicit verbal denial personality" (9). To determine the significance of this personality type for behavioral reSponse, a structured questionnaire was developed. In interviews with two members of the family, the patient’s usual attitudes and interests in 15 Specific areas were explored. Each characteristic was rated as being absent, moderately present or markedly present. Scores of 0, l and 2, reapectively, were assigned, and added - the resulting score being termed the "denial personality score" (10). (d) Treatment: Electroshock was administered on a schedule of three treatments a week. A minimum of 12 treatments was given, except in a few �cases where a severe confusional state appeared ment was determined by earlier. The course of treat- the supervising psychiatrist in charge of the electro- unit, based upon clinical criteria. Treatments were grandznal, using either a Medcraft alternating current instrument or a Reiter C-h? electro- shock stimulator. Patients were generally premedicated with.intravenous pentothal prior to the treatment. In the past year, a subconvulsive therapy group was instituted. Randemxy selected electroshock referrals received 12-h2 subconvulsive treatthe ments, under pentothal premedication. These patients were subjected to same test procedures and the same behavioral evaluations as the grand mal therapy subjects. Neither the psychiatrist making the evaluation, the patient's therapist, nor the patient was cognizant of which patients received which.form of therapy. The data for this series of‘patients being evaluated, and reference will be made only is now to the general observations. �III. Observations: A. Role of Altered Cerebral Function in Behavior: 1. Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and maintenance of high degree delta activity much and short term clinical ratings (6). or the patients who were rated weeks of improved, 90$ had high degree delta EEG records in the 3rd and hth treatment, while of the unimproved patients, only relationship between delta activity and 20% had such records. The clinical ratings is seen in Figure 1. In subsequent series, these observations were extended in a predictive much study. Based on the earlier Observations, it was suggested that the improved patients were those in high degree whom delta activity had been in the course of treatment and sustained. Records during the ant third weeks of treatment, therefore, were assessed. The results induced early second in Sh consecutive patients are noted in Table 1. veloped high degree delta ment, such 67% rated were activity were activity during the second much improved, so while only EEG High Delta and who de- third weeks of treat- of the patients without I Activity During Second, Third‘weeks of Treatment. Clinical Rating Much Imgroved Delta 30% the patients rated. TABLE Patients with Of Mbderately'lrunnved Unimproved (11%) Both High (18) 12 (67%) h (22%) 2 (16) u (25%) 8 (50%) h (25% None High (20) 6 (30%) 7 (35%) 7 One High (35%) �a7; 2. AmObarbital Test: In the of 2h patients, preViouSly reported (2), initial series eleven patients were rated as testreactions after 7 to much improved, and all 9 treatments and sustained had positive amObarbital this response. 0f the positive amobarbital reaponses in the third week and 28% in the fourth week, but these were not sustained. A comparison of'both the EEG Observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. unimproved In 77 patients, 15% had patients tested to date, observations during the second weeks of treatment were examined activity 75% and had both and third for the presence of high degree delta positive amobarbital test results. positive amobarbital tests Of the much improved and high EEG patients, delta activity during patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a significant one; and equally significant is this period. Of the unimproved the cluster of negative amobarbital activity and tests, low and moderate EEG clinical rating of unimproved. delta �9 ..—-- m TABLE EEG II and Amobarbital Test Results During Second, Third Weeks of Treatment.* Much Mbderately Improved gnimprovsd Improved Both Pbsitive Amobarbital and High EEG Delta Activity 25 10 3 Either Positive Amcbarbital or High EEG Delta Activity 8 12 5 _£L_ L (25) Neither Positive Amdbarbital nor High EEG Delta Activity (33) (Total) B. 1.1 (19) Clinical Patterns of Behavior: In these patients, we have observed including the absence of noticeable varied responses to electroshock symptoms with a return of yrs-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic complaints and preoccupations, states of increased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of behavioral change is seen to alteration in the neurophysiologic indices. brain During electroshock, with the gradual induction of states of altered function, and their restitution in the weeks following cessation of therapy, be related to the degree of behavior Shows characteristic patterns. The following are but a few of the are observed during the period of increasing and waning gross patterns that states of altered brain.function. Anearly change in behavior in retarded subjects, for example, rO-‘fi’lt. * Significant at hotter than .01 level of confidence. x»,-~-n---.' ~rmw-n. may it...“ �be a change in the degree of neatness and participation in interest in personal care. This ward is activities and increased succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest of illness, and in the future insistence upon going home. becomes prominent. Pre-morbid evidence, and the EEG returns to normal At patterns of behavior are in and the amdbarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed and during treatment, withdraw from.participation in heapital activities, Amocomplain increasingly oi memory loss, physical distress and insomnia. barbital tests and electroencephalograms may show the same degree of change as in the first group. with cessation of treatment, there is either a return to the depressed state, or a persistent emphasis physical complaints of the treatment. Another pattern, seen is the loss is on the memory loss and in hostile, negativistic and withdrawn patients, development of hyperactive, hypomanic, and impulsive behavior. Memory marked, and clinical disorientation and confusion may be noted at thelieight o£1neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional formation become prominent, to be followed by withdrawal and mutism. C. Effect of Subconvulsive Therapy: interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by observations in the subconvulsive group. Twenty-seven subjects received subconvulsive The �~10; electroencephalogram therapy instead of grand mal. Minimal changes in the behavior and in smobarbital tests were induced, and the changes in clinical limited. The electroencephalograms demonstrated either no delta or were a minimal amount of such activity. In patient no were moderate or high activity records observed. In the amobarbital tests, only each instance three patients had positive tests during, treatment, and in it occurred only once . No change in symptoms or behavior was noted in degree delta treatment. twenty-times. Nineteen were referred for a second course of degree Grand mal electroshock induced changes in brain function of high delta activity and/or repeated positive amobarbital tests in fourteen of while of the these. All fourteen showed significant changes in behavior; five patients in whom the physiologic indices showed only minor changes, only two patients showed a definite behavioral change. of Personalitywin the Adaptiverg‘e‘spggg: the Another variable in the adaptive response of the patient is and behavior - the habitual attitudes, patterns of perception 1). Role personalitw and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients mechanisms to the clinical result. The showing denial relatives of h? patients were inter- Scores ranged from viewed, and denial, personality scores assessed. O to 25, scores were divided into two groups: scores from and those from O - 10 as 11 to 25 were classes as the "high denial group" with a median of 11. the “low denial The gar-mp." 0f the ,.latients with high denial personality scores (Table 58%; were in the much improved group, and. only one patient (1%) was III), in �911- the unimproved group. The ratings of for the patients with - about one third appearing in improvement low denial personality scores were random i each rating category. lean; Relation of Denial Personality Scores to Clinical Response to Electroshock Much Improved Moderately Improved Unimpmved Total M9&1}EI., §9ar£ 11 — 25 1h 9 1 2h 0 - 10 7 9 7 23 21 18 8 h? Total The difference in the denial scores between the improved patients, when compared to the unimproved much or the moderately patients, is statistically significant. That the personality ratings were indeed reflective of the patients' adaptive reaponse under the conditions of altered. brain function is noted. in the correlation of these scores with actual changes in language patterns which had *een described (11) as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classified according to whether or not he shone 6. three or more explicit language changes . The group of patients with high denial personality scores showed a significantly greater number of language changes than patients with low personality scores. The co- efficient of correlation is +.7l, which is significant at better than the 1% level of confidence. �IV. Discussign: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn (l) , and again by Kahn, (3), Aird (’4), and Ulett (5a, b). Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. He have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital Fink and 'E-i‘einstein (2), and the observations of Roth as indices of altered brain function. Other measures, applied in the serial fashion, will, we believe, demonstrate the in behavior or alteration in brain function. Under the conditions of the induced change same same relation to changes in brain function, The type of adaptation altered patterns of adaptation are expressed. these varies, apparently dependent upon the personality organization. In studies we have noted the relationship of an "explicit verbal denial" personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews (11) . We have observed that patients with high denial scores are those are more likely to who The type of adaptation be evaluated as is varied, "much improved" (Table III). however, as we have described here. In this context, therefore, the conclusion is affirmed that electroshock is a in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. means of inducing: change We have emphasized " change in behavior" vious studies, we in this report. In pre- related our observation to "improvement." "Improvement" �:13- derivitive evaluation of the induced behavioral change, which is dependend upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, is a who had been withdrawn, is seclusive, and crying, and had expressed suicidal thoughts, no longer is jovial, frienc‘ly and euphoric, denies his problems and sees his previous thoughts of suicide as is made. To "silly," a rating of "Inuch improved" the extent that a schizophrenic patient delusional, less excited, and less however, the induced behavior one is perceived as less rated as "improved." When, of increased anxiety and fearmlness, or loss, pain or other physical symptoms, or delusional thoughts, a rating of "unimproved" will be made. persistent complaints about excitement and is t-Iithdrawn, he is memory studies amplify the present neumphysiologic-adaptive hypothesis of electroshock action. Further studies, defining the significant aspects of personality and of the expectations of the environment on the patterns of These behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquillizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. �V. gunnery and. Conclusions: 1. This report sumarizes continuing esperimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an altera- tion in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The depending upon the subject 1;. pattern of behavioral alteration is shown to vary markedly, the degree of induced cerebral dysfunction, the personality of and. the environmental situation. "Improvement" ratings are seen as a Special case of behavioral the type of adantation elicited, the expectation of the therapist , adninistrator and family, and the tolerance of the milieu. change dependent upon this neurophysiologic-adaptive hypothesis of electmshocl: action to other forms of somatic therapies is suggested. S. The extension of �m REFEIUQI‘ICES l. Juno‘s—t Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its relation to the Theory of Shock Therapy, Am. J. Psychiat” 109: 22-26, 1952. of Amobarbital 1. and Weinstein, E.A.: RelationA.I—-I.A. Arch. Neurol. Electroshock, in Test to Clinical Improvement 1956. and Psychiat., IQ: 23-29, Roth, 1-1.: Changes in the EEG under Barbiturate Anesthesia Proclucec‘v by Electro-Convulsive Treatment and their Significance for the Theory of EST Action, EEG. Clin. Neurophysiol., _3.: 261-280, 1951. Kahn, R.L., Fink, 3. h. Pace, J.EI., Hernaff, M.K. and Bowditch, 5.0.: Neurophysiologic Effects of lectrically Induced Convulsions, A.:-I.A. Arch. Neurol. and Psychiat., 15: 371-378, 1956. Aird, Ran, Strait, L.A., . G.A., Smith, K. 5a. Ulett, Subconvulsive Shock and Gleeser, G.C.: Evaluation of Convulsive and Therapies Utilizing a Control Group, Am. J. Psychiat., 112: 795-802, 1956. 5b. Glasser, G.C., Caldtrell, B.M., and Smith, K.: The Use of I'iatched Groups in the Evaluation of Convulsive and Subcommlsive Biotoshock, Bull. Mann. 015.11., 6a. 6b. _1__8_: 138-1h6, 1951.. H. and Kahn, R.L.: Quantitative Studies of Slow Wave Followi.n:_; Electroshock, EEG Clin. Neurophysiol” _8_: 158 Fink, Activity (Abst.) 1956. EEG Delta Activity to Behavioral and ___: Relation of Response in hilactroshock: Quantitative Serial Studies, A.itI.A. Arch. Eleurol. and Psychiat. (in press). 7. E-Jeinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.:Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic Brain F‘lisease, Am. J. Psychiatu .133: 889-89h, 1953. 8. Shagass, C. : The Sedation Threshold. 9. Weinstein, E.A. and Kahn, R.L.: Personality Factors in Denial of illness, in Psychiatric Patients, A.1-I.A. Arch. Neurol. and EEG A Method for Estimating Tension Clin. Neurophysiol., Psychiat., _6_: 221-233, 1951;. 99;: 355-367, 1953. Parsonality Factors in Behavioral to Electroshock Therapy, Coni‘. Neurol., (in press) Response 10 . Kahn, R.L. and Fink, 14.: 11. Kahn, R.L. and Fink, 141.: Changes in languAge During Té‘lectroshock Therapy, in P cho tholo g; Comunication (Hoch, P. and Zubin, J., 13623.), Grune and tratton, N.Y., 1957. (in press). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental studies of the electroshock process. Dis Nerv Syst. 1958 Mar;19(3):113-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-30-007 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and reprint. Reprint from Diseases of the Nervous System, Vol.XIX, No.3, March 1958 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0cb0657cbbdab38351d56e14b15f8cbf.pdf 7766c5312815a1dcb5171a3528e92d6e PDF Text Text Reprinted from The Journal of the American Medical Association April 12, 1958, Vol. 166 Copyright 1958, by American Medical Association COMPARATIVE STUDY OF CI] LORPROMAZINE AND INSULIN COMA IN THERAPY OF PSYCHOSIS Max Fink, M.D., Robert Shaw, M.D., George E. Gross, M.D. and Frederick S. Coleman, M.D., Glen Oaks, N. Y. With the advent of “newer” drugs for the treatment of psychiatric illnesses and the concomitant awareness that the effectiveness of insulin coma therapy was limited, a control drug therapy—insulin coma study was undertaken. Preliminary trials with various medicaments available in 1954 demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports had noted its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. The study was designed to assess the therapeutic efficacy and indications for intensive chlorproma: zine therapy, compared to classic insulin coma therapy, an in open-ward, voluntarily hospitalized psychiatric population. Subjects and Method All patients referred for insulin coma therapy during the period Sept. 1, 1955, to Dec. 31, 1956, were observed. Supervising psychiatrists made the recommendation for insulin coma therapy independent of the research group. Their criteria for referral were those implicitly held by the hospital administration and were not altered for this study, Randomly selected patients were placed on chlorpromazine therapy instead of insulin coma therapy. This selection was made by the psychiatrist in charge of the insulin therapy unit without prior notice of the referring therapist or the supervising psychiatrist. Sixty patients were referred for insulin coma therapy during the study period, and half of these received chlorpromazine. Insulin Coma.—The standard technique of Sakel for insulin coma was used. All patients received 50 comas, each of a duration of at least one hour, at the physiological level of Babinski reflex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous administration of glucose. Treatments were given five times weekly for a period of three to four months. Chlorpromazine.—To establish an equivalent group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased until well-defined physiological effects were observed. These included rigidity, drooling and fixed facies, seizures, or severe dermatitis. In most instances this was achieved below 1,400 mg. daily, although dosages were increased to 3,600 mg. in one patient. In each instance, the drug dosage was slowly reduced until From the Department of Experimental Psychiatry, Hillside Hospital. The effectiveness of chlorpromazine was compared with that of insulin coma in 60 patients referred for insulin coma therapy. One- half the group, selected on a random basis, received chlorpromazine by mouth for at least three months in doses adjusted so as to fall just short of toxicity in the individual patient,- this dosage varied from 300 mg. to 2,000 mg. daily, with a median of 800 mg. The insulin coma was induced by a standard technique 50 times in each patient. Although many minor differences were noted in comparing the effects of these two methods of treatment, the ultimate results at the time of discharge were essentially the same for the two groups of patients. Neither treatment affected the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management. a maintenance dose, just under that producing toxicity, was obtained. This varied from 300 mg. to 2,000 mg. daily with a median of 800 mg. To determine the comparability of the subjects in the random sampling procedures used in this study, the groups were compared as to their psychi— atric diagnoses and ages. Table 1 shows a comparison of the groups as to diagnoses and demonstrates an equal distribution of subjects in each category. In the analysis of the age distribution, the median age for patients subjected to insulin coma was 24 years, with a range of 17 to 38; the median age for patients receiving chlorpromazine was 28, with a range of 19 to 42. Here, too, the distribution shows no significant difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals. After completion of the treatment period, reports of the patients’ behavior were obtained from the therapist and supervising psychiatrist. The “improvement” rating was determined by the medical director at the patient’s discharge conference and was based on the fourfold scale of recovered, much improved, improved, and unimproved. Neither the authors nor the supervisor of the insulin therapy unit participated in these evaluations. �THERAPY OF PSYCHOSIS—FINK ET AL. Vol. 166, No. 15 Observations Clinical Observations—The following clinical effects were noted in patients who received chlorpromazine and in those subjected to insulin coma therapy. Chlorpromazine: Chlorpromazine induced motor retardation in all subjects. Overactive, destructive behavior rapidly disappeared, and patients became more tractable, less negativistic, and less violent. The nurses’ and therapists’ records noted patients as “less easily excited and frightened,” “cooperating TABLE l.—P.s-ychiatric Psychoneuxosis ....................... Schizophrenia, paranoid ..... Schizophrenia, catatonic ............ Schizophrenia, mixed ................. Schizophrenia, hebephrenic .......... Manic-depressive psychosis ........... Diagnoses Insulin Coma Chlorpromazine 1 2 10 7 10 7 8 3 1 6 2 3 better in ward activities,” and “less restless and less panic-ridden.” One-third of the patients were more sociable and less seclusive and were noted to care for themselves in a more presentable fashion. In instances where severe motor symptoms supervened, however, the patients were less able to care for themselves; they became sloppy and failed to dress themselves. Such periods were usually short and could be significantly modified either by a reduction in drug dosage or by anti-Parkinsonism drugs. Affective changes during chlorpromazine treatment were varied. Four patients became increasingly agitated, tense, and tremulous and either refused to continue on the drug regimen or were induced to do so only with difficulty. Such an affective “storm” appeared early in the treatment and persisted. In four other patients, depressive symptoms were relieved with an increase in affective lability and responsivity. Depressive ideation increased, associated with complaints of insomnia and anorexia in two patients. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of chlorpromazine therapy in 12 patients. Eight had a loss or a significant diminution of their psychotic ideation. In five, hallucinatory and referential experiences were no longer reported even on inquiry, and, in three others, delusional ideas were less prominent. In one patient, phobias were relieved and the patient could once again participate in ward activities. In another, hypochondriasis was sufficiently modified to permit a more meaningful relationship between therapist and patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration and resulted in discontinuation of the drug regimen. 1847 Insulin Coma: The clinical observations in this group were similar to those reported by others.‘ Alteration in behavior was prominent in all patients once repeated comas were induced. Overactive, hostile behavior rapidly diminished and was replaced by alternating periods of somnolence, irritability, and withdrawal. In most patients, nausea, abdominal distress, belching, sweating, and lassi— tude were common sequelae each afternoon and assumed prominence in the recorded reports. These symptoms often interfered with the patients’ ability to care for themselves, and they became unkempt in their dress. Changes in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, dis— appearing in these on direct inquiry. Suicidal and outWardly directed destructive thoughts were modified in three patients, only to recur in each at the end of the treatment period. Mood changes were small. Increasing agitation, tension, and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms was noted early in the treatment and was sustained. In the usual practice of the treatment unit, con— current electroconvulsive therapy was instituted when behavioral control by insulin coma alone was limited. In six patients, such combined treatment was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well defined alteration in behavior, but this was unsustained. None of these patients was rated as improved on discharge. Discharge Evaluation—All patients were dis— charged from the hospital within four months of the end of treatment. Table 2 lists the hospital discharge evaluations for patients treated with chlorpromazine and insulin coma. Ratings in Patients Treated with Chlorpromazine and Insulin Coma TABLE 2.-—Discharge Treatment ........................ ........................ Recovered, no. Much improved, no. .................. Improved, no. Iinimproved, no. ..................... Chlorpromazine Insulin Comafi 2 0 4 17 5 15 7 10 Included in the group of patients treated with chlorpromazine who were rated as unimproved were four who received inadequate course of therapy (less than one month) because of complications of the therapy. Of the 10 patients treated with insulin coma who were rated as unimproved, four had inadequate courses of therapy, two because of complications (seizures and prolonged coma), one be— cause she became more disturbed, and one because of administrative transfer to another facility. �‘ THERAPY OF PSYCHOSIS—FINK ET AL. 1848 It apparent that there is no difference in the clinical evaluation at the time of discharge between the group receiving insulin coma and that receiving chlorpromazine. To determine whether this sample was biased because of its small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported.2 In table 3, the discharge ratings for both is TABLE 3.-—Discharge Ratings Compared for 1950 and 1956 ............................. ....................... Improved, % ......... .................... Unimproved, % ........................... Recovered, % Much improved, % _ Present Group (30 Subjects) 1950 Group (48 Subjects) 0 14 17 19 42 50 33 ‘25 years are compared. The percentage improvement rates for each category are not significantly different. Toxicity and Complications—Patients receiving chlorpromazine and those subjected to insulin coma therapy were compared as to toxic reactions and complications, with the following effects noted. Chlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to a level producing symptoms of toxicity. In this context, all patients developed significant drug effects. Rigidity of extremities, accompanied by a decrease in facial expression, drooling, and festination, was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Most patients became drowsy, retarded, and less active in ward activities. In four patients increased tension, agitation, restlessness, and excitement supervened, leading to a discontinuation of the drug regimen in two. Seizures occurred spontaneously in three patients. Pretreatment electroencephalograms had manifested no dysrhythmia, and no history of seizures had been elicited. In each, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema to mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine hydrochloride therapy was substituted for chlorpromazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from that noted in patients receiving chlorpromazine. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than 0.5% of subjects treated. In the preliminary studies at Hillside Hospital, 3 patients of a group of 20 developed transient clinical jaundice. J.A.M.A., April 12, 1958 Electroencephalograms were obtained in 20 of the patients who received chlorpromazine. With increasing doses, the modulation of the record became more irregular in each. A moderate amount of low-voltage 4-7 cps delta and theta activity was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow-wave activity and the drug dosage. Insulin Coma: The complications of insulin coma therapy in this series were not unusual. Insulin resistance was noted only once and was eventually overcome by the method of alternating dosages. Prolonged reactions occurred in three patients. In each, neurological examination and electroencepha— lography demonstrated signs of persistent central nervous system dysfunction for at least 10 days. Aphasia, hemiparesis, and paresthesias were frequent in five patients and transient in eight others. Seizures occurred in five patients and were recurrent in three. Frequent secondary reactions, nausea, vomiting, abdominal distress, sweating, pallor, lassitude, and generalized weakness occurred in all patients with varying frequencies. The complications of both forms of treatment are listed in table 4. Certain effects, such as dermatitis and hypotension, secondary reactions, and prolonged coma are individual for each therapy, and seizures, agitation, and refusal of therapy were noted with both regimens. The frequencies of these are not significantly different. Effects on Psychotherapeutic Relationship—Pa— tients were referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. TABLE 4.-C0mplicati0ns of Treatment with Chlorpromazine and Insulin Coma Treatment _______./\—————5 Agitation and panic .................. Dermatitis, severe ..................... ............................... Refusal of further therapy .......... Hypotension .......................... Secondary reaction, frequent ........ Prolonged coma (>6 hr.) ............ Insulin resistance ..................... Seizures Chlorpronmzine Insulin Coma 4 3 3 3 2 5 2 2 6 3 . . . 1 Chlorpromazine: During the period of effective drug action, 15 of the patients treated with chlorpromazine were described by the therapist in response to an inquiry as “more accessible,” “speaking more freely,” and “more amenable to psychotherapy.” The behavioral changes could be classified in two groups: subjects in whom tension and preoccupation with somatic symptoms became much less, and those in whom hallucinatory or delusional preoccupations ended. Such changes in �I Vol. 166, No, 15 THERAPY OF PSYCHOSIS—FINK ET AL. in— described as an we1e frequuitly '.*‘-1;welationship stww‘arease in “contact In 13 subjects, psychotherapy either was still‘not feasible” or had become less feasible because of increasing uncontrolled tension, anxiety, or preoccupation with the side-effects of wthe drug regimen. Insulin Coma: Similar observations were made in the patients treated with insulin. Of the 30 patients, 7 were noted to be less tense and less anxious during therapeutic sessions. The theiapists noted that the patient “verbalized more freelv” and was more aware of his environment.” Four patients were specifically treated with a “modified anaclitic” approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional tactics. In the remaining patients (19), while supportive, educational, and environmental manipulating techniques were applied, the therapists were no more successful than prior to insulin therapy. In 11 patients, the physiological effects of the treatments (secondary reactions, sweating, nausea, vomiting, and weight gain) were reported as interfering with psychotherapeutic attempts. Comment Clinical Considerations—In these patients, nei— ther chlorpromazine in high therapeutic doses nor insulin coma specifically modified the psychotic had of 88% these Since a diagpatients process. nosis of schizophrenic illnesses, we concluded that neither treatment has a specificity in altering the schizophrenic process. When given in adequate dosage, however, both treatments are potent methods for the alteration of behavior. In the discharge evaluations, the treatments are similar. In only 20% of the patients were induced behavioral patterns persistent, with the rating “much improved” or “recovered.” For the others, the induced behavioral changes were transient or minimal. Since these therapies fail to induce a recovery from the psychotic process, consideration should be given to their ameliorative, palliative, and supportive aspects. Symptomatic relief was frequent but generally limited to the treatment period. Patients were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is little advantage in either therapy. Both methods were said to enhance relationship therapy, although the therapists’ evaluations favored chlorpromazine therapy. Excluding those who deveIOped increased agitation, patients were more comfortable, more alert, and physically better able to discuss their feelings and experiences while on chlorpromazine treatment. It is clear that“interpretive” psychotherapy is not enhanced, rather, 1849 supportive, educative, reorienting, and directive types of therapy are. When there is a modification of agitated, hallucinatory, depressed, manic, or aggressive behavior, both the therapist and the patient are more comfortable and better able to discuss the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assume decisive significance. To maintain such therapy after discharge and continue thereby the relationship established in the hospital setting may be an important element in sustaining the behavioral changes induced by hospitalization. Other Studies.—While many reports of the treatment of psychosis by chlorpromazine have appeared, we are aware of only one similar comparative study. Boardman, Lomas, and Markowe,3 after a review of the problem, reported a study of 100 patients randomly divided into two groups of 50 and treated with either insulin coma or chlorpromazine. The chlorpromazine dosage was lower than that used in the present series (average 300 mg), but the drug period (three months) was the same. Their observations are directly comparable to this study. They reported no difference either in discharge evaluations or in symptom assessments for either treatment group. The patients treated with chlorpromazine, however, remained in the hospital an average of 6.2 weeks less than the subjects treated with insulin. This was a significant difference between the groups. They concluded, “There is inconclusive evidence that chlorpromazine has advantages over insulin in the treatment of schizophrenia [but] insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the first treatment of choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been confirmed by an adequate follow-up study.” Boardman and his co-workers emphasize the problem of evaluating the therapeutic efficacy of insulin coma. They note a number of reports that raise doubts as to the efficacy of insulin coma therapy in schizophrenia. Bourne,4 in an extensive review of the merits of insulin therapy in schizophrenia, concluded, “There is no proof of any specific therapeutic effect, and the long term prognosis is in no way influenced.” The recent observations of insulin treatment of 5 schizophrenia by Ackner, Harris, and Oldham are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbiturate coma in the same ward and under similar conditions. Evaluations of results were made by psychiatrists without knowl- �1850 THERAPY OF PSYCHOSIS—FINK ET AL. edge of which treatment the patients received. The authors noted a similar outcome, whether the loss of consciousness was induced by a barbitufate or by insulin, and concluded that insulin was not a specific therapeutic agent in the outcome. In the follow-up studies done in this hospital,2 the therapeutic results of insulin coma therapy were disappointing. Patients referred for insulin coma had the longest period of hospitalization (6.5 months, as against 6.04 with'psychotherapy and 4.95 with electroshock), the poorest discharge‘ rating (33% recovered and much improved as against 63% with psychotherapy and 67% with electro— shock), and, within four years, a 50% rehospitalization rate (compared to 33% with psychotherapy and 29% with electroshock). While these observa— tions reflect the idea that the more severely ill patients are referred for insulin coma, they also support the belief that insulin coma is not a specific treatment for the patients referred. From these reports we would conclude that, despite considerable study and the passage of many years, insulin coma therapy has not been shown to induce persistent behavioral changes more frequently than other nonspecific, less dangerous, and less expensive therapies. To the list of alternate therapies of limited value in the management of psychosis we may now add Chlorpromazine, not— ing, however, its advantage of lesser risk and ease of administration. Dosage of Chlorpromazine.—F0r the purpose of assuring an adequate level of Chlorpromazine dosage for evaluation, the amount of medicament given was increased in all subjects to t0xic levels. This level was too high for its behavioral effects, as evidenced by the reduction in all responsive cases to maintenance levels of 300 to 2,000 mg. It is our impression that Chlorpromazine affects the function of the central nervous system (as evidenced by changes in modulation and per cent time delta in the electroencephalogram and the systemic phenomena of rigidity and lassitude) and results in a nonspecific alteration in behavior.6A Such behavioral change is varied and is dependent on a variety of factors, of which the personality organization and the expectancy of the milieu are significant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness, and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances where an affective “storm” supervenes, continuation of therapy at ].A.M.A., April 12, 1958 higher levels, with concomitant administration of trihexyphenidyl hydrochloride (Artane) and benztropine (Cogentin) methanesulfonate should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology and to the present concept of the mode of action of electroshock therapy.6 Summary In a.study of patients referred for insulin coma therapy in an open-ward, voluntary psychiatric hospital, patients received randomly either insulin coma therapy or intensive Chlorpromazine therapy. Chlorpromazine was found to be as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications, or effects on the psychotherapeutic relationship for either therapy. In comparison to insulin coma, Chlorpromazine is safer, easier to administer, and lends itself to long—term management. Patients receiving chlorpromazine therapy are more comfortable than those receiving insulin coma. No evidence has been educed that either therapy has altered the basic schizophrenic process, nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. 75—59 263rd St. (Dr. Fink). This study was supported by the Board of Directors" search Fund of the Society of the Hillside Hospital. Re— The chlorpromazine used in this study was supplied as Thorazine by Smith, Kline & French Laboratories, Philadelphia. The promazine hydrochloride used in this study was supplied as Sparine by Wyeth, lnc., Philadelphia. References and Hoch, P. H.: Shock Treatments, Psychosurgery, and Other Somatic Treatments in Psychiatry, ed. 2, New York, Grune and Stratton, lnc., 1952. 2. Rachlin, H. L., and others: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. 5:17-40 (Jan) 1956. 3. Boardman, R. H.; Lomas, J.; and Markowe, M.: Insulin and Chlorpromazine in Schizophrenia: Comparative Study in Previously Untreated Cases, Lancet 2:487—494 (Sept. 8) 1. Kalinowsky, L. B., 1956. 4. Bourne, H.: Insulin Myth, Lancet 2:964—968 (Nov. 7) 1953. 5. Ackner, B.; Harris, A.; and Oldham, A. J.: Insulin Treatment of Schizophrenia: Controlled Study, Lancet 2: 607-611 (March 23) 1957. 6. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A. M. A. Arch. Neurol. 81 Psychiat. 78:516— 525 (Nov.) 1957. 6A. Fink, M.: Unified Theory of Action of Physiodynamic Therapies, J. Hillside Hosp. 6:197-206 (Oct.) 1957. �Printed in U. S. A. �Cjéz,,4./rv./¢ COMPARATIVE STUDY OF CHIDRPROMAZINE AND INSULIN COIvIA IN THE THERAPY 0}”? PSYCHOSIS *- Max ColemanAM.D. Fink M.D., Robert Shaw M.D., George E. Gross M.D., and Frederick S. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. Supported by the Board of Directors' Research Fund of the Society of the Hillside Hospital. 7-22-57: IV �Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Peychosis for the treatment of psychiatric illnesses, and the concomitant awareness that the effectiveness of insulin With the advent of "newer" drugs limited, a control drug therapy-insulin coma study was undertaken. Preliminary trials with various medications available in l95h demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports coma therapy had noted was its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. study was designed to assess the therapeutic efficacy and indications for intensive chlorpromazine therapy compared to classical insulin coma therapy in an openaward, voluntary hospitalized psychiatric population. The Subjects and Method All patients referred for insulin coma therapy during the period September 1, 1955 to December 31, 1956 were observed. Supervising psychiatrists made the recommendation for insulin group. Their criteria for referral coma therapy independent of the research were those implicitly held by the beepital administration, and were not altered for this study. Randomly selected patients were placed on chlorpromazine therapy instead of insulin psychiatrist in charge of the insulin therapy unit, without prior notice of the referring therapist or the super- coma. This selection was made by the vising psychiatrist. Sixty patients were referred for insulin during the study period, and half received chlorpromazine. coma therapy �.2... a) Insulin Coma: The patients received standard technique of Sakel was used. All 50 comes, each of a duration of at least one hour at the physiologic level of Babinski reflex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous glucose. Treatments were given five times weekly, b) Chlorpromazine: was given team and To for a period of B-h months. establish an equivalent group, chlorpromaziner for at least three months. Dosages were determined by the research were rapidly increased until well defined physiologic effects were observed. These included rigidity, drooling and fixed facies, seizures or severe dermatitis. In most instances this was achieved below lhOO mgm daily patient. In each instance, slowly reduced until a maintenance dose, just under although dosages were increased to 3600 the drug dosage toxicity, was was obtained. a median of 800 mgm in This varied from 300 one mgm to 2000 mgm daily with mgm. To determine the comparability of the subjects resulting from the in this study, the groups were compared as to their psychiatric diagnoses and ages. Table I compares both groups as to diagnoses, and demonstrates an equal distribution of subjects in random sampling procedures used each category. ‘M% c: such-on .m & Chlorpromazine supplied as "Thorazine" through courtesy of Smith, Kline 3 French, Inc. �.3TABLE I PSYCHIATRIC DIAGNOSES Insulin Psychoneuresis Coma Chlorpromazine 1 2 10 10 Schizophrenia, Catatonic 7 7 Schizophrenia, Mixed 8 6 Schizophrenia, Hebephrenic 3 2 HaniooDepressive Psychosis l 3 Schizophrenia, Paranoid In the analysis of the age distribution, the patients was 21; for the insulin with a range of 17 to 38 ; while the chlorpromazine patients had a median age of 28 and a range of 19-122. shows no median age Here, too, the distribution significant. difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals . Following completion of the treatment period, reports of the patients' behavior were obtained from the therapist and supervising psychiatrist. Medical Director The "improvement" at the patient's Discharge four~fold scale of recovered, rating was determ‘ned by the Conference and was based on the much improved, improved and unimproved. None of the authors, nor the supervisor of the insulin therapy unit, participated in these evaluations. �Observatigns 1. Clinical Observations all subjects. Overactive, destructive behavior rapidly disappeared, patients in ghlgrpromazine: Chlorpromazine induced motor retardation a) became more tractable, less negativistic and less violent. and The therapists' records note patients as "less easily excited and frightened," "cooperates better in ward activities," and "less restless and less panic ridden." One-third of the patients were more sociable and less nurses' and seclusive, and were noted fashion. In instances patients were to dress. modified to care for themselves in a more presentable where severe motor symptoms supervened, however, the less able to care for themselves; Such periods were usually short, became sloppy and significantly and could be either by a reduction in drug dosage or by anti-Parkinson drugs. Affective changes during chlorpromazine were varied. became failed increasingly agitated, tense continue on and tremulous and patients either refused to the drug regimen or were induced only with difficulty. affective "storm" appeared early in the treatment other patients, depressive affective lability and symptoms were medication was persisted. In four relieved, with an increase in patients. The continued, however, with an eventual alleviation. In most mood changes were Ideation and Such an reaponsivity. Depressive ideation increased, assoc- iated with complaints of insomnia patients, Fbur was and anorexia, in two small. dramatically altered during the period of chlorpromazine therapy in twelve patients. Eight had a loss or a significant diminution of their psychotic ideation. In five, hallucinatory and referential experiences �.5. inquiry were no longer reported even on once in three others, delusional patient, phobias were relieved and the again participate in ward activities. In another, ideas were less prominent. In patient could and One hypochondriasis was sufficiently modified to permit a more meaningful relatedness of therapist became more prominent. and patient. In one patient, paranoid ideation This was associated with increasing anxiety and panic during drug administration, and resulted in discontinuation of the drug regimen. b) Insulin similar to those reported prominent in all patients clinical observations in this group'were others (1). Alteration in behavior was The Coma: by once repeated comes were induced. hostile behavior rapidly diminished, of somnolence, irritability and and was replaced by Overactive, alternating periods withdrawal. In most patients, nausea, distress, belching, sweating and lassitude were common sequellae each afternoon, and assumed prominence in the recorded reports. These abdominal symptoms often interfered with the patient's ability to care for themselves, and fliey became unkempt in their dress. in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, disappearing in these on direct inquiry. Suicidal and outwardly directed destructive thoughts were modified in three patients, only to recur in each Changes at the end of the treatment Mood period. changes were small. Increasing agitation, tension and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms were noted early in �-6the treatment, and was sustained. In the usual practice of the treatment unit, concurrent electroconvulsive therapy was instituted when behavioral control by insulin limited. In six patients, such combined treatment was coma alone was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well defined alteration in behavior, but this sustained. None was un- of these patients was rated as improved on discharge. 2. Discharge Evaluation All patients were discharged from the hospital within four months of the end of treatment. Table for both the chlorpromazine and II lists the hospital discharge evaluations insulin coma TABLE treated patients. I}; DISCHARGE RATINGS Chlorpromazine Insulin 1. Recovered 2 O 2. much Improved h 5 3. Improved 17 15 h. Uhimproved 7 10 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate course of therapy (less than one month) because of complications of the therapy. four Of the ten unimproved insulin had inadequate courses of therapy (seizures, prolonged - coma patients, two because of complications coma), one because she became more fourth by administrative transfer to another facility. disturbed, and the �-7. It is apparent that there is no difference in the clinical evaluation at the time of discharge between the insulin coma treated groups. To determine whether this sample and the chlorpromazine its was biased because of small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported (2). In Table III, the discharge ratings for both years are compared. TABLE Present Group 1950 Group (30 subjects) (h8 subjects) 0 1h% 17% 19% Improved 50% h2% Ikrhmproved 33% 25% Recovered Much The III Improved percent improvement rates for each category are not significantly different. 3. Toxicitx and Complications a) ghlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to symptoms of toxicity. In this context, all patients developed significant drug effects. Rigidity of extremities, accom— in facial eXpression, drooling and festination was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Host patients became drowsy, retarded, and less active in ward panied by a decrease activities. In four patients increased tension, agitation, restlessness and excitement supervened, leading in two. to a discontinuation of the drug regimen �-8Seizures occurred spontaneously in three patients. Pre-treatment electroencephalograms had manifested no dysrhythmia and no history of elicited. In seizures did not develop at the seizures each, the drug medication was reduced, and had been lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema ato mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In dze third, promazine* therapy was substituted for chlorpromazine, with a was relief of the dermatitis. The indistinguishable in this patient behavioral effects of the promazine from that noted for the chlorpromazine group. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than %% of subjects treated **. Electroencephalograms were obtained in twenty of the chlorpromazine patients. With increasing doses, the modulation of the record irregular in each. activity A became more moderate amount of low voltage h-7 cps delta and theta was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow wave activity b) series were and the drug dosage; Insulin Coma: The complications of insulin not unusual. Insulin resistance eventually overcome by the method of coma therapy in this was noted only once, and was alternating dosages. Prolonged reactions * Supplied as "Sparine" through courtesy of Uyeth & Co. as In the preliminary studies at Hillside Hospital, three patients of a group of twenty developed transient clinical jaundice. �-9occurred in three patients. In each, neurologic examination and electroencephalography demonstrated signs of persistent central nervous system dysfunction for paresthesias at least ten days. Transient aphasia, hemiparesis, were frequent transient in eight others. were recurrent in three. Frequent in five patients, Seizures occurred in five patients, and and secondary reactions, nausea, vomiting, abdominal lassitude and and generalized weakness occurred distress, sweating, pallor, in all patients in varying frequencies. The complications of both forms of treatment are listed in Table IV. Certain effects, as dermatitis and hypotension, secondary reactions and prolonged coma are individual for each therapy, and seizures, agitation and refusal of therapy were noted in both regimens. The frequencies of these are not significantly different. TABLE IV COMPLICATIONS Chlorpromazine Insulin Agitation and Panic h 3 Dermatitis, severe 3 - Seizures 3 5 Refusal of further therapy 2 2 Hypotension 2 — Secondary reaction, frequent - 5 Prolonged Coma ( + Insulin Resistance 6 hours) 3 l Coma �.10.- h. Effects on the Psychotherapeutic Relationship In.this setting, patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effective drug action, treated patients were described by the fifteen of the chlorpromazine— therapist in re6ponse to an inquiry as "more accessible," "Spoke more freely" and were "more amenable to psychotherapy." subjects in The behavioral changes could be classified into two groups: whom tension and preoccupation with somatic symptoms became much hallucinatory or delusional preoccupations ended. Such changes in relationship'were frequently described as an increase in "contact." In thirteen subjects, psychotherapy was either still "not feasible" less, and those in whom less feasible because of increasing, uncontrolled tension, anxiety or preoccupation with the side effects of the drug regimen. Similar observations were made in the insulin treated patients. Of the thirty patients, seven were noted to be less tense and less anxious during or had become therapeutic sessions. more freely" The therapists noted that the patient "verbalized and "was mere aware of his environment." Four patients were specifically treated with a "modified anaclitic" approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional ive, educational therapists tactics. In the remaining patients (19), while support- and environmental manipulating techniques were were no more successful than applied, the prior to insulin therapy. In eleven patients, the physiologic effects of the treatments (secondary reactions, sweating, nausea, vomiting and'weight gain) were reported as interfering with psychotherapeutic attempts. �-11Discussion 1. Clinical Considerations In these patients neither chlorpromazine in high therapeutic doses nor insulin specifically modified the psychotic process. Since 88% of these patients were diagnosed as suffering from schizophrenic illnesses, we concluded thatiieither treatment has a specificity in altering the schizocoma phrenic process. shen given in adequate dosage, however, both treatments are potent methods for u1e alteration of behavior. the treatments are similar. ioral patterns persistent In only and others, the induced behavioral Since these therapies 20% rated as of the patients were induced behav- much improved or recovered. For the transient or minimal. Chang 5 were fail to In the discharge evaluations, induce a recovery from the psychotic process, then consideration should be given to their ameliorative, palliative and supportive aSpects. Symptomatic to the treatment period. Patients relief was frequent, but generally limited were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is advantage of either therapy. Both methods were said to enhance little relationship therapy although the therapists' evaluations favored chlorpromazine therapy. Excluding those who developed increased agitation, patients were more comfortable, more alert and physically better able to discuss their feelings and experiences while on chlorpromazine, than on insulin coma. It is clear that "interpretive" psychotherapy is not enhanced, but rather supportive, educative, re-orienting and directive types of therapy. When there is a modification of agitated, hallucinatory, depressed, manic or aggressive behavior, than both the therapist and the patient arernore comfortable and able to discuss �-12the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assumes decisive significance. To maintain such therapy after discharge continue thereby the relationship established in the hospital setting an important element in sustaining the behavioral changes induced by and may be hospital- ization. 2. Other Studies While many appeared, we reports of the treatment of psychosis by chlorpromazine have are aware of only one similar comparative study. Boardman, Lomas and Harkowe one hundred (3), after a review of the problem, report their study of patients randomly divided into two groups of SO and treated either insulin coma or chlcrpromazine. The chlorpromazine dosage was lower than that in this series (average 300 mgm) but the drug period (3 months) was the by Their observations are directly comparable to same. no difference in the discharge evaluations, nor in this study. They reported assessments for symptom either treatment group. The chlorprcmazine treated patients, box-raver, remained in the hoslaital less than the insulin treated subjects. This was a significant difference between the groups. They concluded that: "There is inconclusive evidence that chlorpromazine has advantages over insulin in the an average of 6.2 weeks treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness on the nurses. Chlorpromazine is the phrenia, but this conClusion and has is for the patients first and greater strain treatment of choice in schizo- based on the immediate results of treatment not yet been confirmed by an adequate follow-up study." �«n13- his co-workers emphasize the problem of evaluating the Boardman and therapeutic efficacy of insulin coma. They note a number of raise doubts as to the efficacy of insulin coma reports that therapy in schizophrenia. (h), in an extensive review of the merits of insulin therapy in Boume is no proof of any Specific therapeutic the long term prognosis is in no way influenced." schizophrenia concluded that "there effect, he and recent observations of insulin treatment of schizophrenia by Harris and Oldham ( S) Aclmer, are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbit- urate coma results in the same ward and under were made by patients received. similar conditions. Phraluations of psychiatrists without The knowledge of which medication the authors noted a similar outcome whether the loss of consciousness was induced by a barbiturate or by insulin, and concluded that insulin was not a specific therapeutic agent in the outcome. In the fol] oar-up studies in this hospital (2), the therapeutic results for insulin coma therapy were disappointing. In that report, patients ferred for insulin coma had re— the longest period of hospitalization (6.50 months for electroshock), poorest discharge rating (3325 recovered. and much improved, 1?. 63:5 for psychotherapy and 67% for electroshock), and within four years, a 5015 re-hospitalization rate (compared to 33% for psychotheram and 29% for electroshock). while these observations reflect 1g 6.0).: for psychotherapy and 14.95 the observation that the more severely coma, it also ill patients are referred. for insulin supports the belief that insulin coma is not a specific treatment for the patients referred. From these reports and the passage of many we would conclude years, insulin that, deepite considerable study coma therapy has not been shown to �.mpersistent behavioral changes more frequently than other non~specific, less dangerous and less expensive therapies. To the list of alternate induce therapies of limited value in the chlorpromazine, noting, however, management of psychosis we may now add its advantage of lesser risk and ease of adninis tration . 3. Dosage of Chlorpromazine for For the purpose of assuring an adequate level of chlorpromazine evaluation, the medication This level was too high duction in was increased in all subjects to toxic levels. fox-its behavioral effects, as evidenced by the re- all responsive cases to maintenance levels of 300 to 2000 mgm. our impression that chlorpromazine affects the function of the central nervous system (as evidenced by changes in.modulation and percent time delta in the electroencephalogram and systemic phenomena of rigidity It is results in a non-Specific alteration in behavior. Such behavioral change is varied and is dependent upon a.variety of factors, of which the personality organization and the expectancy of the milieu are sigand lassitude) and nificant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity, and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances uhere an affective "storm" supervenes, continuation of the drug at higher levels, with concomitant artane and cogentin, should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology, and to the present concept of the action of electroshock therapy (6). mode of �.15Conclusions 1. In a study of patients referred for insulin open ward, voluntary insulin coma psychiatric hospital, patients coma therapy in an randomly received either therapy or intensive chlorpromazine therapy. 2. Chlorpromazine was as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications or effects on the psychoflaerapeutic relationship for either therapy. 3. In comparison to insulin administer, and lends itself to coma, dilorpromazine long term management. is safer, easier to Patients receiving chlorprcmazine therapy arernore comfortable than those receiving insulin coma. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. b. No evidence has been educed �REFERENCES l. Kalinousky, L.B. and Hoch, P.H.: Shock Treatments, Psychosurgery, and. other Somatic Treatments in Psychiatry, Grune and Stratton, 13.15. 3 1952. Rachlin, H.L., Goldman, (3.5., Gurvitz, $1., Lurie, A. and Rachlin, L.: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. §_: 174.0, 195 6. 3. Insulin and Chlorpromazine Comparative Study in Previously Untreated Cases, Lancet, Sept. 8, 1956, pp. 1:87—1:91. Boardman, R.H., Lamas, J. in Schizophrenia - and liarkma‘e, M.: A Boume, H.: The Insulin Myth, Lancet, Nov. 7, 1953, pp. 961;~968. Ackner, B. , Harris, A. and Oldham, A.J.: Insulin Treatment of Schizophrenia - A Controller} Study, Lancet, March 23, 1957, pp. 607-6110 Fink, 1-1. and Kahn, R.L.: Relation of ETTG Delta Response in Electroshock: Quantitative Arch. Neurol. and Psychiat. (in Activity to Behavioral Serial Studies, AJ'LA. press). �January 31, 1957 Subject: Drs. From: To: - Insulin Control Chlorpromazine Max Study: Interim Report Fink, Robert Shaw, George Gross and Fred Coleman Dr. Joseph S. A. Miller, Dr. Simon Kwalwasser and the Research Committee of Medical Board Following insulin During is a summary of the observations in the control chlorpromazine- study, instituted September 1, 1955 and completed January 1, 1957. coma this period, 59 patients were referred for insulin coma Half therapy. of the group was placed, by random sampling, on chlorpromazine * therapy in- stead of insulin coma. Four patients received both insulin and chlorpromazine therapy. of the patients of therapy of less than who received chlorpromazine, seven received courses one month. patients, three had an of the 29 insulin inadequate course of therapy. I. During the period l95h—1955, preliminary PROHLEH: azime resulted in the awareness and safe. In view of the unusually poor trials of that the drug showing of was the insulin chlorpromp both potent coma populat- ion in the 1950 Fbllowaup Study (1), and the appearance of numerous articles in the psychiatric literature recommending chlorpromazine as a therapy schizophrenia, a comparative study of chlorpromazine taken. The a) - insulin for coma was under- following questions were postulated: What b) What is the clinical effect of adequate doses of chlorpromazine? is its therapeutic efficacy'when compared to insulin coma therapy? 0) ‘Ehat are the indications (and contraindications) for the use of chlorpromazine and/or insulin coma? * Chlorpromazine supplied as "Thorazine" through the courtesy of Smith, Kline and French 00., Philadelphia. Rachlin, H,L., Goldman, G.S., Gurvitz, M., Lurie, A., and Rachlin, L.: Follow—up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside HOSp., _5_: 17-ho, 1956. (1) �«2. II. All patients referred for insulin SUBJECTS: coma therapy during the period September 1, 1955 and December 31, 1956 were observed. Supervising psychiatrists made the recommendation independent of the research group. Their by the hospital administration, patients made by coma therapy criteria were those implicitly held and were not were placed on chlorpromazine for insulin altered for this study. Selected therapy. selection The was random and the supervising psychiatrist of the physical therapy unit, without prior notice of the referring therapist. III. a.) Insulin nga; EETEQQ: standard technic of Sakel was used. The All patients received 50 comes, each of a duration of one hour or longer at the physiologic level flex or deeper. Recovery ous glucose. of Babinski reflex or absent was induced by gavage and lid re- occasionally by intraven- Treatments were given five times weekly, for a period of 3-h months. b.) Chlorpromazin : To establish a complementary therapeutic group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased clear-cut physiologic effects ifest rigidity, drooling, ere dermatitis. were observed. These included and fixed clinically mans facies; or toxicity, as seizures or sev- In each instance, the drug dosage was slowly reduced a maintenance dose, until just under toxicity, was obtained. until This was maintained for the duration of the observation period. Laboratory blood counts, tests were carried out at irregular intervals liver function tests, glucose tolerance tests and included and electroenceph- alogramS. In both experimental groups, behavioral observations were made at'weekLy intervals. Following completion of the treatment period, reports of the ther- �4-3- apist and supervising psychiatrist were obtained. The rating of "improvement" Conwas that established by the Medical Director at the patient's Discharge ference. IV: RESULTS: Chlorpromazine A. l. until signs creased rapidly of was achieved in daily dosages to 3600 in mgm. 2000 mgm. one patient. of chlorpromazine was in- The dosage QEEEEE.22.22EQEEEEEEEEEEF rigidity appeared. In most instances this below lhOO mgm. although dosages were increased The maintenance dose varied from 300 mgm. to daily. 2. Clinical effects of chlorpromazine: motor retardation in all subjects. Chlorpromazine induced a Overactive, destructive behavior rapidly disappeared, and the patients were more tractable, less negativistic and less violent. The nurses' and therapists' records relate that patients are "less easily excited and frightened," "cooperates better in "less restless and less panic-ridden." ward activities," and One-third of the patients were more sociable and less seclusive, and were noted to care for themselves in a more presentable fashion. In the instances where severe parkinsonism supervened, however, the patients were less able to care for themselves; became sloppy and failed to dress. by Such periods were short or could be significantly modified anti-parkinson drugsn Affective changes during chlorpromazine were varied. In four instances, the patients became increasingly agitated, tense, tremnlous and either refused to continue on the drug regimen or were induced only with difficulty. Such an persisted. In four other instances, depressive symptoms were significantly relieved, with an increase in affective lability and responsivity. In two patients, deaffective "storm" appeared early in the therapy and �.u. pressive ideation increased and was associated with complaints of insomnia. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of-chlorpromazine therapy in twelve of the patients. Eight patients had a loss or a significant diminution of psychotic ideation. In five, the hallucinatory and referential xperiences were no longer reported even on inquiry; and in three others, delusional ideation was less prominent. In one patient, phobias were relieved to a degree that the patient could participate in ward activities. In another, hypochondriasis was sufficiently modified to permit of a more meaningful latedness of therapist and re— patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration, with resultant discontinuation of the drug regimen. 3. Effects en the psychotherapeutic relationship; Patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effectiwadrug activity, ten of the patients were described by the therapist in reSponse to an enquiry as "more accessible," "spoke more freely" and were "more amenable to psychotherapy." The responses could be classified into two groups: the subjects whose tension and pre— occupation with somatic symptoms became much less and those in whom halluc- inatory or delusional preoccupations ended. In each instance, the therapist described the change in relationship as an increase in "contact". In twelve subjects, psychotherapy was either still "not feasible" or "less so because of increasing, uncontrolled tension." �-5. In no instance did the problem of drug addiction or drug dependence play a role, nor was there an appreciation that drug therapy altered the therapeutic relationship adversely. h. §g§igg§ twenty four have left the hospital. thirty patients in this series, or the 93 "improvement": Table I lists the number of patients evaluated by the Discharge Conference, according to the four-fold classification in use in the hospital. For comparison, the discharge ratings of the insulin coma therapy patients, following the TABLE same criteria, have been included. I DISCHARGE RATINGS Chlogpromazine Insulin l. Recovered 1 O 2. Much Improved 3 1 3. Improved 15 10 h. Unimproved S 8 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate courses of therapy (less than one month) because of complications of the therapy. or the eight unimproved insulin coma patients, four had inadequate courses of therapy - two because of complications (seiz- ures, prolonged coma), one because she was a severe the fourth by administrative transfer to the V. A. 5. Toxicity g£_chlorpromazine: management problem; and Inherent in the design of were the high doses of chlorpromazine, pushed to symptoms of this study toxicity. In this context, all patients developed significant drug effects. In all, rigidity of extremities appeared; frequently accompanied by a decrease in facial expression, drooling and festination. In a number of patients the pafkinsona. �~6— ian features appeared as the drug dosage was reduced. symptoms were became drowsy, relieved when retarded, the drug and was discontinued. less active in ward In.each patient the Almost all patients activities. In four pat- ients, increased tension, agitation, restlessness and excitement supervened, to a degree that led to a discontinuation of the drug regimen. Seizures occurred in three patients. Ineaach, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. Severe, intractable skin reaction occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine * therapy was substituted for chloru promazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from the chlorpromazine group. All patients developed a skin photosensitivity so that on exposure to sun, transient erythema developed. Refusal of further medication because of drug effects occurred in two patients. Both developed severe tension and agitation. In two other instances, agitation resulted in the therapist insisting upon a change in treatment regimen. Table II lists the complications of both treatments. Certain effects are individual to the type of therapy, as dermatitis for chlorpromazine; and prolonged coma, severe secondary reactions and nausea and vomiting in insulin coma. 0there, as seizures, fainting spells, and increased are seen in both. *- Surplied as "Sparine" by the courtesy of Hyeth and Co. states of agitation �'77“ II TABLE COMPLICATIONS Insulin _Chlorpromazine Coma “ Agitation h and Panic 2 - Dermatitis, severe 3 Seizures 3 3 Refusal of further therapy 2 2 Hypotension 2 - Secondary reaction, frequent - 5 - 3 ~ 1 Prolonged Coma (+ 6 hours) Insulin Resistance In this chlorpromazine series, no patients developed clinical jaundice. This complication has been variously reported as occurring in less than %% of the subjects treated.* Liver function and blood element studies were done in this group of patients. Changes were small, and at the recommendation of the medical consultant, the studies were discontinued. Electroencephalograms were obtained patients. and On in fifteen of the chlorpromazine adequate doses, a moderate amount of low voltage theta activity was induced. This activity h—7 cps.delta was exaggerated by hypervent- ilation. There was a suggestive relationship between the degree of the induced slow wave activity and the drug dosage. 6. Adjuvants tg_Chlorpromazine: With the development of rigidity, festination, and drooling, patients received cogentin or artane medication. Both drugs relieved the symptoms, and in a few instances, to a significant * In the initial studies at Hillside twenty developed Hospital, three patients of a group of transient clinical jaundice. �-8degree. Concomitant with the relief of the rigidity a feeling of euphoria and wellabeing was occasionally noted. In one of the patients who developed effect. therapy, anti- an affective "storm" the administration of artane had a salutary In patients who developed seizures during insulin coma convulsant medication (dilantin, phenobarbital) has been routinely employed. Such agents were on lowered not used with chlorpromazine as the seizures did not recur dosages. Insulin B. Coma Theragz clinical effects, complications, the treatment results of insulin ccma therapy have been exhaustively reported. In this series, twenty-nine patients began insulin coma therapy. Of these, nineteen have completed their period of hOSpitalization and ten are either completing their treatment perThe iod or are awaiting discharge. The over-all ratings of "improvement" are listed in Table I. When comp pared with the Hillside HOSpital Follow-up Study of 1955, the percent improve— ment in each category is not significantly different, although the trend is less optimistically than the 1950 group. In Table III the percentages are listed for each evaluation category of this to rate the present series somewhat group compared to the 1950 populatidn. TABLE INSULIN III COMA THERAPY Present Group E 1. Recovered 0% 2. Much h% 19% 3. Improved 52% h2% h. Unimproved hh% 25% Such a Improved difference in trend, if sustained, 1h% may reflect a variety of factors, including changes in criteria of "improvement;" prior administration �.9... tranquillizing agents exerting a selectivity on the population admitted to the hOSpital; and changes in staff criteria for referral for in» of the newer Sulin coma therapy. complication rate in this insulin group is comparable to published studies. No unusual complications, and no deaths were observed. The role of psychotherapy in patients undergoing insulin coma therapy The is complex. In this group, four patients were treated with a "modified anaclitic" approach and an effort at establishing a working psychotherapeutic relationship was made. In the remaining patients, no unusual efforts at psychotherapy were made, with the consensus that a supportive, educative, enviru onmental-manipulative, reassuring type of therapy was achieved, to varying degrees. Therapists reported (in 7 instances) that patients were less tense less anxious during sessions while in coma therapy. In eight patients the physiologic effects of the treatment (secondary reactions, sweating, nausea, vomiting, weight gain) interfered with relationship therapy to a significant and degree. C. Therapeutic Results in Relation to Final Diagnosis Table IV lists the final diagnostic categories for the patients in each group. All diagnoses were represented in each series with an equivalent distribution. TABLE IV EBYCHIATRIC DIAGNOSES Insulin Coma Chlorpromazine Psychoneurosis l 2 Schizophrenia, Paranoid 0\ we U1 O\ U1 \n \» to +4 DD Schizophrenia, Catatonic Schizophrenia, Mixed Schizophrenia, Hebephrenic Manic Depressive Psychosis �~10— No diagnostic group had a significantly better treatment response than any other with either form of therapy. V. DISCUSSION: A. Comparison of Chlorpromazine and Insulin Coma Therapies: Neither chlorpromazine in high therapeutic doses, nor insulin are Specific treatments for schizophrenia. The discharge evaluations both treatments are not significantly different. There is, coma, for however, a def- inite tendency for more patients in the chlorpromazine group to be rated in the better classifications than in the insulin coma group. The trend assumes significance when both the type of sampling and the qualitative aspects of the treatments are taken into account. the The random sampling is exemplified by resultant matching of diagnoses. Since these treatments have not resulted in a recovery from the psychotic process, then their ameliorative, palliative and supportive aSpects must be considered. The insulin coma patients are usually uncomfortable throughout their treatment period. Nausea, vomiting, secondary reactions, are Prolonged coma common. loss of is a and drowsiness realistic threat; as well as the threat to life. The chlorprcmazine patients also suffered considerable disagreeable side effects. Parkinsonism, drowsiness, and skin reactions are significant, must be considered as concomitant management problems. and Seizures and jaundice are the most severe reactions, and to date, have not been permanent. It is possible to modify the significance of these side effects to a considerable extent by anti-parkinson and anti-convulsant medication. There is no question, furthermore, as to the ease with which chlorprom- azine can be administered, in contrast to insulin coma. A significant element in the use of these agents in the therapy of schiz- �.11... ophrenia is concomitant psychotherapy. Such relationship therapy by both It was therapies. apparent in the therapist's evaluations, however, that the chlorpromazine regimen was apy. Patients, excluding those comfortable, alert iences while on and was enhanced more conducive to concomitant verbal who developed ther- increased agitation, were more physically able to discuss their feelings and exper- chlorpromazine, than insulin coma. In another respect, the ease of administration of chlorpromazine advantage. Patients who respond to drug therapy can is of be maintained on such therapy for as long as needed, even on an outpatient basis, while the "course" of insulin coma is limited. Are these treatments equivalent? Can one be substituted for the other? While these questions cannot be answered by the data the negative can be denied. groups are not The in a positive assertidn, results of these treatments in equivalent different with regard to the discharge evaluation. The changes in behavior noted and the symptoms alleviated are not significantly different. In this series, three patients had adequate courses of both regimens. Two have been discharged"improved," and the third is still in the hospital. There has been no significant differences in their reSponse to either form of therapy. Comparison With Other Studies: B. While many studies of chlorpromazine in schizophrenia have appeared, only one report of a controlled study is available. gt_al_ (2) after an excellent review of the problem, report their results in one hundred patients, coma randomly divided into two groups of SO and Boardman, treated either by insulin or chlorpromazine. Their chlorpromazine dosage was lower than in this series (average 300 mgm) but the drug period ( 3 months ) was the same. Their observations are directly comparable to this series. They noted that the over(2) et a1: Insulin and Chlorpremazine in Schizophrenia — Study of Previously Untreated Cases, Lancet g5 h87-h9l, Comparative (September) 1956. Boardman, R.H. A �all clinical results were slightly more favorable in the chlorpromazine group than in the insulin group judging both by interview status and by a rating scale of difference was not of high statistical signif- The symptom change. state, however, that the chlorpromazine patients remained in the hospital an average of 6.2 weeks less; and that this difference was statistically significant. They concluded that: "There is inconclusive evidence icance. They did that chlorpromazine has advantages over insulin in the treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the first treatment of -choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been confirmed by an adequate follow-up study." In Boardman‘s review, due cognizance therapeutic efficacy of insulin come. He is given to the problem of the notes the number of'dissident re- ports that raise doubts as to the role of insulin In this regard, for insulin it is therapy in schizophrenia. important to note the results of the Hillside Follow-up in which patients referred for coma, coma such therapy had the period of hOSpitalization, poorest discharge ratings, and a ization rate (compared to 33% for psychotherapy and 29% 50% longest rehosPital- for the electroshock therapy groups). Two other control studies of chlorpromazine in psychoses are relevant to this report. "blind" study ment at Feldman gjgggp (5) Topeka reporting the observations in a controlled, State HOSpital noted a significant degree of improve- for chlorpromazine. They<eoncluded that "thorazine was found to be useful in converting acutely disturbed psychotics into tractable, accessible patients who could (S) Feldman, P.E. then participate more actively in the hOSpital rehabili- et al: A Controlled, Blind Study of Effects of Thorazine Clinic, a9; 25-h7, 1956. on Psychotic Behavior, Bull. Men. �.13... tatidn program." Tenenblatt and Spagno (6), describing the St. Elizabeth's Hospital eXperience, in another control study, noted significant behavioral effects in psychotic illnesses other than involutional psychoses. Effect of Study D. An on Staff: inherent factor in a control study of any therapeutic modality is the effect that the knowledge of random selection of patients or the use of placebos has on the therapist in his choice of therapy. sulin coma referrals were to be given Knowledge that in- either chlorpromazine or insulin coma created a feeling of insecurity and impotence in the therapist. Their control of the therapeutic situation was in a decrease in the drug effects, and number of felt as severely constricted. This resulted referrals, an exaggeration of the physiologic in the patients expressing doubts as to the therapeutic efficacy of the drug despite significant changes in ward behavior. On numer- therapists called to enquire which therapy their patient, referral for ICT had not yet been made, would get. Prior prejudice ous occasions, ‘whose suitability of either therapy resulted in the therapist's expressing disappointment at the modality used. In two instances, such preabout the judices led to early discontinuation of chlorpromazine therapy, when the pat~ ient experienced eanLy signs of drug effects. E. Dosage of Chlorpromazine: For the purposes of assuring an adequate level of chlorpromazine for evaluation, the medication was "pushed" in level in was too high all all subjects to toxicity. This for its behavioral effects, as evidenced responsive cases to maintenance levels of by the reductidn hOO-lOOO mgm. The effects of parkinsonism, drowsiness and lassitude are prdbably necessary concomitants (6) Tenenblatt, 3.8. and Spagno, A.: A Controlled Study of Chlorpromazine Therapy in Chronic Psychotic Patients, Quart. Rev. Peych. & Neurol., �1":114- of the therapy; and should be induced effect is desired. In instances where in all patients in an whom a therapeutic affective "storm" supervenes, con- inuation of the drug at higher levels, with concomitant artane or cogentin, should be considered. VI. CONCLUSIONS: In a control study of patients referred for insulin coma therapy, chlorprcmazine therapy was found to be as effective in modifying psychotic behavior patterns as insulin charge ratings to be coma therapy. is There better for the chlorpromazine a tendency for the group than dis- for the insulin coma group. In comparison to insulin coma to administer, more controllable in therapy, chlorpromazine is safer, easier its effects, and has fewer side effects. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity for either form of therapy for schizophrenic illnesses. No evidence has been educed �February 3, 1958. that at a bucuti 1.. t :1 1251 : or EEG Dona Maturity to Bohuioml Quaint-Adv. 801-111 Studiu, “Hg, . kaponn in metro-hock: a: Arch. chhnt. 18; 516-525. 1957. Fink, H. and Kuhn, my a.L.s 3818321511 . Mime flux-spin, Units.“ Theory of the Action of 1957. 197-306. g. Hillside 3032. 9: ILL: Significance of Individual Variability in ma human to moctmlhock, g. Bullio- Raga. Q: 229-21“), 1957. link, 91.: A 3. m, h. Join, 5. Kuhn, 3.1.. and $. him, 8.1... J. «In An abacus.” Study of Went-.1031 £111.16. Hog. 9,: 207.215, 1957. link, In blink, PchhiaMc Interview, Figural Artur Induced mm (1957). g: Perception of m5. Puma)... mum, Altered Bruin 1n 361 H. and Pink, 15.: Social Salaam of Factorl 1n 216-228, 1957. 7. 3. and Pink, Ha Role or Stimulus Intensity 1n Pomcpuan tom, ' Simultaneous Gunman: Electrical Stimuli, 1. munch Hog). 9" 2181.250; 195?. at ‘ mama“ 8. Karin, 8. (With Tameka, 8. and Friedman, 8.): Pomeptim Stw o: Ambit-lanai, mg, hard, I: inching.. 1Q: 1&7-176, 19 7. 9. Punter. in; H. (with Geldfarb, Lgflé. knack, H. LE. 322‘ E a g Md it): gaunt. fl! (with‘marb, m): Test in Schilophrcnic 0111mm, 6354-6132, 1957. htum of Orientation in Childm in 303.1de Instant. for 8mm Bonnier Daemon, her. J. Mama . 213538-552, 195?. n. (with Battarnby, v.3. and Radar, 14.3.): Tnchia’wteopic hunk, “minimum of Contour 1n fluent: with Brain mange, J, Cog. algal. gm 61° fl. 3’ 220.227, 1957. Pollack, K. (with Battersw, $1.3. and War, 11.3.): Visual Deficit After Brain Damage in Man as Hammad with Rupidlyakpoud chromatic Stimn, mr. BIS-“2.9;. £2} 7’ 1‘68, 19570 0 13. Pollack, u. (with 00161111), in): cum-a1 ma Ehviromntal Factors attracting Complex Exception in the Institutionaliud Aged, ,1. Gomntolu l2“: ’1, “374‘38’ 19570 �Wf— ,. . , , . ~v-wwwavw—wmvwwnw—wu—va . «m <-~w—-~ uv-v—r rvs—«wv flv‘w—I-‘V n V'Wuzwr- may, mm "—31-— "Wu Flbmuy 3, 1958. Imagination! in Pro”: 1. 3., Mfo, J. humor, with mantra-hook 2. Pink, 3. Pink, IL, Shut, R... Grass, 0. and Colo-Inn, F.3d and Kuhn, Yuma“, J, 3.1.: chhomompenuc Techniques Hang. (in press). was 8.. [$11, 3.1.. tad anon, 14.1.: fluctuahook Prone-l, m, luv. “perinatal M. mama). J. r ‘mo (in Phi.)i and Insulin Cm in the Studio: of the (in press). Omani» Study of Therapy of Psychosis, * h. Pink, 5. ma, LL. 11.: 2E8 Laura}. Gnu Gun. In macaw. a u m- Indu a! the Sedation Munch}, in press). W. and Pink, 24.: humanity Factors (in nutmnhock Therapy, in Buhuioral mu). name to .- v- w. 1r, ,mrnv .7 w K, - �Luvzuv-amwnvww «7,. w—nwrruwm...»~.\,..—... W. WA R .. ran n-«cmvrrme—u»:‘v' February m. »u r’er’I-‘vs 3 , 1958 . many: in m Rayon-buy. Inflow“ York, Pom-my 1957. 1. Fink, IL: Individual 2. fink, Mu cut-m 3. Pink, 3., Kuhn, 8.1:. 1nd km :1; the Sociow no scanty, In 1n Enluation of Clinical Bolivian}. physiologie Alp-ct... Presented at LBJ... at Motropoutan Band Change: Neuro- ma tabla, Chicugo, by 1957. Exporiunm Gm, LL: of Biological Pm“. Juno 1957. Studio: of the msctmahock Psychiatry, Atlantic City, H. and Kuhn, R.L.I mum of amt-wean: Role of Alteration in Brain Function in Bah-dot. Pnsented at. Int. Congas: of Pnychntry, Zurich, Sept. 1957. h. fink, S. I!” xfin, 3.14. ”d “an, 3.! “ICC“ Qt 01:!qu “tend 3w m’Function on Pomaption. Pruemad at the 17 Int. Congrats of Psycholog, Ema-1c, August 1957. ' 6. Fink, II. and him, 3.1“: Random Pattoml in Induced Stat» of Aland Road at w. New Ion Divisional Hating, A.P.A. 1m. 1957. Brain 7. Pink, Mu 8. on m ma sumnwm tar hoary of Le Enact. or M,Pmaou of Conwlaivo Thu-um. Read It. Mom “Inflation of manna mum. of m quancy Shirt for Plychintz-y. Simian“SOQCW‘ HoY: 30'. 1957- ”Mum EEG 13101313511). anecphalographm, Nov 9. 10. Road at. M30, 4.: 1621:, Doc. 1957. Bahamian). chug” Plyohomum in Evaluation of Clinical Round Tabla, Chicago, Hay 1957. lingnhuc “pom. Fromm at A.P.A., in hymn-Le Interview. NationA.P.A.. Nov. 1957. MIC, J.: Lu Obj-«tin Study of had at um How Iork Divisions). Mating, in Buhuioral Euponu to metre-hock Thonpy. haunted at meta-omen}: Research “mention, [11:21, 3.1.. and Pink, 11.: Pomonality Factor! Chicago, Ram, New 1957. LL. and link, Aland Brain Mu Pompticn or Function. Road We! Figures Arte:-InInduood Ierk, August 1957. at Ann. Plyehol. Luau” Karin, H. (with runabout, S. and Friedman, 84): Pomption Expouunu in a Study of Allah-Amen. End at Suction on lourolog I: Plychintry of Ed. of Kodiak)! and LY. Roux-01. Socioty, NJ. Jm. 1957. low �__. _.__ .7...._—M wvwwfiwww «V . ., m«m1.1m: 1. _ (5....»“1 .._ _ w. ....,._-,_..,..._.. «1...; .I.-....._.L,,.r..». w“ynw-WMW r‘m-vnr—Vwfltnflw’all ' 7 I-vrn" “rm” ‘ nun—mm.—.,.m~ I2 (Iith Italahau; s. and lhindnan, 3.): th- Relation a: Ambasulnneo Mansion and Monty 1n Wan-antic mum... and at Amt. Mabel. Ame. Sept. 1957. (New Kerk). 15. Karin, B. (with Tarmac»: and Mama, 8.): Stun” in “bitumen. 1h. lbrin, H. to Pnlantad boron Sahildar Sociew, M York, 00%. 1957. 16. Pamak, H. (with Galena), W. and Dam, 14.): Pain mucus in Schumann 02:11am. Haunted at Mr. Orthapaychntrio mac. Chicago, Marah 1957. 17. ‘ M.‘(v1th Integer, H.P.)I.Oan1mtor'and Bantam Put-m 1n o: lamina, Sahisophnnia Wldran. P's-mug! at Mr. knack, Am 18. Pollack, H. (with Butterfly, v.3. and Bond-r, 11.8.): figure-mane! Pamphlet: Tumor. But! *Enmm Payahol. uses... In York in Plunges with 13111 0“.an 19 7o it Pollack, K. (with Batu-thy, H. 3. and Bondar, 3.3.): Datum in Visual Phraoption in Brain mm:- Patten“. Flaunt-d baton Int. Congrats or ngcha1., aux: 1957. (Brunloll). .20. anuok, K. (with Battarnby, v.3. and Bondar, 14.3.): Visual M1611: After with Rapidly-kpand Chmtia 9mg. a Mutant! Assoc" Nu Int-k, Sept. 1957. Pmud at Ann. PaychoI. Brain 1:: Man Stimuli. Pollack, H. (with Goldhrb, A.): Cultural and Environ-um Factor: Aged. Presented “hating (De-plan: Pox-caption in tin Institutiamliud at the “analogical Society, Cleveland, 00%. 1957. 22. Pollack, 11.: Brain Dung... Pmanud It. Nil mm Inhalation and Childhood Sauomania. Hating, MPJ. new. 1957. York Divisions). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. 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From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., in part, by grant M—927, National Institutes of Mental Health, National Institutes of Health, U.S. Public Health Service. Aided, Read at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. V:3-l-58 New York, N.Y. �Electroencephalographic Correlates of the Electroshock Process During the past few years, renewed attention has been given to the relation between changes in measures of cerebral function, and the behavioral changes induced by electroshock (l, 2). Alteration in various aspects of the electroencephalogram has been emphasized by various observers (3, h) in cerebral function. In an initial study in this laboratory, a significant relationship between the degree and duration of induced delta activity and clinical evaluation of "improvement" was observed (6). Subsequent studies have focused on as a sensitive index of changes ' various parameters of the EEG changes including frequency of type of current, age of subject and pre-treatment record It is treatment,' characteristics. the purpose of this report to assess the relation of these aSpects of treatment to changes in the EEG and in clinical response; and to describe the role of serial electroencephalograms in the rational management and study of convulsive therapies. �-2- man: One hundred and seventy-three consecutive electroshock referrals have been studied. Electroencephalograms were taken before treatment, after treatment at weekly intervals during and following the course of therapy until the record had achieved its pre-treatment and on a day characteristics. Patients in whom demonstrated slow wave or spike All the EEG delta activity. the pre-treatment electroencephalogram activity were excluded from the series. records were quantitatively measured for the amount of On the basis of the per-cent time, slowest frequency, highest voltage and longest duration of bursts of slow waves, in selected lead combinations, the records were classified into "high," "moderate" and "low" degrees of delta activity, according to criteria previously published (6). Three convulsive techniques were employed: suprathreshold alternating current, threshold alternating current current methods. The and parathreshold unidirectional alternating current suprathreShold (7) and unidirect- ional parathreshold (8) treatments followed established techniques. In the threshold alternating current method, patients without prior sedation received small amounts of current (90 volts for 0.2 second), usually sufficient for a petit mal response. intervals voltage, and if necessary, duration.was increased until a grand mal convulsion was inAt 20 second voltage and duration necessary to induce a grand mal duced. The minimal was the threshold value. In addition, a convulsive-subconvulsive control study was instituted during a period of these observations. Randomly selected patients referred . �.3for electrotherapy received subconvulsive therapy instead of grand mal. In this technique, patients were given pentothal intravenously until asleep, and then either low voltage unidirectional current fbr 60 seconds alternating current of 80 to 120 volts for 0.2 second were administered for one to three applications, for a total of 2h to 36 petit mal (8) or responses. Of the 173 electrotherapy referrals, lh6 received grand threshold alternating current, 57 by current and 63 by 26 by suprathreshold mal therapy - alternating parathreshold unidirectional current methods. Twenty- seven subjects received a course of subconvulsive therapy. All treatments were given three times a week, for 12-20 treannents. failed to develop a significant behavioral or clinical response, or middle or high degrees of delta activity in the EEG, were subsequently Patients Who treated five to ten times per week. Evaluations of clinical reaponse were trist ment and resident therapists on two occasions. At the supervising psychia- the height of the treat- effect, the degree of behavioral change was scored as ”marked," "moderate," "minimal” orfhone." in behavior in interviews These made by after treatment was terminated. and were based on the ratings were estimates of the change and on the ward from the Ratings of "improvement" were also weeks made by pre-treatment patterns. these physicians two to three These ratings were value judgments four-fold classification of "recovered," "improved” and "unimproved or worse" (2, 6). "much improved," �RESULTS: 1. Variability in Delta Activity'with Convulsive Therapy: variability in the degree of induced delta activity reparted in the initial 2h patients {6) is confinned in these series of convulsive therapy referrals (Table I). While the number of high degree The wide records increases with treatment, fourth week, are still rated as 27% ”low" degrees of TABLE Degree of EEG in the third week, and 18% in the delta activity. I Delta Activity with Convulsive Therapy (Per-cent of Group) Treatment Period h 28 h6 60 Moderate Degree 12 21 27 22 Lou'Degree 68 h8 25 18 16 3 2 o High Degree No Delta Activity 2. Role of Convulsion in The EEG Response: significance of the convulsion per gg in the EEG and behavioral response was assessed in the convulsive-subconvulsive study. Of the h? subjects*'who received convulsive therapy in this study, 9 had * These included 28 subjects who received grand mal therapy on a random selection basis, plus 19 subconvulsive subjects referred for a "second course" of therapy. �-5high degree delta records in both second, third and fourth weeks of ment, 12 during two of the three weeks, and 13 during one of the periods. Thirteen of the h? subjects failed to show a treattest high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta activity records during any week of treatment. Low degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. In concurrent behavioral ratings, 25 of initial 28 subjects in the convulsive group showed marked behavioral change; while of the subconvulsive group, Of the 21; of the 27 showed Bdnimal or no behavioral changes (Table latter group, 19 were referred II). for a second course of therapy. In 1h of these, grand mal electroshock induced high degree delta activity all significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroShock, all and showed a showed middle degree records; and change. three of the five Showed a behavioral Thus, of the h? convulsive therapy subjects, h2 showed a behavioral change. significant �—6— II TABLE Ratings of Behavioral Change: Convulsive - Sdbconvulsive Therapies (Fburth-Fifth'weeks of Treatment), Moderate marked Minimal yggg i Convulsive Therapy (A?) 27 15 5 0 O 3 8 16 Subconvulsive Therapy (27) In evaluations of the degree of "improvement" 51% of the convulsive therapy group were rated as "recovered," and evaluated as sustaining the "improved," and only however, but 70% 11% III). as "improved" (Table 32% 7% were rated same weeks after treatment, "much improved" On discharge, degrees of improvement, while were ”unimproved." in the tWo first two were “unimproved," two weeks or 51% were h2% were 0f the subconvulsive group, categories, 19% after treatment. As in the "improved," these were re- ferred for a second course of therapy, hosPital discharge evaluations do not reflect the effects of subconvulsive therapy. TABLE III Ratings of Improvement: CoHVulsive-Subconvulsive Therapies (TWO Weeks After Last Treatment) Recovered Much Improved Improved Unimproved, worse Convulsive Therapy (h?) 9 15 15 8 Sdbconvulsive Therapy (27) 2 l 5 19 �Convulsive therapy induced and more favorable evaluations The significantly greater behavioral change of improvement than did subconvulsive therapy. clinical observations thus parallel the electroencephalographic data. Also, patients who showed.neither an convulsive therapy, EEG Showed both EEG and or a behavioral response to behavioral changes when Sub- placed on convulsive therapy. 3. Role of Type of Convulsive Therapy: In view of the variety of electroshock techniques employed, the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock on EEG delta activity undertaken. The results are graphically presented in Figures first figure relates and 1 and was 2. The the treatment type to the percentage of records demon- strating high degrees of EEG delta activity in each treatment group during the second, third and fburth weeks of treatment. In each period, treatnent with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unidirectional current and with alternating current at threshold strength was less effective than the supra- threshold alternating current technique in each period; the unidirectional current treatment being method only more effective than the threShold alternating current early in the course'of therapy.* Subconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same relationship by measuring the per cent of each treatment group showing no delta activity or only low degrees * The differences between suprathreshold and threShold treatment methods are significant at .05 by chi square in the h-é and 7-9 treatment periods, but not in 10-12 period. Parathreshold treatment methods are not significantly different free the other two methods during any treatment_period. �-8of such activity. Here, the subconvulsive group is 100% for each treatment period. Suprathreshold alternating current techniques the least number of such records in eaoh period, with threShold show and parathreshold techniques in between. h. Freguenqy of Treatment: Another factor is the frequency in the rate of development of delta activity of treatment. While three times a week, a number activity were treated were given more who all patients and In nine such patients, treatments in each instance middle or high degrees of delta activity were induced. Similar previously demonstrated by Pacella 5. Factor of In the initially treated failed to develop high degrees of delta intensively. daily or twice daily, were at 31. (9), correlates were EEG and Callaway (10). V Age: initial series of'patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta activity during the first and second weeks of treatment; while older subjects developed such activity to a significant degree during the third week. By the fourth week of treatment, age no longer between the groups. Combining the data from supports this observation. all differentiated convulsive therapies During the Second week, h3% of records are in patients under the age of no; but only 30% in patients from h0-60, and 18% in patients 61 and over. In the third measured high degree delta and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects have high degree delta records times per week. when treated 3 �.9TABLE Variation in Per IV Cent High Degree Delta EEG Records with Age * 9 Treatment Period Second week Third week Fourth'week in. is. 2:2 nee ho years (28) 15% 61% 69% ’41-50 Years (28) 29% h0% 56% 51-60 years (28) 32% 56% 55% Over 61 years (18) 18% 50% 80% es To ' 6. Pre-Treatnent Record Characteristics: Previous reports, summarized by Chusid and Pacella (3), noted a significant relationship between pre-treatmnt reca» rd character- istics and the degree of induced "abnonnality." Predominant alpha rhythm, “abnormal" (3) or “borderline abnormal" (11) records were more develop alterations in the EEG liable to than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment'record demonstrated diffuse slow wave activity, spike or spike wave activity were not included in the statistical analyses. Eight such subjects were «- difference in incidence of hig1 degree records is significant at .01 level of confidence between the second and fourth weeks and .05 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. The �-10.. treated with convulsive techniques, high degrees of delta activity however; and seven of them developed earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre-treatment alpha . and the degree of induced delta activity was undertaken. Rank order correlations of the preetreatment per cent time alpha in selected leads (anterior temporaldvertex) with the degree of delta activity during the third and fourth weeks of treatment of +.2h and +.3S reapectively. The in h3 patients demonstrated correlations relationship in the fourth week significant at the .05 level of confidence; while that in the third fails of significance, although the trend is indicated. is week �.11.. DISCUSSION: aspects of these studies warrant discussion: the significance of the convulsion in the electroshock process; and the role of serial electroTwo encephalograms in the rational management and’study of convulsive therapies. In the early studies of convulsive therapy numerous authors, including Kalinowsky 23 El. (12) and Pacella and electroencephalographic gt.§£. (9), emphasized both the clinical differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes Similarly, electroencephalograms in grand activity, while in petit mal therapy, no in less than 25% of subjects. mal therapy demonstrate delta delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, and focal convulsive techniques in each, in.turn,,discarded in routine therapy. Bergman §§.§l, (13), for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records at 15 such "seizures;“ while 70-75% had "abnormal” records after have been described, and Ulettgt El, (1h), in a careful convulsive-subconvulsive control study,reported a significant difference in the clinical response of grand mal seizures. patients receiving convulsive therapies convulsive (33%), or controls (38%). reSponse in the He (60-80%) and those noted two groups, and emphasized the for the therapeutic effect. ReCent fine discrepancy in the EEG significance of the seizure additional reports based on a variety of data further emphasize receiving sub- flue by various observers, significance of the convulsion �.12.. in the therapeutic response (h, 15, 16). convulsions per g2 are, or which thus indicates that reflect, the significant physiologic events are the basis for therapeutic efficacy of convulsive therapies. If the convulsion is the essential element both in the the behavioral response, does the any The evidence EEG and in induction of the seizure play mode of role in.this reSponse?. In the studies reported here, small differences in both the degree of EEG delta activity and the rate of its development different methods of induction of grand mal seizure. Ulett gt 3;, (1h) reported an improvement rate of 57% for the alternating current cenvulsive technique, and 76% for the photo-metrazol were observed between technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulsive photoametrazol technique. In a discussion of this report, Kalinowsky noted.that metrazol convulsions have impressed various workers as being more efficacious than induced convulsions. convulsant drug, PM More electrically recently, Edwalds, (17) describing a 1090, ascribed to it new clinical results slightly better than electroconvulsive techniques. further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance~ we have of clonic or tonic phase, apnea, 332. All grand mal seizures are seemingly not equivalent; and a seizure is not an "all or Different seizure patterns occur and these may none" phenomenon. reflect differences in the physiologic effect of different treatment methods. Further studies of this problem are in progress (18). �-13 .- While this variability in clinical results is reported, it is clear that with repeated canvulsions, rates no matter how induced, improvenent per cent are observed. The differences between various types of treatment are small, and, for the most part, may be readily obviated by of 60 to 80 the simple expedient of increasing the frequency or number of treatments. We may conclude way that convulsive therapy is nonpspecific with regard to the the convulsion is induced. The significant element is the brain change subsequent to the convulsion, and not the agent used in bringing about this brain change. In previous reports (6, 19, 20) convulsive therapy we have noted that is also non-Specific with regard to its application in mental illness, and in its clinical effects. and behavioral The present studies, amplify , therefore, the previous conclusion of the non-Specificity of convulsive we have therapies. applied methods of quantitative, serial studies reported here. EEG analyses in the clinical estimates of behavioral While change have yielded similar data, such evaluations are more dependent on the attitudes of the observer (21), and less amenable to quantification than the EEG. Application of EEG analyses to problemsin convulsive therapies provides a rational basis for the comparison of different treatment techniques. “we have previously noted clinical management patients who that EEG analyses may be applied in the of patients receiving convulsive therapy (6). In fail to show a significant behavioral response on treatnent regimens of three times per week, an electroencephalogram may serve as a �guide for further therapy. In those subjects in.whom high degree delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a more effective oonvulsant method, may result in the neurophysiologic changes. If the degree of delta activity is high and sustained for a number of weeks, other factors as personality (22) or environmental (19) may be assumed to preclude a satisfactory behavioral response, even when the neurophysiologic substrate and further convulsive therapy application has been suggested EEG may well be discontinued. by Roth (5) A is assured; similar for thiopental activated records. The successful application of quantitative convulsive therapies, has led to dynamic EEG techniques to their application to other physio- therapies. Recent reports from these laboratories note a similar application for the rational psychopharmacologic agents (20). management and understanding of �.15sunnru AND CONCLUSIONS: Serial quantitative analysis of the degree of induced activity in were made 173 consecutive EEG delta electrotherapy referrals. Patients were treated by three convulsive methods: suprathreShold alternating current, threshold alternating current and parathreshold unidirectional current. Random electrotherapy patients received a course of subcdnvulsive treatment instead of grand mal, in a convulsive-subconvulsive control study. 1. An induced grand mal convulsion is essential both for the electro- encephalographic and the behavioral changes ascribed to ”shock" therapy. 2. The rate (a) two The EEG delta activity of seizure induction: suprathreshold Mode techniques induce techniques. and degree of induced EEG changes earlier and is dependent upon: alternating current to a higher degree than threshold results of unidirectional current methods fall between these techniques. (b) Frequency of treatment: increasing frequency inereases degree of EEG delta activity. (c) Age of subject: Patients under delta activity earlier than older patients, but ment, differences are insignificant. (d) Pre-treatment record hS develop by the greater degrees of fourth week of treat- characteristics: Patients with dysrhythmic records or high per-cent time alpha activity develop greater degrees of delta activityearlier than patients with low per-cent time alpha activity. 3. It is suggested that serial quantitative electroencephalography provides a rational basis for the study and the clinical management of convulsive therapies. �REFERENCES l. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. 1.92: 22-26, 1952. Psychiat. 2. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobartital Test 3. Chusid, J.G. and Pacella, B.L.: The Electroencephalogram in the Electric Shock Therapies, J. Nerv. & Ment. Dis. 116: 95-107, 1952. h. Roth, 14.: Changes S. Roth, to Clinical Improvenent in Electroshock, AMA. Arch. Neurol. in the under Barbiturate Anaesthesia Produced by Treatment and Their Significance for the Electro-Convulsive ECT EEG Clin. Neurophysiol. 2: 261-280, 1951. Theory of Action, Kay, D.W.K., Shaw, J. and Green, J.: Prognosis and Pentethal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG Clin. Neurophysiol. _9_: 225—237, 1957. 7:41., ’ Fink, EEG M. and Kahn, R.L.: Relation of Electroencephalographic Delta A.M.A. Arch. Activity to Behavioral Beeponse in Electroshock, Neurol. and Psychiat. Z_8_: 516-525, 1957. 7. Kalinowsky, L. and Hoch, P.: ghock Treatments, Psychosurgegy and Other Somatic Treatments in Psychiatry, Grune and Stratton, N.Y. 1992. 8. Alexander, L.: Treatment of Mental Disorder, W.B. Saunders Co., Philadelphia, 1953. 9. Pacella, B.L., Barrera, E5. and Kalinowsky, L.: Variations in the Ele ctroencephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Paychiat. 367-38u, 19u2. g: 10. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Neurophysio . a: 157-162, 1950. ll. Kennard, M. and Willner, M.D.: Significance of Changes in the Electro— encephalogram which Results from Shock Therapy, Am. J. Psychiat. 1L2: : 12. 13. Olin. uo-us, 19m. Kalinowsky, L., Barrera, Reaponse l9LL2. EEG ms. in Electric and Horowitz, W.A.: The "Petit-Mal" Shock Therapy, Am.J. Psychiat. 28;: 708-711, " P.5., Impastato, D.J., Berg, S. and Feinstein, R...‘ Electroencephalographic Changes Following Electrically Induced Focal Bergman, Seizures, Conf. Neurol. 12: 271-277, .1953. �W K. and Gleser, 6.0.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, A31: Jo MChiat. 112: 79S~802, 19560 Ulett, GA” Smith, 15. weinstein, E. and Kahn, R.L.: Denial of Illness, 0.0. Thomas, Springfield, 1955. 16. Fleming, “13.0.: An Inquiry into the Mechanism of Action of Electric J. Nerv. & Ment. Dis. 121;: th-hSO, 1956. Shock. Treatments, 17. Edwalds, R.M.: Intravenous Administration of PM 1090: Clinical Elmerience with a New Convulsant Dmg. Read at FLY. Divisional Meeting A.P.A. 1957. 18. Green, M.A.: Significance ‘of Individual Variability in "EEG Respome to Electroshock, J. Hillside Hosp. é: 229-210, 1957. 19. Fink, M., Kahn, R.L. and Green, “.11.: Experimental Studies of the Electroshock Process, Dis. New. 835 . (in press). 20. Fink, M.: 21. Fink, A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside M. and Kahn, 9: 197-206, 1957. R.L.: Behavioral Patterns in Induced States of Hosp. Altered Brain Function. 1957. 22. Read at N.Y. Divisional Meeting A.P.A. Personality Factors in Behavioral Response to Electroshock Therapy, Coni‘. Neurol. (in press). Kahn, R.L. and Fink, 14.: �ELECTROENCEPHALOGRAPHIC CORRELATES OF THE ELECTROSHOCK PROCESS MAX FINK, M.D., and MARTIN A. GREEN, M.D. From the Department of Experimental Psychi: atry, Hillside Hospital, Glen Oaks, .N. Y. Pro blem : In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment; on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varial, including unidirectional and alternating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12-20 treatments. Patients who failed to develop a clinical response, or EEG changes of significant degree, were subsequently treated at 5-10 times per week. The EEG records were classified for degree of delta activity into “high," “middle” and “low" degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest amplitude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. _ Results .' ~ .4]; 3, 54 I ._ 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was significantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subCOnvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional but by the 4th week of treatment, the di' erences were eliminated. '4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. ”firuments, ‘ Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. . 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient 3) Early. and sustained high degree electroencephalographic delta activity is a necessary,, though not sufficient, pre-requisite for improvement in the electroshock process. ’4 ; Avf" �TRQIW m Subuuowluve Conoubwc \\ d, AC. and u“ .. fiYc-‘Hol‘b _ Paiszélfiftfl’l _ A “ \t W: 0 2a 3! 4¢v 93¢ {I to 057:0 7‘ �. t‘, “i. I 3 “fatig- ‘ flcrld;é J 1’ 3547.79 5‘ ”WW 55/ (7.?” Mfl m- a; V Ear fl<.a..ma'" 7”,... 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WM¢L7A WWMZZ/é ffffww/CL/MJZ’LWM'ZW 421W yzzofs‘vwéz OWW/éfléuWWay /%WMMM/&aw Mu>4/L-a\ WW 4% )O/M/Mé’ Mr IQM Muwr‘ flay, $4]de Wit/WC! fww fiWM My“ wag/WM?" MAW WM M WM WM MWM‘. jWL/éjfm/fifou/W 4»! sd/zw ,e/Ze‘e/MW. flaw-‘7 ��*2 31”ka only; and m wrehnws 1;) obaomd in mbcmvulsive or petfi» m1 curmt We! high degree mm. shaman? mam-um). max—mat, but by flu hth ml: of tmtmnt, the 3) Alfiemflng mar than tbs not. me. mm m a. instruments EEG were ' mum mm a» dance at m aimmty and direct relationshiptom. thatmqueneyoftmtmntxmdm L ’ ‘ Gmlusgm'i ‘ 2mm 2.qu mmmmummamgammm‘ 1) mm in a 2-, mm of mm mmw he ‘ m m or the Mes-tint: a! damn abnormliw is rented. to a) the induction of mm m mm. l 2) 10% type or electrical and us Mama mm meme I a) 1m frequency or tnatmt I 6) ago of the 3) fiodmmtim patiant 1n olectmahmk therapy as m mamahouk, manuals-1m alwmszmk, ammatmmm therapy .- wnm do not dmlep delta abnonmlity in than Wt, fail M whim tha therapeutic msulta at mud m1 exmam. this plaeabo affect. The limited a arrimy or mass pmduru is probably due to �Electmaephalagnphio many ' flax 1* From flak, 11.9., comma at the Prone“ Robert L. the Department at Experimental M3. 3“ IMO; i Electmhook m and H. Green, 3.9. mummy, Hillside Hospital, 613:: ���.3 I “,— “A May .— - ,. Mu may or flu mam-m M's-3., Mn A. «ma. 3.»... m mm. 2., an. an». hm mammmwuuauuudumbmm mama hm Wumm mm meta-W MM mam; many bun W- mu 411 m; tmmt «www.mtmmmmwmmwm mm m We! pun-Wt Wam- mum www.mmmmwnmmmzw mum-m Was um mama-1 Mum Me for In many mum-ca it Wm as g dry their 33m- mock, ma M W“ 1240 mm“. atmum‘mwwmaamm.umwu mam-m.mnmmmmmammmma mmmmWWtwmamuwwm WHWW'WWNMWMWIWMW: nut-m tho pm mu; mam-*4... mu I“ awn“, amt V‘ IMWWdWhmw.mm-WM,M m'mM§ msmumWMWqu-y,mzomm “mm; M 3-95 1997;: 2 ‘s g 1 1 -§ 5 ��Electroencephalographic Correlates of the Electroshock H Max Fink, 14.13., W Process MW 1. . *- 14‘1” P: Green, H.D./ 1/ 4.. W. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. =,\ �Problem: In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral reSponse has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalogram before on a day after a treatment” mg card» ofiuntime intervals during, and following IKE/MA retheir pie-treatment characteristics. treatment at weekly . cords had achieved ‘ .“ -~ 7 1-..9- ~. WW . ~~~~~ . mm ' ~ ' ~ . ”will. . Treatment was stituted at three times per week for 12—20 treatments. West-of atients who failed to develop a clinical response, or EEG changes of significant de- WM m gree, were At ated The EEG 9"“ M" /{“" records were classified for degree of delta abnomality fiih records/gang the following indices: “high" "middle" and "low" the percent-time delta; highest percent-time delta :1 wave in the record; highest amplitude ivity. ng * 5"“ Results: M 1) A W‘ -Ax/1 74 ' gs «Ede:94‘»!wa by the supervising M M fxwvm/ positive correlation was slowest delta; and duration of burst act- Kiwi” W W WM i/fal law/Mm a: fin oi‘ .0 lead; any M psychiatrist 3f 1‘41. W dan— Mflmdgmmzé “fimmmal? A}. established between the development of ram I’lZunfgy ��In)" l- .J, nmmwmmuwuuunmbmm ammmwmmwammmm 7mm mmwmmgmawmaw ummmvmrmmwmummumw mmmmnmmmm; Wt”.- W mum‘mmammmwmmru-mmm mommimmmfiwmummum mmmumwuamm.umwu mummmmmam ' ”T” . «mfiwwwumm,mwmm I EMA : I/r/rp ��(“7 ,. ' 9/“ ;\\ KM 4/ 44(ég/7’M4 4% 4%”‘49444.44.44 /4u44.. fiod—n—«a— A: 44.4.44. 14 m @ 4 4 4 L?! («I , I er!) ,1 rd 449-64 -wmm.mm.mnu4— Md ‘chZJ‘M- if éw/AMM -4444 (24 [44/2444] 444 743444.444. ~ 4444424444; (4472442444,) 44 444444 4245/44“ mafia-,4 fiwjj/WJZM 444444 W \WW’W ‘ 44.4 I 44444444444444 44- £441,148 ‘43 44.474444744- 44.4444/‘ WU) Ker-44444.4. 447444.544” MMW //-/v -n $4244 77 rte—“4.44.4 1/ 44444 45/4 4 ’4 (I) @)(3) 4045': ...44. 4..."... ..... ~ £44444 {Que/7 5:7 82444444 44,444 4 K M444 4244 5447 47,424,, 4244444 ,. �1: 2/1/58 EEG Correlates of Electroshock Process During the past few years, incnasing attention has been given to the ic relation between changes in the electroencephalogram and the behavioral change induced by electroshock. The initial application of EEG techniques to the electr0310ck problem in the period l9hO-l950, was summarized in an excellent review of treatments in 1952, that the who noted rather than the degree of induced neurophysiologic (reflected in the peutic by Chusid and Pacella outcome. EEG) These was the primary number change factor related to favorable thera- studies, largely based on descriptive analyses of pre and post-treatment records, were followed by serial quantitative analyses. In 1951 and 1952, Roth analyzed the in patients during a course of was related to the process ECT and of recovery. In 1953, in the laboratories EEG activated by this- He concluded that thiopental delta noted that induced detal activity at Hillside Hospital, we analysis of neurophysiologic bases of electroshock, based " undertook an on a hypothesis expressed by Weinstein and his coaworkere in which they related improvement in electroshock to persistent states of altered cerebral function. Our �-2... first did studies utilized the amobarbital test show a provement. relationShip and these, parenthetically, between changes in language and Our second index was the ratings of delta index of the electroencephalogram. In our original review of patients, recently reported, significant relationship between the degree delta activity It is and im— and we noted a duration of the induced clinical evaluation of behavioral change and "improvement." our purpose tonight to review these findings; to describe subsequent studies in which various aSpects of the treatment process were the degree of EEG delta activity; and to conclude with a related to summary of the present neurophysiologic adaptive view of convulsive therapy. One hundred and have been studied. a day forty-eight consecutive patien electroshock referrals Electroencephalograms were taken before treatment, on after a treatment at weekly intervals during, course of therapy, istics. until the record had achieved and following the its pre-treatment character- Various treatment procedures have been used, including alternating current threshold and suprathreshold electrodhock; parathreshold unidirectional current electroshock; and subconvulsive techniques with pentothal premedication. �-3- alternating current suprathreshold The K ) and unidirectional parathreshold (Reiter) teChniques are well described in the threshold alternating current patients, without prior sedation, received a methods, for 0.1 second, which was usually sufficient for a petit 20 second second. intervals, voltage increased by 10 volts 90 until a grand mal absence. At up to mal convulsion was induced. just necessary to induce a grand 1&0 volts, 0.1 mal was the threshold voltage and The value. In subconvulsive techniques, patients were given pentothal intravenously asleep, volts Voltage was then reduced to 100 volts x 0.2 second, and increased by 10 volt steps time was current, low and then either low voltage . current of or alternating unidirectional current for ”a 80 nvolts x until 60 seconds; . . 0.1 second were administered for one to three applications. All treatments were given three times a week treatments. Patients who failed to develop clinical reSponse, or EEG changes of treated 5-10 times per All EEG a initially, for 12-00 significant behavioral or significant degree, were subsequently week. records were quantitatively measured for the degree of delta activity. This index was determined by measuring the per cent time delta �.uin 180 seconds of each of three lead combinations, and both the average _and the highest index in any one lead were used; the slowest frequency and highest amplitude delta; Records in the and the initial series duration of the longest burst were placed those with the greatest changes in slow Degree Delta Activity." Delta Activity" and "Low Degree week of The specific limits of ratings of Low degree treatment. 3) Evaluations of changes in behavior were and "High were "Moderate Degree following three slides demonstrate a High-Middle and psychiatrist upper third - earlier report. (Figs. 1, 2, weeks thirds Delta Activity." record obtained during the fourth The The activity - were called wave The middle and lower each range are described in the The into sequence. . made by the supervising resident therapist at the height of the treatment effect. "improvement" were made by these physicians two to after treatment was terminated, and were based on the three four fold "much improved," "Improved" and "unimproved classification of "re00vered," or‘worse." In our initial reports ( , ) we noted that patients who developed �-5high degree delta sustained, activity early, and in whom such delta activity was were evaluated as "much improved" or "recovered" with a greater incidence than those patients who failed to demonstrate significantly delta such activity. These observations are portrayed in slide h. (Slide h; These patients had been treated with a unidirectional convulsive therapy. In a subsequent series of 5b ~ in Graph EST #1) which the degree of patients, a predictive study was undertaken delta activity induced during the second weeks of treatment was determined. 0f the subjects in whom and high degrees of delta activity were induced during both weeks, 67% were eventually much improved; while of those either week, only 30% who did rated as not have a high degree record in were so evaluated. treated with a unidiructional current; third and Of these patients, half were half with a suprathreshold alternating current technique. Slide 5 - (Table I, Exp. Studies) Results: 1. Role of Convulsion§:in Therapy. In the most recent series of patients, randomly selected subjects �-5received subconvulsive therapies instead of grand mal; and both alternating current Of and unidirectional current techniques were used. the subjects who received convulsive therapy, ______had high degree delta records in both second, third and fourth weeks of treatment; .____ during periods. two of the three weeks, and ____ during only one of the Only _____ subjects failed to show a single high record test on con- vulsive therapy. Of 27 the/subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. Low activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. Concurrent analyses of the behavioral ratings showed _____ of the con- vulsive group rated as showing marked behavioral change; while of the suboonvulsive group, 25 showed no behavioral changes. were referred for a second course of therapy. In 1h of electroshock induced high degree delta activity and behavioral change. activity Of the five who all Of these, nineteen these, grand mal showed a significant failed to demonstrate high degree delta on convulsive electroshock, all-showed middle degree records; �-7and two of the five 2. Factor of Type showed a behavioral change. of Therapy: In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock in EEG delta activity was undertaken. The results are graphically presented in Figures 7. The first related the percentage of records in each treatment group during the second, third and fourth weeks of treatment high degrees of EEG current techniques The gave a lower percentage of high degree unidirectional technique was also degree delta delta records. less effective'than the supra- all these periods. Although effective than threshold alternating current course of therapy. who demonstrated delta activity. In each period,threshold alternating threshold alternating current technique, in more 6 and methods early in the Note, that subconvulsive techniques yield no high activity records. In the next figure, the converse is demonstrated. The relationship between type of treatment, treatment period and percentage of treatment group showing no delta activity or only low degrees of such activity. �-3Here, the subconvulsive group is for each treatment period. Supra- 100% threshold alternating current techniques show the least number of Such records in each period. 3. Frequency of Treatment: Another factor on the rate of development of delta frequency treatment. While convulsive therapies were treated given daily or twice daily. activity were initially treated three failed to develop high degrees of delta activity times a week, a number who on all patients activity is the In all more sudh intensively. Treatments were instances high degrees of delta were induced. u. Factors of In the Age and Diagnosis: initial series of patients, it was noted that younger patients, under #5 years of age, developedlgreater degrees of delta the first such activity during and second weeks of treatment; while older subjects developed activity to a significant degree during the third week. week of treatment, age was no longer a By the fourth differentiating aSpect between the groups. With increasing series of patients, utilizing various treatment techniques, the differences between successive groups is largely a matter of treatment technique rather than age. �.9Similarly, conventional discharge diagnoses bear to the rate or degree of delta activity induced. in young schizophrenics, no The relation either delta activity induced older depressed, older schizophrenic paranoid, younger reactive depressed subjects are similar in indidence of high, middle and low degrees not, of itself, a at different stages of therapy. The diagnosis is significant neurophysiologic factor in electroshock. and �combining the data from all convulsive therapies supports this observa— tion. During the second week,h3% of records are high degree delta in patients ho; but only 30% in patients from uo-so, and 18% 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3 of the subjects have high degree when treated 3 delta records times per week. TABLE Variation in % High Degree Delta EEG Records with Age Treatment Pe riod To ho years hl-SO (28) (25) h3% 61% 69% 29% h0% 56% 51-60 (28) 32% 56% 55% 61+ (18) 18% 50% 80% S. Pre-Treatment Record Characteristibs: Previous reports, summarized by Chusid and Pacella; a ( ) rated significant relationship between pre-treatment records characteristics the degree of induced "abnormality? Escords with predominant alpha rhythm or "abnormal" (Chusid and Pacella) or "borderline abnonnal" and �.10- liable to developé alterations in the (Bagchi §£.El) records were more EEG than those with predominantly low voltage fast activity patterns. Rank order correlations of the pre-treahent per cent time alpha in selected leads (anterior temporal - vertex) with the degree of delta activity during the third and fourth patients demonstrated correlations of +.2h The weeks of treatment in h3 and +.35 reSpectively rehationship in the fourth week is significant at the .05 level of confidence; while that in the third week the trend fails of significance, although is apparently indicated. Discussion: Two aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and fine role of electro- encephalography in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the initial studies of convulsive therapy numerous authors, Kalinowsky including Kalmaasky at al,(l9h2), and Pacella gt_§l:(l9h2) emphasized both the clinical and electroencephalographic differences and petit-mal responses. provement in 60 to 80% While grand mal between the grand-mal seizures induced clinical im- of cases, petit mal induced changes in less than �.1125% of subjects. Similarly, the electroencephalographic reSponse to grand mal is one of delta activity, and to petit mal, is delta activity. no In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been described, and each, in turn, discarded in routine therapy. Bergman gt_§l”( ) for example, in describing the electroencquh- eIographic effects of focal seizure techniques noted that patients had normal records "abnormal" records after after 15 such l0% "seizures;" while grand mal seizures. Ulett gt §l° 20 of the - 75% had ), in a ( careful control convulsive-subconvulsive amdy, reported the significant differences in the clinical changes between the convulsive therapies (60-80%) and subconvulsive (33%), and noted the discrepancy response in the two groups, and emphasized the in EEQ significance of the seizure for the therapeutic effect. These studies emphasize the significance of the grand mal convulsion, both for the clinical therapeutic effect and the electroencephalographic reaponse. Recent reports by various observers, and based on a variety of data, support this conclusion. If the convulsion is the essential element in the EEG and �-12behavioral reSponse in electrotherapy, does convulsion is the induced?. In the studies reported here, small differences in both the degree of were observed. it matter in what way EEG delta activity and the rate of the development Clinical evaluation demonstrated concomitant greater degrees of clinical efficacy for the suprathreshold alternating current method to the two other convulsive techniques. 'Other studies have also for various convulsive techniques. shown differences in clinical results Ulett gt_§l. ( ) noted similar differences in clinical results in a study of patients receiving alternating current5'and photic-metrazole convulsive and subconvulsive techniques. He reported improvement rate of Sl%,'76% and concluded, 33% respectively; that the convulsive photoshock technique clinical efficacy. Epstein and Wender (1955) compared unidirectional current techniques, and reported no results but that unidirectional techniques required more had the than alternating current methods. More a new convulsant drug,.Hfl 1090, ascribed to greater than electroconvulsive techniques. and greatest alternating and difference in clinical one to two treatments recently, Edwalds, describing it a clinical efficacy slightly �-13while some variability in clinical results is reported, is clear that with repeated convulsions, provement rates of 60 and for the most part, treatment. regard to have noted we may its 80% are induced; may be no matter how induced, imThe differences are small, obviated by increasing the frequency of conclude that convulsive therapy mode of tat - it is non-specific with induction. In previous reports convulsive therapy (EEG is non-specific with Theory) we regard to their application in mental illness, nor is their clinical or behavioral effects. The present studies amplify, therefore, the previous conclusion that convulsive therapies are non-Specific. 2. Role of Electroencephalography in Convulsive Therapy: we have applied methods of quantitative, serial in the studies reported here. change may give similar data, such evaluations are the attitudes of the observer of EEG ( analyses clinical estimates of behavioral While on EEG ) than the EEG. more closely dependent Further application Analyses to other problems in convulsive therapies may provide a rational basis for comparison of different treatment techniques. �We have previously noted in the clinical management of that EEG analyses may be applied patients receiving convulsive therapy. of In our experience, the early and sustained induction of high degreaydelta _ activity provides the physiologic basis for behavioral vulsive therapy. a An electroencephalogram in patients significant behavioral response per week may subjects in change who in fail on treatment regimens of high delta to show three times serve as a rational basis for clinical management. whom con— In those activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a thera- peutically more effective convulsant If the physiologic changes. be maintained may ( ) for a or environmental ( havioral response, even and degree of delta number of weeks, other ) may be assumed to when further convulsive therapy records. result in the neuro- activity is high; and it factors, as personality preclude s satisfactory be- the neurophysiologic substrate is assured; application has been suggested EEG method, may may welllae discontinued. by Roth ( ) A similar for thiopental activated �.1 5.. lhe successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these application for the rational management pharmacologic agents Summary and ( Conclusions: ). laboratories note a similar and understanding of psycho- �to“ Win the Natalya”. Watmfimmbun gim nation bum inflamed by It: omwgek. _ than olectmnuplaham In 1953. in the and behavioral mum at. dung" mud. Hospital, We“ of ashram-1019a: upon“ at olmtrouhook m mm. swim: ( champs in )1n were band on which may a. Win mm by Romain and his muted imprmmt 1n 01.6mm to tho a» mom” Mom: of paraiamat sum at altered mmbml function. mmmmmmw< Luminanctwnmtmuump how the damn am mum a: fin 1mm den-a activity and mum «alum of huh-mm damp and “W.“ this report to "view than finding” to describe mum nmrophyuiolom to nuggut aspect: of u. Almanac-1m or maps-oat. of minimum: 3%! On. W bun swans. 3nd It 1. at W at mt Media in mini: m mun-at woo.” In. ”mud; MWmm in mud!“ and and sum). mom“. {Wfit acne-anti" «hammock Marni: a". um um baton taunts-ant, and an ammrttmtatmmquadummfmmw-mm �4-2. of therapy meal the noon: Md «mum. 45* M‘ Pntimts- mfipn-matnnt or significant . bum its pwtmhmt m dual-tramw- 31w m a; mum activity, mm are «eluded from tho curios. Fm tmww madman «playing 611nm 1) umg/aumam W at. “mm: 3) MW“ mm mpnthnuhold It) mbommlsiva tonhmqwu‘ with pantothnl Wt 813de m tall dumrlhod. 5%: ( 9 ma pmdicttion. Tm ( gunman; ) hummus damning current. method patients, Mind 1w “mats, mu sufficient tor a phi: 3:1 mm”. and, (Maugham); ummmm lawman! In the thrown!!! fitment prior «mum. ~ W of “dam he.“ M915 smug a) nun-mung «mm at. 3* mm“; (90 Volt. M 20 for 0.1 sound), mad Manila, may, it mam-,7, duration: in” 1mm mm a and m]. whim m mama. mmmomd timmcuurytojutincmma gmdmlmtho, thruhold value. 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EEG an. activity. mutant um: daunting «mat It mmknshald high.” mom: In each period, otnncth and with numung mt at thmshou oft-cu" thin tho lupnfihnlhad alumnus mnem- m tho ‘ ' the tau-angst; m 1m mm, in out mar-cum; curl-mt. tmtamt being not: «mm than the tux-«hold 11th Suboomumn #:00QO yield no high dam «in: activity neural. cum-at. uthod only curly 1n the Mum WWW“: treatment the am come of mumpwmng pox-«near wh/mpwoungno «Inactivity such trut- ”may of my: (low mu mom. What with Winch 1m). nun-mt ported; of the «new. third and fourth molt: of mt Whiting mm dam of » a: nativity. 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Dog“ mu ma mm with La * m m mm we no M 51+ 0 m be as) has (as) m (as) (13) W 1:2 as M 691 he: saw 32: 5a 95:: 18: 50: M no durum in 1mm of high dome mom 1: significant u .013 andhurthtruaunnd .OSShomthoummtndthird mic: or tun-em in patient: «or 50 your: at nan) but is not uwimny manna“ 61:1on for the“ put-1m in groups and» 50 yum. �.9. mum "pom, mm by Gama and mu“ )mm . IWmt mktimhip batman pmmst. aunt heard Mauritian and m m W “nbmlity.” new nu: mm: at or 'abnoml' (Ohmic! and alpha mm M113) or “bomflino ulnar-t3! (Hum 91 9;.) 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W: M «poet- at” than the not an. that”... mt dimuon; tho Winn“ of, whim 1n the 01.6%!“th pm“; and the r910 at «an nontra- W! mopbnlomph (1) 1n the In the including mama: and may or convulsive therapies. mud and“: of cumulus." therapy lawman whim-c. hum-kw the clinical Ind «Mom: ‘ fig. (19%), and Plum 5;. (193:2) aphasia! bah 01¢“ch diatom bum the grim n.1, mpoutm “WM mammmm-Wamm 1mm"mntinwtomofmu. ptfitnlindwod Weamhlstmafiof mycu. mm. flu chem-pulmyhle mm. to m a! mu ”Univ, and {no pout m1, 1: In subsequent. you-I, various no delta grand an in mum. W131“, has! CW, mflmtiml “hunting, mopohr unwitting. foul contain" techniquu have been �.11. thd in mum. than”. Barman 33 3;. mum, and nah, in turn, ) tar example, in mung an cloutWaganc «not: or ( focal "inure manna-u Mad that art-r a), 15 inch "maumr' m1- "isms. Matt 93 g. study, repel-Md a halving ( of patients had - 753 had “abnormal" ), in a ammo-at autumn mm mom _ max-d: utter grand «ram comm). «muywmbeomhin 1n «mm-:1 roman "a! panam- amid" that-apt“ (W) ma theta minus abnormal-1v. (331). or control: (381). no tho two 70 70% mp3, and new tho war-may 1n the 3m noon-- in mum the signification at flu loam for tho thanpuutic strict. Mint additional upon-h 17 various ohsarvm, band an a «flaw of (Rain-“1n and an, alpha“ th- awinmaa at tho ”amnion. m, Roth, mung). rpm, the mm. mnem- um minim par a, an a:- mu tho significant physiologic mu mm m the has for thirty-nut: If an. convulsion «fancy or 'oamluva than-qua." I both it tho mud chant/1n mu m and in tho behavioral "903380, does m node of inflation at the role in um “spam-7. In the chads." ”ported ham. uny “mama Min-mm in both the dam- ot‘ “ism play any Oman Em hut-.2 sun-u- mu activity �.12. the and at» of 11:»: “mu m abut-"d bum Miami mod: of imitation or grind u). m. m an m. pmidu but: far the mama Mm't tint .mpnthxuhold m @0an album-ting current “chum m mt “tutu. m We cmuloiva than”. “the: India ban the sham moms cumulus.“ “Wu”. exam in clinical results for 813% g 51.. ( ) mud 31:11.11- mum. ms; in mm:- mdiu or Mum waiving atom-um mt mmlpin and mumml mvulnm m! mbmvukin tech.- 1i: amen niquu. no "ported Wat. m. at $73. 763 ad 331 yumfiuln mam flat the Wain Manhunt: Wm bud tho amt.“ clinical «tinny. non may, W, doom-thing n m «walnut: and drug, a: 1090, named to it a clinical mam; unghuy gmur um dawns." wanna“. w studios an have mm mm m «Wm mam-d by Mom Wm» hm! um manna” of latency, duration, prom-mac In of claim: or tonic ammt phi“, am, two. um; not :11 mind In}, From that. Sundial, it has Mm him: at. minimum; and that : �:31)’ W; m mm a not an an or w“ cum and than my unset dim-mt. taut-mt aimed. Dunn-mo mum panama dutannm in Mahala «rout. of tho Mar mm" 01' this probhn an 11: 9'08“”- thn this "unmey in clinical 1:3qu in ”period, it in clear ma, ups-mt. raw or - in chum-d. m dflhmu human var-1m W or mutant m 3.311, and, for ma most part, be mm w increasing the 1:qu flnt with rap-wad comma”. no author he! 60 305 may com!” may: in nonwith mum to film W tho minim in Mad. The simiflmt or amber at mutants. it. any Mic «mm that amt u the bran W Mum. ta the uranium, and not an mat mamas-1mm mama“... Inwim mm (3m, Theory) in we: noted that commits.” map? 1: l1” 1%. application in with mam maul, m: in its clinical and with Wticity of convulsive. flan-pin. to I bender-1 «facts. no pron-at studs.» «3mm winters, the pram» at the ”and comm �U. have appliad ”mode or quantitative, serial me the m1: studies} mporud here. We in clinical estimates at behainnl change ‘ may give of tho xinihr data, obumr ( ' ) than an m. Us lava dependent an tho m a prawn/mum]. buns for Miami tmtmnt technique“ pmionlly noted that mm mm: my be applied in the clinical magnum. or patients receiving oonmlsivo therapy tin I um tad» Wr applicttion at m analyse: to other pmhlm in convulsive thumps.” compariaon of am such evaluations am @mnua ”ported here, the curly and ( )- In sustained induction at high dam,» a! do“: activity provides the phyaiolagic bait for behavioral in cumulative mmpy. «mango fail to thm char 3 mu. increasing a electroencephalogram in patients uwflmt Wen]. times per week aunt. In An w when mutant. tummy, Mummiaogic more big: delta activity has withholding effective «walnut. If changes. it my be 31an for tmtmt ”31mm of norm as a rational basis for clinical manage» mbaem in thonpeutiany aspen”. on who o. tho dome of nmbor of not. been induced, pmdimtien, 0r shifting to mum, my resuli in the mm activl ty is 11139 mks, nth» future, and a punctuality �~15— ( ) or mama}. ( behavioral response, and ) my be can when the «me! to panama. a utiatactory Wide-go mbctrato is assured; further eomhivo therapy my will tion has bum suggested by an Ruth ( moons-tn]. application of convulsive therapies, ) be discontinue. m gaunt: similar applica- for buoyant-.1 activated 330 record» quantum." ‘m tachniquu to bu led to their application to nth“ hemp-us. accent reports from than laboratories not. for A as MW“ similar applicatim mum-1 moment and man-Italians of paychephameolom ( ). �416~ gagglnnianus 1.‘ In aerial qynntitativn analysis of aetitity in degroe of induced EEG delta anhjocta receiving variant convnlaivo therapies, a poaitdvu relationship betuoon the digrea o! indueod delta activity and bath tbs dagroe oi'bohavioral ehnngo and ratings of impruvamsnt 2. and induced grand mfll convulaian An is reported. 1: elscntinl for both the EEG behlviaral change. 3. Th3 rate a. and dogrcc‘of induced Hbdo dalta activity is dependent upon: at soiturc inductian b. Fruqunncy at treatment a. Ag. 0! lnb3oct d. Pre¢treatmsnt h. It is pmuvidoa a recommended EEG record characteristics that aerial quantitative electroencephalography rational basis both for the study and clinical managenant or variaus paychodynlmie therapies. �II: 2-5-58. 0131/11.!" Correlates of the Electroshock Pincess EEG During the past feW'years, renewed attention has been given to the relation between changes in the electroencephalogram and behavioral changes induced by electroshock. In 1953, an analysis of neurophysiologic aspects of electroshock studies ( in the laboratories at Hillside Hospital, ) in was undertaken. were based on a hypothesis expressed by Weinstein and which they related improvement The his co-workers in.electro$hock to the development of persistent states of altered cerebral function. In thii initial EEG study ( ), we noted a significant relationship between the degree and duration of the induced delta activity evaluations of tIhI=HIIEIEIIEZl=E=IIi§"improvement." It is and clinical the purpose of this report to review these findings; to describe recent studies in which various neurophysiologic aSpects of the treatment process were assessed; and to suggest the application of electroencephalography in.studies and rational management of physiodynamic One hundred and been studied. a day therapies. forty-eight consecutive electroshock referrals have Electroencephalograms were taken before treatment, and on after a treatment at weekly intervals during and following the course �-2- until the record of therapy flag»! Patientsbflwyhgug‘pre-treatment IN EEG - . eggpktfd’ef’d .,,.,;‘""flWh . activity, an...“ M"M fiignificant asymmetry were MW’O‘Mmmws-‘W pre-treatment characteristics. demonstrated slogwgave or spike . WW its had achieved series. from the { ‘ {V .up-w‘ . Four treatmentt procedures employing g different types of stimuli have ' i V . 1) been used; /alternating current at-threshold strength; 2) alternating current at suprathreshold strength; unidirectional current (parathreshold); 3)- h) subconvulsive techniques with pentothal premedication. The alternating current suprathreshold are well described. ( ) and unidirectional parathreshold ( ) techniques In the threshold alternating current method patients, without prior sedation, received low currents, (90 volts for 0.1 second), usually Sufficient for a and, if petit mal response. At 20 second intervals, voltage ,_ thewmwmm necessary, duration! were increased until a grand mal convulsion was induced. In subconvulsive techniques, patients were given pentothal intravenously until asleep, and then either voltage unidirectional current for ); or alternating current of seconds ( administered treatments . low l 80 (30 to 120 volts x 0.1 second were for one to three applications, for a total of 2).; to 36 petit mal �All treatments were given three'times a week Patients treatments. clinical response, who initially, for 12-20 failed to develop a significant behavioral or or‘EEG changes of significant degree, were subsequently treated 5-10 times per week. All records were quantitatively measured for the degree of delta EEG Ml WM! We! MM‘AWW activity Masada—WW ‘ delta activity, "moderate" or "low" degreet . l‘ . . I i 5 3 . The 30W week of (Figs. 1, treatment. 2,3) Evaluations of changes in behavior were made by the supervising psychiatrist resident therapist at the heigat of the treatment effect. The of "improvement" were made by these physicians tw0 to three weeks treatment "high, " following three slides demonstrate a high, middle and low degree delta record: during the fourth and M was In our after terminated, and were based on the four fold classification of _ "recovered," ratings ”va ”much improved,"nand "unimproved initial reports (' , ') we noted or worse." that patients who developed �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta such activity. These observations are portrayed in slide h. (Slide u: Est #1) Graph Ecsults: The “W etweeni“! relation neurophysiologic 5" . . and behaVioral response W111 be assessed according to five aspects: 1) 0 2) Type of Convulsive Therapy 3) Frequency of Treatment h) Factor of 5) Pre-treatment Record Characteristics ’Of Age the uz’subgacts’WHo”retaived‘ccnvuISive‘tnerapy, 7 nan nigh delta records in both second, third two of the three weeks, of the u? subjects and fourth weeks of treatment; and 13 during only one of the failed to show a UEgIEE" 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta sudh activity. These observations are portrayed in slide h. (Slide u: Graph Est #1) WWW Results: 1. convulsive vs Subconvulsive Techniques: In the most recent series eizpahaaaih randomly selected patients re— ferred for electrotherapy received subconvulsive therapies instead of grand mal; and both alternating current and unidirectional current techniques were used. or the h? subjects who received convulsive therapy, delta records in both second, third two of the three weeks, and show a had high degree fourth weeks of treatment; and 13 during only one of the of the h? subjects failed to 9 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �.5demonstrated middle or high degree delta Y3...” of treatment.§ x Low ( / activity records during any week degrees of delta activity were notedhifiwthree subjects during both tgexsecond and third weeks of treatment, and I“ .,.,_,_.,.-‘ ”mud,” Y , “W", v V .V,. inAB subjects ,, ’dmfigthefourth Week alli'lll=l==I-I behavioral ratings Concurrent subjects in the convulsive group rated as shining showed hZ of the h? marked behavioral change; hat ‘ while of the subconvulsive group, , ioral changes. of therapy. the Of latter 25 of the minimal or no behav- 27 group, 19 were referred for a second course In 1h of these, grand mal electroshock induced high degree delta n...» . 4,7,.“ .;...-....‘..,r,, 9...“; .. n .mm ., 3., ,. .~-wms...mu m-.. _,. ”a”. .. activity "Walnut... all showed a V.-.~...,..,..~..,.u.ma..~m.—.~..._..Mn...._,.m.. m failed all 4 f. ./ ..,,,.A. . .- significant behavioral change.#fgf the five t. ' to demgnstrate high degreewdeita “if I/VFI' My" : ’ activity a” , Thus, convulsive therapy induced showing on five . Mm)“.- . showed a behaVioral ”n,mmwm .,wmlumwflun. significantly greater behavioral changes neither an EEG EEG delta activity. Furthermore, or behavioral response to subconvulsive therapy, showed both the-EEG and behavioral changes therapy. convulsive”2lectroshock, delta activity, while subconvulsive therapy induced minimal behavioral change, and minimal patients 51/ Who~~ I” “(my We“ EEG ,4 .2 shdwed middle degreeprecords; and two of the associated with """ ------—--- 5"“ , /,/r ,//'change.; a r and when placed on convulsive r. e r. a 7.“, �-b2. Role of Type of Convulsive Therapy: In view of the variety of electrOShock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock undertaken. The first The delta activity on EEG results are graphically presented in Figures 5 was and 6. figure relates the treatment type to the percentage of records in each treatment group during the second, third and fourth weeks of treat- delta activity. In each period, ment demonstrating high degrees of EEG treatment with alternating current at suprathreshbld strength gave the highest percentage of high degree delta records. ieeetment'uéth-unidirect- ional current and*lith alternating current at threshold strength was less effective than the suprathreshold alternating current technique, in each period; a the udtfiiEgfigie;;%reurrent treatment being more effective than the threshold alternating current method only early in the course of therapy. Subconvulsive techniques yield no high degree delta The next figure demonstrates the same activity records. relationship by measuring the treatment per cent of each/group showing no delta activity or only low degrees of such activity. Here, the subconvulsive group is 100% for each treatment �-7period. Suprathreshold alternating current techniques number of such records in each period, with threshold show the least and parathreshold techniques in between. 3. Frequency of Treatment: factor Another dn the rate of development of delta activity is the frequency of treatment. While times aweek, a number who on convulsive therapies all patients were initially treated three failed to develop high degrees of delta activity were treated more In nine such patients, intensively. treatments were given daily or_twice daily, and in each instance middle or high degrees of delta activity were induced. previouSly demonstrated by Pacella gt El. h. Factor of In the ( Similar EEG ), and Callaway ( ). Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta first correlates were and second weeks cf activity during the treatnent; while older subjects developed such activity to a significant degree during of treatment, age was no longer a fine third week. By the fourth week differentiating asPect between the groups. . �-8data from all convulsive therapies supports this observation. Combining the During the second week, under'the age of ho; h=t===:;.30% ' patients "www-W” 9,.0. .. 1M 1‘ . at . on.» . , of records are high degree h3% M 61 and over. In the n.-“5.”. m1”- A, “W third in patients from delta in patients WW WM M ‘4 treated 3 ~ ‘ , W. W"; A .W‘ andfidpproXimately 2/;xtf the subjects n:/}pfiger present M” when cue-yaw and fourth weeks, the differences arep ~ «idelta records in hO-CO, and 18% timéé per W99§° ,fffl have wwww‘t4m HM\“ " ”a“ “by" ‘ high degree W“”w" ‘f" Mama.W ”Q h/‘ WWW, Wn.fi,,,,.,-r..m TABLE Variation in % High Degree Delta EEG Records with Age * Treatment Pariod 5g: ' in is. 2:2 are 61% 69% (28) m ul-so (28) 29% m 56% 51-60 (28) 432% 56% 55% 61+ (18) 18% 50% 80% To no years * The difference in incidence of high degree records is significant at .Ol% between the second and fourth weeks and .05% between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. �S. \ Pre-Treatment Record Characteristics: In earlier studies, a relationship between pre-treatment record characteristics, notably degree of abnormality or predominant alpha, the degree of induced "abnormality" was noted ( , ). and g In these series of patients, subjects whose pre-treatment record demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniques and seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertakenjémk order between pre-treatment alpha and correlations of the pre-treatment per cent time alpha ée—Ge-lMed-fieds—éea-teWfl—aemfi-with the degree of delta 4. patients demonstrated correlation‘ of . 95’ M activity during the third-and four weeks of treatment in M/Wima . 4'“ M +.35’ if ' I43 f5” 4d” �-95. Pie-Treatment Record Characteristics: Previous reports, summarized by Chusid and Pacella,( ) noted a significant relationship between pre-treat ment record characteristics and the degree of induced "abnormality." Records with predominant alpha rhythn or "abnormal" (Chusid and Pacella) or "borderline abnormal" (Bagchi 33 13;.) records were more liable to develop alterations in the EEG than those with fast activity patterns. predominantly low voltage ,1 In these series of patients, subjects whose pre-treatment record~ demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniquesfland seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertaken'éxk. per cent time alpha degree of delta order activity during the third—and patients demonstrated correlation( of 05’ correlations of the pre-treatment WWWWith a, , between pre-treatment alpha and M/W/mu . M the four weeks of treatment in 4'“ W +35) [a ' 1.13 ”(tyne/l @4’” �gr.“ 3 r% \ -1¢¥“""‘MI‘CWEHi ‘ — n—fJ‘r‘mWfi“ is” w? \\\\- r" ”y, wwfl:;¢"‘”w {awr rth geefi'is Significant at the IQ§hlével of . the relatidfiship in The , .10- ,_ PMW’MW v . . . > I? if“? f e . . ificénfidence; while thatflin the . ”His" ”419"“ M third . a"? "’1’ if.” . fix ,q/J’WNW lynx-"”61 (”fl ”M" . . ' . the trend rewindicated. ’71" a/«am “Mmmmmwmm“minim“..m“, Discussion: aspects of these studies warrant discussion; the significance of Two the convulsion in the electroshock process; and the role of serial electroencephalogragh in the rational management and study of convulsive therapies. (1) Significance of Convulsions:’ In the initial studies of convulsive therapy numerous authors, including Kalinowsky gt_gl. (19h2), and Pacella gt fil‘ (19h2) emphasized both clinical the and electroencephalographic ‘3' petit and , .. “7:4!“{ "5 “vfiflu.. “2. ‘ ., r , mal responses. ',>~'(:.w ’ i differences idwmaewa‘huwmmmm. I'“.fi:W’"amhma-~vmmm~a While Sa-‘iukw‘fl-‘Ih-m‘yow'wwmmmww“ ‘ anthem," between the grand mal. k» " qut‘w' cal 'mal seizures inducedngflmd c 12 prove- gfietrfi‘w affix), ‘ ducedfiphafiges MW“ in less than 25% 0 4745“ M M one of delta activity:‘and to petit mal, is no delta activity. . WW 7 mm M In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been �.11described, and each, in turn, discarded in routine therapy. ( gt al. for example, in describing the electroencephalographic effects of ) focal seizure techniques noted that 70% I after mal Bergman 15 such of patients had normal records 4 "seizures;" while seizures. Ulett 23 El. 70 - 75% after had "abnormal" records grand ), in a careful control convulsive-subconvulsive ( study, reported a significant difference in clinical reSponse of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive w” as; 6L. (33%).{es—eontrele-438%92J He noted the discrepancy in the . . EEG response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. Recent additidnal reports on a by various observers, based variety of data,&emphasize the significance of the convulsion. (Weinstein and Kahn, Roth, Fleming). Thus, the evidence indicates that convulsions per se, are’or reflectlgthe significant physiologic events which are 0 the bases for therapeutic efficacy of "convulsive therapies." . both If the convulsion is the essential element/in the . . behavioral reponse, does the mode EEG and in the of induction of the seizure play role in this reSponse?. In the studies reported here, small but cally significant differences in both the degree of EEG any dLr statisti- delta activity �-12— and the rate of its ' development were observed between different methods of induction of grand mal seizure. Ulett gt al, ( ) reported an improvement rate of current convulsive technidue, but and concluded 76% 57% for alternating for the photic metrazol technique, that the convulsive photo-metrazol technique had a greater clinical efficacy. convulsant drug, PM More recently, Edwalds, describing a 1090, ascribed to it a new clinical efficacy slightly greater than electroconvulsive techniques. "we have further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance of clonic or tonic phase, apnea, seemingly not equivalent; and a etc. All grand mal seizures are �‘ .13seizure is not an "all or occur and these may none" phenomenon. Different; seizure patterns reflect the differences in physiologic effect of the different treatment method: Further studies of this problem are in progress. While that with repeated convulsions, of 60 - 80% are obServed. The or number of treatments. We Specific with regard to the differences is the brain may way is clear no matter how induced, improvement are small, and, for the most part, element it this variability in clinical results is reported, may be between various types of treatment obviated by increasing the frequency conclude‘that convulsive therapy the convulsion is induced. change subsequent rates to the convulsion, The and is non- significant not the agent ‘ \ . 92;}, \‘> �-1u- 2. Role of Electroencephalography in Convulsive Therapy: have applied methods of quantitative, We serial EEG analyses in the studies reported here. While clinical estimates of behavioral change may give similar data, such evaluations are more dependent on the attitudes Wé‘v M30 Further application of Wt. of the observer ( 3 than the EEG.‘ EEG analyses to a (5M basis rer'ZZ‘ other problems in convulsive therapies'mey providfiérational \ MM41$;r’.11.~:a"3"‘“é-e?fof we have clinical different treatment techniques. previously noted that management of EEG analyses may be applied patients receiving convulsive therapy ( in the ). In the experiences reported here, the early and sustained induction of high degrees of delta activity provides the physiologic basis for behavioral change fail to in convulsive therapy. show a three times per ment. An electroencephalogram in patients significant behavioral response week may who on treatment regimens of serve as a rational basis for clinical manage- In those subjects in whom high delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a therapeutically more effective convulsant method, neurophysiologic changes. If the it may number of weeks, be maintained for a degree of delta may result in the activity is high; and other factors, as personality �-15( ) or environmental ( behavioral response, even and ) may when further convulsive therapy tion has been suggested by , _. *MM‘ ,nm4.~~-> ....~,..~v~m be assumed to preclude a satisfactory the neurophsyiologic substrate is assured; may well be discontinued. Roth ( ‘) A similar applica- for thiopental activated «AW‘~ EEG records. V . The successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational agents.( ). management and understanding of psychopharmacologic ..,. awuwlw'uuw... �-16Conclusions: 1. In serial quantitative analysis of degree of induced EEG delta activity in subjects receiving various convulsive therapies, a positive relationship between the degree of induced delta activity degree of behavioral change and ratings of improvement 2. An induced grand mal convulsion and both the is reported. is essential for both the EEG and behavioral change. 3. rate The a. and degree of induced Mode of delta activity is dependent upon: seizure induction b. Eiequency of treatment _ c. . 'h. It is Age of subject d. Pre-treatment recommended EEG record characteristics that serial quantitative electroencephalography provides a rational basis both for the study and clinical management of S various pix-Lodynamic therapies. �EASTERN PSYCHIATRIC RESEARCH ASSOCIATIQNHINC. OFFICERS 1957-1958 DR. DAVID J. IMPASTATO. SEC'Y-TREAS. 40 FIFTH AVENU’ETNEW YORK 11. N.Y. DR. LEO ALEXANDER. PRES. ‘33 DR. LAWRENCE H GAHAGAN, ASST. SEC'Y-TREAS. 164 EAST 74TH STREET NEW YORK 21. NHY " MARLBOROUGH ST.. BOSTON. MASS. i DR. THEODORE R. ROBIE. PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. DR. DR . DR. DR. DR DR. WILLIAM L. HOLT. JR. ‘IST VICE‘PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICEsPRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. Y. 0 0.0 COUNCIL JOSEPH EPSTEIN EMERICH FRIEDMAN WILLIAM FURST' "' PASQUALE LgorE‘sA'rA NICHOLAS Locngeio '* EVELYN‘IV'EY ' w O .0 TWELFTH SCIENTIFIC MEETING; THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SgHARP NEW YORK UNIVERSITY MEDICAL SCHOOL ALUMNIHALL-‘HALLH AII 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) o '0. “O o 0‘ PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing Completion Test (An Incisive Interpretation of the Unconscious) Ferruccio (Ii Cori, M. D. Discussant: Dr. David Wechsler 3. Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detail do you use in your examination of patients and the recording of your findings? ��EASTERN PSYCHIATRIC RESEARCH ASSOCIATION. INC. OFFICERS 1957-1958 DR. LEO ALEXANDER. PRES. 433 MARLBOROUGH 5.," BOSTON. _ MAss. DR. DAVID J. IMPASTATO. SEC Y-TREAs. 40 FIFTH AVENUE NEw YORK N. Y .f'W‘" 1“" AssT I-I SEC‘-Y TREAs. DR. LAWRENCE GAHAGAN 154 EAST 74TH STREET NEw YORK 21. N. v. II COUNCIL DR. THEODORE R. ROBIE, PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. JOSEPH EPSTEIN DR.’ EMERICH FRIEDMAN DR. WILLIAM FURST DR. PASQUALE LOTESTA DR. NICHOLAS LOCA'SCIo DR . EVELYN IVEY DR. WILLIAM L. HOLT. JR. IST VICE-PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICE-PRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. V. , 0 0.0 .0. I ' ‘ L I O 0.0 TWELFTH SCIENTIFIC MEETIN‘C THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SHARP NEW YORK UNIVERSITY MEDICAI_,,SCI:IQOL ALUMNI HALL— HALL "A" 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) O 0.. M 9 0.. PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing CompIetion Test (An Incisive Interpretation of the Unconscious) F erruccio di Cori, M. D. Discussant: 3. Dr. David WechsIer Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detaiI do you use in your examination of patients and the recording of your findings? �”mm: W A! 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W:- & both for the. candy and mm Wm at ���Electroencephhlographic Correlates of the Electroshock Process MB): Fink MOD. and Martin A. Green PM). From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, in part, by grant M-927, National Institutes of Mental Health, National Institutes of Health, [1.8. Public Health Service. Aided, at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. Read E: 2- 15- :2 New York, N .Y. �EEG Correlates of the Electroshock Process During the past few years, renewed attention has been given b relation between changes in the electroencephalogram and behavioral changes induced by electroshock ( l-h ). Based on a hypothesis expressed flie by weinstein and his coaworkers (5% in which they related improvement in electroshock to the development of persistent states of altered cerebral function, analysis of the neurophysiologic aSpects of electroshock an was undertaken in the laboratories at the Hillside Hospital in 1953. In fig initial EEG study,” a significant relationship between the degree and duration of the induced delta activity and clinical evaluations of behavioral change and "improvement" was reportedayeThis study was based on convulsions induced by a unidirectional current instrument '(Reiter). Subsequent eXperiences with alternating current techniques demonstrated differences in the rate and degree of development of delta activity. Age of subject and frequency of treatment were also factors in the EEG reSponse to convulsions. It is the purpose of this report to assess the role of treatment method, age of subject, frequency of treatment and pre-treatment EEG record Characteristics in the EEG and clinical re- sponse to convulsive therapy. Method: : hundred and £e££f3i=irt consecutive electroshock One been a day studied. Electroencephalograms after of therapy Patients wave fl a treatment were taken before treatment, and on at weekly intervals during until the record referrals have had achieved its and following the course pre-treatment characteristics. in.whom the pre-treatment electroencephalogram demonstrated slow AsymmeM/ or Spike activity, or significant aaaynetcy; were excluded from the series. �M Wflnfi rig/L Wm MW W Jam ”WWW- fight/M4 W M WWW W (W) Jam MM WMWWW/ WWWW2AW W; Jaww W ,asJ—u—m 4/— .49 «3'44» :L WWWWW.%II: WWWWWMMW W fléfiw‘jfl. W’ W .WM MAJJA MM Wag/d �-2employing different eatments proceo Four ‘ van-us of stimuli alte .‘. ‘. current at t-- old strengthf" al - ‘ a current at suprathreshold ‘directio: current ngth; 4 w (parathreshold); t) s unvulsive techniques with -ntothal premedication. have been used' , ~. _ _ nat' The ‘ - ‘ alternating current suprathreshold (7) km W fiatients, unidirectional parathreshold and MW b‘ currenté’ ., without prior sedation, received for? second), usually sufficient for a petit mal response. odes second 3", (90 volts At 20 W intewals‘voltage, and; if necessary, duration! ale-re increased . . , until a grand to "Nu“ In the threshold alternating current (8) techniQues aae‘ well described. method ‘ mal convulsion was induced. mwmnl- The “voltage and induce a grand mal was the threshold value. be necessary In subconvulsive techniques, patients were given pentothal intravenously gor (>0 until asleep, either seconds (8); or alternating were administered petit and then for one to three low voltage, currentoi' 80 unidirectional current to l20 voltsfirézsecond applications, for a total of 2b to 3.6 mal All treatments were given three times a treatments. Patients week initially, for 12-20 failed to develop a significant behavioral or m m 55;, Mew $3 :13; gm W, were subsequently who clinical reSponse, or Jo treats (1% times per week. All activity. EEG ‘ b records were quantitatively measured for the degree of delta The "records were evaluated as to whether they demonstrated "high," "moderate" or "low" degrees of delta activity, according; to criteria pre- viously published (6). Evaluations of changes in behavior were psychiatrist and made by the supervising resident therapist at the height of the treatment effect) �, WWW WM/Jéw A?%MWW%4 /¢(WWW’MW” JKWWM HQWWWi ' ‘ �-3... and were scored as "marked," "moderate,"'hdndmal" or "none.” "improvement" were made by these physicians two ratings of The to three weeks after treatment was terminated, and were based on the four fold classifica— tion of "recovered,” "much improved," and "unimproved or worse.“ (6) Results: 1. Convulsive vs Subconvulsive Techniques: W MW, ' WW therapgrfglhad the h? subjectstwho received convulsive high degree Of delta records in-both second, third two of the three weeks, and of the )4? 13 subjects failed to the 27 subjects who and during Show a convulsive therapy. Of 6";gr one “a Low weeks of treatment; 12 during of the test periods. Thirteen high degree delta record on received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. fourth activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. neahJ-l’ 21‘ ln concurrent behavioral ratings, hirof the.fifl subjects in the ‘ convulsive group showed marked behavioral change; while of the subcdn- vulsive group, (Table I). therapy. *» Y‘aab éacbndldb ham, ‘ fl Of 2h of the the or 27 showed minimal latter group, 19 were no behavioral changes. referred for a second course of In lb of these, grand mal electroshock induced high degree delta .RE niekagd: uan W‘LWM ,_ AAAAaaeut "W wthwfi W ynxuduvuax “Gunrfl nta. waT‘5~/::L¢Gfie , . I �.uactivity and all showed a significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroshock, all WW m Showed middle degree behafloral change. m. L *3 3 hawk»: records; and two of the five 47 I TABIE Showed a W! 4‘ 9““..44 b ' Ratings of Behavioral Change; Convulsive—Subconvulsive Therapies (Tourth-Fifth'weeks of Treatment) Degree of Change Moderate Minimal 27 15 S O O 3 8 16 Marked ConvulSive Therapy (h?) Subconvulsive Therapy (27) None In evaluations two weeks after-treatment of the degree of "improveof the convulsive therapy grongj::ted as "much improved" or "recovered," and 32% as "improved."qag% discharge, 51% were evaluatedileZS ment," 51% sustaining the and only were were 7% same degrees of improvement, while were "unimproved." rated in the first Of "unimproved;"figfigeiggége§:§§:$§%§:red do were "improved," the subconvulsive group, however, two categorie51’19% hOSpital discharge evaluations h2% in the "improved,“ but for a 11% 70% second course of therapy, not reflect the effects of subconvulsive therapy. II TABLE Ratings of Improvement: Convulsive-Subconvulsive Therapies (Two'fleeks After Last Treatment) Recovered Much Improved Improved Unimproved Worse Convulsive Therapy (h?) 9 15 15 8 Subconvulsive Therapy (27) 2 l S 19 �W. .r -5... din=;.€onvulsive therapyinduced signiiicantly greater behavioral MM“ whichchange and eva uations of improvement thangsubconvulsive therapy We The parallel the electroencephalogr . Also, patients -EEG clinical I observations“ ”A“! who showed neither showed both or a behavioral response to subconvulsive therapy, and behavioral changes when placed on convulsive an EEG therapy. 2.- Role of Type of Convulsive Therapy; In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analgrsis of the was undertaken. 2. The effect The oi‘ type of electroshock on EEG delta actvity results are graphically presented in Figures first figure relates 1 and the treatment type to the percentage of weeks record ‘n each treatment group during the second, third and fourth tre:Egentgggégggggating:high degrees of EEG delta actigggi) In each of period, treatment with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unicurrent and with alternating current at threshold strength was directional less efi'ective than the suprathreshold alternating current techniquef.in each period; the unidirectional current treatment being more effective than the threshold alternating current method only early in the course of therapy.* Vsubconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same the per cent of each treatment group showing 7“: relationship no by measuring delta activity or only low ncés ..-»_. :v-n suprathe a‘, ent perins, tre Eur, .l-i-o . an. etho’.'5 - thre o'd reatv t si " Can at .05 by chi 7—9 “-3 ou- in} vDi7”e~' ces b tw-z para --12 0-" 0d“; no ignifican ' dWL- ‘ j . hold met‘ods, and for each method �at Mt“ M74 @WWAEW �-6Here, the subconvulsive group degrees of such activity. is lOO%_for each treatment period. Suprathreshold alternating current techniques show the least number of such records in each period, with threshold and parathreshold techniques in between. 3. Frequengy of Treatment: Another factor in the rate of development of delta activity is the frequency of treatment. While all patients were initially treated three ltimes a week, a number who failed to develop high degrees cf delta activity on convulsive therapies were treated more intensively. In nine daily or twice daily, and in each instance middle or high degrees of delta activity were induced. Similar such patients, treatments were given correlates were previously demonstrated Callaway (10). EEG h. Factor of In the by Pacella gt'gl. (9), Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta the first such and second weeks of activity during treatment; while older subjects developed activity to a significant degree during the third week. fourth week of treatment, the groups. Combining observation. and By the differentiating aSpect between the data from.all convulsive therapies supports this age was no longer a IMring the second week, h3% of records are high degree delta in patients under the age of no; but only 30% in patients from uo—oo, and 18% in patients 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects degree delta records when treated 3 times per week. have high �-7TABLE Variation in % High Degree Delta Suwd To DO years (28) Records With Age M film k2 29% ' W % Treatment Period $9.213 69% 61% h3% (28) Lil-50 EEG lit-.9. £211 £59. III W W ‘ 31-66 (28) 32% 56% 55% (18) 18% 50% 80% ‘ 61+ 5. Pre-Treatment Record Characteristics: * Previous reports, summarized by Chusid and Pacella, ($3 noted a significant relationship between pre—treatment record characteristics and the degree of induced "abnormality." Predominant alpha rhythm, "abnormal" (3» or "borderline abnormal" (11) records were more liable to develop alterations in the EEG than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment record demonstrated diffuse slow wave were not included activity, spike or spike wave activity in the statistical analyses. Eight such subjects were saven of them developed high degrees ”treated with convulsive technique? and of delta activity earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre—treatment alpha and the degree of induced delta activity was undertaken, Rank order * The difference in incidence of high degree records is significant at .0 between the second and fourth weeks and .051 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. WW WM *7 �-8correlations of the pre-treatment per cent time alpha in selected leads (anterior temporalavertex) with the degree of delta activity during the third and fourth weeks of treatment in _tions of +.2u and +.35 reSpectively. week is significant at third'week N£L0 Two h3 The patients demonstrated correlarelationship in the fourth the .05 level of confidence; while fails of significance, although the trend that in the is indicated. aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and the role of serial electroencephalograms in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the éfiéggél studies of convulsive therapy numerous authors, including Kalinowsky 2:". g. (12), and Pacella §_t_ (9)7 emphasized 3;]: both the clinical and electroenCephalographic'differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes subjects. Similarly, electroencephalograms in grand delta activity, while in petit mal therapy, no in less than 25% of mal therapy demonstate delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, been described, and and focal convulsive tedhniques have in each, in turn, discarded in routine therapy. Bergman §t_al, (13b for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records 70-75% had "abnormal" records after grand after 15 such "seizures;”'while J �-9mal seizures. Ulett gt a;. (1h), in a careful control convulsive-sub- convulsive study, reported a significant difference in the clinical response of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive (33%), or controls (38%). EEG He noted the discrepancy in the response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. W Recent additional reports by various observers, based on a variety of data further emphasize the significance, of the convulsion in the therapeutiC'responSe (1, l5, 16).ffieinstein—end thus indicates that convulsions per; are, or reflect, the significant physiologic events which are the basis The evidence se_ fortherapeutic efficacy of convulsive therapies. If the convulsion is the essential the behavioral reSponse, does the any role in this reSponse?. in both the degree of EEG mode element both in the EEG and in of induction of the seizure play In the studies reported here, small differences delta activity and the rate of its development were observed between differentxnethods of induction of grand mal seizure.jh/§ Ulett gt a}: (11;) reportedan improvement rate of 57% for the alternating current convulsive technique, and 70% for the phodio-metrazol technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulSive photo-metrazol technique. this repert, Kalinowsky noted 'various workers as being vulsions. Eh More more that metrazol convulsions have impressed efficacious than electrically induced con- recently, Edualds, (l7) describing a 1090, ascribed to it In a discussion of new convulsant drug, a clinical results slightly better than electro- convulsive techniques. 'We have further noted that the convulsions induced by various tech- niques have varying characteristics of latency, duration, preponderance �.10of clonic or tonic phase, apnea, not equivalent; and etc. "All grand mal seizures are seemingly a seizure is not an "all or none" phenomenon. Different reflect the differences inhphysiologic effect of the different treatment methodfp Further studies of this problem seizure patterns occur and these ‘are in progress. While this variability in clinical results is reported, that with repeated convulsions, 'of 00 may - 80% are observed. The differences element is the brain may way rates between various types of treatment benobv1ated byzincreagang the frequency we may conclude specific with regard to the is clear no matter how induced, improvement are small, and, for the most part, or number of treatments. it that convulsive therapy is the convulsion is induced. The DOD? significant change subsequent to the convulsion, and not the agent in bringing about this brain change. In previous reports (6, 18, 19) we have noted that convulsive therapy is also non-specific with regard to its application in mental illness, and in its clinical and behavioral effects.used The present studies amplify, therefore, the previous conclusion of the non- Specificity of convulsive therapies. 2. Role of Electroencephalography in Oonvulsive Therapy: applied methods of quantitative, serial EEG analyses in the studies reported here. While clinical estimates of behavioral change have we have yielded similar data, such evaluations are more dependent on the attitudes of the observer (20), and less amenable to quantification than the EEG. Further application of EEG-analyses to other problems in convulsive therapies provide a rational basis for the comparison of different treatment techniques. we have clinical previously noted that management of EEG analysis may be applied in the patients receiving convulsive therapy (6). In patients �.11Who fail to significant behavioral response show a on treatment regimens of three times per week, an electroencephalogram may serve as a guide for further therapy. In thise subjects in whom high degree delta activity has not been induced, increasing treatment frequency, withholding pre- medication, or shifting to a more effective convulsant method, may result in the neurophysiologic changes. If the degree of delta‘activity is high and sustained for a or environment#(18) number of weeks, other may be assumed factora',as personality (21) to preclude a satisfactory behavioral reSponse, even when the neurophysiologic substrate convulsive therapy is assured; and further well be discontinued. A similar application has been suggested by Roth (3) for thiopental activated EEG records. The may successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational management and understanding of psychopharmacologic agents (19). ��3;; Zn, ~ 6w WMMWL, _ ~ 4; �(«My REFERENCES 1. Roth, 1.: Changes in the EEG Under Barbiturate Anaesthesia Produced by W.Q Electro-Convulsive Treatment and Their Significance for the . Theory of ECT Action, 3: 251-280, 1951. 33. £5 Clin. Neurophysiol. Roth, M., Kay, D. W.K., Shaw, J. and Green, J.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG “a..- Clin. Neurophy61ol. :2, Chusid, J. G. and Pacella, B. L.: Shock Therapies, h. Ulett, G. and ,1 MM Johnson, _ J. Nerv. m M. W.: 225-237, 1957. 2_: The Electroencephalogram in the Electric:;> &:Ment. Dis. 116: 95-107, 1952. m" "' any...MA... mm:-W M and Scopolamine Upon Efiect of Atropine Electroencephalographic Changes Induced w”,// 1. By Electroconvulsive . Therapy, EEG.,Clin. Neurophysiol. 2: 217-22h, 1957. S. ‘Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Its Relation to the Therapy: Psychiat. 6. Fink, M. of Shock Therapy, and Kahn, R.L.: Relation of Electroencephalographic Delta Neurol. & EBSponse in Electroshock, A.M.A. Arch. Psychiat. Z§: 51o5525, 1957. Kalinowsky, L. and Hoch, P.: Shock Treatments, Psychosurgery And Oflier Somatic Treatments in_Psyohiatry, Grune 8. éfl:_i; 192: 22-26, 1952. Activity to Behavioral 7. Theory & Stratton, N.Y., 1952. Alexander L.: Treatment of Mental Disorder, W.B. Saunders Co. fhiladelphia, 1953. 9. Pacella, B.L., Barrera, E.S. and Kalinowsky, L.: Variations in the Electro- encephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Psychiat. g1: 307-38u, 19h2. �10° 11 . Callaway, 3.: Slow wave Phenomena in Intensive E1ectroshock,«Elootpa. tag; ennaphalggrfik'Clin. Neurophysiol. a: 157-162, 1950. t K)~u~uu¢,nk‘04+&.LUéQQNUM’ antm 3‘ v~n£.aax+ueB ox BK 33,; swam: n 3,. H AW“ um “3' W i?! p 12. Kelinowsky, L., Barrera E.S. and Horowitz, WA“ in Electric Shock Therapy, Am. The J. Psychiat. .y. i'c I 4"?“ use... "Petit-Mal" Response 2Q: 708-711, l9h2. 13. Bergman, P.S., Impastato, D.J., Berg, S. and Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Fbcal Seizures, Conf. Neurol. 11: 271-277, 1953. 1h. Ulett, G.A., Smith, K. and Gleser, 0.0.: Evaluation of ConvulSive and Subconvulsive Shock Therapies Utilizing a Control Group, gm;_g, szchiat. 113: 795-802, 1956. 15. Wéinstein, E. and Kahn, R.L.: Denial of Illness, C.C. Thomas, Springfield, i 1955. 16. Fleming, T.C.: An Treatments l7. Edwalds, Inquiry into the Mechanism of Action of Electric Shock 'Jidbnuav'nfiuatJWor ,WO-ASO , 1950 . K.M.: Intravenous Administration of with a New Convulsant Drug. Read at PM 1090: Clinical Experience N.Y. Divisional Meeting A.P.A. 1957. 18. Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the ElectroShock Process, Dis. Nerv. Sys. 19. Fink, M.: A Unified Theory of the ACtion of Physiod namic Therapies, J. Hillside 20. Fink, M. and Hosp .__(_3_§ 19 7-200, 1957 . Kahn, R.L.: Behavioral Patterns Brain Function. 21. (in press). Read Kahn, R.L. and Fink, M.: at in Induced States of Altered N.Y. Divisional Meeting A.P.A., 1957. Personality Factors in Behavioral Electroshock Therapy, Conf. Neurol. (in press). Response to �mmfimu mumm. in M minions: W manta, mm mm am mm mu, 3.1. a: mm mm, mam mm mum mm M Mia mu: m“. &, M. at mutmmmummmmwmumamrmxm. VIM ����m W a: moo nativity «many to: tho uwmmthomw Migration“ (Miamimdmthouoomw the «Mo Wvomwmmufiml) Withomotmm room: Woo with Moment, Magenfl MWm«on ntod u “MAW of data. muty. yW WW 1 4- .. 11111 . . mammumuwumamuwmw 25mm W» W t mm ”mm Wt? 'W 28 12“ 21 8'! a 66." h“ 35 13 16“ 3 2 a M K 60 t wowmammmmgmmmw stumpWM Wommmmmmmlfim at m woman” mind Wm t1»npy*1n this M. m: who 34? 9 .3, ommamae monmmmmmmmmywamm 19 ”loom mu, plat tofu-rod for t «W W“ of thong, ' Win . fl UWJOOM �����m Mm Mm am m 1%- M 61 M 1:: (28) W (38) M M W (28) 311‘ 565 (18) W 30% , thmum mwmmammflva thmm Wsmflmt Wampum “W" (flw‘W W“ (n)mmmmmw mmnwpum. mmmerpmmmwmmm~mam ‘- _'mmunwmmu%%wapm§uwmw mmmwmmamummwa. thmmm �“Nuthmmw Mgr: than m 3mm of A. ma W,mm,W. mama“mmWWW pom, mu nativity without. such M for mm wan-«mam» Mutiny. WM maym at the man hum put-mm awn mmarwu1ummuymmm. mum mumaunpmmmmmmamnmmm (wwwm)uwmmdmummwmm m gm was « tantalum w a: mum. mm mum m at Nflbwhfimmunlyo mmumpmm comma mm“ mw3mmsmmmmm Wmum am at mum, among: an m u Mam. . ��������Reprinted from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958. Electroencephalographic Correlates of the Electroshock Process and MARTIN A. GREEN, M.D. In the course of an evaluation of the role of a1tered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re—assessed. MAX FINK, M.D., Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment, on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varied, including unidirectional and alter— nating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12 to 20 treatments. Patients who failed to develop a clinical response, or EEG changes of significant degree, Were subsequently treated at 5 to 10 times per week. The EEG records were classified for degree of delta activity into “high,” “middle” and “low” degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest ampli— tude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the Read at the meeting of Eastern Psychiatric Research Association, Inc., held Feb. 6, 1958. electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. Results: 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was significantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subconvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional instruments, but by the 4th week of treatment, the differences were eliminated. 4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient. 3) Early and sustained high degree electroencephalographic delta activity is a necessary, though not sufficient, pre-requisite for improvement in the electroshock process. - �mmmmm Garnish” at the mammoak Mam Hawaii‘s WWW at Moan rawhiam, 35.11.3169 363331981, men Oaks, m... mamas a: mm mm mums. w grunt 16-927: 33.131th um, in wt, M. ”03¢ M116 English From the Mfltfiflfl Band at 131-13 Halal, mm at the Eastern mum autumn ”Manama, fiat York, Pcbmary 6,. 1953. Whip-$8 Saran. 3.1. �WWMMW.WMMMMfimhm Wmmmmmmammmwmmmm WWW.1IW (1.1).. Wflflmhwma mmmwmamtafl) unmuwmwmamMMIMm. mmmw Want Mummy m an m a mum 1mm muw um mlmum may in this laboratory, a 65 «mu um! at Wfi'mmw). mammmmuuam mmmmatmmwmmtmmutmmm, W a: W, mot mbmwm-mms mm mm“. Itismmwadmmwtfiomummuuondflauum MwmumammmwMommmamw WWWduflflahquowhflnufimlm mm am of mm" mm. and ���in mm Wm: GW‘WWW' The wide variability-1n the mm of mm mums»newt-w in the initial 2h gamma» (‘6) is aanfimw in them string a: mmulaiva mmyy ”towns ( table I) . While the number of law v-meamu $.12, mm We Ward: mama“ with treatmenb, 7m in the third min; and 3.8% in than fourth max, urn mu rut-ma a “1M flames at am». nativity. We of EEG Dalia Activity with convulsive Therapy (Emmi; M .122 ,. High MW h - M) 2mmt Pogod ‘ L 1:2 28 1:6 66 2% Mamie Dame 1?. 21 27 32 W 99W 63 W 25 18 16 3 2 a m 2mm mmw Tim behavioral signfiimm mama was of the amused in emmion $110? m a 1n the: EEG ma muwmbwmlsiva flaw. m the h? mhjaictu" the maniac! taminva therapy in mi: “My; «It m mlmfim mu, incluéod 28 summit»: the pins 19 .» . cm“ of therapy. 9 had grand m1 therapy can a rmdm mimd ~ m3aota Mama for a “mound in ����of me netiv-ity. Kara. the mbcomuleive group in for each 100% treatment per-lee. Sumthrenheld alternating current techniques the least member mmmeld enact of such remade in each period, with thmmeld me teehniqma in between. it. leather teeter in the rate is the Mme? at treatment. three time a week, a while number whe a Miami. of delta aeflvity all patients were initially treated failed develop high degrees of “be delta activity were treated were intoneively. In em! mh peanuts, mama were given daily or twine daily, and in each instance new» or high degrees? 91’ delta activity were induced.- Similar wimely 5. F- by ' ter of In the ' Mem'gg g. EEG (9),. and con-slates were enemy (3.0). a initial «new of ptiente, it we noted that yemger patients, under 15 yum of age, Malay-ad greater $339“ ex acne nativity during the fix-at. and heme! weeks of treatment; while clear mbjeete developed such nativity he a eigfiflmt degree during the mix-d week. By the fourth ml: at treatment, age no longer differentiated batman the gmups. supports Cambining the this observance. date free all convulsive therapies During the amend week, ha; of weaves are magma mg: eeme dam: in mean-es we.» the age at in pastimes and rm bones. and 18% in pemente mm wake, the difference: 2mm 63. and no; but mr. my 30% In the third are no longer present and 3.15mewa of the eubaeete have high degree eelta meeree when treated 3 time per week. �3353;;an mmgwmwmlaa 5% Ta ha W50 Over has ascoraanaaafiw rm‘ Huh ma SE)... W (28) 69% (28) 56% years (28) 55% m 6-1 6. *1. 18$ (18) arms = Mag» Mama W 30a 50% ma. a 6mm and Panama (3)., mated a significant whammy betwan mamatmnt roan rd charaataru mm and the degree a: mum «WWW mama alpha mum. abnormal“ (11) awards were mm mam ta “shawl“ (3) an Mean reports, by imam Malaya alteratiana in tha am than thaaa with p «w- tly 1m: whim : that nativity pattamm In these am” er patients, mamas: who» m m~matmt mama nativity; apika er spike wave nativity damatmtad diffuse allow Eight shah subjects were were not incluéad in the atatisfical Wat. , a ma diffemnaa in incidence af h1g1 dama.,maords in signiflaazat at .01 1mm}. of amtidanaa batman tha ascend and 111m weeka am! .05 the aacond and thud mks af ammm. in pntiants over 250 years at age; but is neat. aigwiaantly diffamnt far than periods in amupa amm- ‘50 mm Fm» �����am far Wr mum. than 12mm, mv In m nah been maimiim, m" mm to activity a. mm in mm high dam «its: imminent tramway, 33.ng . m effusive mamlmt mined, m mmphysioloaa gimme-u If the dew cf do“: 9.me for a wiw 01’ Ma, Wimp taggers u 9-. .5, t? is high and (23) w ammunbal (19) my be ”m6 to minim a utisfwmxy . m iflma mama is «was mammal magma, men when Mm remit in, film ade , ,s .. . mm“ that-spy m will. (1153de. similar applicatim has hm suggest“: m (5) far thiamm ”bland we} mrahar ha A by am mm. m ammm'vl maintain ma uwmqma ta mmhive W121“, but led to their diminution in amt Win-- Me alumina. W mec npplioatim 13$ Mt. “ports firm the” laboratories min a W mum amt! (26) ,; applieatien tar WM aid warming at ���11;. maids, 15‘; 310 3135 . W, 30. Gamay, An 1935.- ,1: am oxidation at mews 1956. a nu. 3m.: um Wan-awn at m 1090. mama. Inquiry into the sex-«mm, 3.3.: ' a: W. mm,Mariammm»: with a m flew 9mg. am at 21:2. minim Hating LfiPi‘J HA. I 19570 Signifimaa or mmm vmbili‘g in m magma Experimental stud-1W My Edi-m and am; 31*.“ My My; (in mm). 33m. 8 mun-9mm}: Rowan, W ‘ . 6f “13 o the Action or Physiodsmmia Therapies, m, 14,: 1 Unwed Thom a:197%.;195?‘ , 21. LG»: Shook m, 19a K; and “W,springtiad,m Rd“! W a! 16. 1?. 6:13.: Evaluatim at ma Mr, (3th 00mm}. fir. gamma“ m1: Wraps.“ Winning a £34., Smith, 52* 3.1m Bahamian]. mum in Induced sung or M; n. ma Kuhn. Brain mum. Rand at NJ. Bifiaioml mung MPJ. Ligand 3‘9 7‘. ‘ 22. Kuhn, 3.1:. and Fiat, 14.: ; A,“ Mummy Futon in Behavioral Mama to Mammw}: “therapy, Gama m:1. (in press). ����“x 1%! mmmmmmwwmmmwmsw wuwmmfi ‘xmméugunrwar mum's, far w mum,mwmmwormmumum mmwwmwmmmmmwmu muuwmmuumnwhs. WMWmW rwmmmmmmummcymmmm mmmmm. mum-Mt m m ”##1##“, We“ m Mmaummwnmwmmywm,mm want? mam, MW W wmmmummmmmthmm mm mu to, at lama huh activity, me! for my: Wfim a! an mmt ma pu- mum. alpha was the We. cream mtfltymmmmwmormmmmema ‘tgfifimafwma “ ' ‘ ' mm u¢mwmm4munmmmwrmw ’ WW. W! z.-m:auumnwmummuuuuwumt mm: man-mm durum m mammmmtmmmmwgmmm (a) W a: am mm. m mm uMmmmmm. 31* mamam am am am �mm: mm; 1W m W mum m mmar-W: Mrwmwmm at (M ‘ we. at Mm“ (a) at «inactivity «mm hf {mm—m. (a) m m mums. warm as inmate-at. but, my the What W «Woman: “new: rm m with vammfimdwmuwm W‘ mm- M whim: WW W mu up» mama. WIta» W mafia ~1me m Mmammmmmmammm a: (3) «1' 1. Wu W. nativity that aw: 1w WWt ‘ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Electroencephalographic correlates of the electroshock process. Dis. Nerv.Syst., 19: 227, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-32-009 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 12 items. 1: [preprint]. 2: Edit page. 3: Hand drawn graphs. 4: Handwritten notes. 5: Drafts. 6: Program for Eastern Psychiatric Research Association, Inc. Twelfth Scientific Meeting, February 6, 1958 (handwritten notes on back). 7: [preprint]. 8: Final copies. 9: Reprint from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958 (one page). 10: [preprint]. 11: Discussion - NY Neurological Society 3-11-58. 12: [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/549693df019a0cabd2aa7cfa90ad3ced.pdf 62db1d0b502fce82996214e0276f034a PDF Text Text ’i' WM 3mm; lacunae Whammy mum. a: convulsive ma Ems in 1:33,“;ant W Mhim Fth mm m 1-. 0-. A. 3.1% of mmm mmm, m the mam. mm m, 34.1., $1”. W Hakim}. W? of the Unfiml Wfim%_ a! Manta Insti‘MkaWWith, mm fiflm mm: mm 80m“. He: 33.113169 -' Aldus! 3.33.1513, 01' a Se Wolagiaal W an arm mmg, Howof1m 3mmandm- ammal Psychiatry, Kw Yam assuming mum may, of 10-613mm, flu: Kerk, 13., 1953:. Promtud a mama: . » ‘ 5.. #- sky and Mb �II: 3-1148 Experiment-3. Shame at cmvuhive and 13mg momma: in Psychiatry: Mafia mummy mum e the vapor rule a: the We pearly Mined. adequate aw sumac therapies in This results, in part, femhflon of their we at aetian. increasing evidence for a frw In the the leak at an put an: yam mmfiyaiolafiemptiw view of electromoek therapy has been presented by Wemtein and Kuhn, Bath, and view, the madam Wynne prawn 1n electrocheek is [319128. in thin Mex-1m to a Imminent. alteration in cerebral function mm: madden the milieu for a change in adaptatim of the aubjwt in his anvimmnt. having the past four years in the we have attuned the autism between mum and the behavioral name physiedynemic therapioa .. laboratariu of Hillside hospital, alteration in urinal: indicate of brain at psych “trite patients ta three of the emmmwk, Win one and *tmqullieere." me nemyhyaielogcudapuw view at sleet-manna has been Wind in the” studies; has been preheated. and widenae Recently, the mar “trimmers.” :5qu we for a similar View of insulin coneep’t. em has been fruitfully extended to the The» studies provide the hands for a gmmlimtim �«2* «meaning ta a! W the. mode of the experimental mum at these therapies "idem measurable éetomine whether or not the be tenight male mean I’m their ability ta inane: manned- may altemtian in aembral function; it in ear PW the" therapist. nation of and the wrelluy questing, alteration in eerebral fumtion is efficacy of these thempiea, or mether me}: a, necessary whether mfitien for the We: in brain aunties: m a “maimfian” er "11331th when" have used We View). mime indie» of brain {Manon including mar llama, m mule pomoptual mice, and uhangea in orientatian patterns at new both clinically and utter intmmua mbarbital which be generally knew me the ”m1 test." the delta index In electroencephalographic studies, ehanges in in meuutod words mm at altered brain mum. For have been “and to be a mauve latm this mica, ehangos in this W will be ctr-eased. In the initial rotomd for mmleive nudism of normative patients therapy, oleetrmcephalogram were amazed before, tmemnt at weekly intmala timing therapy. m1 therapy three time a week, fer a total of The and an a day ate: a patients rewind 312-20 applieatim. m6 �a, thte 31w were nativity. In the mun}. We Wt the 01' the heme witty tenet, m quantitatively Mum delta eetivity during by determining the per tee-t time maintenm » each we}: at eeeh mfiflty, the and the duretiee amt WW, e: berets in selected team were then new we the W thin! were at treatment We. the emm ae "high," theeeeenethieeeefinieflcfimdfimmethMuVW demure! Mite entirety. “tee tee their We: he met meets the noted in the rim. short term emu rem (he make poet Wheat) new means: peyehutuc trauma, and were “Mentally moved“ and "We” elseeed as ”wet theme,“ �.h... In the first toms of mutants, a Want relationship human the early influation of high degree: of delta nativity, and clinical rating. at ”math Wad” m crammed. may put: «at at the “cm-ids in tho 313.1: much mma group mm high dogm mu by this 14-6 Manning pemntaga my unstained at um 91‘ the unimproved first ulna mks, 90% in the third and fourth mm. and the In mtmt, pawn“ dumped 121$ dogma! data «cards in tho and only 20% of the records in the tenth-h week are to elusifiod. Baud can those mum, u wanna nudy m undertaken. mum-d: obtained during the amend find Wad for that. 15h:- dogroe a: W w; third mic: or mutant. mm delta nativity, and it tun 0:31:1de than patients the had high degree: a! (with activity during then periods would that better ratings of ”Wat“ than puma“ in two when �~s~ such damn mm. of delta activity were not This prediction was Fig. 5 m“ ' 1mm 1mm, an occasions were 67% at the patients with high degree records ”mach improved," “minprmd” 705 were while m: ”moderately 31‘ on both patients withaut such "earth,- tamed." Further aorrabomtzlon was obtained in a canvulaivoumbeonvulaiva control ”My. Connemara m convulsive who car of. middlo waiving referrals were plum aims:- an mboonvulsiva therapy on a random remind aubaonvulaim antivity 3110 chrothampy trauma, mm min. a: Wmm slow wave or high dogma in any use): of treatment. Waive therapy, patients 27 or; 28 EEG subjects high degree records were observed in 20 rimming the second to 1‘0qu weeks of treatment. Or 23, and the 27 mboomlsive patients, at the“, 19 mm retomd for ml elactromock induood no change 3. ”cont! in behavior coma of tmtmnt. high dogmas of delta antivity in 1h in each, a significant behavioral Me was notad. in was when! at" Grand We, and In the rim panama �«a. Iii-ham; Inch ‘ delta chug», «my m ahead a m cm“ of mutant hehmiwal W183.“ thumw indium that m slaw mo nanny 1-: as: 1nd»: at tbs chums in «ma imam man are promise to the Maria“ ' aha-nae in this turn a: flwpoim or their elmtmaophdogmpma 1 moaningml W. and a mum. annual manage attack, renump Luther: um dogma ma type of mam W m mmbml function and the clinical behavioral rum is observed. The Waxing agents to imam aim of central nervous system @atmtion, a motor rigidity, deputation, «summit and. MW ability of the aver m Wu Imam. - mod on ohmumm nude in mm expat-1mm am in We manual: at various ms in ms mama-r143 partisan, m have also bun notoé. than me «that: m be clusfliod awarding to men in the {macaw spectrum, and m at three broad Wu: " met �“1.? 1. mm new we mum II. Instance 111. high voltage Bethrmiution WWW- with that activity. with voltage and {macaw Singularity we irregular that». activity. at the drugs that induce increased slew have mtivity the phonothiaeiha enemies. pmiee and Wine m elm We. Each drug also induce; aims in mmeptim, megawatts mum in fierivatim, I epilogue shadow, and induce; enamel “thin-mien naming“ pumm. ’In the enamel eat-vice at amazes Hospital, pneumonia but in all patients reaching Mammalian, 10% of and «um: have been observed in Whit: patient. fithent 3 Wm history Renee-pine how induced of ”18mm else moms delta nativity, but only when gim in it high dosage levels, it the mggmm Mum: in opium, Munroe in mm», the clinical are elemet maples. Indeed We tut nativity, barbiturate “than agents differ from the phanethiuinee and "sperms in not warming «hum. and whenoeim in me. at drugs that induce immune high voltage ah merchants hm dean. Woman, or mm their anhiamlmt nativity is measurable. �.3. minimum in readily “Mum. and ”ism: hm hm charred. Varima drug: indwo EEG domabrmiaatiw with varying «flaw. lamina and damning; bamamina mm W a: mama two reports either of . MW, in mt bean «baa-wad with miss: will. than eat that: drugs, user have ”isms nr parkinamiam in. than clinical «tents «gm: at phnnothimM derimtiws, ma Wad «synchroninmm with Dalia activity has and «flaw. we found Ilium-azure. mama“, dimm and WWW have been that: to mam-unis. the EEG delta moral! or patient! undergoing 010W tummy. ’16-: 6x '3': 3» M the» minor 9. Winery, ahlorpmsim, parphonuim and ”amino haw been amiatontly annually reported as paymwio barman:- panama. in me frequancioa to the most. mus are also the ma. range. mini in $3ng drugs that. mmbmte, Mm momma and groan the man. 1:6an �m 01mm 1m mm. in tha than an m agents we pmdueo m man-ea mum at :m tmunwiw er doaynchwniuum. mum, an delta range is t mcmtmt at signifimt behavioral in cumulus.“ therapy, an .3 (i5) " may, 12: the m tnqumay shut in the situate. “ magma ofinmlmemthampymbcamodina 13.22113:- rwhim. During usually pal-auto for «an am, EEG delta mmuw 1: manna, mm: to a few hams-a after gauge. not. 23212222 Mmumm, . 1— V mo third of patimta waiving hospital, 131mm” aphasia or prolonged EEG change: or alarm activity am, far “the: m 2231:! relation bahmgral am mey in this am and“. an» such pomt fer elm, and 122 «mm: mu of pmlmgad mm. how 13th am, fitmd brain function am! mama has: been (anew at length by various authan Him (20220121233 that. dam. He We study. sloop Woman”: is related be 22;: 1226226321921 of organia brain haw abnamd a 31:11“ relationship, and reported am «nah A 322 you old aabimphme puma“. with puma“ 13mm: �«It» Now a loft magnum eating mm: em thmpyi efmurMe fom: With the unset nmmmamwmmmmmW. paw « withdrawal cooperative attitude. the» mm pattern we Hie mum by I Mmdly We: can wemmd by delta clung“ in the We, (6) W: While in him net bad the perennial opportunity to etudy lobetw intimate from the $93.11*. of View at this awry, mmeebumere clearly dome a of delta aetivi ty are present for W in 3 1’30 relatienmih me in all subdue“ peatwpcneivoly arm periods, up to three yours. «1mm the report: at We and peniet flux-them, pests-operative m a frequent ”museum, being varieealy report“ a new 26% of subjects. �D‘IESE: has, what: "Mm “Moi thumpiw point of flaw of an alteration in brain node at whim. Those m We of the imam, we may in!” a. chanson in hahnvior. «he» at these madman puma a m mum afimfim a! the mam alteratian in brain taxation. mum 115an by am in than in Miami at W the 111.1101: «hangs data range, mm is signiflaanaa a: that-aw; um with an W “we“. Man :0: the mucus af faction with reaultmt Ghana“ in brain . thawing m swayed rm the apoctm of 1mm in aynahrmuatien, mat. «mouths in altering Mmatin EEG mung” immunity: proud“ the mum m delta shirt has boa: alearly dwamtmtod in elmtroaonvulsin film m be mama iron the available data for the W pmm» Wattage agents, whammy and insulin can. mat a «mummy mu. m 3mg, mg drug atfce'aa. and maarpina m Manet” mm Wed mmmauon. has am apoaificity is Thou drugs tam .. have been at paychntic mutton soon in the analyses 61‘ mm a delta shift - thc mmfifium mandamus! mom as effeetivc Miriam and 31m.» aa Potent mumminogans. �4%." ma mt‘ma a. synchronimman in 1210 have strum of ohms: in lawn beta range, as in contrast, are poor Viki“ ( aha ) . « 03.80 in has potent. Drug: a hammme, dict-hum am! ”mains, Wars: mm and illusory Momma. mamlihathat WW“: and «9:9me sedation and trwquinsafim, but that man“ we avmahmnuaticm, with than; of mam mooted by manna-d and in 11191 dosage inch-1m maisty, obnmtians are clarity maniatent when awclw in him mam of marginal: and . . raga-Glen of the mm“ a: am am amum, shifts in tha pattern a: m alwtrmaephalogrm in thy dimtim of domchmiumm new in “mam um Maw, >ha11ueimtiom, fantasies, illusions or tremors, and in with mgriu, mlmtian 801: alum and Mammal of mahmniuuam ‘mefi pursuant clung” in mabrai imam “feat behavior mm mm»:- m with an fl'hefltifin in tbs in. 91' than we; *memd' or 'abutomtéd.‘ antral mam mm mum, thaw an upon“ a: mam:- including .mpmn, ma, arm, attitudo. mo aéaptive :11 not Rather, is an alarmist: mam-Wt. We mdar an“ conditimn in variable �.43.. fer eeeh eebJeet end is Gee-Wt mm. W puma-3.1m and the duration of the dieeueeed in behavior are “Wamhtfl matteetere es the type at teierenee, nether abut-term with; . ehenge 1d net "do eve-Tented by the The” rating; “may hem no value psychiatrist as 3W, mentions. a. . «2qu In this meta-e3" the Mamie men”, they men in «relented ale inpmtehent. Ahmed the Wed behavioral name, Mm temwmnw The induce a hehmveral alteratim or eerehrel Imam themem net I ‘cmlieetien' or [In *entemw «new but the chaired goal ef these fame of during the peat the therapy . Mum. u automate w the individual hehevierel new. to the degree of upon and alteration in brain renewal: have The inflated ehe’epe e W “mm mm mmmm and mix-Wm on harem. er the may tine-guest therapies intmchxeeé thirty rem, me eppehenflye has been a. epeeitie agent fer a: psycho»: (in the tense mat penieil‘lin 1e emeifle Tar WW! and nieetmic mid for pellegm émntia) , but rather with greater or lesser degrees of epplieehmty behavior by altering the hombre}. when. and mm etiieaey in altering �, in m, we hm: mm the nmmsiologie upsets at, mm WW3 woman, and hm «minded am; the therapeutic pram of ammonia, insulin can, mtw and trmqnilimrs my Mutant Ilka-mum in «new in uhptaticm at fin mama. mm; pmm the silica a» s. be 3.36de to tha inductian at .J‘mbsactb his 1- , a em Wt. the «flaw at web mutant. mthod in mm to its mmw w W a pursuant. «hung: in! mmbml functim, of mm m «It: shift in the m 'speom with Wad mum“ may but a, amuimt W. management of Such a ' a» bu appliabflity in m m at those thumping to the scram of m payohophfimuolngia agents. and as 3 arms of mnmfizysiofimwu atom m further new of Matter and" � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental studies of convulsive and drug therapies in psychiatry: theoretical implications. Arch. Neurol. Psychiat. (Chic.), 80:733-734, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-33a-010 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/4d1964245452e951a0fc4a640e62c9dc.pdf 68280c1aa72a42e9812ae2fd531e09b0 PDF Text Text 50 ALTERATION OF BRAIN FUNCTION IN THERAPY MAX FINK following summary of observations made at a 200-bed voluntary, nonprofit, open-ward psychiatric hospital during the past three years is presented as the basis for discussion. The major interest of our Research Service is an investigation of the mode of action of various somatic therapies, especially electroshock and drugs. The disciplines represented in the research unit are clinical and psycho« dynamic psychiatry, neuropsychology, and experimental and clinical psychology. The following data summarize various studies that have previously been reported only in part: (I) High-dose reserpine for relief of anxiety: double-blind placebo study. (2) Chlorpromazine-insulin coma study. (3) Electroencephalographic effects of various drugs. (4) Electroshock process: concurrent psychiatric, psychologic, and neurophysiologic observations. HE OBSERVATIONS Reserpine In a placebo-controlled, double-blind study of oral and intramuscular reserpine, consecutive patients referred for drug therapy were rated for degree of manifest anxiety.1 The patients with high degrees of anxiety received randomized three-week periods iof reserpine therapy, divided into the following daily dosage periods: 10 mg. of reserpine (5 mg. oral, 5 mg. intramuscular), 5 mg. of reserpine (oral or intramuscular), or Reprinted from Psychopharmacology Frontiers. Proceedings of the Psychopharmacology Symposium of the Second International Congress of Psychiatry held in Zurich, Sw1tzerland on September 2-4, 1957. Published and copyrighted 1959 by Little, Brown and Company, Boston 6, Massachusetts, USA. �326 PSYCHQPHARMACOLOGY FRONTIERS placebo. Drugs were administered daily. None of the observing therapists knew which sequence was being followed or the dosages administered. Relief of anxiety symptoms related to drug dosage was seen in 20 per cent of the group. In 80 per cent no relief was noted, and of these, onethird exhibited severe depressive reactions which eventually responded to electroshock therapy. The high doses of reserpine administered resulted in significant clinical manifestations in every patient. The be~ havioral changes induced were directly related to the degree of concomitant physiologic disturbance. It was the conclusion of this study that high-dosage reserpine therapy has limited usefulness in the relief of anxiety symptoms. The dangers of induced depressions were clearly manifest, and the uncomfortable nature of the side effects of drug administration has resulted in a limited application of this drug in this environment. Chlorpromazine-insulin coma During a fifteen-month period, all patients referred by the supervising psychiatrists at this hospital for insulin coma therapy were divided by random sampling into an experimental group and a control group.2 The control group received classical insulin coma treatment, following the basic technique of Sakel. All patients received fifty comas, each of a duration of one hour or longer, at the physiologic level of Babinski reflex or absent lid reflex or deeper. The experimental group received chlorpromazine therapy in rapidly increasing dosages until toxicity had been induced. When toxic signs of rigidity, drooling, fixed facies, seizures, dermatitis, or marked weakness appeared, the dosage was gradually reduced until a maintenance level was obtained. Patients were sustained on this regime for a period of three to four months. In both groups, behavioral observations were made by investigators none of whom was the for referred treatment, resulting were Sixty patients therapist. patient’s in two groups of 30 each. The maintenance dosage of chlorpromazine was 300 to 2000 mg. daily. Initial dosages ranged from 1400 to 3600 mg. daily. Chlorpromazine induced motor retardation in all subjects. Overactive, destructive behavior rapidly disappeared, and the patients were more tractable, less negativistic, and less violent. One-third of the patients were more sociable and less seclusive, and were noted to care for themselves in a more presentable fashion. In the instances where severe parkinsonism supervened, however, the patients were less able to care for themselves, became sloppy, and failed to dress. Affective changes during chlorpromazine were varied. Four patients became increasingly agitated, tense, and tremulous, and either refused to continue on the drug regime or were induced to do so only with �MODE or ACTION 327 difficulty. Such an affective .storm appeared early in the therapy and persisted. .. In 4 other cases, depressive symptoms were significantly relieved, with an increase in affective lability and responsivity. In 2 patients, depressive ideation increased and was associated with complaints of insomnia. The medication was continued, however, with eventual alleviation. In most patients mood changes were small. Ideation was altered during the period of chlorpromazine therapy in 12 of the patients. Eight patients had a loss or a significant diminution of psychotic ideation. In 5, the hallucinatory and referential experiences were no longer reported even on inquiry, and in 3 others, delusional ideation was less prominent. In 1 patient, however, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration, with resultant discontinuation of the drug regime. The clinical effects of insulin coma therapy have been exhaustively reported, and the findings in this series are comparable to those previously published. With regard to the evaluation of improvement, all 60 patients of this study have been discharged from the hospital. Table I lists patients according to the four-fold classification in use in the hospital at the discharge conference. TABLE I DISCHARGE RATINGS Chlorpromazine Insulin Coma Recovered Much improved Improved Unimproved 2 4 0 5 l7 l5 7 10 Inherent in the design of this study were high doses of chlorpromazine, pushed until symptoms of toxicity appeared. In this context, therefore, all patients developed significant drug effects. In all, rigidity of extremities appeared, frequently accompanied by a decrease in facial expression, drooling, and festination. Untoward complications are listed in Table II. Electroencephalograms were obtained in 20 of the chlorpromazine patients. On adequate doses, concomitant with a change in clinical behavior a moderate amount of low-voltage 4 to 7 cps delta and theta activity was observed. This activity was exaggerated by hyperventilation. In the 3 patients in whom seizures were induced, the delta activity was not significantly different from the remainder of the group. There was a �328 PSYCHOPHARMACOLOGY FRONTIERS suggestive relationship between the degree of the induced slow-wave activity and the drug dosage. TABLE II COMPLICATIONS Chlorpromazine Agitation and panic Dermatitis, severe Seizures Refusal of further therapy Hypotension Secondary reaction, frequent Prolonged coma (more than 6 hours) Insulin resistance Regression of behavior 4 3 3 2 Insulin Coma 3 5 2 2 — — Dab—409ml 2 It was the conclusion of this study that neither Chlorpromazine in high doses nor insulin coma is a specific treatment for schizophrenia. It was noted that these treatments were devices to temporarily alter behavior that had been socially unacceptable. Since Chlorpromazine was safer, easier to administer, and more controllable in its effect and had fewer side effects, it was recommended that it replace insulin coma. Role of electroencephalographic changes in behavioral change As noted in the following section, a direct relation between changes in electroencephalographic delta and behavioral changes in electroshock had been observed in these laboratories. For this reason, a survey of the role of various newer drug agents was undertaken to determine the potential relationship between behavioral change and electroencephalographic effects. Chlorpromazine and promazine are effective agents for the induction of changes in motor patterns of behavior. Concomitant electroencephalographic effects are the induction of delta activity, a desynchronization of the record, and a decrease in the amount of fast activity. Both drugs also induce seizure activity spontaneously in patients who have not had seizures prior to the administration of the drugs, and in whom pre-treatment electroencephalograms have not demonstrated dysrhythmic activity. Reserpine, while inducing a definite parkinsonian syndrome, does not generally induce seizures. At therapeutic levels, the changes in the electroencephalogram are limited to an increase in fast activity. We have not observed delta activity in any patient receiving reserpine. In patients receiving meprobamate, also, delta activity has not been observed. Records consistently demonstrate high-voltage beta activity, similar to barbiturate. Clinically, meprobamate has some effect in �MODE OF ACTION 329 reducing seizure activity. When dosages are suddenly reduced, we have observed spontaneous seizures in 2 subjects. This observation is similar to that noted in animals.3 Electroshock evalution studies In the course of an extensive evaluation of the electroshock process, a direct relationship has been observed between the degree of induced delta activity and the degree of behavioral change.4 We observed that serial records taken during the course of electroshock therapy and measured for quantitative changes in delta activity could serve as a guide to the therapeutic outcome. Of 11 patients who were clinically rated much improved, 10 had high-degree delta records in the third and fourth weeks of treatment, whereas of 7 unimproved patients only 1 had such a record. In a subsequent series,5 these observations were extended in a predictive study. It was suggested by these initial observations that the much improved patients were those in whom high-degree delta activity had been induced early in the course of treatment and sustained. Records taken during the second and third weeks of treatment were assessed. The results in 54 consecutive patients are noted in Table 111. Of the patients who developed high-degree delta activity during the second and third weeks of treatment, 67 per cent were rated much improved, whereas only 30 per cent of the patients without such activity were so rated. TABLE III PATIENTS WITH HIGH DELTA ACTIVITY IN EEG DURING SECOND AND THIRD WEEKS OF TREATMENT EEG Delta Both high (18) One high (16) None high (20) Much Improved 12 (67%) 4 (25%) 6 (30%) Clinical Rating Unimproved Moderately Improved 4 (22%) 8 7 (50%) (35%) ' 2 (11%) 4 (25%) 7 (35%) Delta activity in the electroencephalogram reflects the state of brain function, and is a guide to alterations in that state. To verify the relationship between delta activity and behavioral change, concomitant amobarbital tests for altered brain function6 were done in this series of patients. It was observed that the amobarbital test results were parallel to the electroencephalographic effects.7 Of patients in the initial series who had been rated as much improved, all had positive amobarbital test reactions after the seventh to ninth weeks of treatment and sustained this response. Of the unimproved patients, however, 15 per cent had �PSYCHOPHARMACOLOGY FRONTIERS 330 positive amobarbital responses in the third week and 28 per cent in the fourth week, but these responses were not sustained. A comparison of both electroencephalographic observations and the amobarbital test data, as related to the eventual clinical ratings, is seen in Table IV.5 TABLE IV ’ EEG AND AMOBARBITAL TEST RESULTS DURING SECOND AND THIRD WEEKS OF TREATMENT Much Improved Moderately Improved Unimproved Both positive amobarbital and high EEG delta activity Either positive amobarbital or high EEG delta activity Neither positive amobarbital nor high EEG delta activity Totals It 25 10 3 8 12 5 0 3 11 33 25 19 apparent that the cluster of positive amobarbital tests, high EEG delta activity, and the much improved clinical ratings is a significant one; equally significant is the cluster of negative amobarbital tests, low to moderate EEG delta activity, and a clinical rating of “unimproved.” In the clinical observations in the electroshock study varied behavioral responses were observed. These included the absence of noticeable symptoms with the return of pre-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic complaints and preoccupations; states of increased panic, excitement, and agitation; and varying degrees of withdrawal and seclusiveness. Similar psychopathologic reactions were observed in schizophrenic patients undergoing either chlorpromazine or insulin coma treatments, or patients with severe manifest anxiety undergoing reserpine therapy. In the electroshock group, the degree of behavioral change was directly related to the degree of alteration in neurophysiologic indices. This direct relationship between neurophysiologic change and behavior was even more clearly manifested in a group of patients treated with subconvulsive therapy. In another control study, 27 subjects received subconvulsive therapy instead of grand mal therapy. The electroencephalo— grams demonstrated either no delta activity or a minimal amount of such activity during the course of treatment. In no patient were moderate or high-degree delta activity records observed. In the amobarbital tests, only 3 patients had positive reactions during treatment, and'in each instance this. occurred only once. Of the 27 subjects no change in sympis �MODE OF ACTION 331' toms or behavior was noted in 23. Nineteen were later referred for a second course of treatment. Of these, grand mal electroshock induced changes in brain function reflected by high-degree delta activity and /or repeated positive amobarbital tests in 14. All 14 showed significant changes in behavior, whereas of the 5 patients in whom physiologic indices showed only minor changes, only 2 showed a definite behavioral change. It is important to note that there was no direct relationship between the physiologic changes and a specific type of behavioral change. There was, however, a direct relationship between the degree of induced physiologic change in brain function and the degree of behavioral change. In a further attempt to determine the relationship between the type of behavioral change and other variables, we have carried out studies on the role of personality in the behavorial response.8 The initial study of the role of personality was devoted to a study of the relation between the characterologic disposition of patients to show denial mechanisms and the clinical results. The relatives of 47 patients were interviewed and denial personality scores were assessed, following a structured interview. Denial scores range from 0 to 25, with a median of 11. The scores were then divided into two groups: scores from 11 to 25 were classed as high denial and those from 0 to 10 as low denial. Of patients with high denial personality scores, 58 per cent were in the much improved group and only 1 patient was in the unimproved group. The ratings of improvement for the patients with low denial personality scores were random, about one-third appearing in each rating category. These studies support the present neurophysiologic adaptive hypothesis of the mode of action of electroshock therapy. This hypothesis notes that alteration in brain function is the central effect of electroshock therapy and is a prerequisite to behavioral change. It also notes that under the conditions of the induced change in brain function, altered patterns of adaptation are expressed. The type of adaptation varies, apparently dependent upon the personality organization. CONCLUSIONS Largely on the basis of these observations, as well as of reports of numerous other observers, the following conclusions regarding the role of physiodynamic therapies in schizophrenia are suggested: (1) None of the present therapeutic regimes, including insulin coma therapy, electroshock therapy, and the newer drug therapies including chlorpromazine, reserpine, meprobamate, and promazine, are specific for schizophrenic illnesses. No evidence has been educed that any of these therapies have altered the basic schizophrenic process. �332 PSYCHOPHARMACOLOGY FRONTIERS (2) Behavorial change in electroshock has been shown to be depend- ent on an alteration in brain function, as evidenced by serial changes in delta activity in the electroencephalogram. Under these conditions, the pattern of behavioral alteration varies markedly, depending on the degree of induced cerebral dysfunction, the personality of the subject, and the environmental situation. (3) The newer drug therapies have effects on brain function in direct proportion "to their ability to alter behavior as determined by clinical observation. The parallel between electroencephalographic change and behavioral change leads to the proposition that the mode of action of newer drug therapies may be similar to that of electroshock therapy; viz., by altering brain function in a nonspecific manner, behavioral changes are induced.9 To the extent that the behavioral alteration is of a kind that is rated as improved by the environment, the drugs are considered satisfactory therapeutic agents. In this regard, it is important to note that improvement ratings are but a special case of behavioral change, dependent on the type of adaptation elicited, the expectation of the therapist, administrator, and family, and the tolerance of the milieu. REFERENCES l. Wachspress, M., Blumberg, A. G., Fink, M., and Miller, J. S. A. Evaluation of high-dose reserpine therapy for relief of anxiety. 1. Hillside Hosp, 5: 67, 1956. Fink, M., Shaw, R., Gross, G. C., and Coleman, F. S. Comparative study of chlorpromazine and insulin coma in therapy of psychosis. ]. A. M. A. In press. 3. Wikler, A. Personal communication. 4. Fink, M., and Kahn, R. L. Relation of EEG delta activity to behavioral redr Arch. A. A. Neural. M. studies. serial electroshock: in quantitative sponse Psychiat., 78: 516, 1957. 5. Fink, M., Kahn, R. L., and Green, M. A. Experimental studies of the electroshock process. Dis. Nerv. System, 19: 113, 1958. 6. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L. Diagnostic use of amobarbital sodium (“Amytal Sodium”) in organic brain disease. Am. ]. Psychiat., 112: 889, 1953. 7. Kahn, R. L., Fink, M., and Weinstein, E. A. Relation of amobarbital test to clinical improvement in electroshock. A. M. A. Arch. Neurol. 69' Psychiat., 76: 2. 23, 1956. Kahn, R. L., and Fink, M. Personality factors in behavioral response to electroshock therapy. Confinia neural. In press. 9. Fink, M. A unified theory of the action of physiodynamic therapies. J. Hillside 8. Hosp, 6: 197, 1957. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alteration of brain function in therapy. In NS Kline (ed.), Psychopharmacology Frontiers. Little, Brown & Co., Boston, 1959: 325-332. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-33b-011 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from Psychopharmacology Frontiers. Proceedings of the Psychopharmacology Symposium of the Second International Congress of Psychiatry held in Zurich, Sw1tzerland on September 2-4, 1957. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effect of anticholinergic compounds on post-convulsive electroencephalogram and behavior. Electroencephalogr Clin Neurophysiol.,10:776, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-34a-012 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/ab4087755279fc01b94c0135ed348fc4.pdf b42318ee79fcb2ebd0a6f398dbb0a0b0 PDF Text Text EFFECT OF ANTICHOLINERGIC COMPOUNDS (IN POST CONVULSIVE ELECTROENCEPHALIIGRAM AND BEHAVIOR 0F PSYCHIATRIC PATIENTS MAX FINK, M.D. Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. Reprinted from "Electrrrrrephalography and Clinical Neurophysiology Ioumal" Vol. 12, No.2, May 1960. �EFFECT OF ANTICHOLINERGIC COMPOUNDS ON POST CONVULSIVE ELECTROENCEPHALOGRAM AND BEHAVIOR OF PSYCHIATRIC PATIENTS 1 MAX FINK, M.D. Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. (Received for publication: March 11, 1959) Demonstrations of the significance of high voltage EEG delta activity in the convulsive therapy process (Roth et al. 1951, 1957; Fink and Kahn 1957) and the report that this delta activity was blocked by the administration of atropine and scopolamine (Ulett and Johnson 1957) provided the basis for these studies. As there were attendant unpleasant systemic effects with the administration of these agents, reports describing diethazine as an antieholinergic compound with potent neurologic but minimal systemic effects (J enkner and Lechner 1955; Lechner 1956) led us to undertake studies similar to those of Ulett and Johnson using this compound (Fink 1958). Observa— tions with diethazine led to the investigation of other experimental anticholinergic agents. This report describes clinical and electroencephalographic observations incident to the intravenous administration of various anticholinergic agents in psychiatric patients at various stages of convulsive therapy and relates the observations to hypotheses concern— ing the mode of action of convulsive therapy and of hallucinogens. Patients have been observed at various stages of the treatment process. The observations were made in the EEG laboratory, using a standard 8 channel EEG recorder and needle electrodes applied in 17 lead placements following Strauss et al. (1952). In each trial, the compound under study was administered intravenously at a set rate per minute until clinical behavior or electrographic changes were observed. The compounds studied have been dietha— zine (Heymans et al. 1949), Win-2299 (Pennes and Hoch 1957), benactyzine (Jacobson 1955), JB-318 and JB-336 (Abood et all. 1958) and atropine. Diethazine was administered at 25 mg. per minute for a total of 175-250 mg. (2.5-5.0 mg/kg.) ; Win-2299 and benactyzine at 0.5 mg. per minute for 2 to 5 mg. (0.02-0.15 mg/kg.) ; and JB-318, JB-336, and atropine at 0.4 mg. per minute for 1.2 to 4.0 mg. (0.01-0.10 mg/kg.). OBSERVATIONS (a) Diethazine. The administration of diethazine in 15 patients prior to convulsive resulted in a decrease in EEG volttherapy SUBJECTS AND METHOD ages an-d a desynchronization of all freThe subjects were 90 psychiatric patients quencies. Prevailing rhythmic patterns bereferred for convulsive therapy. Ages ranged came less pronounced. In some instances, symfrom 18 to 67 years, and diagnoses included metric low voltage 6—7 c/sec. activity appeared schizophrenic reactions and manic-depressive and was most apparent in frontal and anterior and involutional-depressive psychoses. A va— temporal leads (Fink 1958). ried number of subjects were studied for each In 25 patients with varying degrees of induced high voltage delta activity during compound for a total of 107 observations. convulsive therapy (Fink and Kahn 1957), 1Aided, in part, by grants M-927 and MY-2092 there was a significant decrease in voltage and of the National Institute of Mental Health, National in per cent time of slow wave activity. From Institutes of Health, US. Public Health Service. 45 of in frontothe delta cent an average per Atlantic Read at the American EEG Society, occipital leads, there was a reduction to a City, June, 1958. [359] . �MAX FINK 360 mean of 20 per cent. Both random and burst delta activity diminished. Low voltage alpha and beta frequencies became more prominent. The usual increase in per cent time and in voltage of slow wave activity with hyperventilation was no longer apparent. These electrographic effects appeared during drug administration and persisted for 1 to 5 hours (Fink 1958). Concurrent with these electrographic effects, we observed distinctive systemic and complaints of abdominal griping. Such effects were generally less prominent than the electrographic or behavioral. Behaviorally, patients became irritable, restless, tense and excited, and it was difficult to maintain eyelid closure. They complained of feelings of unreality and of tingling, weakness and heaviness of the extremities. Complaints that colors were pale or more intense, halos about lights and changing shadows were accompanied by delusional thoughts about W W W mm W W W W W W W W W W WWWW PRE-DRUG LF-LO WWW/(WWW RF—RO + 40 MINS. AFTER 3.2 mg. WM + 80 MINS. wwwwvuwwmm WWWM wwwmmmw LAT-LF MAM-«Mm RAT-RF LF-RF LPT-LO 0-0 RPT'RO SouVLlsfi- #2016 HH Fig.1 Effect of i.v. Win-2299. Note desynchronization of frequencies after behavioral changes. The initial systemic effects were episodes of coughing and complaints of dryness of the mouth. Skin remained dry and the heart rate increased by 5 to 10 per cent. This increase was rarely noted by the subject, and was not accompanied by precordial distress. There was no change in pupillary size, and constriction in response to light was prompt. There were occasional 3.2 mg. (Female, age 41). their illness, the setting of the test procedure or the examiner ’s identity. (1)) Win-2299. The report by Pennes and Hoch (1957) that Win-2299 induced illusory and hallucinatory states in man, led to this next study. On intravenous administration of Win-2299, both electrographic and behavioral effects similar to diethazine were observed. In 5 patients without EEG slow wave �ANTICHOLINERGIC COMPOUNDS AND POST CONVULSIVE EEG activity, desynchronization of frequencies and a decrease in voltages were noted in four (fig. 1). In 11 patients with high voltage delta activity there was a decrease in amplitude and per cent time of slow wave activity with an increase in the per cent time of alpha and beta frequencies. The mean delta activity dropped from 50 to 23 per cent (fig. 2). Associated with these electrographic effects were clinical patterns of restlessness and excitement, and minimal systemic effects. PaPRE-DRUG 361 rate was unaffected except in patients who became. overtly excited and fearful, in whom tachycardia appeared during this excitement period. Dryness of the mouth was reported only on direct inquiry. (c) Benactyzine. Reports that benactyzine induced EEG desynchronization (Coady and Jewesbury 1956), its anticholinergic nature, and the structural similarity to diethazine and to Win-2299 led to our testing of this compound. Intravenous administration in 12 subjects elicited similar clinical and + 40 MINS. AFTER 2.0 mg. + 60 MINS. LF-LO W WW W” W WW W WWWW Wm Wm M W MW RF- R0 Wm WM RAT-RF WWW WNW LPT-LO 0-0 RPT-RO 50ml I SEC. # 1977 HH Fig. 2 Effect of i.v. Win-2299 on post—convulsive delta activity. Record taken 24 hours after convulsion #8. Note desynchronization of frequencies and persistence after 2.0 mg. (Female, age 51). tients became fearful and tense. Visual illusory sensations were reported and were associated in these subjects with delusional elaborations about their hospital experience. Excitement was accompanied by ideas of reference, and in two subjects, intravenous chlorpromazine was administered to halt this process. These behavioral changes appeared during drug administration or within 10 min, and disappeared within 2 to 3 hours. Systemic effects were slight. There were neither cough nor respiratory distress. Heart electrographic patterns. Both in the well modulated alpha record and in the record with high voltage delta activity, desynchronization was prompt. Delta activity decreased from a mean time of 39 to 16 per cent in 8 subjects (fig. 3, 4). These electrographic patterns were again accompanied by clinical restlessness, irritability and excitement. Artifact-free recording was more difficult. The illusory sensations and delusional thoughts seen with the initial compounds were not noted at these dosage �MAX FIN K 362 levels. Systemic effects were similar to Win2299. activity and clinical somnolence, we administered this anticholinergic agent intravenously in 15 subjects, in dosages of 0.8 to 4.0 mg. (.01-.10 mg/kg.). In 6 subjects without EEG delta activity, there were no changes in EEG pattern during drug administration nor for 10-20 min. thereafter. During a period of lassitu-de, decreased voltages, minimal desynchronization, and an increase in per cent time delta were noted. In subjects with delta activity, there was (d) Piperidylbenzilates. Following recent reports by Abood et al. (1958) that various piperidylbenzilates with measurable anticholinergic activity induced hallucinations in psychiatric subjects, we tested JB-318 and JB— 336 in 24 subjects. The electrographic patterns were identical with the other experimental anticholinergic compounds. Desynchronization of frequencies was noted during W W W W WM W W W WWW WWW WW PRE-DRUG LF-LO + 30 l0 MINS. AFTER |.5 + 50 MINS. MINS. mg. RF-RO LAT-LF RAT-RF LFTRF .. LPT-LO .. "A“... WWW/w WWW/WW 0'0 RPT-RO WM 50ml— WNWMNW‘AMAM. I Fig. SEC. WWW # |922 HH 3 Efftct of i.v. benactyzine. Note persistent decrease in voltages and desynchronization after 1.5 mg. (Female, age 34). the injection or within 15 min. and persisted for one to 4 hours (fig. 5). In each instance in which desynchronization was observed, clinical restlessness, excitement, illusory and hallucinatory activity were noted, and were concurrent with the electrographic changes. In two instances the behavioral changes were halted by the intravenous administration of chlorpromazine. (e) Atropine. Considering the numerous reports that atropine induced EEG slow wave an apparent initial decrease in voltage and per cent time of such activity during the first 10 min. after administration, followed by a return to original values during the period of quietude. In neither period were the changes significant (fig. 6). Systemic effects were prominent during the injection with increased respiratory rate, pallor, dry skin and dry mouth, precordial complaints and an increase in heart rate up to 100 per cent. Subjects became restless and �ANTICHOLINERGIC COMPOUNDS AND POST CONVULSIVE EEG recording became difficult. Within 10 min. these symptoms subsided and the subjects became drowsy and relaxed. 363 atropine under similar experimental condi- tions. These observations can be related to theories of the mode of action of convulsive DISCUSSION therapy; to concepts of the basis of experIn these studies, various experimental imentally induce-d hallucinations; and to recompounds with measurable anticholinergic ports of the effects of atropine on EEG patactivity have been observed to have similar terns. electrographic and behavioral effects. Elec(a) Convulsive therapy process. Earlier trographically, each agent induced a desyn- studies indicated that the development of high PRE-DRUG LF-LO RF-RO LAT-LF W + l0 2 MINS.AFTER MINS. |.5 mg. M +50 MINS. WW Wm «MW—MAW .AWNV'VW W W W WM W W W WW WW RAT-RF LF-RF LPT-LO Wm MWM'W 0-0 WWW/v RPT-RO WW4{)0qu #ZOIB HH Fig.4 Effect of i.v. benactyzine on post-convulsive delta activity. Record taken 24 hours after convulsion # 7. Note desynchronization of frequencies after 1.5 mg. (Female, age 33). chronization of frequencies and a decrease in voltages, which was most prominent in subjects with delta activity following convulsive therapy. Behaviorally, these electrographic patterns were associated with stimulating, excitatory, illusory and hallucinatory activity. To a lesser degree, minimal systemic changes in heart rate, salivation and sweating were noted. These latter systemic effects were more prominent in patients given intravenous voltage slow wave activity was a neurophysiologic correlate of behavioral change in convulsive therapy, and a necessary, though not sufficient, condition for clinical improvement (Fink and Kahn 1957). In summarizing the observations of numerous authors on the relation of acetylcholine metabolism to trauma of the central nervous system and to convulsions (Fink 1958) it was suggested that a biochemical concomitant of the induced EEG slow �MAX FINK 364 WWW WWVWWWW PRE-DRUG LF-LO AFTER 2.4 MG.IV l0 MINUTES AFTER WWW mm WWW WWW W W WWW W PR=|08 PR=96 .18 318- N-ETHYL, 3-PIPERIDYLBENZILATE PR=84 SOuvL—_ # 2|50 HH ISEC. Fig. 5 Effect of JB-318 on post-convulsive delta activity. Record taken 24 hours after convulsion #9. Note desynchronization of frequencies, decreased voltages after 2.4 mg. Cardiac rate shows 10 per cent increase. (Female, age 27). Similar records observed with PRE- DRUG JB—336. AFTER 2.0 MG. IV AFTER 30 MINUTES LAT-LF # 2|90HH HR=78 HR=|50 Fig. 50va__ l 6 SEC. Effect of small doses of i.v. atropine on post-convulsive delta activity. Record taken 24 hours after convulsion #6. Note minimal effect on delta activity and associated increase in heart 2.0 mg., 025 mg/kg.) rate, with persistence. (Male, age 18. Atropine : �ANTICHOLINERGIC COMPOUNDS AND POST CONVULSIVE EEG wave activity was an increase-d level of acetylcholine-cholinesterase activity of the central nervous system. The present observations of alterations in the slow wave activity of convulsive therapy by these experimental anticholinergic compounds are consistent with this suggestion. That the problem is more complex is indicated by reports of compounds with other biochemical activity also affecting slow wave activity in a similar fashion. Amphetamine (Lennox et al. 1951), Mescaline (Merlis and Hunter 1955; Denber 1955), lysergic acid diethylamide (Bente et al. 1957 a, b) and diphenhydramine (Diaz—Guerrero ct al. 1956) also reduce-d post-convulsive slow wave activity. In these reports, such a reduction was accompanied by excitatory and stimulating effects on behavior. These compounds, how— ever, are primarily sympathomimetic and antihistaminic in pharmacologic activity and not anticholinergic. The similar effects of these diverse biochemical agents on electrographic patterns and on clinical behavior may be considered within theoretic constructs of the relation of synaptic activity to behavior as expressed by Marazzi (1953, 1957), Bradley and Elkes (1957), Evarts (1958 a, b), Sherwood (1958) and Woolley (1958). These authors suggest that two types of interacting chemoresponsive receptors exist within the nervous system which are selectively responsive to cholinergic or to adrenergic agents. Where such receptors exist, they exert opposing stimulatory or inhibitory action. Thus, repeated induced convulsions may lead to a change in synaptic cholinergic activity, reflected in surface electrodes as high voltage slow wave activity. Administration of anticholinergic agents may alter synaptic activity, resulting in a decrease in the manifest cortical electrical activity to preconvulsive levels. Administration of sympathomimetic agents may achieve the same electrical effects by increasing the level of adrenergic activity. The manifest slow wave activity, so prominent and so persistent in the post-seizure EEG, may thus be viewed as resulting from a persistent alteration in the synaptic activity of large numbers of cells of the central nervous 365 system. The delicate nature of this balance is seen in the ready reversibility with alerting, time, and the wide variety of pharmacologic agents noted here. While an alteration in synaptic activity may underlie the behavioral changes in convulsive therapy, the mechanism by which such alteration is developed or sustained is unclear. The observation by Aird et al. (1956 a, b, 1958), that an increase in permeability of the blood brain barrier followed repeated induced convulsions suggests one way in which synaptic changes may be mediated. The consistent nature of these neurophysiologic observations makes an exclusively psychologic explanation of the mode of action of convulsive therapy less tenable. These studies are consistent, however, with the neurophysiologic-adaptive view of the convulsive therapy process which suggests that neurophysiologic changes provide the substrate for alterations in all aspects of the subject’s clinical behavior; the type of behavioral alteration being dependent upon the type and degree of neurophysiologic change, the personality of the subject and the expectations and tolerance of the milieu (Weinstein and Kahn 1955; Fink and Kahn 1957; Fink 1957). (b) Neurophysiology of hallucinogenic activity. The effects of anticholinergic compounds-on EEG and behavior may also be related to the understanding of experimental hallucinogenic activity. Each of these experimental compounds induced excitatory behavior, including illusory and hallucinatory phenomena. Here, too, a synaptic model may be applicable. Sympathomimetic agents, as Mescaline, LSD and amphetamine, and anticholinergic agents as those described here, are also potent hallucinogens. A neuropharmacologic basis for such behavior may be characterized as an alteration in the level of synaptic activity in the direction of increased inhibition (decreased transmission) of stimuli. The clinical efficacy of convulsive therapy in modifying hallucinatory activity may lie in alterations at this neurophysiologic level. The effects of such hallucinogenic blocking agents as chlorpromazine and Reserpine on EEG electrical activity are consistent with such a view. Both compounds induce EEG �366 MAX FINK hypersynchrony in man (Bente and Itil 1954, 1958) and block the EEG desynchronization effects of LSD and Mescaline (Schwartz ct al. 1955). Chlorpromazine was found equally potent in aborting the excitatory activity of the experimental anticholinergic compounds in these studies. (0) Relation to atropine. Comparison of the systemic and neurologic effects of experimental anticholinergic compounds with atropine reveals differences in initial focus of action. Experience with atropine at physiologic and toxic levels in man indicate that the predominant effects are focused at peripheral nervous structures. Initial bradycardia, followed by tachycardia, loss of sweating and salivation, pupillary dilation, intestinal relaxation and decreased motility are amongst the effects at low (0.2-1.2 mg.) dosages. At higher dosages (2-5 mg), the neurologic effects of ataxia, irritability, disorientation, and delirium are observed (Goodman and Gilman 1955). In contrast, the experimental anticholinergic agents in dosages sufficient for central nervous system effects manifest little peripheral activity. The central effects are observed early and may continue for extensive the dosage of atropine varied from 0.5 to 7 mg/ kg. — a range roughly comparable to the dosages used in atropine coma therapy (Forrer and Miller 1958) . In the present studies, the EEG effects of low dosages of intravenous atropine (0.01 to 0.10 mg/kg.) were minimal and systemic effects considerable, confirming similar observations by Verdeaux and Marty (1954) and by Danielopolu et al. (1955). The slow wave activity so prominent in animals and man at high dosages of atropine, may not be a manifestation of the initial or direct effects of atropine, but a reflection of a more widespread alteration in body physiology. Thus, while considerable speculation as to central neurophysiology has been based on studies with atropine, such observations provide a special case of anticholinergic effects. The anticholinergic activity established in observations in vitro and in the peripheral nervous system, may not be the effective physiologic activity in the large doses necessary to affect central structures. The experimental compounds, however, provide more suitable agents for the study of central neurophysiologic (anticholinergic) patterns than atropine, as, for example, in a re-evaluation of the studies of craniocerebral trauma and epilepsy. Ward’s (1950) reports of the efficacy of high doses of atropine in altering the clinical manifestations of head trauma indicated that effective doses brought with them severe systemic effects. The failure of atropine and scopolamine to affect epilepsy may be related to the inability of these compounds to reach the central nervous system in adequate quantity. It would seem advisable, therefore, to repeat these studies utilizing such more centrally active anticholinergic compounds as used in the experiments reported here. periods without gastrointestinal, cardiac or pupillary changes. It is within the context of the focus of activity in relation to dosage that the apparent discrepant EEG observations of the effects of atropine (in inducing slow wave activity) and these experimental anticholinergic compounds may be reconciled. Wescoe et al. (1948) administering 1.0 to 3.0 mg/kg. atropine in curarized cats and monkeys and Fun— derburk and Case (1951) using 0.4 to 1.2 mg/ kg. in curarized cats, observed high voltage EEG slow wave activity. Wikler (1952, 1957) reported that 7.2 mg/kg. atropine on SUMMARY unanesthetized, uncurarized dogs produced 1. Experimental anticholinergic comslow similar to wave” sleep. “spindle patterns Rinaldi and Himwich (1955 a, b) reported pounds (diethazine, Win-2299, benactyzine, JB-318 and administered to JB-336), psy0.5 2.0 of doses to that atropine in mg/kg. chiatric patients at various stages of convulin curarized rabbits exaggerated EEG sleep sive associated with: therapy, were of the inhibited and the alerting patterns EEG to peripheral stimuli. Similar observa- (a) desynchronization of EEG rhythms with tions have been reported by Bradley and Elkes a blocking of post-convulsive delta activ(1953) in the conscious cat. In each instance ity ; �ANTICHOLINERGIO COMPOUNDS AND POST CONVULSIVE EEG 367 (a) des effets systémiques de faiblesse musculaire, sécheresse buccale, sécheresse cutanée et tachycardie. Les effets de comportement, électrographiques et systémiques étaient concurrents. 2. Ces observations sont consistentes avec The electrographic, behavioral and systemic la suggestion qu’un concomittant neurophysiologique de la thérapie convulsive soit l’augeffects were concurrent. 2. These observations are consistent with mentation de l’activité cholinergique du systéme nerveux central. the suggestion that a neurophysiologic conco3. Des observations sur le fait que le LSD, mitant of convulsive therapy is an increase in central nervous system cholinergic activity. l’amphétamine, 1e Mescaline, et le diphenhy3. Observations that LSD, amphetamine, dramine — agents sympathicomimétiques et Mescaline and diphenhydramine —- sympatho- antihistaminiques — induisent également une mimetic and antihistaminic agents — also in— désynchronisation EEG, le blocage de l’acti— duce EEG desynchronization, blocking of vité delta post-convulsive et l’activité clinique post convulsive delta activity and clinical excitatoire, soutiennent la suggestion que des excitatory activity support the suggestion that variations de comportement et electrographibehavioral and electrographic patterns may ques puissent étre basées sur des alterations be based on alterations in synaptic activity. de l’activité synaptique. On suggere que l’acIt is suggested that increased synaptic activ- tivité synaptique augmentée (effets cholinerity (cholinergic, sympatholytic effects) is giques, sympatholytiques) soit associée a l’hyassociated with EEG hypersynchronization, persynchronisation EEG, la sé-dation clinique and clinical sedation and euphoria; while de- et l’euphorie; tandis que l’activité synaptique creased synaptic activity (anticholinergic, diminuée (anticholinergique, sympathomimesympathomimetic) is associated with EEG tique) soit associée a la désynchronisation desynchronization and clinical excitatory and EEG et des états cliniques excitatoires et hallucinogéniques. hallucinogenic states. 4. Des observations contradictoires avec 4. Discrepant observations with atropine are related to significant differences in dosage. atropine sont en relation avec des differences Re-assessment of the role of anticholinergic signifi'catives de dosage. Une reevaluation du role d’agents anticholinergiques dans les trau— is seizure and in head states trauma agents matismes craniens et les états comitiauX semsuggested. 5. These observations amplify the neuro- ble étre indiquée. 5. Ces observations amplifient l’hypothese physiologic-adaptive hypothesis of the mode of action of convulsive therapy and of exper- neurophysiologique-adaptive du mode 01 ’action de la thérapie convulsivante et des états halluimental hallucinogenic states. cinogenes expérimentaux. (b) alerting, excitatory behavioral response with illusory, delusional and hallucinatory i-deation; and, (a) systemic effects of muscular weakness, dryness of the mouth, dry skin and tachycardia. RESUME Des composés anticholinergiques eXpérimentauX (diethazine, Win-2299, benactyzine, JB-318 et J 13-336), administrés a des patients psychiatriques a des étapes différentes d’une thérapie convulsivante, étaient associés avec: ZUSAMMENFASSUNG 1. (a) une désynchronisation des rythmes EEG, avec un blocage de l’activité delta postconvulsive; (b) une réponse de comportement excitatoire, vigilante, avec de l’idéation illusoire, délusionnelle et hallucinatoire, et Mischungen von experimentellen anticholinergischen Stoffen (Diethazine, Win2299, Benactyzine, JB-318 und J 13-336) wurden psychiatrischen Patienten verabreicht welche sich in verschiedenen Stadien der konvulsiven Therapie befanden. Hierbei wurde folgendes beobachtet: 1. (a) Eine Desynchronisierung der EEGRhythmen mit Blockierung der postkonvulsiven Delta-Aktivit'at. �MAX FINK 368 (b) Eine Weckreaktion mit erregtem Benehmen, welches mit Illusionen, Halluzinationen und Wahnideen einherging. (c) Allgemeineffekte charakterisiert durch Muskelschwache, Trockenheit des Mundes und der Haut und Tachykar-die. Die elektrographischen- und Allgemeineffekte, sowie die Veranderungen des Benehmens erfolgten gleichzeitig. 2. Diese Beobachtungen stehen nicht in Konflikt mit der Theorie, wonach eine Erhahung der cholinergischen Aktivit'at im zentralen Nervensystem eine neurophysiologische Folgeerscheinung der konvulsiven Therapie darstellt. 3. Die Beobachtungen, dass LSD, Amphetamin, Meskalin und Diphenhydramin sympathomimetische und antihistaminische Stoffe —— ebenfalls die EEG-Desynchronisation herbeifiihren, die postkonvulsive DeltaAktivitat blockieren und die klinische Erregtheit dampfen, unterstiitzen die Annahme, dass elektrographische Veranderungen sowie solche des Benehmens auf Anderungen der synaptischen Aktivit'at zuriickgefiirt werden konnen. Es Wird angenommen, dass eine erh'ohte synaptische Aktivitat (cholinergische, sympathikolytische Effekte) assoziiert ist mit Hypersynchronisierung des EEG’s, mit klinischer Sedation und Euphorie, W'ahrenddem eine verminderte synaptische Aktivit'at (anticholinergische, sympathikomimetische Effekte) assoziiert ist mit Desynchronisierung des EEG und mit klinischen halluzinatorischen Erregungszustanden. 4. Abweichende Beobachtungen mit Atropin stehen mit signifikanten Differenzen in der Dosierung in Beziehung. Die Rolle, welche anticholinergische Stoffe bei Kopftrauma und Anfallszust'anden spielen, sollte erneut in Betracht gezogen werden. 5. Diese Beobachtungen unterstiitzen die neurophysiologische Hypothese fiber die Aktionsart der konvulsiven Therapie und der experimentellen halluzinatorischen Zust'ande. I am grateful for the technical assistance of Mrs. Hannah Mosquera in EEG recording and analyses. 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Effect of atropine and scopolamine upon electroencephalographic changes induced by electroconvulsive therapy. EEG Olin. Neurophysiol, 1957, 9: 217—224. VERDEAUX, G. et MARTY, R. Action sur l’électroencé- phalogramme de substances pharmacodynamiques d’intérét clinique. Rev. Neural, 1954, .91: 405-427. WARD, A. Atropine in the treatment of closed head injury. J. Neurosurg., 1950, 7: 398-402. WEINSTEIN, E. A. and KAHN, R. L. Denial, of Illness: Symbolic and Physiological Aspects. C. Thomas, Springfield, 111., 1955. 0., GREEN, R. E., MCNAMARA, B. P. and KR-OP, S. The influence of atropine and scopolamine on the central effects of DFP. J. Phar- WESCOE, W. macol, 1948, .92: 63-72. WIKLER, A. Pharmacologic dissociation of behavior and EEG “sleep patterns” in dogs: morphine, N’allylnormorphine and atropine. Prac. Soc. Exper. Biol. Med., 1952, 79: 261—265. WIKLER, A. The Relation of Psychiatry ta Pharmacology. Wm. Wilkins, Baltimore, 1957. WOOLLEY, D. W. Serotonin in mental disorders. Res. Publ. Ass. nerv. ment. Dis., 1958, 36': 381-400. Reference: FINK, M. Effect of anticholinergic compounds on post convulsive EEG and behavior of psychiatric patients. EEG Olin. Neuraphysial., 1960,12: 359-369. W w IN �ANNOUNCEMENT WEEK—END COURSE IN "EEG AND CLINICAL NEUROPHYSIOLOGY IN PAEDIATRIC PROBLEMS” Institute of Child Health, Hospital for Sick Children, University of London, London, England Saturday, June 18th, 1960 9.45 a.m. Introduction. 10.00 a.m. Electrocorticography During Operations for Partial Epilepsy. 11.15 a.m. Coffee. 11.30 a.m. Motor Function and The Basal Ganglia. 1.00 p.m. Lunch. 2.00 p.m. Behaviour after Cerebral Lesions in Children and Adults. 3.15 p.m. Tea. 3.30 p.m. Diffuse Systems in the Brain: Physiological and Pharmacological Mechanisms. Dr. Otto Magnus, Head EEG Dept, St. Ursule Clinic, Wassenaar and “Meer en Boslk’ ’, Hemsteede, Holland. Dr. John A. V. Bates, Neurological Research Unit (M.R.C.), The National Hospital, Queen Square. Prof. H. L. Teuber and Dr. R. Rudel, Dept. of Psychiatry and Neurology, New York University, Bellevue Medical Centre. Dr. Philip Bradley, Dept. Experimental Psychiatry, University of Birmingham, Hon. Director M.R.C., Neuropharmacology Research Group Sunday, June 19th, 1960 10.00 a.m. Circulatory Arrest. 11.15 a.m. Coffee. 11.30 a.m. The Clinical Physiology of the Lower Motor Neurone. Dr. G. Pampiglione, Dept. Clinical Neurophysiology, Hospital for Sick Children, Lecturer Institute of Child Health, University of London. Dr. J. A. Simpson, Neurology Unit, Northern General Hospital, and University Department of Neurology, Edinburgh. ��,. ,r" . 7/ Editor-imChief E L E C T R O E N C E p H A LO G R A p H Y Montreal Neurological Institute 3801 University Street Montreal 2' Canada AND HERBERT H. JASPER CLINICAL Editorial Assistant Montreal IItlleurological Institute 3801 niversity Street “m“l 2. R' S. SCHWAB . Massachusetts General Hospital Boston 14. Mass” U.S.A. H. FISCHGOLD 9 ans “élP‘FQ‘” . rance l NEUROPHYSIOLOGY PIERRE GLOOR M Associate Editors Clinical and Laboratory Notes can“ d ° . An International )ournal European Office Managing Editors W. STORM VAN LEBUWEN OTTO MAGNUS THE E.E.G. JOURNAL Aid. Electro-Neurologie Academisch Ziekenhuis Leiden, Holland. StreEt Montreal 2' Canada . 3801 univerSity my 6 , 1959 a Technical Notes _H. {WM 3,1111%??? D.lVlSlon o e rca ec romcs College of Medicine Iowa City. Iowa. LI.S.A. F. BUCHTHAL Universitetets Izeurofysiologiske Institut Copen aaen. Denmark _ _ Index and Review of Literature C. E. HENRY Institute of Living 200 Retreat Avenue Hartford, Conn., U.S.A. Dr. Max Fink, Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. N. Y. Dear Dr. Fink: I., - Effect of Anticholinergic Compounds on Post Behavior of Psychiatric Patients Convulsive I am pleased to inform you that the above manuscript has been reviewed by members of our Editorial Board and recommended for publication with some revision. < .. ”by/finwfilw... l , Re: MS 981 EEG & In the first place, I am sorry to have to ask you to condense the manuscript to about two thirds of its present size, since we have had to institute a more stringent regulation regarding the length of manuscripts, due to an excessive amount of material for publication. I should think that this condensation could well be made in your study by reducing the length of your discussion and trimming up descriptions in places where elaboration of drug action is perhaps not necessary, as such information may well be available in current pharmacological literature. also that you consider alternative hypotheIt is recommended modes and of action. Reference to the work by Aird, other possible see; on Cerebro-vascular Permeability, to be found in the Archives of 1956, the Journal of Nervous and Mental Disease of 1956, the Archives of 1958 and the Journal of Neurosurgery of 1952 might be worthwhile. Your synaptic theory would be stronger if it was not over-emphasized and made clear that it is only a tentative hypotheses throughout, perhaps particularly in the conclusions where it should be quite clear that your statements are hypothetical rather than proven, since the relationship between the EEG patterns and synaptic activity is a very tenuous one and may, at times be inverted. We also would like to have some legends for your illustrations make them to clear and independent of the text. Official organ of the International Federation of Societies for Electroencephalography and Clinical Neurophysiology, Inc. �ELECTROENCEPHALOGRAPHY Editor—in-Chief HERBERT H. JASPER Montreal Neurological Institute 3801 University Street Montreal 2. Canada R. S. SCHWAB Massachusetts General Hospital Boston 14. Mass.. U.S.A. AND C LI N I C A L Editorial Assistant H. FISCHGOLD NEUROPHYSIOLOGY PIERRE GLOOR Montreal Neurological Institute 3801 University Street Montreal 2. Canada H. W. SHIPTON THE EEG. JOURNAL Division of Medical Electronics College of Medicine Iowa City, Iowa. U.S.A. F. BUCHTHAL Universitetets Neurofysiologiske Institut Copenhagen. Denmark 3801 University Street. Montreal 2, Canada Index and Review of Literature EurOpean Office Managing Editors OTTO MAGNUS Afd. Electro-Neurologie Academisch Ziekenhuis Leiden, Holland. 1 rue Lu Cases Paris VII. France Technical Notes An International Iournal W. STORM VAN LEEUWEN Associate Editors Clinical and Laboratory Notes C. E. HENRY Institute of Living 200 Retreat Avenue Hartford, Conn.. U.S.A. _ 2 _ to your illustrations, we compliment you on their clarity and clean presentation; but there is some question as to whether they are all needed to make your points. If you can find some way of reducing their number to enable further condensation of your presentation, it would be adWith regard visable. sorry to cause you this extra trouble with your manusa splendid piece of work; but we feel that due to our own publication problems, and for the benefit of the clarity and conciseness of your presentation, the above alterations would be advisable. cript, which I am is obviously Yours sincerely, / Wt Herbert H. Ja Editor-in-Ch' f e rmrx HHJ/nb Official organ of the International Federation of Societies for Electroencephalography and Clinical Neurophysiology. Inc. �lurch 9, 1959. the Editor, EEG Journal, 3801 University Street, Hentranl, 2, Clnldl. Dear Dr. Jasper: I :1 enclosing a copy of a report entitled Effect of Anticholinargic Compounds on PostOonvulaivc EEG tad Behavior of Psychiatric Patients“ for your consideration for publication in the EEG Journal. Ran: thanks for yam: consideratiun. “The Sincortly yours, m Junk, 31:33 14.». �Hay 20, 1959. Dr. Herbert H. The EEG 3801 Jasper, Editorain-Chier, Journal, University Street, Montreal, 2, censda. Re: as 981 Jasper: I as pleased.to return the enclosed manuscript which has been edited according to your suggestions. I found your comments and reoosnendatiens helpful and have been able to condense the manuscript oonsidersbly. I trust that it will still read intelligibly. Dear Dr. by I have reduced the nnnber of illustrations 1958 the since the tee diethasine deleting cots, report has adequate pictures. I have also taken out one each or the piperidylbensilate and atropine figures, leasing but six figures for the final manuscript. Legends for each of the illustrations are eppended after the rersr~ CBCOEe I had seas difficulty in encespassing the obsersetiens or iird in this report, since he has not attempted a generalisation of nenrophyeiologic change and behavior. As I interpret his studies, he has observed changes in distribution of large molecules in spinal fluid after convulsive therapy. This observation say or say not be consistent with changes in cholinergic, adrenerxio or synaptic relationships but in no wise excludes the concoaitsnt changes suggested by our studies. In any case, I have screed that the synaptic theory has been rather strongly pot and have modified the language considerably, including what I believe is a relevant reference to iird's studies. Except for the hypotheses suggested by Roth and Blett, which I believe are consistent with the suggestions or this report I know or no other systeaatio atteapt to relate nenrophysiologic and behavior changes after convulsive therapy. I would be pleased to include such studies. �Dr. Earhart H. and Jaipur, (Contd) #2 I an grateful for your vary kind caaoidcratioa nest £hut¢htrul criticism. I stunt that this copy a: the unnuseript any aunt with your approv:1. Sincoruly yours, an aran Fink, rm. �Anticholinergic Hellucinogene and Post Convaleive' EEG From and Behavior the Department of Experimental Psychiatry, Hillside Hoepitel, Glen Oaks, L.I., N.I. Aided, in part, by grant M~927 and HY~2092 of the National Institute of Mental Health, National Institutes of Health, 0.8. Public Health Service. Read at the VII: 1/59 - American EEG EEG Society, Atlantic City, June, 1958. �Anticholinergic Hellucinogens and Post Convuleive EEG and Behavior In 1956 Ulett and Johnson ( ) reported that atropine and scopolanine blocked the eppesranee ot the high voltege activity usually induced by convulsive therapy. that the dose of atropine necessary to affect the They EEG delta also noted EEG was such es to be associated with unpleasant systemic effects. Reports by Jenkner compound & Lechner ( ) describing diethaeine es en enticholinergio with potent neurologic but minimal systemic effects led us to undertake studies using this compound ( similar to those of Ulett and Johnson ); and these observations, in turn, led to an investigation of other experimental anticholinergic agents. It is the purpose of this report to describe clinical and electro- encephalographic observations incident to the intravenous administrao tion of various anticholinergic agents in psychiatric patients at verious stages of convulsive therapy and to relate these observations to hypotheses concerning the node of action of convulsive therapy ( ) and of exogenous hellucinogene ( ). �-2SUBJECTS AND METHOD: subjects were consecutive referrals for convulsive Our therapy in an open ward volunhry psychiatric hospital. While varying numbers of subjects have been studied for each compound, subjects in 106 experiments have been essayed. 88 Iron 18 Agesranged to 67 years, and diagnoses include schizophrenic reactions, manioudepressive and involutional depressive psychoses. Patients have been studied at various stages of the treatnent process. EEG The observations were laboratory, using a made standard 8 in acute experiments in the channel EEG recorder and needle electrodes applied in 17 lead placements following Strauss 33_5l ( ). In each experiment, the compound under study was administered intravenously at a set rate per minute, until clinical behavioral or electrographic changes were observed. have been atropine. diethasine, Each is a Win~22§9, The compounds studied benactysine, JB-318, JB-336, and potent enticholinergic agent in vitro. Diethasine (diethylaminoethylwxwdibensoparathiazine), for example, induces nydriasis end hypotension, suppresses salivation and blocks the bradycardia, salivation and seizures of acetylcholine and �-3fluorophclphntc ). ( win-2299 (2-diethylnninoethyl cyclopcnty1-2, thienyl-glycolnte) end benactysine (2-diethy1nninocthy1 benzilnte) are synthetic nnticholinergic agents with potent central neurologic effects nininal peripheral systemic effects and cnd JB~336 two ). Diethazine 175-250 ninnte for ). JBnBlB 2 to of a recent series of synthetic antichclinergic central potency compounds or high total of , (N-ethyl-3~piporidy1benzilatc, X-nethy1o3~piperidy1~ bennilcto) are ( ( was mgm; and high administered at hallucinogenic activity 25 mgm. Win-2299 and benactyzine 5 mgm.; and per minute for a at 0.5 mgm. JB-318, JB~336, and atropine :31. per minute for 1.2 to h.0 mgm. at per O.h �OBSERVATIONS: (a) Diethaeine: As previously reported administration of diethacine in 15 ), the ( patiente prior to convulsive therapy resulted in a decrease in voltages and a deaynchronisation of all frequencies. Prevailing prominent. instances, symmetric In some activity appeared, temporal leede. rhythmic patterns beoane leee most prominent in the The low voltage 6;? cps frontal and anterior alpha frequency fies not altered, but the build-up in voltage and the slower frequencies induced by hyper- ventilation vere blocked (Fig. 1). -Q-‘-Fig. 1 UUUUU Q-flO-u-n--In 25 patients during convulsive therapy, with varying degrees of induced high voltage delta activity significant decrease both in voltage slow wave hSfi neon activity. From an and in 20%. ) there was a per cent time of average per cent tine delta of in the {route-occipital leads, there per cent time or ( was a Both random and reduction to a burst delta �-5- activity diminished became prominent. slow wave activity increase in per cent time and voltage of The on voltage alpha and beta frequencies hyperventilation was no longer apparent. clectrographic effects appeared during drug administration These persisted for and and low one to five hours (Fig. 2). ‘fl’--“---yig. 2 fi‘-‘~“---Concurrent with those electrographic effects, distinctive systemic effect was an and S The observed initial systemic episode of coughing and the occasional spontaneous complaint of dry mouth. by behavioral changes. we to 10 per cent. Skin remained dry and-heart This increase was rate increased rarely associated by pron cordial awareness. Baring the period of observation pupils were not altered, and responded pronptly to light and near vision. were There occasional complaints of abdominal griping. These effects, however, were generally or behavioral. less prominent than the electrographic �-6. Beheviorelly, patients became more irritable and restless. They became tense end excited, end it use difficult to neintein eyelid closure. They complained of feelings of unreslity and of dysthesias of the extremities. Visual illusory phenomena and delusional thoughts about their illness, the setting or the test procedure or the examiner's identity were also reported. were cherecteristic in behavior. chenges in lenguege There sssocieted with this change Syntectic language patterns ( altered in ) were 1 fashion opposite to that previously described for amobarbitel ( ) so node and that verbal denial, minimization, cliches, third person past tense became less prominent. nese of speech, measured by dyadic TTR, The degree of repetitive- decreased )whieh ( eltered opposite to that described for convulsive therapy (b) Win-2299: Reports by Pennes enticholinergic men ( ) compound, Uin~2299, induced led to this next study. 0n that an is ( en ). eXperinentel excitetory states in intravenous edninistretion of 2—5 n3n., both elsctrogrephic end behavioral effects similar to diethesine were observed. In five petients without EEG slow were �-7- ectivity, deeynohroniaetion of frequencies and a decrease in voltages were noted in four (Fig. 3). -‘h‘-----‘ ‘-0-----~~ In 11 patients with high voltage delta activity there wee a decrease in amplitude and per cent time or slow wave activity with an increase in alpha and beta frequencies. The noun cent tine delta activity dropped from (Fig. h). 50% to 23% per ‘—-~..—“--‘ Fig. h -~--~-~-“Associated with these electrographie effects were minimal systemic effects but prominent clinical patterns of restlessness and excitement. Patients became fearful and tense. Visual eeneetione were reported and in three subjects, delusional eleboretiene about their hoepitel experience were prominent. These beheviorel chengee Appeared during drug administration or within ten ninetel, end disappeered, at theee doeege levels, within two to three hours. �-8Reports that beneetyzine induced Benectzzine: (C) deeynchronizeticn ( and ) EEG its structural similarity both to diethanine end Win-2299 led to our testing of this compound. Intrevenoue adminiatretion in 12 subjects elicited similar clinical end electrogrephic patterns. Both in the well modulated alpha record and in the recerd with high voltage delta activity, deeynchronieetion wee prompt. Delta activity decreased from a teen per cent time of 39% to 16% in subjects (Figs. 5, 6). 8 n--fi-¢-----Figs. 5, 6 ”0.“--“u-fi'flfiu- These electrcgraphic patterns were again accompanied by clinical restlessness, irritability tree recording wee here difficult. delusional thoughte seen with the noted et these dceege levels. orienteticn ( wee an excitement. Artifact- The illusory eeneeticne initiel compounds were and not In patients with nenifeet die- end language changes ), however, there end associated with convulsive therepy alerting petterne, as noted with diethezine. and a reversal cf the language �-9(d) Piperioylbensilstesz Following recent reports by Abood ( ) that verious piperidylbensilates both manifested cnticholinerzic activity tested and induced two of hallucinations in psychiatric subjects, these, JB-318 end JB~336 in 2h subjects. we The electrographic patterns were identical to these other experimental Onset of desynchronizetion was during coupounds; injection or within 15 minutes and persisted for one to four hours (Fig. 7, 8). .n...‘..“... Figs. 7, 8 ---0------uIn each instance in which desynchronizetion was observed, restlessness and clinical excitement, illusory and hallucinatory activity iwere noted, and were concurrent with the electrogrsphic changes. In two instances the beheviorel chenges were halted by the subsequent intravenous edninistretion of chlorpronesine. (e) itrogine: Continuing our study of enticholinergic compounds, we administered atropine intravenously inlh subjects, in doseges of 0.8 to h.0 ngn. Systemic effects were prominent during the iniection with increased respiratory rate, pellor, dry skin end dry mouth, precordiel complaints and nerked techycerdie �-10- (Pig. 9). Subjects became restless and fearful and recording became and the difficult. Within ten minutes these symptoms subsided subjects became drowsy and relaxed. In six subjects without delta activity} no change in pattern was seen during drug administration or for minutes thereafter. During the period of voltages and ninisal desynchronisetion was no was EEG 10—20 lassitnde, decreased observed, but there significant difference in per cent tine delta. Fig. 9 -fi.--‘.& In subjects with delta activity, there was an apparent initial decrease in voltage and per cent time of such activity during the first ten minutes after administration, followed by a return to original values during the period of quietude. period were the changes significant (Fig. 10). “-~-“---~ In neither �-11DISGUSSIOH: Various experinentel compounds with measurable enti— cholinergie activity have thus been shown to have similar electrographic and behavioral effects. Electrogrephicslly, each agent induces a desynchronizstion of frequencies and s in decrease Ind voltages, which is most prominent in subjects with delta activity following therapeutically induced convulsions. Beheviorally, these electrogrsphic patterns are associated with stimulating, excitstory, illusory and hallucinatory ectivity. To e lesser degree, nininsl systemic heart rate, sslivetion, sweating letter systenic effects ere and changes in ptpil are noted. more prominent in These patients given intravenous atropine under sinilsr experimental conditions. These observstinns can be relsted to theories of the node of action of convulsive therapy and the basis for the induced slow were activity; to concepts of the besis of experimentally induced hallucinations; and to the conflicting reports of the effects of atropine on nervous ectivity. �-12- (a) Convnlsive therapyuprocees: In earlier studies we indicated that the develcpnent of high voltage slow wave activity was the neurophysiologic correlate of behavioral change in convulsive therapy, and a necessary, though not eufficient, condition for clinical improvement ( ). During the past ten years, numerous authors including Bernstein, Tower and chachern, Ward, Sachs and Huge have reported similarities in the biochenical changes of the central nervous system in convulsive therapy to that seen in crania— cerebral trauna ( ). They observed an increase in cholinergic activity, nanirested by an elevation of free acetylcholine and pseudocholineaterase in the spinal fluid, and associated with high voltage slow wave activity. Sinilar high voltage slow wave activity has been reported after the administration of the cholinesterase blocking agent (di-isoprcpylfluorophoephate),I with attendant increase in cholinergic activity. In addition, the increase in central nervous system cholitergic activity by topical administration of acetylcholine induces high voltage ~ bursts and spike activity ( ). blocking of the behavioral and electrographic effects of convulsive therapy by the antichelinergic actiyity of atropine and scopolanine (Ulett and Johnson) are replicated by these observations on diethazine, Win-2299, benactyzine and the piperidylbensilates. The potent anticholinergic activity or The cent!!! each of these compounds (with apparent predominant locus or activity in the central nervous system) supports the �suggestions that the biochenioal basis for the induced activity of convulsive therapy results slow wave from an increased level of central acetylcholine~cholinestereos activity; While these observations demonstrate that anti— choliuergic compounds are effective in reducing slow activity, reports of other compounds with have also appeared. ( ), nescaline similar effects Agents such as anphetanine (Bensedrine) ), lysergic Acid diethylanide“ ( wave and diphenhydrasine (Benedryl) convulsive slow wave ectivity. ( ) ( ) also reduce poet~ These compounds are primarily synpathoniuetio and antihistaminic in pharmacologio aytivity, yet each has excitstory and stimulating effects ( and , , , ). The on behavior relations of these various anticholinergic synpathoninetic agents say be related within constructs of synaptic activity. observations have been confirmed in this laboratory. Intravenous adainistration of So~1oo genus LSD in subjects withoutldelta activity induced EEG desynchronisation one to two hours after administration. In subjects with delta activity there is a marked reduction of delta with the re-essertion of proainont, high voltage alpha frequencies. These �~1h- In a study or the effects or various agents on the EEG and the behavior of unaneethetised cats with chronic implanted electrodes, Bradley and llkes ( ) postulsted the existence of two, or possibly three, types of interacting chenoreeponsive receptors within the central nervous system: cholinergie, nonucholinergic susceptible to anphetaeine, nonucholinergic susceptible to Harassi and Hart pathways in the on evoked ( ) LSD eXplondng and tryptaminie derivatives. intercortical (transcellosal) cat, described the effects of various potentials on end oonpounds direct electrical stinulation. They postulated the presence or two chenoreceptive potentialities of the synapse - cholinergic and edrenergic - with opposing stimulatory and inhibitory ectien. been described by Hoolley ( Similar constructs have ), Evarts ( ( ) and Sherwood ). According to these models, the administration of snticholinerzic agents, or of sympathoninetic agents, results in equivalent synaptic electrical effects, and nresnnebly, similar electrogrsphic and snpethnine, nescaline end behavioral effects. LSD Thus adrenaline, inhibit the level of electrical �-15- activity at synapses as effectively as the blocking or inactivation of acetylcholine by atropine end other enti~ cholinergic compounds. In the light of these scggesticns, the present eXperinents permit a mere specific hypothesis regarding the phernacclcgic basis cf the convulsive therapy process. Repeated induced convulsions lead to an increase in the synaptic or xyxplttl cholinergic activity which voltage slow wave activity.; electrical activity (and of is reflected in surface electrodes level ) as angnented high Administration at anticholinergic agents reduces the level of synaptic activity, resulting in a decrease in the manifest cortical electrical activity to precenvulsive levels. may also achieve the Administration or synpathcmisetic agents same electrical effects, not by eltering the level of cholinergic activity but, by increasing the level of adrenergic activity. The nsnirest slow wave prominent and so persistent in the waking state ( ) nay thus be viewed as a EEG activity, so or the pcst~seisure persistent alteretion in synaptic transmission activity or large numbers of cells of the �central nervous system. is seen in the ready ( ) and The delicate nature or this balance reversibility with alerting ( ), tine the wide variety of pharmacologic agents noted here. Repeated induced convulsions may thus be described as a device to create biochemical changes in the brain for their resulting behavioral effects. view a Such/formulation that convulsive therapy is process ( a is consistent with the nonuspecifio therapeutic ). the initial suggestion ( ) basis for the convulsive therapy process that the pharaaeologio may lie in an alteration in acetylcholine-oholinesterase relationshipsban thus be focused on the alteration in the level of synaptic activity. In this regard, the observation that diphenhydranine, primarily an anti-histaminic agent, also reduces slow induced convulsions ( ), and the wave activity of observations by Sachs ( ) that increased amounts or serotinin appear in the spinal fluid after convulsions suggest that this image in convulsive therapy is oversimplified. ’ 0; synaptie activity Further studies or the effects or various drugs on the postcseiaure electrical ‘ �activity are warranted. (b) Iearophyeiolggy or hallucinogenic These EEG activity; observations of anticholinergic compounds delta activity also related to concepts of eXperinental may be hallucinogenic activity. Each of these compounds induced excitatory behavior including illusory and Here, too, synaptic models phenomena.* on hallucinatory may be applicable. Synpathoninetic egents, ae mesoaline, LSD, and amphetamine, and anticholinergic agents as those described here, are equally potent hallucinogens. i necrophareacologic basis for such behavior nay be characterised as an alteration in the level of synaptic activity in the direction of increased inhibition (decreased transmission) of stimuli. The clinical efficacy hallucinatory activity biochemical level. ester: ( The may of convulcite therapy in modifying thus In the doses used, higher dosage ( A in alterations at this effects or hallucinogenic blocking agents ), as chlorpronarine for benactysine. lie and reserpine, on EEG electrical hallucinatory phenomena were not observed report of such activity was reported at ). �~18~ ectivity are consistent with EEG hypersynchrony in non effects of LSD end LSD and such a View. ), block the ( nesculine ), ( and Both compounds induce EEG desynchronizetion in animal studies, block neeceline behavioral and electrographic effects ); ( Chlorpronaoine was found equally potent in abutting the excitatory activity of these experimental anticholinergics in these studies. (c) Relation to atropine: Comparison of the oystenic and central effects or these experimental anticholinergic conponnda with atropine reveals significant differences. Extensive experience with atropine at physiologic end toxic levels in men indicate that the predominant Initial effects are focused at peripheral nervous structures. bradycnrdia, followed by marked tachycardia, loss of sweating and salivation, papillary dilation, intestinal relaxation and decreased motility are amongst the effects at physiologic (O.2~l.2) dodagee. At higher dosages (2-5 mg), the central nervous irritability, disorientation, oyeton effects of ataxia, delirinn ( may be observed ( ), anonnta ranging Iron ). In the atropine 32 to 212 some end studies 33:. injected intra- �.19nuacularly into psychiatric petiente resulted in the following ( sequence )t ”There is an induction period or 15 to minutes 20 after adninietretion characterised by restlessness, occasionally mild exoitenent, confusion, and at times nausea and vomiting. This proceeds, smoothly and predictably, to muscular inooordinetion, ataxia, weakness, vertigo and difficulty in articulation. An acute brain syndrome with memory disturbance, disorientation, elouded consciousness, illusions and most frequently visual hallucinations vergee into delirium come... ' Thus and rapidly proceeds to central nervous system effects are preoedodhnd accompanied by marked peripheral effects. In contrast, these experimental enticholinergic agents, in equivalent dosage ranges, manifest and lurked central. The are observed early and effecto may on little peripheral effects the central nervous system continue for extensive periods and in higher dosages with minimal peripheral nervous effects. It ie within this context of central tarsus peripheral predominant sets or activity that the apparent discrepant EEG observations of the etteete of atropine (in inducing elow wave �.20- activity) these experimental enticholinergic compounds and be reconciled. The variable EEG effects, like the verieble behavioral effects are dose related. adminietering l~3 mg/Kg may Weeeae exist 33‘3l ( ) atropine in curarized cats and monkeys using O.h to 1.2 mg/kg in curerized and Funderburk and Case ( ) cats, produced high voltage slow wave activity. Wikler ( ) reported that 7.2 mg/kg atropine in unanosthetized, ancnrarized patterns strikingly similar to dogs produced "epindle slow wave" sleep. 'Rinaldi and Himwioh ( ) reported that atropine in doeee of 0.5 to 2.0'mg/kg in cnrarized rabbits exaggerated patterns and inhibited the electing of the EEG EEG sleep to various peripheral stimuli. _Sinilar observations have been observed by Bradley and Bikes ( ) in the conscious oat. In each instance the dosage of atropine varied from 0.5 g 3 mg/kg- a range roughly comparable to the massive dosages need in atropine coma therapy. Yet what of the electrographie eitects in lower In our observations, the EEG effects of dosage? low dosages of intravenous atropine (006‘ .06 ng/kg) were minimal. Similar obeervatione have been reported by Danielopelie, Guirgee end Drooen �021-: ( ) who specifically releted the effects to dosage level. EEG with high doeeges of atropine (h-B ng/kg) in rabbits einiler high voltage nixed slow and feet (21-30 ope) activity was observed, while with low deeegee (2h~.8 ng/kg) the original rapid rhythms remained unehenged. These authors thus suggested ! flat atropinegs effects were multiple end doee determined, and related the observations to similar findings with regerd to EEG heart rate. Denielopelu atropine slow down ( ( observed that small doses of cardiac rhythm nine while larger doses cenee eexeklteiien acceleration. been confirmed ) These obeervetiene have recently ). Thus, while oonsidereble speculation as to central neurophysiology he: been related to observations with atropine, these observations provide e special case of atropine effects. The entiohelinergic activity, so prominently established in observations in vitroI end in the peripheral nervoue system, may not be the effective physiologic activity in the large doses neeeeee y to reach central structure. It is poeeible that the experimentel entichelinergic compounds used in the present studies �-22protfie more suitable experimental tools fer the elucidation of central neurophysiologic nativity than atropine. In part, these differences may be related to difference- in etrnctnrel chemistry. Each of these experimental cenponnde contain a tertiary canine linkage, while atropine (and ecopolemine) quaternary centnin a qxxtx:xznx linkage. Such differences may be clearly observed in the structure~ectivity relationships or the piperidyl- bennilatee ). ( While Hwnethyl-B-piperidylbenzilete and Nsethyla 3-piperidxlbeneilate have potent enticholinergic and hallucinogenic potency, Hedinethyl~3~piperidylbeneilete - the quaternary conpennd - has considerable in vitro anticholinergic activity, and no hallucinogenic property. The significance of tertiary amine linkage for central neurophysiolcgic effect: he: been repeatedly affirmed by numerous observers, and neat recently by Pennel Denber; ( ), Theee e Hake ( ) and Plodnerk ( ). structure~aetivity relations lend theneelves to re-eveluation or studies or creniccerebrel trenne Ward's ( ) ( and epilepsy. reports orfithe efficacy of high doses of etrepine in altering the clinical manifestations of head trauma indicated ), �-23- that effective dose: brought with Thu them severe systemic effects. failure of the oxtohaive studies a: the efficacy or atropinc and soopalunine in epilepsy ( ) any be related to : failure of these quaternary compounds to reach the central nervous syntax in adequate quantity. It would noun advisable, therefore, to, ropoat those studies utilizing such more potent, more centrally specific, antieholinorgic canpaunds as used in the eXporixonts reported here. �lj MS 981 W Mel 3;..." EFFECT OF ANTICHOLINERGIC COMPOUNDS EEG AND BEHAVIOR OF Max (Received ON POST CONVULSIVE PSYCHIATRIC PATIENTS Fink M.D. for publication: march 11, 1959) v v-u-u. From the Department of Experimental Psychiatry, Hillside Hospital, L.I., Glen Oaks, Aided, in Institute N.Y. M-927 and MY-2092 of the National Health, National Institutes of Health, by grants part, Mental of U.S. Public Health Service. Read at the American W-EEG 3§5357k? EEG Society, Atlantic City, June, 1958. �MS 981 ANTICHOLINERGIC COMPOUNDS AND POST CONVULSIVE EEG �Effect of Anticholinergic EEG and Behavior of Compounds on Post Convulsive Psychiatric Patients Mcsfl—vsflswfi kg 76.: gagifisignificance of high voltage EEG delta activity in the convulsive therapy process (Roth gt_gl, 1951, 1957; report that this delta activity was blocked by the administration of-eniiehnlinersic ealfiifiiaa atropine and scopolamine (Ulett and Johnson, 1957) provided the basis for these studies. As there were attendant unpleasant systemic effects with the administration of these agents, reports describing diethazine as an anticholinergic Fink and Kahn, 1957) and the with potent neurologic but minimal systemic effects (Jenkner and Lechner, 1955; Lechner, 1956) led us to undertake studies similar to those of Ulett and Johnson using this compound (Fink, 1958). “@bservations with compound diethazine led to the investigation of other experimental anticholinergic agents. This report describes clinical and electroencephalographic observations incident to the intravenous administration of various anticholinergic agents in psychiatric patients at various stages of convulsive therapy and relates the observations to hypotheses concerning the mode of action of convulsive therapy and of hallucinogens. �SUBJECTS AND METHOD: subjects were ninety psychiatric patients referred for convulsive therapy. Ages ranged from 18 to 67 years, and diagnoses included amcaai-t!=s£ schizophrenic The reactions‘ and manic-depressive and involutional—depressive varied number of subjects were studied for each compound for a total of 107 observations. Patients have been observed at various stages of the treatment process. The observations were made in the EEG laboratory, using a standard 8 channel EEG recorder and needle electrodes applied in 17 lead placements following Strauss gt_§l (1952). In each trial, the compound under study was administered intravenously at a set rate per minute until clinical behavior or electrographic changes were observed «a -'w ‘M psychoses. Www'” mam. "4”,...“ A." A Hm , ‘5 was”“My HM A r-m new M, -J:,M-,_.m,..\. "was... “A...“ i, ,1“. The ine, JB3l8 JB~336, and atrOpine.{ Each is a potent “p' a: icholinergic agent in vitro. Diethazine (lgflgéwdaetfiyl- \\ ‘H‘benact v. __~ ‘ (2-diethylamipdéthyl fignzilate) are synthetic anticholinergic '- 3‘ .h u k‘ ‘ ‘ �W [M fiW/émgw (m w 1,?de //h)1 (Maw (WW. a /¢‘¢¢) ’ f flux-322.497“ f E (W . 7’6’33“ wit/4&4, xiJ'C) 7 I (W fig?) 17”} M .7313”: W �agents with potent neurologic effects and minimal peripheral P’w ‘nwV""' systemic effects W JB- 318 and JB~336(N~et§gl~3flwiperidylbenzilafe N-methyl-~3two of a new series of syntfiébiq piperidylbenzilatafl (Pennes and Hocn%wl9§7?“§:c9bson, 1955) """ ‘m‘,’ anticholiHErgic compounds w'th a»? éfimm‘ distinct hallucinogenic 1958). et a1, g Diethazine administered at _activity __ ’ total (Abood was mac?“ 25 mg per minute for 2.5-5.0 mg/kg); Win-2299 and mg per minute for 2 to 5 mg (0.020.15 mg/kg); and JB-318, JB-336, and atropine at O.h mg per minute for 1.2 to h.o mg (0.0l~0.10 mg/kg). of 175-250 benactyzine at 0.5 a mg ( �OBSERVATIONS: administration of diethazine in fifteen patients prior to convulsive therapy resulted in a decrease in EEG voltages and a desynchronization of all frequencies,€¥$§3;=;$§8%. Prevailing rhythmic (a) Diethazine: patterns became The less pronounced. In symmetric low voltage 6-? cps most apparent in W frontal and some activity appeared and was _ (F3416 anterior temporal leads. ammmmmwmmm~.w fequencyas not send, ”Mm“ Thz“‘;“i”;“n. instances, ,, .1. >u-L—‘7‘? mm»- ,.... .14.“ mm“. We they”; In twenty~five patients with varying degrees of induced high voltage delta activity during convulsive therapy (Fink and Kahn, 1957), there was a significant decrease in voltage and in per cent time of slow wave activity. From an average-pal—Icnt-ttne delta of h5% in the front-occipital leads, there was a reduction to a mean uggzggntntine of 20%. Both random and burst delta activity voltage alpha and beta frequencies became more prominent. The usual increase in per cent time and in voltage of slow wave activity with hyperventilation sans-no diminished. Low 51, \} "it; 2’ lfJ?e>» �-5longer apparent. These electrographic effects appeared during drug administration and persisted for one to five hours Mfifl (Fun/t} xqs’f) Concurrent with these electrographic effects, we observed distinctive systemic and behavioral changes. The initial systemic effects were episodes of coughing and complaints of dryness of the mouth. Skin remained dry and the heart rate increased by S to 10 per cent. This increase was rarely noted by the subject, and was not accompanied by ,n» precordial distress. -9ar&ng—tho—peried~e£w- , Gems/haflhv observationnfihere was no change in pupillary size, and their response to light was prompt. There were occasional complaints of abdominal griping. Ihfiégweffects were generally less prominent than the electrographic or behavioral. Behaviorally, patients became irritable, restless, tense and excited, and it was difficult to maintain eyelid closure. They complained of feelings of unreality and of tingling, weakness and heaviness of the extremities. Complaints that colors were pale or more intense, halos about lights and changing shadows were accompanied by delusional thoughts about their illness, the setting of the test procedure or the examiner's identity.4p . AM �-7(b) Win-2299: The report by Pennes and Koch (1957) that Win-2299r—aaother_axparamoatalwaatieholinergée~eempound1 induced illusory and hallucinatory states in man, led to this next study. 0n intravenous administration of Win-2299, both electrographic and behavioral effects similar to diethazine were observed. In five patients without EEG slow wave activity, desynchronization of frequencies a decrease in and voltages were noted in four;éi§igggg; {Vfgf / ), In eleven patients with high voltage delta activity there was a decrease in amplitude and per cent time of slow wave activity with an increase in the per cent time of alpha and beta frequencies. dropped from 50% to 23% The mean pea—eoat—tine (Fig.1;3. Fig.3 delta activity 3" Associated with these electrographic effects were clinical patterns of restlessness and excitement, and effects. Patients became fearful and tense. Visual illusory sensations were reported and were minimal systemic associated in these subjects with delusional elaborations �-3about their hospital experience. Excitement was accompanied by ideas of reference, and in two subjects, intravenous chlorpromazine was administered to halt this process. These behavioral changes appeared during drug administration or within ten minutes, and disappeared within two to three hours. effects were slight. There were neither cough nor respiratory distress. Heart rate was unaffected except in patients who became overtly excited Systemic fearful, in and whom excitement period. on ' tachycardia appeared during this Dryness of the mouth was reported only direct inquiry. (c) Benactyzine: Reports that benactyzine induced EEG desynchronization (Coady and Jewesbury, 1956), its anticholinergic nature, and the structural similarity to diethazine and to Win-2299 led to our testing of this compound. Intravenous administration in 12 subjects elicited similar clinical and electrographic patterns. Both in the well modulated alpha record and in the record with high voltage delta activity, desynchronization was prompt. Delta activity decreased in 8 subjects from a mean pti—OUI$ time of Wfifi/d} 39% to 16% �-9These electrographic patterns were again accompanied clinical restlessness, irritability and excitement. Artifact-free recording was more difficult. The illusory by sensations and delusional thoughts seen with the initial compounds were not noted at these dosage levels. Systemic effects were similar to Win-2299. (d) Piperidylbenzilates: Following recent reports by Abcod et a1 (1958) that various piperidylbenzilates with measurable anticholinergic activity induced hallucina- tions in paychiatric subjects, we tested JB-318 and JB-336 in 2h subjects. The electrographic patterns were identical with the other experimental anticholinergic compounds. —¥he— ur ng e njection or Waffles ync hroniza ti onA? ?- duufdtvthhfhfl within 15 minutes and persisted for one to four hours (Fig. 5: t). ‘ , Figs. 5f In each instance in which desynchronization was observed, clinical restlessness, excitement, illusory and hallucinatory activity were noted, and were concurrent with the electrographic changes. In two instances the behavioral changes were halted by the intravenous administration of chlorpromazine. �-10Considering the numerous reports (e) Atropine: that atropine induced EEG slow wave activity and clinical somnolence, we administered this anticholinergic agent intravenously in 15 subjects, in dosages of 0.8 to h.0 In six subjects without EEG delta mg (.01-.10 mg/kg). activity, there were no changes in EEG pattern during drug administration nor for 10-20 minutes thereafter. During a period of lassitude, decreased voltages, minimal desynchronization, and an increase in per cent time delta were noted. In subjects with delta activity, there was an apparent initial decrease in voltage and per cent time of such activity during the first ten minutes after administration, followed by a return to original values during the period of quietude. was» In neither period (@3925) were the changes significanta �-11- Systemic effects were prominent during the injection with increased respiratory rate, pallor, dry skin and dry mouth, precordial complaints and an increase in heart rate up to 100%. Subjects became restless and recording became difficult. Within ten minutes these symptoms subsided and the subjects became drowsy and relaxed. �-12- arious experimental compounds with measurable anticholinergic activity have been observed to have similar electrographic and behavioral effectsignmthnsematudiOOVM Electrographically, each agent induced a desynchronization of frecuencies and a decrease in voltages, which was most prominent in subjects with delta activity following convulsive therapy. Behaviorally, these electrographic patterns were associated with stimulating, excitatory, lesser degree, minimal systemic changes in heart rate, salivation and sweating were noted. These latter systemic effects were more prominent in patients given intravenous atropine under similar experimental conditions. These observations can be related to theories of the mode of action of convulsive therapy;and-ofirthevastS“fvr' illusory and hallucinatory activity. ‘thauaadnoedfiaiew—wamowaewévttyj To a to concepts of the basis of experimentally induced hallucinations; and to.thv reports of the effects of atropine on EEG patterns. (a) Convulsive therapy process: Earlier studies indicated that the development of high voltage slow wave activity was 4:; neurophysiologic correlate of behavioral change in convulsive therapy, and a necessary, though not sufficient, condition for clinical improvement (Fink and Kahn, 1957). In summarizing the observations of numerous �-13the relation of acetylcholine metabolism to 1;” 4o $vuuna andAconvulsions (Fink, central nervous system Ckxcxnurnsd'éjf 5L biochemical bootseinn the the 1958) it was suggested that induced EEG slow wave activity lay-fin an increased level of acetylcholine-cholinesterase activity of the central authors on nervous system. in the slow wave 1? present observations of tin alterations_ activity of convulsive therapy by these The experimental anticholinergic compounds are consistent with this suggestion. is indicated by reports of compounds with other biochemical activity also affecting slow wave activity in a similar fashion. Amphetamine That the problemis more complex gt_§l, 1951), mescaline (Merlis and Hunter, 1955; ‘Ib (Bente gt_§1, %§?b§i$ 1955), lysergic acid diethylamide ”iuuéig,snd diphenhydramine (Diaz-Guerrero et a1,1956) also reduced post-convulsive slow wave activity. In these reports, such a reduction was accompanied by excitatory and stimulating effects on behavior. These compounds, however, are primarily sympathomimetic and antihistaminic in pharmacologic activity and not anticholinergic. The similar effects of these diverse biochemical agents on electrographic patterns and amuauibusfi be behavior may rat-ind within theoretic on clinical (Lennox «K2~Kssrsr'6247 ‘fitfiix “fi’ constructs of synaptic activity;r— mm w The existence oftwo, or possibly three, Mypee cf interact~ 'AQ/ 1. m.“- ing chemo~re§pofisive receptors withinthd‘central ner::gg,system �/ (I W24: L M7? 5 ,7 v M/ ’46; MW w- M} Arm/a; Ail/”M Wag .- f �“Jamal-un- h awmh'auu: gnaw“WWW WU“we ' lead to a change in synaptic cholinergic activityywhésh—és— reflected:h11llhsurface electrodes as augusntsd high voltage slow wave activity. Administration of anticholinergic agenggijltenfl'synaptic activity, resulting in a decrease in the manifest cortical electrical activity to preconvulsive levels. Administration of sympathomimetic agents 3f-lg-‘Leja-‘fiieve/ the same electrical effectsr-s-s-t-by—ns4tssang—tha—1saol—sfrehoiénsrgss—sstinitanbat by increasing the level of adrenergic activity. The manifest slow wave A activity, so prominent and so persistent in thsffi::;ng£§;:& -ss«the—pust-setzure-statej may thus be viewed as tho resulttnf persistent alteration in the synaptic tssssméssésn activity of large numbers of cells of the central nervous system. The delicate nature of this balance is seen in the ready reversibility with alerting, time, and the wide ~qflra variety of pharmacologic agents.nntsdwhaner-m~m~"~"“ ’jifi/ér\:;> The consistent nature of these neurophysiologic observations all. makes an exclusively psychologic explanation of the mode of action of convulsive therapy less tenable. These studies are consistent, however, with the neurophysiologic-adaptive view of the convulsive therapy process which suggests that neurophysiOlogic chanazMs provide the substrate for alterations in all aspects of cligical behavior} fg’h" �Ma . ,W‘ w, .M Won/7w AC ,W W hyLWM MWMWM'W“ W 5 I414} 2‘5 Maxwu 4; ’ :73? (/ija; Z; W Wag a, WM7£ ILL-«44.1“ 04”), MLIMK W; ”W MW; “4344: a' WM W I a; a. L « �-17- we, of~the—oabaeetp"{fln type of behavioral alteration ts fisvwig dependent upon the type and degree of neurOphysiologic change, the personality of the subject and the expectations and tolerance of the milieu (Weinstein and Kahn, 1955; Fink and Kahn, 1957; Fink, 1957). (b) Neurophysiology of hallucinogenic activity: The effects of anticholinergic compounds on EEG and behavior may also be related to the understanding of experimental hallucinogenic activity. Each of these/tzzgfunds induced illusory excitatory behavior, including 4L phenomena. m Here, too, the synaptic and hallucinatory model] may be applicable. Sympathomimetic agents, as mescaline, LSD and described amphetamine, and anticholinergic agents as those here, are 01-‘3iv potent hallucinogens. A neuropharmacologic basis for such behavior may be characterized as an alteration in the level of synaptic activity in the direction of increased inhibition (decreased transmission) of stimuli. ‘The clinical efficacy of convulsive therapy in modifying hallucinatory activity may lie in alterations at this neurophysiologic level. . The effects of such hallucino- genic blocking agents as chlorpromazine and reserpine on EEG electrical activity are consistent with such a view. Both compounds induce EEG hypersynchrony in man (Bente and Itil, 19Sh, 1958) and block the EEG desynchronization effects of LSD and mescaline (Schwarz et al, 1955). �-19Chlorpromazine was found equally potent in aborting the excitatory activity of the experimental anticholinergic compounds in these studies. (0) Relation to atropine: Comparison of the systemic and neurologic effects of eXperimental anticholinergic with atropine reveals signi£ieaat differences.«av ax/Aaf compounds {pH/95 s:%bé§i£3§§§§2::ence with atropine at physiologic and toxic levels in man indicate that the predominant effects are focused at peripheral nervous structures. Initial bradycardia, followed,by tachycardia, loss of sweating and salivation, pupillary dilation, intestinal relaxation and decreased motility are amongst the effects at low (0.2-1.2 mg) dosages. At higher dosages (2-5 mg), the neurologic effects and delirium are of ataxia, irritability, disorientation, Mgr...“ observed (Goodman and Gilman, 1955). In atrop' e coma therapy, 7amounts ranging from 32 to 212 g injected int amuscularly into psychiat ic patients resul s in the fell wing sequence (Forrer and Miller, 1958): "Th re is an induc ion period of 15 to 20 minufes after adminis ration charactkrized by V mm:Wm..- ! 2 I . Jonfusion, and . restlessnessg ceaselonally mil excitement, at times naufca and rarely vo ting. This p oceeds, smoothly and predictably, to muscular coordination, ataxia, weakness, vertigo and ifficulty in artffulation. An cute brain syndrome wit. memory dis turbanhe, disorienta ion, clouded illusions and mtst frequently kisual hallucinaconsciousnesf, tions mergesa into delirium and§.:;rapid1y proceehs to coma. ..." I ‘ I ’ ; �-20.. Thus/central nervous system effects arevprecededwwv accompanied by marked peripheral effects?” contrast, the experimental anticholinergic agents in dosages sufficient for central nervous system effects manifest little peripheral activity. The central effects are observed early and may continue for extensive periods without gastrointestinal, cardiac or pupillary changes. It is within the context of the focus of activity and w. -din relation to dosage that the apparent discrepant EEG observations of the effects of atropine (in inducing slow wave activity) and these experimental anticholinergic In reconciled. Wescoe gt_al (l9h8) administering 1.0 to 3.0 mg/kg atropine in curarized cats and monkeys and Funderburk and Case (1951) using O.h to 1.2 mg/kg in curarized cats, observed high voltage EEG slow wave activity. Wikler (1952, 1957) reported that 7.2 mg/kg atropine on unanesthetized, uncurarized dogs produced "spindle slow wave" patterns at-ihiugiy similar to sleep. Rinaldi and Himwich (1955a, b) reported that atropine in doses of 0.5 to 2.0 mg/kg in curarized rabbits exaggerated EEG sleep patterns and inhibited the alerting of the EEG to unit-l: peripheral stimuli. Similar observations have been reported by compounds may be Bradley and Elkes (1953) in the conscious cat. In each instance the dosage of atropine varied from 0.5 to 7 mg/kg - a range roughly comparable to the dosages used in atropine (me'w‘ Md: We’rfrfg. “ma therapy! �: M 4% 1mg,» Jyyzmw f)”; r gag“; m mflfl/w 1:; @c‘jf jaw/(4,4,2... W a; 351,, fgflzfl, �-21'éoueraduuage? Auéf In thelzn;tudies, the ‘g’ flfimal EEG effects of low dosages of intravenous atropine (0.01 to 0.10 mg/kg) were minimalaasfi CMMHKM éfi, ifikbfi iconfirming similar observations by Verdeaux anglflgrfizw (195h) and by Danielopolu et al (1955)., Danielopolu et a1” Wmmwflwawmqum specifically related the EEG effects to dosage levelvfw” ith high dosages of atropine in rabbits ( h to flffig/kg) . W wa‘ianMu-‘rm‘m. -W«m««uw~w ~w-wwmw~wmmw .; m W. ..,..-..g., , m ,u . swan-bani" .twmi-mc”1; ~11.»- . man. ; they observed similar high voltage mixed slofifand fast activity, while with low dosage (.Zh t9 id mg/kg) the original apid rhythms remained hgphanged. These authors It fy~”' thus sugges d that atropinetg effects were multiple and“ related the EEG ob rvationgxtg similar findings with rega dfitfi heart rate. Danie ported earlier that s 11 doses of atropinesloqed cardiac rhythms while/larger dose caused acceleration. These dose determine ’ and cardiac observations have recentlyxbeen confirmed (Morton 232;; ‘ Thus, while considerable speculation as to central neurophysiology has been based on studies with atropine, té§LL——— special case of anticholinergic effects. The anticholinergic activity,—eo—pnonéaeatky established in observations in vitro and in the peripheral nervous system, may not be the effective physiologic activity in the large doses necessary to affect central such observations provide a �.. 2 2 - Th3’2xperimental compounds z:::=zm—the~preeontm the flflfigw provide more structures. s-‘bu-d‘éoo flow/M)“: udtuoédubéon of suitablewe} Wfor central neurophysiologic (anticholinergic) patterns than atropine] M, #AMcuu/eml AM» In part, these physiologic differences may be re to differences in structural chemistry. Each of the experimental compounds contains a tertiary amine linka e, while atropine contains a quaternary linkage. The e fect of structure on in vivo pharmacology may be clea y observed in the structure-activity relationships of e piperidyl- benzilates (Abood 22.21:.1953)' While -methyl-3-piperidylbenzilate and N-ethyl-B-piperidy enzilate have potent anticholinergic and hallucinoge \c-potency, N—dimethyl-B-piperidylbenzilate - the quate ary compound - has considerable in vitro anticholinergic tivity but no hallucinogenic property. nd Hoch (1957), Denber (1958), Naka (1958) and Flodmark i (1958). f_ _-‘_ , f - . in.a re-evaluation 05‘studies ,_”4 , 1 7 ,. _éwr of craniocerebral trauma and epilepsy. Ward's (1950) reports of the efficacy of high doses of atropine in altering the clinical manifestations of head trauma indicated that effective doses brought with �-23- effects. The failure of atropine to affect epilepsy may be related to the them severe systemic and scopolamine inability of these quota-unis compounds to reach the central nervous system in adequate quantity. It would seem advisable, therefore, to repeat these studies utilizing ardfiuf such mere-paten%7~more centrally speeésée..anticholinergic , compounds as used in the experiments reported here. �'Zh' SUMMARY: 1. EXperimental anticholinergic compounds (diethazine, Win-2299, benactyzine, JB-318 and JB—336), administered to psychiatric patients at various stages of convulsive therapy, were associated with: (a) desynchronization of EEG rhythms with a blocking of post-convulsive delta activity; (b) alerting, excitatory behavioral reaponse with illusory, delusional and hallucinatory ideation; and, (c) systemic effects of muscular weakness, dryness of the mouth, dry skin and tachycardia. electrographic behavioral and systemic effects were The concurrent. that an fl; 2. observations are consistent with the suggestion “faxmufaui These We!) thug,” ” ' of convulsive therapy'iilllllr.4fl increase in central nervous system cholinergic activity. 3. Observations that LSD, amphetamine, mescaline and diphenhydramine - synpathomimetic and also induce desynchronization, blocking of post convulsive EEG delta activity antihistaminic agents - and clinical excitatory activity support the suggestion that bUth-hhu behavioral and electrographic based on alterations in synaptic activity,, sis Patterns Increased synaptic activity (cholinergic, sympatholytic effects) we ,4 �-25- hypersynchronization, and clinical sedation and euphoria; while decreased synaptic activity (anticholinergic, sympathomimetic) is associated with EEG desynchronization and clinical excitatory and hallucinogenic is associated with EEG states. Discrepant observations with the-entéehottnergifi agent? atropine are related to significant differences inrfiéfvfifygw’ h. .thawnantzalMnenuensmsaatanmaiflactsmofimhighudeaagamainapinefl Re-assessment in_man_maxanataha4nninanil¥_anaiahnlinargis. of the role of anticholinergic agents in head trauma and seizure states is suggested. 5. These observations amplify the neurophysiologicadaptive hypothesis of the mode of action of convulsive therapy and of experimental hallucinogenic states. �ACKNOWLEDGEMENT: I Hannah {Efl grateful for the technical assistance of Mrs. Mosquera in EEG recording and analyses; and—to— am Supplies of the various pharmaceuticals were made freely available by Lakeside Laboratories (JB-318 and JB-336), Merck Sharpe & Dohme (benactyzine), Sandoz Pharmaceuticals (LSD-25), Sterling—Winthrop (Win-2299) and Smith, Kline & French Laboratories (diethazine, chlorpromazine) �:f/ébétp/g 04M¢MW71M£04¢ W, 2: wow f/éétdi./g.7 JAM/47 7249.; ’9‘” M MW «044ml. W,- m; {fJZ/ E.- 37I-370‘ �-27Abood, L.G., W4} “E:ZLE:D Ostfeld, A.M. and Biel, J. new group of A psychotomimetic agents. Proc. Soc. Exper. Biol. Med., 1958’ 21: hq'é‘h86o Bente, D. and Itil, T. Zfir Wirkung des Phenothiazinkorpers Megaphen auf dasuMehschliche Hirnstrombild. Arzneimittelforsch§:“l95h, Z: h18-h23. Bente, D. and Itil, T. A comparison of the action of various phenothiazine compounds on the human EEG. Trans. Int. Cong. of NeurgpsychOpharm., 1958, (in press). Itil, Electroencephalographic studies concerning the action of LSD-25. EEG Clin. Bente, D., T. and Schmid, E.E. Neuroghysiol., 1957, 2: Bente, D., Itil, 359 (abst.). T. and Schmid, E. E. Elektroencephalon graphische Studien zur Wirkungsweise des LSD-25. Psychiat. et Neurol., 1958, $25: 273-28h. Bradley, P.B. and Elkes, J. The effect of atropine, hyoscyamine, physostigmine and neostigmine on the electrical activity of the brain of the conscious cat. J. thsiol., 1953, lfig: 1h_-15; Bradley, P.B. and Elkes, J. The effects of some drugs on the electrical activity of the brain. Brain, 1957, g9: 77-117. Coady, A. and Jewesbury, E.C. A clinical trial of benactyzine hydro<3hlcride ("Suavitil") as a‘physical relaxant. Brit. Med. Jour., 1956, l: h85-h87. �-2&- Danielopolu, D., Giurgea, C. and Drocon, G. Electroencephalographic study of the non specific pharmacodynamics of the stimulatory effect of atropine on the cerebral cortex. ” Fiziologicheskiy Zhurnal SSSR, 1955, El: 60l~611. Denber, H.C.B. Studies on mescaline: III. Action in epileptics. Psychiat. Quart., 1955, 32: h33-u38. 9.,see;4a;é:§;fs;ag"inasced stgtgg”.gsembiagg“..tur.11y occuring MW psychoses,‘mgM ~jrbpicDrugs. Elseviar, / r Amsterdam. 1957, 263S Diaz-Guerrero, R., Feinstein, R. and Gottlieb, J. S. EEG findings following intravenous injection of diphenhydramine hydrochloride (Benadrylr). EEG Clin Neuro— ‘ 7 Evarts, E.V. Neurophysiological correlates of pharmacologically induced behavioral disturbances. Res. Publ. Ass. Nerv. Ment. Evarts, E.V. Dis., 1958, 2§:3b7-380. Chemical bases for psychoses. Concepts of Psychoses. 1958, Fink, M. A Chemical McDowell, Oblensky Inc., N.Y. hl-62. unified theory of the action of physiodynamic therapies. J. Hillside Hosp., 1957, g: 197-206. Fink, M. Effect of anticholinergic agent, diethazine, on behavior: Significance for theory of convulsive therapy. A.M.A. Arch. Neurol. & Psychiat., 1958, EEG and 29: 380-387; M Wflifi‘f‘féy A2u&“x dad Akhaifin, za37.,/ff4: £1.J./Ita4u/t-W‘Wfi fifi¢’{7¢£ �-29Fink, Relation of electroencephalographic delta activity to behavioral response in electroshock. M. and Kahn, R.L. A.M.A. Arch. Fink,mu. and Neurol. Jarre, J. & Psychiat., 1957, Drug induced changes 1Q: 516-525. in interviEW“‘ patterns.iiconf”“onoFsychodynamic Aspects of Neuro- leptic ‘‘‘‘‘‘ ) FloemargE S. ,afiines ed. J. Sarwer-Foner (in press). effect of some tertiary andwgnatornary QEggs, The EEG Clin. Neuro~ activity. “MM“MW 753 (abst. ). WNW WM 1958,10: mag; on a3”rww¢ m“ at“ M“ Forrer, fik and.Miller, J.J. Atropine coma: A somatic therapy in psychiatry. Am. J. Psychiat., 1958, 115: G. h55~h58. rFunderburk, W.H. and Case, T.J. cortical potentials. EEG The effect of atropine on Clin. Neurophysiol. 1951, 2: 213'2230 Goodman, L.S. and Gilman, A. Pharmacological Basis of Therapeutics. Macmillan, N.Y. 1955. Heymans, C., Estable, J.J. and de Bonneveaux, S.C. Sur la pharmacologie de la phenothiazinyl~ethy1diethylamine P.). Arch. Int. Pharmacodyn..l9h9, 79: 123-138. Jacobson, E. Suavitil, et nyt stof pa centralnervesystemet. Egg: 11b7-1151. med specifik virkning Ugeskrift for Laeger, 1955, \ “1v, . 1.. ... WWW»-.- �-30. Jaffe, J. An % .5 .1...WW... objectiveeWudy6f communication 1npsychiatric . E A. WM... J H11151de Hosp., 1957, 6: 207- 215. L_wwflwaéminterviews.; Jenkner, F. L. and Lechner, H. The effect of diparcol on i A...“ ( 3 _5/ the electroencephalogram 1n the normal subject and in those with cerebral trauma. EEG Clin. Neuroghzsiol., 1955, 1: 303-305. Kahn, R. L., Fink, M. and Weinstein, E. A. Relation of amobarbita1.test to clinical.&mprovement in electroshock.Wégégfkefirch. Neurol. &szchiat., 1956, 76: #‘YMW n Maren Kahn, W» A: ,F1nk, M. RL.and shock. Ps WM““‘0 Changes in language "‘"' Ann/n" .3!" w». déy;gf Communication. Grune c /’”’“MFStratton, NY. MHA./ danng“éIectro- f & 1958, 126- 139. Lechner, H. 0n the influence of anticholinergic drugs on the EEG of recent closed craniocerebral injuries. EEG Clin. Neurophysiol., 1956, 8: 71h-715. The Lennox, M.A., Ruch, T.C. and Guterman, B. benzedrine on the post-electroshock effect of EEG. EEG Clin. Neurophysiol., 1951, 2: 63-69. Marazzi, A.S. Some indications of cerebral humeral mechanisms. Science, 1953, 118: 367-370. -Marazzi, A-S. Effects of psychotomimetic drugs on cerebral synapses. I t .,.«-~,«.... Psrchotropic Drugs. Amsterdam, 1957, 283-286. u s. Elsevier, “.11Relationship gflhAIEucffiéééns mun-qua- a. M. z ._ may, 13;:w365-367. 2 ' aAd Hart E. E. Marauai,A “NW 5%”to adrenergic cerebraineurohumors. Science, 1955, w.“c.m,, ”“Vmw~emn f .1 �-31- Studies on mescaline: II. Electroencephalogram in schizophrenics. Pszchiat. Merlis, S. and Hunter, W. Quart., 1955, 29: u3o-h32. W Morton, H. J. - WM...wr-i“ mm“wv'wm‘ and Thomas, r E T. ,.. MW~;:-a‘ ST MW own—VT“ mam»Warmest“ “: “NM“ 2,1958 13131315 HIM-~14“ humumwnhaartwrat? emfancet Naka, u. Effect of atropineon thew if , ..:. ¢~w m«w. v,;<w~1»~ww-.. Afloé:§€fi?bpgychopharm., 1958, wammwa Pennes, H.E. and Koch, P.H. ,1 I"; anununnwwnmsu ”N; . Trans. Int. Cong. wunme:::;::ZZZZZZZw (in press) Psychotomimetics, clinical theoretical considerations: Harmine, Nalline. Amer. J. Pszghiat., 1957, 112: and Win-2299 and 887-892. Rinaldi, F. and Himwich, H.E. Alerting responses and actions of atropine and cholinergic drugs. fi;fl;§. Arch. Neurol. and Psychiat., 1955, 12: 387-395. Rinaldi, F. and Himwich, H.E. Cholinergic mechanism involved in function of mesodiencephalic activating system. A.M.A. Arch. Neurol. & Psychiat., 1955, 12: 396-h02. Roth, the EEG under barbiturate anesthesia produced by electro-convulsive treatment and their significance for the theory of ECT action. §§§_ Clin. Neurophzsiol., 1951, 2: 261-280. M. Changes in Roth, M., Kay, D.W.K., Shaw, J. and Green, J. Prognosis pentothal induced electroencephalographic changes in electroconvulsive treatment. EEG Clin. Neuro- and �-32Schwarz, R.E., Bickford, R.G. and Rome, H.P. Reversibility of induced psychosis with chlorpromazine. Mega 2522. Clin., 1955, 29: h07-h17. Central cerebral chemicals and their relation to psychoses. Chemical Concepts of Sherwood, S.L. Pszchosis. McDowell, Oblensky, N.Y., 1958,v268-276. Strauss, H., Ostow, M. and Greenstein, L. Diagnostic Electroencephalography, prune Ulett, Stratton, N.Y., 1952. & Effect of atropine and scopolamine upon electroencephalographic changes induced by electroconvulsive therapy. EEG Clin. G. A. and Johnson, M.W. Neurophzsiol., 1957, 2: 217-22h. Verdeaux, G. and gramme de _4kum..u“W" clinique. WhamWmmw uwm “my echovsky, M. Marty, R. Action sur l'electroencephalo- substances pharmacodynamiques Rev. A d'interet Neurol., l95h, 91: hOS-h27. psych031s caused intoxicgtlonwWwAgggBayohiat by benactyzine Wmmwaw 'et www.mo.‘w:_mh‘”w mu... W NW. grams ”KM—i ““"C;L;ww ”w Mes-mm Neurol. Scand. M fi,‘ "”§2}&, A. Atropine in the treatment of closed head injury. J. Neurosurg., 1950, 1: 398-h02. Weinstein, E.A. and Kahn, R.L. Denial of Illness: Symbolic and physiological aspects. Springfield, 111., 1955. C. Thomas, R.E., McNamara, B.P. and Krop, S. influence of atropine and scopolamine on the Wescoe, W.C., Green, The central effects of 63-72. DFP. J. Pharmacol., l9h8, 22: �-33. dissociation of behavior and EEG "sleep patterns" in «iogs: morphine, N-allylnormorphine and atropine. Proc. Soc. Exper. Wikler; A. Pharmacologic Biol. Med., 1952, 12: 261—265. Wikler, A. The Relation of szghiatry to Pharmacologz. Wilkins, Baltimore, 1957. Woolley, D.W. Serotonin in mental disorders. Res. Publ. Ass. Nerv. Ment. Dis., 1958, 2g: 381-h00. Wm. �On this sheet please prepare for publication in BIOLOGICAL ABSTRACTS a typewritten (double spaced) abstract of your paper and attach it to your corrected proof. Since proof cannot be furnished, check your abstract critically—especially the citation, scientific names, formulas, chemicals, and technical terms. An abstract should be an informative digest of the significant content and conclusions of the paper, not a mere description. It should be intelligible in itself, without reference to the original, but is not intended to substitute for it. It should be brief (preferably less than 3% of the original), written in whole sentences, not telegraphic phrases. For directions, please see the reverse. Sample Citation: DOE, JOHN J. (U. Commonwealth, Capitol City), and RICHARD ROE. Metabolism of phosphorus in rats. Jour. Pest Control Res. 37(4): 152-165. 1957. Detach here and return lower portion only �A GUIDE FOR THE PREPARATION OF ABSTRACTS CONTENT—Include: 1. Name of organism, and objective of the study. 2. Materials, manner of use, or route of administration, principal findings, and results. 3. New techniques, their uses and qualities. 4. New apparatus, its intended use, and if commercially available, name and address of its manufacturer. 5. New or verified data of permanent value, e.g., absorption spectra, chromosome numbers, constants, mathematical or chemical formulae. 6. New genera of animals/ plants, new classifications, new distribution records. (For systematic data, see below.) ,7. New theories, new interpretations, evaluations, if possible; if not, reference to them. ‘ -Omit: Information contained in the title. 2. Additions, corrections, or any information not contained in the original published paper. 1. FOR SYSTEMATIC PAPERS—Additional instructions. FORM: 1. Write the name of a subgenus, genus, or any supergeneric taxon, if old, in small letters with a capital initial; if new, all in capitals. The name of a species, subspecies, variety, or form is never capitalized. 2. Alwa rs underline the name of a genus, subgenus, s ecies, su species, variety, and form: with a straight ' e if old, with a wavy line if new. No other group name is ever underlined. Write the name of a new combination of a species from one genus to another) transfer ‘ (e5: a straight line under the old and a wavy line under the new or shifted part, followed by the basonym and its author in parentheses. CONTENT: Be alert to information other than the formal, strictly taxonomic and nomenclatural. Summarize or men— tion new data in any biologic field—life history, morphology, biogeography, cytology, ecolo , evolution. (Nontaxonomists welcome such information. NEW TAXA. Omit detailed descriptions, long synonymies and ~ �DEC 7'5 3.959 m, x. (mm. Hume-1. mm m, a. 1.). mm or MWo W m m. W on Wu But EEG mum- and 101. mm mummrm mm (cu-mum. win-2299‘. administer“ to mum-'10 patent- flung, are «minted with n blocking Wtua Fatima. . JB~318 and 38-1336). Wu of of. with! It various «mutation a: mm, than at EEG rhythm pelt—amid” delta wtivity; darting, mum-y illusory. donning: and mnucinatory mum; and attacks of Ins-mm mimosa, drynosa of the mouth, dry akin md can— halyard“. The cloemgraphic, behaviml and manic offsets behavioral We mt.The“ mom. with m ' Mmtiam suggest. that. a «mimosa: film is an 1mm in mtml mama “timers What at convulsive dim Mastic” that LSD, «momma, 30mm and aynpumm and awakening agomm -. also mam EEG deaymhnoniuum, blocking of post «mun delta activity and clinical Quinton? nativity support. the suggestion hand on that behavioral and durum in mm scum“ mug activity ehctmgnphie panama any be It is suggest“ that. increased (ahelinorzia, mamas atom) 1: associated mm EEG and cumin}. mum and euphoria while Mmud Widen, �‘_ W", . ”-77 .V . ,. . . ,, .. .. w. . ..‘Vr._.wum“.mmm————__——_q‘_ 02¢ mm activity (autumn-31¢, metie) is associated filth Em WWfian and clinical .33th and WWW: cum. Wampum; observations with atropine are round to significant hmmmnt a: the role of mtichonmme agents in head tram md «ism auto-n in mggaltad. no” chain-tum mpnfy the mmyhyaiologimfinptin Wham at the m or motion of cmlsiv. thorny and of ”puma hallucinogenic out». Mfume” in damage. �HS 981 33130? 0! ANTIGBOLINERGIG GOHPGUIDS OI P03? GOHVULSIVE EEG AID BEHAVIOR OF PSIGEIATRIG PATIENTS nux Fink H.D. (Rocoivod for publication: larch 11, 1959) Iron tho Departnont of Exporinonttl Psychiatry, Hillaid. Ronpitnl, Glon Oaks, L.I., 3.1. purt, by grant. H-927 and 31-2092 at the Nationtl Mental Hotlth, lutionul Institutes of Health, 3.8. Public Konlth Serviel. Icad at tho Alcricun EEG fiocioty, Atlantic City, June, 1958. Aided, 1n Institute of 11: 5/59 �HS 981 AlfialflLIlElGIG GOHPOUIDS AID POST GOIVULSIVE EEG �Ettact or Anticholinargie Compounds on Post Convulaiva EEG and Bohavior at Psychiatric Patients BIG Daaanatrationa or the aignificanea or high voltage dolta activity in the gonvulsive therapy procaaa (Roth w, this delta activity report that was blocked by the adniniatration or atropina and acopolanina (Ulatt and Johnaon, 1957) provided the basis for than. studioa. A: there were attendant nnplaaaant ayatoaic effects with the adniniatration of than: agents, report: describing diethalina as an antiehalin~ crgic compound with potent neurologic but minimal systolic affects (Janknor and Lcehnar, 19553 Laehnar, 1956) led an to undartaka studio: similar to those of Blott and Johuaon using this coapound (link, 1958). aboarvationa with diathasine lad to the invaatigation of othar experimental anticholinargic 1951, 1957; Fink and Kahn, 1957) and thc agonta. report daaeribac clinical and olactrooncaphalo» graphiu observations ineidant to the intravenous adniniatration at various anticholinarzie agent: in psychiatric patients at various stage: of convulsive therapy and relates the obaarvationa Thia to hypotheaaa eonaerning tho and. or action a! canvulaivc therapy and of hallucinogcna. �SEBJEGTS LIE KETKODi subjects were ninety psychiatric patients referred for convulsive theraoy. ages ranged from 18 to 67 years, and diagnoeee included schizophrenia reactions end nanio-deoroeaive end involutiona1~depreaeive peyohoeeo. a varied number of eubjeote were etudied for eaoh oonpoond for a total of 107 observations. Patients have been obeerved at variooe etagea or the treatment prooeee. The obeervatione were made in the EEG laboratory, using a standard 8 channel EEG recorder and noodle oleotrodee applied in 17 lead placements following Streuee £t_2; (1952). In eeoh trial, the compound under study we: administered intravenously at a set rato per uinnte until clinical behavior or electrogrephio changes were The obeerved. The compounds et a1, 19h9), studied have been diethezine (Reynane Win-2299 (Pennee and Hooh, 1957), benactyoine (Jacobeon, 1955). JB~318 end JB~336 (Abood ££_5;, 1958) end atropine. Diethaoine was administered at 25 mg per minute for a total or 175-250 I: (3.5-5.9 nelkg); w1n~2299 and bonaotyeine at 0.5 mg per ainute for 2 to 5 e3 (0.02~0.15 eg/kg)3 and JB~318, JB~336, and atropine et O.h mg per minute for 1.2 to h.0 mg (0.01~0.10 mg/kg). �OBSERVATIOHSa- (a) Diethaeine: administration of diethaeine in fifteen patients prior to convulsive therapy reaultea in a decrease in EEG voltages and a deeynchronieaticn of all trequenciee. Prevailing rhythmic patterne becane leee pro» nuanced. In acne inatanoee, symmetric low voltage 6-7 epa activity appeared and wee aoet apparent in frontal and anterior temporal leade (gink, 1958). In twentyative patiente with varying degreee of induced high voltage delta activity during convulsive therapy (rink and Kahn, 1957), there was a significant decreaae in voltage and in per cent tine of aloe wave activity. Iron an average delta or hSS in the trontnoeeipital leade, there was a reduction to a mean of 201. Both render and beret delta activity dininiehed. Low voltage alpha and beta frequencies became more prominent. The usual increase in per cent tine and in voltage or slow wave activity with hyperventilation was no'lenger apparent. Theee electrographic effects appeared during drug administration and pereieted for one to five houra (link, 1958). The . Concurrent.vi}h these electregraphic effecte, we cbeerved dietinctive eyetemic and behavioral changes. The initial eyetenie effects were episodes of coughing and complaints of dryneee of the mouth. Skin reaained dry and the heart rate increased by 5 to 10 per cent. this increase �-5- rarely noted by the preoordial'dietraea. not aoconpahied There was no change in papillary by sine, and constriction in response to light wan prompt. There were occasional oozplainte or abdominal griping. Such effects were generally less prominent than the electrographio or behavioral. was eubja ot, and was lehaviorally, patients hooano irritable, restless, tense and excited, and it was difficult to maintain eyelid closure. they oonplained or feelings of unreality and or tingling, weakneee and heavineea or the extremities. Oonplainte that color: were pale or more intenea, halos about lights and changing shadows were accompanied by delusional thoughts about their illness, the setting of the test procedure or the axaainer'e identity. (h) that Win—2229: Win-2299 induced The report illusory by Pennee and Hoch (1957) hallucinatory states in intravenone aaniniatration and led to this next etudy. 0n o: win-2299. both electrographic and behavioral attests einilar to diethaeine were obaerved. In five patients without EEG aloe wave activity, deeynohronisatien of frequencies and a deoreaee in voltagee were noted in four (Fig.1). “QC“.-.‘-- man, fig. 1 In eleven patiohto with high voltage delta activity there was a decrease in amplitude and per oent time of slow wave activity with an increase in the par cent tine of alpha and �.5beta trequcnciee. tc 235 (Fig. 2). The neen delte ectivity dropped tron Fig. 50$ 2 ,ieeccietcd with these clectrcgrephic effecte were clinicel patterns of reetlceeceee end excitement, end minimal eyetcuic effecte. Petiente becene teertul end tense. Vieuel illuecry eeueeticne were reported end were ececcieted in theee eubjecte with deleeicnel elebcreticne about their hospital experience. Excitenent yea ecccnpenied by ideas of reference, end in two chjecte, intrevencue chlcrprcnesine wee edainietered to halt this process. Theee behevicrel chengee eppeered during drug eduinietreticn or within ten minutes, end disappeared within two to three hcnre. systenic effects were alight. there were neither cough nor rcepiretcry dietrccc. Scert rete wee unettected except in petieate who becene overtly excited and teertcl, in vhcn techycerdie eppeered during thie excitement peried; Dryneee cf the ecuth wee repcrted only on direct inquiry. (c) Benectieine: Reports that bonectyeine induced EEG deeynchrcniseticn (Ccedy end Jeweebury, 1956), its enti~ chclinerzic nature, end the etrccturel cinilerity to dietheeine and to Win-2299 led to our touting ct thin ccnpcund. Intrevencne edninietreticn in 12 subjects elicited similar clinical and electrcgrephic petterne. Bath in the well ncduleted elphe record and in the reccrd with high vcltege delte ectivity, deeynchrcnieeticn wee prompt. Dclte ectivity decreased trcn - �.5a mean time of 391 to 165 in 8 Fig-t, These electroxraphic by subjects (Fig. 3, h). 3, h~ patterns were ngnin acconpuniod clinical roctlenlneol, irrittbility and oxeitcmont. Artifactwrree recording was nor; difficult.. the illusory sensitionl ind dblunional thoughts a¢en with the initinl aénpounds were hot notad at then. dongs. luvtla. Syatcnie effects wore niuilar to Win-229?. ‘ (d) Piparigylbanzilatoa: Following racont reports by Ahead 33_§; (1958) that various pipcridylbcnailatca with nynaurxblo antichoiincrgie activity induced hallucinations in psyehintrie subjects, we taut-d JB~318 and JB~336 in 2h vubjoets. Thu olectrogrnphic'pntterns wort identical with the other experihonttl antiehulinorgia compounds. Dosynchrenination of troquancios wan noted during the injectian or within 15-minute: and pornistod tar due tp {our hanrs (Pig. 5). O’Qflflfiflw Fig. 5 In each inataneq in whieh duaynchronixation was obaarvad,‘ ainicnl restlolancau, excitcnont, illunary and hallucinatory activity were acted, and were eonuurrant with the nloetrographie changes. In two inatuneoa the behaviornl changoa wore haltcd by tho intravonoua administration or chlerprenasino. , �-7-(c) Atronins: Considering the numerous reports that atropine_indnced EEG elow wave activity and clinical eonnolence, we adninistered this anticholinergic agent intravenously in 15 aanecte, in dosages of 0.8 to h.0 as (.01~.1o ng/kg). In six snbjecte without EEG delta activity, there were no changes in EEG pattern during drug administration nor for 10-20 minutes theratter.. During a period of laseitude, decreased voltages, minimal desynchronication, and an increase in per cent tine'delta were noted. In subjects with delta activity, there nae an apparent initial decrease in voltage and per cent tine or each activity during the first ten ninutes after adainistration, followed by a return to original values during the period of quietode. In neither period were the changes significant,: (31:. 6). fi Fig. 6 systemic effects were prominent during the injection with increased respiratory rate, pallor, dry skin and dry precordial complaints increase in heart rate up to 10oz. Subjects became restless and recording became difficult. Within ten ninntes these symptoms subsided and the subjects became drowey and relaxed. mouth, and an �-8DESGU$SION3 In those studies, varione experimental compounds with neaenrable anticholinorgic activity have been obeerved to have similar electrosrephic and behavioral effecte.' Electrographically, each agent induced a doeynchronination of frequencies and a decrease in voltages, which was most prominent in cubjocte with delta activity following convulsive therapy. Behaviorally, theee electrographic patterns were aceociated with stimulating, excitatcry, illusory and hallucinatory activity. To a leeeer degree, ainiaal oysteaic changes in heart rate, eelivetion and eweating were noted. Theeo latter eyeteaic cffccte were lore prominent in patiente given intravenous atropine under einilar experimental conditione. Thceo obecrvatione can be related to theories of the node of action of convnleive therapy; to concepts of the basic of experimentally induced hallucinatione; and to roporte of tho effocte of atropine on EEG patterns. (a) Convaleivo thcrggy process: Earlier etndieo indicated that the development of high voltage slow wave activity wee a nenrophyeiologic correlate of behavioral changc in convulsive therapy, and a necessary, though not sufficient, condition for clinical improvement (Pink and Kuhn, 1957). In enanarieing the obeervationc of nuaerone authors on the relation of acetylchcline metabolic: to trauma of the central nervous eycten and to convnleione (Pink, 1958) it wee enggeeted that a biocheaical concoaitant of the induced EEG �.9. alov wove ootivity to. an increased level or acotyicholinoo‘ oholinootorooo activity of tho central nervous system. Tho . pro-ant oboorvations of altorotiono 1n the slow wave activity at oonvnloivo thorapy by that. oxporiuontal antioholinorgic compounds or. oonaiatont with this suggestion. That tho problon 13 not. complex is indicated by reports or oonpoundn with other biochemical activity alto ottocting clot wave nativity in o aililor faahion. Alphotnnino (Lonoox‘:1_g;, 1951), nonoalioo (Karlia and Router. 19553 Dunbar, 1955), lyoorgio acid diothylonido (Dante gg_g;, 1957 a,b) and diphonhydranino (Bios-Guerrero £3;=;, 1956) olso reduced post-convulsive slow wave activity. In these reports, such a reduction vac aooonpnniod by excitntory nod stinuloting effects on bohtvior. Those conponndo, hovovor, are prinarily oynpathoninotio and antihistoninio in pharfiaoologio activity and not antioholinorgie; 81n113r_oftocto of those divoroo bioohomical ngontt on olootrographio patterns and on cliniool behavior may be oonoidorod within thoorotio oooatruota of the relation of synaptic ootivity to behavior on oxproauod by Harolsi (1953, 1957), Brndloy and Blkool(1957), Evarts (1958 .,b), Sherwood Tho thono author: nnzgoot thot tvo ohonoroopon-ivo roooptorl oxiot within (1958) and Hoolloy (1958). typos or interootiog the nervous oyston which or. Iolootively roopoouivo to oholioorgio or to udrenorgio agonto. whore ouch rocoptorl oxilt, they oxort oppoaiog ntinolotory or inhibitory ootioo. �-10Thus, repeeted induced oeuvuleione mey lead to e choose in eyneptio eholiaergio activity, reflected in surface electrodes on high voltage slew wove activity. Administration or enticholinergio egente may alter eyneptie nativity, resulting in e decrease in the manifest aortioel electrioel eotivity to preoenvuleivo levels. Adeinietretion of eyupethoeinetio egente eey eohievo the gene electrical effects by inoreeeing the level of edrenergie activity. The neoiteet elov weve activity, so proninent end so pereietent in the poet~eeisure 328, any thne be vieved ee resulting from n persistent elteretion in the synaptic activity of large hunters of cello of the control rnervone eyeten. The delicate netnre or this balance is seen in the reedy reversibility with alerting, tine, and the wide variety of phernnoologio agents noted here. While an alteretion in synaptic activity may underlie the behavioral changes in coovulsive therapy, the neoheniel elteration is developed or eueteinod is uncleer. The obeervation by iird gt~gl‘(l956 e,b, 1958), that an inoreeee in permeability of the blood brain barrier followed‘ by which such repeeted indooed convulsion: euggeeta one sz in which synoptic ehengee eey be mediated. coneietent neture or these neurophysiolozio observation: nekee en exclusively payehologic explenetion e: the node or action of convulsive therapy lees teneble. These etudiee ere ooneietent, however, with the neurunxmyeiologio~‘ adoptive view or the convulsive therepy preoeee whioh eugzeete The �«11 an that nenrcphyeielcgic chengee provide the enbetrate for alterations in all aepecte cf the enbject'e clinical behavior; the type or behavieral eitereticn being dependent upon the type and degree of neurophyeiclcgic change, the personality or the eubject and the expectations and tolerance of the milieu (Weinetein and Kahn, 1955) link and Kahn, 1957; Pink, 1957). (b) leurcphyeialegy c: hallucinczenic activity: The effects of antichelinergic ccnpcnnde on EEG and behavior nay alec be related to the underetandinz or experinental hellucin» ct theee experinental ccnpcunde induced excitatery behavior, including illneery and hallucinatory phenomena. Here, tee, a synaptic nedel any be applicable. cgenic activity. Each sympathceinetic agente, ae neecaline, LSD and anphetanine, and anticheiinergic agente ea thcee described here, are alee potent hallucinogene. i necropharnacelcgic basis for each behavior nay be characterised ae an alteration in the level or eynaptic activity in the direction of increased inhibition (decreeeed tranenieeicn) or etincli. The clinical efficacy of ccnvnleive therapy in modifying hallucinatcry activity nay lie in alterations at thie nenro~ physiologic level, The effects or ench hallucinogenic blocking agents ae chlcrprenacine and rceerpine on EEG electricl activity are ccneietent with each a View. Both ccnponnde induce EEG hypereynchreny in nan (Bente and 339 deaynchrcnicaticn effects of 1955). Chlorpromazine was Itil, 195k. 1958} and b10¢k thd neeceline (Schware gt_3;, found equally potent in aborting the LSD and �-12. exoitatory activity of the experimental anticholinergic coupouoda in these etudiea. (c) Relation to atropine: Goapariaon or the eyetenic land neurologio effects of experimental anticholioergie compounds with atropine reveals ditterencea in initial focus of action, Exoerienco with atropine at physiologic and toxic levela in nan indicate that the prodoainant effects are :ocuaed at peripheral nervooe ctroctnroa. Initial bradycardia, followed by tachycardia, lose or creating and ealivaticn, papillary dilation, intestinal relaxation and decreased motility are. aaonget the effects at low (0.2-1.2'ug) dooagoa. At higher doaagea (ans :3), the neurolggic effects of ataxia, irritability, disorientation, and delirium are observed (Goodlla and Gilnan, 1955). ‘ In contrast, the experimental anticholinergic agents in doaegoo sufficient for central nervous system effects manifest little peripheral activity. The central effects are observed early and may continue for exteneive periods without gaetro~ intentinal, cardiac or pupillery changes. It ie within the context of the tocue or activity in relation to dosage that the apparent discrepant EEG observations or the effects or atropine (in inducing aloe wave activity) and the-e experimental antioholinergic coapounda nay be reconciled. I weecee 33_g; (19h8) administering 1.0 to 3.0 ag/kg atropine in curariadd cata and monkeys and funderbuzk and Ceae (1951) using 0.h to 1.2 ag/kg in curarised cata, observed high voltage EEG �.13.. aloe wave activity. Hitler (1952, 1957) reported that 7;! Ig/kg atropine on unaneethetiaed, uncurarieed deg: produced "spindle slow wave” patterns eiuilar t6 sleep.) Rinaldi and 'Hinwich (1955a, b) reported that atropine in doses of 0.5 to 2.0 mg/kg in curarized rabbits exaggerated EEG sleep patterns and inhibited the alerting or the EEG to peripheral stimuli. Sinilar observations have been reported by Bradley and Elkee (1953) in the cenecione cat. In each instance the doeage at atrepine varied tree 0.5 ta 7 ng/kg . a range roughly eoeparable te the deaagea need in atropine coma therapy (Ferret and Miller, ; 1958). In the present etudiee, the EEG effects at low deeagee of intravenous atropine (6.01 to 0.10 mg/kg) were minimal and systemic éfteete censiderable,cenriraing einilar observations by Verdeaux and Hartylfl95h) and by Danielepalu g§_3; (1955). the slow wave activify an prominent in animals and man at high doeazea at atropine, may not be a manifestation of the initial or direct effects at atropine, but a reflection of a more widespread alteration in body yhieialogy. Thee, while eeneiderable epeeulatien aa ta central neurophysiology has been based on studiee with atreyine, each abeervatione provide a epecial'caee at anticholinergic affects. the anticholinergic activity eetabliehed in observation: in vitro and in the peripheral nervous eyitee, may net be the effective physiologic activity in the large deaea necessary to affect centraldr‘cturee, rhe experimental cenpounde, however, provide mere euitahle �“15- for thu study of cantrnl nturaphysiologic (tnticholinargic) patterns thnn stropine, as, for oxunplc, 1a a ra~ovu1uut1an or the studio: at ertnieeorcbral trauaa :nd dpilcpay. Wtrd'l (1950)'r¢p¢rtl or the otticney a: high do... of atrepino in altering the clinical n‘n1£0ltatienl of hoad trnuau indicutod that effective dose: brought with than Invor¢ systolic ortoctl. the tntluro of ntgopino and scopolnninc to affect cpilcpny any be rolatod to th; inability agontn that. to rcgah thu cintral norvoua system in tdnquato quanlty. It would stun ndviugblo, thoroforo, to rcpuat that. Studio: utilising inch fiorc ccntrnlly active of eoupounda anticholinargic hora. compound; 18 used in the oxporimonta rapartud �-15SUHNARI: _ 1. Experinontsl natiohclincrgic compounds (dicthntinc, .Win«2299. bannctysino, JB~318 and JB~336), adainintorcd to paychiutric patients nt variant stcgcs c: convulsive therapy, wcro aascciated tith: (a) dcnynchrcniunticn of EEG rhythm: with a blocking of paltnccnvulcivo delta activity! (b) alurtina, cxcitatcry bahtvicral rolpcnao with illnlcry, delusional and hallucinatory idonticng and, (c) systemic Ottocts of muscular Icahn-cs, dryncun of thc month, dry skin cad tcchycardia. 2h. oltctrcgraphic bohavicral and systemic nrfncts were ccn~ current. 2. Thou. obscrvnticna are consist-at with tho auggonticn thut a nourcphysiclczic ccnconitant or convulsive therapy is ca incroulo in contral norvcul Iynton cholinorgic activity. Obscrvctionn that LSD, anphotuninc, nouculinc and diphonhydranino - tynpnthouinctic tad antihiatnninic agents . 31:0 induco BEG dcnynchrcniuaticn, blocking of part convullivc 3. doltn activity an; clinicsl cxcitntcry activity cuppcrt‘thc luggcsticn thut behavioral and clectrographic patterns may be bclud on altcrcticns in syntptic activity. )It is nuggclt that incrca-od synaptic activity (cholinorgic, aynpnthclytic ctructa) in calccintod with EEG hypornynchrcnisaticn, Aka clinicul �~16~ Itdgtion and ourhoria; whilo dtcrtasod synaptic activity (untieholinorgie, uynpathoninottc) is associated with EEG doayuchronization and clinical Ixeitatory and hulluainocanic stutou. nascrcpunt obscrvatiana with gtropinu art rulattd ta significant difroruncca 1n doaagc. Ronaasoaununt or tub h. rain or anticholinorcic taunts state: 1n hild truunt 3nd noisurn luggoatod. 5. These obaurvations amplify the neurophysioloxtcw tdaptivo hypothonia a: the and. at tcticn or convulsive thcrupy and of experinontnl hallucinogenic Itaton. 18 �-17“ AGKEOULBDG§§§§ga I u: gr‘totul far the tcchnicul auuiutanee of Bra. Etnnnh fibuquorn in recording and nnulyaoa. Supplici ot‘tho various pharnncauticals were and. froely availtblc by Lake-1d. Laboratories (JD-318 and JB-336), Herck sharps & Donna (bounctyzinc); Sand»: Pharnnconticaln (nan-25). Sturlingwmthrup (win-2299) sud Smith, x11" und Preach Lnboratorica (ditthnsino, chlarpronastna). EEG �-18REFEREIOEB Ahead, L.G., Oottuld, A.H. and 31.1, J. A now group of psyohotominutic agonta. Proc. Soc. Expor. Biol. 804., 1958, 21: h83~h86. 11rd, 3.3. c11.1..1 oorrolnton o: clootroahook thorapy. 5:5:5: Arch. laurel. & quohiat., 1958, 12; 633-639. Lira, 3.8., Strait, L.A., Puoc, J.W., Hronott, 3.x. and Bowditch, 8. Neurophysiologic ottootn of olootrioolly induood convulsions. A.n.;. Aroh. lourol. & Pglghiot., 1956, 15: 371-»3'28. Dante; D. and Itil, T. Zur Hirknng do: Phonothiuninkorporo out do: Honaohlicho Hirnatronbild. Arsnoinittoltoroogg, 195k, 1} h18~h23. Bantu, D. and Itila I. A conporilon of tho action of various nogaphon phonothhsino compounds on tho human EEG. Trans. Int. Gong. of Houroagycggzyarm., 1958, (in gross). lonto, 9., 1%11, I. and Schnid, 3.3.. Eloctrouncophalographtc atndioo ooncorning the action or LSD-25. lourozhzliol., Bonto, D., I Itil, !. EEG Olin. 1957, 2} 359 (ubo£.) and Schnid, 3.x. Eloktrooncopholoo graphilcho studion our Wirkungauoiuo do: L8D~25. ggyohiut. at louro1., 1958, £25: 273~28h. Bradloy, P.B. and Bikes, J. the ottoct of atropine, hyosoynnine, phyooottgnino and noosttguino on the oleotriool ontivity of tho broin of the conscious cutoo J. thl1o1., 1953, ggga 1h~15. �‘19Bradley, P.B. and Bikes, J. effects of drugs on the electricel activity of the brain. gggég, 1957, fig:' The some * 77~117. 3.0. A clinical trial of benectysine hydrochloride ('8uev1t11') as e phyeiael relexent. gggg. andy, 1. end Jewesbnby, Hed. ‘Ben1e10pelu, Jean, 1956, y 1.85—1.87. 9., Giurgee, c. end Brocan, G. Eleotroencephele~ grephic study at the,non~epoeitic phernecedynenice of the etimnlnigry effect at etrnpine on ths corebrel cortex. Iiiieégggcheekly Zhurnel 8858,'1955. g5: 601~611. Defiber, 3.6.3. Stud1ee on neecelinec III. letien 1n epileptice. 3933.,1955, 29: h33~h38. mm. Die.2~auerrero, R., re1nete1n, R. and eettlieb, J. a. EEG finding: following intrevenoue injection of d1phenhydramine hydrachloride (Benadrylr). Ema. Olin. Beure» 2n;.1.1., 1956, g; 299-306. Everte, E.V. Heurophysiologicel correlates of pherueeologicelly induced behavioral disturbencee. Ree. Publ. lee. xerv. .uent. 91... 1958, 29: 3h7-38o. Everte, 3.7. Chemical bases for peyohoeee. Chenicel Conceggg e! Pezphoeee. XuBovell, Dbleneky Inc., H.!. 1958, k1~62. link, a. A unified theery of the ection or phyeiodyuenic y therapies. J. Hilleide leep.. 1957. g; 197-206. l1nk, K. Efreet e: entichelinergic egent, dietheeine, an EEG and behevier: 81¢n1t1cence for theory at convulsive therapy. I 1.3.1. laurel. a Peyehiet., 1958, 80: 380~3873 end Biologicel Peyvhiet_z, ed. J. neeeernen, Grune & Stretton I. 3., Arch. 1959’ 1811*19he �-20- rink, Rnlation or olectrocncophnlogrqphic delta activity ta bohuvioral rulponao in aloctrolheck. H. and Kuhn, R.L. A.H.A. Arch. tartar, a. lourol. and 3111:», J.J. & szuhint., 1957, 13} 516~525. Atropiuo cont: A‘Ionatic therapy in psychiatry. Lu. J. quehint., 1958, $35; h55~£58. rundcrburk, w.n. 1nd Onto, !.J. rho affect of ntropino an cortical pot-ntiuln. EEG Olin. lburophlniel. 1951, g: 213~223. L.8. and Gilnnn, A. Pharmacolqlgcll Basin of Thorazcntieu. Kacxillan, I.!. 1955. Hoynans,.c., Establo, J.J. and dc Bonncvnanx, 3.6. sir 1: Boodnan, I - pharmacologio d0 11 phonothiaz1ny1-oth71d10thylnninc (2987 R.P.). Arch. Int. Pharmacofizg; 19h9, 12; 123-138. Ito: ltd spacitik virkning p: contruluorvoayltonot. g‘plkritt far Lqugg, 1955, 3E2: Jacobson, E. Susvitil, at nyt ' 11h7~1151. Jonknor, 1.2. tad Lochnor, a. Th0 offset or diparoel on tho olcctrooncophnlogran in tho nnrnul Inhaoct und in than. with corobral iguana. BEG Olin. lenrophyniol., 1955. 1; ' 303-305. Lochnor, the influence or naticholinorgic drugs on the EEG Clin. EEG at rcchnt OIOIId crtniccrobral injuries. lourenhyliol., 1956, g. 71h'71§.' a. 0n Lonnox, H.A., Ruck, 1.0. :nd Gutornnn, B. The the postuoloctroshock lourozhza1a1., 1951, g: 63~69. boas-aria. on oft-ct EEG. EEG of 0113. �-21. 'Hereeei, A.$.- Sene indicetiene e: oerebrel hnnerel necheniene. science, 1953, 1;81 367-370. lereeei, A.8. Etteete ;;“peycheten1eet1c druxe eynepeee. Egyehotrepie Bragg. on cerebrel Eleevier, Aneterden, 1957, 283~28h. Herlie, 3. end Hunter, 7. Studies en eeecelinee II. Electra. eneephelegren in echieephreniee. fezghiet. 93ert., 1955, Pennee, 8.3. mum”. end neck, P.H. Peychetonimetice, clinicel end theoretical eeneideretiene: Hernine, w1n~2299 end leiline. Amer. J. Pelehiet., 1957, ;;3: 887~892. Rineldi, 7. end ninwich, 3.3. Alerting repeneee end ectione or etrepine end chelinergic drnge. A.H.A. Areh. Neural. end Rineldi, I. Pezehiet., 1955, 12: 387-395. Cholinergie nechenien involved in functien of neeodieneephelic ectiveting eyeten. ena ninwieh, H.E. leurel. e Peychiet., 1955. 1;: 396-h02. 3. Chengee 1n the nu unau- bubttnrete mu...“ produced by electroaeonvuleive treetnent end their significance fer the theory or E0! eetien. BEG clin. leureghzeiel., 1951, 3: 261-280. A.H.A. Arch. Roth, 30th, l., D.W.l., Sher, J. end Green, J.‘ Pregneeie end pentethel induced.electroencephelegrephie changes in Key, electreeenvemlve treeteent. E36 6113. leereggzg}el. 1957, 2: 225-237. �a22- 3.2., Bicktord, 3.0. Schwarn, and Rona, H.P. inducod psycho-it with ohlorpronasino. 1955. 2Q; h07oh17. Bhorvood, 3.x. Contrul oorohrol ohoniools dud Rovoroihility or Proc. Hiya Clin.. their rolation to paychonol. chonioal Gonoopto or £329hoaiu. xenowoll, Oblonlky, 3.2., 1958, 268~276. Btrnuol, 3., Ootov, H. and are-nutoin, L. Diagnostic Electroonccpholggrtphz, Gruno & Strntton, R.I., 1952. Vlott, 6.1. and Johanna, u.w. Ettoct o! ntropino and acopolonino upon alootrooncophalogrnphio changos induced by olootroconvulaivo thorapy. EEG Olin. lonrophzgiol., 1957,‘2: 217-22h. a. and Harty, R.‘ Action our l'oloctroonoopholocronno do ouhstancol phnrnacodynauiquoo d'intorot cliniquo. Vordoaux, Rev. Word, A. lourol., 195k, 2;:‘hosuh27. Atropino in the troatnont of cloood hood injury. J. lourouur‘., 1950,‘ls 398-h02. Uninstoin, 3.A. ond Kuhn, R.L. Doniol of Illness: aznholie and_phyoio1o§ict1 oqpooto. c. rhonal, Springfield, 111., 1955. Roscoe, nonunora, B.P. and Krop, 8. Tho influonco of atropine and aeopolonino on tho control ottooto of 91?. J. Phnrnaeo1., 19h8, 23: 63~72. w.c., Groom, E.B. Uiklor, A. Pharnocologic dissociation of behavior and EEG ”sloop pattorns' in dogs: morphine, l'nllylnornorphino and atropine. Ptoc. Soc. up». 31.31. 14“., 1952, 12: 261-265. �«~23. the 1.1915593 or P£Ich1utrl to thaaoLg‘z. Wu. Wilkins, Bathe", 1957. Woollcy, BAY. Scrotum”: in maul disorders. Ru. Pub]... Hitler, A. A". new. Hunt. 913., 1953, 29 381-4400. �aasaaaa '13. 1a Effiflt or :1 313.1299. was. anuyuchraaiiattua a! troqucaatnu nXtur 3.! 3:. (Fig.1.. 88' kl). 11:. 3. Efrhet at 1' Reward satin 31n~2299 an pottueoavu131Vt 2h hoard dulta :ettvtiy: artor aouvulsiau #8. flat. dauznchrinilatioa at tvcguuueaou and yursiniana. nttor 2.0 is. ("l‘l’fi ago 51). ‘ attooz a: It nuuuutwtaaot uni. perutntaut apero¢ac 1n rol‘agu: and duawachviatnntsaa art-r 1.5 It. (Filtllg “. 3’4). Ettoct at 1V aunuotrtfin- an yaatuoauvulatvo.doltt nottvaty. accord tokua 2£ hctru arch: cauvuzntau I7. lot. tetrachruntnttton or {toquuuclco urtor 1.5 ug. (tumult. It! 3)). 9“. 5. . Rttcat I: Jimfllfi an yout~¢¢uvulliau Rigord takun 2% hour: ¢¢I%& tttnr cunrulttan #9. nativity: lat. duarunhroattttiua a: Irvquuuotnn, fineronagd rulingslttar !.h It. eur‘taa vita 330'! 101 tuartalt. (vaunlo. ago :7). 5&l11lr run-van thwarted math £I~336. �’1‘. 6. ”net or «$11 «Inn 62 I? “up“. an ”anemia" «In «an». nun mm: 2!; hour. um amass.» #6. 30%: man an.“ an delta “tint: and ”min“ menu. in heart an, with partition“. (mo. :3. “mam . 2.0 In. «025 Int/u). 18. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effect of antichlolinergic compounds on post convulsive electroencephalogram and behavior of psychiatric patients. Electroencephalogr Clin Neurophysiol. 1960 May; 12:359-69. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-34b-013 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 6 items. 1: Reprint from Electroencephalography and Clinical Neurophysiology JournalVol. 12, No.2, May 1960. 2: Letters. 3: [preprint]. 4: [Post print?]. 5: Publication submission info. 6: Drafts. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/86dcc852ef57150af5b9234a4c32a667.pdf 0ab52ac497e61e2b06bc38b78babd96f PDF Text Text EFFECTS OF DIFFUSE ALTERED BRAIN FUNCTION ON PERCEPTION BY MAX FINK, ROBERT L. KAHN and HYMAN KORIN ( Hillside Hospital, New York) PROBLEM Recent studies of the relation of perceptual alteration following brain damage have emphasized the role of focal damage. To determine the patterns Of perceptual changes with diffuse alterations in brain function, the following studies were undertaken. SUBJECTS AND METHOD Consecutive subjects in a psychiatric hospital referred for electroshock therapy were studied. Alteration in brain function was induced by varying the frequency, number and severity of the induced convulsions. The following tests were applied before treatment, at weekly intervals during, and two weeks after treatment terminated. A) Measures of altered brain function: Two quantitative indices were used to determine the degree of altered cerebral function: 1) the per cent time, amplitude and lowest frequency of the induced delta response in serial electroencephalograms; 2) changes in orientation and in language following the administration of intravenous amobarbital sodium. B) Perceptual Tests: 1) Tactile: Threshold perception (100 ‘X, point) of square wave electrical stimuli was determined for different body areas. Stimuli were then applied simultaneously to two body areas, with interspersed single stimuli in random fashion, and the subject was asked to report where he felt the stimulation. 2) Visual: a) Figure—Ground: Using embedded figures (Gottschaldt) of increasing complexity, subjects were requested to identify a simple geometric figure in a complex background. b) Tachistoscopic recognition: paired words were presented at rapid exposures to subjects. The words were matched according to tables of frequency in common usage, and were of two groups: relating to illness or to the body, and those not relating to illness. Words were matched \ randomly. ‘ �2 THEME 9 RESULTS With increasing degrees of altered brain function, there were increasing errors in reporting the simultaneous tactile stimuli. There was a concomitant rise in the threshold of perception. With high degrees of cerebral dysfunction, mislocalization of responses appeared, in addition to the persistent failure to report one of the stimuli. 2) The ability to isolate embedded figures was impaired in direct relation to the severity of the alteration in brain function. 3) Threshold for the perception of words increased and subjects were unable to identify two words with increasing degrees of cerebral dysfunction. 4) Changes in perception were highly correlated with other behavioral changes, indicative of an altered interaction with the environment. 1) CONCLUSION Diffuse alteration in brain function, as measured by electroencephalographic delta and orientation tests after amobarbital, results in alteration of perceptual patterns marked by an increase in threshold, impaired discrimination of stimuli, of which the ability to discriminate a figure from a complex background is a special example. 2) Alteration in perception represents one aspect of an altered behavioral interaction with the environment, rather than a specific physiological defect. This factor should be considered in perceptual studies in focal brain lesions as well. 1) ape. Inf. (Dong. fliefioa E .- /f57 - gVH-SJa/S �3mm of Emma Altered Brain mum on Pomepticm m Fink, 11.13., mm; L. Kuhn, Bun. md than Karin, 31.33. mm gt the IV International Wrens of Psycholow, annuals, My 30, 3.957. �m at mm» Alton! Brain mum on Pauptian m of this study at alteration in Won fol-loving Mg» in «abut; mum ha been devoted to ram Mom u in nus-31m imam, dials 1!: head’ m md brain tumor. Litfln emphasis usually placed an the We effects of such hum on the pommml prom». In tha acme of this :tudiu in 1:ka therapy, we charred that may 13th aanaidonble neutral 0: the down at induce-d alteration of brain mum. In these studies we ware impressed with the wide variability in the behavioral and nmphyaiologie response 91‘ our subjects to apparent ‘ aquivalent mailbox-n of convulnima. madam We have Max:815? reported the a! the belaviaral napmsaa and the W: inter- dew of apparent new Widow-c manna-grandma mortistodowribgpomoptualchanmmrm conditions cf differing determine the down of diffuse alum brain relatiwahtp of the function, and 150 136th We to the indueed amm- physiologie change. I Three perceptual M113 Visual Visual mm mm utilised: perception of Gamma“ mm wave electriwl 1.3QO or mad gamma stimuli figure; :04»th of tachistooaopdcally presumed wows. �_...___.1 em: subjects were 2310 53 meetive hospitalized patients, rerun-ed fer electroshock. Brain mention was altered by meaning remitted grand m1 cemuleim under pentefiml pmdicetim. a rmqwncy of three time per week. The convulsions were given For a control group, randomly eelected therapy; with equivalent umber of patients received eubeomalsivo Wimtim at pontothnl but with web» eonvuleive doses of electric current. All weluetiwe and same as in the experimental gmup at ~ and the type or each subject was not known to any of the tests were the thetmt in we fer investigator: until the experiment we ended. We Wmmgic indie“ were used. mameMz-ama, taken at weekly intervale an a day after an indueed maveleian, and mfitetively measured for the degree of incheed delta activity; and mobarbital taste for main disease. In this test, the language responses on a etenéandiled interview, are ”use“! after intravenous mobarbital. Mammal, 1W altered eembral fxemtice. denial, disorientation, and eyntuetieel as an 1nd!“ of Both changes have been enema these tests erem applied lure-armament and during the 2nd, are and 5th week: of treatment. The technique ef etch of the three pemeptual tasks will be doaeribad with the eomspmding results. For mm: a! thin mamtetien, the m mm to the quantitative «pacts only, and aa them is a wide variability in mangle response, we idu meant group data for obamatim apex-junta). and control groups wording to» the dogma at first; mum ded- than were physiologic change. the observation: �__.____1 _. In this talk, isolated square WWW 1mm ma emu-ital atimuli were 81ml» We mmugh attnclwd 1 on .. dine electrodes. delivemd to two body point.) valwa were doteminod :or «fix my part and $11“th the tasting, random single stimuli were interspersed to Meme errors due to fluctuatien ef threshold. Subjects were whed to threshold (100% _ localim the nppliefi atimli. Slide 1 deem-1b“ the mean number of errors mtreament, and at the Widogic effect, which is manly after the 12th tram-b. The mzbeouvulsiw (mtml) group shes: a drop in the number of errors, the Mod pmotioa effect.» This canvulsivo group, tamer, Ihm height a? the induced & Meant increase in errors. patients with a who had first The immune in we: were _ manna. Pn-tmtnent,the In Slide 2, the group differences are diffemce in the number of more in the treatment course the difference: In Slide 3. the ineWimt, because ml. of the induced In the firm; section, the subjects in than Waive, and later m—tmtad been treated by a Waive course of thumpy. marked but at the height on? significant mum We is “tossed. who have had two new or thus positive to those with either no uobcrbitn tests during tmtmt are panties new. or only am. The number of errors: are higher in patients with mom positive moberbital responses. diffemnee 101' rm the pmmtmatmnt score, the group with the greater 601%! the Mm m aignificantlv different Wiologie avenge. In the second section, the encephalograpme Furthomom, in comparing the me melts response; and in physiologic inclines are oompared. film are noted for the electro- third motion, the two new �«hm Errors in the 5:9er of ammo“ tactile mm 1mm with increasing degree: at altered brain function. 3: Bamegtim ‘01 W FM, 3: In true task, goo-atria figma embedded in a. complex dasigmd field are premtod «ml the subject is asked to tame the 9112913 figm. The slide 14 shown and subcmvulaive minim or Bath field. simple figure is: simultaneously pmmted above thh complex the man manor warm». 'i'ha 91‘ art-era before and anhconvflaivo or control group, with no mnmphyaiologio change, thaws a drop Waive gramme show utter eumulaiva in the amber of an increase in true tugboa- or W mm. «mm. compared aide 5, the aubeomulaiw and Gamma” m bath befm am} mg the 5th week of treatment. man mamas, m difi'amwe in the who: of arrow is acted. It the height of tha cleara— In shock effact, the convulsive Wits We group makes aigzrii‘iomxtly more Change. the group. (31163 6) . visualized next tha in than calmly new am are divided warding to than degree of effect in Here, the Mrs than W a: the mutual to“, W Magic the oluctmonaaphnlngm, and tha mama data, there is a simficant diffemca in the mmbar of mm undo. Patients with higher dame: cf hummimgic chums mks fin mt errant ”100th for their equivalence in fmmncy in mush matched, was mounted at rm. diffemnt speed: of mum Pairad words, usage and :3de taming from m to 250 rimmmdu 2130 of for a total mm. mum 13311607, the The mm m puma tn u wen-act morainewhgmupmpwmtefi. Harem, thumb- Wimt eonvulsive or control gmup ohm a amp in the number of while the group sham a much smaller practice effect. minim emu, �.59 In the are mud M 313.60 (8), the proutmtmat. and post-treatmnt «com The groups urination 1n the are 11611 More, untamed number of. arrears with alters-d and in both there is a brain function, Mt, the is greater than the convulsive. Thou are mt simifiaant. reduction in the aubconwlaive groups differences are and}. and In Slide 9, the role of neurophysinlagic change is again assess'efl. toe, as in the wading slide,» them in a deem it: the pmtiae This is clearly effect with the greater the change in carebml now in tha canwlaxva Wagon seem, uhomtha patients with mm but Waugh Mags show a decrease in armra, while theme with the mam“. Hero, tam. Mainlogio change show a small umber of arrears. Ia this tank, in mtmat to the two pmeding on», the effect of altered 13min functim is not manifest in an increase in the umber or errors, but is seen only when the enacted immanent in performance fails WW1? mm thou-gum in «row mum In: m NM in psychiatric patients by the remand 92mm“). induction at grand m1 control Win emu perceptual in and experimental to chanson in degree when perceptual tasks, portion to the dogma er «smut-a1 cmlsim. in emu“ mp9, the mammalian) at on? «tubal figuration hm baen obsozvod. increasing arrow" in pemaptian in pro- mm dwmfim in muréphyaiologic. indie” at mum m be observed. In addition to these pomeptual ml: changes, humor, there arm commmt altamtim in behavior, language. ariontatien, attitude and mad, and these am: highly Mama Mending upon individual 612mm“: 1n the subject“. ”the panorama). altemtima ducrihco’ here :3me but �we upset at tbs clung» in the Mom: 111th Farmer studiufi cf this in ”spouse to mmbral lesions are mm hater in pmgrcsa. 91' tam. at” organism. indium mmw � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effects of diffuse altered brain function on perception. In Proc. XV Int. Congr. Psychol. North Holland, Amsterdam: 1959:15: 238-239. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-35-001 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Korin, Hyman Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and a publication copy. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/8d591c235c58b9d455d7cbdd43d00916.pdf ebb607fbcf115668ef8fa3c0792cd5b3 PDF Text Text PSYCHOLOGICAL FACTORS AFFECTING INDIVIDUAL DIFFERENCES IN BEHAVIORAL RESPONSE TO CONVULSIVE THERAPY MAX FINK, M.D., ROBERT L. KAHN, PHD. AND MAX POLLACK, PHD. Reprinted from THE JOURNAL or NERVOUS Volume 128, N0. 3, March Printed in U.S.A. AND MENTAL DIBEABE 1959 �JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 128, No. 3, March 1959 Reprinted from THE Printed in U.S.A. PSYCHOLOGICAL FACTORS AFFECTING INDIVIDUAL DIFFERENCES IN BEHAVIORAL RESPONSE TO CONVULSIVE THERAPY1 MAX FINK, MD.,2 ROBERT L. KAHN, PHD. AND MAX POLLACK, PHD. INTRODUCTION While convulsive therapy is generally considered specific for the symptomatic re— lief of depression and agitation, and for the relief of such “illnesses” as manic-depressive and involutional psychotic reactions, the behavioral response to such therapy is highly variable. In initial attempts at understanding this behavioral variability, differences in physiologic response were sought. Neurophysiologic change was measured in various ways (4). The quantitative measures of induced EEG delta activity (1) and changes in language after amobarbital (3, 7) provided the best indices. Considerable variability in these indices among patients with equivalent numbers of treatment was observed. We concluded that the development of an alteration in brain function, as measured by a high degree of EEG delta activity (1) and positive amobarbital tests (7) was a prerequisite to behavioral change in convulsive therapy. It was apparent, however, that such changes, although necessary, were not sufficient for improvement (2). Indeed, among patients with maximal neu— rophysiologic change, all patterns of behavioral adaptation were manifest, and ratings of improvement ranged from “re— covered” to “unimproved” and “worse.” Equating segments of the observed popu— lation according to nosologic or sympto— matic categories also failed to explain the variability in behavioral response. While among patients in the manic-depressive and 1Aided in part by Grants M-927 and MY-2092 National Institute of Mental Health, US. Public Health Service. Read at the Section of Convulsive Disorders and Brain Function, American Psychiatric Association, San Francisco, May, 1958. EThe Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. involutional depressive groups a higher inci— dence of hypomanic and euphoric modes of adaptation were observed, and thus ratings of “recovered” and “much improved” were more frequent, there still were many subjects in these groups who manifested paranoid and somatization modes, and were rated “unimproved.” In the investigations of convulsive therapy, various tests of perceptual organization and indices of sociologic background have been studied which reflect the individual differences in the subjects. Of these, some measures correlated highly with the behavioral response to convulsive therapy. The psychological measures employed have been Rorschach responses (11), “explicit verbal denial” tendencies as measured in structured interviews with family members (12), and scores on the California F Scale (8, 10). The sociologic variables have been chronologic age, years of education and place of birth. It is the purpose of this report to summarize the observations of the relationship between these indices and the variability of the behavioral response to convulsive therapy as reflected in evalua— tions of improvement. METHODS The population has been consecutive referrals for convulsive therapy in a voluntary, non-profit, urban psychiatric hospital. Patients were generally Jewish, of low and middle socio-economic classes with a mean educational level of 10.5 years. Ages ranged from 16 to 67 with a mean of 41 years. Diagnoses included schizophrenia, manicdepressive, psychoneurotic and involutional depressive reactions. As segments of the population were studied by various procedures at different times, the tables reflect 243 �244 FINK, KAHN AND POLLACK the different numbers of subjects that were included in each procedure. All patients received electroconvulsive therapy three times a week, using either unidirectional or alternating current instruments. The various psychological tests were administered Within the week prior to treat— ment. We have previously described the be— havioral changes in convulsive therapy as variations of five modes of adaptation (euphoric, hypomanic, somatization, paranoid withdrawal and panic), and emphasized that the evaluations of “improvement” in convulsive therapy are value judgments of the induced behavioral changes (2). Patients who manifest euphoric and hypomanic adaptive modes are those generally rated as “much improved” and “recovered” by therapists and administrator, while those who manifest paranoid-withdrawal, somatization or panic modes are generally regarded as “unimproved” or “worse.” For this report, evaluations of the patient’s behavior and ratings of improvement were made either two to three weeks after termination of treatment (Tables 1, 2, 3) or at the time of discharge from the hospital (Table 4). TABLE 1 Relation of Rorschach Factors to Clinical Response in Convulsive Therapy Much Improved N Moderately Improved and Unimproved Movement 39 11 (28%) 28 (72%) No Human Movement 48 28 (58%) 20 (42%) Human (M) x2 = 676* p < Form Color (FC) No Form Color 34 7 53 32 Both M and FC Either M or F0 Neither M nor FC 24 4 25 10 38 25 (21%) 27 (79%) (60%) 21 (40%) x2 = 11.57* p < .001 I X2 * .01 (17%) 20 (40%) 15 (66%) 13 = 14.83 p < (83%) (60%) (34%) .001 With Yates’ correction for discontinuity OBSERVATIONS RORSCHACH TEST PATTERNS The Rorschach tests were administered in conventional fashion and scored according to established criteria (13) for specific factors as number and type of movement, color, form, shading and total number of whole responses. For each of these factors, significant differences were observed be— tween the group of patients rated as “much improved” and the combined groups of those patients evaluated as “moderately improved” and “unimproved.” Subjects with human movement responses were evaluated as “much improved” significantly less often than subjects without such responses. The presence of form color responses was significantly correlated with lack of improvement, and when this factor was combined with human movement, the ratings were significantly poorer than when neither form color nor human movement were reported (Table 1). Similarly, patients rated “much improved” gave fewer total responses, fewer total movement responses and fewer content categories; but the per cent whole, popular and form responses were signifi— cantly greater than in the groups rated as “unimproved” and “moderately improved” (Table 2). “DENIAL PERSONALITY” SCORE In their study of denial of illness, Weinstein and Kahn (14, 16) described the characteristics of an “explicit verbal denial” personality type.3 In an initial group of convulsive therapy patients, the hypothesis was tested that those patients who most closely approximated this personality type would be most likely to be rated as “much improved.” “Denial personality” scores were 3“They were people with compulsive drives, a great need for prestige and the esteem of others, and a record of always having denied felt inadequacies. ...Life experiences had been valued not for their intrinsic satisfactions but as a means of maintaining prestige and “security.” (14). �245 PERSONALITY ASPECTS OF CONVULSIVE THERAPY established pretreatment in independent structured family interviews. Fifteen spe— cific areas of behavior were assessed and scores of 0, 1, and 2 were assigned for each of these areas according to whether the subject least, moderately or most approximated the characteristics of the “explicit verbal denial” personality type. In interviews with relatives of 47 patients, scores ranged from zero to twenty-five, with a median of eleven. Subjects with scores above eleven were classed into a high denial group, while those with scores below, into a low denial group. Patients with high denial personality scores were most likely to be rated as “much improved,” with only one patient rated as “unimproved.” Of patients with low denial scores, clinical ratings occurred on a chance basis in each evaluation category (Table 3). The difference in the denial scores be— tween the much and moderately improved patients, when compared to the unimproved patients, is statistically significant at the one per cent level (12). In a further elaboration of these personality types, studies of the total in—patient population were undertaken. Certain sociologic and psychological factors were studied in all patients in residence on March 7, 1957. These included the California F Scale, age, years of education and place of birth (8). TABLE 2 Relation of Rorschach Factors to Clinical Response in Convulsive Therapy Dif— N Mean S. D. ference Number of Responses Much Improved 3813.00 6.7 Moderate, Unimproved 48 19.5 12.8 52 ' 7*... 6 Per Cent Whole Responses 38 37.6 21.013 Much Improved ' 23 ' 0*... Moderate,Unimproved 4824.4 18.2 Per Cent Popular Responses Much Improved Moderate,Unimproved Number Movement sponses Much Improved 38 37.7 21.6 11 1 2 8** ' ' 48 26.6 14.3 Re- Moderate,Unimproved 38 2.3 48 4.9 Number Content Categories 38 3.8 Much Improved Moderate, Unimproved Per Cent Form Responses Much Improved Moderate,Unimproved 4.9 48 2.7 5 1 2.2 2.3 2 ' 62 ' 7,“. 1 ' 12 ' 1* 38 71.8 19.0 9 ' 92 ' 2* 48 61.9 21.4 Significant at .01 level Significant at .05 level ** * TABLE 3 Relation of Denial Personality Scores to Clinical Response in Electroshock Mod- N CALIFORNIA F SCALE The California F Scale consists of a series of extreme or stereotyped statements con— cerning social and personal attitudes. The subject reads each statement and then reports the extent of his agreement or disagreement. Originally presented as a guide to a subject’s capacity for ethnocentrism and authoritarianism, the method has recently been explored as a measure of stereotypy and rigidity in communication (8, 10). The test was presented to all patients prior to treatment and scored on a scale of ten to seventy. The figures represent maximal dis- t Personality Score High Denial—(11—25) Low Denial—(040) 24 23 NEE] erately ImImproved proved proved 14 7 9 9 l-| 7 agreement (low score) and maximal agree— ment (high score) with the statements. There was a significant relationship (p < .05) between the pretreatment test scores and evaluations of the clinical response to convulsive therapy (Table 4). For patients rated as “recovered,” the mean F score was 53.1, while for those rated as “unimproved” �246 FINK, KAHN AND POLLACK TABLE 4 Relation of Social Factors to Discharge Ratings in Convulsive Therapy N Recovered Much Improved Improved and proved Unim— 8 26 23 $3 “*3 a ‘3 >§ E5 2 2 2 a. &° 53.151.6 9.4 50 41.843.810.6 35 39.732.312.3 17 the score was 39.7, reflecting greater degrees of agreement with the stereotyped statements of the test for the “recovered” group. SOCIOLOGIC FACTORS When analyses were made of the relation between improvement ratings in convulsive therapy and age, years of education and place of birth, significant relationships were observed for each of these variables. The “recovered” patients were significantly older (p < .001) and had significantly fewer years of schooling (p < .05) than the “unimproved” group. While a larger percentage of the “recovered” patients than the “unimproved” patients was foreign-born (50 per cent vs. 17 per cent), the differences were not significant. In each category, the “much improved” subjects fell in between (Table 4). DISCUSSION We have noted that measures of perceptual organization, personality traits and sociologic data are related to the degree of improvement shown by subjects with cone vulsive therapy. These observations pr0v vide an understanding of the individual variability in the behavioral response to convulsive therapy under conditions of ap~ parently equivalent degrees of altered brain function. In their studies of patients with brain disease, Weinstein and Kahn described be— havioral patterns as ludic behavior (15), increased smiling and laughter, denial of illness, minimization and displacement of symptoms, and altered sexual behavior achieving prominence in the milieu of a1— tered brain function. They suggested that the manifestation of these behavioral patterns also provided the basis for the evaluation of improvement in convulsive therapy (16). In these studies of patients in con— vulsive therapy the same patterns of laughing and smiling, denial, displacement, minimization and altered sexual activity do indeed occur in the milieu of the induced altered orientation and discrimination (2). It is the patients demonstrating these altered behavior patterns who are rated as “recovered” or “much improved”; while those patients failing to show these patterns or doing so transiently are evaluated as “unimproved” or “improved.” Recent studies of changes in language with convulsive therapy have further amplified an understanding of these behavioral responses. Alteration in syntactic aspects of language has been related to clinical ratings (9). Patients evaluated as “recovered” and “much improved” demonstrated significantly greater use of the past or future tense and the third person mode with qualifica— tion, evasion, denial, displacement, clichés, and cryptic and stereotyped expressions during treatment than did “unimproved” patients. More recently, Jaffe et al. (6) reported that formal speech patterns also were characteristically altered. In dyadic interactive speech analyses (5), increased repetitiveness and stereotypy were associated with syntactic language changes during convulsive therapy. In the studies reported here, aspects of personality organization have been defined which are related to the type of behavioral response incident to convulsive therapy. The Rorschach patterns of the more favorably rated group are generally associated with greater degrees of conventionality and stereotypy, and little introspectiveness, imagination, empathy and creativity. Similarly, the higher F scores of the more favorably rated group is consistent with greater �PERSONALITY ASPECTS OF CONVULSIVE THERAPY degrees of ethnocentrism, authoritarianism, rigidity and conventionality. In present day urban culture older patients generally have less formal education and a greater number are foreign born than younger patients. These sociologic factors are also associated with greater adherence to conformist ideologies and ethnocentric identification. We may conclude that those patients who ap— proximate the “explicit verbal denial” personality type, and who are non—empathic, non-introspective, stereotyped, rigid and conventional are most likely to manifest the euphoric and hypomanic modes of behavior under the conditions of altered brain function induced by repeated convulsions. Such patients also rely primarily on nonverbal patterns of communication, and with treatment evince increasing use of the lan— guage patterns of repetitiveness, denial, displacement and third person. These changes in language and behavior are the cues to which psychiatrists and administrators respond in their evaluations, and thus provide the basis for the clinical ratings of “re— covered” and “much improved” (9). In contrast, those subjects who are em— pathic and introspective, who are not rigid, conventional or stereotyped, and who rely primarily on verbal patterns of communica— tion are less likely to manifest the ludic behavioral modes of euphoria and hypomania. With the induced alteration in brain function they manifest increased somatiza— tion, withdrawal, projection, anxiety, panic and intellectualization. Their speech is pre— dominantly in the present tense and in the first person mode without displacement, denial or clichés. Clinically, such patients are rated as “unimproved” or “worse.” Thus, while altered brain function is essential for a behavioral change in convulsive therapy, individual differences in personality organization provide the basis for the variability in the types of behavioral changes and in the clinical ratings of improvement. In another report (12) it was suggested that the personality attributes 247 which provide the background for improve— ment with convulsive therapy also provide the basis for the depressive adaptation ini— tially. It was noted that numerous authors had described a characteristic pre-depressive personality type, with a prominence of the features of perfectionism, rigidity, con— scientiousness, and stereotypy. The social factors, Rorschach and F scale patterns described here also support such a suggestion. Ludic patterns of depression and mania are more prominent in older, less educated sub— jects. The conventionality, rigidity and stereotypy associated with the findings on the F scale and the Rorschach test are also prominent in depressive illnesses. It is probable that the depressive psychotic reaction and the euphoric-hypomanic behavioral re— sponse in convulsive therapy may be as— pects under different neurophysiologic con— ditions of an adaptive pattern in subjects with a personality organization marked by stereotypy, rigidity, conventionality and poor capacity for introspection and em- pathy. CONCLUSION In studies of convulsive therapy, differences in personality organization and sociologic aspects of history have been related to differences in behavioral response. Persons who are stereotyped, rigid, non-empathic and non-introspective, as defined by explicit criteria in Rorschach, F Scale and structured family interviews, and who are less edu— cated, older and foreign born are more likely to manifest behavioral modes of euphoria and hypomania and to be evaluated as “recovered” and “much improved.” Patients who are introspective, empathic, non-stereotyped, native born, better educated and young are more likely to manifest somatiza— tion, paranoid—withdrawal and panic modes of behavior with convulsive therapy, and to be rated as “unimproved” or “worse.” While an induced alteration in brain func— tion is necessary for behavioral change in the convulsive therapy process, personality �248 FINK, KAHN AND POLLACK organization and sociologic factors are de— terminants of the type of behavioral change, and of the clinical ratings of degree of improvement. 1. REFERENCES FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock: quantitative serial studies. A. M. A. Arch. Neurol. & Psychiat, 78: 516— 525, 1957. 2. FINK, M. AND KAHN, R. L. Behavioral patterns of induced states of altered brain function. Presented at the NY. Divisional Meeting A.P.A., Nov. 1957. 3. FINK, M., KAHN, R. L. AND GREEN, M. A. Experimental studies of the electroshock proc— ess. Dis. Nerv. System, 19: 113—118, 1958. 4. FINK, M., KAHN, R. L. AND KORIN, H. Relation of tests of altered brain function to behavioral change following induced convulsions. In Proceedings I nternat. Congress N eurologic Sciences, Brussels, 1958 (In press). 5. JAFFE, J. Language of the dyad. Psychiatry, 21: 249—258,1958. 6. JAFFE, J., KAHN, R. L. 7. AND . 216—228, 1957. . KAHN, R. L. AND FINK, M. Changes in lan- guage during electroshock therapy. In Psychopathology of Communication, Hoch, P. and Zubin, J., eds. Grune & Stratton, New York, 1958. 10. KAHN, R. L. AND FINK, M. The relation of F score to behavioral and physiologic response with altered brain function. Presented at Eastern Psychological Assoc, Phila., April, 1958. 11. KAHN, R. L. 12. 13. 14. FINK, M. Com- munication patterns with altered brain function. Presented at Eastern Psychological Assoc., Phila., April, 1958. KAHN, R. L., FINK, M. AND WEINSTEIN, E. A. Relation of amobarbital test to clinical im— provement in electroshock. A. M. A. Arch. Neurol. & Psychiat, 76: 23—29, 1956. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in selection of therapy in a voluntary mental hospital. J. Hillside Hosp., 6: 15. 16. M. Prognostic application of psychological techniques in convulsive therapy. Dis. Nerv. System (In press). KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock therapy. Conf. Neurol. (In press). KLOPFER, B. AND KELLEY, D. The Rorschach Technique. World Book Co., New York, 1942. WEINSTEIN, E. A. AND KAHN, R. L. Personality factors in denial of illness. A. M. A. Arch. Neurol. & Psychiat., 69: 355—367, 1953. WEINSTEIN, E. A. AND KAHN, R. L. Ludic behavior in patients with brain disease. J. Hillside Hosp., 3: 98—106, 1954. WEINSTEIN, E. A. AND KAHN, R. L. Denial of Illness. C. C. Thomas, Springfield, Ill., 1955. AND POLLACK, ��m.v..ww.. _._’—_w L. ����unma‘mww ”WNW. mwmmmmmmem M'Wt Wmemwmmg mmmmmm a .‘ Wmimfimxmtmmwwu mummmammmmhum MWWFW(%M}§ mwmmm mwmmatmmmmum. mum umwamm‘ ‘ “at“ - ��wmmmwummumtmm Wm»m:mwwm,m,rm WWWMrotmm. mmdmu fluMWu’MWWWaWWM «in» ' m W “W“ mwmmmmmvmmm mm w «- and “mmuwmawmmmuWa-m WMWMMmemuImeW (ma). mm,mummww”tw mmmwwcmm. mm ‘ ��ms s: 3 {8 a 5 M 3.5:: flat? 8.2. h! 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Punt _ �Psychologic Variables and Neurophysiologic Reaponsivity In Convulsive Therapy Max Fink 14.13., Robert L. Kahn Ph. 13., PollacK Ph.D., Max Eric Karp B.A. and George Krauthamer Ph.D. / MiConsecutive referrals for convulsive therapy of psychologic were studied by a measures prior to treatment, and by variety; electro- encephalogram prior to and at weekly intervals during treatment. Alterations in brain function, as reflected Wm and amplitude were examined EEG frequency, modulation, pattern variables’W in relation to these and improvement on in by changes to behavioral change and a clinical gating of teminatMtreafmren‘t . Significant relationships ”if”; were observed induced change and the following pre-treatment variables: EEG (W m W (a) Educational level > ‘ between the degree of -”M(b) . i5- Rorschach criteria ' (c) ‘ (d) . 0} . Mnemr, 8.4,, M Ma... {@3/apmaw {magmg /,~:.,W2M7/5,,+. - «1' Jul deft“ WW 4% significant relationship ia-legiesee existed between alteration of brain function and treatmet induced behavioral change. degree Metfffrfifififrtmm_.._.a,._m.,...,hz:€.5...» 7‘» «9 a' “W” ' delta a ~- . A clinical rating of improve“be!” 0 ,mx fwfl’ A h #5.» da » - QC . (Hréy 50’4”“? “flaw mentm‘honever, was contingent” upon high degree delta activity4ude pretreatment psychologic pattem‘W) , sociologic status and environmental '- “)2, «Km , expectationxr. Conclusions: fi’ehavioral change was related to electrographic change. while—a— rating of "improved" socio—psychologic 0b Iivz'taa-additionally dependent upon a factors. Mor-eover, neurophysiologic (rate figme of change) to induced convulsions \ pretreatment psychologic variables. ,1' , ' constillation responsivity of 46“ significantly related to ’4' �l' “ s —2- W .. Past studies of the relation of electrographic change to behavioral change M have yielded con radictony results. These variations in outcome may be due to differences in the personality characteristics of the populatioz%tudied since L... patternsm related not only to the type and duration of socio-pscyhologic induced behavioral change but to the degree of electrographic change as well. ) , present results underline the fact that a univariate analysis of neurophysiologic and. behavioral relationships is no lonser adeouate to the problems of experimental psychiatry, and the application methods of The multivariate analysis is From / recommended. the Department of Experimental Psychiatry, Hillside Hospital Glen Uaks, _ of” L.I., 3/31/60 1,12 ‘W'o Am. N.Y. EEG �Peychologic Verieblee end Heurephyeielogic neeponeivity In Convaleive Therepy H.D., Robert L. Kehn Pb. B., Hex Polleek Ph. 9., Eric Kerp 8.1. end Gear‘s Kreuthemer Ph. D. Hex Fink caneecutive reterrele for convulsive therepy were etudied by e veriety of psycholcgic neeeuree prier to treetnent, end by electreeneephelogrene priortc end et weekly intervals during treat» sent. Alterations in brein funetian, ee reflected EEG by changes in frequency, modulation, pattern and emplitude were exemined in relation ta these verieblee, retinx of impraveuent an and to behavioral chense and e elinieel termination at treatment. aignificent relationship: (ch12) degree otinduced EEG change end the were cheerved between the tellewin; pro-treatment verieblee: / (e) Educetianel level (b) Borechack criterie at Movenent, cola: end number at reepanaee Embedded figures tent 5c) d) Alphe index A eignificent reletionnhip also existed between ulteretien of brain functien and treatment induceé behavioral change. a: behavioral chenge clinicel retina wee The releted to the degree at doth activity. degree A of improvement an the ether hand, wee contingent net only upan high degree delta activity but 1139 upen pretreatment �-2psycholozic puttcrna, acciolugic atatuu and :nvironmontal czpoetu» tians. In convulsiva thornpy, bchuvieral china. 1: concluaianl: rolntnd tn oloctrojruphic ahango. ally doplndont upon n A rgtin; at "iaprovod" is udditienu conttullutien of nocia-puychalogic fucters. Haruovor, nourophyniologie rolponnivity (rate or dogrco or chug.) to induced convulntian any :13» be ainnitiauntly rulgtod to prttrtat~ meat 0! p'ycholugic itriabloa. Putt studio: at tn. rclution or uloctroxrnphic chums. to bchnvieral chancc 1n aonvnlaivo thar¢py hgvo yieldod contradietery results. Thoad variations in outeon. may be due to dirtcraneca in the per-antlity ehnrtgtoristtel at the papulntinns atadiad sine. aocio~puychelogic pattorno may be relatud act only ta th. type tad durntion of induced behavioral chang¢,but to the dagrue a! cloetron graphic chance as well. The proutnt ralultu undarlino tho itct that a univtriato unllyais or nouraphyaiologic and bah;vioru1 rolatianahipa is no lengur aduqutto to the prablonl a! prorinonttl psychiatry, und the npplication or methods or From rocommandad. the Dopnrtuqnt of Exporinontnl Psychiatry, Hillaido Hospital Glon Oaks, 1v: nultivaridn analysis in h/l/éc 3.1. L.I., Am. 320 �‘ ,é?" /' / (o 1/, "y .4 Psychologic Variables and Neurophysiologic Responsivity In Convulsive Therapy Max Fink M.D., Robert L. Kahn Ph. D., Max Pollack Ph. D., Eric Karp B.A. and George Krauthamer Ph. D. Consecutive referrals for convulsive therapy were studied fig: a. variety of psychologic measures préer—te treatment, by a and by electroencephalograms priogflb and at weekly intervals during treatment. Alterations in brain function, as reflected 91/ ~EEG “fig; r5313r «35? a». in affflzf‘flgfi" Qi’e‘u frequency, modulation, pattern and amplitudeflwere examined in relation to these variables, rating of improvement on and to behavioral change and degree ofinduced a ébg: m Educationa Rorschacfi e \.of reaponses Embedded figures test Alpha index 0 "d A and the 25% a clinical termination of treatment. Significant relationships (chizi xi, 3F 5.3,“,change of 2‘33; by changes were observed between the following pre— treatment variables: A, ovement,A color, and number of significant relationship also existed between alteration brain function Aand treatment induced behavioral change imbald£££§§WW, WW C56Mamet, (Wheg “Mbehaxlnnalxchangemuas.relaxed.tewthedegreeofwdglfi33%;:gfirw £17MM4/sgéf “3...: W clanaeelwrati“g“cfimimprgyementan“: an s: {:Lflflu 49; ‘odZEfMM,4 9% only upon high degree 3%”;ng Clzbwi ,1? W4 'Mcthermnafidwwwas My»: delta activity but also upon y A 'x contingent not pretreatment �\ -2psychologic patterns, sociologic status and environmental expectae tions. Conclusions: In convulsive therapy, behavioral change is i related to electrographic change. ally dependent upon a A ' is addition— rating of aou:;;:::ew3‘ constgllation of socio—psychologic factors. Moreover, neurophysiologic responsivity (rate or degree of chage) to induced convul€2§0n§may also be significantly related to pretreat— ment ,/ psychologic variables. Past studies of the relation of electrographic change to behavioral change in convulsive therapy have yielded contradictory results. 'These variations in outcome may be due to differences in the personality characteristics of the populations studied)since socio—psychologic Kflwaaah patterns meynbe related not only to the type and duration of induced behavioral change,but to the degree of electro— graphic change as well. dwadfiffffl present results mad-niIl-Iib-ifliit thatdfl‘univariate analysis or ngfisflb 4o of neurophysiologic and behavioral relationships gfikno longerfiadequate The \ tojthe problems of experimental psychiatry, ’ and the . application of 1 methods of multivarian analysis is recommended. From the Department of Experimental Psychiatry, Glen Oaks, L. I. 1v: h/1/60 Am. N. Y. EEG Hillside HOSpital - �01:? ////’ m ' Individual Differences in Neurophysiologic Responsivity to Convulsive Therapy Previous studies indicated that an alteration in brain function was requisite to/tkéfbehavioral change and ratings of improvement in convulsive therapy. has been The type of behavioral change related to various perceptual,psychologic, and social aspects of the individual's history and behavior.The present study demonstrates significant relationships between the degree of 037' -convulsive neurophysiolegic change and amobarbital test (EEG slow wave activity response) and pro-treatment perceptual{MW‘ 4, , ' personality functioning (educational level, Rorschach, figure5 \ . {A 1‘ 1 groun While Mylo “W“; ’/ f relationshipeztsfiuu'n neurophysiolegic “a. 3mm meeewnefi a-dL J3 ”(a[7w // ,3 5‘ 1%?!” ”Z personality measures have generally not been-establisheéi these observations indiate that the rate and degree of change] in neurophysiologic .m (mm/Me may indeed be related to personality cognitive Illfllllflr(perceptualenillI-Ig style). 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Psychological factors affecting individual differences in behavioral response to convulsive therapy. J Nerv Ment Dis. 1959 Mar;128(3):243-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-36-002 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Pollack, Max Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 3 items. 1: Reprint from THE JOURNAL or NERVOUS AND MENTAL DISEASE Volume 128, N0. 3, March 1959. 2: [preprint]. 3: 2 drafts and one abstract. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/c02d31143a5f498973505a8a964ce076.pdf b8c3ce2c33d87b8f3f28b4f66c1d2afb PDF Text Text Reprinted from Neuro-Psychopharrnacology EEG AND BEHAVIORAL EFFECTS OF PSYCHOPHARMACOLOGIC AGENTS* M. FINK Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, N. Y. (U.S.A.) Recent studies have presented data supporting a neurophysiologic—adaptive View of the convulsive therapy process“: 15. This hypothesis holds that the clinical efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in cerebral function, which provides the milieu for changes in the subject’s inter— action with the environment. In these studies the best index of neurophysiologic change has been those aspects of cerebral function reflected by 8 activity in the electroencephalogramS—lo. The efficacy of newer psychopharmaceuticals in altering psychotic behavior patterns led to the suggestion of a similar hypothesis for the mode of action of these agents“, and to studies of the relationship and specificity of altered behavioral patterns to neurophysiologic change as reflected in electroencephalography. This report summarizes some of the experimental data observed in on—going tests of this hypo— thesis. ‘ SUBJECTS AND METHODS We have studied consecutive patients, suffering from depressive psychoses, agitated and excited schizophrenic states and severe psychoneurotic disorders, referred for physiodynamic therapies (convulsive, psychotropic drug, insulin coma) in a voluntary, open—ward, psychiatric hospital. Serial electroencephalograms were taken prior to, Aided, in part, by grants M-927 and MY—2092, National Institute of Mental Health, National Institutes of Health, U.S.P.H.S., and Bristol, Wyeth and Smith, Kline and French Laboratories. * References p. 446 . �M. FINK 442 during and after the course of therapy. In addition, at various stages of the treatment As done. convulsive both studies chlorand were acute experimental program promazine therapies elicit varying degrees of EEG slow wave activity, these acute observations have been made in two groups of subjects: those without slow wave activity, and those with diffuse slow wave (HSD, LSD) or burst and slow wave (BSD) activity”. Observations have been made in the EEG laboratory. Following a routine bipolar EEG recording, an unstructured psychiatric interview was tape—recorded. Under continuous EEG recording, medication was administered intravenously at a set rate until EEG or behavioral effects were observed. Following the injection the interview was repeated and recorded. Periods of EEG recording and interview recording were alternated for the duration of the drug activity. Behavioral evaluations have been based both on clinical descriptions by the participants (subject, physician and technician) and analyses of changes in language patterns12:14. Electroencephalograms were measured for shifts in dominant frequencies, and changes in voltage, modulation, and per cent time of or, {3 and 8 frequency bands. The psychopharmacologic agents were administered orally for extended periods in clinical trials, and intravenously in the acute experimental trials (Table I). Dosage for each compound varied, but in each instance sufficient medication has been given to achieve clinical behavioral effects. TABLE I PSYCHOPHARMACOLOGIC AGENTS STUDIED (Oral and intravenous) Chlorpromazine Prom azine Triflupromazine Perphenazine * Reserpine Iproniazid ** Deanola ** Amobarbital ** Thiopental Atropine Diethazine Amphetamine Methamphetamine Meprobamate * ** LSD—2 5b ** Win—22996 ** J B—3 I 8d J B-336e ** Benactyzine Dimethylaminoethanoll". b Lysergic acid diethylamide. 0 2-Diethylaminoethyl cyclopentyl (2-thieny1) glycolatel“. d N—Ethyl—3-piperidy1 benzilatel. e N-Methy1-3—piperidyl benzilatel. a * Oral only. H Intravenous only. OBSERVATIONS (a) Electroencephalographic Four broad types of EEG patterns may be identified according to the characteristics of frequency shift and synchronization‘l: References 35. 446. �443 INVESTIGATONS IN NORMAL HUMAN SUBJECTS I) Increase in slow wave activity and in synchrony; Increase in synchrony without frequency shift; 3) Increase in fast wave activity and in synchrony; 4) Desynchronization and frequency irregularity. Examples of each are seen in Figs. 1—4. During convulsive therapy, an increase in slow wave activity and synchrony is manifests. With drug administration similar changes in frequency spectrum and in synchrony can be observed. Such changes include an augmentation of the slow wave activity8 or a marked decrease in such activity with desynchronization of frequencies? .Of the psychopharmaceuticals tested in acute experiments an increase in synchrony With or Without an increase in slow Wave activity has been observed for chlorpromazine, promazine, and triflupromazine. Barbiturates regularly induce an increase in fast activity With an increase in synchrony, While amphetamine and 2) W W W MW W WWW WWW |600 PER DAY 3 MONTHS IZOO MG PER DAY 2 MONTHS PRE-DRUG LAT—LF MG WWW/WWW , LPT-LO ‘ 0-0 RPT-RO JWVWWMMNMM it 2049 HH 4* 2143 HH 2l95 50M— ISEC HH Fig. I. Chlorpromazine, oral (male, age I 5). 800 - PRE-DRUG MG | ‘WWW ' PER DAY MONTH wwwwvwwwmmwm LAT'LF AFTER 350 MG LAT-LF RAT-RF RAT-RF \ LF-RF ’ LF-RF W LPT‘LO LPT-LO NWWMMWM WWWNWWWWMWWVI o-o “MIN/WWW . MAM/WM wmwm |9|5 # |962 SOle—l RPT-RO a: W W W W mm PRE-DRUG HH - SEC HH Fig. 2. Chlorpromazine, oral (female, age 34). www—fiu o-o M‘WVWM WWW , Ill/WWW RPT-RO 5°VV‘—_|SEC #0 2'51 HH Fig. 3. Amobarbital, intravenous (male, age 31). methamphetamine increase fast activity Without increased synchrony. Desynchronization of frequencies is prominent after diethazine, LSD-25, Win-2299, JB-3I8, JB-336, and benactyzine. Refeyences p. 446. �M. FINK 444 In subjects with post—convulsive 3 activity, acute administration of chlorpromazine, promazine, triflupromazine, amobarbital and pentothal increased the per W W ,W W W» PRE-bRUG LF-LO WWW _ MIN + 80 MIN wWWM-NMWNM Rf-RO LAT-LP + 40 AFTER 3.2 mg .. RAT-RF LPT-LO . I 0-0 “WW“M‘M‘WW“ RPT-RO WWWW WW WW | SEC #ZOISIHH Fig. 4. Win-2299, intravenous (female, age 41). cent time and voltage of slow wave activity. Decrease in voltage and per cent time of slow wave activity is seen with LSD-25, benactyzine, Win—2299, JB-3I8, JB-336 and diethazine5’ 6. Similar electrographic patterns are noted in chronic oral administration of these compounds. Chlorpromazine, promazine, high doses of reserpine and occasionally perphenazine elicit increased synchronization and a shift of frequencies to the 8 range. Increased synchronization without frequency shift is occasionally observed with iproniazid. Increased high voltage fast activity is observed with meprobamate and barbiturates. Oral administration of LSD-25 and benactyzine induces EEG desynchronization with an increase in fast frequencies. (6) Behavioral Initial studies of convulsive therapy noted that behavioral change was dependent upon the development of synchronous slow wave activitys. Prominent among the associated behavioral effects were sedation, tranquillization and euphoria in agitated, depressed subjects, and a decrease in somatization, paranoid ideation, hallucinations and delusions in schizophrenic and excited subjects. Increasing agitation, paranoid ideation and panic were observed in less than IO 0/0 of the subjects. Similar behavioral relationships were prominent with these psychopharmacologic agents. In acute experiments, administration of chlorpromazine, promazine and triflupromazine was associated with increasing sedation, drowsiness, denial and euphoria, decreasing agitation, panic, excitement and delusional and hallucinatory activity, and minimization and displacement of symptoms. Sedation, euphoria, denial and minimization were similarly associated with amobarbital. Administration of amphetamine and methamphetamine resulted in behavioral alerting, hypomania, excitement, and increased motor activity. Similar increased alerting, excitement, tension and panic were observed after benactyzine. In addition to these patterns, illusory sensations and hallucinatory, delusional and paranoid ideation were observed with diethazine, LSD-25, Win-2299, JB—3I8, and J 13-336- References {3. 446. �INVESTIGATIONS IN NORMAL HUMAN SUBJECTS 445 Equally prominent with the behavioral changes were alterations in patterns of language. Previous studies of convulsive therapy had indicated that specific syntactic language patterns (as in the use of the third person mode, past and future tense, dis— placement, minimization, denial, clichés, and cryptic remarks) increased with increasing neurophysiologic change”. These language patterns were further exaggerated by intravenous amobarbita114’15. In the present studies, chlorpromazine, triflupromazine and iproniazid increased these language patterns. Diethazine, LSD—25, Win-2299, and benactyzine decreased and reversed these language patterns, increasing the use of the present tense, first person mode, and somatization7. Relation of behavioral and electrographic observations The electrographic patterns Were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquillization, euphoria, sedation and minimization of symptoms were commonly associated with increased EEG synchronization and shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with a desynchronization of frequencies. Similar patterns were demonstrated in subjects with prior 8 activity. Agents that tended to synchronize frequencies, as chlorpromazine and barbiturates, augmented the per cent time 8 activity and enhanced clinical patterns, while agents that desynchronized frequencies, as diethane, LSD—25 and benactyzine, minimized the clinical effects ascribed to repeated convulsions5-7. (0)} DISCUSSION These observations are consistent with the neurophysiologic—adaptive hypothesis of the mode of action of the newer psychopharmaceuticals“. This hypothesis states that the clinical efficacy of psychotropic drugs is dependent upon the induction of a per— sistent alteration in cerebral function which provides the milieu for changes in the subjects’ interaction with the environment. The variety of neurophysiologic patterns induced by these agents is in contrast to the limited patterns resulting from convulsive therapy and thus provides amplification of the original hypothesis. It is evident from these studies that the type of neurophysiologic alteration induced, as reflected in EEG synchrony and frequency patterns, is related to specific types of behavioral adaptation. With increasing synchrony and a shift to the 8 frequency spectrum, tranquillization, sedation and decreased agitation become prominent, while desynchronization and a shift to [3 frequencies are associated with excitement, illusions and delusional ideation. These studies are also consistent with numerous reports of the neurophysiologic effects of these compoundsm’ll’ 13:19:21, and specifically support and amplify those of WIKLER who concluded, in his studies of morphine and mescaline, that “regardless of the nature of the drug administered, shifts in the pattern of the electroencephalogram in the direction of desynchronization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness”2°. This hypothesis, and the electrographic measure of neurophysiologic change, lends itself to application in the assay of new psychotropic drugs“, the rational References p. 446. �446 M. FINK application of pharmacotherapy7, and as a basis for further experimental study of neurophysiologic—behaviora1 relationships in psychiatry. ACKNOWLEDGEMENT We are grateful for the cooperation of the following laboratories who made supplies of the various psychopharmaceuticals freely available: Ciba Pharmaceutical Prods. (reserpine), Lakeside Laboratories (JB—318, 336), Eli Lilly & Co. (amobarbital), Merck, Sharpe & Dohme (benactyzine), Riker Laboratories (deanol), Roche Laboratories (iproniazid), Sandoz Pharmaceuticals (LSD-25), Schering Corp. (perphenazine), Smith, Kline & French Laboratories (chlorpromazine, diethazine), E. R. Squibb & Sons (triflupromazine), Winthrop Laboratories (Win—2299), Wyeth Laboratories (promazine, meprobamate) . REFERENCES 1 L. G. ABOOD, A. M. OSTFELD AND J. BIEL, Proc. Soc. Exptl. Biol. Med., 97 (1958) 483. 2 3 4 5 6 7 K. ANDERMANN, Med. ]. Australia, 2 (1957) 1. P. B. BRADLEY AND J. ELKES, Brain, 80 (1957) 77. M. FINK, ]. Hillside Hosp, 6 (1957) 197. M. FINK, A.M.A. Arch. Neurol. Psychiat., 80 (1958) 380. M. FINK, Electroencephalog. and Clin. Neurophysiol., IO (1958) 776. M. F INK, J. JAFFE AND R. L. KAHN, Drug—induced changes in interview patterns: linguistic and neurophysiologic indices, in J. SARWER-FONER, The Dynamics of Psychiatric Drug Therapy, Springfield, Ill. 8 M. FINK AND R. L. KAHN, A.M.A. Arch. Neurol. Psychiat., 78 (1957) 516. 9 M. FINK, R. L. KAHN AND M. A. GREEN, Diseases of Nervous System, 19 (1958) 113. 10 M. FINK, R. L. KAHN AND H. KORIN, Proc. Intern. Congr. Neurol. Sci, 1957, Brussels, in the press. 11 S. GARATTINI AND V. GHETTI, Psychotropic Drugs, Elsevier, Amsterdam, 1957. 12 J. JAFFE, ]. Hillside Hosp, 6 (1957) 207. 13 R. S. JORGENSEN AND M. H. WULFF, Electroencephalog. and Clin. Neurophysiol., 10 (1958) 325. 14 R. L. KAHN AND M. FINK, in P. HOCH AND J. ZUBIN, Psychopathology of Communication, Grune & Stratton, New York, 1958, p. 126. 15 R. L. KAHN, M. FINK AND E. A. WEINSTEIN, A.M.A. Arch. Neurol. Psychiat., 76 (1956) 23. 13 H. PENNES AND P. HOCH, Am. Psychiat., 113 (1957) 887. ]. 17 C. C. PFEIFFER et al., Science, 126 (1957) 610. 13 H. STRAUSS, M. OSTOW AND L. GREENSTEIN, Diagnostic Electroencephalography, Grune & Stratton, New York, 1952. 19 G. VERDEAUX AND R. MARTY, Rev. neurol., 91 (1954) 405. 20 A. WIKLER, Nervous Mental Disease, 120 (1954) 157. ]. 21 D. L. WINFIELD AND G. H. AIVAZIAN, Electroencephalog. and Clin. Neurophysiol., 10 (1958) 575. C. C. THOMAS, Printed in The Netherlands �EEG and Behavioral Effects of Psychopharmacologic Agents Max From Fink MOD. the Department of Ekperimental Psychiatry, Hillside Heapital, Glen Oaks, L010, NIY. Institute of Mental in part, by grants III-927 and MY—2092 , National Health, National Institutes of Health, U.S.P.H.S., and Bristol, Smith, Kline Aided, French and Wyeth Laboratories. Read at the Collegian Internationale Neuro-Psychophamacologicum, September 12, 1958. IV:9-3-53 Rune, and �EEG and Behavioral Effects of ggzchophgrmacologic Aggnts Recent studies have presented data supporting a neurophysiologica adaptive view of the convulsive therapy process (1, 2). This hypothesis holds that the clinical efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in cerebral function, which provides the milieu for changes in the subject's interaction with the environment. In these studies the best index of neuroplnrsiologic change has been those aspects of cerebral function reflected by delta activity in the electroencephalogram (3 ,h,5). efficacy of newer psychopharmaceuticals in altering psychotic behavior patterns led to the suggestion of a similar hypothesis for the mode of action of these agents (2), and to studies of the relationship The and specificity of altered behavioral patterns to neurophysiologjc as reflected in electroencephalogram. experimental data observed in ongoing SUBJECTS AND We change This report smunarizes some of the tests of this hypothesis. MODS: patients, suffering from depressive excited schizophrenic states and severe psycho- have studied consecutive psychoses, agitated and neurotic disorders, referred for physiodynamic therapies (convulsive, psychotropic drug, insulin coma) in a voluntary, open-wand, psychiatric hospital. Serial electroencephalograms were taken prior to, during and sitar the course of therapy. In addition, at various stages of the treatment and program acute experimental studies were done. As both convulsive chlorpromazine therapies elicit varying degrees of EEG slow wave activity, �.2these acute observations have been made in without slow wave activity, and those with diffuse s1 or burst EEG w wave (HSD, LSD) activity (6). and leW'WaVB (BSD) Observations have been bipolar of subjects: those two groups in the made laboratory. Following a routine EEG recording, an unstructured psychiatric interview recorded. Under continuous EE‘3 intravenously at a set rate until was recording, medication was administered EEG or behavioral effects were observed. Following the injection the interview was repeated and recorded. EEG drug tape- Periods of recording and interview recording were alternated for the duration of activity. Behavioral evaluations have been based both on clinical descriptions by the participants (subject, physician changes in language patterns and technician) and analyses of (7,8). Electroencephalograms were measured for shifts in dominant frequencies, and changes in voltage, modulation, and per cent time of alpha, beta and delta frequency bands. The psychopharmacologic agents were administered periods in clinical trials (Table I). trials, Dosage and intravenously for each compound orally for extended in the acute experimental varied, but in each instance sufficient medication has been given to achieve clinical behavioral effects. �I TABLE PSYCHOPHARMAGOIDGIC AGENTS STUDIED (Oral and Intravenous) chlorpromazine amobarbital atropine ** promazine thiopenzal ** diethazine ** LSD-25 triflupromazine (b) " perphenazine amphetamine Win~2299 reserpine* methamphetamine JB-318 (c) (d) ** JB—336 (e) iproniazid deanol (a) meprobamate ** * benactyzine a. dimethylaminoethanol (9 ) b. lysergic acid diethylamide c. 2-d1ethylaminoethyl cyclopentyl (2-thieny1) glycolate (10) d. n~ethyl-3~p1peridy1benzilate (11) e. n-methyl—B—p1peridy1benzilate (11) * oral only ** intravenous only ** �OBSERVATIONS: (a) Electroencephalographic: patterns, observed on acute drug be identifieci according to the characteristics Four broad types of administration, of frequency may shift EEG and synchronization (2): activity in synchrony; 1) Increase in slow 2) Increase in synchrony without frequency shift; 3) Increase in wave fast wave activity and and h) Desynchronization and frequency Examples of each are seen in figures l-h. -0- ---”-“-U- u -- Fig. 1, 2, 3, ,4 in synchrony; irregularity. �-5 During convulsive therapy, an increase in slow wave synchrony is manifest. (Fig.5) ‘iith Fig. activity and drug administration similar changes 5 -------in frequency spectrum and in synchrony are observed (Figs. 6, 7). Figs. 6 7 0f the psychophnrmaceuticals tested in acute experiments in synchrony with Sr without an increase in observed for chlorpromazine, promazine regularly induced an increase and slow wave triflupromazine. in fast activity with an prominent after diethazine, increase activity has been Barbiturates increase in synchrony, while amphetamine and methamphetamine increased without increased synchrony. an fast activity Desynchronization of frequencies was LSD-25, Win-2299, JB-BlB, JB-336 and benactyzine. In subjects with post-convulsive delta activity, acute administration of chlorpromazine, promazine, triflupromazine, amobarbital and pentothal increased the per cent time and voltage of slow wave activity. Decrease in voltage and per cent time of slow wave activity was seen with LSD-25, benactysine, Win-2299, JB-318, JB~336, and diethazine (12-13). Similar electrographic patterns administration of these compounds. were noted in chronic oral Chlorpromazine, promazine, high do$s of reserpine and occasionally perphenazine elicited increased synchronization and a shift of frequencies to the delta range. Increased �.6synchronization without frequency shift was occasionally observed with iproniazid. Increased high voltage fast activity was observed with meprobamate and barbiturates. benactyzine induced EEG Oral administration of LSD-25 and desynchronization with an increase in fast frequencies. (b2 Behavioral: Initial studies of convulsive therapy noted that behavioral change was dependent upon the development of synchronous slow wave (3). Prominent among tranquillization activity the associated behavioral effects were sedation, and euphoria in agitated, depressed subjects, and a decrease in somatization, paranoid ideation, hallucinations and delusions in schizophrenic ideation and excited subjects. Increasing agitation, paranoid and panic were observed in less than Similar behavioral relationships pharmacologic agents. 10% of the subjects. were prominent with these psycho~ In acute experiments, administration of chlorpromazine, promazine and triflupromazine was associated with increasing sedation, drowsiness, denial and euphoria, decreasing agitation, panic, excitement and delusional and hallucinatory activity, and minimization and displacement of symptoms. Sedation, euphoria, denial and minimization were similarly associated with amobarbital. Administration of amphetamine and methamphetamine resulted in behavioral alerting, hypomania, excitement, and increased motor activity. Similar increased alerting, excitement, tension and panic were observed after benactyzine. In addition to these patterns, illusory sensations and hallucinatory, delusional diethazine, and paranoid ideation LSD-25, Win-2299, JB-318 and JB—336. were observed with �-7Equally prominent with the behavioral changes were alterations in patterns of language. Previous studies of convulsive therapy had indicated that specific syntactic language patterns (as in the use of the third person mode, past and future tense, displacement, minimization, denial, cliches, and cryptic remarks) increased with increasing neurophysiologic change (7). These language patterns were further exaggerated by intravenous amobarbital (l, 7). In the present studies, chlorpromazine, triflupromazine and iproniazid increased these language patterns. Diethazine, LSD-25, Win-2299, and benactyzine decreased and reversed these language patterns, increasing the use of the present tense, first person mode, and somatization (1h). (0) Relation of Behavioral The and Electrqgraphic Observations: electrographic patterns were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquillization, euphoria, sedation.and minimization of symptoms were commonly synchronization and associated with increased EEG shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with a desynchronization of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorpromazine and barbiturates, augmented the per cent time delta activity and enhanced clinical patterns, while agents that desynchroniaed frequencies, as diethazine, LSD-2S and benactyzine, minimized the clinical effects ascribed to repeated convulsions (12, 13, 1h). �-8DISCUSSION: These observations are consistent with the neurophysiologic-adaptive hypothesis of the mode of action of the newer psychopharmaceuticals (2). is This hypothesis states that the clinical efficacy of psychotropic drugs persistent/alteration in cerebral function which provides the milieu for changes in the subjects' interaction with the dependent upon the induction of a variety of neurophysiologic patterns induced by these agents is in contrast to the limited patterns resulting from convulsive therapy and thus provide amplification of the original hypothesis. It is environment. The evident from these studies that the type of neurophysiologic alteration induced, as reflected in EEG synchrony and frequency to specific types of behavioral adaptation. a With patterns, is related increasing synchrony shift to the delta frequency spectrum, tranquillization, sedation and and decreased agitation become prominent, while desynchronization and a shift to beta frequencies are associated with excitement, illusions and delusional ' ideation. These studies are also consistent with numerous reports of the neuroand physiologic effects of these compounds (15-20), and specifically support amplify those of Wikler who concluded, in his studies of morphine and mescaline, that "regardless of the nature of the drug administered, shifts in the pattern of the electroencephalogram in the direction of desynchroniza- tion occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness" (21). This hypothesis, and the electrographic measure of neurophysiologic change, lends itself to application in the assay of the rational application of pharmacotherapy (lb), new psychotropic drugs and as a (2% basis for further experimental study of neurophysiologic-behavioral relationships in psychiatry. �SUMMKRI AND CONCLUSIONS: The relation between electroencephalographic change and behavioral response was determined on acute and chronic administration of a variety of psychopharmacologic agents in voluntary, openoward, psychiatric patients. EEG patterns were classed according to effects on synchrony and frequency patterns. Behavioral and language pattern changes were noted as concurrent with Agents EEG response. that induced an alteration in neurophysiology manifest as increased synchrony and frequency slowing in EEG were associated with behavioral sedation, tranquillity, and minimization of symptoms. Increased synchrony and increased frequency were associated with sedation, euphoria, hypomania and decreased somatization. Desynchronization of frequencies was accompanied by increasing agitation, excitement, somatization, illusory phenomena and and hallucinatory delusional ideation. The neurophysiologiccadaptive hypothesis of the psychotropic drugs is supported; mode of action of and the value of electroencephalography in the behavioral assay of these agents is suggested. �-10REFERENCES and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electrashack, A.M.A. Arch. Neural. & Psychiat. 1Q: 23-29, 1956. l. Kahn, R.L. , Fink, 2. Fink, 3. Fink, h. Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the Electroshock Process, Dis. Nerv. . 12: 113-118, 1958. M.: A M. Unified Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp. é: 197-206, 1957. Balatian of EEG Delta Activity to Behavioral Response in ElectraShock: Quantitative Serial Studies, A.M.A. Arch. Neural. & Psychiat. 1.8.: 516-525, 1957. M. and Kahn, R.L.: a Fink, , Kahn, R.L. and Karin, H.: Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions, Prac. Int. Cong. Neural. Sci,, 1957, Brussels, (in press). M. Strauss, , Ostaw, ography, Grune H. Kahn, R.L. and M. & and Greenstein, L.: Diagnostic Electroencephal- Stratton, N.Y., 1952. Fink, M. : Changes in Language During Electroshock and Therapy, in Psychopathalgg of Comunication eds. Hoch, P. Zubin, J., Grune & Stratton, NJ. 1958, 33-139. Jai‘fe, J .: An J. Hillside Hosp. é: 207-215, 1957. - Pfeiffer, C.C. et a1.: Stimulant Effect of 2 - dimethylaminoethanal _12__§: 610-611, views, 9. 10. Objective Study of Communication in Psychiatric Inter- Precursor of Brain Acetylcholine, Science Pogsible 19 7. Pennes, H. and Hach, P.: Psychatomimetics, Clinical and Theoretical Considerations, Amer. J. Psychiatn 113: 887-892, 1957. Abaod, L.G., Osti‘ield, A.M. and Biel, J.: mimetic Agents, Proc. Soc. Exp. Biol. A New Group of Psychoto- Med. 21: h83-h86, 1958. Effect of Anti-Cholinergic Agent, Diethazine, on ER} and 12. Fink, 13. Fink, M.: Effect of Anti-Cholinergic Compounds an Post-convulsive EEG and Behavior, EEG. Clin. Neurophysiol. (in press). 14.: Behavior: Significance for Theory of Convulsive Therapy, A.M.A. Arch. Neural. & Psychiat; (in press). �-11.. REFERENCES Fink, M. and Jaffe, J.: Drug Induced Changes in Interview Patterns: and Neurophysiologic Indices, in Conference on amic A ects of Neurole tic D 3, ed. 3. Sarwer- Linguistic P chc oner in press . 150 Verdeaux, G. and Marty, R.: Action sur L'Electroencephalogramme de Substances Pharmacodynamiques D'interet Clinique, Rev. Neurol. ............._.. 2;: 1.05-4.27, 195a. 16. Andermann, K.: Electroencephalographic Evidence of Personality Change Produced by Ataractic Drugs in Mentally Disturbed 17. Bradley, P.B. and Elkes, J.: The Effects of Some Drugs on Electrical Activity of the Brain, Brain, g9: 77-117, the 1957. 18. Garattini, S. 19. Jorgensen, R.S. and wulff, M.H.: The Effect of Orally Administered Chlorpromazine on the Electroencephalogram of Man, EEG. Clin. ' and Ghetti, V., Amsterdam, .1957. eds.: Psychotropic Drugs, Elsevier, Neuroghysiol. 39: 325-329, 1958. 20. Winfield, D.L. and Aivazian, G.H.: EEG. Changes Associated with Sparine Therapy, EEG. Clin Neurophysiol. $9: 575, Inégnsive 19 . Wikler, A.: Clinical and Electroencephalographic Studies on the Effects of Mescaline, N-allynormorphine and.Morphine inLMan, J. Nerv. Ment. Dis. 120: 157-175, 19Sh. �-12.. FIGURES 1. Chlorpromazine, oral (male, age 15). 2. Chlorpromazine, oral (female, age 3b). 3. Amobarbital, intravenous (male, age 31). Win-2299, intravenous (female, age bl). flectroconmllsive Therapy (female, age 55). Amobarbital, intravenous (female, age 36). Win-2299, intravenous (female, age 51). �ACKNOWEDGEMENT are grateful for the cooperation of the following laboratories who made supplies of the various psychopharmaceuticals We fully available: Ciba Pharmaceutical Prods. (reserpine), Lakeside Laboratories (JB—318, 336), Eli Lilly 8: Co. (amobarbital), Merck Sharpe 8c Dohme (benactyzine), Riker Laboratories (Deanol), Roche Laboratories (iproniazid), Sandoz Pharmaceuticals (LSD-25), Schering Corp. (perphenazine), Smith, Kline 8: French Laboratories (chlorpromazine, diethazine), E.R. Squibb & Sons (triflupromazine), Winthrop Laboratories (Win-2299) and Wyeth Laboratories (promazine, meprobamate ) . � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource EEG and behavioral effects of psychopharmacologic agents. In P. B. Bradley, P. Deniker, and C. Radouco-Thomas (eds.), Neuro-Psychopharmacology. Elsevier, Amsterdam, 1959, 1: 441-46. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-37b-003 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprint from Neuro-Psychopharrnacology Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/e014a6afb9c7514b91c71748685499ca.pdf 9f4aefec5e8c130c970f3538c3603299 PDF Text Text ELECTROENCEPHALOGRAPHIC AND BEHAVIORAL EFFECTS OF TOFRANIL Max Fink, M.D. Reprinted from “CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL” Volume 4 Special Supplement, 1959 McGill University Conference on Depression and Allied States, Montreal, March 19-21, 1959 �ELECTROENCEPHALOGRAPHIC AND BEHAVIORAL EFFECTS OF TOFRKNIL MAX FINK* With the rapid increase in the number of potential psychopharmaceuticals, the need for screening technics has become more acute. In studies of the electro— graphic patterns of convulsive therapy, the hypothesis evolved that behavioral changes induced by new compounds could be related to their neurophysiologic effects as reflected by the type and degree of electrographic change (1, 2). This suggestion followed a similar one by Wikler (3) who stated that “regardless of the nature of the drug administered, shifts in the pattern of the electroencephalogram in the direction ofdesynchronization occurred in association with anxiety, hallucina— tions, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness.” Studies with various psychotropics (4) and anticholinergic hallucinogens (5, 6) supported such a relationship. It is the purpose of this preliminary report to describe initial behavioral and electrographic observa— tions with Tofranil'l, a new psychopharmaceutical, and to relate these observations to the neurophysiologic—adaptive hypothesis of the mode of action of physiodynamic therapies (1). Methods Two types of studies were undertaken in an open—ward, voluntary hospitalized population. In 28 acute experiments, consecutive patients referred for physiodynamic therapies were tested in the EEG laboratory at various stages of treat— ment. Tofranil solution (10 mg/ml) was administered intravenously at a set rate (1 ml/4O sec.) until electrographic or behavioral changes became prominent, for a total of 40—125 mg (0.5—mg/kg). Behavioral observation and electrographic record— ing continued for one to three hours. A second group of 16 patients manifesting depressive, withdrawn or retarded behavior were referred by their therapists for pharmacotherapy. The patients received daily oral Tofranil, 75—250 mg. Behavioral observations and EEG recordings were made prior to and during treatment. Patients ranged in age from 17 to 58, and were diagnosed as suffering from schizophrenia, manic-depressive and involutional depressive psychoses, and psychoneuroses. ' Observations I. dcute Studies: On acute administration, there was an initial restlessness, associated with dizziness, dry mouth, “faintness,” nausea, and on four occasions, vomiting. These symptoms persisted for 10—20 minutes, and were accompanied by lassitude, heaviness of the extremities and eventual drowsiness. Heart rate was un— changed or slowed. Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographic patterns accompanying these behavioral changes were initiated by a gradual decrease in voltages during the injection. By ten minutes, the per cent time alpha and mean alpha voltage had been halved. In four patients with moderate amounts of beta activity, such activity increased in voltage and low behavioral with association lassitude, time. minutes, By in cent twenty per voltage (to 50 microvolts) random theta frequencies (5-7 cps) appeared (Figures 1 and 2). *Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. Aided in part by grants M-927 and MY-2092 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service; and by a grant from Geigy Pharmaceuticals. The technical assistance of Mrs. Hannah Mosquera in EEG recording is gratefully acknowledged. ’rTrade Mark. �Special Supplement pre-d rug WWW WWW LF-LO 8167 DEPRESSION AND ALLIED STATES W W after 75 mg after 30 minutes WNW RF-RO wWWv«w¢wanMV‘ I‘VWW LAT-LF RAT-RF k/\_Jl/L,Ah/L JL/\,JA/A,_JL/\, =72 #2638Hh WW W WWW HR after 45 minutes HR 50 Mv|—_l SEC. =74 HR =72 1 Fig. 1 Effect of intravenous Tofrinil on EEG delta (female, aged 46) pre—drug LF-LO «wwNWVHMWwNmN RF-RO WWW LAT-LF W W after 100 mg after 30 minutes hv after 30 minutes “NV“WJWWWWVVV¢ UWMerVkmeV4 WWW WWW RAT-RF LF-RF LPT-LO 0-0 EKG plvltul HR=84 #2138HH W MymMA/VW-WVN MWVWVWMN‘ HR=108 50/.1vl—__J 1 Fig. 2 HR=84 SEC. Effect of intravenous Tofrinil on EEG delta (male, aged 37) HR=9O �8168 Vol. 4, 1959 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL In six records with post—convulsive delta activity, there was a marked decrease in voltages and per cent time of slow wave activity. These electrographic patterns persisted for half—an-hour to two hours (Figure 3). There was considerable individual variability in the EEG response. In patients who received 100 mg or more of Tofranil, EEG and behavioral changes were Observed in all but three. In six patients, dosage Of Tofranil less than 50 mg were not associated with either EEG or behavioral changes. 2. Chronic fldministmtion Studies: Sixteen patients, manifesting depressive symptoms with varying degrees of insomnia, anorexia, withdrawal, and agitation, have received Tofranil medication for four weeks or longer. Medication was given in oral divided doses of 100—250 mg per day. Behavioral changes generally appeared during the second and were maximal during the third week of treatment. LF-lO after 100 mg pre-drug W W WW W W WWW RF-RO RAT-RF LF-RF . LPT-LO 0-0 #2348 after 30 minutes after 15 minutes iv HR=86 HR=84 ,_~,\_M, amw HR=75 50 uv HR=72 l_ 1 __ SEC. _J Fig. 3 Effect Of Tofranil on EEG delta (female, aged 41: 24 hours post convulsion no. 7) The most prominent behavioral adaptation was euphoric denial, which was noted in eight patients. The depressive attitude was nO longer apparent. They participated more fully in ward activities, complained less of somatic symptoms, and denied, minimized or displaced their illness on inquiry. Agitation decreased, and complaints of insomnia became less. It became increasingly difficult to discuss significant life relationships as the patients pressed for an early discharge from the hospital. In three patients somatization and restlessness increased, and depressive affect persisted. In two of these, restlessness, insomnia and vomiting led to cessation of therapy. Sweating increased in most patients, but became a focus of attention in these subjects. NO change in symptoms were noted in five patients after four weeks of therapy. While no serious complications of therapy were noted, nausea, increased sweating, vomiting, dryness Of the mouth, restlessness and excitement, and increasing �Special Supplement DEPRESSION AND ALLIED STATES $169 insomnia were reported. These were prominent early in therapy, and except for the vomiting and restlessness, did not limit the treatment. In three subjects medica— tion was initially administered parenterally without untoward effects. Abnormal motor patterns and seizures were not noted in these patients at these dosages. Electrographic studies on chronic administration showed minimal changes. Voltages became lower and record modulation became poorer. Well—defined fast activity became more prominent, and in four subjects low-voltage theta (5—7 cps) activity was noted. Discussion These observations indicate that Tofranil is an active central nervous system agent in man, both on oral and intravenous administration. The neurophysiologic effects are manifest electrographically as desynchronization of rhythms and a shift-in frequency spectrum to the slower range. In depressed retarded subjects, Tofrinil administration is associated with such behavioral changes as decreased depressive affect with increased participation in ward activities, increased use of denial patterns (7) and occasional excitement. In comparison to our previous experience with other physiodynamic therapies, the behavioral and electrographic patterns of Tofranil are most like those seen with central anticholinergic agents. We observed desynchronization of frequencies, with an increase in theta activity, to be prominent with experimental anticholinergic compounds such as diethazine and benactyzine* (5, 6). In those studies, electro— graphic desynchronization was associated with behavioral alerting, excitement and illusory and hallucinatory activity. On Tofranil administration, similar electrographic patterns of desynchronization were observed, accompanied by euphoria and increased ward participation. While we have not observed hallucinatory activity at our dosage ranges, Lehmann (it a]. (9) have reported hallucinations and hypomanic excitement in 7 of 84 patients receiving Tofra‘mil. In earlier reports, Wikler (3, 10) suggested that the electrographic patterns of synchronization and desynchronization reflected neuron systems distinct from those neuron systems subserving such functions as ‘sensation,’ ‘ideation’ and ‘level of awareness.’ While these systems were frequently interlocked, dissociation between EEG pattern and behavior was observable under a variety of drug—induced states. In our earlier studies we were impressed that the electrographic and behavioral patterns seen after induced convulsions, anticholinergic compounds and phreno— tropic agents were directly related. On acute administration of Tofranil, however, electrographic desynchronization was associated with clinical sedation. These studies are consistent with Wikler’s suggestion. These observations permit the classification of the neuropharmacologic activity of Tofrinil in the central nervous system as predominantly anticholinergic. However, we have noted aspects of the electrographic and behavioral patterns reminis— cent of increased cholinergic activity. These include the electrographic shift to slower frequencies and sedative, euphoriant behavioral effects. Such observations suggest that there may also be an effective degree of central cholinergic activity. Summary Intravenous administration of Tofranil in 28 voluntary, open—ward psychiatric patients elicited electrographic patterns of desynchronization and an increase of theta rhythms, associated with behavioral alerting, relaxation and lassitude. Chronic administration of oral Tofrinil in 16 depressed and retarded psychiatric subjects elicited behavioral adaptations of euphoric denial in eight, restlessness 'A recent report by Abood and Meduna (8) relates the behavioral. improvement in depressed patients with a new central anticholinergic agent which has Similar electrographic patterns. J B-329, H ” �8170 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol.4,1959 and somatization in three and no change in five. During the fifth week of adminis— tration, electrographic desynchronization was manifest. It is concluded that Tofranil is an active central nervous system agent, with a Spectrum of activity most like experimental anticholinergic hallucinogens. The theoretic significance for neurophysiologic-behavioral constructs is briefly discussed. Résumé Nous avons étudié la relation existant entre les efiets du Tofrinil sur le com— portement et sur le tracé électrographique, chez des patients atteints de psychoses aigués ou chroniques. Mét/zode Cas aigus: les patients retenus étaient examinés avant le traitement physioin— celui—ci. Tofranil Le de administré était stades divers ainsi en qu’a dynamique, jections intraveineuses d’une solution a 10 mg/ml, jusqu’a un total de 40—125 mg (0,5_2,5 mg/kg), concurremment avec des examens électro—encé—phalographiques. Cas chroniques: des patients présentant de la depression et un ralentissement du comportement étaient mis a la dose de 75—250 mg de Tofrz'mil par jour. Les examens encéphalographiques et du comportement étaient effectués avant le début du traitement, et a intervalles d’une semaine au cours de celui—ci. Observations 1° Cas aigus a) Comportement: au cours de l’administration du medicament, sur 28 cas, nous avons noté des nausées, des vertiges et de la faiblesse. Quatre fois des vomissements sont survenus. Le rythme cardiaque est demeuré inchangé, ou s’est ralenti. En 10 minutes ces symptOmes diminuaient d’intensité et les patients se détendaient. b) Electro-mcéphalogmmme: pendant le traitement, il y a eu une diminution du voltage dans toutes les fréquences. En 10 minutes le pourcentage de temps alpha baissait et les voltages tombaient a la moitié de leurs valeurs initiales. Chez les sujets a activité béta (4 cas), celle—ci devenait plus importante. Au bout de 20 5—7 de lentes ondes des minutes, cps, atteignant 50 microvolts, apparaissaient ici et la. Dans les enregistrements avec activité delta postconvulsive (6 cas) nous avons noté une baisse marquee des voltages et des pourcentages de temps danS l’activité des ondes lentes. Ces tracés électrographiques persistaient pendant M-Z heures. 2° Cas chroniques a) Comporz‘emem: seize sujets ont été observes a ce jour. Les effets~initiaux de la medication furent des nausées, deS vomissements, de l’agitation et de l’excita— tion, une exagération de l’insomnie et une transpiration tres augmentée dont se plaignaient les malades. Le traitement a été interrompu dans deux cas avec agita— tion. Des 13 autres sujets, 6 ont vu leurs symptOmeS de depression S’amender et ont pu reprendre une plus grande activité; ils ont pu étre renvoyés chez euX, ou ont été prévus pour un prochain licenciement. Les autres n’ont guere présenté de chan— a la soumis été n’ont leurs thérapeutique que pendant dans symptOmes, ou gements un temps trop court. &) Electra—encéphdlogmmme: Les enregistrements obtenus pendant 1e traite— ment n’ont montré que peu de modifications. Leur modulation était appauvrie et leurs voltages abaissés. Une activité rapide bien caractérisée a pris de l’impor— 5—7 de a bas activité noté voltage 4 malades chez une cps. nous avons tance; Conclusion: 1° Chez les psychopathes, les effets electrographiques du Tofrinil sont une Ces a tracés has lentes d’ondes activité voltage. suivie une désynchronisation, par a alors ressemblent les traités, et dans chroniques moins cas prédominants sont ceux que l’on Obtient avec la benactyzine. ' �Special Supplement DEPRESSION AND ALLIED STATES 2° En ce qui concerne le comportement, nous constatons une $171 augmentation de la motilité, un changement dans l’humeur et un malade plus éveillé. 3° Ces observations concordent avec les hypotheses neuro—physiologico—adaptatives expliquant 1e mode d’action des traitements physiodynamiques des psychoses. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Fink, M.: Hillside Hosp. J. 6:197, 1957. Fink, M.: Alteration of brain function in therapy, in Kline, N. S.: Psychopharmacology frontiers, Boston, Little, Brown, 1959, pp. 325-333. Wilder, A.: J. Nerv. & Ment. Dis. 120:157, 1954. Fink, M.: EEG and behavioral effects of psychopharmacologic agents. Read at 1st International Congress of Neuro—psycho—pharmacology, Rome, September 1958. In press. Fink, M.: A. M. A. Arch. Neurol. 8: Psychiat. 80:380, 1958. Fink, M.: Electroencephalog. 8t Clin. Neurophysiol. 10:776, 1958. Weinstein, E. A., and Kahn, R. L.: Denial of illness: symbolic and physiological aspects, Springfield, 111., C. C. Thomas, 1955. 'Abood, L. G., and Meduna, L. J.: J. Nerv. & Ment. Dis. 127:546, 1958. Lehmann, H., Cahn, C. H., and de Verteuil, R.: Canad. Psychiat. A. J. 3:155, 1958. Wikler, A.: Proc. Soc. Exper. Biol. & Med. 79:26], 1952. General discussion from the floor (summarized) The question was asked whether administration of a large dose of Tofranil once a day would not be as effective as multiple dosage. This would of course be a tremendous saving in the time of the nurses involved. In answer it was stated that Tofrénil is best given not in one large daily dose but in a series of small doses such as 2 tablets t.i.d. It was also brought out that Tofranil has a tremendous influence on transference phenomena and that these can be analyzed in dreams and symbolisms. While such observa— tions have been made, definitive results must await an extensive study. Another discussant asked what is the difference between the effect of barbiturates and anticholin— ergic drugs on the EEG. One discussant felt that the EEG was a poor tool, since it could be modified in only two ways, synchronization or desynchronization, and firm conclusions should not be drawn from such changes. He therefore felt that analogies between diethazine and Tofrénil were dubious and that nausea was not a specific effect of Tofranil. He wondered if EEG changes would always exist in the absence of nausea, and felt it important to correlate EEG changes with clinical changes. In replying to these comments, Dr. Fink stated that he considered Tofrfinil an anticholinergic drug because of its similarity to other anticholinergic drugs in regard to its EEG patterns. Dr. Fink recalled that Dr. Sigg’s paper had also indicated that Tofrfinil was an anticholinergic drug. Many anticholinergic compounds appear to have rather specific central effects, and some are also experimental hallucinogens. In his experience, barbiturates produce not desynchronization, but rather synchronization. This becomes clear if the factors of dosage and time are considered. Thus the initial effect is hypersynchronization; if the drug is continued, sleep is of course produced and the initial effect disappears. The author replied to the criticism of his use of EEG. He agreed that it is a poor tool in many respects, but that it is possible to analyze EEG records for synchronization, desynchronization and fre uency shifts. One obtains different patterns with different agents even in the same patient. Dr. Fink explained that he was making a long—term study, and hoped that more conclusive data could be offered at a later time. ��’*” EEG uni nahtviernl striat: .2 nu nah, Torranil 3...». * 2h: rulltion hotvtcu thc filcetragrcphie and behaviortl «Itcctt at retranil in velunthry paychintrie pationtt wan datarnincd in taut. and thrsnic ntudioa. _ Kathodnr latto: Ganaaeutiva patiants rcturrod for phytiodynunic thtrupiol ttntod not: prior to and at yariatu itngal Of therapy. With 330 rocordinc, retruail nelution (10 ng/oc) was adminintorud intruvanouuly for I total of h0~125 I; (0.S~2.5 ng/ks). chronic: Pttiontp annitslting duprctuivo tad rotnrdod bchlvior aura plnoud an rogiucua o: 7S~2oe lg renunil daily. EEG oxnniuntionn and hchuyiornl obsothtiaus war. and. prior to and It weekly int-yttla during troutncnt. Oblarvntianus 1. Acute Stadielt a. Buhfiyiora Baring drug zduiniltrutiou in 25 albjoata, 3.13033, EIuIIncoo in! Ionknoan wort rcpcrtud. Viniting ocearrcd an tour oecaaicnc. fictrt rgto was Inshtngod, tr nluvcd. In 1&3 Iinutca, th... aynptoun were 103:, und puticnta war. roluxod. b. EEG: During ndninistrttion thtrc was a dccruuuc in yoltagc a: all trcquonans. By tan minuttu, thc par cant tint alpha ducronsed, lad valtngea were halt at thc initial values. In pationts with sodurnto anonntn of but. uctiyity (h), auch activity hocuno morc yroxincnt. fly taunty mintha, slow It?! nativity of k-7 apt, up to 50 uiarovclta upponrnd, rundouly. In roenrd: with poat~eenvulaiva daltg activity (6), thert in a nurkcd docrotio in voltngcn and in par tent tin. of claw wave nativity. tutu: electraartphic pattcrn: pcraictcd far 2. Chrunia I studioat _Bchnvi¢rn i. rittouu patient: hay. 2 hours.\ boon under ebccrvutiou to data. -Iai -n a van a at nodicntian inaludod nanaou (a) vaulting (a), roatlouuuocn lad axaitantnt (2), insomnin oxaggorntod (35, And aonplainta o: oxacstivo uwiating (11). In tha tun pationtn with roitlsasnoal, nedic;~. tit» at: diaoontinund. a: the thirtaon pntionts, nix Innitcttni In 3110'iatiun or symptoms a: doprnulion with incronnad pnrtiaipation in activitics, Ind hava Bean dilahargad or rccaunoudcd tar diuehnrga. Th: rcaaiuing buy. nhaun littlc engage in a tan. (3) at thcrapy ht! baan patitntl udniniltorud for too thort a ptriod (hgfp 3:. mm: In neat-d. «ht-sin“ during hottmnt, tiniaul change: taro obIcrvoa. fieduiation a: rucordu was poortr with lcwor yoltncct. H011 dutinod rant activity bee... not. proninont; tad in tour subject. 10v waltago 5~7 cps activity VI! noted. conclusion. Ll Sloetrozrtphic extactn o: Totrunil in payehiutriu patiuntc are thus: of duayuehroniantion, tullowod by law voltngo slaw wtva nativity. * Iron thc Duplrtuant at magazinpnttl Payehintry, nilluidc Rhapital, glig ggk" L010 301% �.2th¢to pattorna arc 1.0: proninnnt an chrcnie udntnintrntiau, tad rononblo that. or bnunctynin0¢ 2) Dihtviornl offset: arc that; of alurtiuc, Iced ch¢n¢a and inurilnnd motility. «autistant with fiha nauraphyszolagtau :Athivu hypathuntu at :h: act. at action or physiodyuania thcrupion 3) Thnss abaorvution¢ nae of paychoucu. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Electroencephalographic and behavioral effects of tofranil. Can Psychiatr Assoc J. 1959;4(Suppl):166-71. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-38a-004 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint from CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Volume 4 Special Supplement, 1959 McGill University Conference on Depression and Allied States, Montreal, March 19-21, 1959 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/261abbc7e46388bc86f6597be731bd1c.pdf 0134e8d9c4e023061da7cfc3c500f0f0 PDF Text Text t Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Max Fink, McDo Robert L. Kahn Ph.D. and Hyman From Korin Ph.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks,N.Y. Institute of Mental Health, National Health Service. United Public States of Health, Institutes Aided by Grant M-927 of the National (in part) at the Divisional Meeting A.P.A., Montreal, November, 1956, and International Congress of Neurological Sciences, Brussels, July, 1957. the at Read 12-3-57 “W5, $9; WW7 A“! �Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Numerous studies have been.reported assessing the type, duration and significance of mental changes following electroshock. These reports vary widely in their descriptions and meaningful conclusion regarding the it is difficult to arrive at a relation of such mental changes to clinical response. Basic to these differences in observation are the vexing problems of the definition and the ways of measurement of organictype reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definition of the problem. In the present study, various tests of brain function were applied serially to patients in mhom‘behavicr was altered by repeated inductions of grand mal convulsions (Electroshock). The data comparing the serial changes in these indices are presented. METHOD: Definition of "organic mental changes": conventional conception The of organic mental changes includes such behavioral changes as impairment of memory and of the discrimination of differences on perceptual tasks; disorientation for time, date, or place; errors tractibility and inability to handle perserveration in speech on more than one and behavior; emotional calculation tests; dis- situation at a time; lability; and loss of interest in one's appearance and in the environment. Most studies assess the relationship of memory loss or clinically manifest disorientation to improvement following by tests of simple electroshock. The memory loss is usually measured recall, information, personal events, digit memory span, �~2r etc.: while disorientation is place, date, determined by questions the examiner, 323, name of Such tests of relating to present memory and of orientation, however, discriminate primarily only severe degrees of dysF function. In the present studies, cognizant of the difficulties inherent in clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, simple types of dysfunction. The four'measures selected as being sensitive to varying aspects and degrees of cerebral dysfunction.were: a) The degree of delta activity in the electroencephalogram (1). b) in language and orientation following the administration of amobarbital sodium - the "amytal test" for organic brain Changes disease (2, 3). c) Alteration in perception of multiple simultaneous d) Changes in tests of recall of the interpolation of reading Time of Testing: A common lists tactile stimuli (h). words, both with and without of nonsense syllables (5). second factor to be considered is the time of application of these tests in relation to the treatment program. Observers have reported the development of organic changes in the Numerous few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third at pretreatment levels, orientation is re-instituted. course of therapy the electroencephalogram is memory changes have disappeared and week following an extensive �-BIn the present studies, the electroshock treatment schedule was main- tained at three times per week with Reiter electroshock, during the all patients receiving conventional initial three weeks. In the fourth week, treatment frequency was occasionally reduced to two times per week. All patients received a out at weekly minimmn intervals of twelve treatments. All on a day following a tests were carried treatment during the course of therapy. Following termination: of therapy, weekly testing was continued until the tests returned to their initial level. third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definition and evaluation of "improvement." The evaluation of clinical Behavior Ratings: response to therapy A is a subjective value judgment by the therapist or adninistrator which reflects a divergence of goals, judgments, and compromises. Significant variables in the evaluation of "improvement" are the type, severity and duration of the pets“. ent' s illness, his premcrbid personality, the sociologic (family) constellation to which he will return, and the expectations (both conscious and unconscious) of the institution, of the patient and of the family. of the evaluation of the treannent result is also a the therapist, of Furthermore , the time most sigaificant variable. The parameters of evaluation have not been satisfactorily delineated. In this study, the following compromises have been made. All evaluations qualified psychiatrist who has no responsibility for the selection of subjects or application of the treatments. Patients are made by an independent are seen weekly and conferences are held with the therapist to assess the �.Ll. therapeutic goals before treatment and the therapist‘s estimate of the respOnse after treatment. The finai evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behavior. we have used a three-fold classification of improved" and "uninmuoved," with the and "unimproved" "much improved," "moderately intent that the categories respectively "much improved" would describe patients at the extremes of the response continuum. The patients rated as those "much improved" were showed the symptoms which brought them.to the who no longer hospital, their physicians believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The "unimproved" patients were those noticeable change in behavior who manifested no clearly or'Who became worse. The "moderately improved" patients showed some change but continued to manifest signs of'mental illness. some symptomatic relief, which was transient. They in behavior, typically showed �.5. RESULTS : Twenty-four consecutive electroshock patients were studied. these, eleven and were Of "much improved," seven as "unimproved," rated as six as "nmderately improved." (a) Electroencephalogrems: EEG records, using conventional leads, were measured for the average per cent time delta activity, and highest per cent time delta in any one lead; the Slowest frequency in the record; and the duration and amplitude of delta burst activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. The upper 1/3 of the records were described as "high delta activity" and the lowest 1/3 as "low delta activity." pretreatment records showed delta activity. During the course of electroshock delta activity appeared in all records to varying degrees. It No was apparent within the on the third with high first week following EEG week of treatment and the 7~9 treatments. The usually reached a peak results for those delta activity are seen in Table I. TABLE EEG - % I High Delta Activity 1-3 h—é 7-9 10-12 25 80 91 88 Moderately Improved (6) 0 16 50 ho unimproved (7) o o o 20 Treatment Period: much Improved (11) �~6(b) AmObarbital Test: In these tests (2, 3) the patients are asked series of questions relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in a orientation and awareness of illness are scored as "positive" amytal response, reflecting a change in brain function ascribed to “organic brain disease" (2). The results are noted in the next table. TABLE II Amvtal Test -.% Positive Treatment Period: 1-3 11-6 7-9 10-12 13-15 Much Improved (11) us 61; 100 89 100 Moderately Improved (6) 20 33 67 20 25 Unimproved (7) 1h 16 16 33 o The data of Tables The congruence I and II have been graphically portrayed in Figure of the observations of the degree of delta activity EEG l. and test responses is demonstrated. (Fig. 1) Tests: In this test (5) a list of three letter common the per cent positive amytal (c) Memos! words were presented for 10 to patients by flash cards. trials. After this, lists interpolated. The of 3 recall of the first The cards were presented letter nonsense syllables list were of'wordStmas.then tested, and the number of words recalled in each session was scored. An impairment in recall function decrement was maximal in the second was apparent and third in all subjects. This weeks of sustained as long as treatments were administered treatment, 3 times a week. and was �-7The decrease in ability to recall the word list is noted in the next table o TABLE III anaiment in Recall - Marked Decrement % Treatment Period 1-3 1456 7-9 10-12 Improved (9) o 11 33 o Moderately Improved (h) 0 SO SO 0 Unimproved (7) 0 1h 0 0 Much the scores are compared with the mprovement rating, there is no significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to When two times per week indicates that this more severe degrees test is a measure of only the of cerebral dysfmction. tests the patient is touched by the examiner simultaneously on the cheek and the hand, and asked to localize the stimuli. The tests are repeated for 10 trials using varying combinations of cheek, hand, shoulder and thigh. Persistent failure to (d) Tactile Perceptual Tests: In these report the stimuli or to mislocalize a stimulus beyond the tenth indicative, in adults, of altered cerebral function (h). one of trial is In all subjects, this test was negative before patients. In nine patients, two observed, and of these, six were in the much responses were observed in 19 of the consecutive responses were improved and three treatment. Positive 21; in the moderately improved groups. �In the next table the positive responses were charted with relation to the treatment period and of positive regaonses is to the clinical evaluation. be noted in the first A high incidence two groups, and many fewer such responses in the unimproved group. TABLE Face Hand Test IV - % Positive 1-3 h-6 7-9 10-12 13-15 Much Improved (11) 16 no in h3 60 Moderately Improved (6) 60 1:3 2:3 30 o o 16 12 11 o Treatment Period Unimproved (7) �DISCUSSION: Three aspects of these observations warrant elaboration. sensitivity and the and stability The of these indices of altered brain function significance for a definition of altered cerebral function; the relation of these indices during and evaluation; and after treatment to the clinical the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function'was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions persistently positive for one to three weeks fOIIOWing treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perceptual tests also showed changes but these appeared late (in the 2nd and remained week of treatment) and disappeared rapidly when treatment frequency was reduced. Tests of recall function and tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced to another‘variable, it is important, the operation (or test) and the Because these tests have varying change in brain function therefore, to clearly define both sensitivity of the operation which forms the basis for the estimation of altered cerebral function. sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent �~10- treatment, while changes in recall function and simultaneous tactile perception are rapidly 0f the function, clinical lost, when treatment frequency reduced. correlations possible with these tests of brain many we have selected the relation of these test results to the improvement rating. ‘With the EEG-and amytal relationships between the appearance of test changes improvement are is clearly observed. In the positive amytal tests and high degree were more marked, and were sustained EEG tests significant and much improved clinical patients, abnormality appeared early, for longer periods (on the treatment regimen) than in the unimproved patients. The same moderately improved patients were in between. relation between altered brain function and clinical response This is noted only with the data obtained during the course of therapy. There is no correlation of improvement ratings with post-ptreatment test results. This divergence is related to the timing of test applications, in the conclusions of other studies and may explain the discrepancies of this prdblem. These Observations can also be mode of action of electrochock. related to an understanding of the In 1952,'Weinstein, Linn and Kahn (6) postulated that the function of electroshock therapy was to "initiate the production of a state of altered brain function in which the patient his problems." These observations support the first part of this hypothesis. namely, that a state of altered cerebral function is can deny induced by electroshock. Also, in patients who.improved, the altered state is more prominent, appears earlier and is more persistent than in �, those who fail to improve. Of the eleven positive amytal tests (while positive test); and ten had high had one of the unimproved .11.much improved patients, all 5 of the 7 unimproved never had a EEG abnormality records, while only patients had such a record. It is our condlusion significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. that early? sustained and �4.2;» W: In a study of the relation of tests of altered brain function to improvement in electroshock, of change it was observed that while indicators in brain function vary in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. The reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is and the dependent on and early, sustained that electroshock therapy and marked changes may be in mental function; described as the non-Specific, traumatic induction of states of altered cerebral function in which the subject reacts with new patterns of adaptation. �REFERENCES 1- Fink, M. and Kahn, R.L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neural. & chhiatflfi: 516.525, 1957. _ Kahn, R.L. and Malitz, 3.: Serial Administration Test" for Brain Disease. Its Diagnostic and of "Anvtal Prognostic Value, A.M.A. Arch. Neural. & Psychiat. 217-226, 1951;. 2. Weinstein, E.A,, _’_?_I_: 3. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M,A. Arch. jieurol. 8c Psychiat" Zé: 23-29, 1956. and Bender, M.B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, NeurologX, _2_: h. Fink, M., Green, ILA. h6—58. 1952. H. , Fink, M. and Kwalwasser, 8.: Memory and Learning to Improvement Neuron-o, $6.: 88'96’ 1956. 5. Karin, Relation of Changes in in Electroshock, Conf. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat., 109: 22-26, 1952’. �--- .. anEu’mlJ-Jfial from , “T'he FLSL , ,.. -n Congress of Neur-ofogical ’, Brussels, 1.;7. Vol. III. EEG, Clinical Neurophysiology ces -pllepsy. Pergamon Press; London, New York & Paris 1959 "Emmi , RELATION OF TESTS OF ALTERED BRAIN FUNCTION TO BEHAVIORAL CHANGE FOLLOWING INDUCED CONVULSIONS DANS CEREBRALE FONCTIONNELLE ALTERATION D'UNE ROLE LE CHANGEMENT DE COMPORTEMENT SUCCEDANT A DES CONVULSIONS PROVOQUEES MAX FINK, ROBERT L.KAHN and HYMAN KORIN New York, U.S.A. Numerous studies have been reported assessing the type, duration and significance of mental changes following electroshock. These reports vary widely in their descriptions and it is difficult to arrive at a meaningful conclusion regarding the relation of such mental changes to clinical the in vexing observation differences to are these Basic response. problems of the definition and the ways of measurement of organic—type reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definitiOn of the problem. In the to function of applied serially brain were various tests present study, of inductions grand altered whom behaviour by in repeated was patients mal convulsions (Electro shock). The data comparing the serial changes in these indices are presented. MET HOD Definition of 'organic mental changes' The conventional conception of organic mental changes includes such of of discrimination the and of behavioural changes as impairment memory differences on perceptual tasks; disorientation for time, date, or place; handle to and more inability caICulation 0n distractibility tests; errors than one situation at a time; per serveration in speech and behaviour; emotional lability; and loss of interest in one‘s appearance and in the environment. Most studies assess the relationship of memory loss or clinically manifest disorientation to improvement following electroshock. The memory loss is usually measured by tests of simple recall, informa: while disorientation is etc. tion, personal events, digit memory span, determined by questions relating to present place, date, name of the examiner, etc. Such tests of memory and of orientation, however, discriminate primarily only severe degrees of dysfunction. In the present studies, cognizant of the difficulties inherent in simple clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, to sensitive selected four being The as of measures types dysfunction. varying aspects and degrees of cerebral dysfunction were: (a) The degree of delta activity in the electroencephalogram (l). (b) Changes in language and orientation following the administration of amobarbital sodium - the 'amytal test' for organic brain disease (2, 3). 613 ‘ �614 M. FINK, R.L.KAHN and H.KORIN (c) Alteration in perception of multiple simultaneous tactile stimuli ((1) (4). Changes in tests of recall of common words, both with and without the interpolation of reading lists of nonsense syllables (5). Time of Testing A second factor to be considered is the time of application of these tests in relation to the treatment program. Numerous observers have reported the development of organic changes in the few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third week following an extensive course of therapy the electroencephalogram is at pretreatment levels, memory changes have disappeared and orientation is re-instituted. In the present studies, the electroshock treatment schedule was maintained at three times per week with all patients receiving conventional Reiter electroshock, during the initial three weeks. In the fourth week, treatment frequency was occasionally reduced to two times per week. All patients received a minimum of tWelve treatments. All tests were carried out at weekly intervals on a day following a treatment during the course of therapy. Following termination of therapy, weekly testing was c0ntinued until the tests returned to their initial level. Behavior Ratings A third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definitiOn and evaluation of 'improvement‘. The evaluation of clinical response to therapy is a subjective value judgment by the therapist or administrator which reflects a divergence of goals, judgments , and compromises. Significant variables in the evaluation of 'improvement' are the type, severity and duration of the patient's illness, his premorbid personality, the sociologic (family) constellation to which he will return, and the expectatious (both conscious and unconscious) of the therapist, of the institution, of the patient and of the family. Furthermore, the time of the evaluation of the treatment result is also a most significant variable. The parameters of evaluation have not been satisfactOrily delineated. In this study, the following compromises have been made. All evaluations are made by an independent qualified psychiatrist who has no responsibility for the selection of ‘subjects or application of the treatments. Patients are seen weekly and conferences are held with the therapist to assess the therapeutic goals before treatment and the therapist's estimate of the response after treatment. The final evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behaviour. We have used a three-fold classification of 'much improved' , 'moderately improved' and 'unimproved' , with the intent that the 'much improved' and 'unimproved' categories respectively would describe patients at the extremes of the response continuum. The patients rated as 'much improved' were those who no longer showed the symptoms which brought them to the hospital, their physicians ' �Relation of tests of altered brain fimction to behavioral change 615 believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The 'unimproved' patients were those who manifested no clearly noticeable change in behaviour or who became worse. The 'moderately improved' patients showed some change in behaviour, but continued to manifest signs of mental illness. They typically showed some symptomatic relief, which was transient. RESULTS Twenty-four consecutive electroshock patients were studied. Of these, eleven were rated as 'much improved', seven as 'unimproved', and six as 'moderately improved'. (a) Electro enc ephalogr am s EEG records, using conventional leads, were measured for the average per cent time delta activity, and highest per cent time delta in any one lead; the slowest frequency in the record; and the duration and amplitude of delta bur st activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. The upper 1/3 of the records were described as 'high delta activity' and the lowest 1/3 as 'low delta activity'. No pretreatment records showed delta activity. During the course of electroshock delta activity appeared in all records to varying degrees. It was apparent within the first week of treatment and usually reached a peak on the third week following the 7-9 treatments. The results for those with high EEG delta activity are seen in Table I. TABLE I EEG - % High Delta Activity Treatment Period: Much Improved (11) Moderately Improved (6) Unimproved (7) (b) 'W .....'-.——-—- a .- 1-3 4-6 7-9 25 80 91 50 10-12 —-——————__.____—_~__ 0 0 16 0 0 88 40 20 Amobarbital Te st In these tests (2, 3) the patients are asked a series of questiOns relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in orientation and awareness of illness are scored as 'positive' amytal response, reflecting a change in brain function ascribed to 'organic brain disease' (2.). The reSults are noted in the next table. �616 M. FINK, R.L.KAHN and H.KORIN TAB—Ly; Arnytal Test - % Positive Treatment Period Much Improved (ll) 1-3 4-6 7-9 10-12 45 20 Moderately Improved (6) Unimproved (7) 64 100 33 67 14 16 16 89 20 33 13-15 100 25 0 (c) Memory Tests: In this test (5) a list of three letter common words were presented to patients by flash cards. The cards were presented for 10 trials. After this, lists of 3 letter nonsense syllables were interpolated. The recall of the first list of words was then tested, and the number of words recalled in each session was scored. An impairment in recall function was apparent in all subjects. This decrement was maximal in the second and third weeks of treatment, and was sustained as long as treatments were administered 3 times a week. The decrease in ability to recall the word list is noted in the next table. TABLE III Impairment in Recall - % Marked Decrement Treatment Period Much Improved (9) Moderately Improved (4) Unimproved (7) 1-3 4-6 7-9 10—12 0 0 0 ll 33 50 0 50 l4 0 O 0 are compared with the improvement rating, there is no significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to two times per week indicates that this test is a measure of only the more severe degrees of cerebral dysfunction. (d) Tactile Perceptual Tests In these tests the patient is touched by the examiner simultaneously on the cheek and the hand, and asked to localise the stimuli. The tests are repeated for 10 trials using varying combinations of cheek, hand, shoulder and thigh. Persistent failure to report one of the stimuli or to mislocalise a stimulus beyond the tenth trial is indicative, in adults, of altered cerebral function (4). In all subjects, this test was negative before treatment. Positive When the scores �Relation of tests of altered brain fimction to behavioral change 61 7 responses were observed in 19 of the 24 patients. In nine patients, two consecutive responses were observed, and of these, six were in the much improved and three in the moderately improved groups. In the next table the positive responses were charted with relation to the treatment period and the clinical evaluation. A high incidence of positive responses is to be noted in the first two groups, and many fewer such responses in the unimproved group. w Face Hand Test - % Positive Treatment Period 1-3 4-6 7-9 10-12 13-15 Much Improved (11) 16 Moderately Improved (6) Unimproved (7) 60 O 4o 43 16 47 43 12 43 3O ll 60 0 0 DISCUSSION Three aspects of these observations warrant elaboration. The sensitivity and stability of these indices of altered brain function and the significance for a definition of altered cerebral function; the relation Of these indices during and after treatment to the clinical evaluation; and the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions and remained persistently positive for one to three weeks following treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perceptual tests also showed changesbut these appeared late (in the 2nd week of treatment) and disappeared rapidly when treatment frequency was reduced. Tests of recall function and tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced change in brain function to another variable, it is important, therefore, to clearly define both the operation (or test) and the sensitivity of the operatiOn which forms the basis for the estimation of altered cerebral function. Because these tests have varying sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent treatment, while changes in recall function and simultaneous tactile perception are rapidly lost, when treatment frequency is reduced. Of the many correlations possible with these tests of brain function, we have selected the relation of these test results to the clinical improvement rating. With the EEG and amytal tests significant relationships between the appearance of test changes and clinical improvement are clearly observed. In the much improved patients, positive amytal tests �618 M. FINK, R.L.KAHN and H.KORIN and high degree EEG abnormality appeared early, were more marked, and were sustained for longer periods (on the same treatment‘regimen) than in the unimproved patients. The moderately improved patients were in between. This relation between altered brain function and clinical response is noted only with the data obtained during the course of therapy. There is no correlation of improvement ratings with post-treatment test results. This divergence is related to the timing of test applications, and may explain the discrepancies in the conclusions of other studies of this problem. These observations can also be related to an understanding of the mode of action of electroshock. In 1952, Weinstein, Linn and Kahn (6) postulated that the function of electroshock therapy was to 'initiate the production of a state of altered brain function in which the patient can deny his problems'. These observations Support the first part of this hypothesis, namely, that a state of altered cerebral function is induced by electroshock. Also, in patients who improved, the altered state is more prominent, appears earlier and is more persistent than in those who fail to improve. Of the eleven much improved patients, all had positive amytal tests (while 5 of the 7 unimproved never had a positive test); and ten had high EEG abnormality records, while only one of the unimproved patients had such a record. It is our conclusion that early, sustained and significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. ' SUMMARY In a study of the relation of tests of altered brain function to improvement in electroshock, it was observed that while indicators of change in brain function vary in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. The reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study and the difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is dependent on early, sustained and marked changes in mental function; and that electroshock therapy may be described as the non— specific, traumatic induction of states of altered cerebral function in which the subject reacts with new patterns of adaptation. REFERENCES l. 2. 3. Fink, M. and Kahn, R.L. Relation of EEG delta activity to behavioral response in electroschock: quantitative serial studies. A.M.A. Arch. Neurol. and Psychiat. , 1957, 78: 516-525. Weinstein, E.A. , Kahn, R.L. and Malitz, S. Serial administration of 'Amytal Test' for brain disease. Its diagnostic and prognostic value. A.M.A. Arch. Neurol. and Psychiat. , 195.4, 71: 217-226. Kahn, R.L. , Fink, M. and Weinstein, E.A. Relation of amobarbital test to clinical improvement in electroshock. A. M. A. Arch. Neurol. and Psychiat. , 1956, 76: 23-29. �Relation of tests of altered brain function to behavioral change 619 Fink, M. , Green, M.A. and Bender, M.B. The face-hand test as a diagnostic sign of organic mental syndrome. Neurology, 1952, 2: 46-58. Korin, H. , Fink, M. and Kwalwasser, S. Relation of changes in memory and learning to improvement in electroshock. Conf. Neurol. , 1956, 16: 88-96. Weinstein, E.A. , Linn, L. and Kahn, R.L. Psychosis during electro‘ shock therapy: its relation to the theory of shock therapy. Am. J. Psychiat. , 1952, 109: 22-26. Dept. of Experimental Psychiatry, Hillside Hosp-ital, Glen Oaks, N. Y. , U.S.A. ‘ ��Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Max Fink, Rebert L. IIOD c Kahn Ph.D. and Hyman From Karin Fh.D. the Department of Experimental Peychiatry, Hillside Hospital, Glen Oaks,N.Y. Aided by Grant M~927 of the National Institute of Mental Health, National Institutes of Health, United States Pablic Health Service. (in ,art) at the Divisional Meeting A. P .A., Montreal, November, 1956, and at the International Congress oi Neurological Sciences, Brussels, July, 1957. Read 12—3-57 �Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Numerous and studies have been reported assessing the type, duration significance of mental changes following electroshock. vary widely in their descriptions and meaningful conclusion regarding the it is difficult These reports to arrive at a relation cf such mental changes to clinical response. Basic to these differences in observation are the vexing problems of the definition and the ways of measurement of organic; type reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definition of the problem. In the present study, various applied serially to patients in whom tests of brain function were behavior was altered by repeated inductions of grand mal convulsions (Electroshock). The data comparing the serial changes in these indices are presented. . METHOD: Definition of “organic mental changes": conventional conception The of organic mental changes includes sudh behavioral changes as impairment of memory and of the discrimination of differences on perceptual tasks; disorientation for time, date, or place; errors tractibility and inability to handle perserveration in speech on more than one and behavior; emotional calculation tests; dis- situation at a time; lability; interest in one's appearance and in his environment. the relationship of memory tests of simple loss of studies assess loss or clinically manifest disorientation to improvement following electroshock. The memory loss by Most and is usually measured recall, information, personal events, digit memory span, �«2- etc.: while disorientation is place, date, name of determined by questions the examiner, etc, Such tests of relating.to present memory and of orientation, however, discriminate primarily only severe degrees of dysfunction. In the present studies, cognizant of the difficulties inherent in simple clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, types of dysfunction. The four measures selected as being sensitive to varyinD aspects and degrees of cerebral dysfunction were: delta activity in the electroencephalogram (1). b) Changes in language and orientation following the administration of amobarbital sodium - the "amytal test" for organic brain a) The degree of disease (2, 3). c) Alteration in perception of multiple simultaneous tactile stimuli (h). d) Changes in tests of recall of the interpolation of reading Time of Testing: A common lists words, both with and without of nonsense syllables (5). second factor to be considered is the time of application of these tests in relation to the treatment program. observers have reported the development of organic changes in the Numerous few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third is at pretreatment levels, orientation is re-instituted. course of therapy the electroencephalogram memory changes have disappeared and week following an extensive �.3In the present studies, the electroshock treatment schedule was main- tained at three times per all patients receiving conventional initial three weeks. In the fourth week, week with Reiter electroshock, during the treatment frequency was occasionally reduced to two times per week. All patients received a out at weekly minimum intervals of twelve treatments. All on a day following a tests were carried treatment during the course of therapy. Following termination of therapy, weekly testing was continued until the tests returned to their initial level. Behavior Ratings: A third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definition and evaluation of "improvement." The evaluation of clinical is a subjective value administrator which reflects a divergence response to therapy judgment by the therapist or of goals, judgments, and com- promises. Significant variables in the evaluation of "improvement” are the type, severity and duration of the patient's illness, his premorbid personality, the sociologic (family) constellation to which he will return, and the expectations (both conscious and unconscious) of the therapist, of the institution, of the patient and of the family. Furthermore, the time of the evaluation of the treatment result is also a most significant variable. The parameters of evaluation have not been satisfactoriLy delineated. In this study, the following compromises have been made. All evaluations are made by an independent qualified psychiatrist who has no responsibility for the selection of subjects or application of the treatments. Patients are seen weekly and conferences are held with the therapist to assess the �.44.. therapeutic goals before treatment and the therapist‘s estimate of the final evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behavior. reaponse after treatment. we have used a The three-fold classification of improved" and "unimproved," with the "much improved," "moderately intent that the "much improved" and "unimproved" categories respectively would describe patients at the extremes of the response continuum. The patients rated as "much improved" were showed the symptoms which brought them those who no longer to the hospital, their physicians believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The "unimproved" patients were those noticeable change in behavior or The who became "moderately improved" patients manifested no clearly Who worse. showed some change but continued to manifest signs of'mental illness. some symptomatic relief, which was transient. They in behavior, typically showed �-5RESULTS : Twenty-four consecutive electroshock patients were studied. "much improved," seven as "unimproved," these, eleven were rated as and Of six as "moderately improved." (a) Electroencephalograns: EEG records, using conventional leads, highest lead; the Slowest frequency in the record; were measured for the average per cent time delta activity, and per cent time delta in any one and the duration and amplitude of delta burst activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. were described as "high delta activity" and The upper 1/3 of the records the lowest 1/3 as "low delta activity.” No electroshock delta activity appeared in was apparent within the on the activity. pretreatment records showed delta third with high first week following EEG all records to varying degrees. week of treatment and the 7-9 treatments. delta activity are seen in Table TABLE EEG . % During the course of The usually reached a peak results for those I. I Hiqh Delta Activity Treatment Period: 10-12 1-3 h—é 7—9 25 80 91 88 Moderately Improved (6) o 16 so ho Unimproved (7) o o o 20 finch Improved (ll) It �a (b) ~6- Amobarbital Test; In these tests (2, 3) the patients are asked series of questions relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in a orientation and awareness of illness are scored as "positive" amytal reSponse, reflecting a change in brain function ascribed to "organic brain disease" (2). The results are noted in the next table. TABLE Amytal Test - II % Positive Treatment Period: 1-3 h-6 7-9 10-12 13-15 Much Improved (11) £15 61; 100 89 100 Moderately Improved (6) 20 33 67 20 25 Unimproved (7) 1h 16 16 33 o The data of Tables The congruence of I and II have been graphically portrayed in Figure 1. the observations of the degree of EEG delta activity and the per cent positive amytal test reSponses is demonstrated. (Fig. I) (0) Memory Tests: In this test (5) a list of three letter common words were presented to patients by flash cards. The cards were presented for 10 trials. After this, lists interpolated. The of 3 recall of the first letter list nonsense syllables were of words wens then tested, and the number of words recalled in each session was scored. An impairment in recall function was apparent in all subjects. This decrement was maximal in the second and third weeks of treatment, and was sustained as long as treatments were administered 3 times a week. �.’ ~7The decrease in ability to recall the word list is noted in the next table. TABLE Impairment in Recall III - % Marked Decrement 1-3 Treatment Period Mnch Improved (9) Moderately Improved (h) ' Unimproved (7) When h-é 7-9 10-12 O 11 33 O 0 SO SO 0 0 1h 0 0 the scores are compared with the improvement rating, there is significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to two times per week indicates that this test is a measure of only the no more severe degrees of cerebral dysfunction. tests the patient is touched the cheek and the hand, and asked to (6) Tactile Perceptual Tests: In these by the examiner simultaneously on localize the stimuli. The tests are repeated for combinations of cheek, hand, shoulder and thigh. report one 10 trials using varying Persistent failure to of the stimuli or to mislocalize a stimulus beyond the tenth trial is indicative, in adults, of altered cerebral function (h). In all subjects, this test was negative before treatment. Positive two responses were observed in 19 of the 2h patients. In nine patients, consecutive responses were observed, and of these, six were in the much improved and three in the moderately improved groups. �In the next table the positive responses were charted.with relation to the treatment period of positive responses and is to the dlinical evaluation. be noted in the first A high incidence two groups, and many fewer such responses in the unimproved group. TABLE Face Hand Test IV - % Positive Treatment Period Much Improéed (11) . a Moderately Improved (6) Unimproved (7) ~ 1-3 h-6 7-9 10-12 13-15 16 ho h7 h3 60 60 h3 AB 30 O 0- 16 12 11 O �DISCUSSION: Three aspects of these observations warrant elaboration. sensitivity and stability The of these indices of altered brain function significance for a definition of altered cerebral function; the relation of these indices during and after treatment to the clinical and the evaluation; and the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function.was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions persistently positive for cne to three weeks following treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perand remained ceptual tests also showed changes but week of treatment) and disappeared . was reduced. Tests of recall function and these appeared late (in the rapidly when 2nd treatment frequency tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced to another variable, the operation (or it is test) change in brain function important, therefore, to clearly define both and the sensitivity of the operation which forms the basis for the estimation of altered cerebral function. Because these tests have varying sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent �{-10- treatment, while changes in recall function and simultaneous tactile perception are rapidly lost, when treatment frequency is reduced. Of the many correlations possible with these tests of brain function, we have selected the relation of these test results to the clinical improvement rating. With the EEG and clinical much improved patients, relationships between the appearance of test changes improvement are clearly observed. In the positive amytal tests and high degree EEG tests significant and amytal abnormality appeared early, were more marked, and were sustained for longer periods (on the same treatment regimen) than in the unimproved patients. The moderately improved patients were in between. relation between altered brain function and clinical response This only with the data obtained during the course of therapy. is noted There is results. no correlation of This divergence improvement is related to the timing of test applications, in the conclusions of other studies and may explain the discrepancies of ratings with post-treatment test this prdblem. These observations can also be mode of related to an understanding of the action of electroshock. In postulated that the function 1952, Weinstein, Linn and Kahn (6) of electroshock therapy was to ”initiate the production of a state of altered brain function in which the patient can deny his problems." These observations support the first part of this hypothesis, namely, that a state of altered cerebral function is induced by electroshock. Also, in patients who.improved, the altered state is more prominent, appears earlier and is more persistent than in �.11.. those had who fail to improve. Of the eleven positive amytal tests (while positive test); 5 of the much improved 7 patients, all unimproved never had a and ten had high EEG abnormality records, while only one of the unimproved patients had such a record. It is our conclusion significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. that early, sustained and �SUMMARY: In a study of the relation of tests of altered brain function to improvement in electroShock, of change in brain function vary it was observed that while indicators in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study The difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is and the dependent on early, sustained and marked changes in mental function; that electroshock therapy may be described as the non-specific, traumatic induction of states of altered cerebral function in'which and the subject reacts with new patterns of adaptation. �REFERENCES l. Fink, Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & PsychiatJfi: M. and Kahn, R.L.: 516‘5251 1957. Kahn, R.L. and Malitz, 5.: Serial Administration of "Amytal Test" for Brain Disease. Its Diagnostic and Prognostic Value, A.M.A. Arch. Neurol. Psychiat. 23;: 2. Heinstein, E.A., <3». 217-226, 19st. 3. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electro shock, A.I'I.A. Arch. Neurol. a Psychiat., 19: 23-29, 1956. h. Pink, Grren, HA. and Bender, H.B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurolo fl. , _2_: 116—58, 1952. 1-1., H. , Fink, 1'1. and Kwalwasser, 8.: Memory and Learning to Improvement 5. Korin, I‘Ieinstein, 13.A., Linn, L. and Kahn, shock Therapv: Relation of Changes in in Electroshock, Conf. R.L.: Psychosis During Electro- Its Relation to the Theory of Shock Therapy, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of tests of altered brain function to behavioral change following induced convulsions. In L. van Bogaert and J. Radermecker (eds.), First International Congress of Neurological Sciences. Pergamon Press, London, 1959, 3:613-619. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-39-005 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Korin, Hyman Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Two [preprints] and one reprint. Reprint from The First International Congress of Neurological Sciences, Brussels, 1957, Vol. III EEG, Clinical Neurophysiology and Epilepsy. Peramon Press; London, New York & Paris, 1959 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0a74924969c48b97fad064f4d827441c.pdf e33e0604bf1a53d201e8e551507b5084 PDF Text Text Founded in 1887 by G. STANuIY HALL OFFPRINTED FROM THE AMERICAN JOURNAL OF PSYCHOLOGY EDITED BY KARL M. DALLENBACH UNIVERSITY OF TEXAS AND M. E. BITTERMAN BRYN MAWR COLLEGE E. B. NEWMAN HARVARD UNIVERSITY WITH THE COOPERATION OF E. G. BORING, Harvard University; W. K. ESTES, Indiana University; J. P. GUILFORD, University of Southern California; HARRY HBLSON, University of Texas; E. R. HILGARD, Stanford University; FRANCIS W. IRWIN, University of Pennsylvania; G. L. KREEZER, Washington University; D. G. MARQUIS, Social Science Research Council; GEORGE A. MILLER, Harvard University; W. B. PILLSBURY, University of Michigan; LEO PosTMAN, University of California; W. C. H. PRENTICE, Swarthmore College; T. A. RYAN, Cornell University. THE ROLE OF SET IN THE PERCEPTION OF ‘SIMULTANEOUS TACTILE STIMULI By HYMAN KORIN and MAX FINK, Glenn Oaks, Long Island September, 1959, Vol. LXXII pp. 384—392 Published b The American Journal of Psychology. Department of sychology, University of Texas, Austin. Tex. �Founded in 1887 by G. STANLEY HALL OFFPRINTED FROM THE AMERICAN JOURNAL OF PSYCHOLOGY EDITED BY KARL M. DALLENBACH UNIVERSITY OF TEXAS AND M. E. BITTERMAN BRYN MAWR COLLEGE E. B. NEWMAN HARVARD UNIVERSITY WITH THE COOPERATION OF E. G. BORING, Harvard University; W. K. ESTES, Indiana University; j. P. University of Southern California; HARRY HELSON, University of Texas; E. R. HILGARD, Stanford University; FRANCIS W. IRWIN, University of Pennsylvania; G. L. KREEZER, Washington University; D. G. MARQUIS, Social Science Research Council; GEORGE A. MILLER, Harvard University; W. B. PILLSBURY, University of Michigan; LEO POSTMAN, University of California; W. C. H. PRENTICE, Swarthmore College; T. A. RYAN, Cornell University. GUILFORD, THE ROLE OF SET IN THE PERCEPTION OF SIMULTANEOUS TACTILE STIMULI By HYMAN KORIN and MAX FINK, Glenn Oaks, Long Island September, 1959, Vol. LXXII pp. 384-392 Published by The American Journal of Psychology, Department of Psychology. University of Texas, Austin, Tex. �THE ROLE OF SET IN THE PERCEPTION OF SIMULTANEOUS TACTILE STIMULI By HYMAN KORIN and MAX FINK, Glenn Oaks, Long Island The influential role of ‘mental set’ in determining a subject’s response to a perceptual task has been well documented.] In studies of the perception of simultaneous, tactile stimuli, various patterns of response have been observed which seemed to be the result of a set induced by suggestion. This investigation was undertaken to determine the relation between different conditions of ‘set’ and the frequency and type of perceptual error elicited in tests with simultaneous, tactile stimuli. Recently the advantages of the simultaneous stimulation of different body-parts in tests of tactile perception have been stressed.2 Simultaneous stimulation may elicit perceptual errors under conditions in which successive single stimulations are correctly perceived. When two stimuli are applied to body-parts at the same time, only one stimulus may be reported —an error referred to as 'extinction’; or one stimulus may be perceived correctly and the other mislocalized—an error called 'displacement.’ Occasionally, if a single stimulus is interspersed in the testing-sequence, it may be reported correctly, but an additional, extraneous stimulus may also be reported—an error of ‘confabulation.’ Such errors of extinction, displacement, and confabulation are significantly increased in patients with brain dysfunction. When errors of extinction and displacement occur, they are elicited in a consistent pattern. Thus, on stimulation of the hand and face, the stimulus to the face is usually reported correctly, while that to the hand is mislocalized or not reported. By testing various combinations of bodyparts, an ‘order of dominance’ may be determined in which stimuli to the face and genital areas are most often perceived and those to the hand are for publication September 23, 1958. From the Department of Experimental Psychiatry, Hillside Hospital, Glenn Oaks, Long Island, New York and aided in part by Grant M-927, National Institute of Health, US. Public Health Service. 1]. J. Gibson, A critical review of the concept of set in contemporary experimental psychology, Pryc/aol. 32111., 38, 1941, 781—817; Robert Leeper, Cognitive processes, in S. S. Stevens (ed), Handbook of Evperimeoto] Psychology, 1951, 730-757. 2M. B. Bender, Disorder: in Perception, 1952; M. B. Bender, M. A. Green, and Max Fink, Patterns of perceptual organization with simultaneous stimuli, A.M.A. Arc/a. Neural. é Put/riot, 72, 1954, 233-255; Fink, Green and Bender, The facehand test as a diagnostic sign of organic mental syndrome, Neurol., 2, 1952, 46-58. * Received 384 �SIMULTANEOUS TACTILE STIMULI 385 least often perceived. Between these extremes, stimuli to the shoulder, foot, buttock, breast, back, thigh and abdomen are perceived in a gradient.3 Theories involving factors of rostral dominance,‘ maturation,“ inattention,6 and inherent body-image,7 have been advanced to explain the organization of these perceptual patterns, but no one theory has adequately explained all the facts. We have ascribed significance to the relative intensity of the stimuli and the thresholdvalue in the frequency and the pattern of the 'extinction’ error, when electrical stimuli are applied at threshold and suprathreshold intensities.8 The present study was undertaken to assess the relation between ‘set’ induced by suggestion and errors of 'confabulation’ and 'displacement.’ The specific problem studied is whether an 'inquiry’ into the testing pro— cedure is significantly related to the frequency and type of these errors. Since these errors are most prominent in $5 with cerebral dysfunction, patients undergoing convulsive and subconvulsive therapies were studied. Subjects. The 55 were 61 consecutive psychotic patients referred for electroconvulsive therapy. Their ages ranged between 21—67 yr., mean age being 46 yr. Thirtyseven of them received convulsive therapy; 14 first received subconvulsive therapy and then convulsive therapy; and 10 received subconvulsive therapy alone. The 55 were selected for convulsive or subconvulsive treatment on a random basis by the supervising psychiatrist. Procedure. Two model S-4B Grass square-wave stimulators were synchronized to deliver either single or simultaneous electrical stimuli. An isolation unit was connected with each stimulator to eliminate artifacts and the Output was visually monitored by an oscilloscope. A switch-box was inserted in the circuit to permit independent selection of the various parts of the body. The active and indifferent electrodes for each part were small 3fig-in. steel disks, placed l-in. apart and secured with tape. Bentonite electrode paste was rubbed into the skin of each area before the electrodes were applied. The patient was placed on a couch in a relaxed and supine position. To alleviate undue anxiety, the nature of the testing was described. It was emphasized that a slight tap-like sensation would be felt. The electrodes were then placed on (a) the dorsum of the hands, (b) the mandibular area of both cheeks, and (c) the medial aspect of the calves of the legs. aBender, Green, and Fink, op. .cit., 253-255. 4R. Cohn, On certain aspects of the sensory organization of the human brain: I. A study in rostral dominance as determined by ipsilateral simultaneous stimulation, ]. new. mem‘. Dis., 113, 1951, 471-484; II. A study in rostral dominance in chil1, 1951, 110-122. Neurol., dren, 5 Louis Linn, Some developmental aspects of the body image, Int. ]. Pryc/ooanol., 36, 1955, 1-7. 6Macdonald Critchley, The phenomenon of tactile inattention with specific references to pariental lesions, Brain, 72, 1949, 538-561. 7Bender, op. cit., 77-88. 8 Hyman Korin and Max Fink, Role of stimulus intensity in perception of simultaneous electrical cutaneous stimuli, I. Hillside H0511, 6, 1957, 241-250 �386 KORIN AND FINK Thresholds for the various body-parts were first determined. At a frequency of 0.3 cycles per sec. and a pulse-duration of 50 m.sec., the voltage was increased in uniform increments of 5 v. to the hands and 1 v. to the cheeks every 6.7 sec. (2 pulses) until 5 perceived 100% of the stimulations. After a 10-sec. interval, voltages were decreased until the sensation was no longer reported. After another 10sec. interval, voltages were increased by 1 v. every 6 sec. until the patient again reported 100% of the stimulations. This reading was considered the minimal voltage required to produce threshold-sensation. After thresholds were determined, testing with a random series of 4 single and 6 double simultaneous stimulations followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and the left cheek (homologous stimulation). Stimuli were applied either simultaneously or to one part singly, in a mixed order, for 10 trials. The order of presentation of the heterologous and homologous stimulation was alternated. Failure to report the interspersed single stimuli served as an index that the perceptual threshold had changed. At such times the threshold was again determined, and the 10 test-trials were repeated. Threshold changes, however, occurred infrequently during testing. The patients were tested in two groups: an ‘inquiry' group and a 'no-inqury’ group. The ‘inquiry’ group, consisting of 24 convulsive and 9 subconvulsive 55, was asked the question ”anywhere else?" after each response to a stimulation. No question was asked of the 'no-inquiry’ group, which consisted of 27 convulsive and 15 subconvulsive $5. (The total number of Ss exceeds 61, since 1 S in the 'inquiry’ group and 13 Ss in the ‘no-inquiry’ group were included both in the convulsive and the subconvulsive series.) Electroencephalograms were obtained weekly, on a day following a treatment. These records were quantitatively measured for the degree of induced slow-wave (delta) activity.9 Both the convulsive and the subconvulsive treatments were administered three times weekly on alternative days. Remltr: (1) Errors of confabulation. A response was scored as a confabulation if two stimuli were reported when only a single stimulus was applied. The observations are noted in Table I. In the 'inquiry’ group, confabulatory errors were elicted before treatment from both types of Ss—convulsive and subconvulsive. During treatment, the mean error increased from 0.08 to 0.72 among the ‘convulsive’ Ss and from 0.22 to 0.70 among the ‘subconvulsive’ ones. After treatment, the mean number of confabulations persisted in the ‘subconvulsive’ 55 (1.00) but declined in the ‘convulsive’ ones (0.10); the difference 0.90 being significant at better than the 5% level.10 In the 'no-inquiry’ 9Max Fink and R. L. Kahn, Relation of EEG delta activity to behavioral response in electroshock: Quantitative serial studies, A.M.A. Arc/9. Neural. <5 Psytbidt., 78, 1957, 516-525. 1” The Mann-Whitney ‘U'-test was used to test the significance of these data and those that follow as the scores were not drawn from a normally distributed population. Since the 'U'-test is based on rank-order of the scores, the differences between means are only grossly related to level of significance. �387 SIMULTANEOUS TACTILE STIMULI group, few confabulations occurred at any interval of testing for either the convulsive or the subconvulsive 55. Before treatment, the subconvulsive, ‘inquiry’ 55 made significantly more confabulatory errors than the subconvulsive, ‘no-inquiry’ 55. In a comparison of the ‘inquiry and ‘no-inquiry’ procedures during treatment, the differences were significant both in the convulsive and subconvulsive groups of $5. The differences during treatment are based on the substantial increase in the number of confabulations of the ‘inquiry’ group. After treatment, the confabulations of the convulsive, ‘inquiry’ group decreased to the pretreatment level, and the differences between the convulsive, 'inquiry’ and ‘no-inquiry’ groups were not significant. Though the mean TABLE I MEAN NUMBER ERRORS 0P CONFABULATION No inquiry Inquiry Period convul’ subr convul. sive (N: 24) Pretreatment Treatment Post’treatment * p<o.os; .08 .72 . 10 (N= 9) . 22 .70 I .oo Tp<o.o3; ——————— convul’ subr convul. sive (N: 27) (N: 15) o .11 . 06 o .05 —-— Diff. between inquiry and no! —— inquiry convul’ subr sive convul. .08 .22: .61]L . o4 .65T — Diff. between convulsive and subconvulsive —— inquiry n0r inquiry . 14 .02 . 90* 0 .06 — Ip<o.01. number of errors of the subconvulsive, 'inquiry’ 55 increased after treatment, a comparison between the ‘inquiry’ and 'no-inquiry’ subconvulsive 55 could not be made. Data were not obtained after treatment from the subconvulsive ‘no-inquiry’ 55 because they were transferred to convulsive treatment and were not available for testing. (2) Error; of dirplacement. A response was scored as a displacement if the locus of one of two stimuli was reported correctly and the other incorrectly. Displacements were rarely elicited from the Ss in any of the groups (Table II). The mean number of displacements tended to increase during treatment for the convulsive 55, but the differences from the pretreatment period lack significance. ( 3 ) Error: of extinction. An error was scored as an extinction if only one of two simultaneously applied stimuli was reported. The difference in the number of errors of extinction between the ‘inquiry’ and ‘no-inquiry’ groups was not significant at any period during the course of therapy both for the convulsive and subconvulsive 55 (Table III). During treatment, the mean number of extinctions decreased in all groups. At this period, �388 KORIN AND FINK the difference between the convulsive and subconvulsive, 'inquiry’ 55 was significant. After treatment the errors of all the groups decreased further. (-4) Errors of confaémlatz'on and change: in EEG. An analysis was made of the number of confabulatory errors elicited in convulsive Ss in relation to the degree of electroencephalographic change. ‘Inquiry’ $3 with high degrees of delta activity made significantly more confabulatory errors than inquiry patients with moderate and low degrees of delta activity (Table IV), while few errors were reported by the ‘no-inquiry’ Ss regardless of the change in the EEG. The mean scores of the moderate and low EEG among the ‘inquiry’ 55 was similar to the mean scores of the ‘no-inquiry' ones. N0 EEG slow-wave activity or low degrees of such activity occurred in TABLE II MEAN NUMBER ERRORS Post—treatment * DISPLACEMENT Convulsive Period* Pretreatment Treatment or inquiry . o6 . 09 . 08 Subconvulsive no’inquiry - . 07 . IO . 02 inquiry o .02 . 06 nOrinquiry 0 .01 o Inter! and intrargroup differences are not significant at any period. the subconvulsive 55. As had been indicated, however, the number of confabulatory errors of the subconvulsive group increased significantly during and after treatment. This increase resulted from increasing confabulatory errors in four of the nine patients. Dircmrz'on. Errors of displacement, confabulation, and extinction are elicited when sequences of multiple and single tactile stimuli are applied to various parts of the body. In clinical tests with touch stimulation, these errors are most prominent in patients with cerebral disease.11 Theories which have been advanced to account for the occurrence of such errors have therefore emphasized endogenous factors involving the central nervous system. Numerous studies of the role of set in perception indicate, nevertheless, that the frequency and type of response to a perceptual task may be markedly altered by the immediate aspects of a situation.12 In this study the stimulus-situation has been varied to bring about differing conditions of mental set. The endogenous factors have not, however, been 11Pink, Green, and Bender, op. cit., 46-58. 12Leeper, op. cit, 752-757; Max Pollack, W. S. Battersby, and M. B. Bender, Tachistoscopic identification of contours in patients with brain damage, I. romp. playriol. Pry/301., 50, 1957, 220-227. �389 SIMULTANEO US TACTILE STIMULI neglected and the relation between the effects of diflerent degrees of brain dysfunction has also been determined. In the course of convulsive therapy a marked increase in the number of confabulatory errors is brought about by the ES query: “anywhere else?” which followed every stimulation. Of the convulsive 55 who were asked this question, confabulations were elicited primarily in the group with high degrees of EEG slow-wave activity (marked cerebral dysfuncTABLE III MEAN NUMBER ERRORS 0F EXTINCTION Period Inquiry ———————-——— convul— sive Pretreatment Treatment Postvtreatment * subr convul. (N: 24) (N: 9) I6 2.03 1.37 I . 67 1.14 2. .89 Diff. between No inquiry ————— convulv sive (N= 27) 2. 76 1.71 1.44 sub convul. (N: 15') inquiry and n0vinquiry -——-—~—convulr subv vulsive convul. 2. 37 1.27 —— .60 .32 .07 .70 \ .13 — Diff. between convulsive and subconvulsive N0 inquiry .49 .39 .89* .44 — .48 inquiry p<o.os. TABLE IV RELATION BETWEEN EEG DELTA ACTIVITY AND MEAN NUMBER OF CONFABULATORY ERRORS Degree of Delta activity Group inquiry no inquiry .81 .10 high moderatealow Diff. Signif. (N= 9) (N=2I) .19 (N= 10) .07 (N: 6) .62 .03 p<0.05 N.S. tion) and not in the group with low and moderate degrees (minimal cerebral dysfunction). The importance of the inquiry is emphasized by the consideration that, regardless of changes in the EEG, there was little tendency for confabulatory errors to occur among the convulsive 55 when no inquiry was made. Thus both inquiry and high degrees of EEG delta activity provided the milieu favorable to evoking confabulatory errors in the c0nvulsive therapy 55. Subconvulsive 35 present a different picture. Although virtually no delta activity is induced by subconvulsive therapy, the number of confabulatory errors of four of the nine subconvulsive Ss queried increased substantially during the treatment. Furthermore, while the confabulatory errors of these four subconvulsive Ss persisted and even increased following the course of therapy, the errors of the convulsive Ss queried, in contrast, decreased to the pretreatment level. Patterns of reversible error manifested �390 KORIN AND FINK by convulsive 55 have been reported in the various studies of the effects of electroshock on different types of mental functioning.13 It was expected, however, that confabulations would not be elicited in subconvulsive $5 at is cerebral that earlier observations of view dysfunction in period, any not induced in these patients.14 An explanation for the differences between the ‘convulsive’ and subc0nvulsive ‘inquiry’ 55 is that their therapies had differing effects on the factor of practice. In 'convulsive’ 55, treatment diminished the practiceeffect, including those both with low and high degrees of slow-wave EEG activity. For each test-interval, it was as if the ‘convulsive’ 55 were starting anew. Under these conditions, only $5 with high EEG delta activity manifested a confabulatory set within a single test-period. After the course of therapy, with the disappearance of the delta activity, convulsive 35 were performing at the pretreatment-level. In the ‘subconvulsive’ $5, the set established in the pretreatment-interval was reinforced during each test-period during treatment. Thus the subconvulsive S 5 made even more confabulatory errors after treatment. The results for the subconvulsive group of 55 indicate that certain of them Such brain-function. of alteration without make an errors confabulatory may 53 are apparently influenced by the E and may be described as being suggestible or acquiescent. The failure of the convulsive $5 to establish a set which persisted for prolonged intervals of time, as did the subconvulsive SS, sugS’s If convulsive from effect derived for the basis therapy. a therapeutic gests such mental set, an interpretation as a pathological, regarded are symptoms is particularly appropriate. From the point of view of concepts of mental set, the effect of induced convulsions is to bring about a disruption of maladaptive patterns of behavior. The number of displacement-errors remained the same regardless of whether an inquiry was made. These errors occurred much less frequently than confabulations. During treatment, approximately 30% of the convulsive $5 of both the ‘inquiry’ and ‘no inquiry’ groups responded with at least one displacement. This finding compares closely with the results of 33% with displacements obtained in a study of a similar population of Hyman Korin, Max Fink, and S. Kwalwasser, Relation of changes in memory and learning to improvement in electroshock. Conf. Neurol., 16, 1956, 88-96; Max Fink, R. L. Kahn. and Hyman Korin, Effects of diffuse altered brain function on XV C(mf. of Pryc/ool. Proceed, 1958, 238—239. perception. 1“ Fink, Kahn, and Green, Experimental studies of the electroshock process, Dir. New. $315., 19, 1958, 113-118. ’3 �SIMULTANEOUS TACTILE STIMULI 391 electroshock Ss in which touch-stimuli were applied by the clinical method. Errors of displacement are not a prominent type of error in an electroshock population. With regard to errors of extinction, differences were not significant between the ‘inquiry’ and ‘no inquiry’ groups. The high number of errors of extinction before treatment and the subsequent decrease in errors during treatment, noted in this study, is in contrast to the results obtained with clinical tactile techniques. If clinical methods are used, few errors of extinction are elicited before treatment and there is a marked increase in error during treatment. The results obtained in this study are probably related to the initial difliculty experienced by Ss in perceiving electrical stimuli at threshold and the rapid adaptation to the technique in further testing. These factors play a greater role than the changes induced by the treatment. In initial studies with threshold electrical stimuli, it was believed that a more sensitive test of changes in brain-function than the clinical tactile method could be devised.15 For clinical purposes, however, the perceptual patterns obtained with electrical stimulation lack sufficient discriminability as indices of brain dysfunction. In part, the deficiencies of the method may be ascribed to the necessity for using fixed electrodes and limitations in switching arrangements at threshold. For clinical testing, therefore, simultaneous tactile stimuli applied rapidly in a varied sequence remains the best index of altered brain function.1‘6 Summary and conclmiom. This study of the perception of simultaneously applied tactile stimuli was undertaken to determine the relation between the frequency of perceptual errors to the inquiry made by E. The relations among inquiry, perceptual response, and the degree of brain dysfunction were also considered. In the test-procedure, the threshold (100% point) for square-wave electrical stimuli applied to the hand and cheek of 61 psychiatric patients was determined. Sequences of two simultaneous and single stimuli were applied in a mixed order for the hand and cheek (heterologous stimulation) and both cheeks (homologous stimulation). Heterologous and homologous trials were alternated for each patient. For one group, an inquiry was made following each response to a stimulation, while in a second 15 16 217. Fink, Green, and Bender, op. (13., 46-58. Green and Fink, Standardization of the face-hand test, Neurology, 4, 1954, 211- �392 KORIN AND FINK convulsive 55 treated either made. or The by were was no inquiry group, subconvulsive courses of therapy, at three times a week for 12—20 applications. There was a significant relationship between the frequency of confabulatory errors and the inquiry (suggestion-induced set’) in both convulsive and subconvulsive patients. The confabulatory tendencies of these patients, however, differed greatly. Although the errors for both increased during treatment, errors decreased after treatment for the convulsive differfurther. increased The subconvulsive but in the errors group group, ences between 'inquiry’ and 'no inquiry’ groups with regard to errors of extinction or displacement were insignificant. In 'convulsive-inquiry’ 55, the confabulatory errors of those with high degrees of EEG slow-wave activity were significantly more frequent than those with a low or moderate degrees of slow wave activity. The results of this study lead to the following conclusions: (1) In tests with simultaneous electrical tactile stimuli the number of confabulatory errors is related to an induced set suggested by ES inquiry. (2 ) The number of confabultory errors is increased in $5 with braindysfunction in relation to an inquiry, but may also be induced in patients without brain-dysfunction who are acquiescent and susceptible to suggestion. (3) The frequency of errors of displacement or extinction is not related to the ‘inquiry’ procedure. ��”era Role of Stimulus Intensity in Perception of Simultaneous Tactile Stimuli Hyman Karin, H!» on. and max From ELY. fink, MOD. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Institute 10-9 ’57 of the National Institute of Mental Health, National of Health, 11.5. Public Health Service. grant M—927 .M/J- I 44/ f7 �III: Role of Stimulus 10/9/57 Intensity in Perception of Simultaneous Tactile Stimuli and his coIn the course of the extensive investigations by Bender stimuli, workers (1, 2, 3,) into the perception of multiple simultaneous of two stimuli the pattern of failure of subjects to accurately report one Since led to a concept of an "order of dominance" in cutaneous perception. dominance to biologic and then, the relationShip of the observed pattern of been the subject of psychiatric concepts of body image and body scheme has considerable speculation (h, 7, 8, 1h). The interrelationship of body areas was initially clearly demonstrated was noted in simultaneous tactile tests of face and hand (2) in which it that the stimuli to the hand were frequently not reported or mislocalized. inference These phenomena of "extinction" and "displacement“ led to the that cheek area stimuli were "dominant" to reports, Bender, Pink inance for and Green (3, 10, tactile stimuli in ll, fell stimuli. In subsequent 12) described a pattern of dom- which the face and the primary genital areas were the most perceptive or dominant body dominant; and the shoulder, hand areas; the hand was the foot, buttock, breast, back, thigh, between these extremes in a mild gradient. least and abdomen These observations were made were most in normal adults and children and psychiatric patients, but the major portion clearly discerned in patients with brain disease. Indeed, of the data relates to a group of patients with severe diffuse brain dys- function under observation in a general psychiatric hospital. Bender, The basis for these phenomena is unclear. In their review, Green and Fink (3), after considering hypotheses ascribing significance to and neurophysiologic anatomic, psychophysiologic, genetic, environmental �i "no one theory‘adequately explains the organization factors, conclude that of .2- this pattern. Learning and maturation are probably factors, but appears to be mostly inherent." brain disease and normal young it (h, 5), in studies of patients with Cohn children, emphasized the rostral order of significance to "an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain." He noted specifically, also, that this pattern was primarily associated with "the dominance and ascribed over-all sentient function of the brain." A elaboration of a maturational more extensive and developmental explanation of the order of dominance was proposed by Linn (1h). Taking the infantile patterns of sucking and feeding as a model, Linn ascribes primitiveness in the development of the body image; the dominant role of the genital area to the intensity of pleasurable sensation that the infant elicits from masturbation; and the subordinate position face dominance to role as an exploring and tension-relieving appendage holds second place in awareness to its stimulation of the more of the hand to it wherein exciting A its its mouth and genitalia. neurophysiologic view was advanced by Critchley (6, 7), who after expressing a preference for the term "tactile inattention" instead of "extinction," emphasized the rostral order of dominance. He stated that "strong stimulation of the healthy side suppresses the attentuated sensations on the impaired side," patients is probably no more than an which may be demonstrated besides the tactile - that "tactile inattention in parietal and concluded instance of local neglect or disregard, at times in many other spheres of consciousness whether motor, visual or spatial." �.3... A psychophysiologic explanation workers (10, 11), who found no tactile threshold for was eschewed by Bender and relation between the order of touch or pin prick. (8), however, insisted that these patterns an overcome by were only apparent when They hand stimulus by a stimulus four stimuli to the hand. dominance and Denny-Brown, Meyer and Horenstein alteration or loss of two-point discrimination. that the extinction of the his co- The dominance there was further demonstrated to the leg could be of the cheek to the hand could not, however, be altered by ten stimuli to the hand. following data further emphasizes psychophysiologic factors. These The studies represent the initial report of the technic of simultaneous hand of tactile stimulation tests to the alteration in brain function induced measurment of the In the course of of an investigation into the application problem of by electroshock therapy. this study electrical stimuli were applied to the cheek and psychiatric patients. Stimuli were either at threshold or supra- threshold levels. Two (a) aspects of the data are presented: The effect of alteration of relative strength of stimulus in the order of dominance (b) :3va JECTS The on face-hand tests; and Relation of perceptual thresholds to the order of dominance. ms I-‘IETHOD: subjects were electroshock therapy. mean age was 3h consecutive psychiatric patients referred for The range of their ages was between 21 and 65 and the h5. Eleven patients were diagnosed as involutional melancholia, thirteen as manic-depressive, depressed, eight as schizophrenia,and two as psychoneurosis mixed type. All testing was done prior to a course of electro- �.11.. shock therapy and no patient had clinical or EEG evidence of altered brain function. Two model S—hB Grass squareswave stimulators were synchronized to deliver either single or unit was connected was monitored two simultaneous electrical stimuli. to each stimulator to eliminate artifacts visually by an oscilloscope. A An isolation and the output switch bdx inserted in the circuit permitted independent selection of the various body parts. An active and an indifferent electrode required for each body part were small 3/8" steel discs placed 1" apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. patient was placed on a couch in a relaxed and supine pbsiticn.. To alleviate undue anxiety the nature of the testing was described. It was emphasized that only a slight tap-like sensation would be felt. The electrodes The were then placed on (1) the dorsum of the hands, (2) the mandibular area of both cheeks and (3) the medial calf area of the legs. In the testing procedure, thresholds for the various first determined. At 50 body parts were a frequency of .3 cycles/second, and a pulse duration of milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, ceived 100 percent of the stimuli. Increments of hand and increments of 1 5 until the subject pervolts were applied to the volt to the cheeks. After a ten second interval, until sensation disappeared.' After another ten second interval, the voltage was gradually increased by 1 volt each 6 seconds until the patient reported 100 percent of the stimuli again. This reading was the voltage was decreased considered the minimal voltage required to produce threshold sensation. �-5- and After the thresholds were determined, testing with a series of single double simultaneous stimuli followed. The body parts tested were the right and hand and left left cheek (heterologous stimulation) and the cheek homologous stimulation). taneously or one part singly in a Both mixed order parts right cheek were stimulated simul- for ten trials for each of the iollowing conditions:(l) threshold (2) suprathreshold (10 percent above the threshold), (3) one body part at suprathreshold and the other at threshold and (h) the reverse (3). The order of presentation of conditions (1) and (2) for conditions (3) was alternated for different subjects and (h). Similarly the order of presentation of the heterologous logous stimulation was and the same was done and homo- alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. occurred, stimulation was increased until a and 10 new threshold When this change was determined trails were started anew. RESULTS: A. Threshold Values. The threshold stimulation for perception cheeks and legs. (Table for the hands, was determined I). TABLE Mean Thresholds and I Standard Deviations of Body Parts Right Hand Hand Left Right Left 7.85 29.25 22.35 2h.50 19.52 h.86 1h.88 '13.60 13.99 Left Cheek Cheek Threshold (volts) 6.76 Standard Deviation h.h7 Mean Right Leg Leg ' 13.6h �~6The threshold values for the hands and legs are 3 to h times higher than the thresholds for the cheeks. While the threshold values in the legs are less than in the hands, these differences lack statistical significance. Variability of the threshold is considerably greater in the hands and legs, than in the cheeks. There is virtually no overlapping of thresholds, however, where the cheeks and the hands are concerned. B. Extinction Patterns: difference between the The or the left number of extinctions of the right cheek on stimulation of both parts with hand either threshold or suprathreshold stimuli was not significant (Table II). Also, when both cheeks were stimulated with either threshold or suprathreshold stimuli, there were no differences in the number of extinctionszhzeach cheek . (Table III). In contrast to these observations, stimulating one body part with a suprathreshold stimulus and the other at threshold, resulted in a significant increase in the failure to report the body part stimulated at threshold. Thus the cheek was dominant over the hand, or the hand was dominant over the cheek depending on the body part to which the stronger stimulus was applied (Table II). Altering the relative strength of the stimuli applied to the cheeks resulted in a similar predictable change in the pattern of dominance (Table III). Further analysis of the data in Table II indicates that the hand was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.0h) for the threshold - suprathreshold condition. This tendency is also evident at suprathreshold. If it is considerefi when both that the parts were stimulated mean threshold for the hands �mua mama mmbn mmma nwmmw eUHmmwowa mmeOWmmw ma mmuo m& ma mcwuwdwwmmwowa mfi mum mum ofimmw oummw fin pa mcmumwuwmmuowm mcvumdunmmuowa efiflmmUowa awnmmwowa Kama counudwoum ow .wm m.wo H.0m zwmb H.ww nummw mxdwunawoum ow mxaqudMosm afiammwowo om saws ow H.wm .mm .mm abwbm mum H.mm cummw -mma mmuo HH madusodwoum mun mcwwpdwummwowa mmum mow v.0: m.om .m4 .OH <muwwnm dwwwmwmuom mwwe:Hdeou z.m. wAAuow vAnuow 2.m. mwmswwwombom �Emma abomw Hmwfi wear wumue wows avummuowm drummvown ma mcwuwawuwmwowm mchm&UHmmwowm owmmw ofimmw numGWm owwmwm ma ma QUGmW mum mw ma ma grammwowa meU& mum mcvum: awnmmuowm on .om .wm .Hm .ww saws nonmwdHOUm Hmwd mxwucnduoam Kama Qummw ow mxauuodwoum awwmmwowm on ow 3mm: avwbm H.mm .H# .w4 .rw mum mumwfi . mxwwannwoum md woaw.nwmme owmmw mcwumauammUowo won <muewum H.mm .mm .Hm .om wanmuwuom mdwstwmawou u‘AmoH v_Auom z.m. z.m. mumsuwwnmbnm HHH - �-7- is approximately 30 volts, while for the the difference in incidence of extinction stimulation was set at ten percent may be explained. above the threshold stimulus was therefore increased by 3 is cheeks the threshold volts 7 volts, Suprathreshold value. The hand and the face stimulus by only increase, although proportionately equivalent, appears to have given greater relative strength to the hand 1 volt above the threshold value. Such an stimulus. C. Incidence of Extinction: Regardless of pattern, the mean total of the number of extinctions heterologous body parts were stimulated at threshold than when these parts were stimulated with suprathreshold stimuli (Table IV). For these same conditions of stimulation the differences between the mean was greater number of when extinctions obtained on homologous stimulation of the cheeks lack statistical significance but the results are in the direction that a greater number of extinctions occur when two body which indicate parts are stimulated at threshold (Table IV). The failure to obtain a significant difference in the latter instance is partly due to the fact that relatively few extinctions are elicited total when homologous number of parts are stimulated. These findings on the extinctions are in agreement with previous observations (2). �2. TABLE Mean IV of Combined Number of extinctions For Varying Conditions of Threshold and Suprathreshold Both Parts at Threshold A - Cheek B — Band A - Left B - Right % Cheek Cheek Both Parts SuprathreShold 3.11 1.63 .85 .56 Differences between the at mean number of % Stimuli A B - SuprathreShold - Threshold A B 1.68 1.31 extinctions at threshold - Threshold — 2oh3 1.10 and the other three conditions of stimulation are significant for the cheek and hand but are insignificant for both cheeks. SupraThreshold �-8DISCUSSION: pattern of extinction following stimulation.with threshold and suprathreshold stimuli has been determined. In contrast to the findings The of Bender, link and Green (2), face stimuli were not reported more frequently than hand stimuli when either simultaneous threShold or suprathreshold stimuli were applied. Under these conditions, neverthless, it is clear that the pattern.of extinction for any the body parts can be readily altered by stimulus varying the relative strength of the stimuli. Thus,a suprathreshold applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimuli intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand is due to an inherent factor, perceived body image, rostral dominance, developmental principle, or a learned factor, are not supported by these observations. If any of these been elicited factors were involved, a pattern of face when dominance should have the hand and cheek were stimulated with equivalent stimuli at threshold and suprathreshold intensities. Although, more recently, Bender (3) has advanced an inherent factor theory, he previously attributed the extinction phenomenon to differences in the thresholds of the various body parts and to the intensity of the stimulation used (1), strength of the The finding. in this study, that differences in the simu taneous stimuli can supports a stimulus intensity hypothesis. alter the pattern By of extinction inference, differences in threshold also play a significant role. That an intense stimulus elsewhere could raise the pain threshold as This much as 35% has been denonstrated by Hardy, Wolf and Goodell (13). �-9:- effect of a relatively intense stimulus on the threshold of another stimulus has also been found by investigators using other stimuli (8, 9). The problem still remains, however, how it is that a pattern of dominance, particularly of the hierarchy determined by Bender and his coworkers, may be elicited when presumably equivalent stimuli are applied by touch of hand. The results of this study suggest an explanation. Stimuli of differing intensities are required to elicit a threshold sensation for various body parts. ’Uhen these stimuli are increased 10 percent, the resultant stimuli are proportional and are perceived as equivalent. In contrast, in clinically touching two body parts, the stimuli are disproportionate relative to the threshold value although approximately of equal intensity in their application. differences in threShold for the hand and cheek, the tactile to the cheek stimulus/is proportionately more above the threshold than the stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and Because of the has been considered "dominant." A threshold hypothesis was rejected (3) on the basis that the thresholds for pressure and pain do not strictly corre5pond to the dominance order elicited by the double simultaneous stimulation tests. Most difficult to reconcile is Von Frey's finding that the pressure threshold obtained by Von Frey (16) of the glans penis, which is second in dominance rank only to the cheek in tested, is 111 grams per square millimeter; While the hand, whichzislll least dominant, is only 12 grams per a group of ten body parts the threshold of square millimeter. Unfortunately, thresholds in the genital area for male and female have seldom been determined. Von Frey's list of thresholds (16) is based on a single subject. His more detailed observations (17), however, indicate that �.10- is virtually there no pressure sense the perception of pain, warmth, and in the glans penis or clitoris, although cold is well developed. It is quite with touch possible that the punctate pressure threshold does not correlate there the genital area is concerned but that instead some other sense or combination of senses Thresholds and is involved. for the dorsum of the hand and the cheek obtained by Von Frey other investigators indicate that the cheek is considerably more sensitive in agreement with the thresholds obtained in this study. In a recent study of thresholds at various body sites Sigel than the hand. These findings are dorsum of the (15) reported that "leg areas including thigh and ankle, also definite tendency for higher thresholds. Scalp, The anterior chest temple, forehead and face tended to have lower thresholds. lower thresholds. arm and anterior wrist areas showed a tendency for and hands and the palm showed a upper Neck areas, ment there Bender and abdomen and upper back showed no is no disagreement with definite trend." In this state- the order of dominance as determined by his coworkers. the experimental results obtained here, it is proposed that the may dominance hierarchy elicited under the conditions of simultaneous testing of the be explained in rational terms on the basis of the relative strength From stimuli and the area stimulus theoretic constructs:n threshold, without the invocation of other �-llSUM-JURY: Using square wave the hands, cheeks, and electrical stimuli, the threshold for perception in calves were detennined in 3h psychiatric patients. Simultaneous stimuli were applied in random sequence to combinations of cheek and hand and both cheeks, at threshold, suprathreshold and combinations of threshold and suprathreshold intensities. MWSmmmmwsmmwdmcrfimhwmwswmmmwddmmmwwm the differences between the number of extinctions in either part were NOT significant. With stimuli of unequal intensity, however, (one stimulus at threshold and one suprathreshold) there was a significant increase in the failure to report the threshold stimulus. The total number of extinctions is greater with threshold, than with suprathreshold stimuli; ans greater in heterologous than in homologous patterns of stimulation. LOPELEQ-‘Pist The tests may clinically observed order of dominance in simultaneous tactile he explained by psychophysiological phenomena without resort to theoretic constructs. Differences in the hireshold of perception in various body parts provide the basis for the observed pattern of errors on simultaneous tactile tests at suprathreshold levels, �Biblio ranhv 1. W“ Bender, M;B. (1952): Disorders in Perception Sprin Bender, HgB., Fink, M; and Green, M.A. (1951): Patterns in Perception Tests of Face on Simultaneous field, Illinois. and Hand, A.M.A: Arch. Neurol. & Psychiat. éé} 355-362. 3. Bender, H.B., Green, H.A. and Fink, M. (l95h): Patterns of Perceptual Organization with Simultaneous Stimuli, EgyChiat., Neurol. n lg: 233-255. Cohn, R. (1951): On Certain Aspects of Human A.M.A. Arch. Brain: A the Sensory Organization of the Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation, J. Nerv: Ment. Dis. 113: h71~h8h. S. Cohn, R. (1951): On Certain Aspects of Sensory Organization of the Brain: II — Human A Study in Rostral Dominance in Children, Neuroloav, 1; 119-122. Critchley, n. (1953): Critchley, M. The Parietal Lobes, a Go. (19h9): Phenomenon of Tactile Inattention with Special Reference to Earietal Lesions. Denny-Brown, London: Edward Arnold 3., Meyer, J.S: grain, 12: 538-561. and Horenstein, S. (1952): The Significance of Perceptual Rivalry Resulting from Parietal Lesion, grain, 15; h33~h7la 9. Dunoker, K. (1937): Some Preliminary Exneriments on the Mutual Influence of Seine, Psychpl. Forsdh, g1: 311-326. 10. Fink, M. and Bender, H.E. (1953): Perception of Simultaneous Stimuli in Normal ChilCren, 1-Ieurologq, ;: 27~3h. Tactile �Bibliograghv 11. Fink, H., Green, M.A. and Bender, M.D. (1953): Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects, gig. , Q1: . LLB-449 12. Fink, M., Green, M.A. and Bender, M.B. J. Merv. & Ment. (l952):The Face-Hand Test as a Diagnostic Sign of Organic Mental 85ndrome, Neurologz, g; hé-SB. 13. Haroy, J.D., wolf, H.S. and Goodall, H. (19h0): Studies on Pain. New Method for measuring Pain Threshold: Observations Summation of Pain, J. Clin. Invest., l2: on A Spatial 6&9-658. Linn, L. (1955): Some Developmental Aspects of the Body Image, 223! J. Eszchoana1., 2g; 1-7. Sigel, H. (1952): Cutaneous Sensory Threshold Frequency Squareédave Current: Site II. - The Stimulation with High Relationship of and Skin Diseases to the Seesory Threshold, Body J. Invest. Derm., lg: hh7-h51. 16. Von Frey, E. (189M): Beitrage zur Physiologie des Schmerzinns, Egg. Sachs. Ges. 17. diss., Von Frey, M. (1895): gé: 185-196 and 283-296. Beitrege znr sinnephysiologie Haut, Ber. Sachs. 99g. ‘L;iss., £2: 166-18u. �Karin: Amer. J. Psychol. VI: 8-12-58 Role of Suggestion-Induced Set in the Perception of Simultaneous Tactile Stimuli Hyman Korin.fh.D. and max Fink M.D. From the Department of Experimental Paychiatry, Hillside Hospital, Glen Oaks, L.I., (in part) by grant 14-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Read at the Eastern PSydhological AsSOCiation, Philadelphia, April 11, 1958. Aided N.Y. �Role of Suggestion-Induced Set in the Perception of Simultaneous Tactile Stimuli influential role of "mental set" in determining subject response to a perceptual task has been well documented (1). In studies of the The perception of simultaneous tactile stimuli, various patterns of response were observed which seemed to be the result of "suggestion-induced set." This investigation was undertaken, to determine the different conditions of "set" relation between and the frequency and type of perceptual error elicited in tests with simultaneous stimuli. Recently the advantages of the simultaneous stimulation of body parts in tactile perceptual tests has been stressed (2). simultaneous stimulation may elicit The technique of perceptual errors under conditions in which successive single stimuli are correctly perceived. 'are applied to body parts at the same time, for example, only may be reported - may be perceived correctly and the other'mislocalized an error referred to as "extinction"; or "displacement." Uccasionally, if testing sequence, these stimuli - stimuli two stimulus one one stimulus error called single stimuli are interspersed in the may be an correctly reported, but an additional, extraneous stimulus, (referred to as a "confabulation") Such ‘When errors of extinction, displacement, may also and confabulation are be reported. significantly increased in patients with brain dysfunction. 1. R. Leeper, Cognitive processes, in 5.5. Stevens, Handbook of Experimental Psychology, 1951. 2. M. B. Bender, Disorders in Perception, 1952; Bender, Patterns of perceptual organization with simultaneous stimuli; A.M.A. Arch. Neurgl. & Psychiat. M.A. Green and M. Fink, 1g: 195h, 233-255; Fink, Green and Bender. The face hand test as a diagnostic sign of organic mental syndrome, Neurcl. g: 1952, h6—58. �.2errors of extinction and diaplacement occur, they are elicited in a consistent pattern. Thus, on stimulation of the hand and face, the stimulus to the face is usually reported correctly while that to the hand When is mislocalized or not reported. parts, an "order of and testing various combinations of dominance" may be described genital areas are often perceived. By in which body stimuli to the face most often perceived and those to the hand are least stimuli to the shoulder, foot, are perceived in a gradient (3). Between these extremes, buttock, breast, back, thigh and abdomen Theories inyolving factors of rostral dominance (h), maturation (S), inattention (6), and inherent body image (7) have been advanced to explain the organization of these perceptual patterns, but no one theory has adequately explained all the facts. Previously (8) we have ascribed significance to the relative intensity of the stimuli and the threshold value in the frequency and the pattern of the "extinction" error, when electrical stimuli are applied 3. Bender, h. Green and Fink, 02. cit., 233-255. certain aspects of the sensory organization of the brain. I: A study in rostral dominance as determined by ipsilateral simultaneous stimulation, g, Nerv. Ment. Dis. Eli: 1951, h7l-h8h; II: A study in rostral dominance in children, 32339;. I, 1951, 110-122. R. Cohn, On human S. Linn, Louis: Some developnental aspects of the body images, Int. Jour. Psychoanal. 2gp 1955, 1-7. 6. Critchley, The phenomena of tactile inattention with specific references to parietal lesions, Brain 1;, l9h9, 538-561. M. _ 7. Rnder, 8. Op. Cite, 77-88. Fink, Role of stimulus intensity in perception of simultaneous electrical cutaneous stimuli, J. Hillside Hosp. H. Korin and M. Q, 1957, 2&1-250. �.3threshold and suprathreshold intensities. The present study was undertaken to assess the-relation between "suggestion-induced set" and errors of confaoulaticn and diSplacement. The Specific problem studied is whether in the testing procedure is significantly related to the frequency and type of these errors. Since these errors are most prominent an "inquiry" in Subjects with cerebral dysfunction, patients undergoing convulsive and subconvulsive therapies were studied. Subjects: The subjects were 61 consecutive psychotic electroconvulsive therapy. patients referred for Their ages ranged between 21 and 67 and the ho. Thirty-seven patients received convulsive therapy, While fourteen first received subconvulsive therapy and then were transferred to mean age was convulsive therapy. Ten patients were treated with subconvulsive therapy only. Patients were selected for the convulsive or subconvulsive treatment on a random basis by the supervising psychiatrist. �Procedure: Two model S-hB Grass squaredwave stimulators were synchronized to deliver either single or simultaneous electrical stimuli. An isolation unit was connected with each stimulator to eliminate artifacts and the output was visually monitored by an oscilloscope. A switch box was inserted in the circuit to permit independent selection of the various body parts. The active and indifferent electrodes for each body part were small 3/8" steel discs, placed 1" apart and secured with tape. Bentonite electrode paste was rubbed into the skin of each area before the electrodes were applied. The patient was placed on a couch in a relaxed and supine position. alleviate undue anxiety the nature of the testing was described. It was emphasized that a slight tap-like sensation.would be felt. The electrodes To were then placed on (a) the dorsum of the hands, (b) the mandibular area of both cheeks and (c) the medial aspect of the calves of the legs. Thresholds for the various body parts were first determined. At a frequency of .3 cycles per second and a pulse duration of the voltage was increased in SO millbeccnds, uniform increments of five volts to the hands volt to the cheeks every 6.7 seconds (2 pulses) until the subject perceived 100 per cent of the stimuli. After a ten second interval, voltages and One were decreased second until the sensation was no longer interval, voltages were increased patient again reported 100 by 1 reported. After another ten volt every 6 seconds per cent of the stimuli. This reading until the was considered the minimal voltage required to produce threshold sensation. After thresholds h single were were determined, and 6 double simultaneous the right hand and left testing with a random stimuli followed. In body series of parts tested cheek (heterologous stimulation) and the right �-scheek and left cheek (homologous stimulation). Stimuli were applied either simultaneously or to one part singly, in a mixed order for ten trials (Table homologous I). The order of presentation of the heterologous and stimulation was alternated. TABLE I Failure to report the interSpersed single stimuli served as an index that the perceptual threshold had changed. Such a change occurred infrequently, and at these times the threShold was again determined, and the 10 testing trials were repeated. patients were tested in The "no-inquiry" group. The and nine'subconvulsive two groups: an "inquiry" group and a "inquiry“ group, consisting of 2h convulsive subjects, was asked the question-"anywhere after each responseto a stimulation. No question "no-inquiry" group, which consisted of 27 convulsive and was asked else" of the 15 suboonvulsive patients. This total exceeds 61, since one patient in the inquiry group and thirteen in the no-inquiry group were included both in the convulsive and the subconvulsive series. Electroencephalograms were obtained day following a treatment. in each patient weekly These records were quantitatively for the degree of induced leW'wave (delta) activity (9). on the meaSured Both the convulsive and the subconvulsive treatments were administered three times weekly on alternate days. 9. Pink and R.L. Kahn, Relation of EEG delta activity to behavioral reSponse in electroshock: Quantitative serial studies, A.M.A. Arch. Neurol. & Psychiat. 78 M. 1957: 516‘525 o �TABLE I Order of Presentation of Stimuli Right Hand Left Cheek Right Cheek Left Cheek 'Right hand-Left cheek Right cheek Right hand Right cheekéLeft cheek Left cheek Left cheek Right hand-Left cheek Right cheek Right hand-Left cheek Right cheek-Left cheek Left cheek Right cheek-Left cheek Right hand-Left cheek Left cheek Right hand Right cheek-Left cheek Right hand-Left cheek Right cheek Right hand-Left cheek Right cheek-Left cheek �“HW1 Results: A. two Confabulation Error: stimuli were reported A reaponse was scored as a confabulation when only a single stimulus was applied. if The II. observations are noted in Table TmBLE Convulsive vs Subconvulsive: II Confabulatory errors were elicited pretreatment both in the convulsive and the subconvulsive patients. During treatment the errors increased with approximately the same frequency. The in the convulsive treated patients and from .22 to .70 in the subconvulsive treated patients. Post-treatment, mean error increased from .08 to .72 however, the mean number of confabuLations persisted in the subconvulsive patients (1.00) but declined in the convulsive patients (.10). The difference in number of errors between the convulsive and subconvulsive groups is significant post-treatment, but not in either the pretreatment or treatment periods. In the no-inquiry group few confabulations occurred at any interval of testing for either the convulsive or the subccnvulsive patients. Inquiry vs No-Inquiry: While the differences in the mean number of errors reported by the subconvulsive and the convulsive patients lacks 'significance pretreatment, that between the subconvulsive inquiry differed significantly from the subconvulsive no-inquiry patients. During treatment the number df confabulations increased, and this difference in a comparison of the inquiry and is significant the no-inquiry procedures, both in the convulsive and subconvulsive groups. These differences during the treatment interval are based on the of the inquiry group. substantial increase in the number of confabulations �Hangs». Wmdgmgmfi womduagmggd Ex» % dwm awm mmdm * .1. 6 u w .8. .8. .8 A A km .8 Zn»: conqspmw<m A Huncwnw Foo mum mumswwwomsom. .8 moouwm. .8 .mm .E o 2% mucoouafiwmw<w 3M55L23H¢3m% duo awm mm¢m ac: .8 swwow zaps zug oon<deH<m mwwwmwmsomm domd zusvoa zongncwuw mowwoz. AHNV n cwwtmmu swm .om 0 ow zuwm Hpmnm mscoonqswmw<m Iml mwbnm HH smmsm mvuPHmm oouwmcspmdwob awn muw ad: we onww .8 wome .3 .0m Hunmwuq. oouafiwqum ZonHunnMHw Upwwmwmbom «ama wuwowm .3. wm mou mwommpw % dmmma u .0m .3 Hupswflw. ZouHunswww dwawmuobom mzwoqachqum mwmbwmwombom HmHmdma on 5. is Hmbw ac wow enamw Hm4mH .8 * éwmmm ow om .8 .E Hunzwaw wawmambom mayooudcpmw<m oon<¢wqumu mguooudcwqum oos<sHmH4m. - u .oo o zoquncwuw uwwmmambnm �-9After the course of therapy, the confabulations of the convulsive inquiry patients decreased to the pretreatment level, between the convulsive inquiry and no-inquiry groups not significant. In contrast, the mean number and differences at this time were of errors of the subconvulsive inquiry patients increased. Data for the post-treatment subconvulsive no-inquiry group was not available as these patients to convulsive treatment A and were not were usually transferred available for post-treatment tests. comparison between the inquiry and no-inquiry subconvulsive patients post-treatment cannot be made. B. Displacement Error: one of two stimuli was reported A reSponse was scored as a displacement correctly and the other was if mislocalized. rarely elicited in any of the greups (Table III). of displacements tended to be greater, however, during Displacements were The mean number treatment for the convulsive patients but the differences from the pretreatment interval lack significance. �—10‘TABLE mean Number III of Digplacement Errors Convulsive No-Inqyiry Inquiry Subconvulsive No-Inquiry Inquiry Pretreatment .06 .07 0 Treatment .09 .10 .02 .01 Post-Treatment .08 .02 .06 0 Inter and intra group differences are not significant 0 at any interval. �-llC. Extinction Error: An error one of two simultaneously applied stimuli extinction error between the inquiry at any scored as an "extinction" was reported. was if only difference in The and no-inquiry groups was not significant interval during the course of therapy both for the convulsive and subconvulsive patients (Table IV). During treatment, the mean number of extinctions decreased in all groups. this interval, the difference At between the convulsive and subconvulsive inquiry patients was Postetreatment the errors of D. Confabulation number Error all and significant. the groups decreased further. EEG Change; An analysis was made of the of confabulation errors elicited in convulsive patients in relation Inquiry patients with high to the degree of encephalographic change. degrees of delta activity made significantly more confabulation errors than inquiry patients with moderate and low degrees of delta activity. (Table V), while few errors were reported in the no-inquiry patients regardless of the degree of and low EEG inquiry groups EEG was change. The mean similar to the score of the moderate mean scores of the no-inquiry ‘ patients. No EEG slow wave subconvulsive activity or patients. number of confabulation significantly during low degrees of such occurred activity/in the However, as had previously been indicated, the errors of the subconvulsive group increased and after treatment. increasing confabulation errors in four This increase resulted from of the nine Pqu-u-u-Iu-o-O-u ‘- patients. �eaflsma Wmfimfifia womdlawmmdsmuw H.w< PS who 2n»: ooudswmwdm .x. annwnw 6A. .mw FE ”7% zuw mfidaobdspmwdo 00“ :wms H.rr ffi mid Zamq ZdSUmH oosagHmH<m ow zoquncHHw wabm I VB PS spun mdeHOdHob zuHm mscoos<¢wmw<w H< muaoum .ON .3 .8 Huncwuwu oon<cwmw<m ZOIHsnsHHw mHHmmHmbnm ZOIHSQsHHwHsnzwnw. t .S .3 wawmnmuom mcvaon<cwmw<m . bHHonmbom mzvooudcwmw<m .rw .mw .5 oosdswquou Hangwaq * I .E .3 uwmwmwmbow mcvoob<¢wmw<m zongnsqu aoadcwmwdm. �.13.. TABLE V Relation Between Degree of EEG-Delta Activity and Number of Confabulation Errors Mean Degree of Delta Activity High Mean Number Confabulation Errors ) ) ) Inquiry No Inquiry .81 (N.=9) .10 (N=21) Mederete-Low Difference .19 (Halo) .62 .07 (N=b) .03 Significance p 4 .05 N.S. �Discussion: elicited Displacement, confabulation and extinction errors are sequences of multiple and single tactile stimuli are applied to tests with touch stimulation, these errors are In clinical when body parts. most prominent in patients with cerebral disease (10). Theories Which have been advanced to account for the occurrence of such errors have therefore emphasized endogenous factors involving the central nervous system. That the fre- quency and type of response to a perceptual task may be markedly altered by the immediate aspects of a situation is indicated by the numerous studies of the role of set in perception (11). In this study the stimulus situation has been varied to bring about differing conditions of mental set. factors have not been neglected, and the relation between the effects of different degrees of brain dysfunction has also been However, the endogenous determined. In the course of convulsive therapy a marked increase in the number of confabulation errors is brought about by the examiner's query of "anywhere else?" following each stimulation. of the convulsive patients who were asked the question, confabulations were elicited primarily inthe group with high degrees of EEG 81 w wave activity (marked cerebral dysfunction) and not in the group with low and moderate degrees (minimal cerebral dysfunction). The importance of the inquiry is thus enphasized by the consideration that activity, there was little tendency for confabulation errors to occur in convulsive patients when no inquiry was regardless of changes in EEG 10. Fink, Green and Bender, op. 11. Leeper, op. M. Pollack, cit., - cit. , 146-58. . .S. Battersby and M.B.Bender, Tachistoscopic identification of contours in patients with brain damage, J. Comp. Physiol. Bszghol. g9, 1957, 220-227. made. �.15Thus both inquiry and high degrees of EEG delta activity provided the milieu faVOrable to evoking confabulatory errors. patients present a different picture. Although, virtually delta activity is induced by subconvulsive therapy, the number of Subconvulsive no confabulation errors of four of the nine subconvulsive patients queried increased substantially during the treatment. Furthermore, While the confabulation errors of these subconvulsive patients persisted and even increased following the course of flierapy, those of the convulsive patients queried, in contrast, decreased to the pretreatment level. Patterns of reversible decrement manifested by convulsive patients has been reported WW studies of the effects of electroShock in the of mental functioning (12). However, it was on different types expected that confabulations elicited in subconvulsive patients at any interval, in.view of earlier observations that cerebral dysfunction is not induced in these would not be patients (13). An explanation for the differences between the convulsive and convulsive inquiry patients is that their therapies had differing sub— effects- the practice factor. In convulsive patients, treatment diminished the practice effect in all subjects, including those both with low and high on degrees of slow wave activity. Fbr each test interval, it was as if the 12. H.Korin, M. Fink and S. Kwalwasser, Relation of changes in memory and learning to ercts improvement in electroshock, lg, 1956, 88-96; M. Fink, R.L. Kahn andon of diffuse altered brain function of Psychol. Proceed., 1958, 238-239. EE’Conf. perception, Conf. Neural. 13. Fink, R.L. Kahn and M.A. Green, Experimental Studies of the electroshock process, Dis. Nerv. 528. 12, 1958, M. 113-118. �-16convulsive patients were starting anew. patients with high EEG Under these conditions only delta activity manifested a confabulatory set within a single test period. After the course of therapy, with the disappearance of the delta activity, convulsive patients were performing at the pretreatment level. In the subconvulsive patients, the set established in the pretreatment interval test period during treatment. more confebulatory The may make Such was re-enforced during each Thus the subconvulsive patients made even errors post-treatment. results for the subconvulsive group indicate that certain patients confabulation errors without an alteration of brain function. patients are apparently influenced as being suggestible or acquiescent. by the examiner and may be described The failure of the convulsive patients .to establish a set which persisted for prolonged intervals of time as did the subconvulsive patients suggests a basis for the therapeutic effect derived from convulsive therapy. ‘If the symptoms of the patient are interpretation is particularly appropriate. From the point of view of concepts of mental set, the effect of induced convulsions is to bring about a disruption of maladaptive patterns regarded as a pathologic mental set, such an of behavior. The number of displacement errors remained the whether an inquiry was made. than confabulations. same regardless of errors occurred much During treatment approximately 30% patients of both the inquiry These less frequently of the convulsive and no-inquiry groups responded with one diaplacement. This finding compares at least closely with the results of 33% with displacements obtained in a study of a similar population of electroshock patients in which touch stimuli were applied by the 1h. M. Fink, unpublished data. clinical method (1h) �Displacement errors are not a prominent type of error in an electroShock pepulation. With regard to the extinction error, differences were not significant between inquiry and no-inquiry groups. The high number of extinction errors pretreatment and the subsequent decrease in errors during treatment, in this study, is in contrast If clinical-tactile to the results obtained with clinical tactile techniques. extinction errors are elicited increase in error during treatment. The methods are used, few is a marked results obtained in this Study are probably related to the initial difficulty experienced by the patient in perceiving electrical stimuli at threshold pretreatment and there the rapid adaptation to the technique in further testing. play a greater role than the changes induced by the treatment. and In that a initial studies Bore with threShold electrical stimuli, it These factors was believed sensitive test of changes in brain function than the clinical- for clinical purposes the perceptual patterns obtained with electrical stimulation lack sufficient tactile method (15) could be devised. however, discriminability as indices of brain dysfunction. In part, the deficiences of the method may be ascribed to the necessity for using fixed electrodes and limitations in switching arrangements at threshold. For clinical . testing, therefore, simultaneous tactile stimuli applied rapidly in varied sequence remains the best index= of altered brain function (16). 15. Fink, Green.and Bender, gghgit,, h6-58 16. M. Green and M. Fink, Standardization of the face-hand test, Neurology, h l95h, 211-217. �-18.. Summary: tactile This study of the perception of simultaneously applied stimuli was undertaken to determine the relation between the frequency of perceptual errors to the inquiry made by the examiner. The relation between inquiry, perceptual response and the degree of brain dysfunction was also considered. In the test procedure, the threshold (100 per cent point) for square wave electrical stimuli, applied to the patients was applied and in a mixed order to both cheeks trials made determined. Sequences of was two simultaneous and for the hand (homologous were alternated hand and cheek of 61 psychiatric single stimuli and cheek (heterogenous stimulation) stimulation) Heterologous and for each patient. For one group, an homologous inquiry was following each reSponse to a stimulation, while in a second group, Patients were treated either-by convulsive or subconvulsive courses of therapy, at three times per-week for 12-20 applications. no inquiry was made. There errors significant relationdhip between the frequency of confabulation the inquiry ("suggestion-induced set") in both convulsive and Was and subconVulsive a patients.v However, the confabulatory tendencies of these patients differed. Although the errors for both increased during treatment, errors decreased post-treatment for the convulsive group, but in the subconvulsive group errors increased inquiry errors further. differences between and no-inquiry groups with regard to were extinction or displacement insignificant. £:;.convulsive-inquiry patients, the confabulatory errors of patients with high degrees of more frequent than those of wave The activity. slow-wave patients with a low activity were significantly or moderate degrees of slow �.19- Conclusions: tests with simultaneous electrical tactile stimuli the number of Confabulatory errors is related to an induced set suggested uy the In examiner' s inquiry. The number of confabulatory errors is increased in patients with brain dysfunction in relation to an inquiry, but may also in patientS'without brain dysfunction.who are acquiescent be induced and susceptible to suggestion. The frequency of displacement or extinction errors to the inquiry procedure. is not related � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Role of set in the perception of simultaneous tactile stimuli. Amer J Psychol. 72:384-392. 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OFFPRINT FROM THE AMERICAN JOURNAL OF PSYCHOLOGY Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/cd19f1b46d47e649344f387e918358a2.pdf 402d7d717080af9c10d773a24db00fb9 PDF Text Text Reprinted from Journal of Neuropsychiatry, Vol. I, No. 1, Sept-Oct. 1959. Personality Factors in Behavioral Response to Electroshock Therapy ROBERT L. KAHN, PH.D., and MAX FINK, M.D. In previous studies”,7 we found that patients who were most likely to improve from electroshock treatment exhibited persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital test for brain disease.10 We reported, furthermore,7 that patients who improved with electroshock treatment had developed a language pattern similar to- that previously described by Weinstein and Kahn}3 in their studies of neurological patients with cerebral dysfunction. Weinstein and Kahn described a language pattern which they called “language of denial” and demonstrated the relationship of this language pattern to the premorbid personality of the patient. On the basis of these observations, we assumed that the patients most likely to benefit from electroshock treatment would be those who most closely approximated the “explicit verbal denial” personality.11 To test this hypothesis, we studied 63 consecutive patients referred for electroshock therapy. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. Thepatients ranged in age from 20 to 66, with a mean of 47, and included 21 men and 42 women. Prior to and during treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient’s family. At the opening of the interview, the relative was asked to describe, in his own words, the patient’s usual interests and attitudes. The relatives were encouraged to talk about any aspect they wished, and the interviewer followed the trend of their talk, rather than proceedFrom the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented at a meeting of Electroshock Research Association, Chicago, 1957. ing in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the “explicit verbal denial” personality. The number and; type of questions required'with each relative varied according to the degree of spontaneous production and the informant’s capacity to comprehend and communicate. The informant was encouraged to give concrete: examples of all statements. The patients were evaluated as to the pres ence and extent of the following character istics: whether they (1) stressed verbal symbols such as resolutions, homilies, cliches-and rationalization; (2) were prestige and; security conscious, and did not enjoy the in; trinsic benefits of health, work, leisure money and property; (3) regarded illnéSs: as an imperfection or disgrace, keeping it an; , secret from family and neighbors, and were reluctant to seek medical care; (4) tended) to “shake off” their own troubles and to be) regarded as practical persons who advise, others; (5) possessed much drive and coma pulsive energy and felt guilty or uneasy if not occupied; (6) were conscientious, with a high sense of duty and responsibility; (7) were sensitive to criticism, regarding it as an attack on their integrity; (8) were proud and tended to avoid help from others; (9) were reserved rather than openly affectionate or emotional; (10) emphasized being correct; (11) lacked imaginativeness and creativity; (12) were not considered by their relatives as dependent; (13) did not discuss sex openly; (14) did not have temper outbursts; and (15) were not “ludic”—a term taken from Piaget8 and used by Weinstein” and Kahn12 to denote comic, tragic or melodramatic behavior. After the interview, each item was rated on a scale of O, 1 or 2. A score of O was given if the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked ,» . , ' ' �' presence of the pattern. The scores for each item were added and, the resultant score termed the “denial personality score.” 2. Clinical Evaluation: Each patient was interviewed prior to treatment and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient’s behavior in the few weeks following the end of the course of treatment, and was based on the evaluation of the patient’s therapist, the therapist’s supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: much improved, moderately improved, or unimproved, following the criteria outlined previouslyf‘ 3. Language Study: In addition to. the clinical interviews, each patient was examined with a standardized series of questions directed at determining his attitude toward his illness. Two of the questions asked were “What is your main trouble?” and “If you had one wish, what would you wish for?” The patients were tested before and during treatment, and the verbatim responses were analyzed for changes in language, according to the method previously described.7 Treatment for all patients consisted of grand mal electroshock, using a Reiter elec— trostimulator or a Medcraft alternating-current instrument, on a schedule of three treatments per week. Of the 63 patients, we were able to- interview the relatives of 47; and the present study refers to this group. The denial personality scores ranged from 0 to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the “high denial” group, while those with scores from 0 to 10 were classed as low in denial tendencies. Personality Score and Clinical Response: Patients with high denial personality scores in these family interviews were most likely to be rated as much improved, and only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as unimproved. ') .« TABLE I Relation of Denial Personality Scores to Clinical Response to Electroshoclc Denial Much Personality Improved Score 11 - 25 0 - 25 14 Total Moderately Improved Unimproved Total 7 9 9 1 7 24 23 21 18 8 47 The difference in the denial scores between the much and moderately improved patients, when compared to the unimproved patients, is statistically significant (at 1% level of confidence by Mann-Whitney U Test). Although the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative Observations: Although there is a relationship between high personality scores and the clinical rating, 30 per cent of the patients with low denial scores were also evaluated as showing a marked improvement. While the group of seven patients is a small one, certain common characteristics can be described. Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or others’ feelings. They relate to the environment primarily by nonverbal forms of communication. They are described by their families as laughing or crying excessively and as showing anger by muteness— “going into a shell,” “walking out of the room in a huff”——or by violent tempers with table-pounding, throwing objects or direct physical assault. Personality Score and Changes in Language: By means of the technique of language analysis described in a previous study,7 the changes in language in clinical interviews ~were compared with the denial personality scores. Nine patterns of language change, such as explicit denial of illness or symptoms, displacement, qualification, etc., have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether �. qr nothe showed three or more explicit language changes. Patients with high denial personality scores showed a greater number of language changes than those with low denial personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes is +.71, significant at better than the 1% level of confidence. TABLE II Relation of Denial Personality Scores to Clinical Language Changes Daring Treatment Denial Personality Scores 11 - 25 (20) 0 - 10 (20) N 0. Language Changes 0 — 2 3 or more .................................. 8 .................................. 17 12 Total ........................................ 25 15 3 Illustrative Cases Case 1. High Denial Personality Score: A 61-yearold housewife was admitted to the hospital with a 15—month history of insomnia, abdominal. pain and fear of cancer. On admission she was depressed, retarded and seclusive, evincing little interest in her surroundings and wandering aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with much integrity. She had no hobbies or outside interests, and was unable to relax; as a consequence, she busied herself with chores at home. She was “mortally afraid” of doctors, minimized her illnesses and concealed ailments even from her husband. Very restrained, she showed no affection or emotion, never discussed sex and rarely lost her temper. She had “a long memory for little things if she felt that she was wronged,” a “streak of stubbornness,” and would “just as soon hold another person responsible for her mistakes.” She was proud and would “rather go- without food” than borrow or take money from others. According to the denial criteria, her score was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a “model” patient who, “while reluctant to discuss her personal feelings, asserted that she had no difficulties at home, had a wonderful husband who was very good to her, considered herself lucky and eagerly anticipated her discharge.” She was discharged with a rating of “much improved.” Case 2. Low Dental Personality Score: A 41year-old housewife was admitted to the hospital with a two-year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission it was noted that the patient paid little attention to her personal appearance, cried readily, showed psychomotor retardation and was circumstantial in speech. The patient was described by her husband as a “negative personality” with whom it was not easy to get along because she was opinionated and argumentative. He regarded her as “completely impractical, with no common sense.” She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. An excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, however, she Would become either completely mute or “very nasty, implying you just don’t know any better.” Although considered a “cold” person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was “naive” and “unrealistic,” believing, for example, that she had a flair for writing although others considered her amateurish. Her personality score was rated as 4. The patient received 18 electroshock treatments, which were terminated at her own insistence because she was too frightened to take any more. At the time of her discharge her doctor noted her as “quite depressed,” but felt it was doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for continued psychotherapy. Discussion The structured family interview was designed to test the Specific hypothesis derived from earlier observations that patients with the “explicit verbal denial” personality are most likely, with electroshock therapy, to show both the language and behavioral changes which are rated as much improved by the examiner. The data support this hypothesis and are also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952.9 They suggest tha “. . . the therapeutic eflicacy of electroconvulsive therapy . . . derives from the production of a. state of brain function in which the mechanism of denial is facilitated in characterologically disposed individuals.” The degree of explicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. On the basis of the present data and methods of analysis, a broader View of’ personality patterns in relation to improvement with EST is now possible. Those patients who are rated as clinically improved are character- ' �8va — _ ,r-Pff-‘wu ‘:_‘_":':'*'r‘-n-€"L ,V"-~.' -: < ,2 ized as: (a) nonempathic—unable to think critically or sensitively about the needs, feelings or communications of others; (b) nonintrospective—unable to think critically about their own feelings or needs, or to achieve insight even with the collaboration of others in the psychotherapeutic relationship; (0) relying heavily on nonverbal communication—even when they are talkative there is little referential communication, the words being clichéd, stereotyped or representative of feelings and emotions rather than transmitters of information; and (d) highly conventional—without imaginative or creative capacity, and with few resources to deal with stressful or new situations. With this pattern as the common background, two classes of patients who respond to treatment can be defined: the driving, conscientious, independent, successful, emotionally controlled person who can be characterized as the “explicit verbal denial” personality type; and the chronically inadequate, affectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short-term response to electroshock, preliminary followup observations indicate that the “explicit verbal denial” personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change shown with altered brain function, however, vary markedly in different patients. Some show mood changes and denial or displacement of symptoms, and are rated as improved. Others develop paranoid agitated states, become withdrawn or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality factors in those cases whose behavioral response was rated as improved. We have not considered the patients who were rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information 4.: in this regard is minimal, as this problem has not been approached with a specific hy-“ pothesis. These observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic premorbid personality. Abraham1 noted that states of depression occur in obsessional persons. Arnot2 described depressed patients as being overconscientious and perfectionistic. Hamilton and Mann,5 reporting various aspects of the personality in involutional depression, included such features as “followed a rigid pattern of behavior . . . displayed a lack of imagination . . . narrow range of interest . . . thorough, conscientious, meticulous devotion to duty . . . lack of feeling for point of view of others . . . hard, uncompromising drivers . . . oversensitive . . reserved.” Cohen et al.,3 in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having little capacity for communicative interchange; and unaware of other persons’ feelings toward them or of their feelings toward others. They emphasized the patients’ inability to communicate verbally and suggested that the therapeutic relationship should be in nonverbal terms rather than emphasizing the intellectual content of the exchange, These studies of the personality background of depression show a pattern that is most similar to those personality aspects which have been described as the “explicit verbal denial” personality. The factor of personality could thus explain the fact that depression is the condition that responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to nonverbal forms of therapy. These factors enable him to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism and prestige consciousness which produce a cat- ' > �.' respOnse in the individual faced astrophic 7 With the loss, of a partner, job, business or u'loiv‘ed one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed “improved” by the family and the therapist. Summary and Conclusions To summarize, we believe that our results show that aspects of personality can be differentiated, which are significantly related to the response to treatment. The basic personality pattern of the patients Who respond best to electroshock treatment can be characterized as (a) nonempathic, (b) nonintrospective, (c) communicating nonverbally and ((1) highly conventional and stereotyped, with little imaginative or creative capacity. Within the context of this common care, there are two main subdivisions of improved patients. One group is comparable with the “explicit verbal denial” personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to be chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are affectively labile and ludic. The same personality factors which contribute to a depressive reaction contribute to a behavioral change, under the conditions of altered brain function following electroshock therapy, which is evaluated as improvement. . . . REFERENCES Abraham, K.: Selected Papers on Psychoanalysis. (The Hogarth Press Ltd., London, 1949.) Arnot, R.: The Predepressed Personality. Arch. Neural. (G Psychiat, 76:617-618 (1956). Cohen, M. B., et al.: An Intensive Study of Twelve Cases of Manic—Depressive Psychosis. Psychiatry, 17 :103-137 (1954). Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock. Arch. Neural. c6 Psychiat, 78:516-525, 1957. 10. 11. 12. 13. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Hoch, P., and Zubin, J. (eds.), Depression, pp. 199-209 (Grune d2 Strattan, New York, 1954). Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neural. c6 Psychiat., 76:23-29 (1956). Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Hoch, P., and Zubin, J. (eds), Psychopathology of Communication, pp. 126. Piaget, J .: Play, Dreams and Imitation in Childhood (W. W. N ortau, New York, 1951). Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat, 109:22-26 (1952). Weinstein, E. A., et al.: Diagnostic Use of Amo— barbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112:889-894 (1953). Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol. (Q Psychiat, 69:355-367 (1953). Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease. J. Hillside H08p., 3:98-106 (1954). Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. (Charles 0'. Thomas, Springfield, Ill., 1955.) ' ��March 1957 £471.“. Personality Factors in Behavioral Response to ElectroShock Therapy Robert L. Kahn, Ph. D. and.Max Fink, From New WW. M. D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, York. Aided by M—92? of the National Institute of Mental Health, National of Health, United States Public Health Service. grant Institutes Presented to the Electroshock Research Association, Chicago, l. , l, , , gnu-H‘SVAmh-fiy, May 1957. �INTRODUCTION The behavioral response of patients receiving electroshock therapy variable. noted In previous studies of the factors related to that patients who showed is this variability early, persistent and relatively we marked degrees of altered brain function, as meaSured by the electroencephalogram and the amobarbital test for brain disease (10), were most response which was rated as improved (h) (6) (7). likely to The show a clinical present study is an investigation of the role of personality in the behavioral response. explicit hypothesis concerning this relationship has been derived An from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), patients patterns as explicit denial of illness; who develop such language we reported that personal, Spatial and temporal displacement of symptoms; and qualification, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) studies of neurological patients with cerebral dysfunction. in their They characteru ized this behavior as the "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "ex- plicit verbal denial" personality (11). the hypothesis was advanced On the basis of these Observations, that those patients this "explicit verbal denial" personality type the behavioral changes The purpose after EST who most closely approximated would be more likely to Show which are rated as improved. of the present study, therefore, was to determine: 1) whether personality characteristics related to the behavioral reSponse to electroshock therapy can be differentiated; and 2) whether patients with greater "denial" tendencies are more likeLy to show proved. behavioral changes after electroshock therapy which are rated as imp �~2~ POPULATION Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was asked to describe, in his interests and attitudes.. The relatives patient's usual encouraged to talk about any own were words, the aSpect they wished, and the interviewer followed the trend of rather than proceeding in a serial fashion. The their talk, interviewer asked questions, however, to obtain information in 15 Specific areas which have been described as characteristic of the "explicit verbal denial" personality. and type of questions required with each The number relative varied according to the de- gree of spontaneous production and the informant's capacity to comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence features: 1) stress verbal symbols such as rationalization; 2) are prestige and and extent of each of the following resolutions, homilies, cliches security conscious, intrinsic benefits of health, work, leisure, money and it a and and do not enjoy the property; 3) regard secret from family and neighbors,-and are reluctant to seek medical care; h) "shake off" their own illness as an imperfection or disgrace, keeping �-3troubles and are considered practical persons who advise others; 5) have drive and compulsive energy, and are guilty or uneasy if not much occupied; 6) are conscientious with a high sense of duty and responsibility; 7) are sensitive it to criticism, regarding as an attack on their integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly affectionate or emotional; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; 13) do not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25) After the interview, each item was rated score of O was given if on a scale of O, 1 or 2. A the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the each item were added and the resultant score pattern. The scores for is termed the "denial personal- ity score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The evaluation was determined by clinical the patient's behavior in the few weeks follow- ing the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist's supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: proved, following the much improved, moderately improved, or unimp criteria outlined previously (6). 3. lgnguagg §t_gy: In addition to the clinical interviews, each patient was examined toward his with a standardized series of questions determining his attitude illness. Two of the questions asked were, "What is your main trouble?" and ”If you had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim reSponses were anal- ized for changes in language according to the method previously described (7). �V «hRESULTS The relatives of scores ranged from h? patients were interviewed. to 25, with a O O denial personality statistical comparison Patients with scores ranging from 25 were consiRered the "high denial" group, while those with scores from to to For median of 11. the patients were divided into two groups. 11 The 10 were classed as low in denial tendencies. Patients with high denial 1. Personality score and clinical reSponse: personality scores in these family interviews were most likely to be as much improved, and only one case was considered unimproved (Table patients with a chance 30% I). In clinical reSponse rating occurred low scores, however, the basis, with rated on of the patients being regarded as unimproved. I TAJLE Relation of Denial Personality Scores to Clinical Response to Electroshock Moderately Much Unimproved Total 9 1 2h 9 7 23 18 8 h? Improved Improved Personality Score - 25 1h 0 ~ 10 7 11 Total . 21 The proved difference in the cenial scores between the patients, significant. % when compared to the unimproved much and moderately im- patients is statistically Although the much improves patients have a higher mean score than the moderately improved group, this Jifference is not significant. 2. Qualitative observations: Although there is a relationship between high denial personality scores she the clinical rating, low denial scores * Significant at ‘1 30% of patients with were also evaluated as showing a marked improvement. 'Hhile 1% .0 ' level of coniidence by HannAWhitney U Test. �-5the group of seven patients be described. and security is a small one, certain common characteristics can Although these Subjects lack the competitive drive, prestige ne ds of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings» They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying excessively; and as showing anger by muteness, "go into a shell," "walk out of the room in a huff," or bv violent tempers with table-pounding, throwing objects or direct physical assault. patients are "ludic," - a term used These by Heinstein and Kahn (12) to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were compared with the denial personality scores. patterns of language change, such as explicit denial of illness or Nine symptoms, displacement, qualification, 323' have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial personality scores showed a greater ality scores ality scores number of language changes, than those with low (Table II). The denial persen- coefficient of correlation between the person- and the number of language Chan es is + .71, significant at better than the 15 level of confidence. * This terizwas taken from Piaget behavior of young children (8). who pplied it to the play and imitative �-6- II TABLE Relation of Denial Personality Dcores to Clinical Language Changes During Treatment Number Language Changes - 0 2 3 or more Personality Scores 11-25 (20) 8 12 0-10 (20) 17 3 Total 25 15 h. Illustrative Cases: Case 1. A month High Denial Personality Score: élayear-old houswife was history of insomnia, abdominal nain admitted to the hospital with a 15 and fear of cancer. she was depressed, retarded, and seclusive, evincing On admission little interest in her surroundin s, and uaneering aimlessly about the ward. The patient was described responsible person with and was unable to home. She was much relax. by her husband as a conscientious, dependable, integrity. She had no As a conseguence, she hobbies, outside interests, busiee herself with chores at "mortallv afraid" of doctors, minimized her illnesses and con- cealed ailments, even from her husband. Very restrained, she onenly showed no affection or emotion, never 6iscusse€ sex had "a long memory for little "streak of stubborness," sible for her mistakes." than borrow or take things and would if she and felt that According to the denial She she was wronged," a "just as soon hold another person She was proud ane would money from rarely lost her temper. "rather go reSponu without food" others. criteria, hrr score was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor �-7called her a "model" patient feelings, asserted that band who was very good her discharge." who, "while reluctant to discuss her personal difficulties at home, had a wonderful husto her, considered herself lucky and eagerly anticipated she had no She was discharged with a Case 2. Low "much improved." Denial Personality Score: hl-year-old housewife A rating of was admitted to the hOSpital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission the patient was showed attention to her personal appearance, cried readily, psychomotor retardation and was circumstantial in speech. The whom He little noted to pay patient it was was described by her husband as a "negative personality" with not easy to get along because she was opinionated and argumentative. regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would ative person, she liked to sations. When put herself out for others. engage An excessively talk- in long, intellectual, pretentious converu angry, however, she would become either completely mute, or "very nasty, implying you just don‘t "cold" person, she was able to know any better." Although considered a talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "un- realistic," believing, for example, that she had a flair for writing although others considered her amateurish. rated as h. Her personality score The patient received eighteen electroshock treatments, which were term» inated at her was frightened to take any more,, At the time of her discharge her doctor noted her as "quite depressed," but felt that ital. it was own insistence because she was too doubtful that she could benefit from further treatment at the hosp- She was discharged with the recommendation for continued psychotherapy. �-8- . DISCUSSION The structured family interview was designed to test the specific hypo— thesis derived from earlier observations that patients with the "explicit verbal denial" personality are most likely to havioral Changes the examiner. show both the language and be- to electroshock therapy which are rated as The data supports this hypothesis and much improved by is also consistent with the theory of the mode of action of electroshock therapy advanced by'Weinstein, that "....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain Linn and Kahn in 1952 (9). They suggest function in which the mechanism of denial is facilitated in characterologically disposed individuals." The degree of explicit verbal denial is, however, only aspect affecting the behavioral reaponse to treatment. one personality the basis of the On present data and methods of analysis a broader view of personality patterns in relation to improvement with rated as clinically empathic - ~ improved are unable to think EST is now possible. Those own who are characterized by such features as: 1) non- critically or sensitively about the needs, ings, or communications of others; 2) non-intrOSpective critically about their patients - — feel- unable to think feelings or needs; unable to achieve insight even with the collaboration of others in the psychotherapeutic relationship; 3) rely heavily on nondverbal Communication little referential -- even.when they are communication, the words being cliched, stereotyped, or .representative of feelings and emotions action and h) highly conventional .. .. rather than transmitters of informp withoutimaginative or creativecapacity, y'and,with few resources to deal with stressful or With talkative there is this pattern as the common new situations. background, two classes of patients who "‘respond to treatment can.be-defined: a) the driving,.conscientious, independent, �.9can be successful, emotionally-controlled person who plicit verbal denial" personality type; b) the chronically inadequate, coming from an impoverished ively labile and ludic, dependent person, cultural background. characterized as the "ex- 'While both types are rated as improved affectsocio- in their short term reSponse to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical reSponse, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change'with electroshock therapy. The kinds of behavioral change shown with however, vary marcedly in different patients. denial or diSplacement of symptoms and paranoid agitated states, become withdrawn, altered brain function, Some show mood changes and are rated as improved. Others develop or show ory complaints, and are rated as unimproved. In additional somatic or memp this study we have stressed the personality factors in those cases whose behavioral reSponse was rated as improved. We have not considered the patients who were rated as only moder- ately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information in this regard is minimal, as These this problem has not been approached with a specific hypothesis. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic predepressed personality. Abraham (1) noted of depression occurred in obsessional persons. Arnot (2) describes that states depressions as being overly Conscientious and perfectionistic. Hamilton and Mann (5), reporting various aSpects of the personality in involutional depress- ion, include such features as "followed a rigid pattern of behavior....dis~ played a lack of imagination...narrou range of interestS..thorough, conscientious, �.10.. meticulous devotion to duty...1ack of feeling for point of view of others... hard, uncompromising drivers...oversensitive...reserved." Cohen, §t_§l'(3) in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige-conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having communicative interchange; and unaware of self or of his feelings toward others. to be little capacity for other persons' feelings toward him- They emphasized the patients' inability that the therapeutic relationship should in non-verbal terms rather than emphasizing the intellectual contents of communicate verbally and Suggested the exchange. studies of the personality background of depression Show a pattern that is most similar to those personality aspects whidh have been described These as the "explicit verbal denial" personality. The factor of personality could thus explain the fact that depression is the condition which responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to non-verbal forms of therapy. These factors enable him to reSpond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, convention- ality, perfectionism, and prestige-consciousness, which produce a catastrophic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed "improved" by the family and the therapist. �.11SUMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for e1ectro~ shock therapy were studied by means of a structured family interview. 2. which are 3. be The results show that aspects of personality can be differentiated significantly related to the reaponse to treatment. The basic personality pattern of the patients who respond characterized as a) non-empathic, b) non-introspective, c) non-verbally, and d) highly conventional and stereotyped, with best can communicate little imagin- ative or creative capacity. h. ‘Within the context of of improved personality, patients. One showing such and emotional control. ically inadequate grounds, uho are this group is core, there are two main subdivisions comparable to the "explicit verbal denial" common features as drive, conscientiousness, independence The oflaer group and dependent, coming consists of persons apt to be chron— from deprived Socio-cultural back- effectively labile and ludic. 5. The relationship between these personality patterns and descriptions of the personality of depressed perSOns is noted. The same personality factors which contribute to a depressive reaction, contribute to a behavioral change under the conditions of which altered brain function following electroshock therapy is evaluated as improvement. �.12.. FERENCES 1. Abraham, K.: Selected Papers on Psychoanalysis. London: Press Ltd., 19h9. Arnot, R.: The chiat., 3. Cohen, h. Fink, Predepressed Personality, Zé: 617—618, 1956. A.M.A. Arch. The Hogarth Neurol. & Psy- B., Baker, G., Cohen, R. A., FrommpReichmann, F. and Ueigert, An Intensive Study of Twelve Cases of Manic-Depressive Psychosis, Psychiat., 11: 103-137, l95h. H. E. V.: M. and Kahn, R. L.: Quantitative Studies of Slow wave Activity EEG Clin. Neurophysiol., Q; 158, 1956. Following Electroshock, Hamilton, D. M. and Mann, W. A.: The Hospital Treatment of Involutional Psychosos, in Depression (Hoch, P. and Zubin, J., eds.), New York: Grune & Stratton, 199-209, 1952. L., Fink, M. and weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Kahn, R. 7. Language During Electroshock Communication (Hock, P. and Zubin, Psychopathology of Kahn, R. L. and Fink, M.: Therapy, in Changes in Eds.) in press. Piaget, J.: Play, Norton, 19 51. Dreams and Imitation in Childhood. New J., York: N. W. 9. Weinstein, E. A., Linn, L. and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Pey- chiat., 193; 22-26, 1952. 10. ‘Weinstein, E. A., Kahn, R. L., Sugarman, L. A. and Linn, L.: Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic Brain Disease, Am. J. Psychiat., 11g} 889-89h, 1953. 11. E. A. and Kahn, R. L.: Arch. Neurol. & A.M.A. ness, neinstein, Personality Factors in Denizl of Psychiat., éfi: 355-367, 1953. Ill- 12. Ueinstein, E. A., Kahn, R. L. and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp., 2; 98-106, l95h. 13. Ueinstein, E. A. and Kahn, R. L.: Denial of siological Aspects. Springfield, Ill.: Illness: Symbolic and Phy- Charles C. Thomas, 1955. �--.f\ ._ Personality Factors in Behavioral Response to Electroshock Therapy Robert L. Kahn, Ph.D. and From Max Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented to the Electroshock Research Association, Chicago, May 5/59 195”. �INTRODUCTION .The behavioral response of patients receiving electro— shock therapy is variable. In previous studies of the factors related to this variability we noted that patients who showed early, persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital most likely to show a test for brain disease (10), clinical response were rated as investigation which was present study is an of the role of personality in the behavioral response. An eXplicit hypothesis concerning this relationship has been derived from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), we reported that improved (h) (6) (7). The develop such language patterns as explicit denial of illness; personal, spatial and temporal displacement of symptoms; and qualification, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) in their studies of neurological patients with cerebral dysfunction. They characterized this behavior as the patients who "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "explicit verbal denial" personality (11). On the basis of these observations, the hypothesis was advanced that �-2- closely approximated this "explicit verbal denial" personality type would be more likely to those patients show who most the behavioral changes after EST which are rated as improved. purpose of the present study, therefore, was to determine: The - 1) whether personality characteristics related to the behavioral response to electroshock therapy can be differ- entiated; and 2) whether patients with greater "denial" tendencies are more likely to show behavioral changes after electroshock therapy which are rated as improved. EQPULATION: Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was 1. �-3asked to describe, in his interests and attitudes. own words, the The relatives patient's usual were encouraged to aspect they wished, and the interviewer followed the trend of their talk, rather than proceeding in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the "eXplicit verbal denial" personality. The number and type of questions required with each relative varied according to the degree of spontaneous production and the informant's capacity to talk about any comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence and extent of 1) stress verbal symbols each of the following features: resolutions, homilies, cliches and rationalization; 2) are prestige and security conscious, and do not enjoy the intrinsic benefits of health, work, leisure, money and such as regard illness as an imperfection or disgrace, keeping it a secret from family and neighbors, and are reluctant to seek medical care; h) "shake off" their own troubles and are considered practical persons who advise 5) have much drive and compulsive energy,.and are others; guilty or uneasy if not occupied; 6) are conscientious property; 3) with a high sense of duty and responsibility; 7) are sensitive to criticism, regarding it as an attack on their �-u- integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly.af£ectionate or emotuonal; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25). After the interview, each item was rated on a scale of 0, 1 or 2. A score of O was given if the aspect was noted 13) do to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the pattern. The scores for each item were added and the resultant scoretns termed the "denial personality score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient's behavior in the few weeks following the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist’s supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. into three groups: much improved, unimproved, following the Patients were classed moderately improved, or criteria outlined previously (6). Study; In addition to the clinical inter~ views, each patient was examined with a standardized series 3. Language �-5of questions determining his attitude toward his illness. Two of the questions asked were, "What is your main trouble?" "If you had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim responses were analyzed for changes in language and according to the method previously described (7). �-6RESULTS relatives of interviewed. The denial personality scores ranged from O to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the "high denial" group, while those with scores from O to 10 were classed as low in denial tendencies. 1. Personality score and clinical response: Patients with high denial personality scores in these family interviews The likely to were most patients h? rated as be were only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as much improved, and unimproved. TABLE I Relation of Denial Personality to Clinical Response to Electroshock Much Moderately 25 1h 9 1 2h to 10 Total 7 9 7 23 21 18 8 h? Improved Improved Total Unimproved Personality Score 11 0 to The difference in the denial scores between the and moderately improved unimproved * patients, when compared much to the patients is statistically significant.* Although Significant at 1% level of confidence by Mann-Whitney U Test. �-7the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative observations: Although there is a relationship between high denial personality scores and the clinical rating, 30% of patients with low denial scores were also evaluated as showing a marked improvement. While the 2. group of seven patients is characteristics a small one, can be described. certain common Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings. They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying excessively; and as showing anger by muteness, "go into a shell," "walk out of the room in a huff," or by violent tempers with table—pounding, throwing objects or direct physical assault. These patients are "ludic," - by Weinstein and Kahn (12) a term used to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were the denial personality scores. Nine patterns of language change, such as explicit denial of illness or compared with * This and term was taken from Piaget imitative behavior of young applied it to the play children (8). who �-8displacement, qualification, 323. have been described as characterically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial symptoms, personality scores showed a greater number of language changes, personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes is + .71, significant at better than the 1% level of confidence. than those with low denial TABLE II Relation of Denial Personality Scores to Clinical Language Changes During Treatment Number Language Changes 0 - 2 Personality Scores 11-25 0-10 (20) (20) ' Total h. Illustrative 3 or more 8 12 1? 3 25 15 Cases: gigh Denial Personality Score; A 61-year-old housewife was admitted to the hospital with a 15 month history of insomnia, abdominal pain and fear of cancer. On admission she was depressed, retarded, and seclusive, evincing little interest in her surroundings, Case 1. aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with and wandering much �-9- integrity. hobbies, outside interests, and was a consequence, she busied herself with She had no unable to relax. As chores at home. She was “mortally afraid" of doctors, minimized her illnesses and concealed ailments, even from her husband. Very restrained, she openly showed no affection rarely lost her temper. She had "a long memory for little things if she felt that she was wronged," a "streak of stubborness," and would "just as soon hold or emotion, never discussed sex and another person reaponsible for her mistakes." She was proud and would "rather go without food" than borrow or take money from others. According to the denial criteria, her score was 20. electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a "model" patient who, "while reluctant to discuss her personal feelings, asserted After that she 20 had no difficulties at home, had a wonderful husband very good to her, considered herself lucky and eagerly anticipated her discharge." She was discharged with a rating who was of "much improved." Denial Personality Score: A hl-year—old housewife was admitted to the hospital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social aetivities, found it increasingly difficult to take care of her Case 2. Low suicidal thoughts. On admission the patient was noted to pay little attention to her personal appearance, cried baby and had �readily, showed psychomotor retardation and was circumstantial in speech. patient was described by her husband as a "negative personality" with whom it was not easy to get along because The she was opinionated and argumentative. He regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, An either completely mute, or "very Just don't know any better." Although however, she would become nasty, implying you considered a "cold" person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "unrealistic," believing, for example, that she had a flair for writing although others considered her amateurish. personality score was rated as h. The patient received eighteen electroshock treatments, which were terminated at her own insistence because she was Her too frightened to take any more. At the time of her discharge her doctor noted her as "quite depressed," but felt that it doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for was continued psychotherapy. �-11- Elialfiilgli structured family interview was designed to test the specific hypothesis derived from earlier observations that patients with the "explicit verbal denial" personality The are most likely to show both the language and behavioral changeswfiflxelectroshock therapy which are rated as much data supports this hypothesis and is also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952 (9). They suggest that "....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain function in which the mechanism of denial improved by the examiner. The is facilitated in characterologically disposed individuals." degree of eXplicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. 0n the basis of the present data and methods The of analysis a broader view of personality patterns in relation to improvement with EST is now possible. These patients who are rated as clinically improved are characterized by such features as: l) non-empathic - - unable to think critically or sensitively about the needs, feelings, or communications of others; 2) non-introspective ~ - unable to think critically about their own feelings or needs; unable to achieve insight even with the collaboration of others in the psychotherapeutic rely heavily on non-verbal communication they are talkative there is little referential relationship; even when 3) - �-12communication, the words being cliched, stereotyped, or representative of feelings and emotions rather than transmitters of information and h) highly conventional - - without imaginative or creative capacity, and with few resources to deal with stressful or With new situations. this pattern as the common background, two classes patients who respond to treatment can be defined: a) the driving, conscientious, independent, successful, emotionallycontrolled person who can be characterized as the "explicit verbal denial" personality type; b) the chronically inadequate, effectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short term response to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. of Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change slacwn with altered brain function, however, vary markedly in different patients. Some show mood changes and denial or displacement of symptoms and are rated as improved. Others develop paranoid agitated states, withdrawn, or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality become �-13- factors in those cases as improved. We whose behavioral response have not considered the patients was rated who were rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relation~ ship between personality and the behavioral reSponse in patients who are rated as unimproved. Present information in this regard is minimal, as this problem has not been approached with a specific hypothesis. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic These predepressed personality. Abraham (I) noted that states of depression occurred in obsessional persons. Arnot (2) describes depressions as being overly conscientious and perfectionistic. Hamilton and Mann (5), reporting various aspects of the personality in involutional depression, include such features as "followed a rigid pattern of behavior.... diaplayed a lack of imagination... narrow range of interests.. thorough, conscientious, meticulous devotion to duty...lack of feeling for point of view of others...hard, uncompromising drivers... intensive study of manic-depressive psychosis, reported their patients oversensitive...reserved." Cohen, sflngg (3) in an as being highly prestige-conscious; problems of little concerned with interpersonal relatedness; stereotyped; conventional; little capacity for communicative interchange; and unaware of other persons’ feelings toward himself or of his having �~1h- feelings toward others; They emphasized the inability to verbally communicate therapeutic relationship should be patients' that the in non-verbal terms rather and suggested than emphasizing the intellectual contents of the exchange. These studies of the personality background of depression show a pattern that is most similar to those personality "explicit verbal personality. The factor of personality could thus the fact that depression is the condition which responds electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are aspects denial" explain best to which have been described as the those which make him responsive to non-verbal forms of therapy. These factors enable him to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism, and prestigeconsciousness, which produce a catastrOphic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed "improved" by the family and the therapist. �-15SQMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for electroshock therapy were studied by means of a structured family interview. 2. The results show that aspects of personality can be differentiated which are significantly related to the reSponse . to treatment. basic personality pattern of the patients who respond best can be characterized as a) non-empathic, b) non-introspective, c) communicate non-verbally, and d) highly conventional and stereotyped, with little imaginative or creative capacity. h. Within the context of this common core, there are two main subdivisions of improved patients. One group is comparable to the Wkplicit verbal denial" personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to 3. The chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are effectively labile and Indie. 5. The relationship between these personality patterns and descriptions of the personality of depressed persons is noted. The same personality factors which contribute to a depressive reaction, contribute to a behavioral change under the conditions of altered brain function following electroshock therapy which is evaluated as improvement. be �116REFERENCES 1. Abraham, K.: SelecteguPafiers on The Hogarth Press Ltd.,‘l9h9. 2. Arnot, R.: The Predepressed Personality, A.M.A. Arch. Neurol. and Psychiat., 1g: 617f618, 1956. Cohen, M.B., Baker, 6., Cohen, R.A., Fromm-Reichmann, F. and Weigert, E.V.: Antintensive Study of Twelve Cases Psychosis, Psychiat., 11: 103-137, 1ofsfianic-Depressive 9 3. Psychoanalysis. London: 5 o R.L.: Quantitative Studies of Slow Wave Activity Following Elastroshock, EEG Clin. Neurophysiol., g: 158, 1956. Fink, M. Hamilton, and Kahn, The_Hospita1 Treatment of D.M. and Mann, W.A.: Involutional Ps choseg, in Depression (Hash, J., 6. 933.5, New Stratton, FT and Zubin, 199-209, 1952. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Kahn, R.L., Fink, A.M.A. Arch. 7. York: Grune E M. Neurol. & Egychiat., lé‘ 23-29, 1956. Kahn, R.L. and Fink, M.: Changes in Language During Electro— shock Therapy, in Psychopathology of Communication (Hoch, Zubin, J., eds.) New York: Grune & Stratton, 1958, P.6and 12 ~139. fi J.: Play) York: W.W. Piaget, 9. Norton, l9Sl. Imitation in Childhood. New Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, 10. Dreams and Am. J. Psychiat., 109: 22-26, 1952. Weinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.: Diagnostic Use of Amobarbitai Sodium ("Amytal Sodium") Am. inSOrganic Brain Disease, ""‘ J. Psychiat., 112: 889-89h, 19 3. 11; Weinstein, E.A. and Kahn, R.L.:’Personality Factors in Denial of Illness, A.M.A. ArCh. Neurol. & Psychiat., £2: 355-367, 1953. 12: Weinstein, E.A., Kahn, R.L. and Sugarman, L.A.* Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp. 2: 98-106, 195h. Weinstein, E.A. and Kahn, R.L.: Denial of Illness: Symbolic and Physiological Aspects. Springfiél’, 111.: Charles i 13. UT Thomas, 1955. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Personality factors in behavioral response to electroshock therapy. J Neuropsychiatr. 1959 Sep-Oct; 1:45-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-41-007 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Two [preprints] and one reprint. Reprint fromJournal of Neuropsychiatry, Vol.I, No.1, Sept-Oct. 1959 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/b97c9ed1045d743c104ef57163e90f61.pdf cca8258a1cb2c00bbe3baaafbd7ccf91 PDF Text Text Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital Duration of Hospitalization. Qis‘éttarge Ratings. and Diagnosis ROBERT L. KAHN. P|1.D.; MAX POLLACK. Ph.D.. AND J’ MAX FINKI M.D. GLEN OAKS. N. Y. �Reprinted from the A. ill. .4. Archives of General Psychiatry December 1959, Vol. 1. pp. 565—574 Copyright 1959, by American .llca’ical Association Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital Duration of Hospitalization, Discharge Ratings, and Diagnosis ROBERT L. KAI-IN, Ph.D.; MAX POLLACK, Ph.D., and The increasing studies of the sociopsy— chological aspects of psychiatric treatment in recent years have primarily been concerned with treatment patterns in the community}? private practice,29 and outpatient clinics.24’2" In the studies reported by Hollingshead, Redlich, and their co—workers “'27 it was found that social class was a major determinant of the type of psy— chiatric treatment in the New Haven com— munity. Patients from the upper classes were more frequently treated with psycho— therapy, while somatic or custodial care was commoner among the lower classes. They summarized their results by noting: “It was found that treatment does not depend on psychological and medical determinants alone, but on the status position of the pa— tient as well.” 27 Weinstock,29 reporting the results of a poll of the American Psycho— analytic Association, observed that the pa— tients being treated by their members in private practice came disproportionately from the better—educated, high—income pop— ulation. Similar findings have been noted in studies of outpatient facilities. Myers and Schaffer 24 showed that the higher a per— son’s social class the more likely he was to be accepted for psychotherapy, treated by more highly trained personnel, and treated intensively over a long period of time. In another study Rosenthal and Frank 28 Submitted for publication April 16, 1959. From the Department of Experimental Psychiatry, Hillside Hospital. Aided, in part, by Grants M-927 and MY—2092, National Institute of Mental Health, National 1n— stitutes of Health, US. Public Health Service. MAX PINK, M.D., Glen Oaks, N.Y. found almost a linear relationship, between educational level and frequency of referral for psychotherapy. A more critical test of the importance of sociopsychologic factors in relation to psychiatric treatment would be in a setting where the same therapeutic techniques and services were equally available to all patients. This requirement is met at Hillside Hospital, which is a nonprofit institution for the treatment of voluntary patients with “early and curable symptoms,” 11 who are admitted regardless of their ability to pay. One of the main criteria for accepting pa— tients is their “ability to participate profit11 in ably Individual psychotherapy.” psychoanalytically oriented psychotherapy is regarded as the primary method of treatment, with physiodynamic therapies available when needed. The average length of hospital stay is seven months, although some patients stay for more than a year. In a previous study of the Hillside Hos— pital population,14 it was shown that the factors of age, education, place of birth, and degree of stereotypy, as measured by the California F Scale,1 were related to the selection of therapy. Those patients who were older, had less education, were foreign—born, and had high scores on the F Scale were more likely to receive convulsive therapy. In contrast, patients who were younger, better—educated, and native—born and obtained low scores on the F Scale re— ceived psychotherapy as their sole form of treatment. The purpose of the present study was to determine the relation of sociopsychological 27/565 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY factors to (1) the duration of hospitaliza— tion, (2) the clinical evaluations at time of discharge, and (3) the final diagnosis. Method Population—The entire inpatient adult population of Hillside Hospital on March 7, 1957, was studied. This consisted of 171 patients, 57 male and 114 female, ranging in age from 16 to 68 years, ' i with a mean of 35 years. Procedure.——The patients were divided according to the duration of hospitalization, clinical response to treatment, and diagnosis. The duration was de— termined by the number of complete months in the hospital. The clinical response and the diagnosis were determined by the medical director at a staff evaluation conference, usually held just prior to the patient’s discharge. Each patient was rated as recovered, much improved, improved, or unim— proved on the basis of the reports of the therapist, supervising psychiatrist, and milieu staff. The discharge diagnoses were divided into four major groups: involutional psychosis, manic—depressive psychosis, schizophrenia, and psychoneurosis. These diagnostic categories included all but three patients in the population. Each patient was tested with a 10-item modi— fication of the California F Scale.” The F Scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism, and rigidity.1 The subject reads 10 statements and indicates to what extent he agrees or disagrees with each, i.e., “a little,” “pretty much," or “very much.” The score for each item 1 to 7, and the total score from range is ranges 10 to 70. High scores indicate greater agreement with the statements. These are extreme, uncritical, or stereotyped expressions. For example, one statement is this: “If people would talk less and work more, everybody would be better off.” 1. Results Length of Hospitalization—In this population the duration of hospitalization ranged from 1 to 16 months, with a median of 7 months. For the purpose of analysis, the population was divided into three groups: 49 patients Who were hospitalized for 1 to 5 months; 64, for 6 to 9 months, and 58 for 10 or more months. The relation of sociopsychological factors to the length of hospitalization is shown in Table l. The group of patients who were hospitalized for the shortest period had 28/566 of Hospitalization: Total Population TABLE 1.——Dnrati0n Months in Hospilal to to 1 6 No. 5 S) or more 1.0 49 64 58 l 6 to 51‘s. filo?) to 5 vs. 10 or more to 9 vs. 10 or more Education. Mean ForeignYr. Born F Score. Mean Mean Yr. 43.9 31.0 45.5 32.5 27.9 10.0 11.9 12.8 Mean M can Difl'e- Mean Differ- ences ences 13.0 § 1.9 T § 40.1 Difi: reneos 1 Age, 3.4 12.9 § 17.6 § 2.8 9.5 § 4.6 * 0.9 41% 19% 10% x ’=15.0 I P<0.05. P<0.02. I P<0.01. § P<0.001. * 1‘ the highest mean F scores, were oldest, and had the least education and the largest per— centage of foreign—born. Conversely, the group in the hospital for 10 months or more had the lowest F scores, were youngest, and had the most education and the smallest percentage of foreign births. Patients who were hospitalized for an intermediate period fell in be;ween these two groups for each of the factors. When the data for those patients who re— ceived convulsive therapy (Table 2) and those who received psychotherapy (Table 3) as their only form of treatment were analyzed separately, similar relationships between sociopsychological factors and length of hospitalization were found within each group. In the psychotherapy group there was an increase in mean years of education with greater months of hospitalization, but the differences fail of significance. It may be noted, however, that many of the patients who were in the hospital for 10 months or more were under 19 years of age and were thus unable to achieve more than a limited number of years of schooling. These same relationships of sociopsychological factors to length of hospitalization were found when the patients were classi— Vol. 1, Dec., 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 2,—Dnration of Hospitalization: Patients Receiving C onvnlswe Therapy F Score, N0. Mean Months in Hospital to 5 6 to 9 10 or more 15 1 17 25 58.2 45.6 34.9 ences to 5 vs. 1 to 5 v8. more 6 to 9 vs. more * T 1 § to 9 10 or 12.61 6 Differences 9.5 Education, Mean ForeignYr. * ‘ Months 1” Hospital Born 67% 24% 16% x2= 12.0 6.5 12.3 13.2 Mean or 1 '50 § 19.6 § * 10.1 1 t to 5 vs. to 5 vs. more to 9173. more 1 § 0.9 Education, Mean Yr. ForeignBorn 11-4 11-7 12.4 29-1 24-8 30% 16% 8% x2=5.4 istic of patients hospitalized for the longest periods. As a group, patients diagnosed as schizophrenic were the most homoge— neous in relation to time in the hospital, showing major differences only in the F score, without a consistent trend for the factors of education or place of birth. 2. Results of Treatment—The relation of sociopsychological factors to evaluation on discharge is shown in Table 5. There to 9 10 or 6 1.6 12.4 10 ences * Mean Differences 141* 0.3 * 1,0 18.4 or 10.8 4.3 0.7 a definite, almost linear, relationship be— tween the ratings of improvement and these factors. Patients in the recovered group had the highest F scores, were oldest, least educated, and showed the highest incidence of foreign birth. In contrast, patients in the unimproved group had the lowest F scores, were younger, better educated, and were mostly native—born. Because of the Wide variability within each group, however, only the factor of age reached a level of statistical significance. Education also sig— nificantly differentiated the groups when dichotomized according to- those who had less than eight years of education and those who had eight years or more. Of the re— covered patients, 29% had less than eight IS fied according to four major diagnostic groups (Table 4). For each diagnostic class, the lowest F scores, youngest mean ages, most years of education, and least percentages of foreign—born were character— Mean Difier- P=0.001. . - . . . 4.—Duration 0f Hospitalization in Patients Classified According to Diagnosis Diagnosis Involutional psychosis ___________________ Manic-depressive psychosis .............. Months in Hospital F Score, Mean 1-5 6-9 58.2 150.9 10+ 1—5 6-9 10+ ........................... 1-5 6-9 10+ ............................ 1-5 10+ Kahn et al. 432 Differences * Psychoneurosis 40-2 38-6 27-8 Mean OHCES 6.7 Mean Yr. 26 Mean Difler5.8 F Score, Mean 33 43 5 Age, 1 P<0.05. P<0.02. P<0.01. P<0.001. TABLE N 0- to 9 or more 6 10 6 10.7 Schizophrenia of Hospitalization: Patients Receiving Psychotherapy Only 1 23.3 10 Mean Yr. 51.7 42.2 32.1 Mean Difier1 Age, TABLE 3.———Dnration Age, Mean Yr. Education, Mean Yr. Foreign-Born 35.0 58.8 54.5 52.3 16.0 40.0 46.1 33.1 46.8 39.1 35.5 11.0 11.7 12.3 39% 23% 40.1 36.6 36.1 41.0 27.1 8.7 12.5 27.1 12.5 50% 19% 13% 36.3 38.5 27.6 27.8 27.8 24.1 13.3 12.3 12.9 7.1 9.6 57% 43% 0 0 10% 8% 12% 39/567 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY TABLE 5.—Discharge Evaluation No. Evaluation ............................... .......................... ................................ ............................. Recovered Much improved Improved Unimproved 17 ' 82 63 9 F Score, Mean Mean Yr. Education, Mean Yr. 42.9 39.0 36.1 31.1 44.5 35.6 31.2 31.1 10.7 11.2 11.2 13.2 Mean Mean Differences M ean Differences Recovered vs. Much Improved _____________________________ Recovered vs. Improved Recovered vs. Unimproved Much Improved vs. Improved Much Improved vs. Unimproved Improved vs. Uni mproved 3.9 6.8 11.8 2.9 7.9 5.0 .................................... ................................. ............................. ........................... ................................. Age, 8.9 13.3 * 13.4 * 4.4 4.5 0.1 T Foreign-Born 41% 22% 16% 11% x2=6.1 Differences I 0.5 0.5 2.5 0.0 2.0 2.0 ‘ P<0.05. t P<0.02. 3 P<0.01. years’ education, while all of the unimproved patients had more than eight years’ educa— tion; the much improved and improved pa— tients were in between. By x2—analysis these results were significant at the 5% level of confidence. When the data were analyzed for the patients treated with convulsive therapy, the trends noted for the population as a whole were intensified (Table 6). Analysis of the patients who received psychotherapy as their only form of treatment (Table 7), however, failed to show any statistically significant pattern. The recovered patients were oldest and had the highest percentage of foreign births, but education and F score did not show any clear trend. TABLE relation of sociopsychological factors to diagnosis is shown in Table 8. Those patients classified as show— ing involutional reactions had the highest F scores, the oldest mean age, the least years of education, and the highest inci— dence of foreign birth. In contrast, pa— tients classified as schizophrenic had the lowest F scores, the youngest mean age, the most years of education, and the least num— ber of foreign—born. Patients classed in manic—depressive psychosis and psycho— neurosis categories were in between with regard to these social factors. 3. Diagnosis.‘—The Comment The present study has demonstrated that sociopsychological factors, in addition to 6.—Discharge Evaluation in Patients Receiving C onvnlsive Therapy Evaluation No. F Score, Mean Recovered _______________________________ Much improved __________________________ Improved and unimproved _______________ 8 26 23 53.1 41.8 39.7 Foreign-Born 51.6 43.8 32.3 9.4 10.6 12.3 50% 35% 17% x '=3.5 Mean Differences Recovered vs. much improved ______________________________ Recovered ”8. improved and unimproved ____________________ Much improved vs. improved and unimproved _____________ Mean Yr. Education, Mean Yr. Age, 11.3 13.4 " 2.1 Mean Mean Differences 7.8 19.3 I 11.5 T 1.2 2.9 1.7 Differences * ‘ P<0.05. P<0.02. 1 P<0.001. 1 30/568 Vat. 1, Dee, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 7.—Discharge Evaluation in Patients Receiving Psychotherapy Only N0. Evaluation ............................... .......................... Recovered Much improved Improved and unimproved ............... 9 54 39 F Score, Mean 32-6 38.1 33.5 Mean Diflerences .............................. ................... ............. Recovered vs. much improved Recovered vs. improved and unimproved Much improved vs. improved and unimproved 5.5 0.9 4.6 their previously determined importance in the selection of treatment, are also signifi— cantly related to the duration of treatment, the evaluation of the results of treatment, and the psychiatric diagnosis. If such re— sults were obtained in a survey of private practitioners, as in the Weinstock report?9 it could be concluded that the limitation of the number of practitioners and the expense of treatment served to select preferred persons from the upper social classes who could afford the treatment in terms of time and money. The present results, however, were obtained in an institution where the various kinds of treatment were equally available to all patients and where the ability to pay was not a factor in the management of the patient. We postulate, therefore, that TABLE Diagnosis N 0. Involutional psychosis ___________________ Manic-Depressive psychosis ______________ Psychoneurosis ___________________________ Schizophrenia ____________________________ 24 39 37 68 .................. ForeigmBorn 38.2 32.2 31.9 12.3 12.0 12.2 33% 15% 18% Mean Differences 6.0 6.3 0.3 x '= 1.8 Mean Difierences 0.3 0.1 0.2 the observed relationships are not due merely to mechanically selective aspects, such as income or the prestige status of the patient. Social factors are important be— cause they are also related to psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. We shall attempt to evaluate these processes and their effect on the psychiatric relationships studied in terms of the influence of sociopsychological factors on the attitude and behavior of the therapist, the patient, and the therapist—pa— tient interaction. Current data both from this laboratory 14 and from others 19'24'27'28 have demon— strated that psychotherapy is most likely to be sustained with those persons who most 8.—Diagnosis F Score, Mean Mean Yr. 52.3 40.8 36.9 32.8 56.7 41.9 29.4 26.1 Mean Mean Differences Involutional vs. Manic-depressive psychosis ________________ Involutional psychosis vs. psychoneurosis Involutional vs. schizophrenia ______________________________ Manic-depressive psychosis vs. psychoneurosis _____________ Manic-depressive psychosis vs. schizophrenia _______________ Psychoneurosis us. schizophrenia___________________________ Mean Yr. Education, Mean Yr. Age, 11.5 15.4 19.5 3.9 8.0 4.1 I i § ’r Age, Education, Mean Yr. 8.9 11.5 11.9 12.7 Differences 14.8 27.3 30.6 12.5 15.8 3.1 2.0 ‘ 3.0 I 4.5 § 0.4 1.6 0.8 § § § § 46% 26% 22% 10% x==14,2 r Mean Differences § Foreign-Born P<0.05. T P<0.02. I P<0.01. § P<0.001. * K ahn et al 31/569 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY closely resemble the therapists with regard to cultural background, systems of value, and communication patterns. With stress at Hillside Hospital on psychoanalytically oriented psychotherapy, it is consistent that those patients who are most like the therapists with regard to these factors would be kept in the, hospital for the longest period. This was true for patients receiving convulsive therapy or psychotherapy and for all diagnostic groups. The length of time a patient remains in a psychiatric facility is related to the particular function and philosophy of the insti— tution. In studies of outpatient clinics ' Which have a psychoanalytic orientation 2438 it has been observed that persons from the higher social classes, determined by education' or income, are treated for a longer period. In contrast, in state mental hos— pitals, patients with/the least education are kept longer and form a higher proportion of the chronically hospitalized group‘.6'17"23 The state—hospital therapist, Viewing the in— Stitution primarily as a custodial facility,12 is evidently oriented toward the more rapid discharge of those patients “who come from a background most like his own. The observation of the relation between sociopsycholo-gical factdrs and improvement rating, particularly in those patients receiv— ing convulsive therapy, may also be related to differences in communication patterns between therapist and patient that result in referral for convulsive therapy. The therapist may set different criteria for im— provement for the;older, lesseducated pa— tients than he does for the younger, more sophisticated ones. In the patient with littlr education and with modes of expression different fromhis own, he may regard, for example, the manifestation of denial or minimization of symptoms as improvement.15 But in patients culturally like him— self, the expression of denial is regarded as a defensive operation, and the patient is considered unimproved. Ratings of improvement are also related to the base line of premorbid functioning. _ 32/570 Thus, the rating of recovered is defined at Hillside Hospital as “the reasonable expectation that the patient will be able to return to his community and function as well, or better, than he did before he became ill.” 11 The therapist’s perception of the patient’s premorbid functioning may be influenced by the distance between his value system and that of the patient’s. The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change may be. For example, for older, lower—class patients the ability to resume work may be the major criterion of improvement. For bettereducated patients work adjustment may be one of many criteria, including such intangible aspects of behavior as insight, work gratification, and ease of sociability. The patient’s expectancy not only of the type of psychiatric treatment but of improvement is also dependent upon social back— ground.12 While the same trends were shown in the psychotherapy patients, the results did not reach the level of statistical significance. This may have been due to the greater homogeneity of these patients for the factors studied, in contrast to the convulsive group. The outpatient study by Rosenthal and Frank 28 also failed to find a relation between social factors and improvement rating in the patients who received psychotherapy. This observation, also, was obtained in a population that was more homogeneous after the initial admission selection process and after the spontaneous screening effected by the patient’s willingness to attend treatment after he had been accepted. The marked relationship between socio~ psychological factors and diagnosis is not surprising. Certainly, the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and in dementia precox the names themselves have a chronological connotation. Landis and Page,19 in 1938, stated that age was the “most important single deterVol. 1, Dec., 19.59 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT mining factor that we can know about men— tal disease.” They asserted that, given the age distribution of a group of patients, they could accurately predict the number in each diagnostic group, as well as the probable outcome with respect to recovery and the length of hospital residence. More recently, Frumkin,8 reporting the median ages of first admissions to a mental hospital in Ohio, observed data similar to our own with re— gard to the ages for the various diagnostic groups. In the present study, however, we have also shown that education, place of birth, and F score significantly differentiate the major diagnostic groups in the hospital. In view of these findings, we have postulated that a psychiatric diagnosis is not just a one—to—one reflection of a specific type of behavior pattern but is also a value judg— ment in terms of social interaction. Thus, both in our own studies and in the work of others 12 it has been noted that patients with similar symptoms will receive different diagnoses, depending on their social background. An additional hypothesis relating sociopsychologic factors to diagnosis may be based on the concept that persons from dif— ferent social backgrounds acquire different habitual modes of adaptation, communica— tion, and expression. Accordingly, under conditions of stress, altered brain function, or states associated with the onset of mental illness, a person will show those behavior patterns or symptoms which are similar to his habitual patterns. Thus, persons from a lower—class social background are more apt to communicate in nonverbal, physical terms, while upper—class people are more likely to do so in ideational and verbal modes. Thus, anger may be expressed by lower—class people by physical violence, while persons from the upper classes are more likely to resort to exhortation or argument. Opler and Singer,25 studying schizo— phrenic Irish and Italian patients in a Veteran’s facility, found significant difKahn et al. ferences in the types of symptoms related to cultural differences in the family backgrounds. Patients from Irish families in which the active expression of emotions were frowned upon and who had dominant, overprotective mothers, were passive, com— pliant, and withdrawn, and were fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of emotion and who were ruled by a dominant father, showed as— saultive and destructive behavior, were diffi— cult to manage, and were rebellious against authority. In a comparable study, Miller and Swan— '22 noted that hospitalized schizophrenic son patients exhibited significant social-class difference in symptomatology. Lower—class patients showed a predominance of “mo— toric themes,” while middle—class patients exhibited “conceptual or r u m i n a t i v e themes.” Hollingshead and Redlich 12 found a marked difference in the type of neuroses shown by persons from different social classes. While hysterical reactions were found predominantly at the lowest social levels, obsessive—compulsive patterns were characteristic of the upper classes. They felt that the lower—class patient expresses his neurosis by acting out, whereas the upper—class neurotic shows his symptoms in ideational dissatisfaction with himself. According to our hypothesis, then, we should expect that persons from lower social levels would show symptoms that are nonverbal, and are expressed predominantly in sensory or motor patterns. Among such types of symptoms would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness, and paral— ysis. In this connection it is noteworthy that both hysteria and manic—depressive psychosis have been reported on the wane in the general population."-”4'8'10 This de— crease, in our View, is related to the general increase in educational level of the country as a whole. One cannot, of course, ascribe 33/571 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY the decrease in hysteria to a greater freedom in sexual matters; hysteria is commonest in more poorly educated people, who are least 2‘6 has reported inhibited sexually.”6 Rees that those British soldiers who had hysteri— cal symptoms in World War II were mainly the mental defectives. He noted that hysterical symptoms were related to intelli— 7 indi— has education. and Freyhan gence cated not only that the present clinical patterns of hysteria are different from those shown at the turn of the century but that such schizophrenic manifestations as “cata— leptic stupors, stereotypical motor peculiar— ities, grandiose excitement, and violent behavior” are difficult to find today. These observations suggest that a sociopsycho— logical framework can lead to the prediction of future patterns of mental illness. In our investigations of persons with depressive psychoses, we have frequently noted a pattern of premorbid behavior char— acterized by lack of imagination, creativity, and introspective capacity, and by conven— tionality and general rigidity.13 Similar patterns have been reported by other .authors.3’5"”'21 We believe that a deprived cultural background, such as that involving little or no education, with the early years spent in an illiterate environment with meager cultural resources, is conducive to the development of such a personality pat— tern. When mentally disordered, such per— sons react with the repertoire of behavior patterns that we term “depression.” It is important to keep in mind that While the relationship between social factors and the psychiatric aspects described is probably applicable as a general principle, the specific findings may vary in different settings or institutions. For example, Hollingshead and Redlich12 found that schizophrenia was a diagnosis proportionately commoner among the lower than among the upper classes, while at Hillside Hospital the schizophrenic patients had the highest education. This discrepancy may be related to differences in composition of the two populations, the Hillside patients being drawn largely from 34/572 the middle—class groups, with relatively few from the upper or lower social classes. In Hillside Hospital the diagnosis of schizo— phrenia may indicate an “interesting” pa— tient, while in a state hospital population the same diagnosis may represent a patient who is “hopeless.” From the perspectives developed in this report, observations which are commonly explained in motivational and “dynamic” terms may also be understood in other ways. Thus, some situations where a pa~' tient is said to be “hostile” or “resisting psychotherapy” may reflect a problem in communication between patient and ther— apist, related to their differences in social background. It also is apparent that the social back— ground of the majority of the mentally ill paients is such as to make the current prac— tice of universally employing a verbal, in— sightful—oriented therapeutic approach a difficult, if not inappropriate, procedure. The answer to the problem of how to treat the vast number of mentally ill may be not to train more and more psychother— apists, but, rather, to develop therapeutic techniques more suitable to the patient’s own systems of value and communication. Summary and Conclusions Significant relationships were found be— tween sociopsychological factors and dura— tion of hospitalization, discharge evaluation, and diagnosis in a voluntary mental hos— pital. Patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign—born, and had the highest scores on the California F Scale. Younger, native—born, more educated, and lower F—score patients were hos— pitalized the longest. The same relationship of these factors to length of hospitalization was found when analyses were made according to type of treatment (convulsive therapy or psycho— therapy) and diagnosis. Discharge evaluations of improvement were significantly related to age, the older Vol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT . patients having the more favorable ratings. Analysis of the data by type of treatment demonstrated that patients rated as recovered or much improved after convulsive therapy had the highest F scores, the least education, and were most likely to be foreign-born. Diagnoses of schizophrenia or psycho— neurosis were associated with lower F scores, younger ages, more education, and native birth. The older, less educated, foreign—born, high-F-score patients were most frequently classified under involu— tional or manic-depressive psychosis. It is postulated that these relationships reflect the influence of social background on psychological processes, such as the habitual patterns of communication, modes of eXpression, and symbolic values. These not only contribute to the pattern of mental ill— ness but affect all aspects of the patient— therapist interaction. Hillside Hospital, 75-59 263d St. (Dr. Fink). REFERENCES Adorno, T. W.; Frenkel—Brunswik, E.; Levinson, D. J., and Sanford, R. N.: The Authoritarian Personality, New York, Harper & Brothers, 1950. 2. Arieti, S.: The Decline of Manic—Depressive Psychosis: Its Significance in the Light of Dynamic and Social Psychiatry, paper read at 113th Annual Meeting of American Psychiatric Association, Chicago, 1957. 3. Arnot, R.: The Predepressed Personality, AMA. Arch. Neurol. & Psychiat. 762617—618, 1. 1956. 4. Chodoff, P.: A Re-examination of Some Aspects of Conversion Hysteria, Psychiatry 17: 75-81, 1954. E; Baker, R; Cohen, R. A.; Fromm-Reichmann, F., and Weigert, E.: An In— tensive Study of 12 Cases of Manic—Depressive Psychosis, Psychiatry 17:103-137, 1954. 6. Dunham, H. W., and Meltzer, B. N.: Predicting Length of Hospitalization of Mental Patients, Am. J. Sociol. 52:123—131, 1946. 7. Freyhan, F. A.: The Impact of Somatic Therapies on Course and Clinical Profile of the Schizophrenias, J. Clin. & Exper. Psychopath. 19: 5. Cohen, M. 195-201, 1958. Frumkin, R. M.: Occupation and Major Mental Disorders, in Mental Health and Mental 8. Kalm et al. Disorder, prepared by a committee of the Society for Study of Social Problems, edited by A. M. Rose, New York, W. W. Norton & Company, Inc., 1955, pp. 136-160. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression, Proceeding 42d Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1952, pp. 199-209. 10. Harvey, W. A.: Changing Syndrome and Culture: Recent Studies in Comparative Psychiatry, Internat. J. Soc. Psychiat. 2:165—171, 1956. 11. Hillside Hospital: Twenty—Ninth Annual Report, 1956. 12. Hollingshead, A. B., and Redlich, F. C.: Social Class and Mental Illness: A Community Study, New York, John Wiley & Sons, Inc., 1958. 13. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. N europsychiatry, to be published. 14. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a. Voluntary Mental Hospital, J. Hillside Hosp. 6: 9. 216-228, 1957. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Proceedings of 46th Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958. 16. Kinsey, A. C.; Pomeroy, W. B., and Martin, C. 13.: Sexual Behavior in the Human Male, Philadelphia, W. B. Saunders Company, 1948. 17. Kramer, M.; Goldstein, H.; Israel, R. H., and JohnsonpN. A.: A Historical Study of the Disposition of First Admissions to a State Mental Hospital, Public Health Monograph No. 32, Government Printing Office, 1955. 18. Kramer, K.; Pollack, E. S., and Redick, R. W.: Studies of Incidence and Prevalence of Hospitalized Mental Disorders in the United States: Current Status and Future Goals, paper read at the 49th Annual Meeting of the American Psychopathological Association, New York, 1959. 19. Landis, C., and Page, I. D.: Modern Society and Mental Disease, New York, Farrar & Rinehart, Inc., 1938. 20. Gallagher, E. B.; Levinson, D. J., and Erlich, I.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hos— pital, edited by M. Greenblatt, D. I. Levinson, and R. H. Williams, Chicago, Free Press, 1957. 21. Malamud, W.; Sands, S. L., and Malamud, I.: The Involutional Psychoses: A Socio—Psy— chiatric Study, Psychosom. Med. 3:410-426, 1941. 22. Miller, D. R., and Swanson, (3.: Defense Against Conflict and Social Background, paper 15. 35/573 V �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY read as part of a symposium at the meeting of the American Psychological Association, September, 1953. 23. Morgan, N. C., and Johnson, N. Disorder, New York, Milbank Memorial Fund, 1950, pp. 51-52. 27. Robinson, H. A.; Redlich, F. C., and Myers, J. K.: Social Structure and Psychiatric Treatment, Am. J. Orthopsychiat. 24:307-316, A.: Failures in Psychiatry: The Chronic Hospital Patient, Am. J. Psychiat. 113 :824-830, 1957. 24. Myers, J. K., and Schaffer, L.: Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic, Am. Sociol. Rev. 19: Frank, J. D.: The Fate of Psychiatric Clinic Outpatients Assigned to Psychotherapy, J. Nerv. & Ment. Dis. 127:330— L.: Ethnic I.: Report of the Central 307-310, 1954. 25. Opler, M. K., and Singer, J. Differences Internat. J. 26. Rees, Gruenberg, 36/574 in Behavior and Psychopathology, Soc. Psychiat 2:11—22, 1956. J. R.: in discussion on paper by E. M., in Epidemiology of Mental Printed and Published 1954. 28. Rosenthal, D., and 343, 1958. 29. Weinstock, H. Committee of the American Psychoanalytic Association, paper read at the 48th Annual Meeting of the American Psychopathologi— cal Association, New York, 1958. Fact—Gathering in the United States of Amerm �a. "—1 “‘1 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** __..1 Fl l I J2 P ] �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen L.I. Oaks, New York, 1959—1962. The cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully acknowledged. ' " Aided, in part, by grants My-2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore .Hospital and Medical Center, 111 East 210th Street, York MIP 10467. New York, New ** Present Address: Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** Present Address: National Institute of Mental Health, 2/1/65 Bethesda, Maryland �their studies of the psychiatric patient popsignificant relationships between an individual's position in the social class structure .and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2)9 The influence of the economic status of the patient on the availability of treating personnel, however, was not excludedo ulation, In New Haven Hollingshead and Redlich have reported Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including in— dividual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to paya In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingso These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i429, greater stereotypy, were often fOund in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredg it was suggested that differencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospitala To test this suggestion it was decided to employ the procedures of the 1957 Hillside study in three institutions Hillside In the survey reported here, —w F. Menninger Memorial Hospital in Topeka and the Hospital, the Massachusetts Mental Health Center in Boston, These institutions were selected with the expectation that they had diverse treatment modalities C. equally available, yet served patients of different social classeso Each provided short—term treatment of voluntary patients and did not provide custodial careo Each is a residency training center with a full time supervisory staff and active research units, emphasizing psycho- analytically—oriented psychotherapyo This study was designed to determine the population characterof the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, istics �METHOD A census of institutions all voluntary, adult patients in residence in in January, 1959. While Menninger and patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizophrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary status. The California F scale was scored for each patient on the census the was undertaken Hillside Hospitals had voluntary day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2-factor index a weighted score of education and occupation - was used (3,4,7). The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trends. These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample Sizes. �RESULTS A. Methodological Problems When of the hospital reporting studies tioned briefly. from one institution, the structure be taken for granted and either ignored or men— In gathering comparable data from multiple institu— may tions, however, the many differences between institutions are accen- tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific dif— ferences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome. 1. Designation of Type of Treatment: designating that the institutions, a The criteria for patient received "psychotherapy" differed making comparisons difficult. among Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychia— trist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. At Menninger At Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicians. No additional fees were charged. At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students. Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident responsible for each case. was Individual institutional diagnostic styles At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems. Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a 2. Diagnosis: made comparisons source of difficult. distortion. �Table I 30 Discharge Ratings of Improvement: Ratings of imw provement at the three hOSpitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings.making it difficult to assess the contribution of each factor of the Menninger system (Table II), For this study the Menninger syndrome rating was compared to the global ratings of the other institutions, Table B. II Inter—hospital Comparison lo Sociopsycholqgical Variables The distribution of the variables of social class, age, among the three institutions education and California F Scale score is presented in Table III. Table III . a) Social Class: The anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age distribution in the institutional populationso �populations also differed in edu_” more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduateo c) Education: The cational attainment, with patients having d) F Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty—one per cent of Menninger patients had F scores below 30, and only eight perm cent with scores of 50 or above -— the higher F scores being assoc— iated with higher degrees of stereotypy, In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 309 Thus, differences in social class, educational attainment and performance on the F Scale were observed. These differences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables among these institutions. 2. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV)c b) Duration of Hospitalization: The three insti~ tutions differed with regard to patient's length of stay (Table IV)o Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two—thirds of the patients were discharged within six months of hospitalizatione MMHC 1,—— c) Discharge Evaluation: In each hospital, most were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved” and only a single patient was scored "recovered" or "much improved"a The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachu— patients setts Mental Health Centera d) nostic groupings Diagnosis: For statistical analysis three diagwere made: schizophrenia, affective disorders, and �psychoneurosis and personality disorders (Table IV)» The diag~ nostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one~quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty perucent of the populationo Table Co IV Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier studyg Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsideo Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals the younger patients remaining for the longest periodso While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year, The — Table V �-7DISCUSSION The patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var~ duration of hospitalization, selection of treatments iables and distributions of diagnoses and discharge evaluations (7), Expectations based on our earlier intra—Hillside Hospital were confirmed, The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions“ Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower preportions of psychoneurotic diagnoses, and the better discharge evaluations, —— It is our impression that these differences in psymore to differences in staff attitudes and social class variables than psychiatric differences in populations, The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. While these styl~ istic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged. chiatric treatment are related Such population and treatment variable relationships interactive are processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presente Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, i£§,, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disordersw Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution, They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residenceo Significant differences did occur, however, in �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to anothero Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi- atric characteristics. In our initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background° It was suggested that the higher the person's social background the more complex the criteria em— ployed° This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would clearly defined. But differences in institutional style made to obtain comparable data. This experience is a cue difficult it to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapieso The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationsc These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the original hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative resultsa Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist—patient interaction, be �-10_ SUMMARY AND CONCLUSION Population characteristics, defined by social class, and F score, were related to treatment variables education age, in three voluntary teaching hospitals. Treatment variables in~ cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluationo Inter-institutional differences were observed in patient social class, years of education and distri— bution of California F scores, but not age. variations in treatment characteristics among significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso a-Similarly, the institution serving lower class patients did have the Shorter periods cf hospitalization, lower proportions of The institutions were psychoneurotic diagnoses, and the better discharge evaluations, These variations in psychiatric practices followed a with the social class differences among the inconsistent pattern and are not regarded as idiosyncratic. stitutions Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula- tions is emphasizedo �REFERENCES 1. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. J. and Sanford, R. N. The Authoritarian Personality. Harper and Brothers, New York, 1950, 990 pp. . and Redlich, F. C. Social Class and Community Study. John Wiley and Sons, Illness: New York, 1958, 442 pp. Hollingshead, Mental Inc., A. B. A . Kahn, R. L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216—228. . Kahn, R. L., Pollack, and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. Arch, Gen Psychiat., 1959, 15 565—574. M. Kahn, R. L., Pollack, M. and Fink, M. Social Attitude (Ca1— ifornia F Scale) and Convulsive Therapy. J4_Akuabhlkuugkjlui., 1960, lfiQ: 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amari_Jm_EfixnhiaL., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile.Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �III TABLE InterhospitaI Comparisons for Sociopsychological Variables Menninger Hillside N (87) (133) 1 31% 7% Hospital Social Class Massachusetts Mental Health Center Hospital (72) 3% 11 51 20 28 III 17 34 13 , 1v 1 34 28 v 0 5 28 x2 = 121.5; df=8: p:<.001 Age N (100) (173) ”(95) < 20 19% 19% 15% 20—39 59 ‘58 52 40 + 22 23 33 : x2 = =~ 32% 41% 12-15 54 51 49 16+ 23 17 10 7 = (91) 9.7; df=4; p<.05 (92) (163) (7%) 10-29 51% 33% 20% 30—49 41 50 38 8 17 42 N s °°re “—— 23% x2 F —= (173) -<12 Education -——'———“:=;= (100) N Years of 3.9; df=4; p=n.s. 50—70 1 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables iMenninger Hillside (100) (173) Hospital N Type of Psychotherapy Treatment Somatic Other X2 = Duration 0? Hospital— lzat1°n Hospital Massachusett Mental Health Center (89) 21% 36% 24% 43 64 68 36 —- 8 82.8; df=4; p(.001 N (100), (173) (95) *7 months 22% 27% 67% 13 42 27 65 31 5 7—11 months 511 months Xzf 90.6; df=4' p<.001 N Recovered, Much Improved Discharge Evaluation Improved Unimproved XZ'= N Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder x2 = (99) (172) (88) 1% 23% 28% 80 62 61 19 15 10 29.3; df=4; p<.001 (95) (171) 4185) 43% 52% 54% 5 22 17 52 26 29 23.8; df=4; p<.001 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age. Menninger Hillside 81 42 20-29 73 36 30-39 61 3O 40—49 30 20 50+ 36 Below 20 MMHC l4 �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sociopsychologic aspects of psychiatric treatment in a voluntary mental hospital: duration of hospitalization, discharge ratings, and diagnosis. AMA Arch Gen Psychiatry. 1959 Dec;1:565-74. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-42-008 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource Kahn, Robert L.; Pollack, Max; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from the A.M.A. Archives of General Psychiatry December 1959, Vol. 1. pp. 565—574 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/718a29ec15d25cbb6a477d3556be0fdd.pdf da7a7236e5d976ec8ac1cfd95b801264 PDF Text Text EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADERMAN, M.D., AND MAX FINK, M.D.1 [Reprinted from THE AMERICAN JOURNAL or Vol. 116, No. 9, March, 1960] PSYCHIATRY, �1960 ] CLINICAL NOTES 839 EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADEBMAN, M.D., AND MAX FINK, M.D.1 While many technics for the administration of insulin in insulin coma therapy have been advocated(3), recent reports(4) have assessed multiple divided doses as more effective and safer than other methods. Previous studies indicated that the production of coma was directly related to the level of hypoglycemia and its duration (1) and that deep coma for sustained periods was essential to the treatment result in insulin therapy(2, 3). It seemed reasonable to test the suggestion of increase-d efficacy for a modified insulin administration by comparing the length and depth of coma and the blood sugar levels in patients treated both by single and divided insulin dose methods. If the divided dose schedule were more effective, it would be expected that the induced coma would be equal or greater in depth and duration; that the time for onset would be equal or shorter; and the blood sugar levels lower for divided dosage than single administration. the dose was increased in 10 unit incre— ments. At the time when coma was produced, a single dose equivalent to the 3 doses was given on the succeeding day. For each treatment, coma depth and the time of onset was determined. Coma was defined as the loss of consciousness (failure to respond meaningfully to verbal signals), associated with the appearance of the Babinski reflex, and the loss of the lid reflex. An adequate coma treatment was defined as the persistence of this depth of coma, or deeper (loss of pupillary or corneal reflexes) for at least one hour. At half-hour intervals true blood sugar levels were serially determined by the Somogyi method. The resulting blood sugar curves and their level at the time of onset of coma, were compared for each subject with the blood sugar curve and coma data obtained on a single administration of an equivalent dose. METHOD The blood sugar levels at various intervals after the administration of divided doses of insulin compared with a single dose of insulin in one patient is presented in Figure 1. This pattern has been reproduced in each of the patients studied. For each, the blood sugar curve drops rapidly in the first hour without respect to the initial dose, and flattens at progressively lower levels as the total dosage of insulin increases. Coma characteristically is reported in subjects in whom the blood sugar curve is below 21 mg.% for an extended period of time(1). The time of onset of coma and the blood sugar level at coma in each of the patients is presented in Table 1. In five of the 6 Consecutive patients referred for insulin coma therapy were given daily increasing amounts of insulin in 3 divided doses until a coma level was achieved. The same total dosage was then given in one injection. Six patients were studied in this manner. Each patient was started on the following insulin dose schedule : first day—10 units; second day—10 units and 2 doses of 5 units each at intervals of one half hour; third day—3 doses of 10 units at half hour intervals ; and fourth day—20 units followed by 2 doses of 10 units. On each successive day From the Departments of Internal Medicine and Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. 1., N. Y. 1 [Reprinted from THE OBSERVATIONS AMERICAN JOURNAL OF PSYCHIATRY, Vol. 116, No. 9, March, 1960] �' 'n' 9 Ir" : 840 CLINICAL NOTES [ March I % TRUE BLOOD SUGAR LEVELS FOLLOWING ADMINISTRATION OF INSULIN IN DIVIDED AND SINGLE DOSE SCHEDULES 9 9° ~7‘ 9; 8° 3 O \\ .- _ \\ I \ 7o \.\ as INSULIN DOSAGE IN UNITS 20.20.20... —---— 10.70.70... .......... 90.90.90“. ———-— ...q’ \ \\ '\ ———- AT auo MINJNYEuRVALS “ " “ I20,I20.I20u." —'-— 360u. IN " " " SINGLE DOSE E K <1 0D U) D oo _J with divided doses in 4 of the 6 cases. It was identical in one and lower with the divided dose in one. As there was no evidence in these studies that the divided dose method was more effective in the production of insulin coma than the single dose method, the divided dose technic was discontinued. m CONCLUSIONS MI 3 a: [— O 60 90 IZO I50 TIME IN MINUTES AFTER ADMINISTRATION 30 IBO ZIO OF INITIAL DOSE 240 cases, there was no difference in the time required to induce coma by either the single or the divided dose methods. In one subject (Sc) coma was observed in 132’) hours with a single dose as compared with 3 hours with divided doses. TABLE 1 ONSET OF COMA AND BLOOD SUGAR WITH DIVIDED AND SINGLE DOSAGE SCHEDULES PT D G H c So V Time for Coma Blood Sugar Value (minutes) (mg. %) Insulin Divided Single Divided Single U nit: Dore Dore Dose Dose 330 360 270 390 360 210 210 210 210 180 210 135 190 210 210 90 210 150 4 14 15 12 12 8 0 4 15 7 8 20 The average blood sugar at the time of coma was lower with the single doses than The coma produced with the divided insulin doses did not occur earlier and was not deeper than that produced by the single dose. The increased effort in divided dose schedules is justified neither by increased safety nor by increased depth or duration of the induced hypoglycemia. There was no, evidence that the initial dose of insulin sensitized the subject so that subsequent doses produced a greater hypoglycemic effect. The total hypoglycemic effect of divided doses appears to be less, if anything, than the effect of a single dose. BIBLIOGRAPHY 1. Blumberg, A. G., Cohen, L., Croghan, J., and Kelsey, D.: J. Hillside Hospital, 5: 41, 1956. 2. Fink, M.: J. Hillside Hospital, 6: 197, 1957. 3. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and Other Treatments in Psychiatry. New York: Crune & Stratton, 1952. 4. Laqueur, H. P., and LaBurt, H. A.: Proc. Annual Meeting, American Psychiatric Association, Phila., 1959. �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Efficacy of divided and single dose schedules in insulin coma therapy. Am J Psychiatry. 1960 Mar; 116:839-40. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-43-009 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Blumberg, Arnold G.; Laderman, Peter; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint from THE AMERICAN JOURNAL of PSYCHIATRY, Vol. 116, No. 9, March, 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0a04fd8af8c99e319cfc9e14d05f3ffd.pdf d38bf0d44fbbfe5439d4cca003bd77b2 PDF Text Text CHANGES IN VERBAL TRANSACTIONS WITH INDUCED ALTERED BRAIN FUNCTION JOSEPH JAFFE, M.D., MAX FINK, MD. Reprinted from Tm: JOURNAL or AND ROBERT L. KAHN, PHJ). NERVOUS AND MENTAL DISEASE 130, No. 3, March 1960 Volume Printed in U.S.A. �Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 130, No. 3, March 1960 Printed in U.S.A. CHANGES IN VERBAL TRANSACTIONS WITH INDUCED ALTERED BRAIN FUNCTION JOSEPH JAFFE, M.D.,1 MAX FINK, MD. Repeated interviews with patients under— going convulsive therapy reveal progressive changes in the interpersonal relationship, which are referable to verbal and non-verbal transactions. While non-verbal aspects of communication are difficult to quantify, techniques are available for the measure— ment of verbal behavior. Using such lin— guistic methods, we have observed systematic alterations in language patterns during convulsive therapy, which were related to independent evaluations of behavioral change and to improvement. The description of these language patterns has provided a useful quantitative method for understand— ing interpersonal changes which occur during therapy. In a syntactic—content analysis of recorded interviews during convulsive therapy (6), such changes as denial (negation), qualification (subjunctive and .adverbial modifiers), displacement (person and tense), and cryptic and clichéd remarks were scored. An increased incidence of these changes in the patients’ speech was related both to the degree of induced altered brain function and to the evaluation of therapeutic response. It has been clinically observed that when the language of the patient is affected by neurologic dysfunction, modification of the interviewer’s speech patterns occur. In the syntactic-content analyses, in which a structured interview was used, the examiner’s participation was restricted to statements in the questionnaire. This two-person inter— 1Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. This study was aided by grants 56-151, Foundations’ Fund for Research in Psychiatry, and M-927 of the National Institute of Mental Health, U. S. Public Health Service. The technical assistance of Mrs. Jean Kolodny and Mrs. Ann Horowitz is gratefully acknowledged. 235 AND ROBERT L. KAHN, PHD. view group (or dyad) therefore assumed special characteristics. Interactive effects were minimized. The constraint of the questionnaire interrupted the reciprocal modification of the examiner’s speech. In such a dyad, scoring of the patient’s responses alone constituted an adequate description of changes in the verbal transactions of the two-person communication system. Judgements as to mental status are usually arrived at in less structured conversa— tions between doctor and patient. It was suggested that measurable changes in language patterns would occur even in con~ ventional clinical interviews, and furthermore that such changes would be related to those observed in structured interviews. The methods of dyadic analysis were developed (3—5) to permit a quantitative description of verbal transactions in unstructured interviews (diagnostic, psycho— therapeutic). In this analysis, the speech of doctor and patient is considered as one continuous behavior, and the measurements are performed on consecutive units, irrespective of speaker. The verbal flow of the interview is thus considered as a single out— put, irrespective of speaker. The justification for this maneuver rests ultimately on the correlation of dyadic speech patterns with those obtained by other methods, and is an aim of the present study. These scoring measures of unstructured interviews have been applied to weekly interviews with patients undergoing convul— sive therapy. It is the purpose of this report to 1) determine the pattern of change in dyadic language measures with convulsive therapy; 2) study the relation of these measures to the degree of induced altered cerebral function; and 3) relate the dyadic scores to syntactic language measures ob- �236 JAFFE, FINK AND KAHN tained concurrently in structured inter- repetitive the interaction. For these studies, both the mean and standard deviation of views. the TTR distribution of each interview sam— SUBJECTS AND METHOD ple was obtained. For the syntactic speech analyses the paTwenty-seven consecutive referrals for convulsive therapy in a voluntary mental tient was seen by another examiner during hospital were studied. On a random basis, the same intervals. This interview consisted ten patients were assigned to a control group of a standardized questionnaire composed and the remaining seventeen constituted the of specific items concerning the major comexperimental group. Both groups were com— plaint, reasons for coming to the hospital, parable for age and education; the convul- and temporal and spatial orientation (9). sive group had a mean age of 47 and 11.7 The verbatim responses were analyzed for mean years of education, while the mean the presence of syntactic language changes age of the subconvulsive group was 47.8, previously described as occurring with inwith a mean of 10.5 years of education. The duced cerebral dysfunction (6). Prior to, and at weekly intervals during investigators had no part in the treatment process, and did not know which cases treatment, an electroencephalogram was reserved as controls until data collection was corded in each patient. These records were measured for the per cent time of induced completed. The experimental (convulsive) group was slow wave activity (1). In the dyadic TTR analyses, experimengiven grand mal electro-convulsive therapy three times weekly, under pentothal pre- tal (convulsive) and control (subconvulmedication for a minimum of 12 treatments. sive) groups were compared. In relating The control subjects were treated in identi— dyadic TTR changes to induced slow wave cal fashion except that they received sub- activity and to syntactic language analyses, convulsive electrostimulation while under the mode of treatment was disregarded, all pentothal premedication. patients being considered as a single group. All patients were interviewed prior to RESULTS treatment, and in the week of the 12th 1. Dyadic TTR: A consistent change was treatment. An unstructured clinical diagnostic interview technique was used centered observed in the TTR patterns of the experiabout the patient’s symptoms and life prob- mental group. Scores for consecutive 25 lems. The patient was encouraged to talk word units of interaction in 500 word samfreely, with occasional guiding interventions ples were plotted before and during the by the interviewer. Long silences resulted treatment course (end of the fourth week). in increased interviewer activity. All inter- Figure 1 shows a graph of the TTR patviews were tape—recorded. terns for one patient. Next to each graph is For the formal dyadic analyses (3, 5), the frequency distribution of the 20 consecu— the first 500 words of each interview were tive scores shown. The change in the distranscribed in temporal sequence without tribution for this case was a decrease in the regard to the speaker. This sample of dyadic mean and an increase in the standard deviaspeech was divided into consecutive 25 word tion of the dyadic TTR. This pattern of units. The type-token ratio (TTR) was cal- change was characteristic of the expericulated for each unit. The type—token ratio mental group. is the number of different words (types) Table 1 shows changes in the group mean divided by the total number of words (to- T TR score during treatment. Although there kens). Thus, the lower the TTR the more was a decrease in both groups, the change �237 LANGUAGE CHANGES WITH BRAIN DYSFUNCTION was significant (p < .01) only in the convulsive group and not in the control (sub— convulsive) group. Table 2 shows the changes in standard deviation of the group TTR scores during treatment. There was a significant increase in standard deviation (p < .01) in the convulsive group. In the control (subcon— vulsivc) group the standard deviation was decreased during treatment. The change, however, did not reach statistical signifi— cance. 2. Relation of Dyadic TTR to EEG changes: The changes in dyadic TTR scores were related to changes in brain function as reflected in measurements of the amount of slow wave activity on the electroencephalogram. For this purpose, the per cent time delta activity in the EEG record obtained in the same week as the interview was used. While almost all members of the experimental group developed prominent amounts of EEG delta activity during treatment, none of the control group demonstrated such changes. Using the method of rank order correlation, the change in standard, deviation of the dyadic TTR correlated +65 with the per cent time of delta activity TABLE 1 Change in Mean TTR with Electroshock Subconvulsive Convulsive .92 j .xv-rp/w. p. l— .76 . /. - - with Electroshoclc Subconvulsive Convulsive ,5 3 83 ° .5660 ,0 .92 El e4 ...76 .68 .60 . .68 D—URING TREATMENT / f .76 T” text). .92 Lo 55 5“ 83 m Ea /\T I .56/6068 .76 TTR FIG. 1. .84 fl—I 6 0 10 17 During Difference treatment treatment 8.6 8.1 76 9.2 —0.5 +1.6* *Significant at 0.01 level, using Wilcoxon’s method of paired replicates. TABLE 3 Relation of Syntactic and Dyadic TTR Language ZWeasnres Dyadic Analysis: Syntactic Analysis N Change in Mean Fewer than two changes Two or more changes Change in Standard Dev1at10n 15 —0.8 —0.1 12 —3.0** +1.4* < .01). The greater increase in variability in the language measure was thus associated With the greater degrees of altered brain function. Changes in the mean T TR, however, were not significantly related to the changes in brain function (r = +19). 3. Relation of Dyadic TTR to Syntactic Language Changes: A comparison of dyadic TTR scores with syntactic aspects of the patient’s speech obtained in independent structured interviews was made. The patients were divided into those who showed two or more syntactic language changes, and those who showed fewer than two such changes, regardless of the type of treatment (Table 3). For the patients showing (19 0 N Group Pre— Significant at 0.02 level. ** Significant at 0.01 level. 0’) . —0.8 —2.4* TABLE 2 Change in Standard Deviation of TTR 25 WORD UNITS) E2 80.3 79.2 * ————“‘7 /' 17 81.1 81.6 Significant at 0.02 level, using Wilcoxon’s method of paired replicates. PRE-TREATMENT 1.0 10 treaItirient tiggffiiltegnt Difference * DYADIC TTR PATTERN (CONSECUTIVE N Group .84 .92 LIO Plot of TTR patterns for one patient (see �238 JAFFE, FINK AND KAHN two or more syntactic changes, both dyadic indices showed a significant change during treatment. There were no significant altera— tions in TTR indices for the group showing fewer than two syntactic changes. DISCUSSION These observations indicate a significant difference in dyadic transactions in the experimental (convulsive) and control (subconvulsive) groups—a difference which is referable to a consistent change in the subjects receiving convulsive therapy. The find: ings are consistent with those reported by Weinstein and Kahn (9) in their studies of patients with altered brain function. They observed increased use of the second and third person, non-aphasic misnaming, cli— chés, stereotyped expressions, condensations and neologisms. These language patterns were termed the “language of denial” and were regarded as symbolic adaptations. Kahn and Fink (6) noted similar language changes in patients with brain function al— tered by convulsive therapy. The present observations indicate that verbal transactions during altered brain function are not only more stereotyped qualitatively, as in the use of clichés, but are also more stereotyped quantitatively as in the increased repetition of words. Thus, analyses of the more formal aspects of speech parallel analyses of content. Alteration in brain function was also related to changes in the dyadic indices. The low, but significant correlation between the dyadic scores and EEG delta activity suggests that the two-person communication system as a whole may reflect neurophysio— logical alteration in one of its participants. The low correlation is consistent with previous observations that the dyadic TTR pattern is sensitive to factors other than al— tered brain function (5). Other studies of the dyadic TTR and syntactic language measures during drug administration (2) are consistent with the present findings. Administration of agents which produce EEG hypersynchrony similar to that of convulsive therapy was associated with changes in both language measures in the direction of increased stereotypy and repetitiveness. Agents which produced EEG desynchronization, however, were associated with decreased repetitiveness and a decreased number of syntactic alterations. These observations, though limited to acute drug interviews, indicate that similar changes in language patterns can be antici— pated in subjects following the chronic administration of psychotropic compounds. We anticipate that alteration in patterns of lan— guage may provide cues for the evaluation of behavioral change in drug therapies as well as in convulsive therapy. It is of significance that changes in dyadic speech are measurable when the neurophysiological status of only one of the participants is altered. This observation is consistent with concepts of verbal behavior as a two-person phenomenon, inseparable from its interpersonal context (7, 8, 10). The method and findings also demonstrate that neurophysiologic effects can be investigated in unstructured interviews and that the results may be related directly to those obtained under more structured experimental conditions. Thus, the measurement of formal aspects of language in clinical interviews may be viewed as another tool of neurophysiologic investigation. CONCLUSION Formal language measures in unstruc— tured clinical interviews were undertaken in the course of a study of convulsive and subconvulsive therapies in a hospitalized psychiatric population. Dyadic TTR (Type—Token-Ratio) measures showed a significant decrease in the mean and an increase in the standard deviation in the subjects receiving convulsive therapy, but no differences in those receiv— ing subconvulsive therapy. The degree of change in dyadic indices was related both to the degree of induced delta activity on �LANGUAGE CHANGES WITH BRAIN DYSFUNCTION the electroencephalogram, and to changes in syntactic language patterns obtained in independent structured interviews. Theoretic implications for the understanding of language changes during altered brain function were discussed. 1. REFERENCES FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock. AMA. Arch. Neurol. & Psychiat., 78: 516—525, 1957. J. AND KAI-IN, R. L. Drug induced changes in interview patterns: Linguistic and neurophysiologic indices. In The Dynamics of Psychiatric Drug Therapy, SarwerFoner, G., ed. C. C Thomas, Springfield, Ill. 2. FINK, M., JAFFE, 3. In press. JAFFE, J. An objective study of communication in psychiatric interviews. J. Hillside Hosp., 6: 207—215,1957. 239 J. Dyadic analysis of two psychoanalytic interviews. Presented in Symposium on Psycholinguistic Analysis of the Psychiatric Interview, Divisional Meeting of A.P.A., New York City, November 28, 1959. JAFFE, J. Language of the dyad. Psychiatry, 21: 4. JAFFE, . 249—258, 1958. . . KAHN, R. L. AND FINK, M. Changes in language during electroshock. In Psychopathology of Communication, Hoch, P. and Zubin, J ., eds., Grune & Stratton, New York, 1958. SAPIR, E. Language: An Introduction to the Study of Speech. Harcourt-Brace, New York, 1949. .SKINNER, B. F. Verbal Behavior. Appleton— Century-Crofts, New York, 1957. . WEINSTEIN, E. A. AND KAHN, R. L. Denial of 10. Illness: Symbolic and Physiological Aspects. C. C Thomas, Springfield, Ill., 1955. ZIPF, G. K. Human Behavior and the Principle of Least Efiort. Addison-Wesley, Cambridge, Mass, 1949. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Changes in verbal transactions with induced altered brain function. J Nerv Ment Dis. 1960 Mar; 130:235-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-44-010 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Jaffe, Joseph; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from The JOURNAL of NERVOUS AND MENTAL DISEASE Volume 130, No. 3, March 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/d22bf8e1eaccf5f9a01c426789665f0e.pdf 7c6234b95a1768fbfe1c37f8a9076215 PDF Text Text Reprinted from THE DYNAMICS OF PSYCHIATRIC DRUG THERAPY Edited by G. J. Sarwer-Foner, M.D. CHARLES C THOMAS ° PUBLISHER 0 Springfield ' Illinois ' U.S.A. W DRUG INDUCED CHANGES IN INTERVIEW PATTERNS: LINGUISTIC AND NEUROPHYSIOLOGIC INDICES By MAX FINK, M.D., JOSEPH JAFFE, M.D., and ROBERT L. KAHN, PHD. In studies of the effects of newer psychopharmacologic agents on behavior, we are inclined to emphasize their effects on the patient. The newer compounds do, indeed, have specific physiologic effects, and we propose to review some of the induced neurophysiologic changes. But psychopharmacologic agents affect more than the patient alone—and it is the interactive effects that are the focus of this conference. I am reminded in this regard of the story told at a similar conference by Dr. David Rioch about a psychopharmacologic his that the On of earlier days an amphetamine. era, agent patients took amphetamine, Dr. Rioch reported, they seemed much better. However, on the day when he took the medication, the patients also were considerably improved! How can such changes in human interaction be measured? Of the many aspects of behavior that are altered by the new agents—and it is clear that all aspects of behavior, as perception, ideation, motor activity, mood and judgment are altered—verbal behavior has numerous attributes that make it suitable for the evaluation of changes in interpersonal relations. Verbal behavior is easily recorded, is readily quantified as it is already in units (words, phrases and sentences) and can be recorded and measured without the introduction of artificial sets, equipment, tests or instructions. Furthermore, speech is the core of psychotherreflect in of and measurement language changes may patterns apy changes in the ongoing relationship. For these reasons, we have Aided by Grants M-927 and MY-2092, National Institute of Mental Health, US. P.H.S., and Grant 56-151 of the Foundations’ Fund for Research in Psychiatry. 29 �The Dynamics of Psychiatric Drug Therapy 30 undertaken studies of language patterns—of the patient and of the therapist—as influenced by the newer psychopharmacologic agents. The groundwork for this report was laid in a study by R. L. Kahn of the language changes following convulsive therapy (1) . Under the conditions of the alteration in brain function induced by repeated convulsions, changes in syntactical aspects of language were observed which were related to the degree of cerebral dysfunction and to clinical ratings of improvement. Prior to treatment patients expressed their problems and their aspirations in the present tense and first person, without denial, evasion or cliche’s. During treatment, however, they increasingly utilized the past or future tense and the third person mode with qualification, evasion, denial, displacement, cliches and cryptic responses. Such language patterns on the part of the patient resulted in an alteration in the language patterns of the thera— pists. They, too, found interpretive statements in the present tense less communicative, and increasing use of the future tense, displacement, and minimization of symptoms as aspects of a reassuring attitude became prominent (2, 3). Syntactic analyses are essentially grammatic content analyses, and are dependent upon interpretations by the observer of the subject’s communication. More recently, the dyadic TTR, another measure of language change, has been applied to this problem by J. Jaffe (4, 5). The two person group, or dyad, comprising the interview is treated as a unitary system. The language measure involves the pooling of the verbal behavior of both participants—the patient and the therapist in psychotherapy. In these studies, the tape recorded interview is transcribed in temporal sequence without regard to the speaker of the words, and then divided into consecutive 25 word units of intereaction. TTR, or type-token-ratio, is an established psychological index of language diversity. The ratio reflects the number of different words (the types) to the total number of words (the tokens) in the sample. The TTR is calculated for each 25 word unit and the pattern of consecutive scores is studied. In patients undergoing convulsive therapy, there was a �The Dynamics of Psychiatric Drug Therapy 3] consistent decrease in the mean TTR and an increase in variability (standard deviation) about the mean. These changes reflect greater stereotypy and repetitiveness in the interaction. In a control group of subjects, without induced brain dysfunction, there was neither a change in mean TTR nor in the degree of variability, although there was a tendency for the variability to decrease (6). When these two language measures—one a grammatic content analysis and the second, a formal diversification score—were compared, a decrease in the mean and an increase in variability of the TTR patterns were observed in the subjects who evinced two or more syntactic language changes. Conversely, in those with less than two syntactic language changes, no significant difference in the mean or standard deviation of TTR was observed. These observations indicate that with increased syntactical language changes, there is also a decrease in language diversity with greater stereotypy and repetitiveness. Furthermore, when analyses of each language measure were made with the degree of induced neurophysiologic change, as reflected in the degree of delta activity in the electroencephalogram, significant differences were shown only by the subjects with high degrees of delta activity. In the earlier studies of convulsive therapy, a neurophysiologic-adaptive hypothesis of the mode of action of this form of therapy was expressed (7). In this hypothesis, the therapeutic process is ascribed to a persistent alteration in cerebral function, which provides the milieu for a change in interaction of the subject with his environment. Recently, this hypothesis has been applied to the newer tranquilizing agents (8) and validating studies are now in progress. The studies of verbal behavior are one part of the investigation. We would like to describe our present experimental techniques, report the data from the neurophysiologic and language studies for a number of compounds, and discuss the significance of language measures as indices of change in the ongoing interpersonal behavior of therapist and patient. �The Dynamics of Psychiatric Drug Therapy 32 METHODS At present, all observations are made in the EEG laboratory. Following a routine EEG recording, an unstructured psychiatric interview, with short periods of structured inquiry, is taperecorded. With EEG running, an intravenous injection is then given at a slow rate. When specific EEG or clinical changes are induced, EEG recording is stopped and the interview repeated. Periods of EEG recording and verbal interaction recording are alternated for the duration of the period of observation. The EEG is measured for changes in synchronization, shifts in dominant frequencies, and per cent time of slow wave (9) , alpha or beta frequencies. The tape recordings are transcribed and measured for the diversification of consecutive 25 word samples of dyadic speech (4, 5) and syntactical changes (1). The dyadic analyses have been described. In the syntactic analyses, the response to three standard questions is evaluated as to changes in grammar and content: “What is your main troubleP”; “Why did you come to this place?”; and “What do you wish for more than anything else?” Changes in syntactical use of person, alteration in tense, evasion (as answering a question with a question or “I don’t disof the the subjunctive, use as by know”), qualification, placement or verbal denial of symptoms, increased use of stereotyped expressions or clichés, cryptic responses or withdrawal and silence were scored as changes in the communication pattern. Consecutive patients referred for drug or convulsive therapies in a voluntary psychiatric hospital were seen prior to, and at various intervals during, treatment. To date, the following agents have been studied by these methods: amobarbital, benactyzine, chlorpromazine, diethazine, iproniazid, lysergic-acid diethylamide and Win-2299 (2-diethy1aminoethy1 cyclopentyl—Z-thienyl— glycolate) . �The Dynamics of Psychiatric Drug Therapy 33 OBSERVATIONS l. Electroencephalogram In a previous study (8), it was observed that agents that increase EEG synchronization or induce a shift in EEG frequencies to the slow range generally induce behavioral changes of sedation and tranquilization. Agents that desynchronize the record, however, or induce irregular fast activity, are associated with hallucinatory, excitatory or illusory activity. Of the first group of agents, we have tested amobarbital and chlorpromazine. Amobarbital regularly induces high voltage, well synchronized, fast activity, at 20-24 cps. The regularity of the appearance of this increased synchronized fast activity has become the basis for the “sedation threshold” (10). Chlorpromazine has a variety of effects, depending upon the pre-injection record. In subjects with well defined alpha activity, both alpha voltages and the percent time alpha activity increase (1 l) With poorly modulated, low voltage, fast records, the per cent time alpha increases. In patients with low degrees of slow wave activity, voltages of slow wave activity increase, and the per cent time of both delta and alpha increase. Diethazine, benactyzine, LSD, and Win-2299 are examples of the second group of compounds. In tests of diethazine (12), in subjects with well modulated high per cent time alpha records, there is a decrease in voltage and per cent time of alpha activity and irregular low voltage fast activity appears. In records with high voltage slow wave activity, decrease in voltage and per cent time of slow wave activity is prominent and is associated with irregular fast activity. Similar patterns have been observed for benactyzine, Win-2299 and LSD. . 2. Language Analyses Changes in language occur with these induced changes in brain function (Table I). With chlorpromazine and amobarbital (Class I) there is a decrease in the mean TTR and an increase in variability (standard deviations) of consecutive scores. These changes are similar to the changes noted earlier for elec— tro convulsive therapy (6) . In contrast, diethazine, benactyzine, �34 The Dynamics of Psychiatric Drug Therapy LSD and Win-2299 (Class II) induce an increase in mean and a decrease in variability. TTR TABLE I TTR Class I Class II CHANGE WITH DRUG ADMINISTRATION (N223) (N227) Difference Class Mean Standard Deviation —0.78 +0.44 +1.42* —l.00“ 220‘ 1.44“ I “ Class II Diethazine Benactyzine Amobarbital (l3) Chlorpromazine (10) LSD-25 Win-2299 p > .02 (9) (5) (3) (10) We have not, as yet, applied syntactic methods of analysis to these recordings. Syntactic analyses were done, however, in the earlier studies of the effects of amobarbital and diethazine in patients with varying amounts of slow wave activity after convulsive therapy. Amobarbital amplified, and diethazine reversed, the syntactic patterns produced by convulsive therapy. With amobarbital, denial, displacement, minimization, and use of third person and future and past tense increased significantly (1), while after diethazine, there was a significant decrease (l2) . DISCUSSION We have observed consistent relationships between the neurophysiologic effects of various drugs and changes in two measures of verbal interaction. We have not underscored, although we have consistently observed, that both the behavioral changes and the clinical ratings of improvement are dependent upon the induction of persistent neurophysiologic changes. We have sug— gested, therefore, that the language changes constitute an important segment of the cues upon which the evaluations of “improvement” are based (1) . These language measures provide an operational basis for studies of changes in interpersonal relations without resort to hypothetic energic or topographic constructs. �The Dynamics of Psychiatric Drug Therapy 35 Also important for our discussion is the demonstration that different patterns of verbal behavior may be related to the different neurophysiologic effects of various therapies. Language analyses provide another means of investigating and measuring neurophysiologic effects. Weinstein and Kahn’s (13) demonstrations that language patterns of orientation, confabulation and denial in structured interviews were valuable indices of brain disease, heralded such applications. The demonstration here of consistent changes in dyadic TTR scores suggests that unstructured verbal interviews may also be used successfully in neurophysiologic analyses. The measures described here are crude, and the data preliminary. The consistent nature of the findings as we have investigated each new agent has been striking. Other language measures have been suggested, including changes in rate of speech, tense, and relative amount of verbalization by each participant. Further analyses with other psychopharmacologic agents, and other measures of language analyses are in progress. How can we relate these observations to the problems of this conference? First, generalizations about the psychologic or psychodynamic effects of psychopharmacologic agents are probably untenable unless the varied neurophysiologic and language behavioral effects are encompassed in the hypothesis. While introspective analyses provide some measure of drug effects, more objective data are needed, and these may be provided by language analyses. For example, the successful use of chlorpromazine in the management of hallucinatory and excited states has been well-documented. In such states, high diversification of language, reflective of diffuse associative processes is prominent. This diversity clinically manifest in tangential, incoherent and neologistic speech, with rapidly shifting frames of reference (5) . With chlorpromazine therapy (and the induced alteration in brain function) there is a decrease in the diversification of the verbal interaction, with a decrease in the use of present tense and first person speech. These language patterns may provide the basis for the change in interaction between therapist and patient. Conversely, in apathetic, redundant, blocked or withdrawn pais �36 The Dynamics of Psychiatric Drug Therapy tients, the administration of LSD (14) or mescaline (15) have been suggested. These agents induce an increase in associative is reflecdiversification a increased which of language processes tion. These agents also increase the use of first person and of facilitate thus and tense speech survey may patterns, present the pafients premnn:atdtudes and feehngs “finch the therapbt is interested in exploring. In summary, we have indicated that concurrent neurophysiologic (EEG) and language behavior (syntactic and dyadic diversification) measures are techniques for the operational analyses of the effects of psychopharmacologic agents, in the two-person system of doctor and patient. Further exploration of language measures are suggested as a rational basis for the understanding of the psychologic effects of these new therapies. REFERENCES Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Hoch, P. and Zubin, J. eds. New York, Grune 8c Stratton, 1958, pp. 126—139. 2. Esecover, H., Jaffe, J., and Kahn, R. L.: Psychotherapeutic techniques with electroshock patients. J. Hillside Hosp, 7: 17-25, 1958. 3. Jaffe, J., Esecover, H., Kahn, R. L., and Fink, M.: Modification of psychotherapeutic and supervisory relationships by altered brain function. 1. In preparation. 4. Jaffe, J. An Objective Study of communication in psychiatric inter— views. ]. Hillside Hosp, 6:207-215, 1957. 5. Jaffe, J. Language of the Dyad. Psychiatry, 21:249-258, 1958. 6. Jaffe, J., Kahn, R. L., and Fink. M.: Communication patterns with altered brain function. Read at Eastern Psychologic Assoc, April 1958. 7. Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation between altered brain function and denial in electroshock therapy. A.M.A. Arch. Neurol. dy' Psychiat., 76:23-29, 1956. 8. Fink, M.: A unified theory of the action of physiodynamic therapies. ]. Hillside Hosp, 6:197—206, 1957. 9. Fink, M., and Kahn, R. L.: Relation of EEG delta activity to behavioral 63' Arch. A.M.A. Neurol. electroshock. in Psychiat., 78:516response 525, 1957. 10. Shagass, C.: The sedation threshold. A method for estimating tension in psychiatric patients. EEG Clin. Neurophysiol, 6:221-233, 1954. ���at 3:2» W mu mm. W WWW “a“ M I. 3., and mm mm mm and It 3.1%., April 12, mum, 11.: 8.1:»: at. 1958. mF?“ '1'? , immummdw mama» was: Wm, mmmumwuwam mu: m). 3,: ... 9 w_ gs 191.206. 1991. �Drug Indueod Ghana-l in Imam“ know: man ma Hwophylielogie XII Indiana ’m 11.9., Jawb- JII‘. xi)... ma Rabat In Kuhn PILD. mmm quoal' find for Rani-eh in Fayehutry. PM the Ewart-mt a! Puemtry, Wain 3mm, Elan om, Jul. , 3.1. Aided by firm“ “2? and name, trident]. 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NWuammmmmumM) w‘nmmw3-MNMW' mmmamu _' Mumamwwammu‘ Mum mmmmmmaflmwm3 ‘ Mmmmm,mww:mmmam thwawmrwmmwunm MW hm,muwmmmmmm(m) MW¢W(WmmflMMWm �tum” for tho apex-gum]. may”: at the «feat: at mcmhac agents, in tho Mm mm a: “Mr a and patient. Further mention Imus: mm“ m :33ng u mum but: far the underflmdinc of the whim «that: 0: than an tharnpiu. at �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Drug induced changes in interview patterns: linguistic and neurophysiologic indices. In G.J. Sarwer-Foner (ed.), The Dynamics of Psychiatric Drug Therapy. C.C. Thomas, Springfield, IL, 1960: 29-44. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-45-011 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Jaffe, Joseph; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint, [preprint] and outline. Reprint from THE DYNAMICS OF PSYCHIATRIC DRUG THERAPY Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/d30b69ef69a8cf00c194481df0db03be.pdf 468179c0544d033b07449c4407b71b92 PDF Text Text Reprinted from THE JOURNAL OF Volume 130, NERvots AND MENTAL DIsEAsE No. 3, March 1960 Printed in (ISA. SOCIAL ATTITUDE (CALIFORNIA F SCALE) AND CONVULSIVE THERAPY ROBERT L. KAHN, PH.D.,1 MAX POLLACK, PH.D. . ,\— AND MAX FINK, M.D. improved was most likely in those who were Studies of the mode of action of convulsive therapy in altering behavior have been under investigation by a variety of experimental methods in our laboratory for several years. Early studies demonstrated a relationship between clinical evaluations of improvement and the degree of altered brain function as measured by the amobarbital test (15) and the electroencephalogram (5). Personality patterns related to a favorable therapeutic outcome have been defined by family interviews (13) and projective techniques (14). Behavioral changes have been measured by complex visual and tactile perceptual tasks (6) and by analyses of changes in syntactical aspects of language (12). More recently we have become increasingly aware of the relation of sociopsycho— logical factors to differences in both referral for, and response to, convulsive therapy. In a study of the entire adult iii-patient population of Hillside Hospital it was found that those patients referred for convulsive therapy were significantly older, more likely to have been foreign-born, had less education and higher scores on the California F Scale than those patients who received psychotherapy alone (17). Of those patients receiving convulsive therapy, a favorable therapeutic evaluation of recovered or much older, more poorly educated, foreign—born and with higher F scores (18). The aim of the present investigations was to study the convulsive therapy process further by the use of the California F Scale (1). Although promulgated in a setting where interest was focused on prejudice and au— thoritarianism, the F Scale was designed to evaluate psychological aspects, such as con— ventionalism, rigidity and stereotypy, related to the manifestation of these social attitudes. It was our specific purpose to determine: 1) what the F Scale measures in a psychiatric population, and 2) how response to the F Scale varies with change in brain function. METHOD Population: These studies have been conducted at Hillside Hospital, a private, nonprofit 200-bed psychiatric hospital in New York City admitting voluntary patients with “early and curable mental illness.” Psychoanalytically—oriented psychotherapy is the treatment of choice for all patients, with somatic therapies (convulsive, insulin coma and drug therapies) regarded as ancillary, but available when needed. The in—patient population consists mainly of middle-class Jewish patients, with a high school education. between the ages of 18 and 40. Most patients are classified into the diagnostic categories of schizophrenia, psychoneurosis, manic-depressive and involutional psychosis. In these studies we have used a ten-item modification of the standard F Scale (8). Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. This investigation was supported in part by grants M-927 and MYw2092 from the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. This paper derives from a presentation given at the Annual Meeting of the Eastern Psychological Association, Philadelphia, 1 April, 1958. 187 �188 KAHN, POLLACK AND FINK TABLE 1 Scores on Conventional and “Reverse” F Scales Dichoto— (grilled I‘OU p S M chzi: iN Cpnv erll— iona Scale hi3: ‘Reverse”' _ Diff. t 51.5 48.1 +25.2 +0.7 20.3* : Scale I 10—37 38—70 * 79' Significanti _ at .001 0.6 level The procedure consists of having the subject read ten statements and indicating to what extent he agrees or disagrees with each, i.e. a little, pretty much, or very much. The score for each item ranges from one to seven, and the total score range is 10 to 70, with high scores indicating greater agreement with the statements. The statements are extreme, uncritical or stereotyped expres— sions, such as: “No sane, normal, decent person would ever think of hurting a close friend or relative” and “If people would talk less and work more, everybody would be better off.” RESULTS ment with the statements. In contrast, the patients who made high scores initially showed little change on retesting, indicating that they agreed with the statements to the same extent even when their meanings were reversed. Change in F Score with convulsive therapy. In a second study, 69 consecutive hospitalized patients referred for convulsive therapy were given the F Scale in the week prior to treatment, on the day following the 12th treatment, and two weeks after the termination of treatment. These patients were divided into two groups; an experimental group of 59, and a control group of ten patients randomly selected from the referrals. In the experimental group all patients received grand mal convulsive therapy, while the control group received subconvulsive electro-stimulation only. All patients were treated three times a week, for a minimum of 12 treatments. The degree of physiologic change during treatment was determined by quantitative analyses of delta activity in the EEG, using techniques previously described (5). EEG records were obtained weekly and the records taken nearest the 12th treatment were measured for the degree of induced slow wave activity (the per cent time occupied by waves of 6 cps or slower for 66 seconds of recording from the anterior temporal—vertex leads). The changes in F score during convulsive treatment are shown in Table 2. There was a mean increase of +5.7 in F score during What the F Scale measures in this population: the “reverse” F Scale. In this study the entire in-patient population was first tested with the conventional scale, then retested one month later with a “reverse” scale (2). In the “reverse” scale the same items are used, but stated in opposite terms to the original. Thus, the first example cited above is changed to read, “A sane, normal, decent person might have to hurt a close friend or relative.” The “reverse” scale is scored in the same manner as the regular scale, with TABLE 2 Efiect of Convulsive Treatment on F Score high scores reflecting greater agreement. The relation of the scores on the convenMean F Score tional to the “reverse” scales is shown in N PreTable 1. The patients were divided into two Mean During t Treatment Difference 22:? the to median groups according score on the conventional scale. Those patients who made Convulsive 59 45.3 51.0 2.02* +5.7 low scores initially, indicating predominant Group 10 48.7 disagreement with the statements, showed a Control 49.2 +0.5 0.02 Group significant increase in score on the “reverse” * scale, indicating that they were now in agreeSignificant at .05 level �189 SOCIAL ATTITUDE AND ECT treatment, a difference significant at the five the of confidence. In level cent contrast, per control group showed a statistically insignificant change during the same period. The effect of convulsive therapy on the F score was further demonstrated by an analysis of seven patients, originally in the control group, who were subsequently placed on a regular course of convulsive therapy. On retest after 12 control treatments their scores were unchanged, with a mean difference from the pretreatment score of +0.1. After 12 convulsive treatments, however, these patients showed a significant mean increase of +9.1. Adequate EEG records at the time of the 12th treatment were obtained for 54 patients. For this analysis the records were divided into two groups according to the degree of slow wave activity: a high delta index group in whom slow wave activity appeared in 40 per cent or more of the selected leads, and a low delta index group in whom the slow wave activity was less than 40 per cent. Changes in F scores during treat— ment for the two groups are shown in Table 3. TABLE 3 Change in F Score and Degree of Induced Cerebral Dysfunction Mean Treatment Treatment Difference Pre- During 27 43.9 52.5 +8.6 23* 27 45.6 49.0 +3.4 0.8 Degree of Slow Wave Activity High Delta Index Low Delta Index * 15 Significant at .05 level The patients with high degrees of slow wave activity had a mean increase in F score of +8.6, significant at the five per cent level of confidence. Those patients with low delta indices showed a relatively small increase of +3.4. While the increase in scores in the low delta activity group was statistically insignificant, it was greater than that of the control group (Table 2). TABLE 4 Pre-Treatment and Post—Treatment F Scores Pre— Post— 21 42.2 40.6 —1.6 0.4 16 42.6 42.1 —0.5 0.1 N High Delta Index Low Delta Index .Mean Treatment Treatment Diflerence I F scores were obtained in 44 patients two weeks after the last treatment (Table 4). The mean difference between pre— and posttreatment scores was statistically insignificant. Furthermore, the same pattern of a small decrease in score was found for both the high and low delta activity groups. DISCUSSION These observations demonstrate the relevance of the F Scale to the convulsive ther— of these An understanding apy process. relationships requires examination of the psychological factors reflected by the F Scale in our population. The observations on the “reverse” F Scale indicate that those patients who disagreed with the original statements (low F score) were responding to the content of the state— ments. This was shown by the high degree of agreement with the reverse statements. Those patients who agreed with the original statements (high F score), however, continued to agree when the statements were reversed. Evidently, these patients were not responding to the content of the statements, but demonstrated a more generalized reac— tion. There have been several studies on non— psychiatric populations using a “reverse” F Scale, with conflicting results. Thus, Chris— tie, Havel and Seidenberg (3) have found a consistent response to content in original and reverse scales, e.g., agreeing to one and disagreeing with the other, while Jackson, Messick and Solley (10) report a positive correlation between agreement on the two scales. In part, these differences may be accounted for by differences in the form of the reversed �190 KAHN, POLLACK AND FINK scale. Jackson and Messick (9) indicated that Christie ct al. (3) modified the language form of the original scale and reversed the content, while Jackson et al. (10) retained the extreme, cliché—ridden style of the origi— nal scale. Jackson and Messick indicate that the response pattern to the F Scale may be interpreted in terms of response style rather than specific item content. On the basis of the data from our population there is a difference between the high and low scorers with respect to the extent that cognitive style affects their response. The high scorers who agree with both forms of the scale show a consistent style of response acquiescence, overgeneralization and conforming to so— cially desirable standards. Those who scored low on the original scale, however, did not show the converse—a consistent pattern of negativism or social non-conformity. Rather, they altered their style to agree with the con— tent when the statements were reversed. Thus, low F score patients were characteristically more critical and discriminating persons, While those with high F scores were more undifferentiating and stereotyped in their reactions. With this conception of the F Scale, the findings in convulsive therapy may be considered. In the selection of treatment in this institution, those patients receiving convul— sive therapy had significantly higher scores than those receiving psychotherapy only (17). That this observation is not simply a reflection of diagnosis is seen in the differentiation by the F score of the selection of treatment even among those patients classi— fied as psychotic depression. The selection of treatment thus seems related to psycho— logical processes reflected in the F Scale. Subjects with high F scores, with stereotypy of thinking and difficulty in introspection, often present a behavioral pattern incompatible with the establishment of the type of interpersonal relationships required in psychoanalytically-oriented psychotherapy. The favorable evaluations of therapeutic response to convulsive therapy in patients with high F scores may be related to personality attributes. The psychological processes reflected in the F Scale are similar to those personality factors previously found to be related to a favorable response to such treatment. In structured family interviews it was observed that the favorably rated patients had personality patterns characterized as nonempathic, nonintrospective, nonverbally communicative, and highly conventional and stereotyped, with little imagi— native or creative capacity (13). Consistent patterns have been shown in Rorschach studies indicating that good prognosis is re— lated to a small number of responses, absence of human movement and little diversification of content (7, 14). The F score increases significantly with convulsive therapy with the extent of in— crease related to the degree of altered brain function, as measured by the degree of induced EEG slow wave activity. This relation of change in behavior to physiological change is an observation that has been consistently noted in convulsive therapy patients (5). The increase in F score during treatment may have been even more marked than actually observed. Several patients of foreign birth and little education had maximum or near maximum scores prior to treatment, thus eliminating or reducing the possibility of an increase on retesting. The change in score with altered brain function is consistent with previous observations on the behavioral effects of convulsive therapy. In accord with our conceptual framework, greater agreement with F Scale items during treatment is related to increased stereotypy and difficulty in discrimination, as well as to increased acquiescence. This is part of a general process which has been noted in linguistic, perceptual and clinical behavioral measures. In their language, convulsive therapy patients show increased denial, evasion, qualification and use of clichés and stereotyped expressions �SOCIAL ATTITUDE AND ECT (12). They also manifest increased repetitiveness of words (11), difficulty in complex visual and tactile perception (6) and figureground discrimination (16). Clinically, they are characteristically more compliant and acquiescent and try to please the examiner (4). SUMMARY A measure of social attitude, the California F Scale, has been utilized in studies of the convulsive therapy process. In a voluntary psychiatric hospital it was noted that patients referred for convulsive therapy had significantly higher F scores than those re— ceiving psychotherapy only. Among the patients receiving convulsive therapy, those with the higher initial F scores were evalu— ated as showing the best clinical results. With treatment there was a significant increase in F score, with the increase related to the degree of altered brain function. Follow— ing treatment the scores returned to their original level. Comparison of results with a conventional and “reverse” F Scale demonstrated that patients with low F scores respond to the content of the questionnaire, while those with high F scores showed a generalized of the con— of independent agreement pattern tent. These results are interpreted in terms of the psychological processes measured by the F Scale. High—scoring patients are considered to be stereotyped in their thinking and to have difficulty in introspection—behavior which is incompatible with psychoanalytically-oriented psychotherapy, rendering them more liable to referral for convulsive therapy. With treatment, such patients are also more likely to develop the language patterns of denial and use of clichés which are the cues for evaluations of clinical improvement. The increase in F score with treatment is comparable to other types of behavioral change, such as increased acquiesin figure-ground increased difficulty cence, 191 discrimination, and increased stereotypy of language. REFERENCES 1. ADORNO, T. W. ET AL. The Authoritarian Personality. Harper, New York, 1950. 2. BAss, B. M. Authoritarianism or acquiescence? J. Abnorm. & Social Psychol., 51: 611—623, 1955. 3. CHRISTIE, R., HAVEL, J. AND SEIDENBERG, B. Is the F Scale irreversible? J. Abnorm. & Social Psychol., 56: 143—159, 1958. 4. FINK, M. AND KAHN, R. L. Behavioral patterns in induced states of altered brain function. Paper read at Divisional Meeting, Am. Psychiat. Ass., New York, November, 1957. 5. FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock: quantitative serial studies. AMA Arch. Neurol. & Psychiat., 78: 516—525, 1957. M., KAHN, R. L. AND KORIN, H. Effects of diffuse altered brain function on perception. Internat. Congr. Psychol, Proc., 15: 6. FINK, 238—239, 1959. 7. FINK, M., KAHN, R. L. AND POLLACK, M. Psychological factors affecting individual differences in behavioral response to con— vulsive therapy. J. Nerv. & Ment. Dis, 128: 243—248, 1959. J. AND ERLICH, I. Some sociopsychological characteristics of patients and their relevance for psychiatric treatment. In The Patient and the Mental Hospital, Greenblatt, M., Levinson, D. J. and Williams, R. H., eds., pp. 357—379. Free Press, Glencoe, 111., 1957. 9. JACKSON, D. N. AND MEssroK, S. J. Content and style in personality assessment. Psychol. Bull., 55: 243—252, 1958. 10. JACKSON, D. N., MESSICK, S. J. AND SOLLEY, C. M. How “rigid” is the authoritarian? J. Abnorm. & Social Psychol., 54: 137—140, 8. GALLAGHER, E. B., LEVINSON, D. 1957. J., FINK, M. AND KAHN, R. L. Com— munication patterns with altered brain function. J. Nerv. & Ment. Dis., 130: 235—239, 11. JAFFE, 1960. 12. KAHN, R. L. AND FINK, M. Changes in language during electroshock therapy. In Psy— chopathology of Communication, Hoch, P. and Zubin, J., eds., pp. 126—319. Grune & Strat— ton, New York, 1958. 13. KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock therapy. J. Neuropsychiat., 1: 45—49, 1959. 14. KAHN, R. L. AND FINK, M. Prognostic value of Rorschach criteria in clinical response to convulsive therapy. J. Neuropsychiat. In press. 15. KAHN, R. L., FINK, M. AND WEINSTEIN, E. A. Relation of amobarbital test to clinical im- �192 KAHN, POLLACK AND FINK provement in electroshock. A.M.A. Arch. Neurol. & Psychiat., 76: 23—29, 1956. 16. KAHN, R. L., POLLACK, M. AND ure—ground discrimination FINK, M. Fig— after induced altered brain function. A.M.A. Arch. Neurol. In press. 17. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in the selection of therapy in a vol— untary mental hospital. J. Hillside Hosp, 6: 216—228, 1957. 18. KAHN, R. L., POLLACK, M. AND FINK, M. Sociopsychological aspects of psychiatric treatment. A.M.A. Arch. Gen. Psychiat., 1: 565—574, 1959. , �Social Attitude (Californin 3 Scale) and convulsivo Ihornpy Robort L.Kahn Ph.n., Kn: Polluek Ph.D. and flux rink H.D. Dcpurtnont a! Experimentnl Psychiatry, Hillside Hospital, 61"! 0.1(3' litre, 3.1. ~ IX; 11/10/59 �mu. 1: part, at t» mun run-hum. tannins“. nuuczym, April, ”58. 3*91‘1 1» try at “.2092 «a put. at um, an” “tuna menu» a: mm mu. “an“ Influx“: of Inn“. was. ”In.“ mm: aunt“. �3.3111 Attitude and E0! �Boeial Attitude (Galifornia I Scale) and Convnleive Therapy Studies of the node of action of convulsive therapy in altering behavior have been under investigation by a variety of experimental methods in our laboratory for several years. Early studies demonstrated a relationship between clinical evaluations of inproveaent and the degree of altered brain function as measured by the aaobarbital test (12) and the electroencephalogram (h). Personality patterns related to a favorable therapeutic outeone have been defined by fanily interviews (13) and projective techniques (15). Behavioral changes have been neasured by eeaplex visual and tactile perceptual tasks (6) and by analyses of changes in syntactical aspects of language (16). recently we have become increasingly aware of the relation of seeiopsyehelegieal factors to differences in both referral for, and response to, convulsive therapy. In a study of the entire adult in-patient population of Hillside hospital it was found that these patients referred for convulsive therapy were significantly older, more likely to have been foreign-born, had less education and higher scores on the Californi I Scale than these patients who received psychotherapy alone (17). Of those patients receiving convulsive therapy, a favorable therapeutic evaluation of recovered er much iapreved was nest likely in those who were older, aore poorly educated, foreign-born and with higher 7 scores (18). Here �1h. 31: 0: ts. pr.nunt tavcnttanttonl.wun to turtle: 'utniy tho convulntvo thorny: pronoun h: £3. at. or «p. 6.113.231: r Saul. (1). Althotgh prcanllt‘nd 1: a cutting white tn‘iroat at: located an prtandicc tad luthnrttnrtanxln, tho I Ital. wt: d-utgnod to it‘lxuto paychcloginnl napocto, such a: convontilnlltun, rigidity and Itarcnfiyyy, rclutcd to thy n;nt£cn#n$t¢n a: tin:- :0aiul attitudes. I It wan OI! apuctltc ptrpnna to how und 2) pnychtatrta poyuzntiou, t acaln 1.210: with Chllg! in brain function. 83:19 acanurul 13 rtiptnao $0 it. I naturist. 1) tint tho �KBIEOD: Pepnlationt These studies have been conducted at hillside Hospital, a private, nanoprerit 200 bed psychiatric hospital in New York City adaitting relentary patients with Iearly and enrahle aental illness". rPsyeheanalytiosllyu oriented psychotherapy is the treatment of choice for all (convulsive, with senatie therapies patients, insulin cans and drug therapies) regarded as ancillary, but available when needed. The in-patient populatien epneiste mainly of niddleclass Jewish patients, with a high school education, between the ages of 18 and ho. Most patients are classified into the diagnostic categories of schieophrenia, psychonenrosis, manicdepressive and invelntienal psychosis. In these studies we have need a ten its: aeditieation e! the standard scale (8). The procedure consists of having the subject read ten stateaents and indicating te‘Whet extent he agrees or disagrees with each, i.e. a little, pretty each, or very such. The score for each item ranges tron one to seven, and the tetal sears range is 10 to 70, with high scores indicating greater asreenent with the otatenents. The statenente are extreme, uncritical er stereotyped expressions, such as: "No sane,neraal, deeent person would ever think or hurting a close friend or relative‘ and "If people would talk less and work acre, everybody would be better air.” �RESELISs the 1 Scale Heaenree in our Po nlatione The i'ne'nn-ae'“ F Scale In this stat: the entire in-patient population was tiret tested with the contentional eeale, then reteeted one nenth later with a 'reveree' eeib (2). 'In the "reverse" scale the sane items were need, but stated in opposite terms to the original. Thus the liret example cited above was ohanged to read, ”A aane, normal, decent person night have to hurt a The close friend or relative." 9reverse'eea1e was scored in the eane manner as the regular scale, with high score: reflecting What greater agreement. the relation of the eeoree on the conventional to the “reverse“ eealee 1e ehovn in table I. The patienta were divided into two group: according to the nedian aoore en the conventional eeele. Those patiente who node low eeeree initially, indicating predoninant dieagraeaent with the etatenente, ehoved a significant innfeaae in score on the 'reveree“ scale, indicating that they were not in agreement with the statements. In contrast, the patients who aade high eeoree initially showed little change on retenting, indieating that they agreed with the etatenente to the sane extent even when their meanings were reversed. -u-abfiooogqfi‘mmn—tun‘m Table I about here Dun-Qn-uueembebuufiua-Oepn. �TABLE I Scar-a on Conventional and 'Rovorao' Dichotonisod Graugs Kcan Scorn conventional Soul. ~!_ I fiction noun Score “levcrao' Se&lo Dirt. .£_ 20.3‘ 10-37 76 26.3 51.5 +25. 2 36.70 79 h7.h h8.1 + ”Signitietnt at .001 luvol 0.7 0.6 �.5- I score with cenvuleive theregz. In e eeoond etody, 69 eoneeoutive heepitelieed petiente referred for eonvnleive therepy were given the r seele in the week prior-to treetwent, on the dey following the 12th treetwent, end two weeke etter the terninetion er treeteent. Theee pdiente were divided into two groupe,en experimentel group of 59, end I control group or ten petiente tenderly selected from the reterrelea In the experieentel group e11 petiente reeeived greed eel oeuvuleive therepy, while the control group received enbeonvuleive electro-etieuletien only. All petiente were treeted three tieee e week, for e nininne Change e1 12 in treeteente. , physiologic ohenge during ‘lreetnent wee deterrined by queutitetive enelyeee of delta eotivity in the EEG, neing teehniquee previoneh deeerihed (h). EEG reoorde were ebteined weekly end the reeerde token neereet the 12th treetnent were neeeered for the degree of induced elow were 6 wevee o: by cent ocoopied ope or (the tine eetivity per elewer for 66 eeeonde of recording from the enterior tenperelvertex leede). The ehengee in r eeore during oonvuleive treetnent ere ehewn in Tehb 2. There wee e ween increeee of +5.? in r eeore during treetwent, e difference eignificent et the 55 level of confidence. In contreet, the control group ehowed e etetietieelly iheighitioent chenge during the eeee period. The degree of �.6. it. attics if nouvnlntvt thorny, an in. r atnvn vat tnrihur dcnouatrafiua by a: ina1ruaa if aovoa pattcltug' originallyjtn the nautrll crux», vi. wart t‘§u¢.u¢ut11 plant: ffltfififi 33%.: an «mutilatvu of neuron $hurtyy. rcculur a a: 13 anntral trunthaut: that: Iqurca utrn tuuhauucu. ‘1‘» a mans ditftruuao :tcn tut protrcatunut tutti Q3 «9.1 errorn. Altar 12 nnuvulntvo trtatlcuta, fiauuvur, than. ptiiia‘t unavod :1mm». a: 09.1 anew. “want u» tibla 5h but. it. its. at tin 12th irontntat pflttflt‘fl. In! $htt tnnlyttn tho Instant Adogua§a BIB roaorda var. ubtntnoa tor a about 3% Itvtdndjin£o tut nauupo'nno.r¢ina ‘9 it. 1.33%. at Ilia var. ntilvltyu a high dixfic 13am: group‘tn ulna slaw unvrunttvtty Ip’cntod 1n ho: or nor. 0: ti. stlcutod Ionic. Qua a lll‘lfl‘fi ludax (ran; 1: that th. III! II'. nafilvtty u:Xcal than 801. Gianna. in I lifivflfl fl!rtll $2¢usnoat fur fit. in. groups .9. shut: in rabid 3. warn ‘ .C'OOUMfiOWQ‘fiQD‘OOO‘ Inhla 3 thont but. fl. “’.*“*Q*&.*QOOQQU In. ytfiiunta with high 4.3!!!! a: axon any! aattvity had n o: «8.é. significanfi tt tho 5! 10'01 at conttdtnnc. than. putianta with 10v 401‘: iadlceu uhluud lama ilerillt 1a 9 t¢¢ru �TABLE 2 Effect of Convulsivo Treatnent on r Score Raga P Saute 1 Pre~ treatnont During Treatment Convuluive Group 59 h5.3 51.0 control Group 10 h8.7 h9.2 ‘ Significant at .05 lovcl noun Difference 3 + 5.7 2.02* + 0.5 0.02 �TABLE 3 Chan 0 in r Scare and chroo or 31.u Huvc ctivit De roe o: Induood Cor-bral Pro» ‘g During front-out rroatnont D stunctioa noun Differenco t ligh molt. Index 27 h3.9 52.5 +8.6 2.3“ Lov'nolta Indox 27 h§.6 h9.0 +3.h 0.8 G Significnnt 1t .05 level �-1- relatively small inereuso of +3.h. Hhilo the increase in scores in the low delta nativity group was stutiatioally insignificant, it ran grout-r thtn that or the control a (table 2). 1 score: were abtainod in hh patient: two racks utter the 1tat troatnnnt (T‘ble h). The noun ditfcrnnec botvccn pro~ tad ponttruatncnt scorcs fill statistically insignifictnt. Furthermore, tho 5.30 puttsrn or a 3:111 door-nae 1n acor$gw found 1nd both the for high delta totittty group: v:a graup .--Q-‘-~-"-..-flfifi-.. Table h thout hora .‘..--*-‘Cfl-‘-‘-~‘-fl‘ �an: t Index Low Delta Indox ttrontncnt 1 Score: Prc~ Pout— Kean Trautnent Trontnent Difference 21 h2.2 h0.6 16 h2.6 h2.1 3| High Delta h ~1.6 «0.5 0.1 �DISGU8SION: These observations demonstrate the relevance of tho to the oonvnleivo therapy proooea. in understanding of theeo relationships requiroe oxanination of the payoholegioal factors reflected by the 7 Scale in our population. The obeorvationa on the reverse F scale indicatee that those pationte who diaagroed with the original etatonente (low r eoore) were responding to the content or the otatonente. Thie nae shown by the high degree or agreement with the rarer-o statoaente. However, thoee patiente who agreed with the original etatononto (high I eoere) continued to agree when the etatenente were revereed. Evidently, these patient: were not reephnding to the oontent e! the atatonente, but deaenatrated a noro generalised reaction. There have been several otudioo on nenpeyohiatrio populations neing a reverse I soelo, with conflicting reenlte. Thno, Christie, floral and Seidonberg (3) have found a coneiatont roeponeo to content in original and rovoreo ooaloe, o. ., agreeing to one and disagreeing with the other, while Jackson, Heeeiok and Selley (9) retort a positive correlation between agreement on the two eoalee. In part, theoe dittoronooe nay be accounted for by difference: in the tern of the rovoreod eoalo. Jackson and Heeeiok (10) indicated that Chrietie gt 3;. (3) modified the language fora of the original scale and reversed the content, while Jaokeon et a1. (9) retained the extreao, olioho1ridden etyle e: the original eoalo. Jackson and noeeick indicate that the reeponoo pattern to 7 Scale �«91- the 1 Scale nsy be interpreted in terne of response style rsther then specific item content. 0n the besis or the dots from our popnlsticn there is s difference between the high end low scores with respect to the extent thst cognitive style effects their response. the high scorers who egree with both ferns or the sonic lion s consistent style of response ecqniescsnoe, evergenerelisetien end contorning to secislly desireble stendsrds. Those who scored low on the originsi sosie, however, did not shoe the converse -. s consistent psttern or negotivisn or sociel nenvcentornity. they eltered their style to egree with the content when the ststononts were reversed. ‘Thns, low I score petients were cherscteristicsily nore critical snd.decrildnsting persons, while these with high I scores were norc nndittcrontieting end stereotyped in their resctione. With this conception of the r Seth, the findings in convulsive thorspy may be considered. In the selection or trectnent in this institntion, those psticnts receiving convulsive therapy had significantly higher scores then those recciving psychotherapy only (17). That this observs~ tion is not Just e reflection of diagnosis is seen in the dittorsntietion by the F score of the selection of trestnent oven snong those pstients clsssitied es psychotic depression. The selection of treatment than scone related to poyohologicsl processes reflected in the r Scale. Subjects with high I �-10. scores, with etereetypy of thinking end difficulty in introepectien, often preeent a behavioral pattern incompatible with the eatebliehaent of the type of interpereenal reletien~ ehipe required in peycheanalytically-eriented psychotherapy. The favorable evaluatiene of therapetic reopenee to eonvulaive therapy in patienta with high I acoree nay be related to pereenality attributee. The psychological prov eeeaee reflected in the I Scale are similar to those pereonality factors previeuely related to a favorable rcepenae to each treatment. In structured family intervieea it vat observed that the faverabl! rated patients had personality patterns characterised as neuenpathic, conintrespectivc, nenverbally eeamenicative, and highly conventional and stereotyped, with little nonnative or creative capacity (13). Genaistent patterns have been aheen in Rcrachaeh etudiee indielting that good prognosis in related to a small number of reepeneee, absence of human movement and little divereifieatien of content (15; 7). The F acere increecee significantly with cenvuleive therapy with the extent of increase related to the degree of altered brain function, as measured by the degree of induced EEG slow wave activity. This relation of change in behavior to physiological change is an observation that has been coneietently noted in cenvulaive therapy patients (h). The increaee in I accre during treataent may have been even �nere marked than eetnelly observed. Severel patients of tereignobirth and little edneetion hed retina: er nee: nexinnn eeeree print to treatment, thne elinineting or reducing the peeeibility er en increeee en retenting. The ehenge in eeere with altered brein function is eeneietent with previous obeervetiene on the behevierel effects 0: convulsive therapy. In eeeerd with our oeueeptnel trenewerk, greater egreenent with I Scele items during treete tent in related to inereeeed etereetypy and difficulty in dieerininetien, ll velx ee increeeed eeqeieeeenee. rue 1e preeeee whieh hee been noted 1n‘11ngn1et1e, e e! general pert neeeuree. and In their behavierel clinieel perceptual language, cenvnleive therepy patient: shew inereeeed deniel, cliche: end etereetyped end er use eve-inn, qualification expreeeiene (16). They elee nenifeet increased repetitiveneee of words (11), difficulty in aenplex Vienel end tectile per— eeptien (6) end figureggreund discriminetien (1h). Clinieelly, eke they chereeterieticelly here oeup}1ent end ecqnieecent and try to pleeee the exeniner (S). �-12- annular: neaenre e: social attitude, the California 1 Scale, has been utilised in etadiee o! the convulsive therapy proceee. In a voluntary psychiatric hoepital it wee noted that patients referred for oonvnlaive therapy had eigniticantly higher I A aoorea than theee receiving psychotherapy only. Anon; the patiente receiving convulsive therapy, theee with the higher initial 7 ecoree were evaluated ae showing the beet clinical reellta. With treatment there waa a significant increase in r ecore, with the ineroaae related to the degree or altered brain function. Following treataent the ecoree returned to their; original level. comparison of reenlte with a conventional and "reverne'l r eoale concentrated that low I acore patiente respond to the content or the questionnaire, while these with high I eoeree ahowed a generalized pattern or agreement independent of the content. There results are interpreted in tern: of the psychological proceeeee neaenred by the F Scale. High 1 score patients are coneidered to be aterectyped in their thinking and to have ditticnlty in introspection ~- behavior whih is incompatible with peychoanalytioally-oriented psychotherapy, rendering than acre liable to referral for convnleive therapy. With treatnent, enoh patients are aleo acre likely to develop the language patterna of denial and nee o: cliche} which are the one: for evalnatione or clinical improvement. the inoreaae in I score with treataont is conparahle to the other types of behavioral �ohnnxo, such :- 1n figure—around of lungntga. inerouocd noqniouconcc, increased ditticnlty disarininntign, tad incroalod stereotypy �Reference- 1. Aderno, !.H., Frankel—Brunswick, 3., Levin-on, D.J. and Sanford, 1.3. The Antheritarian Pereonalitz. Harper, low rerk, 1950. 2. ‘Baee, B. n. Antheritarianion or aeqniooeenoe? J. Abnern. & scan Pezeho1., 5;. 611~623, 1955. 3. chriotie, 3., Havel, 3., and Beidenberg, I. II the P Scale irreversible? J. Abnorn. flee. Pezche1., fig: I 1h3~1§9, 1958. Fink, H. and Kahn, R.L. Reletion of EEG delta activity to behavioral reeponee in electroshock: quantitative eerial etndiee. 1.x.i. Arch. Henrol. & Po ehiat., 1Q; 516-525, 1957. 3.2. and 3ehaviora1 patterno in induced Kahn, n. Iink, etetee or altered brain function. Paper read at Diviaional Meeting, Aner. Peyohiat. Lee., low York, levenber, 1957. 6. Fink, H., Iahn, R.L. and Kevin, 3. Effects of diffuse eltered brain tnnntien en perception. Proc. 1? Int. sonar. szohel. Anatordans Northelolland Pnb1., V pp. 238-239, 1959. Fink, x., Kahn, R.L. and Pollack, Psychological factors attenting individual ditteronoee in behavioral response to convuleive therapy. J. lorv. & lent. Dio., M. 128: 2h3~2h8, 1959. �-2Referancoa Gallagher, E.B., Ltviason, D.J. and Erlich, I. Some sociopsycholcgical chaructoriatics of patiants and their rclavuneo tor paychintric treatnont. In Groonblntt, 9.5. Lovinlon und 3.x. Williams (Edl.) The Pttiont und the Hpntnl iosgittl. The Pro. Prosl, H. alencoo, 111. pp. 357-379, 195?. Jack-on, 3.3., Herrick S.J., and Bailey, c.n. 30v “rigid“ is the autharitnrinn? J. Abnorm. soc. Pnzchol. fig: 137~1h0, 1957. 10. Junk-tn, 9.1. and Herrick, 5.3. content and style in personality anion-none. Patchol. 3‘11., 2;: 2&3-252, 1958. 11. antic, 3., Fiat, R.L. Communication pattorns with ulterod brain function. J. Harv. & Rent. 313., H. and Kuhn, in prons. 12. 8.1., link, E. 3nd WeinttOin, E.A. Relation of anobarhital tent to clinical inprovonont in oloctro¢ Kuhn, shook. A.H.A. Arch. Konrol. Pazchint., 1g. 23»29, 1956. 13. Inna, 1.1. ind link, x. Personality factor: in bohuvior¢1 response to olootraahook thornpy. J. learn I ehiut., l3 h5-h9, 1959. Inna, R.L., Pellaek, l. £34 rink, H. Figaro-ground dinorininaticn after indueod ultcrod brain inaction. A.H.A. Arch. louroi.,fiiu pron: �15. rink, H. Prague-tie value at hereohaeh criteria in clinical response to convulsive therapy. Kuhn, R.L. and Paper read at Bleetreeheck Reaeareh Aee., san Francisco, 1958. 16. Iahn, R.L. and link, H. changes in language during oleetroeheck therapy. In P. flesh and J. Znhin (Ede.), Pazehegatholegz et columnieatien. Grune and stratten, l.‘ Yorke ppe 126‘139e 1958a R.L., Pellaek, H. and link, H. social tactora 1n the selection at therapy in a veluntary mental helpital. J. Hill-1h Hung. Q: nos-:20, 1957. 18. Iahn, n.L., rellaek, H. and rink, u. seexepeyehelexieal aepeete at fieyehiatrie treatleut. Arch. Gen. Pezchiat., in press. 17. Kahn, �Social Attitude Questionnaire (F Scale)* Below are a number of‘statements. For each statement we want you to give us your personal opinion of'whether you agree or disagree, and how much. .3 g 5 8 >3 am :> o (I) :4 fi g >> +3 43 m a {34 m (D M m r1 9 +2 'H H c6 w 0) 3 3 vi H 8 E g 5’ S pm (D ((3 Q1 L" w m a) m a) m m p ’ 0 h w (6 m aw £6 m better When talk less ho w no a -H "-4 rd 0 F1 Pi F4 F4 F1 +4 H U U ................... and work more, everybody would be offOOCOICOOOOOQ. OOOOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOOOOOO . think about it, it is best for him not to but to keep busy with more cheerful things ....... a person has a problem or worry, the youth needs most is strict discipline, rugged determination, and the will to work and fight for family and country ...... What I different kinds of people mix together to protect himself especially carefully infection or disease from them ............... Nowadays when so many so much, a person has against catching an crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse....... . Sex ................... ..................... best teacher or boss is the one who tells us exactly what is to be done and how to go about it. ...... . The ..................... people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down Young People can be divided into two the strong.... ..... ... *From ...................... distinct classes: the weak and .................. ........................ . Gallagher, Levinson and Erlich (1957). Scoring: I agree very much ....... +7 I agree pretty much.....+6 I agree a little ........ +5 I can't say ............ I disagree very much ....... +1 I disagree pretty much ..... +2 I disagree a little +3 +h 43 ho w ....................................... people would h aw m -H 5-4 Science has its place, but there are many important things that must always be beyond human understanding If h a $4 sane, normal decent person could ever think of hurting a close friend or relation.. No 8 ........ $3 as �Appendix Social Attitude Questionnaire (F Scale)* Felow are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I AGREE A LITTLE I DISAGREE A LITTLE I AGREE PRETTY MUCH I DISAGREE PRETTY MUCH I AGREE VERY MUCH I DISAGREE VERY MUCH 1. sane, normal, decent person could ever think of hurting a close friend or relation. No 2. Science has its place, but there are many important things must always be beyond human understanding. 3. If better off. that people would talk less and work more, everybody would be a person has a problem or worry, it is best for him not to think about it, but to keep busy with more cheerful things. tion, A. When 5. What and the the youth needs most is will to strict discipline, rugged determina— fight for family and country. 6. Nowadays when so many different kinds of people mix together much, a person has to protect himself especially carefully against catching an infection or disease from them. work and so 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicaly whipped, or worse. is 8. The best teacher or boss to be done and how to go about is the it. one who tells us exactly what people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down. 9. 10. Young PeOple can be divided the strong. into two distinct classes: the weak and -————————————.__.__—_—______ * Gallagher, Levinson and Erlich (1957). Scoring: Agreement is scored as +7 (agree very much), +6 (agree pretty much), and +5 (agree a little); +h for no response or uncertain; +3 (disagree a little), +2 (disagree pretty much), and +1 (disagree very much). The ten items are summed for a single F—Scale Score. From �CONVULSIVE THERAPY PROJECT — INTERNATIONAL ASSOCIATION FOR PSYCHIATRIC RESEARCH, INC. §gpia1 Attitude Questionnaire {F ScaIe) aha a numbed 05 Atatemcnia. Fox each Ataiemeni we want you to give uA gout geaéonafi Opinion 05 whethea you agaee Befiow on disagree, and .C.‘ 0 how much. g much m G) very H 94 muc 3 >5 JJ U little - much 4-) a H 1—! pretty very CE! cisagree agree say t can I I sane, normal decent person could ever think of hurting a close friend or relation. ..... ‘u.......... ..... No Science has its place, .............,... but there are many important things that must always be beyond human understanding................ If people would talk less and work more, everybody would be better off.................................................... I ‘ then a person has a problem or worry, it is best for him not to think about it, but to keep busy with more cheerful things.... I If I the youth needs most is strict discipline, rugged determina— tion, and the will to work and fight for family and country... What different kinds of people mix together to protect himself especially carefully infection or disease from them ..... ....... Nowadays when so many so much, a person has against catching an I crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse................... .. Sex I ......... ............... . The best teacher or boss is the one is to be done and hOW tells us exactly what to‘go about ituu'oonltocconcoct-cocooooowho Young people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down................ People can be divided into two distinct classes: the weak and the strongOIOOIIOOIOOQOOOOOCOOIIOIOOIOIICOOCIOIOOCOOIIOICI I “"“'{' I i, i ' � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Social attitude (California F Scale) and convulsive therapy. J Nerv Ment Dis. 1960 Mar; 130:187-92. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-46-012 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Kahn, Robert L.; Pollack, Max; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] with questionaire and reprint. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 130, No .3, March 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/bf0b6905f6c2b44054f0b8c530666cd5.pdf b11f5eee6a69d331f4c3c98cd7961516 PDF Text Text Reprinted from the :1. M. :1. Archives of Neurology May 1960, Vol. 2, pp. 547—551 Copyright 1960, by Aerircm Medical Association F igure-Ground Discrimination After Induced Altered Brain Function ROBERT l.. KAHN, Ph.D.; MAX POLLACK, Ph.D., and Studies of complex visual perception with altered brain function in man have not always yielded clear or consistent results. The disagreements may be due to many factors, such as differences in population studied, types of procedures employed, and difficulties in evaluating the degree of alteration in brain function. Electroconvulsive therapy (ECT), however, provides a unique op portunity for studying the effects of cere— bral dysfunction in that more accurate control can be maintained over the degree of induced cerebral dysfunction and its measurement. While most investigations of brain—injured populations have focused on the role of the locus of the lesion on behavior, current studies of ECT have emphasized individual differences. Marked variability has been shown for perceptual}2 behavorial,7 and physiologic 5'8 responses to ECT. Various personality 6'11 and social factors 9'10 have also been related to differences in response to treatment. In the course of an investigation of the perceptual and behavorial changes with ECT, a convulsive—subconvulsive control study was undertaken. In this report, the performance on complex visual tasks is pre— sented. Specifically, the aim was to deter— mine whether perceptual change induced by ECT is related to the degree of altered brain function and clinical behavioral ‘ Accepted for publication Jan. 18, 1960. From The Department of Experimental Psy— chiatry, Hillside Hospital. Presented at the American Psychological Association, New York, August, 1957. Aided by Grants M-927 and MY-2092 of the National Institute of Mental Health, National Institutes of Health, US. Public Health Service. MAX FINK, M.D., Glen Oaks, New York change, and Whether the pretreatment perceptual pattern is related to physiologic changes with treatment. The method used in the study was the perception of embedded geometric figures—— a technique which has been employed in recent years in studies of perceptual change in head trauma and brain tumor pa- tients.1'“"'14 Method Population—Fifty-three consecutive patients referred for ECT were studied. These included 16 men and 37 women, the ages ranging from 22 to 66 years, with a median of 49 years. The patients were divided at random into two groups. A convulsive group, of 29 patients, received grand mal electrotherapy with thiopental (Pentothal) premedication three times a week, using either a Medcraft alternating-current instrument or a. Reiter C-47 electrostimulator. A minimum of 12 treatments was given. The total number of treat— 1. ments was determined by the supervising psychia— trist in charge of the treatment unit on the basis of clinical criteria. A subconvulsive group, of 24 patients, was treated in similar fashion except that only subconvulsive stimulation was given after the thiopental. Fourteen of the subjects in the 'subconvulsive group were subsequently given a regular course of convulsive therapy. 2. Perceptual Task—In the week prior to treat— ment and on the day following the 12th treatment each patient was tested with a modification of the Gottschaldt hidden—figure test developed by Bat— tersby et al.1 The subject is presented with a page containing two forms—a simple geometric figure, and below it a complex figure in which the simple figure is embedded (Figure). The patient is asked to trace a specific geometric figure from the background by outlining it with a colored pencil. The discriminations range in complexity from relatively simple to more complex. There are 25 such discriminations. A maximum of two minutes is allowed for each. Performance is scored in terms of total number of errors. To minimize a practice effect, two equivalent forms of the test were used. The forms were alternated with 77/547 �A.M.A. ARCHIVES OF NEUROLOGY Comparisons for Number of Errorr Before and During EC T TABLE 1.———Intragr0up Type of Treatment Subconvulsivo Convulsive Before No. 24 43 ECT During Differ— ECT once 1’ 7.7 11.8 ~2.3 +2.3 <0.02 10.0 9.5 * (0.02 Intragroup analyses in this and in subsequent tables are based on Wilcoxon’s method of paired replicates. * Results \VAVI ‘7"7V 'AL A AL‘ Figures in hidden-figures test. The preliminary sample used to acquaint the subjects with the task is shown in a; b and c are examples of test figures. In (1 the task is complicated by having the subject determine which of the two single figures can be found in the complex figure. successive patients in pretreatment testing. During treatment the patient was reexamined with the form different from that given initially. 3. Evaluation of Physiologic Change. Two measures of brain function——the electroencephalo— gram and the amobarbital test15—were given to each patient prio1 to and at weekly intervals during treatment. The electroencephalogram was evaluated as to the degree of induced slow-wave activity according to criteria previously published.5 The amobarbital test was noted as positive or negative for brain dysfunction according to standardized criteria}5 The results of these tests during the second, third, and fourth weeks of treatment furnished the criteria for physiologic change. A combined physiologic index was obtained by ascribing to each high—degree slow—wave EEG record and each positive amobarbital test a score of one. The range of physiologic altera— tion thus ranged from 0 to 6. 4. Behavior Ratings.—Each patient’s behavior was evaluated at weekly intervals. After the 12th treatment, a rating for the degree of behavioral change was made according to four classes: marked, moderate, minimal, or none. These ratings of change were not value judgments as to the quality of change but, rather, quantitative estimates of differences in behavior patterns under similar conditions of observation. Thus, such behavior patterns as euphoria, paranoia, and withdrawal might all be rated as equivalent for degree of quantitative change, although the implications of. each for the qualitative evaluation of improvement may be difi'erent. 78/548 The pretreatment and treatment scores and the mean change in the number of er— rors with treatment are shown for each group in Table 1. Intragroup analysis shows that the subconvulsive group made signifi— cantly fewer errors during treatment, whereas the convulsive patients made sig— nificantly more. Prior to treatment, subconvulsive patients made approximately the same number of errors as those in the convulsive group, a mean difference of 0.5 error. During treatment, however, the difference between these bet— at significant (4.1 errors) was groups ter than the 1'% level of confidence. When the data are analyzed with respect to physiologic change, significant increases in errors are found only for those patients with great— er degrees of physiologic change. This re— lationship is present in the analysis of the amobarbital test and the EEG as separate 2,—1ntragroup Comparisons for Number of Errors Before and After EC T in Relation to Degree of Physiologic Change TABLE 3 Mean Difference in No. of Errors During Treatment Physiological Index N Amobarbital Test None or one positive 13 —0.2 Two or three positive Electroencephalogram None or one high delta 28 +3.7 23 +1.7 Two or three high delta Combined Physiologic 0 t0 3 18 +3.3 21 +1.0 20 +3.9 4 to 6 1’ Not significant <0.01 Not significant <0.05 Not significant <0.01 V 01. 2, May, 1960 �FIGURE-GROUND DISCRIMINATION 3,—Intragronp Comparisons for Number of Errors Before and During ECT in Relation to Degree of Behavioral Change 4.—Relation of Pretreatment Errors to Eventnal Degree of Physiologic Change TABLE Degree of Behavioral Change Marked Moderate Minimal or none N Treatment 14 5 ——0.4 Physiologic Change 1’ 0 3 5 <0.01 Not significant Not significant indices, and when the two tests are bined (Table 2). to 2 and N 16 4 and 6 19 8 Mean N o. of Errors Pretreatment 7.9 11.2 13.3 logic change had frequent difficulty following instructions. They would trace the lines com— The relationship between the degree of behavioral change and the change in num— ber of errors during treatment is shown in Table 3. Those patients with minimal or moderate behavior changes did not show an appreciable difference in number of er— rors. Those with marked behavior changes, however, made significantly more errors during treatment. Analysis of the pretreatment error scores in relation to the degree of physiologic change is shown in Table 4. A significant relationship is shown between the pretreatment error scores and the degree of physio— logic change during treatment. Patients with minimal physiologic change during convulsive therapy had a mean pretreat— ment score of 7.9 errors, while those who developed marked physiologic effects had a mean pretreatment score of 13.2. The triserial correlation of pretreatment score and physiologic change is +0.34, significant at the 0.05 level of confidence. Qualitative Data—Alterations in size of figure or in minor aspects of form were common types of error during both testing periods. Certain qualitative patterns were frequently noted during treatment, which occurred only rarely in the pretreatment period. It was common for patients to make no attempt to trace the more complex figures. This failure was often associated with a generalized withdrawal reaction in which theipatient was unresponsive to any stimulus or procedure. Others became hos— tile and negativistic toward the testing. Patients with the greatest amount of physio— Kalm ,et al. During Treatment Mean Difference for Number of Errors During +3.6 +1.0 24 TABLE indiscriminately, without regard for the specific figure to be traced, repeat a previous figure despite changes in the test figure, draw lines where none actually existed, and attempt to trace the stimulus figure while ignoring the more complex test figure. Such patients were likely to respond quickly and impulsively, and showed little concern about making an error even when spontaneously commenting, “I know that’s not right.” Comment This study demonstrates a relationship between the degree of cerebral dysfunction and the degree of perceptual alteration as measured by errors on the embedded-figures test. Patients with subconvulsive stimulation made fewer errors on retesting. Patients receiving convulsive therapy, in whom only minimal physiologic changes were recorded, manifested slight increase or no change in errors. The convulsive patients, however, with the more marked physiologic altera— tions, showed a significant increase in ‘ errors. This interrelationship of brain func— tion and perception may be related both to the perceptual patterns with neurologic dis— orders and t0 the mode of action of con— vulsive therapy. It is evident that perceptual responses systematically vary with the degree of dif— fuse cerebral dysfunction. In relating these patterns to concepts of localized pathology, the role of generalized, nonspecific cerebral dysfunction must be considered. For ex— ample, unilateral spatial “inattention,” fre— quently attributed to parietal lobe lesions alone?!4 has been reported with a variety 79/ 549 �AM. A. ARCHIVES OF NEUROLOGY of lesions provided there was a somato— sensory defect and an associated generalized mental impairment."""16 Teuber and Wein— stein 1“ found that performance on an em— bedded—figures test was unrelated to locus of lesion in cases with penetrating brain wounds, but that aphasic patients made significantly more errors than a nonaphasic group. Pollack et al.,13 using a test identical with that in this study, reported no rela— tionship between errors and the location of lesion in tumor patients. They noted, instead, that the number of errors was related to the severity of general mental changes, manifested as disorientation for time and place. The present observation that perception of embedded figures is re— lated to the degree of diffuse brain dys— function is in accord with these studies of patients with head injuries and brain tu— mors. In previous investigations of the mode of action of convulsive therapy, we have shown that clinical behavioral change is related to the degree of altered brain func— tion.5'7'8 The present study reinforces this observation, the objective criterion of per— ceptual errors being used as an index of behavioral change. As a group, the patients who showed the greatest increase in errors with treatment were those who also showed the most pronounced change in clinical behavior, as assessed by conventional psychiatric evaluation. There appeared to be considerable comparability in the type, as well as the degree, of clinical behavioral change and the quali— tative aspects of performance on the em— bedded-figures test. Failure to attempt the task characteristically accompanied with— drawal or paranoid hostility. A lack of con— cern in correcting errors was associated with clinical euphoria or hypomania. From these behavioral observations, the increases in errors may be attributed to a change in attitude toward the task or examiner, as well as to a specific defect. The altered brain function modified the total pattern of interaction with the environment, of which 80/550 the performance on a complex perceptual task is just one aspect. Previous studies have shown that there is a relationship between the clinical response to convulsive therapy and aspects of personality, defined as the habitual or characteristic modes of response and adaptation.“v1°'11 In this study it has been shown that the pretreatment perceptual performance is related to the physiological response during treatment. This finding suggests that the indi— vidual differences in the development of physiologic change may also be related, in part, to personality factors. Summary and Conclusion Fifty—three consecutive patients referred for electrotherapy were studied before and after treatment on their ability to perceive embedded geometric figures. An experimental group of 29 patients received a course of grand mal therapy with thiopental (Pentothal) premedication. A control group of 24 patients received submnvulsive stimu— lation with thiopental premedication only. The experimental group made significant— ly more errors after treatment than did the controls. Within the experimental group there was considerable variability. Increase in errors was significantly related to the degree of altered brain function and to the degree of behavioral change. Qualitative aspects of perceptual behavior mirrored the pattern of behavioral change observed clinically. Pretreatment error scores were signifi— cantly related to the degree of altered brain function developed during treatment. The significance of this observation in terms of personality factors is indicated. Department of Experimental Psychiatry, Hillside Hospital. REFERENCES l. Battersby, W. S.; Krieger, H. P.; Pollack, M., and Bender, M. B.: Figure-Ground Discrimi— nation and the Abstract Attitude in Patients with Cerebral Neoplasms, A.M.A. Arch. Neurol. & Psychiat. 76 2369, 1956. Vol. 2, May, 1960 �FIGURE-GROUND DISCRIMINA TION Battersby, W. S.; Bender, M. B.; Pollack, M., and Kahn, R. L.: Unilateral Spatial Agnosia (Inattention) in Patients with Cerebral Lesions, Brain 79:68, 1956. 3. Critchley, MacD.: The Parietal Lobes, Baltimore, Williams & Wilkins Company, 1953. 4. Cobb, S.: Amnesia for the Left Limbs De— veloping into Anosognosia, Bull. Los Angeles Neurol. Soc. 12:48, 1947. 5. Fink, M., and Kahn, R. L.: Relation of Electroencephalographic Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 2. 78:516, 1957. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Affecting Individual Differ— ences in Behavioral Response to Convulsive Therapy, J. Nerv. & Ment. Dis. 1282243, 1959. 7. Fink, M.; Kahn, R. L., and Green, M. A.: Experimental Studies of the Electroshock Process, Dis. Nerv. System 19:1, 1958. 8. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improve— ment in Electroshock, A.M.A. Arch. Neurol. & Psychiat. 76:23, 1956. 9. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside Hosp. 6: 6. 216, 1957. Kalm cl 0]. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital, A.M.A. Arch. Gen. Psychiat. 1:565, 1959. 11. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. Neuropsychiat. 1:45, 1959. 12. Landis, C.; Dillon, D., and Leopold, 8.: Changes in Flicker-Fusion Threshold and in Choice Reaction Time Induced by Electroconvul— sive Therapy, J. Psychol. 41:61, 1956. 13. Pollack, M.; Battersby, W. S., and Bender, M. B.: Figure—Ground Discrimination in Patients with Cerebral Tumor, read at Eastern Psychological Association, 1957. 14. Teuber, H. L., and Weinstein, 5.: Ability to Discover Hidden Figures After Cerebral Lesions, A.M.A. Arch. Neurol. & Psychiat. 76: 10. 369, 1956. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: Diagnostic Use of Amo— barbital Sodium (“Amytal Sodium”) in Brain Disease, Am. J. Psychiat. 112 2889. 1953. 16. Weinstein, E. A.; Kahn, R. L., and Slote, W. H.: Withdrawal, Inattention, and Pain Asymbolia, A.M.A. Arch. 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A ultghs dgcrauss or unwahanul tn Ottawa octurrnd in that. who riogtvzaz ahnitd cuntulitvo ally'haallnl thirty: pattlatt thing‘s. in. aunvulsivu pittcatl, houivor, ut‘t pkg-Intogtcul atudr‘luunlatrlitu - & 68. unit anvkud phamaglcgtcux altsruttnn, Ihnvtd a ctxuttlnnat tn¢r0330 1n number at strewn. 1‘4: lntorrnlntaoauhAp at bruit £una££un aha porcupiiuu or caboddcd tsguvuu is in actard wi‘t atudtnn of pu$tnutu with altarud tibia rua¢ttiu an. to htad wutaatoia u (10) uppaytng fwufitr tad taunt. taint: ul-ilur inuhuta 1n QISI& with pauotrattng brain unuadt, tutu alldud that ycrrurllnan Inn_uarnln&ua to lien. or lonlua but ihat uphuuic pntttnto and. nixaittcnntly'unru arvnra thtu & unaunphnnlc bruinwtnjirol group. Pollack g§_g§, (9). 1113‘ ruporfiod Qltc SI an taxation-t1, an taut atuty. tauntttul tit httuuul attain and ‘h. laaation a: 10010: &n tutor patsoutt. fits rnlutol author at that rwporfiad. tuntnnd, in: Irrort it!) to it: stvurtty o: amok unut¢1 changes an dzuaritatntiau. 1‘ should be yuanint o‘t «hat the total prc‘roatunnt than atom. tow I11 pntlcnt- r‘larraa lav upnvulntvo thnruyy fin sauna hy saunt1¢a1 10.5 n linou‘ nun». tat! ctrurn. at. and brain nxmk 21.5%: (9) an um: man tw pltluu“. an” ‘ use populations It. auuparublc 3: turn: .1 a£hnr pntnntfiura £11or1u1u.~ xvuund In $3. and lattata figurt ceuautiwa. a: as. two �‘16“ iii! oaunct in rugurfiud an rntlntttvc o: notnhrtl 43:9inotaou an an inalnfiad out$£y tbairna‘od (It. fit. t¢tn11my at hchavtur. hasn‘t ‘hll beta; :- 3.0Io in tin rolatloatth, your parttvuuaau tn aunt inthu any be due to it: internation a: Ina: tn:$«rn. mu 117thth um. an); an. my “on m nu.»watt nation cnrnbrcl din... uh» lit! fi'tf hit!!! an $ht- iatk than ocntrul llhltt‘l vifih tn§n¢t turtbrnl tunataun. 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"by 9.: Wk mug-ma um m an.“ u 3. n g m an: m tn um» Hm. «I: u “I“ an at“ m was “we. W m �«1 3a References I. Inttarahy, w.s.. traccnr. x.r., reliant, n. and nundlr. 3.3.: figuruogrcmnd ¢£unr£uannt1nu and the abatrtut uttitncn 1n putatuta with narchrax neayltnna. 5,555, ‘4 xi, '_'_, gaig.~;k;w., 19; 369, 195$. 2. rink. I. and Kuhn, Into: leln‘ttn Qt ita ficltl anivtty ‘a behavioral raapouao an electrouhaaks quantitnfiivn ' sorts: utiliaa, ewe .'o 1!? a 516. 1951. J. rink. h. m. I.t. tucturc vayuhnlnnzaal l.u rlmllsh, l.. Ittecttng individual attrcrlacus In hohtvanrtl filviiii Kata. and a. «man mm. mg... m: m. 1939. m. rm, M... and arm. ma... Mora-um mm. ' 0! the alaotveuhaek prune... Egg, leggg 51p., l2! 1. 1958. 5. mm. 2.3... rm, 1:. mt manna, 1m... lemma .3 Innhtrbttaa tout to altfiifill inprrvoann‘ in cleatrclhatk, 1.mt.,‘1§I 83. 1956. 6. Kuhn, 3.3.. Pollnel, fl. and tint, n.a auutul flatari 1n ‘ho taxonfiauu at thtvlwy ta 3 valuntear ninth: hanpttal. ,. 7. .fi _. , uI. go :16”. 1997. Iain, I.L., Pulltnk, and risk, 3.: atatapuylhaluuto firtntlnut an I reinstary ninth! haspt‘tl. 5.x.n. trot. flan. Payer. (In preto). I. tenets, 6.. 3111‘», a. and beeper; 8.! damage: 3: little:lliinn thrtlhfild and in until. vtnnfitlu $1.! Indtotd 1956. by 61. that-pr. a: magenta ‘3 paguhtttrso “wanna“ W... �...L 1.1.23.1...LL hunt. I... ground tuna”. 10. rum, Id. I). 8.3.: W and 'nnna W M. ‘ 5.: woman. attu- {W “any hunt, mm 1;.»- m. 1m. to hunch, 3a.. uh. IJ...‘ Guam. ammo m a a man“ in“ than. 1953. 1!. mm. Wumm M, 1‘va mu“ mm: 11. ma. m4 itltrfintnlttui in pttllut: itth carthvll at Panama“). Amati“. m. m 1957. ‘ mm. 3.4.1. “It. in: m: 889. on «an (Inn: want) ’ . «mm». 8.5.: .1 unhaido‘ tiguruu, g, rugg.. in £23 «u a! 1, 1936. swam mm»: um Wu 3.9M. um. 1M. pot-«yam. a a: W" LA... um .1 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Figure-ground discrimination after induced altered brain function. Arch Neurol. (Chic.) 1960 May; 2:547-51 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-47-013 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Kahn, Robert L.; Pollack, Max; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the A.M.A. Archives of Neurology May 1960, Vol. 2, pp. 547—551 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/fdd65cffa7365ba9ca6ade8a0f3f6e8b.pdf 60ce7c5bb093bf1402d25c650f359a34 PDF Text Text PROCNOSTIC VALUE OF RORSCHACH CRITERIA IN CLINICAL RESPONSE TO CONVULSIVE THERAPY ROBERT L. KAHN, PH.D., and MAX FINK, MD. ABSTRACT In this study of the relationship between premorbid personality factors and clinical responses to convulsive therapy, the Rorschach test was admin— istered to 87 unselected patients prior to the beginning of EC T. A favorable clinical response to ECT was observed in subjects whose Rorschach records revealed a basically conventional and unimaginative personality, generally lacking in empathy, introspectiveness or facility of verbal communication. Post-treatment records (of 41 patients) showed no significant changes. It is therefore concluded that Rorschach patterns reflect basic personality rather than prevailing mood or type of illness. These results indicate that Rorschach patterns can be useful adjuncts in the selection of patients for convulsive therapy. In a series of studies of convulsive therapy we have observed marked individual differences in behavioral response. It has been shown that the induction of a behavioral change is related to the presence of altered brain function;5 Yet, among those with equivalent degrees of physiologic change, there are still differences in the clinical patterns of behavior. While some patients become hypomanic, others show paranoid reactions, withdrawal, increased somatization or expressions of fear.3 We have postulated that personality is one of the significant factors affecting this variability. This hypothesis was tested in a previous study,6 in which each patient’s premorbid personality was evaluated by means of structured interviews with members of his family and with the patient himself. We found that the patients who were rated as recovered or much improved after electroshock treatment were those with the follow- From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., New York. 'This study was supported in part by Research Grant M—927 from the National Institute of Mental Health, US. Public Health Service. Presented at meeting of the Electroshock Research Association, San Francisco, May 11, 1958. ing personality pattern: they were generally nonempathic, nonintrospective, verbally noncommunicative, highly conventional and stereotyped, with little imagination or creative capacity. The concepts derived from these observations lend themselves to study by other methods. In the present study the Rorschach test, another measure of personality, was used. The Rorschach technique has particular advantages in that it is both an instrument for testing the patient directly and, at the same time, a standardized procedure providing data which can be verified by others. The specific purpose of the present study was to determine: (1) the relationship between Rorschach findings and personality aspects previOusly fOund to be significant in family interviews; and (2) the applicability of Rorschach criteria in the prognosis of the clinical response to convulsive therapy. METHOD The population consisted of 87 consecutive, unselected patients referred for convulsive therapy in a voluntary mental hospital. All patients received electroconvulsive therapy (with either unidirectional or alternating-current instruments) three times a week. A mini242 Reprinted from Journal of Neuropsychiatry, Vol. I, No. 5, May—June, 1960 �l 960 mum Of 12 treatments was given, with the staff psychiatrist in charge of the treatment determining the final number on the basis of clinical criteria. The improvement evaluation, made by the staff psychiatrist, was based on the patient’s behavior in the hospital setting during the period of two to four weeks following termination of treatment. In this manner each patient was rated as either much improved, moderately improved Or unimproved. As previously described,5 patients were rated “much improved” if they no longer showed the symptoms which had brought them into the hospital; if, in addition, their doctors felt they were better; and if the nurses’ notes confirmed such aspects as ability to sleep without medication, better appetite, and improved capacity to get along with other patients and participate in hospital activities. “Moderately improved” patients typically showed some symptomatic relief (i.e., acute depressive features might be gone), but not the dramatic changes so evident in the first group. Each of these patients continued to show some noticeable disturbance such as obsessional thinking, paranoid ideas or somatic preoccupation. In the “unimproved” patients, change was either not clearly noticeable or only equivocal or transient. Some showed fluctuations in behavior, at times appearing somewhat improved; but the change was not sustained, so that by the end of treatment they appeared much the same as before. The Rorschach test was given to each patient prior to the beginning of electroconvulsive therapy and, in 41 cases, two weeks after electroconvulsive therapy. The Ror— schach records were scored according to the criteria of Klopfer and Kelley.9 Only those common components were studied, however, which could be analyzed quantitatively. These included: Total number of responses. 2. Per cent whole responses (responses in which a subject uses all of a card for the formation of a concept). 3. Per cent form responses (responses in which the shape of the blot is the sole determinant in the concept formation). 1. 243 JOURNAL OF NEUROPSYCHIATRY Number of content categories included in the responses. 5. Number of movement responses (references to any action or movement). 6. Per cent popular responses (responses statistically given most frequently to a particular blot area). 7. Presence or absence of shading responses (responses in which a subject incorporates the darker and lighter aspects of a blot into his description). 8. Type of movement responses (e.g., human movement, animal movement, etc.). 9. Type of color responses (responses in which the color in a blot plays a recognizable role in the concept formation; when form and color are both significant, color-form [CF] or form-color [FC] is scored, depending on the predominant influence). 4. RESULTS The relation of the various Rorschach factors to clinical changes following ECT is shown in Tables I-IV. In Table I, comparison is made between those patients who were rated as having a good clinical response and those whose response was moderate or poor. The much improved patients had significantly fewer total number of responses, and significantly more per cent whole and form responses. TABLE I RELATION OF RORSCHACH FACTORS TO CLINICAL RESPONSE IN CONVULSIVE THERAPY (NUMBER, PER CENT WHOLE, PER CENT FORM RESPONSES) Number of Responses Much Improved (38) Mean S.D. 13.0 6.7 Moderate or Unimproved (48) 19.5 12.8 Per Cent Whole Responses Much Improved (38) 87.6 21.0 Moderate or Unimproved (48) Per Cent Form Responses Much Improved (38) Moderate or Unimproved (48) Significant at .05 level ** Significant at .01 level * 24.4 18.2 71.8 19.0 61.9 21.4 Diff. t, 6.5 2.7 *" 13. 3.0 H 9.9 2.2 * �244 JOURNAL OF NEUROPSYCHIATRY An analysis of content categories, move- ment responses and popular responses (presented in Table II) reveals that there were significantly fewer content categories and movement responses, and a greater per cent of popular responses in the Rorschach records of the much improved patients, as compared with the records of the unimproved and mod— erately improved groups. As shown in Table III, the much improved patients were also less likely to have any kind of shading response. This table also presents an analysis of the different types Of movement and color responses. Those patients who gave human~movement (M) responses had the TABLE II RELATION OF RORSCHACH FACTORS To CLINICAL RESPONSE IN CONVULSIVE THERAPY (CONTENT CATEGORIES, MOVEMENT AND PER CENT POPULAR RESPONSES) t. Mean Diff. SD. Number of Content Categories Much Improved (38) 3.8 Moderate or Unimproved 4.9 (48) Number of Movement Responses Much Improved (38) 2.3 Moderate or Unimproved 4.9 (48) Per Cent Popular Responses Much Improved (38) 37.7 Moderate or Unimproved (48) 26.6 2.2 2.7 5.1 21.6 poorest clinical responses (28% much improved), while those with no movement of any kind had the best clinical results (63% much improved). Patients with animal-movement (FM) or inanimate-movement (In) responses were rated better than those with human movement but not as well as those with no movement at all. With respect to color, those patients with form-color (FC) responses had the poorest results; those with no color at all, the best—although patients with CF or C responses did almost as well. In Table IV the patients are grouped according to combinations of human-movement (M) and form-color (FC) responses. Of those who had both M and FC, only 17% were rated as much improved; 25% were considered unimproved. In contrast, of those with neither M nor FC, 66% were much improved and only 3% were unimproved. The ratings of the group with one or the other of these determinants (M or F C) fell in between. As 2.3 11.1 2.8 14.3 * Significant at .05 level "* Significant at .01 level MAY-JUNE mentioned, post-treatment records were obtained from 41 patients. Comparison of the pre—treatment and post-treatment records of these patients revealed little change in the types of responses found. With respect to human movement (M), for example, 34 of the records showed no change. In four cases patients with M responses prior to treatment H showed none afterward; three other patients with no M response had such response following treatment. These small changes could be expected on a chance basis. TABLE III RELATION OF RORSCHACH FACTORS TO CLINICAL RESPONSE IN CONVULSIVE THERAPY (SHADING, MOVEMENT AND COLOR) Total No. Much Improved Moderately Improved Un improved Shading 46 15 (33%) 20 (43%) 11 (24%) No Shading 40 23 (58%) 15 (38%) 2 ( 5%) x2 = 8.12 p<.02 Human Movement (M) Animal Movement (FM) and/or Inanimate Movement (In) 39 11 (28%) 19 (49%) 9 (23%) 29 16 (55%) 9 (31%) 4 No Movement (14%) 19 12 (63%) FOrm-Color (FC) 7 (37%) X2 = 10.49 p<.05 Color-Form (CF) and/or Pure Color (C) 34 7 (21%) 18 (53%) 9 (26%) 27 16 (59%) 8 (30%) 3 No Color (11%) 26 16 (62%) . (35%) 1 ( . _ > x2 = 14.98 p<.01 4%) �JOURNAL OF NEUROPSYCHIATRY I960 TABLE IV RELATION 0F RORSCHACH FACTORS To CLINICAL RESPONSE IN CONVULSIVE THERAPY (HUMAN MOVEMENT AND FORM-COLOR) Much Total Moderately Human Improved Unimproved Movement (M) and Form-Color No. Improved (FC) 24 25 4 (17%) 10 (40%) 14 (58%) 9 (36%) 6 (25%) 6 (20%) 38 25 (66%) 12 (32%) 1 FC Neither M nor FC M or M and FC vs. M or FC vs. Neither M nor F0: M and X2 WC vs. Neither M nor FR: .‘(1’ = -: 17.82 12.26 ( 3%) p<.01 p<.00] EPICBISIS The results of this study confirm the findings previously reported concerning the relationship of personality to clinical response after convulsive therapy. Patients who had a good clinical result showed Rorschach records characterized by few responses and little variety of content, no shading or movement or color responses, and a high percentage of whole, form and popular responses. This kind of record indicates a personality pattern which is nonempathic, nonintrospective, verbally noncommunicative, highly conventiOnal and stereotyped and with little manifestation of imagination or creative capacity. These characteristics are identical with those described in the previous study based on interviews with family members.6 The prognostic value of the Rorschach as a clinical instrument is demonstrated by these data. While there are a number of studies in the literature on the prognostic value of the Rorschach in somatic therapy, the results have not been consistent. Rabin,13 for example, states that “single Rorschach factors cannot serve . . . as predictors of improvement.” On the other hand, Piotrowski12 describes specific prognostic criteria. It is likely that the difference in point of view, as well as in the varying criteria offered, reflects differences in the type of population and the variety of somatic treatment observed. Despite these problems, however, those studies 12’ 14 with the largest series of patients have obtained results similar to those of the present study. For ex— ample, their data show that the absence of 245 human movement (M) is more often associated with a favorable clinical response, and that patients with form-color (FC) responses are more likely to have a poor result.14 The significance of our findings might be questioned on the basis that we have demonstrated a relationship merely between clinical response and type of illness, rather than between clinical response and personality pattern. This objection would appear to be sup1“ 4’10'1‘1 the studies ported by numerous which have reported that depressed patients. the most likely candidates for convulsive therapy, show no human-movement or color responses. Our observations, however, substantiated by other studies,1’7!8’“’ Show a constancy of the Rorschach before and after treatment, and indicate that the response pattern reflects aspects of the basic personality rather than transient features such as the prevailing mood or type of illness. REFERENCES l. Beck, S. J.: Arch. Neurol. & 1943. 2. Fink, M., and Kahn, R. L.: 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Psychiat. 50:483. AMA. Arch. Neurol. i7 Psychiat, 78:516-525, 1957. Fink, M., and Kahn, R. L.: paper presented at meeting of A.P.A., New York, 1957. Cuirdham, A.: Brit. J. Med. Psychol., 16:130— 145, 1936. Kahn, R. L., Fink, M., and Weinstein, E. A.: AMA. Arch. Neurol. b Psychiat, 76:23—29. 1956. Kahn, R. L., and Fink, M.: I. Neurop.sychiat., 1: 45-50, 1959. Kelley, D. M., Margolis, H., and Barbera, S. E.: Rorsch. Res. Exch., 5:35-43, 1941. Kisker, C. W.: I. Aim. (J Soc. Psychol., 37:120— 124, 1942. Klopfer, B., and Kelley, D.: The Rorschach Technique, World Book Co., New York, 1942. Levy, D. M., and Beck, S. J.: Am. J. Orthopsy— chiat., 4:31—42, 1934. Pacella, B. L., Piotrowski, Z., and Lewis, N. I). G: Am. J. Psychiat., 104:83-91, 1947. Piotrowski, Z.: Psychiat. Quart, 14:267-273. 1940; 15:807—822, 1941. Rabin, A. 1.: Am. Psychol., 2:284, 1947. Rees, W. L., and Jones, A. M.: J. Ment. Sc., 97: 681-689, 1951. H.: Psychodiagnostics, Crune & Stratton, New York, 1942. 16. Varvel, W. A.: Bull. Menninger Clin., 5:5-12, 15. Rorschach, 1941. �Pragmatic Value of Rorschach Criteria in Clinical Beeponse to Convulsive 'Iherapy Robert L. Kahn Ph.D. and From Max Fink M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., NJ. Aided, in part, by grant Public Health Service. M 927, National Institute of Mental Health, U.S. Presented at the Electroshock Research Association, San Francisco, May 11, 1958. 5-5-58 �Prognostic Value of Rorschach Criteria in Glynical Response RObert L. to Convulsive Therapy W Phone and Max Fink In a series of studies of convulsive therapy MOD. we have observed marked individual differences in behavioral response. It has been shown that the induction of a behavioral change is related to the presence of altered brain function (2, 5). Yet, among those with equivalent degrees of physiologic change, there are still differences in the clinical patterns of behavior. While some patients became hypcmanic, others show paranoid reactions, withdrawal, increased somatization or expressions of fear (3). we have postulated that personality is one of the significant factors affecting this variability. This hypothesis has been tested in a previous study using structured interviews with members of the patient's family (6). It was reported that patients who were rated as recovered or much improved following treatment were generally non-empathic, non-introspective, non- verbally communicative, highly conventional and stereotyped, with imagination or creative capacity. The concepts derived from these observations lend themselves to study by other methods. used little in this study. The Rorschach test, another The Rorschach measure of personality, technique had the advantages both of testing the patient directly and of being a standardized procedure providing data which could be verified by otherS. The specific purpose of the present study was to determine: 1) the relationship between Rorschach findings and personality aspects previously found to be significant in family interviews, and was �.2.2) the application of Rorschach criteria in the prognosis of the clinical response to convulsive therapy. METHOD: The population consisted of 86 consecutive, unselected patients referred for convulsive therapy in a voluntary mental hospital. All patients received electrocommlsive therapy three times a week, using either midirectional or alternating current instruments. A minimmn of 12 treatments was given, with the supervising psychiatrist in charge of the treatment determining the final number on the The improvement exraluation was made by basis of clinical criteria. the supervising psychiatrist the patient's behavior in the hospital setting in a period to four weeks following the termination of treatment. In this and was based on of two patient manner each was rated as either much improved, moderately improved criteria previously described (5). Each patient was given the Rorschach test in the standard mnner in the week prior to treatment. This data constituted the main focus of this or unimproved, using study. To determine however, the of treatment. test was stability of the Rorschach pattern with treatment, readministered two weeks following the termination �RESULTS : A. Relatim of Rorschach Factors to Clinical The Rorschach records were scored according to the criteria of Klopfer and Kelley (9). (July these however, which could be analyzed total Change: common components were studied, quantitatively. These included of responses, 2) per cent whole reSponses, 3) Per cent form responses, )4) number of content categories included in the 1) number responseS, 5) number of movement responses, 6) per cent popular responses, 7) presence or absence of shading responses, movement reaponses, and 8) type of 9) type of color responses. In Table I the comparison is made between those patients who were clinical response and those whose reSponse was moderate or poor. The much improved patients had significantly fewer number of responses, and significantly more per cent whole and form rated as having a responses . good �TABLE I Relation of Rorschach Factors to Clinical Response in Convulaive Therapy: Number, Per Cent Whole, Per Cent Form Responses Number Mean §_:_D_o (38) 13.0 6.7 (h8) 19.5 12.8 of Resmnses Much Improved Moderate or UnimProved Diff. 6.5 L 2.7 *‘hL Per Cent Whole Resmnse Much Improved (38) 37.6 21.0 Moderate or Unimproved (ha) 2h.h 18.2 (38) 71.8 19.0 (ha) 61.9 21 .h 13 .2 3.00 *4:" Per Cent Form Resoonse Much anrorved Moderate or Unmproved 9.9 2.2 * as Significant at .05 level *"‘ Significant at .01 level �-5significantly fewer content categories in the Rorschach records in the much improved patients. (TableJI). They also demonstrated There were fewer movement and a greater per cent of popular responses, than the unimproved and moderately improved groups. TABIEII of have kind to less any likely patients shading responses, as shown in Table III. In this table the comparison is also shown for the different types of movement and. color responses. Those patients who had human movement responses (M) had the poorest clinical were also The much improved had the best results inanimate movement movement improved), while those with no movement of any kind (28% much reaponses (63% much (m) improved). Patients with animal (FM) or reaponses were rated better than those with human but not as well as those without any movement at all. With respect to color, those patients with form color (F0) reaponses had the poorest results, “those with no color at all the best, although patients with CF or C responses did almost as well. TABLE III �.6. TABLEII Relation of Rorschach Factors to Ciinical Response in Convulsive ’Iherapy: Content Categories, Movement and Per Cent Poplgar Responses Number $.13. (38) 3.8 2.2 (he) h.9 2.3 Diff. of Content Categories Much Improved Mod Mean erate or Unimproved ifl, 1.1 2.1 2.6 ** 2.7 11.1 * Number of Moveme‘ot Responses Much Improved (38) 2.3 2.7 Moderate or Unimproved (hi3) h.9 5.1 (38) 37.7 21.6 (h8) 26.6 1h.3 Per Cent Pomar Responses Much Improved Moderate, or Unimproved * Significant ** 2.8 V. at .05 level Significant at .01 level �$3 g 3 35 N 8.V. $8 335 m a m $8 o menu;H m Amaav 305 m H SVQ ”ummnony wmbommfiH NH.w 32 n n 0 «N «x NM QQOJH mmeazpaoo gs ca Nampwhmcos $5 €09 “Rm: N. 3 a m Ammmv Ammov Amawv Ammmv HH ma NH N 0H RS Amwv 8d Amos fig: “many 3.5 ma 3 m 383 Rammv ,mH mu $5 85 8 noaoo omcbmmmm HHH cam [chlmnm¢fl Hmowawao unmsmboz on \xfimmmV cabommgH Awmev myopowm finfim sou: ma nomnomnom mo mbwpmamm I! RE AEhv Aumv upmafiuu¢m pumsmboz Amuv ASV chum 303%: on such pamembnx gamma pmoswboz wfiuflm 02 g noaoo hoaoo_suom n0\unm noxnnm amewq< noaoo hoaoo oz oz �-8In Table IV the patients were grouped according to combinations of H and rated as FC responses. 01‘ those who had both much improved and 25% were of those with neither M nor M and PC only 1775 were considered mimproved. In contrast, EC, 66% were much improved and only 3% were improved. The ratings of the group with one or the other of these deteminants fell in between. unnuumm TABLES IV W...‘. B. chnErison of Pre- and Posttreatment Records Posttreatment records were obtained from hl patients. These showed little difference from the types of responses found prior to treatment. .fith respect to human movement (M), for example, recorfls shared no change. In four cases patients with none afterwards; follow-ring three other patients with no treatment. M M 3h of the responses showed response had such response �«a. TABLE IV Relation of Rorschach Factors to Clinical Response in Convulsive Therapy: Human Movement SM) and Form Color $130) Rorschach ___N__ M and M or FC F0 Neither M M nor FC and FC/Neither Mmr Much Improved (21:) h (25) 10 (ho%) (38) 25 (6655 FC (17%) Moderateg ImEroved W 6 (25%) (36%) 6 (20%) (32%) 1 (3%) 1h (58%) 9 12 x2 = x2 - 12.26 17.82 p < p.<; .01 .001 �.10.. DISCUSSION: this study confirm the findings previously reported concerning the relationship of personality to clinical response after convulsive therapy. Patients who had a good clinical result showed The results of Rorschach records characterized by few responses and content, no shading or movement or little variety of color reaponse, and a high percentage of whole, form and popular reSponses. This pattern indicates a personality pattern which i s non-empathic, non-introspective, non-verbally cormunicative, highly conventional and stereotyped and with little manifestation of imagination or creative capacity. These aspects are identical with these described in the previous study based on interviews with family members (6). The prognostic value of the Rorschach as a clinical instrument is demonstrated by this data. ifhile there are a number of studies in the literature on the prognostic value of the Rorschach in somatic therapy, the results have not been consistent. T:Jhile Rabin (3), for example, has stated that "single Rorschach factors cannot serve ... as predictors of improvement ," Piotrowski has described specific prognostic criteria (12). It is likely that the difference in point of view, as well as in the varying criteria offered, reflects differences in the type of population and the varieties of somatic treatment observed. Despite these problerns, however, the results of those studies with the largest series of patients report similar observations to those in the present study. For example, their data shows that the absence of human movement (M) is more (12, 114) often associated with a favorable clinical response, and that patients �.uwith F0 responses are more likely to have a poor result (1h). The that significance of these results might be questioned on the basis clinical response and type of illness rather than flue personality pattern. In this regard numerous studies have reported that depressed patients, the most likely candidates for convulsive therapy, show no human movement or color we have demonstrated a reSponses (h, 10, 15, 16). by other relationship Our studies (1, 7, 8, 11), after treatment, between observations, however, substantiated show a constancy of the Rorschach before indicate that the reSponse pattern reflects aspects of the basic personality rather than transient features as the and prevailing mood and or type of illness. �SUMMARY.AND CONCLUSION: 1. Eighty-seven unselected cases referred for convulsive therapy were administered a Rorschach test prior to, and two weeks following, treatment. 2. A favorable clinical response was observed in subjects with pretreatment records characterized by few responses, a small number of content categories, absence of shading, movement and color responses (particularly lack of human movement and form color), and a high percentage of whole, form and popular reSponses. This data confirms previous observations on the 3. personality factors to clinical outcome relation of in convulsive flierapy. favorable evaluation is most likely in patients who A are predominantly non-empathic, non-introSpective, nonaverbally communicative, highly conventional and stereotyped, with little imagination or creative capacity. significant change in Rorschach records obtained There was no A. It is that pretreatment Rorschach patterns in this population reflect the basic personality rather than the prevailing following treatment. mood concluded or type of illness. 5. can be patterns, by providing a set of prognostic criteria, useful adjuncts in the selection of patients for convulsive therapy. Rorschach �.13- 2.‘ Fink, 3. and Katm, R.L.: Relation of Electroencephalographic Delta Activity to Behavioral Response in Ele ctroshoclc, A.M.A. Arch. Neurol. 8: P_s,zchiat., IQ: 516-525 (1957). A M. Behavioral Patterns with Induced States of tered Brain Function, Div. Meeting A.P.A. (New York 1957). : 14. Guirdham, A.: Diagnosis of Depression by Med. Psycho . _1_§: 130-115 (1936). 5. Kahn, the Rorschach Test, Brit. J. R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Bnprovement in Electroshock, A.M.A. Arch. Neurol. and Psychiat. 1g: 23-29 (1956). ,: Personality 7. 8. 9. 10. 11. 12. Factors in Behavioral Reaponse to Electroshock Therapy, Conf. Neural. (in press) Kelley, D.M., Margolis, H. and Barbara, S.E.: of the Stability Rorschach Method as Demonstrated in Electric Comrulsive Therapy Cases, Rorsch. Res. Exch., 5: 35-143 (19M). Kisker, G.W.: A Projective Approach to Personality Patterns During Insulin-Shock and Metrazol-Convulsive Therapy, J. Abn. & Soc. 21: 120“12)4 (19112). mo: Klopfer, B. and Kelley, D.: The Rorschach Technigue. (World Book Co. , New York 19h2). levy, D.M. and Beck Psychosis, Am. S.J.: Rorschach Test in Manic-Depressive J. Orthops‘gchiat” ll: 314:2 (19311). The Pacella, B.L., Piotrowski, Z. and Lewis, N.D.C.: The Effects of Electric Convulsive Therapy on Certain Personality Traits in Psychiatric Patients, Am. J. Psvchiat. 1011: 83—91 (19M). Piotrwski, Z.: A Simple Experimental Device for the Prediction Quart., lg: 267-273 (1910); Aid in the Insulin Shock Treatment of Schizophrenia, Psychiat. Quart. 15: 807—822 (19141). �REFERENCES 13. Rabin, A.I: Effects of Electric Shock Treatment upon Some Aspects of Personality and Intellect, Am. PsEhol. g: 281; (1911?). lb. Rees, W.L. and Jenes, A.M.: An Evaluation of the Rorschach Test as a Prognostic Aid in the Treatment of Schizophrenia by Insulin Coma Therapy, Electronarcosis, Electroconvulsive Therapy and Leucotomy, J. Ment. Sci. 97: 681-689 (1951). 15. Rorschach, H.: Psydhodiagnostics (Grune Stratton, The Rorschach Test in Psychotic and Manninger 01111., S: 5'12 (19,41)- 16. Varvel, MtA.: Bull. & New York, 19h2). Neurotic Depressions, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. 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MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS BY ALTERED BRAIN FUNCTION J. JAFFE, M.D., H. ESECOVER, M.D., R. L. KAHN, and M., FINK, M.D. Glen Oaks, N. Y. PHD. This report is derived from a supervisory seminar in which the effects of convulsive treatment upon psychotherapeutic transactions were studied. The therapist’s observations have been described in a previous publication (1) . The present paper describes the process from the frame of reference of the supervisor and supervisory group. It is intended as a complementary set of observations of this combined therapy. In addition, concurrent neurophysiologic data are included, of which both therapist and supervisor were unaware. This additional frame of reference may broaden the understanding of certain phenomena in the patient-therapist, and therapist-supervisor interactions. Our purpose is to demonstrate that the introduction of a measurable physiologic variable is a useful method for the investigation of the psychotherapeutic process. The histories of the patients under study were given in the above-mentioned publication (1). In the following report, a detailed analysis of one of the cases" discussed in that paper is presented as most illustrative of the modification of interpersonal transactions by altered brain function. The patient, a 44—year-old widow and mother of a 12-year-old son, had been admitted to the hospital with symptoms of depression, anxiety, anorexia, varied physical complaints, and feelings of unreality and isolation. In her psychotherapeutic sessions she would reiterate her difficulties in a complaining pattern, repetitiously illustrating her inadequacy. During a three-month-period no improvement occurred and a course of electroshock therapy was recommended. At this juncture the patient was included in the present study. From the Department of Experimental Psychiatry, Hillside Hospital. Aided, in part, by the Foundations’ Fund for Research in Psychiatry (56151) and grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. The assistance of Miss Esther Sanders and Mrs. Anita Bellow, who participated actively in the seminars, is gratefully acknowledged. : * Case #3, G. C. 46 Reprinted from AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. pages 46—55. January, 1961. XV, No. 1, �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 47 The setting was a weekly multi-disciplinary supervisory conference. Included in the group were: (a) the therapist (H.E.), (at the time a senior resident in psychiatry), who presented the case material; (b) a social worker who reported the response of the patient’s family; (c) a psychoanalyst (J .J .), Who dealt mainly with the didactic aspects of psychotherapeutic technique; (d) a psychologist (R.K.), who studied the cases independently; and (e) a neuropsychiatrist (M.F.), who coordinated the discussion. The last two members were aware of the concomitant changes in physiologic measures, and although this information influenced their questions, the data were not introduced at these conferences. The actual somatic treatment was performed by a physician who was not a participant at the meetings. The procedure was informal, with the therapist taking the lead in presenting his verbatim notes of the psychotherapeutic sessions. The order of the case reports and the amount of time devoted to each was not prescribed. Following the spontaneous case presentation, more directive questioning was introduced, aimed at clarifying and relating the information presented by therapist and social worker. Observations made during the period of somatic therapy are depicted in the accompanying chart. During the 94 days of supervision, two different forms of somatic treatment were utilized. This procedure was part of a hospital-wide convulsive-subconvulsive control study then in progress, in which therapists were unaware of the introduction of subconvulsive phases of treatment. . For the first treatment period (27 days) the patient received subconvulsive electro-stimulation with pentothal premedication. Twelve such treatments were given at the rate of three per week. No changes in the quantitative measures of EEG slow wave activity (2) were manifest during this time. This period served to establish a baseline for the behavioral observations and the expectancies of the staff. In the second treatment period (29th to 59th day), grand mal convulsions were induced three times weekly for a total of 14 treatments. In that period, minimal degrees of EEG change were recorded on the 37th day, and moderate degrees were shown on three subsequent recordings. Twelve days after the termination of convulsive therapy, EEG slow wave activity was considerably diminished. This information was not available tothe therapist or the supervisor until after the conclusion of the study. �‘ arr-fir». 48 AMERICAN JOURNAL OF PSYCHOTHERAPY EFFECT OF CHANGING BRAIN FUNCTION ON PSYCHOTHERAPY SUPERVISORS REPORT OF DISCOURAGEMEHT. AVOIDINCE FRUSTRATION. EXHORTATION APlST'S ATTITUDE TNEFMPIST'S REPORT 'SLIGNT CHANGE' (MINIMIZEDI DEPRESSED. couPanmG. SELF—REPROACHFUL, OF FATIENT'S A" ITUDE HELPLESS, HEW COMPLAINTS PARTICIPATION IN ACTIVITIES I I mnznlon } DEPRESSION I I "ORE COMFORTABLE, EASIER TO RELATE. POSITIVE FEELINGS CAUTIOUS, SOLICITOUS CHEERFUL, PRIMPING, SELF- CONVERSATIONALJRUSTING. AFFECTIONATE. ADULATING I I I I “APPRAISAL. SUPPORTIVE, DETACHED ASSERTIVE. OBJECTIVE. INDEPENDENT; ANXIOUS I I ANXIOUS .. .— I __ __ 20~ PAGES nous Unaware 5553101: m 10' 0 WW ......... 26EE 6 ". nu: nun) scum TREATMENT °"""°°""‘ I-COWULSIVE n'0- :— - _-.. B_|—|_I____J__J_l—J_L_'.l—L—L——L—J—-l——I—-—J___ 85 70 75 80 55 0 5 DAYS l0 [5 20 FROM 60 40 45 50 ONSET OF SOMATIC THERAPY 25 30 35 The patient was seen in psychotherapeutic sessions three times weekly throughout her hospitalization. While the therapist was he somatic was unaware that of treatment, the concurrent aware subconvulsive stimulation was given initially, and of the change to convulsive therapy on the 29th day. Changes in the patient-therapist relationship as reported in the supervisory meetings are summarized in the chart and are detailed below. Supervisors’ Notes Ist to 19th day: During the first three weeks the therapist did not discuss this patient in the supervisory group. Other patients occupied the allotted time, in spite of a resolution to consider each patient weekly. In retrospect, the failure to report this patient’s progress canstituted a pattern of avoidance. Somatic therapy had not modified the patient ’3 ward behavior or the doctor-patient relationship. Both were the same as in the initial months of hospitalization. The neurophysiologic indices were unchanged. 20th to 33rd day: The case history was first presented in the meeting on the 20th day. The therapist reported no alteration in �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 4:9 the patient ’3 clinging, whining, helpless attitude throughout the preceding three months. Efforts to explore her problems in living were blocked by physical complaints and by recitals of guilt, selfreproach, and feelings of failure. He was left little opening for comment. In the three supervisory meetings during this period the group atmosphere was one of discouragement whenever this case was presented. The therapist reported impulses to exhort the patient to participate in ward activities, and reacted to her professions of helplessness with the feeling that “she wasn’t trying.” The family reported that the patient considered her doctor “too young,” reflecting her attitude of reproach toward those who were unable to help her. He, in turn, felt that she was “throwing up her hands and giving up.” The therapeutic impasse was empathically communicated to the group by the case report. The transactions during this period were typically those leading to referral of depressed patients for somatic (i.e., nan-verbal) treatment. They may be characterized as follows. Verbal methods of therapy are incompatible with the affective mode of communication adopted by such patients (3'). The doctor’s efforts to help are not met by a collaborative response, and he feels frustrated. The insatiable quality of the patient’s demands also calls forth defensive reactions in the therapist. During this period the mode of somatic treatment was changed from subconvulsive to convulsive. The clinical status and therapeutic relationship, however, continued unaltered. Perhaps the lack of the expected response of somatic treatment contributed to the therapist’s discouragement. He assumed that convulsions had been induced from the outset, and his past experience had led him to anticipate a clinical response by the fourth week of treatment (2). 34th to 42nd day: In the meeting that took place on the 38th day, a “slight change” was reported. Although the patient was still “crying, ranting, raving” in therapy sessions, it was also noted that “she participates in activities a little bit more, but not much.” The therapist and the group discounted this change in social relationships. The first spontaneous complaint of memory difficulty was also reported. The first evidence of neurophysiologic change appeared at this time. The EEG taken the day prior to this meeting showed a significant increase in slow wave activity. �50 AMERICAN JOURNAL OF PSYCHOTHERAPY 43rd to 63rd day: In the meeting on the 45th day the therapist reported a full psychotherapeutic session for the first time. He described the patient as “brighter,” “with a little more rouge and lipstick” and “smiling.” Two days later her mood was noted as “euphoric.” Physical complaints ceased and were replaced by complaints of forgetting. The therapist described this as a “cessation of complaining.” Concomitantly, the affective mode of expression was replace-d by a more intellectualized pattern. Instead of stating “I have to cling to my mother,” the patient said “I’m dependent on my mother for many things.” This was described as “talking about her dependency in a different way.” Another change in communication pattern evoked ‘ ‘uncanny’ ’ feelings in the therapist. He stated that the patient “mentions things we had talked about as if it were new information.” With these changes, there was a concomitant increase in the patient ’s sociability and participation in hospital activities, and a diminution of her clinging to the family and therapist. The supervisory group atmosphere also changed— from one of hopelessness to well-being, with increased joking, smiling, and animated participation. On the 52nd day the therapist reported that the patient dressed seductively and applied fresh make-up for her sessions. She expressed feelings of trust and enjoyment of the meetings. The doctor experienced similar emotions, and was eager to report the progress of this patient. She was now “upset” because she couldn’t recall her problems, and the therapist noted that he was inclined to a directive “remembering” role. She complained of memory loss and attempted to relate in a friendly, realistically gratifying way to prevent further psychologic exploration. A greater detachment from her family was expressed. Social improvement continued. The family stated that she no longer considered the doctor “too young,” but rather a “guiding angel.” The abrupt, gross change in the clinical picture paralleled the development of maximum physiologic change. The three EEG- records during this period showed a moderate degree of slow- wave activity. The advent of positive feelings elicited reciprocal emotions in the therapist which were cammunicated in the supervisory sessions. The aflect was empathically reflected in members of the conference group. (The clinical picture resembled that of a “transference cure.” ) It is of interest that a change from “ physical” to “memory” �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 51 complaints was described as a “cessation of complaining.” Perhaps the memory deficit, an expected concomitant of convulsive therapy, is more acceptable to the staff because it is understandable. They feel a responsibility for this symptom and can authoritatively reassure the patient that it will be transient. An afiectionate dependency may also be more tolerable than a hostile one, especially when accompanied by gratifying social improvement. The language changes are indicative of a more detached, intellectualized cammunication of familiar content (4). The patient now “talked about” rather than emoting or “acting out.” This new language pattern was more in keeping with her background of college education, and the therapist’s implicit expectations (5‘). In contrast to her prior mode of communication it seemed to be more compatible with a psychoanalytioally-oriented approach. The concomitant development of memory difiiculty, however, perpetuated the essentially non-insightful therapeutic situation. 64th to 72nd day: This period followed the termination of somatic treatment. The patient reported a “sudden feeling of selfawareness.” Euphoria and memory difficulty were no longer Observed, and an anxious state supervened. Psychotherapeutic sessions were characterized by more critical appraisal of her life situation. For the first time the doctor gave the patient extra time in the sessions. The group voiced some concern that she was “slipping back.” When the patient occasionally talked positively about career, emancipation from mother, and so forth, the therapist felt called upon to respond optimistically, rather than to explore. There was a revival of Old complaints. At this point, the supervisor and therapist reviewed a tape-res corded therapy session. A recurrence of the earlier verbal patterns could indeed be identified. However, these occurred in circumscribed fashion rather than throughout the interview. The events antecedent tO such periods were examined and the adaptive nature of the recurrent affective patterns became apparent. The EEG record during this period showed a considerable decrease in slow wave activity. There was a concomitant reestablishment of some of the communication patterns which preceded the period of altered brain function. The conference group responded with anxiety, reflected in the solicitousness of the therapist in prolonging the sessions. The phenomenon observed in the supervisory group, for lack of �52 AMERICAN JOURNAL OF PSYCHOTHERAPY Statedependency.” “electroshock be called better term, may a ments were made in the meeting such as “she’s slipping back,” “needs more treatments” and “improvement not holding up.’ These statements imply that the hostile- dependent pattern was being rather depression,” “a nosologic entity, as a thought of primarily than a mode of human relatedness. Perhaps because behavioral it now alone, means psychologic been by effected had not change seemed totally dependent upon the alteration in cerebral function. The change in interaction was conceptualized as the result of the brain syndrome, and not as a function of the doctor-patient relationship. Hence the group’s uneasiness on the sporadic reappearance of preconvulsive patterns. The detailed examination of a taperecorded session revealed the adaptive function of this more circumscribed occurrence of the complaints, and the phenomenon of “electroshock dependency” was not observed in subsequent group meetings. 73rd to 94th day: During this period a more stable psychotheraindebecame The more patient apparent. was relationship peutic assertiveselfand of compliance discussed problems and pendent ness. Although her attitude remained positive and collaborative, her adulation of the therapist diminished. In one session she said She was at you.” I unless won’t better get I angry get “Maybe less elated. She moved from the closed ward to an open cottage, and began to work in the hospital library. Occasional episodes of overt disturbance were treated by the therapist without solicitude. His attitude was one of interest, support and detachment. They discussed plans for discharge and outpatient treatment. Subsidence of the changes in brain function resulting from convulsive therapy permitted a new integration of the doctor-patient relationship. The pattern of a conventional psychotherapeutic situation appeared, which differed both from the original negative and the artificially induced positive relationships. Therapist’s Notes as an Index of Relatedness Following the conclusion of the study, another index of the psydescribed Rioch has investigated. was relationship chotherapeutic stafiof index notes staff of as an volume of the the use progress in his notes a had The kept therapist interaction (6). patient standard stenographic notebook throughout the treatment. A gross count of the number of pages of notes per session was made, and �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 53 is represented graphically on the chart. No written notes were taken during occasional tape-recorded sessions, and these are omitted from the chart. The change in the relationship is apparent from the abrupt and persistent increase in note-taking from the 44th day. This coincided with the first gross change in the electroencephalogram. The notes taken by the two other psychiatrists in the supervisory meetings followed a similar pattern (not illustrated), although with peaks of note-taking at the onset and again at the waning of induced neurophysiologic change. DISCUSSION This report describes an investigation of psychotherapy when somatic therapy is introduced as an adjunctive procedure. One difficulty in the objective study of psychotherapeutic transactions is the absence of a quantifiable and controllable variable. Adjunctive therapies, somatic and pharmacologic, provide such a variable. They produce alteration in behavior as well as measurable neurophysiologic changes (2, 7). This opportunity has been utilized in the present project. For example, one mode of adaptation to altered brain function is a euphoric type of relatedness (8). The occurrence of the phenomenon in this case permitted us to observe how induced alternation of positive and negative attitudes call forth similar attitudes in therapist and supervisor. Another illustration was the discounting of the earliest clinical change during the 34th to 42nd day of treatment. The electroencephalogram indicated the significance of this beginning change in the relationship. The fact that it was minimized demonstrates the obscuring effects of stalf expectancies. Finally, the alteration of brain function was accompanied by a change in complaint pattern, that is, from physical symptoms to memory difficulty. This resulted in a new form of the dependency relationship (43rd to 63rd day) which was experienced differently by the supervisory staff, with resultant change in their feelings about the patient. This effect was also observed in the patient ’s family group. The observations also illustrate a phenomenon peculiar to supervision in group settings. We have called attention to the emotional atmosphere of the group, which seemed to fluctuate in accordance with the therapeutic relationship being described. Hora (9) suggests that the supervisee may communicate the affective aspects of his experience with the patient non-verbally in the supervisory meet- �54 AMERICAN JOURNAL or PSYCHOTHERAPY ing. His formulation is that “The supervisee unconsciously identifies with the patient and involuntarily behaves in such a manner as to elicit in the supervisor those very emotions which he himself experiences while working with the patient, but was unable to convey verbally.” He also describes the diflusion of this affect in the other participants of a supervisory seminar. Thus he reports that “This observation has been subjected to repeated tests in seminars where it was possible to verify the supervisor’s emotional perceptions by matching them with the emotional reactions of the other participants present.” Our work supports such observations and suggests the potential fruitfulness of studies of group dynamics in supervisory seminars. We have noted one change in relatedness resulting from the somatic therapy that had a disjunctive effect upon the relationship (45th day). The patient mentioned familiar topics “as if it were new information.” The “uncanny” quality produced in the therapist and supervisor resulted from the temporary feeling that the therapeutic relationship had no history. Rapport in intensive psychotherapy depends to a great extent upon an accumulated body of shared information. Both doctor and patient take this for granted, and the inability to rely upon it may affect rapport adversely. Other patients in the study, not discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic, and other forms of “acting-out” which were disruptive to the concurrent psychotherapy. In each case the induced behavioral change was related to the personality of the individual patient and occurred at the time of changing brain function (2). Also in each case there were concomitant changes in behavior in the supervisory group. Our experience also highlights some of the difliculties that may develop when the two modes of treatment are used concurrently. Intensive psychotherapy is based upon the conviction of the eflicacy of verbal communication for improvement of the patient ’s adaptation. In the case reported, a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interpersonal communication as the therapeutic instrument. When cerebral change was maximal, a “social recovery” occurred, apparently unrelated to interpretation of psychodynamic factors. When the induced neurophysiologic changes subsided, a recurrence �[MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS ' 55 of earlier communication patterns led the therapist to doubt that the improvement could be perpetuated by interpersonal means alone. To some extent this phenomenon was an expression of differing conceptual and linguistic systems inherent in the two modes of therapy. It is related to the philosophical dichotomy described by Hollingshead and Redlich (10) between practitioners using somatic and analytically-oriented therapies. SUMMARY A study of concurrent somatic therapy and psychotherapy is reported, in which simultaneous observations of serial changes in brain function, the psychotherapeutic relationship and social adaptations were made. The observations in a group supervisory seminar reflected the pattern of neurophysiologic alteration. It is concluded that the introduction of a measurable physiologic variable is a useful method for investigation of interpersonal relationships. 1. 2. 3. BIBLIOGRAPHY Eseeover, H., Jaffe, J. and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients. J. Hillside Hosp, 7: 17, 1958. Fink, M. and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Resp0nse in Electroshock. Quantitative Serial Studies. A.M.A. Arch. Neurol. & Psychiat., 78: 516, 1957. Cohen, M. 8., Baker, G., Cohen, R. A., Fromm-Reichmann, F., and Weigert, E.: An Intensive Study of Twelve Cases of Manic-Depressive Psychosis. Psychiatry, 17: 103, 1954. Kahn, R. L. and Fink, M.: Changes in Language During Electroshock Therapy. In Psychopathology of Communication, P. Hoch and J. Zubin, Eds., Grune & Stratton, 1958. Kahn, R. L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital. A.M.A. Arch. Gen. Psychiat, 1: 565, 1959. Rioch, D. McK.: Research in Psychiatry: Certain Problems and Developments in Multi-Disciplinary Studies. T. W. Salmon Lecture, New York ' 4. 5. 6. Academy of Medicine, 1957. 7. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies. J. Hillside Hosp, 6: 197, 1957. 8. Fink, M., Kahn, R. L. and Green, M.: Experimental Studies of the Electroshock Process. Dis Nero. Sys., 19: 113, 1958. 9. Hora, T.: Phenomenology of the Supervisory Process. Am. J. Psychother., 11: 769, 1957. 10. Hollingshead, A. B. and Redlich, F. 0.: Social Class and Mental Illness. J. Wiley & Son, New York, 1958. ��Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function J. Jaffe, M.D., B. Esecover, M.D. R.L. Kahn, Ph.D. a M. Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. From Aided, in part, by the Foundations' Fund for Research in Psychiatry (56-151) and grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. assistance of Miss Esther Sanders and Mrs. Anita Bellow, caseworkers in the Department of Social Services, who participated actively in the seminars, is gratefully acknowledged. The VII: 11-15-58 �Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function seminar from a supervisory derived is psychotreatment upon convulsive of which the effects in The studied. therapist's were communication therapeutic observations have been described in a previous publication (2), and are based mainly upon his personal experiences with the patients. The present paper describes the process intended as is of frame reference. It from the supervisor;s combined complex of this observations of a complementary set data is neurophysiologic concurrent In addition, therapy. unaware. were and supervisor both which of therapist included, This additional level of observation seems to account for and the in patient-therapist, certain clinical phenomena This report therapist-supervisor interactions. Our purpose is to demonstrate that the introduction method a useful is variables of measurable physiological for the investigation of the psychotherapy process. �METHOD: setting was a weekly multi-disciplinary conference composed of five people, and thus departed from the conventional supervisory situation. The group included: a) the therapist (H.E.), at the time a senior resident in psychiatry, who presented the case material; b) a social worker assigned to The the cases selected for study, who reported the on-going response of the patient's family; c) a psychoanalyst (J.J.), who dealt mainly with the didactic aspects of psychotherapeutic technique; d) a psychologist (R.L.K.), who had studied the cases independently; and e) a neuropsychiatrist (M.F.), who coordinated the discussion. The last two members were aware of concomitant changes in the physiologic measures, and although this information influenced their questions, the data was not introduced at these conferences. The actual somatic treatment was performed by a physician who was not a participant at the meetings. procedure was informal. The therapist took the lead in presenting verbatim notes of his psychotherapy sessions with five patients receiving combined therapy. The order of The the case presentations and the amount of time devoted to each was not prescribed. Following the spontaneous case reports, directive questioning was introduced, aimed at clarifying and relating the information presented by the therapist and the social worker. Although roles were defined, the atmosphere was one of inquiry in which no participant claimed a definitive answer to the problem under investigation. more . �m SUBJECT: case histories of the subjects of this study were In a this (2). report in a publication previous reported most #3 as Case clearly of is presented detailed analysis illustrative of the modification of interpersonal transactions The widow old year by patient, and mother of a 12 year old son, had been admitted to the hospital because of depression, anxiety, anorexia, multiple somatic complaints, and feelings of being "unreal" and isolated. In therapeutic sessions she would reiterate her difficulties 'in a persistent complaining pattern, as illustrations of her altered brain function. This a hh After a three month period of psychotherapy without alteration in the clinical condition it was decided co utilize a course of electroshock therapy. At this time the patient was included in the present project. More detailed description of the psychotherapy sessions is included under "Observations" below. failures and inadequacies. SOMATIC THERAPY: during the intercurrent somatic therapy are depicted in the accompanying chart. During the 9b days of supervision two different forms of somatic treatment 'Serial observations made This procedure was part of a convulsivesubconvulsive control study then in progress, in which the therqmd.was unaware of the introduction of the subconvulsive were utilized. phase of treatment. �-hFor the first period the patient received subconvulsive electrostimulation with pentothal premedicaticn. Twelve such treatments were given at the rate of three per week. No manifest changes in quantitative analyses of the degree of the EEG (3) were observed during this time: in delta activity This period established a baseline for the behavioral observations and the staff eXpectancies. Grand mal convulsions were induced from the 29th to the 59th days of somatic treatment, also at a rate of three per week for a total of 1h treatments. In this convulsive period, minimal degrees of electroencephalographic delta activity appeared on the 37th day, and moderate degrees were shown on three subsequent recordings. On a follow-up record 12 days after the termination of convulsive therapy the delta activity had decreased considerably. This information was not available to the therapist or the supervisor until after the conclusion of the study. The patient was seen in psychotherapy sessions three times a week throughout her hospitalization. While the therapist was aware of the concurrent somatic treatment, he was unaware of the fact that subconvulsive stimulation was given initially, and of the change to convulsive therapy on the 29th day. The changes in patient-therapist relationship as reported in the supervisory meetings is summarized in the chart and is detailed in the following observations. -~‘ -------Figure I 27 day �OBSERVATIONS: let to 19th day: During the first three weeks of somatic treatment the therapist did not discuss this patient in the supervisory in the time, allotted occupied Other all patients group. the in about hear to patient every of resolution our spite study each week. The case histories presented during this time were those of patients undergoing gross day-to-day changes in clinical behavior. Comment: retrospect, we consider the omitted presentation A communication. pattenlof avoidance to be a significant characterized this period. The neurophysiologic indices during this time were unchanged. Similarly, the patient's clinical status and the doctor-patient months the three in same the as were relationship In preceding somatic treatment. 20th to 33rd day: The case history was first presented in the meeting on the 20th day. Over a three month period the psychotherapeutic unable to the being been had unchanged, therapist relationship discern any alteration in the patient's clinging, whining, in her living problems to explore Efforts attitude. helpless of and by long recitals complaints blocked by were physical In three the of and failure. feelings self—reproach, guilt, supervisory meetings during this period the group atmosphere �-6was one of discouragement when this case presented. The therapist reported impulses to exhort the patient to participate in ward activities, and reacted to her professions of helplessness with the subjective feeling that "she was'nt trying." The reproach against those who were unable to help her was reflected in the family's report that the patient considered her therapist "too young." was Comment: therapeutic impasse was empathically communicated to the group by the therapist's report. The interaction during this period may be characterized as follows: After prolonged, unsuccessful efforts at verbal communication the psychotherapist is realistically frustrated (I). The affective mode The patient rendered essentially verbal techniques useless. The doctor's efforts to help were not met by a collaborative response, while the insatiable quality of the patient's demands may also have called forth defensive reactions in the therapist. Such interactions are typically those that lead to the referral of psychotically depressed patients for somatic, 3,3. nonof communication adopted by the verbal forms of therapy. During this period the mode of somatic treatment was changed from subconvulsive to convulsive. The clinical status and therapeutic relationship however, �-7continued unaltered. Perhaps lack of the expected response to somatic treatment contributed to the therapist's discouragement. He assumed that convulsive therapy had begun at the outset, and his past experience had led him to anticipate a clinical response by the fourth week of treatment (3). Bhth to h2nd day: In the meeting that took place on the 38th day, a "slight change" reported. Although the patient was described as still "crying, ranting, and raving“ in therapy sessions, it was reported that "she participates in activities a little bit was more, but not much." The therapist and the tended to minimize the social improvement. The first group spontaneous complaint of memory difficulty was also reported in this meeting. Comment: retrospect, the first evidence of neurophysiologic change had appeared at this time. The electroencephalogram on the day prior to this meeting showed a significant increase in delta activity. The In group discounted the concomitant observation of clinical change in view of a persistent hostile- dependent transference, and negative counter- transference feelings. �23rd to 63rd day: In the meeting on the hSth day the therapist spontaneously reported a full verbatim psychotherapy session for the first time. The patient was described as "brighter," "with a little more rouge and lipstick," and "smiling." Within the next two days he described her mood as ”euphoric.” Physical complaints ceased and were replaced by complaints of forgetting. The therapist, however, described this change as a cessation of "complaining." There was a change in the form of verbal expression although the content remained the same. Her affective mode of expression was replaced by an intellectualized pattern. For example, instead of complaining mother" the patient said, "I'm "I have to cling to my dependent on my mother for many things." The therapist described this change as "talking about her dependency in a different way." Another of his observations, however, was reported with "uncanny" feelings which were shared by the supervisor. He stated that the patient "mentions things we had talked about as if it were new information." With these changes, there was a concomitant increase in her sociability participation in hospital activities, and a diminution of her overt dependency upon family and therapist. The supervisory group atmosphere at this time changed from one of discouragement to a feeling of well-being, with increased Joking, smiling and animated participation. and �-9the 52nd day the therapist reported that the patient dressed seductively and applied fresh make-up for her therapy meetings. She expressed feelings of trust and enjoyment of the sessions. The doctor experienced similar emotions, and was eager to report the progress of this case. The patient was now "upset" because she could'nt remember her problems, and the therapist noted that he was being continually led into a directive "remembering" role. He felt the patient used her memory loss as a defense against further psychologic exploration, and that she preferred to maintain the relationship on a 0n friendly, realistically gratifying level. A greater detachment from her family was also expressed. Indicafima of social improvement were prominent. The family' stated that she no longer considered the doctor "too young," but rather a "guiding angel." Comment: abrupt and gross change in the clinical picture paralleled the development of maximum physiological change in this case. The three electroencephalograms during this period showed a moderate degree of delta activity. The advent of markedly positive feelings elicited reciprocal emotions in the therapist. These were communicated in the supervisory sessions, and were empathically reflected in members of the conference group. The clinical pattern resembled that of a "transference cure." The �-10- It is of interest that change from "physical" to "memory" complaints was described as an overall "decrease in complaining." Perhaps a memory deficit, expected concomitant of convulsive therapy, was ;MOre acceptable to the staff because it was understandable. They felt some responsibility for this Syphon and could authoritatively reassure the patient that it would be transient. It is also probable that an affectionate dependency is more tolerable than a hostile dependency, especially when accompanied by obvious and gratifying social an improvement. The language changes were indicative of a more detached, intellectualized'communication of familiar content (8). The patient at this time "talked about“ rather than emoting or "acting out." These new language patterns were consistent with her college education and, in contrast to her prior mode of communication, appeared to be more compatible with a psychoanalytically-oriented approach. However, there was the concomitant development of memory difficulty, exemplified by her introduction of previously discussed topics as new information. The ne.t effect thus a non-communicative situation with regard to interpretive insight therapy. was �-116hth to 72nd day: This period followed the termination of somatic treatment. The patient reported a "sudden feeling of selfmemory The awareness." euphoria and difficulty were no longer observed, and an anxious state supervened. The content of the psychotherapy sessions changed to a more critical appraisal of her life situation. For the first time the therapist gave the patient extra time in the sessions. The group voiced some concern that she'was "slipping back." When the patient occasionally talked positively about such problems as her emancipation from mother, the therapist was inclined to respond optimistically, rather than to explore. She reacted to this with a revival of old complaints. At this point, supervisor and therapist reviewed a tape recorded therapy session. A recurrence of the earlier pattern could indeed be identified, although in circumscribed fashion rather than throughout the interview. It was possible to examine the antecedent events in the session and to clarify the pattern as an adaptive response to stressful content. Comment: electroencephalogram during this period showed a considerable decrease in slow wave activity. There was a concomitant reestablishment of some of the communication patterns which preceded the The period of altered cerebral function. group responded with uneasiness which The supervisory was reflected �.12in the solicitousness of the therapist in prolonging the sessions. At this point a phenomenon was observed in the supervisory group which, for lack of a better term, may be called "electroshock dependency." Statements were made in the meeting such as, "she's slipping back," "needs more treatments," and "improvement not holding up." These statements imply that the hostile-dependent pattern constituted a nosologic entity - ”a depression" - rather than relatedness. Perhaps because therapeutic change could not be a effected by interpersonal means alone, its persistence seemed dependent upon the alteration in cerebral function. The change in interaction was thus being conceptuala mode of human ized as the result of the brain syndrome, and not as a function of the doctor-patient relationship. Hence the group's uneasiness on the sporadic reappearance of the pre-convulsive interaction pattern. The detailed examination of a tape-recorded session revealed the adaptive function of this more circumscribed occurrence of the complaints, and the phenomenon of "electroshock dependency" was not observed in subsequent group meetings. �-13. 23rd to 9hth daz: During relaionship this period stable psychotherapeutic patient became more independent a more apparent. The and discussed problems of compliance and self-assertiveness. Although her attitude remained positive and collaborative, her gross adulation of the therapist diminished. In one session she said, "Maybe I won't get better unless I get angry was at you.“ She was less elated. She moved from a closed ward to an open cottage, and began to work in the hospital library. Occasional episodes of overt disturbance were handled by the therapist without solicitude. His attitude was one of interest, support and detachment. Patient and therapist discussed plans for discharge and outpatient treatment. The patient was discharged six weeks later. Comment: Subsidence of the changes in brain function resulting from convulsive therapy permitted a new integration of the doctor-patient relationship. The pattern of a conventional psychotherapeutic situation appeared. This differed both from the original negative and the artificially induced positive transference relationships. �WW Therapist's notes as an index of relatedness: Following the conclusion of the study, another index of the psychotherapeutic relationship was investigated. Rioch (9) has described the use of the volume of staff progress notes as an index of staff-patient interaction. The therapist had kept his notes in a standard stenographic notebook throughout the treatment. A gross count of the number of pages of notes per session could be made. This is represented graphically on the chart. As no written notes were taken during the occasional tape-recorded sessions, these were omitted from the chart. The change in the therapeutic relationship is apparent from the abrupt and sustained increase in note-taking from the hhth day on. This coincided with the first gross change in the electroencephalogram. The notes taken by the two other psychiatrists in the supervisory meetings followed a similar pattern, although with peaks of note-taking at the onset and again at the waning of induced neurophysiologic change. �DISCUSSION: primary purpose of this report is to demonstrate the value of a detailed investigation of psychotherapy when somatic therapies are temporarily introduced as adjunctive procedures. One of the difficulties in the objective study of transference and countertransference phenomena is the The absence of a quantifiable and controllable variable. Adjunctive therapies, somatic or pharmacological, provide such a variable. They produce alteration in behavior as well as concomitant, measurable neurophysiologic changes (3, h). This opportunity has been utilized in the present project. For example, one of adaptation to altered brain function is a euphoric type of relatedness (5). The occurrence of the phenomenon in this case permitted us to observe how the induction of mode positive and negative transferences called forth similar countertransference attitudes in therapist and supervisor. Another illustration of this technique was our discounting of the earliest clinical change during the Bhth to h2nd day of somatic treatment. The electroencephalogram gave evidence in favor of the significance of this beginning change in the relationship. The fact that it was minimized demonstrates the obscuring effects of staff expectancies. Finally, the alteration of brain function in this course of psychotherapy was accompanied by a change of the pattern of complaints i;g. from physical symptoms to memory difficulty. This resulted in a modification �-16.. of the dependency relationship (h3rd to 63rd day). The new form of the relationship was experienced differently by the staff, with resultant change in their feelings about the patient. This effect was observed in the patient's family group as well as in the supervisory group. observations illustrate several other phenomena of interest. One is peculiar to supervision in group settings. We have called attention to the emotional atmosphere of the group, which seemed to fluctuate in accordance with the therapeutic relationship being described. Hora (7) believes that the supervises may communicate the affective aspects of his experience with a patient by non-verbal means. His formulation is that "the supervises unconsciously identifies with the patient and involuntarily behaves in such a manner as to elicit in the supervisor those very emotions which he himself experiences while working with the patient, but was unable to convey verbally." He also describes the diffusion of this effect in the other participants of a supervisory seminar. Thus he reports that, "This observation has been subjected to repeated tests in seminars where it was possible to verify the supervisor's emotional perceptions by matching them with the emotional reactions of the other participants present." Our work supports such observations and suggests the potential fruitfulness of studies of group dynamics in supervisory seminars. We have noted one change in relatedness resulting from the somatic therapy that had a disjunctive effect upon the The �-17- relationship (hSth day). The patient mentioned familiar topics "as if it were new information." The "uncanny" quality produced in the therapist and supervisor resulted from the temporary feeling that the therapeutic relationship had no history. Rapport in intensive psychotherapy depends to a great extent upon an accumulated body of shared information. Both doctor and patient take this for granted, and the inability to rely upon it may affect rapport adversely. Other patients in the study,nct discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic and other forms of "acting-out," which were disruptive to the concurrent psychotherapy. In each case the induced behavioral change was related to the personality of the individual patient and occurred at the time of changing brain function (3). Also, in each case, there were concomitant changes in behavior in the supervisory group. The limited scope of this study does not warrant general conclusions as to the efficacy of concurrent somatic treatment and psychotherapy. We have confined the discussion, therefore, to the presentation of methodology and description of the types of observations that can be made in such interdisciplinary approaches. Our experience does highlight, however, some of the difficulties that may develop when the two modes of treatment are used concurrently. Intensive psychotherapy is based upon �-18a conviction as to the the improvement of the efficacy of verbal communication for patient's adaptation. In the case reported a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interpersonal communication as the therapeutic instrument. When cerebral change was maximal a "social recovery" occurred. This was apparently unrelated to interpretation of psychodynamic factors. No increase in awareness of psychological relationships was verbalised. When the induced neurophysiologic changes subsided, there was a partial recurrence of earlier communication patterns. This was accompanied by a brief period of doubt that the modification of behavior could be perpetuated by interpersonal means alone. To some extent this phenomenon was an expression of the different conceptual and linguistic systems inherent in the two modes of therapy. It is related to the philosophical dichotomy described by Hollingshead and Redlich (6) between practitioners using somatic and analytically-oriented therapies. These considerations also arise in the use of psychopharmacologic agents during the course of psychotherapy (h). �SUMMARY: study of the effects of concurrent somatic therapy on psychotherapy is reported, in which simultaneous observations of serial changes in brain function, the psychotherapeutic relationship, and social A adaptation were made. The observations in a group supervisory seminar reflected the pattern of neurophysiolcgical alteration. It is concluded that the introduction of a measurable physiological variable is a useful method for investigation of the psychotherapy process. �REFERENCES l. Cohen, M.B., Baker, 6., Cohen, R.A., Fromm-Reichman, F., and Weigert, E.: An Intensive Study of Twelve Cases of Manic—Depressive Psychosis, Psychiatry $1: 103, 195k. 2. Esecover, 8., Jaffe, J. and Kahn, R.L.: Psychotherapeutie Techniques with Electroshock Patients, J. Hillside Hosp. 1: 17, 1958. Fink, M. and Kahn, R.L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock:Quantitative Serial Studies,A.M.A. Arch. Neurol. & Psychiat. 1Q: 516, 1957. 3. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp.g: 197, 1957. Fink, M., Kahn, R.L. and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. 81 . $2: 113, 1958. Hollingshead, A.B. and Redlich, F.C.: Social Class and Mental Illness, J. Wiley & Son, N.Y. T953. Hora, T.: Phenomenology of the Supervisory Process, Am. J. Psychother. $1: 769, 1957. Kahn, R.L. and Fink, M.: Changes in Language During Electroshock Therapy, in Pa cho atholo of ZuSEn, P. 3. §§3., Grune and Communication, Hoch, & Stratton, 1958. Rioch, D. McK.: Research in Psychiatry: Certain Problems and Developments in Multi-Disciplinary Studies, T.W. Salmon Lectures, 1957 (in press). N.Y. Acad. Med. �noditiaation at Pnynhothornputtta frannaettonu By tltnrod Drain Junction "tt‘, H.B.. E. 3.00.7.7, K.D., R. L. “hn, Phonu ‘fid fl. link, 8.D. ‘0 Iron thy aspartulnt a: Bxportuonsal Psychiatry, £111.16. loupttal, 61.“ O‘k.’ L.I., ‘1’. Aided. in part, by tho Foundationn' thud tar Research in Puyehiutry (SénlSl) and grant 3-927 of the rational Inu‘itutc o: nuntnl lualth, laticntl Inutitflna of nculth, v.5. Public loalth aarvtoo. Tho aunt-tango or 31:: 83th.: sander: :nd Hrs. Anita DCIIOI, who participated auttvoly in tho tcatnnra, 1. gratitully acknavludgod. III 10/30/59 �this rlport ta darivnd from a luporvinory suntan: in which thn affect. at convultivc trontncnt upon p;y¢ho~ thornptut1e trananotxanu war. studiud. rho thornpist'u abrcrvntinnl havo boon douoribod in u previous publicattou (2). in: proaoat pups: accorthcu thn pronoun tr.u tho franc at ratcrcaco at tho atporvisor and ouporvinory group. It 1! intondod an n aonplonontnry hot or obaorVItioua at thin nonbinud therapy. In addition, ouncurront neurophyulalogia ant: arc includad, of vhich both thornpiat and supervisor var. unnuuro. this udditiouul tram. of xutorenoo may broaden the underutnndiug or eurtnin phonononu 1n the pattcnt-thcrapint, and therapiltulnparvitcr tatcraottona. to don-natratt that the intraduction a: a unanurablo phyuiologiaul variablo 1: a ncctul Itthod for the turoatixatinn a: tho payehothcrapy pronoun. Our purpaao 13 �xxggan: tho ootttag too o uookhr oulttodiooaplioory ooporvtoovy oontorouoo. Ioalndod in tho group rotor o) tho thoroptot (3.8.), (at tho ttno o senior rootdont in poynhiotrr), who proooutod tho enoo uotortol; h) o ooatol worhor who roportod tho rooponoo at tho yotiont'o fonily; a) o poyoho~ onolyot (3.5.), who doolt mainly with tho d1doct1e oopocto of psychothoropoutte toohniquo; d) o poychologiot (3.3.). who studiod tho eoooo indopondontly3 and o) o nonrepoyohiotrtot (8.!t). who coordinotod tho diocuooion. rho loot tot nooboro wart ovoro of tho connooitont chouxoo 1: phyoioloxtc honouroo, one olthough thlo intorlotton infloouood thotr quoottouo, tho doto woo not introdtcod ot thooo toaforonooo. rho octuol oo-otlo trootoout woo porforood by o phyoioion who not o porticipont ot tho nootingo. Tho pronodoro woo intoruol, with tho thoroptot toktnx tho lood 1a prooonttnx hto vorbotto uotoo of tho poyohothoropy Tho ooootoao. ordor of tho aooo roporto and tho ooount o: tiuo dovotod to oath woo not prooorihod. Iolloring tho opoutohoouo oooo pronoutotion, morn dironttvo quootiouiag II! Introdoood, otood ot choritytnx and rolottns tho intoraotioa proooutod by thoroptot ond ootiol vortor. woo �803130?! the hintertee e! the enhaeate at thte study were reported in e previeee publication (2). In thie report e detailed enelyeie of Gate #3 (0.0.) 1- presented es meet illustretive or the nodixieation of interpereomel trenaeetiene by extered hrein function. This petieut, e hh your old vitae end nether of e 12 yeer old eon, bed been ednitted to the hoepxtel with eyaptone of depreeeion, enxiety, enorexie, varied phyeicel complaints, end feelings é: unreelity end isoletien. In psychotherapy eeeeione she would reiterete her difficultiee in e cenpleining pattern, repetitiouely illustretinx her inedequecy. During e three nonth period an ilpreveaent occurred end A couree at electroehoek therepy wee reeoeeended. At thte Junotute the patient wee included in the preeent study. vsg§;!:c_rnxnarr: cheervetiene eede dertn; the period of eenetxe therepy ere depleted in the euconpenying ehert. During the 9k deye of supervision tee different levee e: eoeetie treetleut were utilieed. This procedure wee pert e: e heepitel-wide eonvuleiveoeubeeavuleive control etedy then in progreee, in which therepiete were enewere at the introduction or enheonvuleive pheeee e: treetnent. Fer the tit-t treeteent period (21 deye) the patient received eebeenvuleive electra-etlaeletiou with pentethel �‘h. pronodiootiou. roolvo oooh trootnonto ooro givon ot tho roto or throo por rook. lo ohonxoo in tho ooohtitotivo looooroo o: 336 olov oovo ootivity (3) woro monitoot during thio tins. fhio poriod oorvod to ootobiioh o booolino for tho hohoviorol oboorvotiooo and tho oxpootonoioo of tho otott. In tho oooond trootnoht porioo (29th to 59th doyo), grand nol oonvoloiono uoro ihduood thrioo wookly for o totol o: 1h trootnonto. In thio ported, nioiaol dogrooo of EEG ohongo ooro rooordod on tho 37th doy, ond uodoroto dogrooo. woro shown on throo oohooqoont rooordingo. foolvo doyo ottor tho toroiootino o: oonvuloivo thoropy, EEG slow wovo ootivity ooooidorohly dioioiohoo. this intoruhtioo woo not ovoilohlo to tho thoropiot or tho ooporvioor until ottor tho ooholuoioa of tho otooy. woo -fi.‘.‘....‘..0fld.fl. Pic. 1 about horo -DO“-....‘..O-.... rho potioot woo ooon in poyohothoropy ooooiono throo tiloo vookly throughout hor hoopitoliootion. Hhilo tho thoropiot II! ovoro of tho ooooorront oonotio trootnoot, ho woo nnovoro that oohoohvoloivo oti-olotion woo givon initiolly, ohd of tho ohonso to convoloivo thoropy on tho 29th doy. thongoo in tho potiont—thoropiot rolotionohip oo roportod in tho ouporvioory lootiogo oro oonnorisod in tho ohort ond oro dotoilod in tho following ohoorvotiooo. �0188371 ;tt ,IS! 2: 12th dgz; firot throo vookl tho thoropiot did not dioeuoo thio potiont in tho ooporvioory group. othor potionto oooupiod tho allottod tino, in opito o: o rooolutioa to ‘ Daring tho conoidor oaoh potiont vookly. Gounonts In totroppoot, tho toiluro to roport this potiont 'o pragrooo coaotitutod o pottoru or ovoidoneo. sonotiu thoropy hod' not Iodiriod tho potiont'o word bohovior or tho doctor-potiont rolotioaohip. Both voro tho onto to in tho initiol Iontho a: hospital- iootion. rho nonrophyoiologio indieoo voro unohonxod. 20th to 22:4 dog: rho oooo history firot prooontod in tho looting on tho 20th doy. rho thoropiot roportod no oltorotion in tho potiont'o clinging, whining, holplooo ottitudo throughout tho proooding throo uontho. Errorto to oxplorovhor problouo in 1171:; uoro blookod by phyoieol oonplointo and by rocitolo of woo Ho woo loft of toiluro. tooling: guilt, oolt-roprooch, littlo oponiag £0» counont. In tho throo ouporvioory nootingo during thio poriod tho group otnoophoro woo ono of diluenrogonoat thou thio eooo too prooontod. the thoropiot roportod inpulooo to oxhort tho oud �.6patient to participate in ward activitiee, and reacted to her prereeeieue e: helpleeeneae with the feeling that *ehe eaan't trying.‘ eoneidered The taniiy reported that the patient her doctor "tee reung,' retleetiac he: attitede e: repreaoh toearde theee who were unable to help her. He, in turn, felt that eke wee 'threeiuc up he: hende and giving up.“ I gelnenta the therapeutic iayaeee eae eapathieaiiy oeuaenicated to the creep by the cane repert. The transactiene during thie peried were typically theee leading to referral of depreeeed patiente for eeaetia (i.e. noncverbel) treataent. they nay be toileee. Verbal nethede ee eharaeterieed er therapy are inceepatible with the affective made at cannunieetien adapted by each patiente (1). The deetor'e atterte to help are not eat by a eellaheretive reepenee, and he feels treetratea. the ineatieble qeaiifiy er the patient“ dean“ a1" «11. berth deteueive veeetiene in the therapiet. Baring thin period the node or eeaatie treetaent wee chanced tree eaheenveieive to eeafileive. The elinieal etatne and therapeutic relatienehip, hetever, eentiaaed unaltered. Perhaps the lack of the expeated reapenee to �.7. eenetie treetnent eentributed te the thereptet'e dieeeuregeuene. le eeee-ed thet cenvuleteue nee been induced from the euteet, end hie peet experienee bed led hie te entteipete e elinieel reepenee by the fourth week e: teeetlent (3). to ytnd 63!. In the aeetinx thet teak pleee en the 38th day, e “alight chenlef wee reverted; Although the,pet1ent tee etill revinxi 1n therepy eeeeiene, it wee elee renting, 'eryinc, neted thet 'ehe pertteipetee 1a eetivlttee e 11$t1e bit note, but net naeh.’ {he therepiet end the group discounted ehie ehenge an eeeiel relet30nehtpe. the tiret eyeateueoee oonpleint at eeeery dittieelty'vee elee reported. «age: cennent: the Sir-t evidenee er eeurephyetelegte eheuge ep’eered et thie tine. the 3E6 teken the any prter ‘0 thin leetlng eheued e Wm eixuitteent inereeee in slew wave eettvxty. In the neeting en the hSth day fine therepiet reyerted e full perehetherepy eeeelee fer the rivet tine. Re deeertbed the pettent ee 'brighter,’ ”with e little eere reuse end lipetteh' end 'eetltng.‘ rue deye lefier her need wee meted ee 'eupheric.‘ Phyeteel eonpleinte eeeeed end were replaced by aenpleinte of forgetting. The therepiet deeeribed thie ee e *oeeeetteu e: ceapleintng.‘ concomitantly, the effective �.8. expreeeien wee repleeed by e eere intelleeteelieed e: pettern. Ineteed e: etetiux “I here to cling to I: nether“ the petieet eeid '1': dependent en ey nether ter may thus" Thie eee deeerihed ee 'telhina ehent her dependency in e different eey.‘ Another cheese in eeneenioetion pettern eveked 'enoenny‘ reeliuge in the therepiet. fie eteted that the petient 'eentiene things we hed telhed ebout ee it it were nee in:ereetien.' With theee ehenzee,there wee e ceneeeitent iaereeee in the petient'e eeeiehility end perthipetien in heepitel eetiritiee, end e dieieetien er her clinging to the teeily end therepiet. whe euporrieory group etueephere eleo changed free one e: hepeleeeneee te well-being, with increeeed aching, eniling end enineted participation. 0n the 52nd dey the therapist reported thet the petient are-led seductively end epplied treeh rehe-up for eede l V her eeeeiene. She expreeeed toelinge or treat end enjoyment e! the neetinge. the doctor experienced einiler eeetiene, end ere eexer to repert the pregreee of this oeee. fhe patient wee new 'upeet' beeeaee ehe couldn‘t resell her prehlene, end the therapiet noted that he wee inclined to e directive “re-ether. He end she of leee coupleined memory role. ettenpted felt in:' to relete in e triendly, reelieticelly gratifying we: to prevent further peyuhologie exploration. A greater deteehlent from her family wee expreeeed. Seeiel ilpreve-eet continued. the felily eteted thet ehe no ' �.9. long-r onunidorud the doctur 'tao 1033;,” but rnihor a 'guiding nasal.“ Gunnontt Eh: ubrupt, groi- ahnngo in tho picturu parnnllud tn. duvolopttnt or anxiaun physiological change. The 61131031 rayorda during this poriod uhovcd u nodcratl ducts. of slaw wavo activity. Tho udvunt or pcn1tsvo tooling: olicitod -ruciprocnl elation: in thn thordpist which 1n thu supervinery cautions. caununicntad utrt tho attoat was alpsthic:11y rotluctod in nonbiru at the conxcrcuoo group. (rho clinical pioturc roaonbltd that at a 'trtunforonac auro.') throo EEO It 10 .! iattraut that I chant. tron "physical“ to *nnncry’ eonplnintt was dolarlbea 1: I ‘uoaustton at oonpluiulnx.’ Pcrhupa the notary dottctt, an expootnd oonconittnt or oonvulntvc thurnpy, 1. nova acacptablo to the lint: becauau 1t 1- underatundablo. Thu: £001 a rnaponaibility for this tynptoa tad nun tuthorttativoly r033Iuro thu putlatt that it will be transiant. in lifteticnuta dapcndoncy any .100 be more tolorah1c thin a hastilt out, when ucconpnniod bi erutifyinz oaeinl oupccinlly improvonant. Tho langungo change: 3:. indicative of a nor. definah‘d, intqlleotnnltacd ooununicntioa �~10» of taniltar content (8). Th. patinat nor ”talked abaut' ruthor thnn cunting or “acting out.“ This nav 1:33:33. patttrn can nor. in kooping with hat background or oulloau uduaataoa, and the thcrtyint's inplioit unpoetutions (9). In contrast to her prior node of cuuuuntcntton 1t canned ta to nor. noipgtiblo with a purchaauulytically-oriontcd approach. The concomitant dovslopnant of honor: difficulty, howovur, perpetuated thc cantnttully nonninalghtrul thorapuutic nitnnticn. 65th to 12nd gig! than ported followod tho termination a: sciatic trontannt. fhe patiout Inverted a ”auddoa £90115: ’1 3011‘ cvnrouuuo.“ Euphorta and gentry attticulty wit! a. 19:10: tbscrvud, tad an amnion. ltlt. :uportcnod. Payohothortpy toutinnu worn nhnrtctor1s¢d by morn crittcal appruisal at hot 11:. uitunttnn. tar tho first txun tho doctor 3:10 tho Thu tho in auctions. tine group voiced ton. txtra pattont unacorn that aha wt. "olippiuc back.9 thn thd patient. .ccactoually talkud positivolr nbout euro-r, cutncipttiou tron lather, 333., the tharnpist tolt called upon to rospond optiniutically, rather thug to explore. Thurs vs; I rtvivul or old canplnintn. At thin paint, tha supervilar tad thortpist roviovod A nuonion. recurrence of tho ourltor a tnruvroeordcd thtrupy �vorbal putt-run could indeed be tdcntitiod. nauuvur, than. coourrod 1n airuuunoribad fashion ruthor than throughout $30 intervinv. The «wont: nutcccdunt to Inch parlodn worn attainad Ind tha adaptivh nature at the racnrront n£tocttvo pnttornu haunt. apparant. coununt: tundra during this patina showed a considorlbla duoranau in slow The EEG activity. tn: : cauconitant rocntabllihnant at IOII of tho connunieutlon pattorna which pracedod tau period or altered brain function. Th0 coutarsnco group responded with nnxtoty rotlootod in the solicitouunnul of tho thortpiat in pralongtnz in: sonoi¢ns. the phononunan obsorvoa ta ta. nnpcrvitory stain, for luck at a bottnr turn, may be callcd 'alcetronhack dupcndoaoy.‘ statoncntn were lid. in tha matting such us 'cho'u slipping buck,” "no.4. ucr- troutnonts* and ”taprovanont not holding up.“ In... Itatcnonts inyly that the hoitilcodcycndaat panama mm being thought a: primarily as a nonalcgie flntity, ”a dopraauiun,‘ rtthor than a node or Bantu ralatodnunn. Porhapa hcuuuac hohuviorul chnngo had not boon attcctod by psychologic Incas a1930, it new conned tottlly dopondout upon thc alteration in acrcbrul function. yaw. Thurs �1-1 a. rha chins. 1n intoraction was «Qneoptltltibd as th: roanlt of the brain syndroan, find not an a function of tho doatcrupntiont relation. Edna. tho graup'h «acacia... on 6h. ahip. sporadic rcappcaranco or praeouvrloivc puttornt. Thu dotatlcd oxnuinattou of I t‘po~racordud caution rqvualod ti. ndqfitvo functtun or this not. circumacribod occurrcnon of the canvlaiatt, tad the phnnancnon of “electroshock dupnndunay' Vt! not obnorvod in Inblcqucnt group nactinga. 12rd to 25th 4:13 baring this ported a not. stubln yuyvhothorupcntxc rtlatitnlhip was upparont. the ptticnt boots. nor. tndcpnndcnt and d£lcnalad prohlcno a! euupltauoo and uolt~aalurtavoucla. Although hot at$1tudo rousinod petitivo and eollnborutivo, hi! tdlllttin a: the thcrapiat diniutuhod. In on. 3.3.1.: ch. :31! *luyho I vantt xnt buttor union. I get that: at run.“ an. ant lens olntad. 5h. ncvcd troy eh. cloned ward so an upon 00:113., and bugnn *u Ibrk_1a the hospittl library. Occulionll Ipinodul of ownrt disturbance war. ‘run‘cd by tho thcrapiut washout salinituda. n1- attitude us: an: of intorant, tappart sud datuchnont. 1a.: dtnouusod plan: tar dischargo and .u‘pntlunt ‘ruutnnnt. �-13. Gemnentz Suhaidanaa at tha chances in brain fanation raaulting tron_cénvulaiva thorapy permittad a not iatagration or the doatnrfi patiant ralationahip. Thu pattern or a céhvanttanal paychotharapaatic attuatiau appeared, which airfarad both fro: the crazinal negative and the artificially induced poaitiva relatianahipa. rharantat'a nataa an an ands: a: relatedness: Following tha cancluaian of tho study, anathar 1ndax at tho payehotharapautie ralattouahip was invaatigatad. flinch baa daaaribad the use of tha volume or stat: pragraaa nataa aa an 134a: at ata£t«patxant intavactian (10). Tha thorapiat had kapt ht. natal in a standard atanoxraphic notahoak thranzho out tha troatnant. 1 grant count or the aunbar of vagaa or nataa par tau-ion vaa mafia, and in rapraaantcé graphically an aha chart. lo written meta. vara takan daring occasional tapa¢raaardad aaaaioaa, and thaaa ara anittad from tho chart. Tho chance in tha ralatienahip is apparant from tha abrupt and paratatant incraaaa finnota taking from tho hhth day. this aoiuuadad with tha tirat groan changa in tha alaatraanoaphalogran. Tho nut-a takon by aha two ethar psychiatriata in tho unparviaory naatinga rallauad a aiuilar pattorn (not illuatratad), although with peaks 6! actoatakinz at tha onaat and again at the waning or inducad naurophwrialagta changa. �.1h. Iscusa I!hso vaport dasnrlbts an tnvonttgatian at vlrrhat&orapy adjunc$1vu procuauru. an intracuucd as to aauugio thcrupy than and dtftiuulty in fiho fbj.¢$1V! Itudy of puyuhotharupcuttc centrallfiblu ana traanaatttaa it tho abnsncn a: I quanttraablt pharnnool¢gtanl. Ind tauntia thurapton. variablo. ,gdduncttvo bohuvior in altorgtioa product gravid. tank 1 varinblo. racy was. h). (3. change: tn wall I! uniqurablu naurophyaiolauic prudent. «#111334 an. in hula In pnunt urw‘utty 1. tunntluu brain altcrud ta Ixtnpln, oat Iona a! tduyta‘ion tho Eh. at coaurrauco (5). r.1ato¢ncsu 0t typo tuphurio I haw %o inducud obicrv. an phfinanouun in this 0:30 purai‘tcd 9511 forth uttifludto ‘nd accltivo altnrantioi .1 pontttv. Anetta: 5nd uupcrviuor. ‘hcruplut tn llnilnr uttitudca 011n1¢:1 unrlxunt 0: tho discounting ti. alluatrnfitoa wt; The Ilcutroa hand or truntlnut. fihth «:1 to ahnauo during thi beginning this .1 an. :tgnatteuueu instantad ouctphnllarun miniutsud 1t thut Th. tau! fill 13 tho ralnttonuhip. chnng. dcnnunfirt‘oo tho intestine «(Stats 0: uttxt .xpcotancicc. by «coup-uni“ um mum.» brain of ”3.111,”: from uyaptcns phywicul 1n fiulplaznt 5¢3,, puttarn. oh‘nxt : the of 3 tern Thin in ruaultcd ant t0 nounxydtstiauzty. which oxportonocd was 63rd day) to (hjrd dcp¢n¢¢u¢y rtlatlonahlp shuns. rcuul‘nnt with tun supervinary otatt, atttortntly hr nine was rhtu 0:3:ct thy p&t1ant. ubant in thoir :nolinsa w unfit“: �pstient'e resily group. The oheervstions else illnetrete e phenoeeaeh supervieion we heve celled in to settings. greep peculiar sttention to the emotional steoephere or the are up, which seemed to fleateste in eoeerdenue with the therepeetie rea Here the (7) described. thst suggests being istieaehip observed in the supervises say eoanunisete the effective sepsete or his experience with the pstient nenaverhsliy in the eupervisevy nesting. his ternaletien is thet *The supervises unconsciously identities with the petient end invelentsriiy hehevee in such s esnner es te elicit in the supervisor theee very esstiens which he himself experiences ehile working sith the petieat, but use unehle to convey verbally.” He elso describes the diffusion at this extent in the other psrtioipenta or e supervisory sesiner. thus he reports that 'rhis ehservetien hse been suhaeeted to repented tests in eeniners where it use possible to vsrit’ the euyervieor'e enetiohel perceptions by sstehinx thee with the eeotiehsl resctiens or the other psrtieipents present.” Our work supports such observetiene sud suggests the patentiel truitrhlnees or studies or group dynsnies in supervisory eeeiuers. we he's noted one ehenss in reletednese resulting tree the seentie therspy that hsd e disasuetive effect upon the rsletiehship (age dsy). the petieet mentioned teeilier tepiee ”es it it were new infatuation.” the 'nnoenny‘ queiity predeeed in the therepiet end supervisor resulted from the �.16. had no the relationship that therapeutic temporary feeling history. Rapport in intensive psychotherapy depends to a great extent upon an accuaulated body of shared inforaatien. loth doctor and patient take this for granted, and the inability to rely upon it nay affect rapport adversely. Other patients in the study, not discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic and other forns of 'acting-out' which were disruptive 1 to the concurrent psychotherapy. In each case the induced the behavioral change was related to personality of the individual patient end occurred at the time of changing brain function (3). Also in each case there were conconitant changes in behavior in the supervisory group. Our experience also highlights some of the difficulties that nay develop when the two nodes of treatment are used concurrently. Intensive psychotherapy is based upon the conviction as to the efficacy of verbal communication for iaproveaent of the patient's adaptation. In the case reported a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interWhen communication the instrunent. as therapeutic personal cerebral change was aaxinal a “social recovery“ occurred, apparentlr unrelated to interpretation of psychedynanic factors. When the induced neurophysiologic changes subsided, a recurrence of earlier oonnnnication patterns led the therapist to doubt ‘ , �.17- that in. iapravaaant oeuid ha parpatuatad by intarparaoual aaana aloha. to can. extant thin phanauanan was an expraaaioa a: difllrint aancaptual and linguiatic ayataaa ink-rant in in. two node: a: thorapy. It in ralatad to tho philaaaphiaal dichotomy daacriboi by Haliiaxahaad and nadlieh (6) batwaan practitionara using aoaatic and analyticallyariaatad Sharapiaa. I 8931‘!!! i atady a: concurrant aquatic and payohatharapiaa ia taperiad, in which ainnitanaoua obnorvationa of atrial ”in. brain in function, omgu paychothanpaatio ralatiouahip and social adaptation var. Iada. rho ohaarvationa in a afonp aaparviaory salinar ratlaatad tha yattarn or natty; phyaiologia altaratiou. It ia canciudad that tho introduction or a aaaaarabia phyaialosio variable in a aaatul aathod for investigation at intarparaonai ralaiionahipa. �-13. BEIEREIGES 1. count, 1.1., frusn~801¢hn&un, 3iklf, 0., x.n., and Roigzrt, 3.: A: latch-ido‘stugy c§£r:01vo 1., cases .1 Han ouncprunl vs Pay: as a, Ila a g; 103' 1951‘ cohon, u, o queovor, 3., Jntfo, J. and Kuhn, R.L.¢ Payehnthcrnpoutic foehniquoo with Eloctroahook Pattontl, logz.‘1u 17.>1958. 3. rink, J, Hill-1d. l:hn, R.L.a Relation a: nun bolt: Activity Quantitativo to Inhaviorti Responao in Electronhoak. Soraul stadium, A.H.A. Arch. laurel. & Pnzchtat.lgu H. and 516, 1957. h. rink, Emailed Theory of the nation or Phystodynaaic l l.: ibtrnpiufi, J, Hillside 30.2. g; 197. 1957. 5. Pink, l.‘hxnhn, R.L. and aroon, H.c Bxporinnntnl Studio: of I nloctroahoek Fractal, Bin. Not. all. 32: 113, 1958. 6. lalliaglhand, 1.]. and lodlieh, 1.0.: Social Olunl tad flinttl Illnuln, J. U110: & Son, . ., . 7. Kora, 2.: Phononsnology 0! ‘ho Supurvisory Precast, “O J. chhothor. E" 769, 1957. 8. tuba, 8.L. and rink, x.s chanson 1n Lungnngo During Eltatronhock rhor‘py, 1n Palahgfathologi or connnnieatl n, Inch, P. an I a, . o 3., Gran. E 3!:35‘33, I956. (aha, 3.1.. Polltck, H. and rink, K.: sociopuycholocic Aspects a: Psychiatric rroatnnnt 1a a Volunttry xcntal noupital, 1.3.5. Arch. Gen. Pazehiu . (1n proul). 10. Hal-I ROI-arch 1n Pcyuhiutryt curtain Prohlonu sud Dovclepncntn in Hulttufiiaaiplinary studion, 2.8. Stlnon zocturor, l.!. laud. lad., 1957. kiosk, D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Modification of psychotherapeutic transactions by altered brain function. Am J Psychother. 1961 Jan; 15:46-55. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-49-015 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Jaffe J.; Esecover, H., Kahn, R. L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and two [preprints]. Reprint from AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. XV, No. 1, pages 46—55. January, 1961. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/6ae8392f9c68d3b213edf8358a9597ac.pdf bdf1e6bcabb4c1d8c82905940f4f07c2 PDF Text Text REPRINTED FROM E. ROTHLIN (Editor) NEURO-PSYCHOPHARMACOLOGY VOL. 2 (1961) Proceedings of the 2nd International Meeting of the Collegium Internationale Neuro-Psychopharmacologicum IBasle 1960 ELSEVIERPUBLISHINGCOMPANY AMSTERDAM �Reprinted from: E. ROTHLIN (Editor), Neuro-Psychopharmacology, V01. 2 (1961), Proceedings of the 2nd International Meeting of the Collegium Internationale Ne'uro-Psychopharmacologicum, Basle 1960 ‘ NEUROPSYCHOLOGIC RESPONSE PATTERNS OF SOME PSYCHOTROPIC DRUGS MAX POLLACK, ERIC KARP, GEORGE KRAUTHAMER, DONALD F. KLEIN AND MAX FINK Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N. Y. (U.S.A.) PROBLEM This study of the mode of action of some of the newer psychotropic agents was formulated within the framework of a neurophysiologic-adaptive hypothesisl. The concept, derived from earlier work on convulsive therapiesz, views clinical behavioral change as a resultant of the interaction of alterations in brain function and the personality of the subject. The present study emphasizes the question of pattern specificity of drug action and its relation to individual differences in behavioral response. The particular drugs utilized, chlorpromazine3 and imipramine“, were selected on the basis of pilot studies in this institution in which their effectiveness in altering physiologic and behavioral patterns had been demonstrated. This presentation is an interim report of a study currently in progress. METHOD Consecutive referrals for drug administration in a voluntary psychiatric hospital were assigned at random to one of the three drug regimens: (I) chlorpromazine with 1.2% procyclidine added, (2) imipramine, and a (3) placebo. Medication was administered in liquid vehicle in a fixed dosage schedule, to a maximum in four weeks. Chlorproma— zine was begun at 300 mg and increased to 1200 mg daily and imipramine from 75 to 300 mg. Patients continued to be seen three times weekly in individual psychotherapeutic interviews during the period of drug treatment. Analysis of the data is limited to the first 48 cases. These patients are not chronically ill—the majority being admitted for their first hospitalization from the community, and a smaller percentage rehospitalized for a recurrence of their illness. Their mean age was 35.5 years, and years of schooling was 11.9 years. Approximately 57% were diagnosed in the group of schizophrenias, 28% as affective psychoses and I 5 0/5 psycho— neuroses and character disorders. Patients were examined in a four day period prior to drug administration on a fixed schedule of physiological and psychological procedures which was repeated during the sixth week of drug treatment. RESULTS Group changes in some of the measures with drug treatments are shown in Table I. The EEG patterns measured quantitatively through electronic frequency analysis5 References 1). 384. �382 M. POLLACK et al. show that imipramine and chlorpromazine differ significantly from the control group and from each other. There was a significant reduction in the total electrical activity in the imipramine group, while there was an increase both in the amount of slow-wave activity and the slow to fast activity ratios in the chlorpromazine group. TABLE I GROUP CHANGES WITH DRUG TREATMENT EEG Slow/fast ratio Total activity Delta ratio Control I rmpramme Chlarpromazine w it h Procyc l {dine 0 0 co 0| ++ 0 ++ Perceptual Critical flicker fusion 0 Motor Pursuit—rotor Tapping speed Hand steadiness Intellectual WechslerBellevue IQ O O ++ 05 01 —— + O O O + o o Behavorial rating Symptom complaint — 0 Depression + Increase p. + + Increase p. o —- — o No change — Decrease —— Decrease P P 0.05 0.01 The reduction in the critical flicker—fusion (CFF) threshold is noted only for the chlorpromazine group. This test correlated with the increase in EEG slow-wave activity.The motor tests also reflect a differential drug effect with unsteadiness increased by the two drugs, tapping rate unaltered, and pursuit rotor improved only by the imipramine group. The greatest change in intellectual functioning was scored by the no-drug group, present to a lesser degree in the imipramine group and absent in the chlorpromazine group. The lack of equivalent changes for the drug groups may reflect an inhibition of the expected practice effect. In clinical behavior, all groups showed a reduction in complaints on self-rating as measured by the Johns Hopkins Scale, with the reduction being greater for the drug groups. In the Clyde Mood Scale, a Q—sort behavioralrating, there was a quantitative reduction in both the patient’s and the doctor’s ratings of “depression” in the drug group but not for the control group. While these data indicate a pattern that suggests differential drug activity, there was marked heterogeneity within each group on each measure. Table II shows the changes in CFF for each subject. The number within each box refers to the evaluation of a change in behavior, rated on a four—point scale by the evaluating psychiatrist. These are global changes in behavior ratings, and are not necessarily equivalent to References p. 384. �NEUROPSYCHOLOGIC RESPONSE PATTERNS 383 ratings of improvement. (Note that the ratings of behavioral change “3” and “4” were most often associated with changes in CFF of more than one cycle.) Although the difference in mean CFF score between imipramine and the control group was not significant, the difference in variability (F ratio) was significant (P = 0.05). The control group showed a narrow range of change, varying from +1 to ——2 cycles. In contrast, the imipramine group ranged from +2 to ——5 cycles, and chlorpromazine from zero to ——6 cycles. The chlorpromazine group change was in the downward direction only. The individual differences in the alterations of CFF threshold II TABLE CHANGE IN FLICKER FUSION THRESHOLD WITH DRUG TREATMENT Contrél +2 +1 o —1 —2 __3 Imipmmine 2 2 I 4 4 2 I 3 3 1 3 1 1 3 ‘ 2 2 2 I I 3 I I 1 1 3 1 4 2 4 2 ——4 —5 —6 Mean difl. Change in C.P.S. Chlorpromazine Behavorial with Procyclidine change 2 1 4 4 4 4 4 3 2 3 4 4 3 2 ——o.6 ——o.4 TABLE None Mild 3 Moderate 4 Marked I 2 ——3.1 III ‘CHANGE IN EEG (SLOW/FAST/RATIO) WITH DRUG TREATMENT 1mm —.4 ——.3 ——.2 —.1 o +.1 +.2 +.3 +4 +5 2 2 I 2 1 I 4 I 1 3 2 11 1 443111 3 2 322 4 4 3 4 1 3 4 4 3 4 1 1 1 3 3 1 3:22:22“ INone 2 3 Mild Moderate 4 Marked 4 +.6 +-7 4 4 >+-7 Mean diff. Change in slow/fast ratio firearm +.026 +.or4 +.401 are also observable in the electroencephalographic indices. Table III shows the changes in the slow to fast EEG activity ratio demonstrating a wide range in changes for the controls, a similar pattern for the imipramine group, but a change in only one direc— tion—that of increased slowing for the chlorpromazine group. The mean increase in slow-wave activity for the chlorpromazine group was more than I5 times that of the References p. 384. �384 M. POLLACK et al. control and imipramine groups. There was also a significant relation between the increase in slow-wave activity and increasing age with chlorpromazine—older patients being more susceptible to maximum change. DISCUSSION The psychological and EEG findings show that the agents studied affect these random— ly selected subjects differentially, producing drug—specific spectrums of change scores. This demonstration of drug specific profiles based on multiple tests supports previous statements by such workers as WIKLER“, LEHMANN7, and KLERMAN et al.8. It should be noted, however, that these test score profiles are contingent on population characteristics and not solely on the biochemical properties of the agents tested. While no adequate delineation of salient population characteristics is available, two general schemata are in use—the diagnostic nomenclature, and the concept of ”target symp— toms”. Neither scheme adequately reflects population characteristics, and further studies of multivariate behavioral, physiologic and psychologic characteristics are necessary for such delineation. It is thus imperative that drug studies utilize more detailed analyses of pretreatment physiological and psychological functioning. In the absence of such methodological refinements, the present confusing and contradictory data about “drug effects”, “paradoxical reactions”, and imputed specificities will continue. CONCLUSION I. Pattern specificities in various tasks can be identified for group data. 2. Within various groups, individual differences may be great, leading to failure for some group data to achieve significant differences. Further exploration of pattern specifities for subjects is warranted, using some of the more recent statistical techniques of multivariate analysis. 3. Such pattern specificities for clusters of subjects may be a more meaningful way of ordering psychiatric subjects for evaluative studies than conventional nosological methods. 4. Group data for EEG, CFF and behavior are consistent with neurophysiologic— adaptive views of drug therapeutic efficacy. REFERENCES 1 3 3 7 M. FINK, A unified theory of the action of physiodynamic therapies. ]. Hillside Hosp, 6 (1957) 197. M. FINK, Effect of anticholinergic compounds on post-convulsive EEG and behavior of psychiatric patients. Electroencephalog. and Clin. Neurophysiol., 12 (1960) 359. M. FINK, R. SHAW, G. GROSS AND F. S. COLEMAN, Comparative study of chlorpromazine and insulin coma in the therapy of psychosis. ]. Am. Med. Assoc., 166 (1958) 1846. M. FINK, Electroencephalographic and behavioral effects of Tofranil. Cari. Psychiat. Assoc. f., 4 (I959) 166 SG. A. ULET’I‘ AND R. G. LOEFFEL, A new resonator-integrator unit for the automatic brain wave analyser. Electroencephalog. and Clin. Neurophysiol., 5 (1953) 113. A. WIKLER, The Relation of Psychiatry to Pharmacology, Williams & Wilkins, Baltimore, 1957. H. E. LEHMANN AND J. CSANK, Differential screening of phrenotropic agents in man. J. Clin. Exptl. Psychopathol., 18 (1957) 222. G. L. KLERMAN, A. DIMASCIO, M. GREENBLATT AND M. RINKEL, The influence of specific per— sonality patterns on the effects of phrenotropic agents. In Biological Psychiatry, Grune & Stratton, New York, 1959, pp. 224—239. Printed in The Netherlands ��IWEGPSIGIGLMIB RESPGISB ' “runs at sons rsrczonorzc nuns Ha: Fullnek Ph.D., Erie Earp 3.1. George Krauthunor Ph.n., Donald 1. Klein Cad HI! Pink H.D. Ht”. Iran the Dapartnent or Exporinentnl Psychiutry, Hillside Helpital, Glcn Oaks, 3.1., U.I. Prouontod at the Second Meeting of the Gdllogiuu Internationale Houro~ Payehophnrnacologicun, Basal, July 1960. 1?: 7/60 �Probles: _ihis study or the node of action at soae er the never psychotropic agents was teraulated within the tranework of a neurophysielogie—adaptive hypothesis (1). The concept, derived from earlier work on oonvulsive therapies (2), views clinical behavioral change as a resultant of the interaction of alterations in brain function and the personality of the subject. the ,present study enphasises the question or pattern specificity of drug action and its relation to individual differences in behavioral response. The partieelar drugs utilised, ehler» proaasine (3) and iaipranine (h), were selected on the basis of pilot studies in this institution in which their ettectiveu nose in altering physiologic and behavioral patterns had been demonstrated. this preeentatien is currently in progress. an interil report of a study �hethed: VIGonseestiye referrals for drug adninistratien in a voluntary psychiatric hospital were assigned at render to one of the three drug regimens - (1) ohlorpronasine with 1.21 preoyelidine added, (2) inipraaine, and a (3) plaeebo. Hedioatien vas adainietered in liquid vehicle in a fixed dosage schedule, to a saxiaua in tour weeks. chlorproaasine was begun at 300 as. and increased to 1200 :3. daily and iaipraaine tree 75 to 300 as. Patients continued to be seen three times weekly in individual payohotherapeatio interviews during the period of drug treataent. Analysis of the data is liaited to the first us cases. These patients are notohrenioally ill - the majority being adaitted for their first hospitalisation free the ooaaenity, and a saaller percentage rehoepitalised for a recurrence or their illness. Their mean age was 35.5 years, and yeare of schooling was 11.9 years. Apprexiaetel! 575 were diagnosed in the group or sohisophrenias, 281 as affective psychoses and 15S psyche‘ neuroses and eharaoter disorders. Patients were exaained in a four day period prior to drug adainistration on a fixed schedule or physiological and psyche— legieal prooederee which was repeated iering the sixth week of drug treataent. �Results: in cone of the aeaeoree with drug treataente in the figure I. the EEG patterns aeaeored Group changes are shown --~----~--“-. FIGURE I ..—..'.....u. quantitatively through electronic frequency analyeie (5) show that inipranine and ohloryronaeine differ significantly from the control group and from each other. There was a eignificant reduction in the total electrical activity in the inipranine group, while there wee an increase both in the amount of slow ahd wave activity the slow to test activity ratio: in the chlorpronaeine group. -Thc reduction in the critical flickerotueien (CPI) threehold ie noted only for the chlorproxaaine group. Thin test correlated with the increase in EEG elow wave activity. The rotor tests also reflect a differential drug effect with uneteadieeee increased by the two drugs, fiapping rate unaltered, and pursuit rotor inproved only by the igipranine group. The the greatest change in intellectual functionihg rae scored by no-drug group, preeeut to a leeeer degree in the iaipraaine group and absent in the chlorprenaeine group. the lack of equivalent changes for the drug grounsnay reflect an inhibition of the expected practice effect. In clinical behavior, all groups showed a reduction in coupleinte on self-rating ae measured by the Johne napkins Scale, with the reduction being greater for the drug groups. �.h’ 611d. In the load 80:10, 3 Q-Iort bohuviornl rttilg, that. an. a qunatitt‘ivo iodnction in both tho pntaoat'n and tho dfiflttr'. 2:11:33 a: 'dcprocttun' in tn. contrcl fihc drug grvup but ‘ot (tr group. #311. than. du$t indicatc s ptttorn thnt angg-ata dittorontiul drug tcttvlfiy, ‘horo w‘u narkad ho‘crogonuity within tuck grvup an Oneh nonairo. Fitlrc 2 pluts at. ohnngca ------”--‘ FIGURE 2 ouudunouca in ctr tar itch aubaoe‘. rho nunbtr within Ouch ban rotort. the 07:1tatton o: n «inn;- tn bahnviur, rated on t tour-point .031. by sh. ovnlnuting pnynhtutrtnt. it... ‘20 glohnl ch18... 13 bchuvior ratiuga, and gr. not uncocaarily‘oquavglnnt #0 rating. it ingrQVCIdnt. (lot. that £ho ratttan c: habnvtorul '3' tld 'h' IIII aunt often ussoctutcd with ehnngnl 1n err-o: uni. than on. cycle) Althodgh tbs d1£t¢rcnoo in 3033 err near. botviun 'tltpruutno and tho «Chiral group van tot signitiegnt, 6h: atttorcnco 1: vartthtltfiy (1 ratio) III utgnizicgnt (p .o;). admiral It. gran; unused u narruv r.n¢c at chgngo, vnryiu; chaago Iran tron to n! 31:10:. In contrast; tut Slipranlno xrtup :;n¢od +2 tn -5 grains, and chlarpzalnsinn (ran not. to -6 cyclan. Ina chlorprunalinn stump chang- vas a: Shh downward atroction only. the 1nd£v1dnu1 dittorono¢n ta thn t1¢irtiiill If G?! tarantula 1:. .13d ohaorvahln 13 thn olaotro.ncopha10¢raph1¢ «an... run:- 3 an: tho clung“ 1a a. :1» u no «any; +1 an �-5... fi.‘fl---‘fl“.119333 3 O‘flumnabndou ratio demonstrating a wide range in changes fer the controls, a eiailar pattern tor the 1a1praaine group, but a change in enly one direction that of increaaed slewing fer the chlorpreaaaina sweep. The teen increase in elev wave activity for the ehlorpreaaaine group was more than 15 tines that or — the central and 1a1praaine groupe. there was also a aignifieant relation between the increaee in aloe wave activity and increasing age with chlorpreaaaine - elder patiente being late eneceptible te naxinna change. �Dieeeeeion: psychological and £36 findings ehoe that the agente etudied affect theee randomly eeleoted eubjecte differentially, producing drug-epocitio epoctroae or change eooree. This deeonotration or drug epocitic profiles based on multiple tests supports previoue statements by ouch The (7), and Klenaan et al (8). It ehould be noted, however, that theee toot ecore profiles are contingent on population ohareoterietioa and not eolely on the biochemical propertiee e: the agente tested. While no adeqoete delineation of eelient population oheraoterietice ie available, two general eohenata are in nee ~ the diagnoetio neaenclatore, and the concept or I"tax-got eynpteae'. leither ooheee adequately retleete population oharaoterietioe, and further otudiee of multivariate behavioral, phyeiologio end peyohelogio oharaoterietioe are neeeeeary for each delineation. It in thee imperative that drug etodiee utilise more detailed analyses or pretreataent psychological and physiological toentioning. In the abeenoe or euoh aethodological refinements, the present confueing and contradictory data about ”drug effects", "paradoxical reactions“, and iapeted epeoiiicitiee will continue. workere ao Wikler (6), Lohmann �Conclueiefi: (1) ~Psttern speeifieities identified for group dsts. 1n vsrieus tasks can be differencss individusl various Within groups, (2) to dsts sons for group to failure be lesding great, as: of Further explorstien differences. sehisve signifiesnt some using usrrsntsd, is for subjects psttsra speeitities of the nets recent ststistiesl techniques at nultivsrists snslysis. or clusters for Bush (3) pattern speeitieities of psychistrie ordering he nssniugful we: nsre s nsy sabjsets nsselegiesl eenventiensl thsa studies evaluative for subjects methods. . (h) fireup dsts fer use, err and behsvier sre eensistent with nearephysielsgie-sdspt1ts views 9! drug therspeutic etilesey. �‘8REFEREHGES tho Action or of Thoory Enitiod Physiodynonic i Thoropioo. J. Hillaido IOIE. é; 197~206, 1957. 2. link, H: Effect of Anticholinorgio Gonpoundo on Poot~ convulsivo BEG ond Behavior of Psychiatric Potionto. E30 6113. lcurophyoiol. $3: 359-369, 1960 3. Pink, H., Show, 3., Grout, G. and Calcium, 1.8. Corporativo Study of chlorprouojino onc Insulin Geno in the therapy or Poychoéis. J. inor. nod. Aoooc. ;§gs 18h6~18§0, i958. h. rink, H: Electroencephalographic and Behavioral Effects of Torronil. Gonna. Pczch. Assoc. J. g. 166$~1718, 1. rink, K: 1959. Blott, G.A., Ind Lootfcl, 3.6. A new resonator1ntogrotor unit for the antarctic brain wave onolyaor. Clio. Houroghzaiol., g} 113-115, 1953. 6. Viklor, A.: 2&0 Relation of Pazchiotrz to Phornocologz, an. a Wilkins, Boltinoro, 1957. Lohnonn, B.E. and Crank, 3.: Bittorontioi scrocning or Phronotropic Agents in Hon. J. Olin. Razor. Pczchogothol. EEG lg: 222—235, 1957. Klornan, 0.1., Dixaccio, L., firocnblott, K. and Rinkol, H: the Influence of Specific Personality Pottcrnc on the Effects of Phrcnotropio Agents. Biological Pazchiotrz, Gruno & Strottcn, New York, 22h-239, 1959. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Neuropsychologic response patterns of some psychotropic drugs. In E. Rothlin (ed.), Neuro-psychopharmacology. Elsevier, Amsterdam, 1961, 2:381-4 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-50-016 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Pollack, Max; Karp, Eric; Krauthamer; Klein, Donald F.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. REPRINTED FROM E.ROTHLIN (Editor) NEURO-PSYCHOPHARMACOLOGY VOL. 2 (1961). Proceedings of the 2nd International Meeting of the Collegium Internationale Neuro-Psychopharmacologicum Basle 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/2c170ecde2c5784e8f07a062c10eb68d.pdf 5609f5c2406d7b6449fb5af08c8f4105 PDF Text Text Reprinted from: E. ROTHLIN (Editor), Neuro-Psychopharmacology, Vol. 2 (1961), Proceedings of the 2nd International Meeting of the Collegium Internationale Neuro-Psychopharmacologicum, Basle 1960 From the Discussion to the First Symposium: THE PROBLEM OF ANTAGONISTS TO PSYCHOTROPIC DRUGS MAX FINK Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. (U.S.A.) ’ It has been a privilege and a pleasure to read and to listen to the reports by Drs. and DENBER. These authors have approached the problem of antagonists to psychotropic drugs from different vantage points: Dr. GADDUM that of the pharma— cologist — theoretician, assessing general issues; and Dr. DENBER, the experimental clinician with a specific problem exemplifying a theoretic principle. Dr. GADDUM essayed a broad classification of drug antagonisms emphasizing c0mpetitive inhibition. While studies of this concept have a likelihood of clarifying our GADDUM References p. 32. �DISCUSSION 31 knowledge of drug action, there was little that could be specified at present. This View, founded on extensive experience, suggests that a critical appraisal is necessary of the and of relation theories serotonin, fanciful the 5—hydroxytryptophan recent on many amine oxidases, amongst others, to human psychoses. If I interpret Dr. GADDUM’s review correctly, he is describing basic postulates which must be satisfied before drug antagonisms are established, and such establishment is requisite to the determination of the site of action of such interactions. Dr. GADDUM notes, that for the determination of competitive inhibition, four considerations must be fulfilled, i.e.: I. control drugs are not inhibited; 2. antagonistic actions are demonstrable at several sites or systems; 3. dose relationships are systematic; and 4. agents have a common chemical grouping. To these I would also add, that for such determinations of competitive inhibition to have significance for human psycho—pharmacology, the antagonisms should not be based on work limited to a single animal species, but should be demonstrated in man. Dr. DENBER has approached the problem from a specific experiment — the meas— urement of changes in various blood chemical elements and gross clinical behavior in chronic relapsing psychotic subjects. These patients were studied before and after intravenous mescaline followed by a variety of phenothiazine agents administered as “antagonists”. Dr. DENBER confirmed his earlier studies that various phenothiazine derivatives, excepting diethazine, are effective in modifying mescaline clinical affects; and that such effects are related to the halogenation of the chemical ring structure. Parenthetically, we can confirm the observation that diethazine is not an antagonist for hallucinogens, for in our studies diethazine induced illusory states and EEG desynchronization in psychiatric patients, similar to mescalinel. The biochemical data indicates the wide range of behaviors altered by these broad acting agents. Like his earlier studies on the changes in the EEG, and the observations from others of the blocking of induced psychotomimetic effects as measured in frame— theoretic from be this data must a analyzed etc., mood, perception, language, work of the relevance, or imputed causal relations, of such observations to clinical behavior. No such framework is given and the assumed connection between these blood changes and clinical behavior is obscure. Indeed, Dr. DENBER concludes that: “In all probability, the reactions observed represent part of a total body response to a stress-. . Assuming this conclusion is a reasonable working hypothesis, we are taxed by the problem of critical experiments to elucidate the body response to psychotomimetic and psychotropic agents. In this task we are faced by a number of monumental problems, and it is here that Dr. GADDUM’S principles and Dr. DENBER’S experiments approach a common base, albeit tenuous. For what Dr. GADDUM fails to indicate in his principles are the significant behaviors to be studied; while Dr. DENBER selects be— interactive clinical of and —~that blood of behavior global chemistry two aspects havior — as dependent variables. It is the selection of significant experimental variables and their quantification that represents a central problem of human psychopharmacologic research today. Assuming that the laws of human interpersonal behavior are the goals of our studies, and that psychopharmacology represents one aspect of the modification of human References 12. 32. �FIRST SYMPOSIUM 32 interpersonal behavior, what evidence is there that any single aspect of task behavior is correlated with changes in interpersonal behavior induced by drugs? I am troubled by the fact that innumerable investigations have selected a single or few variables on the biochemical level and correlated these with a single or few variables on the behavioral level, the selection of which is not designed to elucidate a theoretic framework but rather based on a vague personal notion. Thus, investigator after investigator selects pole climbing, bar pressing, conditioned avoidance, jiggle cage movement, etc. as single variables in a wide range of animal studies; and rating scales, self—ratings, psychomotor tasks, EEG, blood pressure, and many others in human studies as single significant variables. Few studies assess the relevance of these tasks for the prediction of the direction or efficacy of drug effects on interpersonal behavior. Other significant problems include that of generalizing from non—psychopathic populations to our understanding of disordered human behavior. A sub—aspect of this problem is the generalization from one psychopathic population to another without fully taking into account such population factors as genetic predisposition, early organic traumata, varying acculturation processess and sociologic status upon population characteristics. These aspects may so alter the observations obtained with a specific pharmacologic agent as to give varying, and occasionally opposite results when similar studies are done in different settings. Some years ago, Dr. ABRAHAM WIKLER outlined the problem facing experimental psychopharmacologistsZ. In assessing the relation of psychopharmacology to experimental psychiatry, he recommended: “In psychiatry we need more properly controlled studies on the comparative effects of a variety of drugs, on the behavior of varied, but selected, homogeneous groups of subjects, under varied but standardized experimental conditions, and with varied but specified activities of the observer.” In this I concur and commend it to the Collegium as the most logical beginning to the resolution of the problems of antagonists to psychotropic agents. REFERENCES 1 2 M. FINK, Effect of anticholinergic agent, Diethazine on EEG and behavior: significance for theory of convulsive therapy. A .M.A. Arch. Neurol. Psychiat, 80 (1958) 380. A. WIKLER, The Relation of Psychiatry to Pharmacology, Williams & Wilkins, Baltimore, Md., I957- Printed in‘ The Netherlands �‘ w33;; érn‘msmfi‘ ’1angmgemam: $§i~wgfl .91»: ~' ‘iWMem 423d mmhm: maximmmvmfi .: {Err thwxsfisw 9mm: fim téfim, , . . 1 . Mamiew. > �D First I I S C U 3 8 Synponiun TH! PROBLBH'OF ANTAGOHISTS lax 713k, ~ 0 l 0.1.H.P. TO PSYCKOTROPIC DRUGS H.D. Pro. tho Depart-ant o! Bxporinontal Psychintry, Billlido Hoapitnl, clan Oaks l.!. July hth, 1960, 3:310, Switaorland �It listen has been a privilege and a pleasure to read and to to the reports by Drs. Gaddun and Denber. These authors have approached the problem or antagonists to psychotropic drugs from different vantage points Dr. Gaddna that or the pharmacologist - theoretician, assess~ ing general issues; and Dr. Denber, the experimental-clinician with a specific problen exeaplitying a theoretic principle. — Dr. Gaddnn essayed a breed classification of drug antagonisns emphasising conpetitive inhibition. While studies of this concept have a likelihood of clarifying our knowledge of drug action, there was little that could be specified at present. This view, founded on extensive experience, suggests that a critical appraisal is necessary d’the nany recent fanciful theories on the relation of serotonin, S—hydroxytryptephan and anine oxidases, alongst others, to huaan psychoses. It I interpret Dr. Gaddun's review correctly, he is describing basic postulates which must be satisfied before drug antagonisns are established, and such establishnent is requisite to the deternination of the site of action or such interactions. Dr. Oaddna notes, that for the determination of competitive inhibition, four considerations nuet be fulfilled: i.e.: (1) control drugs are not inhibited; (2) antagonistic actions sre demonstrable at several sites or systems; �To (3) dose rslaticnships are systoaaticg and (h) agonts hsvs a con-on cboaical grouping. that would for ouch dotorsinatioos of thoss I also add, coapotitivo inhibition to have significance for huaan psycho~ pharmacology, tho antagodsus should not be basod on work bo doaonstrablo should but aniacl a to spacios, single liaitod in san. Dr. Donbor has approacbad tho probloa Iron a spocitic oxpariaont - tho aoasursaont of changoa in various blood ohsaical closonta and gross clinical behavior in chronic rolapsiog psychotic and intravonous botoro Thoso studiod attor scro patioots subjects. aoscalino followed by a varicty of phonothiasino agonts adaioistorod so *antsgonists'. Dr. Donbor contirsod his oarlior studios that various phonothiosino dorivativos, oxcspting diothasino, aro ottoctivo in soditying aoscalins clinical atrocts; and that such ottocts arc rolatod to tho halogonation of tho choaical ring structuro. Paronthotically, so can contira tho cbsorvation that diothasino is not an antagonist for hallucinogons, for in our studios diotbasino iodacod illusory stats: and EEG dosynchronisatioc in psychiatric potiouts, aioilar to aoscalino (1). Tbs biochoaicsl data indicatos tho aids songs of bohaviors altorod by thoso broad acting scouts. Liko his oarlior studios? on tho changos in tho EEG, and tho cbsorvations from othors of tho blocking of indccod psychctoaiaotic ottocts as Ioascrod in bo snot data analysod this languago, aood, porcopticc, otc., �-3Iron a theoretic fraaevork of the relevance, or iapcted cancel relatione, of anch obeervationa to clinical behaviour. No Inch fraaevork ia given and the aeauaed connection between these blood changee and clinical behavior in ebecnre. Indeed, Dr. Denber that: "In all probability, the reactione obaerved repreeent part or a total body reaponee to a atreaa- ...' leenaing thie conclnaion ie a reaeonable working hypo-» theeie, we are taxed by the problea of critical experiaente concludee to elucidate the body reeponee to peyohotoaiaetic and paychetropic agent. In thia teak we are faced by a nnaber of aonnaental probleae, and it ie here that Dr. Gaddna'e principlee and Dr. Denber’a experiaenta approach a coaeon baae, albeit tennoce. For what Dr. Gaddna taile to indicate in hie principlee are the eignificant behaviore to be atodied; while Dr. Denber eelecte two aapecta of behavior - that of blood cheaietry and global clinical interactive behavior - aa dependent variables. It in the eelection or significant experiaental variablee and their quantification that repreeente a central problea o: hnaan peyohopharaacologic reeearch today. ieanaing that the lava o: hnaan interpereonal behavior are the goale or our etndiee, and that paychopharnacology repreeenta one aepect of the aodification or hnaan interperaonal behavior, what evidence ie there that any single aepect of teak behavior is correlated with ehangee in interpereonal behavior induced by drugs? �-1... I on troubled by the tent thet innnnereble investicetione heve eelected e eingle or ten veriehlee on the bieeheeioel level end correleted theee with e eincle or ten verieblee on the behevierel level, the eelectien or which ie not deeigncd to elncidete e theoretic freeeeork but rether beeed on e vogue pereenel notion. Thne, inveetigetor efter inveetigetor eelecte pole cliebing, her preeeing, conditioned evoidence, Jigcle cege leveeent, etc. ee eingle veriehlee in e wide reuse of enieel etndiee; end retina ecelec, eelt-retinge, peyohoeotor teeke, EEO, blood preeenre, end eeny othere in hneen etndiee ee single eixnificent verieblee. rev etndiee eeeeee the relevence of these teeke tor the prediction of the direction or etficecy o8 drug ettecte on interpereonel behevior. Other eigniticent prohleee include thet o: generelieing tree non-peyohopethio populetione to our underetending of dieordered hneen behevior. e eobaeepect of this problee is the generelieetien free one peychopethic populetion to enother without ench eccount into populetion rectore ee genetic teking telly prediepoeition, eerly orgenic tredeete, verying eccnlturetion proceeeee end eociologio etetne upon popnletion cherecterietice.» Theee eepeote eey eo elter the oheervetione chteined with e epecifio phereeoologic egeet ee to give verying, end oceeeionelly opposite reenlte when eieiler etndiee ere done in different settings. �-5Solo yoara ago, Dr. Ahrahaa Hiklor ootlinod tho prohloa In aoooooiog (2). paychopharacologiato oxporiaontal facing tho relation of poyohopharoacology to oxporioontal psychiatry, ho roconaondods 'Iu poychiatry Io nood noro properly controllod otndioo on tho oooparativo ottocto of a variety of drogo, on tho behavior of variod, hot ooloctod, hologonoooo groups or ouhaooto, undor variod hot otandardiaod oxporiaontal conditiono, and with variod but opocitiod activitioa of tho oboorvor.’ In this I concur, and connond it to tho collogiuo an the aoot logical hoaiuning to tho roaolution of tho prohloao of antagoniota to psychotropic agonto. �1. link, n: Effect at Antieholinergic Agent, Dietheeine3on EEG end Behavior: Significance fer Theory of Convaleive Therapy. .§_o_ 2. "‘ AHA Arch. figural. a Pezehiet. 380‘387, 1958. Hitler, A: The Relation of Pezphiatrz to Phernecologzl In. Wilkins, Beltinere, 1957. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Problems of antagonists to psychotropic drugs, 30-2 (Discussion, Neuropsychologic response patterns of some psychotropic drugs). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-51-017 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprint from: E.ROTHLIN (Editor), Neuro-Psychopharmacology, Vol. 2 (1961), Proceedings of the 2nd International Meeting of the Collegium Internationale Neuro-Psychopharmacologicum, Basle 1960 From the Discussion to the First Symposium: THE PROBLEM OF ANTAGONISTS TO PSYCHOTROPIC DRUGS Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0a85dc880c126770a2f4471ab91c4072.pdf 44a73db773213930685e535c3d7c50a0 PDF Text Text Inhalant—lnduced Convulsions MAX FINK, M.D.: ROBERT L. KAHN. Ph.D.: ERIC KARP. B.A. MAX POLLACK. Ph.D.; MARTIN A. GREEN. M.D.: BARRE ALAN, MD. AND HENRY J. LEFKOWITS. M.D. GLEN OAKS. LONG ISLAND, N.Y. �Reprinted from the Archives of General Psychiatry March 1961, Vol. 4, pp. 259— 266 Copyright 1961, by American Medical Association llHllllllll|llllllllllllllllll||llllllllll||llllllllllllllllllllllllllllll MAX FINK, M.D. ROBERT L. KAHN, Ph.D. Inhalant—Induced Convulsions Significance for the Theory of the C onvulsive Therapy Process Despite many years of investigation of the convulsive therapy process, there is still much controversy concerning the importance of the seizure itself. Most studies have concluded that the convulsion is a necessary index of cerebral change essential to clinical behavioral change.9'1°'1‘53?"39 Some investigators, nevertheless, have assigned significance not to the seizure but to such factors as the psychological meaning of the treatment to the patient, feelings of fear, and the repeated loss of consciousness.3'4'28 The early studies of Kalinowsky et a1.24 and Pacella et al.,3‘0 demonstrating both clinical and electrographic differences be— Submitted for publication Aug. 26, 1960. From the Department of Experimental Psy— chiatry, Hillside Hospital. Aided by grants MY-2092 and M—927 of the National Institute of Mental Health, US. Public Health Service. g ERIC KARP, B.A. MAX POLLACK, Ph.D. MARTIN A. GREEN, M.D. BARRE ALAN, M.D. AND HENRY J. LEFKOWITS, M.D. GLEN OAKS, LONG ISLAND, N.Y tween grand mal and petit mal treatments indicated the significant role of the seizure. The various studies comparing convulsive with subconvulsive treatment demonstrated that techniques culminating in a convulsion were uniformly associated with measurable degrees of neurophysiologic and behavioral change, while subconvulsive techniques were not.1‘5'1’7"°’3‘40 In recent studies from this laboratory, similar differences in the 2 treatment types were observed for such aspects of behavior as EEG slow-wave ac— tivity,8’10 language changes after amobar— bital,19"21 and perceptual tasks. 1'3 22 25 A second aspect to the problem of under— standing convulsive therapy concerns the relation of the method of inducing the seizure to the therapeutic outcome. Seizure duration, type of current, and electrode placemerit are among the variables that have 65/259 �ARCHIVES OF GENERAL PSYCHIATRY been studied. While the investigations indicate that changes in behavioral and neurophysiologic indices are related to these parameters, the differences reported for the various seizure—producing methods are small and statistically insignificant. Major differ— ences, however, are observed between seizure and nonseizure groups. For example, in a recent monograph, Ottosson reported an increase in the duration of unmodified electrically induced seizures compared with those modified by premedication with lido— Although the lidocaine—treated pa— tients showed less change in indices of anxiety, retardation, and global behavior than patients treated with unmodified seizures, the differences were not significant. In our studies, while seizure duration 17 and type of current 11 have been related to the degree of behavioral and neurophysio— logic change, there were no differences with relation to therapeutic outcome. Thus, while parameters of the seizure method may bear some relation to therapeutic efficacy, the differences are slight among the techniques, provided that grand mal seizures have been induced. Further exploration of the importance of the seizure was made possible by recent experimental interest in seizures induced by inhalant (hexafluorodiethyl ether, Indoklon,7), and intravenous (PM—10906) agents. This study was undertaken to com— pare the electrical and inhalant seizure—pro— ducing methods with regard to effects on clinical behavior, interseizure electroenceph— alogram, and psychologic test performance in order to clarify the role of the mode of seizure induction in the convulsive therapy process. caine.’29 ‘ In a voluntary psychiatric hospital 27 consecutive unselected patients referred for convulsive therapy were randomly divided into 2 groups using a Gellerman order.16 In 12 patients, convulsions were induced by a Medcraft alternating current in— strument using suprathreshold currents, and in 15 others by inhalation of hexafluorodiethyl ether, following the method of Esquibel et al." Premedication in all cases was limited to sublingual atropine (1.0 mg). Treatments were administered 3 times per week for 10 to 24 applications, the total num- 66/260 her being determined by the clinical judgment of the staff psychiatrist. Ages ranged from 19 to 58, with a mean age of 38.5 years in the electric convulsive therapy (ECT) group; and 19 to 49, with a mean age of 35.5 years in the hexafluorodiethyl ether group. The mean years of education were 11.5 years (ECT) and 12.6 years (hexafluorodiethyl ether). Of the 27 subjects, 12 were classified as depressive psy— choses, 8 as schizophrenia, mixed type, and 7 as schizophrenia, paranoid type. The distribution of diagnoses, age range and years of education within the 2 samples, did not differ significantly. Behavioral change was evaluated weekly in interviews by the patient’s therapist and by the staff psychiatrist. Such aspects as mood, ideation, memory, sleep, appetite, speech patterns, participation in group activities, and relation to staff and to other patients were recorded and changes assessed qualitatively. Electroencephalograms were done prior to treatment, weekly during the treatment course on a day after a convulsion, and 2 weeks after the last treatment. Records were measured for the amount of induced slowing (6 cps and slower) in anterior temporal-vertex leads, in 66 second samples.8 Various psychologic procedures were administered prior to treatment, during the fourth week (10—12 treatment period), and 2 weeks after the last treatment. The measures included Wechsler— Bellevue subtests (information, digit span, object assembly, and digit symbol) ; Gottschaldt type embedded geometric figures”; perceptions of pseudo— isochromatic embedded colored figures at high-speed tachistoscopic exposure,31 and a modified California F Scale.28 In addition, spine x-ray studies were done prior to and at the end of the treatment course. Observations Clinical Behavior.—The inhalation of hexafluorodiethyl ether regularly resulted in a grand mal convulsion, similar to that induced electrically. For the hexafluorodiethyl ether group, induction was slower and the initial cry and opisthotonic posturing were often omitted. In clonic and tonic manifestations, postseizure apnea, and post— seizure behavior, the groups resembled each other closely. In short term evaluations of clinical be— havioral change, the types of behavior manifested were similar in the two groups. Patterns of denial, hypomania, withdrawal, somatization, paranoid excitement, and confusional—memory loss were observed in both 1. Vol. 4, March, 1961 �INHALANT—INDUCED CONVULSIONS TABLE l.—Beham'0ral Patterns TABLE No. of Subjects Recovered Much Improved _—A_. ,_._ Indoklon * ETC Eupho;ia, denial, hypomania Somatization, withdrawal Severe confusion, memory loss 6 6 3 7 2 3 Improved Unimproved Indoklon 7 .5 E C ’1‘ 3 6 5 1 x2 * 2,—Discharge Evaluations < 1.0, not significant. Hexafluorodiethyi other. populations with approximately equal frequency (Table 1). Complication rates were similar. While patients tolerated the inhalation procedure, there were frequent episodes of breath holding and leakage about the mask, making this induction less reliable. Fractures were observed radiographically in 3 patients treated with hexafluorodiethyl ether and in during ECT. Administrative evaluations of clinical improvement at the time of discharge from the hospital were equivalent (Table 2). Ratings of recovered and much improved were recorded for approximately half of each group. 2. Electroencephalography.—Interseizure serial electroencephalograms, both qualita— tively and quantitatively were similar in the 2 groups. Progressive symmetric slowing of dominant frequencies and an increase in voltages were apparent in all leads, with frontal and anterior—temporal preponderance. Burst and occasional spike formations were noted in both. Quantitative measures of induced slow—wave activity during each week of treatment were not significantly different (Table 3), although the maximum EEG change appeared earlier in the hexafluorodiethyl ether group than in the ECT group. 3 TABLE N o. 3. Psychologic Measures.—Intergroup analyses (Mann Whitney U Test) of the observations for each of the psychological tasks revealed no difference prior to treat— ment, during the fourth week, and 2 weeks after treatment for the 2 treatment groups. Intragroup analyses, however, showed con— sistent changes in various measures from pretreatment to the fourth week; and from the fourth week to 2 weeks after treatment (Table 4), both in the hexafluorodiethyl ether and in the ECT groups. In the Wechsler—Bellevue subtests, group means showed a significant decrease in scores (poorer performance) for each sub— test during treatment, and a return to pre« treatment levels in the post-treatment period. One subtest, object assembly, demonstrated significantly increased scores after treatment. Similar patterns were observed for the tachistoscopic measures and the F scores. While increased errors on the embedded figure tests were observed during treatment, the difference was not significant. After treatment, the errors in this test decreased significantly from pretreatment scores. On the F scale there was an increase in scores with treatment, and a decrease following treatment. For each of these measures, both treatment groups reflected a similar pattern of change. 3.—Postconvulsive EEG Slow-Wave Activity (Average % Time) Pretreatment 4-6 Rx 7-9 Rx Wk. After Last Treatment 2 10-12 Rx Indokl'm 15 6.0 29.4 50.3 51.2 16.8 E CT 12 4.0 29.8 39.2 47.5 18.0 Fin/a et al. 67/261 �ARCHIVES OF GENERAL PSYCHIATRY TABLE 4.———Eflect of Hexaflnorodieth'yl Ether and Electrically Induced Seizures on Psychologic Test Performances (Scores Expressed as Mean Differences) Pretreatment and Fourth Week 1. Wechsler-Bellevue (weighted subtcst score) ((1) Information (b) (c) ((1) 2. 3. 4. Digit span Ind ECT Ind Ind ECT Ind Digit symbol ECT Ind Tachistoscopy (errors) Ind ECT Ind ECT F scale +1.5 1 +1.7 T +2.7 T +2.3 1 +4.1 * +4.81 +3.3 1 +2.3 1 —1.3 —2.4 * +0.2 T -—0.7 —l.9 * +0.8 . —0.4 +2.7 ‘ +3.5 +0.8 1‘ —0.1 —6.5 —4.9 +9.7 * +8.2 * +2.0 +3.3 +7.7 1 +5.2 1 ECT Embedded figures (errors) Fourth Week and Post-Treatment —2.7 ’ —1.4 —1.3 —2.5 ’r —2.4 I EC‘I‘ Object assembly Pretreatment and Post-Treatment —16.2 —13.1 i ——4.1 1 ——2.1 ——2.6 t ‘ —-—5.9 I --11.6 I —3.9 +1.2 ——4.0 T Ind = Indoklon (hexafluorodiethyl ether). Using Wilcoxon’s T for paired replicates: * p < 0.02' ’r p < 0.05. EEG Correlations. The changes in performance on the psy— chologic tasks from the pretreatment to the fourth week testing period were significant— ly related to the degree of induced EEG slow—wave activity for both groups (Table 5). Rank order correlations demonstrated that decrements in performance on the 4. Test Performance: Wechsler-Bellevue digit span and object as— sembly subtests, tachistoscopy, and em— bedded figures tasks were significantly related to the amount of electrographic change. Similarly, an increase in F score was associated with increased EEG slowing. When the observations in the hexaflu— orodiethyl ether and ECT groups were individually analyzed, significant correla— tions were noted for various tasks. In the hexafluorodiethyl ether group, the deerement TABLE ~ Indoklon ECT Indoklon and ECT ‘ p < in < 68/262 :0 < 0.01. in the Wechsler—Bellevue information and digit span subtests and in tachistoscOpy was related to the degree of EEG slowing. In the ECT group, similar relations were noted for tachistoscopy, Wechsler-Bellevue digit span, and object assembly subtests and the F score. Comment Mode of I ndnction.——The inhalant and the electrically induced seizure groups were indistinguishable on the various measures of behavior at each stage of the treatment process. Since the factor common to both treatments was the induction of seizures and not the method of induction, we may conclude that the method of induction is not a significant variable in the therapy be— in the Specifically, changes process. 1. 5.—Change in Task Performance and Degree of EEG S low—Wave Activity (Pretreatment vs. Fourth Week; Rank Order Correlations) Wechsler-Bellevue Form , I 1 Information Digit Span Object Assembly Symbol 0.73 " 0.28 0.25 0.54 i 0.72 i 0.61 ‘ 0.31 0.60 0.46 0.38 0.34 0.31 1‘ T Digit Tachistoscopy 0.62 0.80 0.67 T * * Embedded Figures 0.13 0.37 0.43 T F Scale 0.12 0.66 0.38 ’r ’r 0.01 0.05 Vol. 4, March, 1961 �INHALANT—INDUCED CONVULSIONS _ havioral and neurophysiologic indices are sider these results as reflecting differences dependent upon the induction of seizures, both in population samples and in methods and not dependent on any single property of scoring behavioral change. While acute of the electrical or the inhalant mode of illness and affective-depressive reactions are induction. described for the majority of subjects in Kurland et a1.26 and Chatrian and Peter— the positive studies,1‘°'27'38 70% of the sub sen5 have also compared electrical and jects in one 4 negative and 100% in another 28 inhalant seizures. Kurland and his co-work- were classed as having schizophrenic re— ers assigned convulsive therapy referrals actions. The facilities in these investigations alternately to hexafluorodiethyl ether and serve chronically ill populations, and prior ECT groups. They reported that behavioral courses of convulsive therapy were recorded ratings, complication rates, psychologic test for nearly half the subjects in one group4 performances, and cardiovascular reactions and 90% in the other.” The failure to obwere similar in the 2 samples. Chatrian and tain significant differences may also lie in Petersen, studying schizophrenic subjects the small samples used to test the null with implanted intracerebral electrodes, re— hypothesis. ported identical electrographic patterns dur— Changes in behavior are observed in all ing seizures and at various postseizure subjects receiving a course of convulsive periods for hexafluorodiethyl ether, pen- therapy,1052930533,38 but those changes evaltylenetetrazol (Metrazol), and electrical uated as clinical improvement occur only techniques. in some. While induced convulsions are a In studies of seizures induced by various sufficient condition for behavioral change, electrical means, equivalent behavioral, psy— they are only a necessary condition for chologic, and electrographic effects have improvement. Thus, measures of behavioral been reported.3’11’29v39 While these studies change, such as memory,25 language,19'21 equate the effects of different convulsive and perception 1332 readily demonstrate sig— techniques, various nonconvulsive methods nificant differences between convulsive and such as subconvulsive, brief stimulus, uni— subconvulsive techniques within the individ— directional stimulating, monopolar stimu- ual differences in personality organization lating, and focal “convulsive” techniques of the subjects. Ratings of “improvement," have been described, and each in turn however, with the personality organ-vary discarded in routine therapy as ineffec— ization of the subject in adap— as expressed tive.1‘°"27'39'4‘° For example, Bergman,2 in tive patterns and flexibility for change; describing the electrographic effects of the with such environmental variables ther— as “focal—seizure” technique noted that 75% apist, staff, and family expectations and of patients had normal records after 15 tolerance for the elicited adaptive behavior. such applications, while 70% had “abnor— and with the duration and degree of induced mal” records after grand mal seizures. Ulett neurophysiologic changes. In global esti— et al.39 have reported differences in the im- mates of “improvement” the environmental provement rates of patients receiving con— variables become prepotent. The failure to vulsive treatments (60%—80%) and those observe significant differences in improve— receiving subconvulsive (33%), or controls ment ratings in convulsive and noncon1‘0 (38%). Our own studies also demon— vulsive groups may be related as much to strate significantly greater degrees of these environmental variables and the perbehavioral and physiologic change for con— sonality characteristics of the subjects as vulsive than for subconvulsive treatments. to the induced physiologic changes. A number of investigators, however, have 2. Significance of the Convulsion.——The failed to observe differences in improvement evidence indicates that convulsions are, or rates for patients treated by convulsive and reflect, the significant physiologic events subconvulsive means?”8 We would con— which are basic for the therapeutic efficacy Fink ct al. 69/263 �ARCHIVES OF GENERAL PSYCHIATRY of convulsive therapies. The specific role of the seizure is, however, not clear. That neither the motor aspects of the seizure nor the accompanying psychologic factors are determining variables is demonstrated by the efficacy of treatments under condi— tions of muscle paralysis and anesthesia?"2 That the loss of consciousness, itself, is not the significant variable is seen in the relative inefficacy of repeated administrations of thiopental (Pentothal) or noncon— vulsive techniques under thiopental.1°'2'7’39 Although the means by which various agents achieve such changes are not speci— fied, it is probable that the seizure is but one expression of a diffuse alteration in cerebral functioning?” It is this alteration in brain function which provides the neces— sary conditions for the behavioral changes of convulsive therapy.14»2°v40 Among the behavioral changes we would include the im— mediate alteration in consciousness, recall, motor patterns, and breathing; and the more persistent psychologic, perceptual, vegeta— tive, physiologic, and hormonal patterns, characteristically described in convulsive therapy. Alterations in brain function are reflected in neurochemical changes as the acetylcho— line and cholinesterasef"7 transaminase,36 and serotonin '34 content of the spinal fluid. They are also observed in such neurophysi— ologic measures as increased delta and theta 1‘8 decreased and beta in activity8 activity electroencephalograms, and in altered elec— 33735 20"21’4‘0 behavioral re— and trographic sponsivity to intravenous barbiturates and to anticholinergic and sympathomimetic agents"!12 The correlations between the degree of neurophysiologic change and changes in perceptual test performance re— ported here are a reflection of these central changes, as are the perceptualf‘ovl‘?”22 lin— guisticf‘w1 and clinical behavioral 10,20 changes described in earlier studies. In a recent review'9 the significance of the acetylcholine—cholinesterase system in these neurochemical alterations was dis— cussed. Observations With various anti— 70/264 cholinergic agents and reports of similar patterns with antihistaminic and sympatho— mimetic agents indicate the necessity for a broadly based View of biochemical and brain function relations, with emphasis on synaptic models.” A suggestive mechanism for the prolonged alterations in brain function is seen in the blood—brain barrier studies of Aird,1 who noted persistent changes in cerebrovascular permeability following in— duced convulsions. He related these to the seizure and not to the passage of electric currents, and suggested that these changes may be the enduring physiologic basis for the induced behavioral change. Thus, we would conclude that the convulsion, per se, is not a necessary condition for behavioral change, but neurochemical change, of which the convulsion is the im— mediate reflection, is prerequisite. Indeed, were persistent neurochemical and neuro— physiologic effects induced as readily by other means, “convulsive” methods would no longer be necessary. In this regard, the nonspecific nature of the convulsive therapy process has been repeatedly emphasized.14v4‘° Summary and Conclusions Consecutive patients referred for convulsive therapy were randomly assigned to treatment courses by an inhalant (hexa— fluorodiethyl ether, Indoklon) or electrical inducing agent. There were no differences in the two groups on behavioral, electrographic, or psychological measures prior to, during, or 2 weeks after treatment. Hospital discharge ratings were equivalent. Intragroup test dif— ferences were noted on all measures in both groups during treatment. These differences were related to the degree of induced neuro— physiologic change and the pattern of such changes were similar in both treatment methods. It is concluded that the observed alterations in, brain function are equivalent to seizures induced by inhalant or electrical means. The nonspecificity of convulsions induced by hexafluorodiethyl ether and the greater difficulty of administration are con— Vol. 4, March, 1961 �INHALANT—INDUCED CONVULS‘IONS sidered as deterrents to the continued clin— ical use of this treatment. The mode of induction of seizures is an insignificant factor in the convulsive therapy process. Seizures are viewed as one index of the persistent neurochemical alterations which are requisite to the behavioral changes of convulsive therapy. These observations are discussed within the framework of the neurophysiologic— adaptive model of the mode of action of somatic therapies in psychiatry. _ The cooperation of Smith Kline & French Laboratories in providing the hexafluorodiethyl ether (Indoklon) used in these studies is grate— fully acknowledged. Department of Experimental Psychiatry, Hillside Hospital, Long Island, N.Y. REFERENCES Aird, R. B.: Clinical Correlates of Electroshock Therapy, A.M.A. Arch. Neurol. & Psychiat. 1. 79:633—639, 1958. Bergman, P. S.; Impastato, D. J.; Berg, S., and Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Focal Seizures, Confinia neurol. 13:271-277, 1953. 3. Brill, N. Q; Crumpton, E; Eiduson, S.; Grayson, H. M.; Hellman, L. 1.; Richards, R. A.; Strassman, H. D., and Unger, A. A.: Investiga— tion of the Therapeutic Components and Various Factors Associated with Improvement with Elec— troconvulsive Treatment: A Preliminary Report, Am. J. Psychiat. 113:997-1008, 1957. 4. Brill, N. Q; Crumpton, E; Eiduson, S.; Grayson, H. M.; Hellman, L. I., and Richards, R. A.: Relative Effectiveness of Various Com— ponents of Electroconvulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 81:627—635, 1959. 5. Chatrian, C. E, and Petersen, M. C.: The Convulsive Patterns Provoked by Indoklon, Metra— 201, and Electro—Shock: Some Depth Electro— graphic Observations in Human Patients, EEG Clin. & Neurophysiol. 12:715-725, 1960. 6. Edwalds, R. M.; Experimental Studies with PM—1090, Int. Rec. Med. & G P Clin. 169 :469— 2. 472, 1956. Esquibel, A.; Krantz, J. C.; Truitt, E. B.; Ling, A. S. C., and Kurland, A. A.: Hexafluoro— diethyl Ether (Indoklon) : Its Use as a Convulsant in Psychiatric Treatment, J. Nerv. & Ment. Dis. 7. 126:530—534, 1958. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 78:516-525, 1957. 8. Pink 61‘ al. Fink, M.; Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 80:380—387, 1958. 10. Fink, M.; Kahn, R. L., and Green, M.; Experimental Studies of the Electroshock Process, Dis. Nerv. 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A.: Relation Between Threshold and Duration of Seizures and Electrographic Change During Convulsive Therapy, J. Nerv. & Ment. Dis. 131:117—120, 1960. l8.Hoag1and, H.; Malamud, W.; Kaufman, I. C., and Pincus, G.: Changes in Electroenceph— alogram and in the Excretion of l7—Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. 8:246-251, 1946. 19. Jaffe, J.; Fink, M., and Kahn, R. L.: Changes in Verbal Transactions with Induced Altered Brain Function, J. Nerv. & Ment. Dis. 130:235-239, 1960. 20. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Arch. Neurol. & Psychiat. 76:23-29, 1956. 21. Kahn, R. L., and Fink, M.; Changes in Language During Electroshock Therapy, in Psy— chopathology of Communication, edited by P. Hoch, and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126—139. 22. Kahn, R. L.; Pollack, M., and Fink, M.; Figure-Ground Discrimination After Induced Al— tered Brain Function, A.M.A. Arch. Neurol. 2 :547551, 1960. 23. Kahn, R. L.; Pollack, M., and Fink, M.; Social Attitude (California F Scale) and Con- vulsive Therapy, J. Nerv. & Ment. Dis. 130:187192, 1960. 24. Kalinowsky, L.; Barrera, E. S., and Horwitz, W. A.: The “Petit Mal” Response in Elec71/265 �ARCHIVES OF GENERAL PSYCHIATRY tric Shock Therapy, Am. J. Psychiat. 98:708-711, Succinylcholine, Dis. Nerv. System 16:237-242, 1942. 25. 1955. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Confinia neurol. 16:88-96, 1956. Kurland, A. A.; Hanlong, T. E.; Esquibel, A. J.; Krantz, J. C., and Sheets, C. S: A Comparative Study .of Hexafluorodiethyl Ether (In— doklon) and Electroconvulsive Therapy, J Nerv. & Ment. Dis. 129:95-98, 1959. 27. Lancaster, H. P.; Steinert, R. R., and Frost, I.: Unilateral Electroconvulsive Therapy, J. Ment. 26. Sc. 104:221-227, 1958. 28. Miller, D. H.; Clancy, J., and Cummings, E.: A Comparison Between Unidirectional Current Non-Convulsive Electrical Stimulation Given with Reiter’s Machine, Standard Alternating Current Electroshock and Pentothal in Chronic Schizo— phrenia, Am. J. Psychiat. 109 2617—620, 1953. 29. Ottosson, J. 0.: Experimental Studies of the Mode of Action of Electroconvulsive Therapy, Acta psychiat. & neurol. scandinav. Supp. 145, 3521—141, 1960. Barrera, E. S., and Kalinowsky, L.: Variations in the Electroencephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Psychiat. 47 2367-384, 1942. 31. Pollack, M.; Battersby, W. S., and Bender, M. B.: Tachistoscopic Identification of Contour in Patients with Brain Damage, J. Comp. & 30. Pacella, B. L. ; Physiol. Psychol. 50:220—227, 1957. 32. Reitman, H. J., and Delgado, E.: Technique for the Modification of Electroshock with 72/266 M.; Kay, D. W. E.; Shaw, J., and Green, J.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG & Clin. Neurophysiol. 9:225-237, 33. Roth, 1957. E: Acetylcholine and Serotonin in the Spinal Fluid, J. Neurosurg. 14 222-27, 1957. 35. Shagass, C.; Mihalik, J., and Jones, A. L.: Clinical Psychiatric Studies Using the Sedation Threshold, J. Psychosom. Res. 2:45-55, 1957. 36. Stevens, J. D.; Majka, F. A., and Humoller, F. L.: Transaminase Activity in the Spinal Fluid in Neuropsychiatric Conditions, Dis. Nerv. System 20 :460-465, 1959. 37. Tower, D. B., and McEachern, D.: The Content and Characterization of Cholinesterases in Human Spinal Fluids, Canad. J. Research 27: 34. Sachs, 132-145, 1949. Ulett, G. A.; Gleser, G. C.; Caldwell, B. M., and Smith, K.: The Use of Matched Groups in the Evaluation of Convulsive and Subconvulsive Photoshock, Bull. Menninger Clin. 18:138-146, 38. 1954. 39. Ulett, G. A.; Smith, K., and Gleser, G. C.: Evaluation of Convulsive Shock Therapies Utiliz— ing a Control Group, Am. J. Psychiat. 1121795802, 1956. 40. Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects, Springfield, 111., Charles C Thomas, Publisher, 1955. Printed and Published in the United States of America ��A-4t - signattscunt at Iuhultnt Inna-ad Guuvulttoun to: thrhucrr at ‘8: canvalnavu rhuranr Pronun- MI". IN; “.8. “It; 4‘. '0”. ’0‘... ”03., In It“ m. M“ m. ,“h“. MO ‘1‘“; “an“ m WM“. '0”. tho nuihud tn tndncanc cotstrc at at stunstxnanoc t8. it. In: in ”09.; m nzoc‘rncouvu1ISVI fihnruyy an. tuvcsttsufiod fir culpartn. tn Ila. ilhllfll‘. hllatincradilihrlothur (IndOkIOI), with it. ciuvunfitnnsi ozaatrical staining tnahatqun. fvuntgbnovuu can-mun Mamas“ mum‘wiu ”an" we and“ um GU» randunxV atticnld irtttlsni gringo. fruuunoafi van Id3131ltnru¢ at to m m: than mi: anus-um. y» mu Thiri fill at datturnann xu sun in. stein! in.bohav10ra1. aloatrlanaophnlggrnyhzu I? 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In nut attains, chili tutunro dur;t10n (17) and typf at current (11) huvc b... ttlatnd t: thu dogruc a: huhnviural gnd unit.» phyltclogic ahsnco, taut. v¢ru no ditturonccs with rolctztu to thorupoutic nutounq. this, wail. ptranttcri a: £hu saith». nu‘hod may hot: sun. rnlntion ta thnrgpo:%1a efficacy. tbs dittorcncon arc clichfi nians {ht tcahntguso, yrovidad that grand uni a¢tsurut havc hO$n 13¢ucod. rlrthur taplcrttsaa it thu taptrtaneo of fin. IoisurQ wt: and. poautblu hr ruetst txpartutntal tntcrant 1n Itififirfil induct! by Anna» (1) ). and tau-“roam (911-1090, (6) 1 than“, ) �as)» am». n3 an “um“: 4» with um" My“. ”a“: "cm am» am. and: um «mum 50 «mm m Wt um»: “um. tum-utm- alumnmmum In an ”rim“ «m u clarity an m. o! m m. of alum “(um a a. mum» them: "maul-n mun. an �Klflfib: triatwutovun cantooutavu ‘sntluctnd puttanti in u vaiuatary plyehintraa hcapttal ruttrrnd tar canvu1n1Vt fihcrapy Hurt rtadonlr dividtd tat. ti. gram». aging n allarn¢u ordor (16). In twlavu pattonta, convulltans utro indusod by a H¢dcrnt% alturuating entrant tanQrtnnut antic nupruthroahuld narrtntcs und in (txtton Othtrn. by inhnlntiou mt htxutlunrtw dio‘hylothnr (Inflation), following tn: nothcd a: Sunnibol ggflgm. (1). Prunodicttsou in :11 euro; vat 11311.6 to unbltnal¢1 atropaum (1.0 :3). Srcuiuantn u‘ro adniuistarcd thr¢c tint. pow v.0: tut 10 ta 2h npyllcatiin! with tan ‘otnl lllhlr ao‘arn£aod by in: clinical Judxuncut it uh: It!!! p1y¢h&ntr1at. 13¢: rtlcud iron 19 ta 58, with a rota ‘3. or 38.5 1“!au in. 3c: group; and 19 fit by. with a noun ‘3. at 35.5 rust: in thc tnfioklun (rump. tn: Ina: what: If aducttinn nut. 11.5 yncra (83?) and 13.6 (Indaklan). 01 tho tvcntronovun libaoots, tuolvc worn «13.113106 in daprtaltvo parohnnct, light at aehsnophrnuit, 11:16 fiwpu. and lovnn :3 schascphr.u1a, partatid twat. Tit dil‘ributiou it diaclanol, a‘. rang. and yuar: o: tduoatloa watts» ta. tug unuplta, did not ditto: ut:ut£1u&nt1y. Ichnvisral eight. wt. tvnluaiod rockly in tattrviuun by th- pacxuat'u thgrnpiu$ aha by an. stat: piratintriut. Such nnpoctn as hand, tdantton, :anorr. $1.0», aypotitn, tycoon puttutna, participatiua in :ronp nativifitua. and rclattta 8. rucnrdod $0 0950? and ¢h3n301 SIIOIIQG p£tianta wurc utttf tad quulttativoly. �lloctrocncophxlagraun var. Geno print ‘u ‘r¢ntnuat. wtokly during in: ‘ruatntut «guru: in a any ut$ar a ounvnlniau, Rocgrdn acunnrod 1.3% troatnon‘. stficr sh. taro ‘8. llé I'lkl 6 ( inflated or uuiuat tinting ‘8. up: and cluwor) in ;ut0210r (at 66 0.0.34 tIIy1:I (a). in Icadt, tauptrtI-vurtax erliflfl plylhblnaie proooduruu var. n¢u133¢arud prtor ‘9 tritiunnt, during tan tourth your (16.12 tron‘naus pawiud). tad tun v¢¢ka uttcr tin Ina! tronilnat. 2h: unapurql xuolndtd wichalor-Iollcvun‘nib‘aa‘c (anttrnntaoa. digit tutu, 083.3% a:ncnbly and digit urah¢1)s Oottnohaxd‘ my». udhcddod guanotrla tigvron (22); parceptinnl yr ptunfiotcachranatac Inboéd:d c.1ur‘d figure: at high Ip§ad"ueh11talatpta :xpouur: (31); and I nodal“! 6.113% I 80.11.: (23). In fiddltitl, lpino tori; Utmdtus «are Gnu. prior ‘c tad In than «a a: “a am”. ‘ tutu” �it. inhalatIQa fit tn‘nflitu Insularlr ranaztua in a grand all douvulttln, 91:11:! it taut taimuut clottrinnllyu fur inc tuflntlou grimy, intuition «an alarm: an; the intitdl try and «patchytanto pnuturin; Hurt fif‘ifi ouittci. In tldttc tad tonic nunttoatntisun, ycst atsnaro taunt, uni goat Intuit. botanist, in. sunny: rattnhltl ulna ofihtr «103.12. In chart Guru tvnltutiaun it 12in£¢d1 bahnvsural «huuxu. it. fight: it buhnvltr nfiutttafiud aura nilmlnr 1: tin tut urcupl. rnsttrua a: dautul. tryonnas:, ufifih‘rarax, tunntttatxnu. paranata tzuitnntut sud iontuntdniX—Innary 10:. air! htilrvfil in it‘s populu‘inuu watt uvpvumfllattly'tqnal trltittfir (tail. 2). I campaiaa$10n rates Etna! I “fiamnauau wore statics. viii. patluntn ‘oxcrutna the Inhalation prifllllri. Chart '0'. Iroqufiufi Upilodii a! hroathwhnltias nut lamina. Ihfifi§ tin muck, naktng ‘hin inttctiia 1:1: :vlhhlc. fruwt‘rta new. obntthd radiogrupttcgllr 1: £lrvc Indolian irattod pcifiufitn and in throw during 36!. Adminaatrattvu tVIlnnfiiaaa a: cizuiaul ingravanaut u. £30 an at “an". :m a. was”: an msnzus "an. t). a: Itcnwnrtd and anon tnyravcd nypruxinutvly half at taah first». Infidnsu first a warn rucordui fur �inturitasuvu aifiina tianrocuunyhaloxruun, town qualtiai$vuiy and qumttttuttvoxy, aura aluilur in the two gvfltyic Frucrncnsvu arunntrtn attains ct inhinant trucuuucxtp and an tactvuuc tn Vil‘icil 1;: I’pllih‘ in :11 lnatu. with trintnl in! naiovttrmtaupiwul yruyduiarunaa. lava: and «human an. swam m «m u an. Mann” antt¢tey tutti; tilt such it ivcnI-lnt warn Ilfi Iaanltiauliay isttcrwut {tibia 3). tafihntgh tan anti!!! III stanza uypntrai «stilt: in fit. thiuklnu trim! than 1: it. In! grin}. nuanurwn OI indsaud ulna Hutu tiltt 3 “~w«.*...u~ mm: 1:1er uhtorvattvau tut tack tic poyvtalociaux twat: (in. man” has It t: or flu rmvuulad a. dattbruaca yriir t9 iroutulnt, flaring tho lihrih unnk, and it! itch: ptntattcutnmnt for fitt it! tsua$naat grfi‘ps. Iatrtm hiiivnr, iatlynoa, li‘l!‘ Gduttttcut ataugul in vurtuuu grit: allltfit (was pruutrautuaut it $ha tutti! tuck; and tron ti: Sturfih 9“! £3 two that. titty trtatnnat (lufili £3, bush in tho Intttiiu sat in tha IQ! grunpo. ....*.....um: I: �an,» x: it: waohalirulililvng tuhsotts, grit; lflfitfl unasud a fillhificnfit «ontnama an wcortt (y‘awcr yuvlorannct) tn! Cunt .3h‘nct iuriaa irtgiunnfifi and u v-fiurn t. yruatrnttunut 10'!!! 3: sh: poabwtvcn‘nnut yurtod. 03¢ Ithioxt, «33.6% Inatufilr, dtntastrntui tlzntrlscatar~inuvouocd Ct0r00«’ditv ‘ifldilil‘¢ stntltr pattern: 0": oha¢rvud fur thy tnotxutoacapiu unusarca use it. I «tints. will. incrcnund arrow: as ch» «abaddfid tight. tutti warn uhtuvvud daring fivtutunas, t3: dt!£:roano an. nafi alaniriafiut. Paatutrautuunt, tin arrays in its: tunfi itartlnca signattcnutlr from prontroufluaat no.9... an tha 1 anti. that; an; incrutso in isflrit utth trottunnt, and a Guavaauv tullduan; ‘runinust. in: each at that. unnausol. tic un clmamtl 13>psr£bmnmn¢a an £ha ynruhnaagta tucks tram tun prumfironiuuufi riirtt itch tnttinu pnrild warn t. ti: uttnllltauttr rulttad fit til angst. orstuiuuud 3!! 310' all. activity to: tutu urtupa (inhia 5). Isak grant inrcllfiiun: inunnctvafiod thgi attriunuSn in porttruuntu on the'wlnluicvu Inlluvu¢ atgit cyan and thattt unocth: aubtttta; tuthiutnueupy tat rtsaruu stat; wart gignitiacntlr rtlutti to ‘ho anniat .1 oltatxagruphlc ahlnst. stuxxnrly, an innrquac in ? utcrn It! ssndaiatod hath 1nflriittfl £13 tilting. anh¢¢d¢d -a..*....., till! 5 �mmmumummzummm amalgam mt mama» mm. immt m W tum-mummy. mewmmm. ml was it. mm“... umwmnm «at a mmmuummmmnumum‘mu at: 31m. m m m. umm nun-m an and hr Wm, mnmnm in“ m at out“ numb}, mm m m min-m W 2-. l‘ �1. W!h: crimp. wuro behaviar tt aloctrioul tudnncd iatxlra £n¢£tttnguinhahlt tn fin. variant statur¢t a: etch ttuxo at tun ‘RUtiliflt proocsl. 813:: in: 1nh&1:nt and tho taatar ens-tn ‘0 bath trOainuntu vns tn. induction st natuurit tad not thg unthnd a: inauotian, u. may Gflflfilud. thu$ it. netted or 1nduet1¢n 33 has a signtttctnt variihlc in th. £h¢rnpy arsenal. apceatie¢lly, chanson in tho bah:v10rn1 and attraphyiitlnsic inflicts ;ro dupcudant tutu the induction 0: taiinrtu, Ind not dapaudout nu nay '1ng1c property or the tluntrieul it tho inhtltnt nod. of induction. Klrland.g§J;;. (26) lad Chutriau and P¢taraoa (5) bath alto conpnrad ¢1natrtea1 ind tahnluut '013Irt3. Karinue and ht: agowurkcru niutgnnd convulylvn thnrapy ruttrraln tltcrw uttoly to Induklua and so: trontnamt cranps. :huy rapcwttd £hnt b¢havtural rataagl, acnyIScutiou rut-a. payehalagia tclt portaru£aeta and aardithluulur roaa‘itun var. 11:11:: in tho tun £3.91... ¢ha%riu| uud itnrn¢a, Itudying schano~ phrcala tahstata with anplantnd inttncurohral altatrodon, ropqrtnd 14¢:Q1aai ultc‘raarsphi¢ pttsoran durzng ncxnurna ind ufi vurtonn puttwltialrt psrzcfln It: Instilon, untrtlua and tlaatrtnsl tuchniauat. In studtu‘ it :dburan inaun¢d by varituu dlcutr1c¢1.n¢tal, Ignivnloa‘ bfihnviorll. ynyahtlogia and �.11. olootrocrophio ortooto hovo boon rovorfiod (3,11,29,39). Vhtlo thooo otudtoo oqnoto tho otroeto or ditforons convuloivo ‘oehaiquoo, voriouo nonooonvuloivo nothodo ouch oo oubconvalotvo, hriot otinuluo. unidiroetlonol otionlotinx, oonopolor otiouu Intang, and tonal *oouvu1311o* toehniquoo hovo boon dooorlbod, and ooch in turn, diocordod in routino thorny: oo inotroctivo (10,27.39,h0). For oxouplo, Borgnon (2), 1n doocrthinu tho olootroarophio ottonto of tho '1ooo1-oo1:nro* touhntquo uotod that 751 o: potionto bod noraol rocordo ortor tlftoon ouoh opplicottooo, whtlo 703 had 'obaornol' records alto: aroma moi ooiauroo. Blott ggflg;& (39) hovo roportod diftoronaoo in tho taprovoaont rotoo at potiouto roooiviag oouvulotvo trootuonto (69.301) sad thooo roooiviag oubconvuloivo (33$), or «outrolo (385). Our own otudioo (10) also dononotroto oignirioontly groooor dogrooo of bohoviorol ond phyoioloaio ohonco zor.eon~ vnloivo than onbaonvuloivoVtrootoonto. A author or inventigotoru, hooovor. hovo toilod to oboorvo dittoroneoo 1n loprcvonout rotoo for potionto trootoa by. convuloivo ond subconvuloave noono (3,h,28). Ho would conoldor thooo rooulta to rolloctiag d;:£oronooo both in popuiotion oonploo and 1a oothodo or ocartng bohovtarol ohonco. whtlo oonto illuooo and orroetivo-dogroooivo rooottono oro doooribod for tho nojority or oubjocto to sho poolttvo otudioo (10.27.38) 70: at tho “Moots 1:. mo and! (h) and 100! 1a anothor (28) voro elooood oo schizophronio rooctiono. rho rootlitioo in thooo 1nvoot1gottono oorvo ohrontoolly 111 ‘ "an“ �~12. populottooo, ond prior oouvooo or ooovuloivo thoropy voro rooordod-tor hourly halt tho oobaooto 1n ouo group (h) and 901 in tho othor (28). 73o toiluro to obtoiu oiguttlolat dittoronooo on: oloo 11o 1n tbo atoll oooploo mood to.toot tho null hypothooto. Chongoo 1n hohovlor oro oboorvod 1a o1! onbaooto roootvio: o oouroo or oonvuloivo thoropy (lo,t9,30,33.38), but thooo chongoo ovoluotoo oo oltntool thyrovooont, occur oaly 1o oooo. whilo induood oonvuloiono oro o ooftiolont condition for hohovtorol chango, tho: oro only o noooooory condition for inprovooont. Thoo, nooouroo or bohovioro1 ohoago, cook to monory (25), longuogo (19,21) ood porooption (13,22) roodtly doooaotroto signittoont d1xtoronooo hotwoon ooavolotvo ono ouboonvuloivo toohniqooo within tho 1nd1vtdoo1 dittorooooo to poroouolity ergoniootlon of tho oohaooto. Iotlago of ”1-provonont', howovor, vary with tho poroonoltty orgootootloo of tho oubaoot oo oxprooood 1n odoptivo yottorno and Iloxibility for ohoogo; with ouch onviroaooutol vortobloo oo thoroptot. ototf and tonily oxpootottono ono toloronoo for tho o11o1tod odopttvo bohoibrg and tho flotation ood dogroo of indoood nourophyoiologio ohougoo. In globol ootiuotoo of “inprovo-ont' tho onvtroa-ontol vortotloo booooo propotont. rho totloro to oboorvo significant dittoronooo 1n taprovolout voting. to rolotod on lock oonvoloivo and noo~oonvu1otvo zroopo no: to to thooo ooviroonontol voriobloo and tho yoroonoltty ohooootorlotion of tho oobaooto, oo to tho indoooo phyotolocio ohoagoo. �.13. 2. Signirtaeuee at the convulsion. The evadenee indicates thet eenvnlaiene ere, er retleet, the eigniticent phyeiolegic event: thigh ere beets tor the therepeuttc ettteeoy e: convuleive therapies. the epeeitie rele e: the eeleure 1:, however, net olenr. Thet nelther the note: eepeete e: the eeteure new the eeceepeuyiux peychelegie fectere ere determining veriehlee 1e deleuetreted by the etrioeey et treeteente under eeudltleue er neeele perelymte end eneetheeie (3!). rhet the leee or ceneeteueueee, iteelf, in net the etzuitteent veriehle 1e seen in the relative luettteeer e: repeated esuintetretiene e: peatethel or not. eenvuletve teehniquee under pentethel (10,2?,39). Without epecityinx the neeae by which verieue egente eohieve eueh oheaxee, it to vrebeble thet the eeieure 1e but one expreeeien e: e dittuee alteration in oerebrel functioning (9.13). It in this elteretien in brain fluetien which prewidee the neeeeeery canditiene for the hehevierel eheasee at oeuvuletve therapy (1h.2o,50). teen: the behevterel chengee we would include the innedzlh exteretten 1a eeueeteueueee, reoell, leter petterne, breethiaa; end the eere pereietent peyehelegie, perceptual, vegetative, phylielacto end heeeenel petterne, characteristically deeerthed in oenvulexve theeepy. titeretieue 1n hretn :enattea ere retleeted in heaven chee1ee1 chengee ee the eeetyleheline end oheltneetereee (3?), trenemueee (36), end "retain (3h) «intent of the epinel fluid. They are elee eheerved in each neurophyeielecle eeeeuree ee inereeeed delta had theta eetivitr (8) end end �«1h. outtvtty (18) out oltorod olootrocrophtc (33.35) and bohovtorol (20,21.h0) rooponotitty to introvououo borbttorotoo sad to outtoholtnorglo and oyspothoolootio ouonto (?,12). rho oorrolotiono botoooa tho dogrno or nooroyhgotologlc choos- ond changoo 1o porooptuol toot portorlouoo roportod how. oro o rotlocfiiou of thooo coastal chongoo. oo oro tho porcoptool (10.13.22) linguiotto (19,91) ond sliniool hohovtorol (10,20) ohoagoo éoooribod an oorlior doorooood boto 1o oloctroouooyhologrooo; studios. In o roaont roviou (9), tho oicattioonoo of tho oootylnholiuéaholxnootorooo oyotoo in thooo nouroohontool sltoéotiono woo «ioouoood. Oboorvoticno with vortono onticholsoorglo ozonto out roporto or oioslor pottorao with antibiotoointc and oynpothoolnsttc ooooto. indieotoo tho noooooity for o broodly boood vtoo or hioohooiool one broth tunotton rolottoao, with oophooto on oyuoptte Iodolo (12). A oocgoot‘vo ooohoaio: so? tho prolougod oltorotioao in broin tnaotlou :- ooon in tho blood~bro1u borrior otodtoo a: Alva (1) who uotod poroiotont «honaoo 1a oorohrovooonlor porooobillty tollovinx induood couvulotouo. fio rolotod thooo to tho ooiluro and not to tho pooooxo of noon-to cox-routs. out! ounootod that tho-o chongoo ooy ho tho enduring phyo1olo¢1¢ booio for indueod tho bohoviorol chongo. Thus, to would concludo thot tho ounvuloion. or no. to not o nocoooory condition for bohoviorol ehoogo, but nonro~ choliool ohongo, of which tho oouvuloion to tho ionodioto "nation, 1o pronoun“. Indood, won pox-noun noun. �015 a aha-10.1 3nd nauraphyalolosie attoeto image-d a: roadily by bu unthodn Ivnld no loncnr uooonlary. 'convuluivofi other manna, In thin rogurd, tho noun-poclxta nature or «a. couvulatvo therapy proocuu has he’s ropcncndly ouphantuad (lh,h0). �an I mg. cg.mm s, conuauuttva put£¢n£u rotnrrid 1.! 5.3131317. therapy var. tunic-1: assign-i to trtutncut tour... (Ind-klcn) or ulnatrtaal inducing tgcnt. by an inhalant Thor. were no dittoroucau in tho two group. on bohavlnrfii, cloatregruphio or psycholcgioul natsuroa prior to, dnrtng. tr lotyttal dicohtrzc rnttnuu var. oqutvalont. tutti-group taat dirt-rtucls unto notad on 311 tun wtcka artor treatunnt. unnanrau in both granps during trnatnont. In... dittuvouafil var. rclutcd to tho dcgrto a: indueod nourophyaioloxie «hang. pattern at such chanzaa not. similar in both troutlau‘ and tho I. th“‘ 0 It is concluded thut tho abhorvod nltarntioul in br‘in function :r. quivnlont with nature: inane“! by inhnlnut or alootrtctl Hanan. rho nououpceitietty of Indaklauconvulnionn and tho ctoattr difficulty of aduintatruston continued the aonnidorod to «ctorrunta clinical at. 3a if. or th£a trtatuant. The nod. or induction or nuisuroa 1: In tuntgnitic.nt (cater in tho convulsivo thornpy process. $e1uutoo tr. “and u on. two: of the ponistont autumnal"). eaavulsiio bchnvicrnl finance: a: uhioh rcquiaito to tho durum- er tharupy. Th... abuortn£ion| at. discus-ad within the tranoutrk at tho nourophyu1olozie-Idupt1vo nude! or thu of abnttic Vfihcr.p1nn 1n payohintry. node of action �0’17. the oo¢90rntion 0! Smith £113. a French Lahcra%orsco in providing the hazarluovodiothyiathar (Indcklon) It’d 1n tho-u atudioo 1n gratefully toknoviodgud. �.15. 1. 11rd, 3.3. clinical Gerrsllfita at Electroshaok Thnrapy, Pazphittg lg: 633n639, 1958. 2. larguan, P.8., rapt-tutu, 9.6., Bars, 3. and foinntoiu, a. filoetrounonyhalocraphic changes talluving olqctrioll induced £0331 a-lunrca. cant. laurel. $3, 971-277, 1953. 3. lrtll, 3.0., Ornlp‘el, 8.. Iiduncu, 3., Gray-on. 3.8.. flollnnn, L.I., Richards, 3.4., stra;tnan, 3.9., and Unsor. 1.1. Invuatigntioa a: sh. thorapoufito coupounnta and variant raetcrl .saoctatnd with tlpruvousut with olectro~ convulsive trontaontt A preliminary vapors. An, J, Ag; Arch, Huurol. & 3&2, 997e1008, 1957. Ptzghint. h. Drill, 1.0., cr‘upton, 3., atducon, 3., arnyaou, 3.I.. lilllll. 1.1.. and Richarda, R.L. Balattvn eruct$vonaao of tartan: coupon-at: a: oloctrcaonvnlotvo thurapy. nu non. lmal. a "paint. 9;, 627.535, 1959. chattiln, 6.3.. and Itoruun, u.a. Thu convuloivo pafit-rnc provokad by Indcklen, Hotrauol and slcetraouheck. Solo dopth clootroxruphio obscrvuticnl in hunnu patiautu. BIO Olin. lturoghzgiol. 33: 715-?!5. 1960. ldvaldn, 1.x. Bxportlnntal utudtoo with Pnn109o. Int. Rue. nod. 1- cm». a g 32;: 1:69-4:79, 1956. 7. lsquthnl, 1., lrants, J.0., tru1t£, 3.3.. Linc. ;.s.c.. tad lurltnd, 1.1. loxntluorodtothyl nth-r gindnklaa) ~ It: us. as a oonvuluant 1n psyuhtctrto trau‘ucat. ' J. larv. flout. nil. 33$: SJO-SJh. 1958. �.19“ EEG end delee activity to of B.L. Kenn, 3. Ieletien link, behesierel reepeaee an electreeheck: Geeetttettve eeriel etudiee. Ant arch. leerel. e Pezehtet, E!) snsasas. 1957. 9. link, I. street of enticheItnercie egent, nietheere. ea :30 eud behevteru atsntrieenee for fiheery er aenvuleive theeepy. A5; trek, leurg;. e Pezghte . £21 380~387. 1958. 10- tier, I., Kenn, 3.3. ens Green, I. lapettleetel etedtee e: the eleatreeheek preoeee. Die. lerv. 813, £23 113.118, 1958. 11. r1nk, I. end oreen, n. sleetreeueepheleerephte eerreletee er ‘ the electrocheek preoeee. Die. [eyes a; . g2; 11?, 1958. 12. rink, 8. street e: entteheXLaerste eeepeunde on peetaeeaveleiee 230 end behavior. 380 clin. leergghzetel. 33: 359o369, 1960. 13. fink, fl., Kenn, R.L. end Kevin, 3. Erteete or dattnee eltered brein funciieu en perception. ?ree. 1' Int. Cong. vgzphel. p. 238-239, lerth lullead Pub1., teeterden, 1959. 15. Flat, n. Alteretiune 1n bre1n reaction in therepy. Pezghe~ ghereeeolegz zgenttere, [113e, I.. ed., p. 325~332, 1959c» 39., ”.tCB, ‘1‘”., ”M Fleetng, r.c. An annuity into the lecheniee o: ectzou of electric eheek treeteente. J. lerv. lent. Die. 12h. k hho~h50, 1956. elteruettnc etienli 1n dieerininetien experieeute. I: eeuet. Patchegg 16. cellereen, L.V. v1eue1 chance orders e! g5, 207-208, 1933. 17. Green, H.A. Reletien between threshold end duretten e! eeienree end electregrephio ehenge during ooeveletve therepy. a.n.n.n. (in preee). �.2918. nugzlsnd, l.. nultnud, w.. xguruan, 1.9. and Finest, a. chant-u 1n aluotroauaophtlogrnu and in £h¢ excretion of 1? - kutorctaraoida aceonpnnyiug aluotroshook thcrnpy or agttntud doproallou. razohouon. and. g. ' ab6~251, 19h6. 19. 1n vorb:1 Ghanaoa an! Kuhn, 3.3. u. Jattc, J.. tint, trunlaataono with inducod :ltorcd hrtiu function. 1960. 23$~239, 52g: 91a, nunt: Icav: J. 90. Kuhn, I.L.. tint, a. and wuinutotu, E.A. lolntton of anubnrhttal 1.1% to clinical inprovcuont 1n oloctraé thank. Arch. laurel: and Puzohint.‘1gs 23-39. 1956. 21. Kuhn, 3.1. an: Pink, H. change. in language during electroshock thorupy. ?: who Ithola' at Communicatian, noun, P. and & Bruno 126~139, Struttou, N.Y.. 1958. Zubiu, 3., tau., 9. 22. tuba, n.L.. Pollack, I. tad rink, n. figuro~gronnd diaerintuutian ARA arch. laurel. inéaood tnnotiua. brain sitarad arts: 3,: Sim-551. 1960. R.L.. Pollack. n. and link, a. soc1;1 attitudo (California I Saul.) and convnlcivo thornpy, 1960. 187-192, ggg, J,l,l,3. 25. laltuovuky. L., Darrora, 8.8. and lorvits, v.1. The “Potst unl' roaponst in olnctrtc shook thcrtpy. Al. J. Pszchiut., 2;. 708-711, 19kt. 25. Kevin, 3., link, I. cad Kwalwnuuor. 3. Relation of ehtnxtu in aviary and luarnlns to inprovununt 1n aloctrouhaek. Gout. 303301. gg; 88-96. 1956. 26. Karinnd, 1.1.. Ibuloug, 1.3., Enquibfil, A.J., Kr¢ntn, 3.6. and Shoots, 6.5. A coupsratlvu utudy of hoxntlnoro~ dicthyl Rthc1 (Indoklon) and cloetraconvulaivo therapy. 19590 ”‘WQ 95"”, 21 fight. 1: I‘m. 23. Kuhn, �.21. 97. Lnnouatqr, H.P., stcincrt, 3.3.. nan trout, I. fintlltornl oluetroconvulstvt thcrtpy. J. Hunt. 3&1. 323: 221-997, 1958. 28. Killer, 3.8., 61:30:, J. conpnriocu between unidiroétioanl entrant nou~oanvnllivc olcatricul uttnulntaon ngon 31th nuttarta nuoh1ao. standard and cunninga, B. A ultornntaa; carraat electroshock and pontothtl in chronic uahtsophronta. An. 3. ?Izghint. £92: 617—620, 1953. 29. citation, 4.0. Exportuontll stndIGI or ‘hn node at nation at clootrooonvull1vo thnrtpy. tot; Pazghtat. & lturol. 86:34. 8322. ;§2,‘§£, 1960. 30. Pnoolla, 3.1.. Darrcra, 8.8.. Illinovlky, L. Varitttono in the oloctrocuecphnlograu unuoota‘od with aloctriu shook therapy in patiga‘a with nuutgl diaurdorn. 19h2. 367~38h. 31, laurel. szohtnt. 31. Pollack, n., Butt-ruby, v.8. and Sander, H.B. rashictosoopio identitiotttnu of content in putzcutu with brain dalnxo. J. Gagg. ’El'3°1° Pczphol. £9: 220~t27. 1957. 32. Boitnnn, !.J. and 3013140. I. technique for tho Iodxtlcatlon or cloutroshook with nuccinyloholinu. Bin. UOIV. szp. 3g: 237«2h2, 1955. 33. Roth, H., x§y, D.H.l., shat, 3., 3nd Brocn. J. Prague-1n :ad poatothal induced olcctvocncuphnlozrnphic changes in olcctroeonvulatvo trontucnt. £36 c113. luncgghzytcl, Arch. Q 2; 925.237. 1951. 3h. agent, a. tootaioholtau and lavaton1u J. louroourg. Akp 2t-21. 1951. 1n the spinal fluid. �.22. 35. Shaun... 6., flxh‘lik, 4., tad Jouco, l.L. cltnxcal pirahiutrie aging tn. nodntaon thrcthuld. J, Patchoaoag a... g; h5~55. 1957. atovoaa, 4.9.. naakn, r.1. and I‘IOIIOP, I.L. Tflfiltltutfll in activity 1: fit. spinal fluid neuropuyehiutric EGO-hfis. 1959. condtttonl. 91a. Harv. gin, g2; attest. 36. 37. I taunt, 9.3., o: choliuottcrason and Bazacharn, B. It: 1n hung» nontnnt and chartuaorluattoa spinal 31:16.. Bahia, g, 31.03roh, 31: 132-1h5. 19h9. 38. 331th; and 0.A., x. 3.x. caldvoll, aloaor. o.c.. Blctt, The to. or natchod group: in thc ova1u§t1¢n at ooavulaivu and Iubeonvulttvo photo-hook. 3311. Inna. czan, 18: 138-1h6, 195k. I. 6.6. Evaluation 0: convultivo thank thoroptcn utilising a control group. £5&4£g 195$. 795-802, ;;ga rgzchtlt. ho. walnutotn, 1.5. sad Kuhn, l.&. Dania: of zllgclns ango;1c and ggzltolo‘tual nggusi. 0.6. than... sprin3t101d, 111., 19550 39. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Inhalant-induced convulsions. Significance for the theory of the convulsive therapy process. Arch Gen Psychiat. 1961 Mar; 4:259-66. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-52-018 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Karp, Eric; Pollack, Max; Green, Martin A.; Barre, Alan; Lefkowits, Henry J. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the Archives of General Psychiatry March 1961, Vol. 4, pp. 259—266 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/12764b529d79f1eb96174bc90f2534b6.pdf ca3411637648ce13d529a98dea9e5b2f PDF Text Text Behavioral Patterns in Convulsive Therapy MAX FINK. MD. AND ROBERT L. KAHN. Ph.D. GLEN OAKS. L. |.. N. Y. �Reprinted flow the Archives of General Psychiatry July 1961, Vol 5, [71). 30— 36 Copyright 1961,]1y Agzeiican Zl/[edical Association Individual differences in the behavioral response to convulsive therapy are marked. In psychiatric practice, patients with similar psychopathologic syndromes, and of similar sex and age, show a variety of clinical responses: Some improve and sustain such change; some improve, only to relapse quickly; and some fail to improve. These differences have been related to the degree and duration of induced neurophysiological change?“6 premorbid patterns of personal— ity,""11'15 sociopsychological characteristics,13' 15 and psychotherapeutic approaches.1 While these studies have emphasized ratings of improvement, the derivative nature of this evaluation and its dependence on staff attitudes, expectations, and family tolerance have been stressed.2""5'8 The manifest behavioral patterns provide the basis for the evaluations of clinical response. It is the purpose of this report to describe behavioral patterns in patients undergoing convulsive therapy and to relate these to problems of the evaluation of improvement and to an understanding of the convulsive therapy process. Behavioral Patterns in Convulsive Therapy Of consecutive patients referred for electroshock therapy during 1956-1957, seventy-three patients were subjects of the analyses described here. The patients were selected for treatment by the resident therapist and the supervising psychiatrist -——the investigators playing no role in their selection. These observations were made during a lllll|llllll|Illllllllllllllllllllllll|lllllllllllllllllllllllllllll|lllllllllllllllllllllllllllllllllllllllllllIlllllllllllllllllllllllll|lllllllllllilllllllllllllllllllllllllllllllllllllllllll MAX FINK, MD. AND ROBERT L. KAHN, Ph.D. GLEN OAKS, L.I., N.Y. convulsive-subconvulsive electroshock study in which subjects referred for therapy were randomly assigned to courses of subconvulsive or con— vulsive treatments. Electroshock was administered 3 times weekly under thiopental sodium (Pentothal) premedica— tion, using either a Reiter unidirectional or a Medcraft alternating current instrument. Grand mal or subconvulsive treatments were administered by altering the strength of current. Neither Submitted for publication Jan.6, 1961. From the Department of Experimental Psy— chiatry, Hillside Hospital. Present Address: Division of Psychiatry, Montefiore Hospital, Bronx, N. Y. (Dr. Kahn). Read in part, at the New York Divisional Meet— ing, American Psychiatric Association, November, 1957. Aided by Grant M- 927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service 52 �CONVULSIVE THERAPY 31 flecting the patient’s adaptation 2 to 4 weeks fol~ lowing the last treatment. patient, therapist, nor evaluating physicians was aware which course of therapy each patient received until after the evaluation period. Changes in brain function were measured at weekly intervals by tests of language patterns both clinically and after amobarbital and by the degree of slow-wave activity in electroencephalograms. The intercorrelation of these indices and their relation to behavioral changes have been reported previously?” The manifest symptom patterns of the referred patients were variable and included suicidal preoccupation, retardation, disturbances of mood and affect, excitement, agitation, panic and tension, delusions, ideas of reference, negativism, withdrawal, and somatic complaints. The clinical diagnoses were depressive psychoses of manic-depressive, involutional and reactive varieties, and schizophrenic psychoses of paranoid, mixed, catatonic, and pseudoneurotic types. Clinical behavior was assessed in weekly psychi— atric interviews, structured perceptual task situa— tions,“'15 and by conferences with the patient’s therapist. In these observations, the evaluation of improvement along the continuum of “recoveredunimproved” appeared inadequate and was supplemented by a rating of the degree of behavioral change. The degree of change in clinical and ward behavior was rated on a 4-point scale of “marked,” “moderate,” “minimal,” or “no change. H These evaluations were not value judgments as to the quality of the change, but rather quantitative es— timates of differences in behavioral patterns under similar conditions of observation. The assigned rating was based on changes observed during the treatment period and for 2 weeks post treatment. Evaluations of improvement response were made on the 4—point scale of “recovered,” “much im— proved,” “improved,” and “unimproved or worse.” These evaluations were value judgments, based upon the behavior of the patient, the therapist’s expectations, the tolerance by therapist and patient of those aspects of behavior often called “side— elfects of the treatment,” and the therapist’s judg— ment as to the family’s attitudes to the patient’s behavior. These evaluations were short—term, re- Observations A. Behavioral Change and Improvement. A comparison of the behavioral ratings and the improvement evaluations is presented in Table 1. That ratings of recovered and much improved were associated with high or moderate degrees of behavioral change is an expected observation. Similarly, that patients with minimal or no change in behavior were evaluated as unimproved or improved, is also expected. The significant relationship, however, lies in the patients showing high and moderate degrees of behavioral change and still rated as showing a poor clinical response. Of the 30 patients observed with high degrees of behavioral change, 17 were evaluated as recovered and much improved, and 13 as improved or un— improved. B. Modes of Adaptation—Analyses of the behavioral patterns of the subjects during and following treatment permitted the description of various modes of adaptation. For illustrative purposes we have described 4 behavioral patterns under the titles of euphoric—hypomanic, somatization, paranoidvuithdrawal, and panic modes. Euphoric-Hypomanic Mode: These subj ects appeared pleasant, affable, and friendly. They dressed neatly, spoke quietly, and participated in ward activities with increased interest. Occasionally they dressed gaudily and smiled and giggled excessively. Pretreatment symptoms were not manifest, and premorbid attitudes and behavior were again prominent. 0f Evaluations of Behavioral Change and Clinical Improvement (Convulsive and Subconvulsive Therapies) TABLE l.——C0mparison Improvement Rating Ichavioral Change High degree change Moderate degree change Minimal degree change No change F ink—K ahn Recovered (30) (17) (10) (16) Much Improved 9 6 0 0 8 3 0 L? 53 Improved Unimproved and Worse 8 6 2 5 5 1 15 5 �32 - In their psychotherapeutic interviews they described their illness in a detached manner, emphasizing “it” (illness) as having “dis— appeared.” They denied having been ill and facetiously suggested they were at the hos— pital for a rest, or that the institution was not a hospital, but a resort or a school. Symptoms were described in the past tense, and the quality of having been a different person during the illness was reiterated. Speech was marked by denial, displacement, evasion, qualification, and cliches.“ The third person mode was frequently used, as in such statements “the doctor says I am ill” or “my wife should have come here.” Gross changes in memory were either not apparent, or were described for the treat— ment period only. The patients expected and accepted these deficits, and neither connection with treatment nor apprehension was expressed. They looked forward to home visits and made realistic discharge plans. While conflicts with family members were described, these were minimized and expressed mainly in the past tense. Referential questions were answered in a referential manner and with— out an arousal of affect. For the more hypo— manic subjects, questions about home planning were responded to nonreferentially, with marked use of inappropriate clichés. When pressed with referential inquiries, they quickly exhibited anxiety and discom— fort, minimized their feelings, and changed the focus of the session. Such adaptations were sustained throughout the discharge planning period. The more hypomanic features were rarely sustained and within a few weeks were replaced by a more stable euphoric or somatization type of adaptation. Somatization Mode: In these subjects, in— cessant complaints about bodily symptoms and loss of memory, demands for reassur— ance and relief, and preoccupation with feel— ings of unreality and confusion dominated behavior. They remained unkempt and their rooms were untidy. When such an adapta— tion appeared early in therapy, further treatment was refused. ARCHIVES OF GENERAL PSYCHIATRY Speech was principally in the present tense and in the first person, with few third person references and a minimal use of clichés, denial, or qualifications. In psycho— therapy sessions, they were demanding and hostile, reporting their problems in terms similar to those used prior to therapy. They complained that the treatment caused addi— tional and more incapacitating difficulties. To referential questions, answers were gen— eraly correct, but associated with complaints of memory impairment. They described their family relations in pretreatment terms, with an occasional “I don’t remember” in response to experiential inquiries. Discharge planning was difficult, since they insisted that their new symptoms prevented any home adaptation. On the ward, their hostile demands for attention and relief of symptoms increased with treatment. Participation in group ac— tivities increased, however, for those sub— jects who had previously been withdrawn and seclusive. Memory complaints were preeminent. Pa— tients demanded reassurance that their memory would return and repeatedly asked if treatment would be harmful. They de— scribed feelings of derealization and con— fusion. Events, bodily feelings, and relations to friends and relatives seemed strange, fuzzy, unclear, and out of focus. While they complained chiefly of memory impairment, they also complained of back pain, headache, tingling of fingers and toes, nausea and weakness, and ascribed these to the treatment. At the end of treatment, the symptoms for which hospitalization had occurred were no longer present, and although complaints were many, their relation to the treatment and their transience was so universally ac— cepted by both the staff and the patients, that the results were evaluated as beneficial. This adaptive mode was sustained into the postdischarge period. Paranoid and Withdrawal Mode: Another pattern was the appearance of paranoid ideation, suspiciousness, hostility, ideas of reference, and delusions. These patients Vol. 5, July, 1961 �CONVULSIVE THERAPY failed to care for themselves and remained unkempt in their dress. Their rooms, in which they remained much of the day, were untidy. Speech was sparse and not spontane— ous. When questioned about their illness, they were hostile and demanded to know why they were questioned. They refused to answer inquiries or categorically denied or agreed to all specific questions. Experi— ential questions were answered referentially. When inquiry was insistent, they denied illness and minimized the symptoms which had resulted in their admission. They refused or avoided sessions with their therapist and insisted convulsive ther— apy be ended because it was harming them. When treatments were continued, they demanded release from the hospital, or pre— cipitated discharge by elopement, suicide attempts, or aggressive and destructive out— bursts. They were unable to discuss their relations with family or friends and focused on demands for either release or relief from somatic symptoms. Hostility was overt and engendered a fearfulness in the staff. On the ward, when coaxed out of seclusion, they were loud, aggressive, and demanding. They were suspicious of attempts at friendliness and expressed thoughts that others wished to harm them or talked about them. While insisting on discharge, no realistic discharge planning was achieved. Their View of the environment was grossly distorted and self—centered, preventing adequate care. In testing, they were uncooperative, and voiced angry suggestions of being experi— mented upon or abused. Complaints of memory impairment were infrequent and occasionally denied even when clinically manifest. On such occasions, they were en— raged at the implied deficit. Panic Mode: These patients became increasingly anxious, agitated, restless, sleep— less, and anorexic. In their dress, they were neat and cared for themselves. Speech pat— terns were unchanged and continued with emphasis on first person and present tense modes. Symptoms were distressing and prominently voiced. When asked about pre— treatment symptoms, these were expressed . Fink—Kuhn 33 in the same terms as those used earlier, with the complaint that treatment had made everything worse. Patients feared treatment and hid on treatment days, or pleaded with the staff to forego further applications. They threatened elopement and if this failed, submitted administrative requests for discharge. On the ward, they continued their pretreatment patterns of minimal participation. On treatment days, they were withdrawn, sullen, and negativistic, and cooperation was poor. They demanded to see their therapists and on such occasions insisted that treatment be discontinued. They were unable to discuss family situations or their attitudes to others, being preoccupied with their feelings of fear. In discussing their home, they insisted on immediate discharge, while stating they were severely frightened, anxious, depressed, and unwell. Ideation was unchanged with fearfulness as the principal affect. Fears of damage to the brain or mind was expressed, accompanied by the awareness that memory impairment may be a Sign of such damage. Complaints of memory impairment were infrequent and when present, were ex— pressed as a specific reason for discontinuation of treatment. Patients were uncooperative and fearful of testing and participated only if encour— aged that such tests may be helpful in the therapist’s decision about further treatment. Occasionally, when treatment was discon~ tinued, a more stable adaptation of relief, acquiescence, and denial appeared. C. Adaptive Mode and Improvement Ratings—Thus, for the various adaptive behavioral patterns, a range of short—term evaluations was observed. Those subjects who developed and sustained the euphoric— hypomanic modes were generally rated as recovered or much improved. Patients with somatization and panic modes were oc— casionally rated as improved, although unimproved ratings were frequent. The paranoid—withdrawal mode was evaluated as unimproved or worse, as were patients exhibiting the panic modes. The relation be— �34 ARCHIVES OF GENERAL PSYCHIATRY TABLE 2.—Adapti7/e Mode and Improvement Improvement Rating Modes Euphoric-Hypomanic Somatlzatlon Paranoid-Withdrawal Panic No adaptive change‘ ‘ Includes subconvulsive (36) (10) 7) ( 7) (13) ( Recovered Much Improved 11 14 0 0 0 0 l 10 5 0 0 0 2 2 l Improved Unimproved, Worse l 4 5 5 12 treated subjects Without second course of ECT. tween adaptive modes and ratings improvement is summarized in Table 2. of Studies relating physiological or psychological aspects of convulsive therapy to clinical outcome have reported inconsistent results}6 Thus, it has been reported that depressed patients respond favorably to convulsive therapy while schizophrenic or neu— rotic subjects do not; while other observers indicate that neurotic depressive patients re— spond badly, and that some schizophrenic subjects do have favorable outcomes. Vari— ous measures have been suggested as predic— tors of improvement, only to fail on more extensive testing. In such instances, the differences in results and discrepancies in convulsion can be related to the utilization of a variety of global estimates of improve— ment as the criterion of behavioral change, without adequate specification of the standards used in the evaluation. Such standards differ widely, depending on institutional populations and staff attitudinal factors. Varying attitudes toward “side-effects,” the use of global rating scales, and varying psychosocial attitudes affecting goals of treatment have each served to make results from different laboratories incom— patible. Thus, in our evaluations of con— vulsive therapy, the development of changes in memory, recall, and orientation have been considered as temporary manifestations of therapy and disregarded in the clinical eval— uations.3'19 Patients developing the euphoric or hypomanic modes, despite concomitant memory loss, have been rated as much im— proved. In a comparable study by Johnson et al.,10 the Lorr global ratings of behavioral change were utilized. In this type of evaluation the changes in memory and orientation are in— Comment These observations emphasize the variety of behavioral adaptations that occur during convulsive therapy and relate short—term evaluations of improvement to the type of behavioral change. Earlier observers of con— vulsive therapy have described a range of behavioral patterns, ascribing the changes to ego adaptive responses, to the trauma of the treatment, organic brain changes, or psychologic significance of the treatment.7' 9'21 These observations that subjects with similar psychopathologic syndromes receiv— ing similar treatment may exhibit discordant behavioral adaptations and be variously rated as recovered or unimproved, are of significance for an understanding of the convulsive therapy process. In earlier studies, the conclusion was reached that persistent alterations in brain function were a necessary condition for behavioral change in convulsive ther:«ipy.2""6 With changes in brain function, all aspects of behavior undergo modification. Percep— tion, mood, affect, judgment, attitude, mem— ory and recall are altered, and with these, the subject’s adaptation in the environment. Not all behavioral changes are viewed as improvement, however. Improvement ap— pears to be a special type of behavioral response, being the subjective estimate by an observer that the patient is “better.” It is based, not only on the patient’s behavior, but also on such nonspecific aspects as the observer’s expectations, and tolerances, and those of the family and environment. 56 Vol. 5, lily, 1961 �CONVULSIVE THERAPY cluded as negative scores in the improvement scoring, so that a high number of subjects were reported as “unimproved or worse.” Besides population differences, this single factor is sufficiently potent to alter the rela— tionships between the 2 studies and justifies the discrepant observations. The use of global estimates of behavioral change in evaluating therapy has other significant deficiencies. Psychiatric therapies are rarely focused, or effective in modifying a single symptom. The induced changes affect a spectrum of behaviors, with varying rates of change for different aspects. Global estimates tend to lose differences in individual elements within the medial designations necessary to define the whole response. In such situations changes in behavior which may be prominent, though not pervasive nor enduring, may dominate the evaluation as to overshadow other, potentially more signif— icant changes. Thus, alterations in memory and recall, or increased somatization or in— creasing withdrawal may dominate unim— proved evaluations; while explicit verbal denial, clichés, and euphoria may lead to recovered or much improved designations. The use of improvement ratings may be empirically justified as an early approxima— tion in studies of a new therapeutic meas— ure, but further analyses of the behavioral ‘ observations are required for understanding and adequately applying the treatment. The typologies described in this report are one approach—one that has been helpful in our understanding of the convulsive therapy process and one that is now being tested in studies of psychopharmacologic agents. In addition to the differences in improve— ment evaluations occasioned by attitudes to “side—effects” and the use of global ratings, there are differences due to the attitudes of therapists toward various sociocultural pop— ulations. The adaptation of explicit verbal denial in a lower class patient in a community institution is welcomed by therapists and family, but the same adaptation in an upper class professional in a psychothera— peutic hospital is considered poor or psy— chotic. The display of rationalization. Fin k—K01m 35 minimization and displacement, even when accompanied by a return to premorbid work levels, is considered marked improvement in one setting, but is viewed as a lack of improvement in another if goals of insight had been set by the therapist. Interference with memory and recall may be disregarded by therapists for one sociocultural group, but arouse empathic solicitude for patients of another social class. Such factors affect not only institutional attitudes, but within an institution, therapists of different thera— peutic orientations may have differing atti— tudes towards evaluations and therapies. The many recent sociocultural studies of thera— pists, and their attitudes towards selection of therapies, are indicative of these attitudinal differences.13'17-18'20'22 It is our impression, therefore, that im— provement ratings are no longer useful devices in evaluating psychiatric therapies. For the symptomatic therapies extant today, which are seemingly not directed toward the alteration of an etiologic factor, typologic descriptions have a greater applicability and empiric justification. Typologies based on concepts of diagnosis, target symptoms, or on dynamic—structural formulations have attempted to structure the pretreatment clusters in which therapies may be effective. Treatment and post—treatment symptom improvement scales have been used with utility. These are limited approximations, however, and there is a need for a broader approach to both the pretreatment and the treatment behavior, and a phenotypic, adaptive be— havioral typology, using multivariate tech— niques of data analysis, seems worthy of assessment. Summary An analysis of the variety of behavioral adaptations of 73 voluntary psychiatric pa— tients undergoing convulsive therapy resulted in the description of 4 major patterns. These are described as euphoric-hypomanic, somatization, paranoid—withdrawal, and pan— ic modes. The relation of these modes to clinical ratings of improvement is described. The �36 ARCHIVES OF GENERAL PSYCHIATRY derivative and generally nonoperational nature of improvement ratings is empha— sized. The difficulties in a communicative definition of this variable is seen as a major factor in the discrepant studies of indices predictive of improvement in convulsive therapy and in understanding the processes of somatic therapies in psychiatry. Therapy (With and W'ithout Atropine), Arch. Gen. Psychiat. 2:324-336, 1960. 11. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, edited by P. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126-139. 12. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Psychiat. 76 :23-29, 1956. 13. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings, and Diagnosis, A.M.A. Arch. Gen. Psychiat. 1:565-574, Max Fink, M.D., Department of Experimental Psychiatry, Hillside Hospital, 75—59 263rd St., Glen Oaks, L.I., N.Y. REFERENCES H Esecover, H.; Jafie, J., and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients, J. Hillside Hosp. 7:17-25, 1958. 2. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp. 6: 1. 1959. 14. Kahn, R. L.; Pollack, M., and Fink, M.: F igure-Ground Discrimination After Induced Altered Brain Function, A.M.A. Arch. Neurol. 2:547-551, 1960. 15. Kahn, R. L.; Pollack, M., and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. Ment. Dis. 130:187—192, 197-206, 1957. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electro— shock: Quantitative Serial Studies, A.M.A. Arch. Neurol. Psychiat. 78:516-525, 1957. 4. Fink, M.; Kahn, R. L., and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. Syst. 19:113~118, 1958. 5. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Afl'ecting Individual Differences in Behavioral Response to Convulsive Therapy, J. Nerv. Ment. Dis. 128 :243-248, 1959. 6. Fink, M.; Kahn, R. L.; Karp, E.; Pollack, M.; Green, M.; Alan, B., and Lef‘kowits, H. J.: Significance of Inhalant Induced Convulsions for the Theory of the Convulsive Therapy Process, Arch. Gen. Psychiat. 4:259-266, 1961. 7. Frosch, J., and Impastat, D.: The Effects of Shock Treatment on the Ego, Psychoanal. Quart. 3. 1960. 16. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and other Somatic Treatments in Psychiatry, New York, Grune & Stratton, Inc., 1952. 17. Kaplan, A. 1., and Lefkowits, H. J.: Influ— ence of Staff Attitudes and Environmental Factors on Treatment Selection, J. Hillside Hosp. 1961, to be published. 18. Klerman, G. L.; Sharaf, M.; Holzman, M., and Levinson, D. J.: Sociopsychological Charac- teristics of Resident Psychiatrists and their Use of Drug Therapy, Amer. J. Psychiat. 117:111-117, 1960. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Confin. Neurol. 16: 19.. 88-96, 1956. 20. McIver, J. and Redlich, F. C.: 17:226-239, 1948. 8. Frosch, J.; Impastato, D.; Ottenheimer, L., and Wortis, S. B.: Some Reactions Seen After Electric Shock Treatment, Amer. J. Psychiat. 102 Patterns of Psychiatric Practice, Amer. J. Psychiat. 115:692- 311—315, 1945. 697, 1959. 21. Millet, J. A. Glueck, B. C.: Psychopathologic Reactions and Electric-Shock Therapy, New York J. Med. 42:1553-1557, 1942. 10. Johnson, L. C.; Ulett, G. A.; Johnson, M.; Smith, K., and Sines, J. 0.: Electroconvulsive Psychosom. Med. 6:226-237, 1944. 22. Pasamanick, B.; Dinitz, S., and Lefton, M.: Psychiatric Orientation and Its Relation to Diag— nosis and Treatment in a Mental Hospital, Amer. J. Psychiat. 116:127-132, 1959. : P., and Morse, E.: On Certain Psychological Aspects of Electroshock Therapy, 9. 58 Printed and Published in the United States of America ��Putt-ran at Bohgvioral chant. and Inprorcnnnt 1n canvullivo rhcrapy In: Pink, x.n. and nobcrt L. Kuhn, Ph.D.* from the Dapartncnt or Expnrinontnl Psychiatry, ulna oakn, L.I., n.x. Hillside noupitsl, gratt K~927 of tho lattcnal Initituta a: nontal noulth, lutional Institutua a: Hatlth, United Status Puhlie Hualth survzoo. Reta in part, gt th.".!. 91'1319311 looting, American Payehintric Aidod by Association Northbor, 1951. : Btvfliomit o: Psych-try. Mutation 30-91%“. *Pruont Bronx, 1.1. VII: 1/61 “an" �Individuol flittoroncoo in tho bohoviorol roopouoo to oonvoloivo thoropy oro oorkod. In poyohiotric proctico, potionto with oanslor poyohopotholoxtc oyudroaoo, one or oililor varioty or olinieol rosponooo: oooo toprovo old ouotoin ouch chongo; oooo 1-provo, only to rolopoo quickly; ond oooo toil to taprovo. rhooo dittorooeoo hovo boon rolotod to tho dogroo ond duration or indoood nourophyoiolociool ehongo (3,6) prooorbtd pottorno or poroonoltty (5,11,15), ooulopoyeholoctool chorootoriotioo (13,15) and porehothoropontto opprooehoo (1). Vh11o thooo otudioo hovo onphooiood voting: 0: taprovooont, tho dorivotivo unturo or thin ovoluotion ond 1t: dopondonco on otort ottttudoo, oxpoctotiono ond tooily toloronco oox ond ago, ohow o has boon strooood (2,h,5,8). rho oonttoot bohoviorol pottorno provido tho boots tor tho ovo$uot1ono of clinical rooponoo. It 1o tho purpooo o: thto roport to doocriborbohovtorol pottorno 1n pottonto nndoraoinz oonvolsivo thoropy, ond to roloto tho-o to problooo of tho ovolootioo of taprovooont and to on ondorotondinx o2 tho coo- vuloivo thoronyIProcooo. �gethod: or consecutive pe$$en$e reterred for electreehoek therepy 63:13; 1956—57. teveatybthree pettente were subjecte e: the eaelyeee eeeeribed here. the patients were selected tor treeto sent by the reeident therepiet end the aupervteiuc peyohietrtefi - the inveetzceterp playing no role in their selection. These convulsive—euhcenvulaSve electroc 3 during were III. obeervettene eheok study a; whieh subject. referred tar enereyy were rendenly unsigned to entrees e: cuboenvuletve er convulsive treetnente. Electroeheek wee edginietered three tines weekly under pentethel preunedieetiea, using either e letter unidirectional er e xederett alternating entrent inattenent. arena eel or enbeenvnleive treetnente were eduin1utered by titering the etrongth of current. leither patient, therapist not eveluetinx phyeiaiene tee evere which entree e1 therapy each pétient received until titer the evaluation period. weeiiy intervals cheese: in urea: tunetion were neeeered at by test: of leagues. petterne both 011336.11: eta etter eneberbitel, and by the degree e: 310: were activity in electroencephelegrene. 2he interoerreletien e: theee indieee 3 �.3cooplointl. rho alinicol dioxnoooo woro doproootvo of nonio—doproooivo, involutioaol ond rooetivo and ooaotic poyuhoooo voriotioo; one oohioophrontc poyehoooo or poronoid, aixod, oototonto and pooudonourotie typoo. clinical bohovior woo oooooood in vookly poyuhiotric intorviovo, otrootorod porooptuol took oituotiono (1h,15) and with contorouooo tho potiont'o thoropiot. II thooo ohoorvo~ by tiono, tho ovolootion of :Iprovouont along tho continual of 'rooovorod-untnprovod' oppooroa inoaoquoto, and woo topplonontod by o roting of tho dogroo of bohoviorol ohongo. rho dogroo of chonzo 1n olinieol tad word hohovior woo totod on o four point ocolo or 'norkod', “nodoroto', 'nininol' or'ho chango'. Thooo ovoluotiono woro not voluo Judznonto no to tho quality of tho ohonxo, but rothor, quontitotivo ootinotoo o: ditforouooo in hohoriorol pottorno undo: oinilor condition: at otoorvotion. rho oooigood voting woo hoood on ohongoo oboorvod during tho trootnont poriod and for too vooko poot~ trootaont. lvolootiono or ingrovonont roopoaoo woro undo on tho four point ocolo or 'rocovorod', 'nuoh taprovod', fitnprovod', and “nailprovod or onroo'. rhooo ovolootaono ooro voluo Judgnouto, hoood upon tho bohovior of tho patient, tho thoroptot'o oxpoctotiono, tho toloronoo by thoropiot and potiont of thooo oopoeto of bohovior otton oollod *oido-orroeto of tho trootnont’, and tho thoropiot'o Judgnont on to tho tonily'o ottitudoo to the potioat'o hohovtor. fhooo ovolnotiono ooro abort-torn, rotlocting tho potiont'o odoptotion two to tour wool“ following the lost troutnOHto �gbaorvationo: (a) Donatioral chango and Ingrovonont coaparioon at tho bahavioral ratingo and tho iaprovoaont ovaluationo 1o proooatod in tabla I. that ratings at rocovorod and nuch iaptovod woro aaaociatod with high or moderate dogrooa at bohavioral change it an oxpoctod obaorvation. similarly, that patioato with ainiaal or no chango in behavior taro avalaotod ao uni-proved or iaprovod, io aloe oxpootod. tho aixaitioant rolatianahip, hovovor, lioa in tho patianta ohooing high and oodorato dogrooo or bohavioral ohoazo and atill ratod ao ohaoiaz a poor oliniaal roopoaao. at tho thirty patioato obaorvad with high dogrooa or hohaviaral ohango, aovontoon voro ovaluatod aa raeavorod and much iaprovod, and thirtoon ao inprovod or aainprovod. l .. --.. . ZLBLI (b) undo: at Adaptation I -“fl--. o: the bohavioral pattorna at tho oobaocto daring and tailoring traataont poraittod tho description or variauo today of adaptation. For illoatrativo purpoooa vo havo doaoribod tour bohoriorol pattorna undo: tho titloa a: oaghorie-hzgoaanio, oaaatiaation. garanoid-withdraoa; and Analyooo Rania nodoo. Bughorio-lzzoaanie Roda: Thooo oubjocta appoarod plaaaant, atrablo and friaudly. they are-sod neatly, opako quiotly, and participated in word activitioo with ineroaaod �Zlflfifi I atnpgrtann 0t Evaluationl Qt nohavttrnl change and clinical Inpruvcnont (c0uvu1317c and subconvnlutru 1h0r&pico) fitting XIErOVOIORt locovorod » _ Itch Inprdvod fininpruvod and Ingrovod 39:30 Bahaviorll Ghangc nigh dogroo change (39) fi lodorato (17) 8 9 8 5 3 6 6 2 Juana (‘10) o a 5 S (16) o 0 1 15 I. change ' ' I' �. ~5-. interest. 'oeeeeieeelly they dreeeed aeadily, end exiled end giggled excessively. Pre-treeteent eyepteee were net eenifeet end preeerbid ettitudee end hehevier were egeie prenieeet. In their peyohetherepeetie interviews they deecrihed their illueee in e deteched leaner, eepheeieieg ”it“ (illneee) ee they denied having-been ill end feeetieeely eeggeeted they were et the heepitel fer e reet; er thet the inetitutiee wee net e heepitel, but e reeert er e eeheel. Syeyteee were deeeribed in the pert teeee, end the geelity of keying been e different pereen during the illeeee hevins “dieeppeered’. reitereted. Speeeh wee eerked by deeiel,.diepleeeeeet, ereeiee, quelitieetiee end eliehee (11). the third pereen wee ' eede wee frequently need, ee in eeeh eteteeeete the doctor eeye 1 en 111' er *ey wife eheeld here eeee here.II Greee ehenzee in neeery were either not eppereat, or were deeeribed fer the treeteeet period only. the petieete expected end eeeepted theee defieite, end neither eeeeectiee with treeteeet her eppreheneien were expreeeed. they looked forward te here wieite end eede reelietie dieeherge pleee. While conflicts with feeily eenbere were deeeribed, theee were eieieieed end expreeeed neiely in the peet tenee. heferentiel qeeetieee were eeewered in e referential nearer end without en ereeeel of effect. for the mere hypeeeeie eebaeete, queetiene eheet here planning were reepended te nearefereetielly, with marked nee of inepprepriete eliehee. When preeeed with referentiel inquiries, they quickly exhibited �.5anxiety and dieeeatort, aiuiaieed their feelings and changed the teeua.e£ the eeeeien. Seek adaptatiene were euetained throughout the discharge planning period. The mere hypeaaaie features were rarely suetained, and within a for weeks were replaced by a mere etable euphoric er aenatizatien types of adaptation. ,8enatizetien Hades In theee_enbdeete, incessant eeaplainte about bodily eyaptene and lees e: eatery, deaands fer reaeeurenee and relief; and preoccupation with feelings of nnreality and eeeteeion doainated behavior. Ehey retained unkempt and their When each an adaptatien appeared early in were untidy. reels therapy, further treatment wee refused. speech nae printiptlly in the present teaee and in the first pereen, eith fee third peraen references and a ainiaai use at clichea, denial er qualifications. In peyohetherapy eeeeiene, they vere-deaandies and hostile, repertihg their prehieae in terae eiailar to these need prier to therapy. !hey eeaplained that the treatment eaaeed additieeel and mere incapacitating difficulties. re referential queatiens, answers were generally correct, but associated with eenplainte of aeaery inpairaent. they deeeribed their taaily relations in yreotreatneet terns, with en oecaaional '1 den't reaenber' in reepenee to experiential inquiriee. Discharge planning eaa dittiealt, as they insisted that their new eynptene prevented any home adaptation. their heetile demands for attentien and relief at eyupteas increased with treetaent. Participation in creep activities inereaaed, however, tar these eabaeete who had an the ward, �-7. previeaely been withdrawn and eeoleeive. Heaory eeaplainte were pre-eaiuent. ratioate deaanded reaaaaranee that their aeaery would return, and repeatedly asked if treatment would he hararul. they deeoribod feelinge of derealiaation and confusion. Erenta, bodily feelinge and relatiena to friends and relativee eeeaed etrange, teeny, unclear, and out of :oeue. While they oonplained ehietly e: book of alao ceaplained pain, headache, they iarairnent, aeaory tingling o: tinsera and teee, aaaaea and roakaoee, and aeorihed there to the troetaent. which end symptom: the for the at treatment, heepitalit iaatioa had occurred were no longer present, and although and to the treatment were relation their their aany, eoaploiate transieaoe eae eo univoreally aeeepted by both the start and the patients, that the rooalte rare evaluated or beneficial. !hie adaptive node wee eeetained into the peat-dieoharge period. Paranoid and Withdrawal lode: Another pattern tea the appearance or paranoid ideation, euepicieuaneea, hostility, ideae of reference and deleaiene. These patients failed to care for theaaolvee, and roaained unkeapt in their dress. Their reeaq.in which they reaained each or the day, were untidy. Speech eaa eparee and not epontaneeaa. when questioned about their illneae, they were hostile and demanded to know why they were queetiened. they retaeed to anewer inquiriee er categorieally denied or agreed to all epecixio queetiene. Experiential caeetiena were anewerod roterantially. When inquiry was ioeietoat, they doeidd illneea and ainiaieed tho ayaptena which �~8- resulted 3: their ednieeien. they retueed er eveided eeeeieee with their therepiet, end ineieted eenvuledve therepy he ended beeeeee iteee herningy then. When treeteente rere continued, they demanded releeee free the_hoepite1, or precipiteted dieeherge by elepeneut, euietde ettelpte er eczreeeive end deetreetdve outberete. They were uneble to diecuee their reletiens with relily or triende, and teeeeed either en deaende fer releeee or relief tree resette eynptoee. Ieettlity wee overt, end engendered e teertelneee 1n the etett. an the nerd, rhea eeexed out of see» Ineien, they were lend, eggreeetve end deeend1ng. They were eeepieieee e: etteepte at friendlteeee, end expreeeed theeghte thet other: edehed to here the: or talked ebefit then. while ineieting en dteeherge, no reelietie dieeherge pleating wee eehseved. their View er the envirtneent wee creeely distorted end eelreeeutered, preventing'edeqnete care. In testing, they were uneeeperetive, end rained angry eeggeetiene a! being experirented ugen or ebueed. Complaints at nenery impairment were intrequent, and occeeienelly denied when even clinicelly meniteet. on such occasione, they were eareged et the inplied deficit. Peale Bede: Theee'pettflate beeene increeeingly enzione, eglteted, reetleee, eleepleee end enorexie. In their dreee, they were neet end eered ror themselves. Speech patterns hed were unehegged end eontinued with eepheeie on tiret pereon and preeent tenee nodes. .synpteme were dietreee1ng end prentuentiy voiced. When asked about preetreetment eynptore, �.9. theee were expreeaed in the aaae terae ae theee need earlier, with the eaaplaint that treataent had aade everything weree. Patienta reared treat-eat and hid an treataent daye, er pleaded with the etatt to forage farther applications. they threatened elepeaent and it thie tailed, enhaitted administrative reqaeata fer discharge. an the ward, they continued their preatreataent patterns at participatien. 0n treataent daye, they were withdrawn, aalien and negativietie, and cooperation wae peer. they deaanded te aee their therapiete and on each eceeeiene ineieted that treataant be discontinued. they were unable to diecnee {anily eitaatiene er their attitudee to ethere, being preo eeeayied with their feeling: at tear. In dieeaeaieg their minimal heaa, they inaiated en iaaediate dieeharge, while atating they were aewerely trightened, anxieaa, depreeeed and unwell. ’Ideatien was unchanged with tearfulneae ae the principal . affect. reare te the brain er aied wae expreeeed, aeeeapaaied by the awareaeee that aeaory iapairaeet may be a sign at each damage. ceaplainta at aeaery inpairaent were in~ ex daaage frequent and when present, were expressed ae a apeeitie reason (or dieeeatinaatiea of treatment. Patiente were uncooperative and fearful at testing, and participated only it encouraged that such decision about further tests may be helpful treataent. occasion. in the therapist's ally, when treatment wae diacentinued, a more stable adaptation of relier, aeqaieeeenee and denial appeared. �' (3) 29:9" tivo H96. and rovunoat n;¢1 3 Thus, fo:_th¢ var1oua_gdaptivq bohnvitrnl ptttornl, a runs; or ihort term evaluations were obsorvad. thus: subjects aha devolaped and sustained the euphoric-hyponanie nodou were generally ratofi us rocaverod or nueh inpravod. Patients uith ponatizatian gnd panic modes were ocgusiantlly rated as improved, nithgugh uninprevod ratings were frequent. The paranoid-with. figural node was evaluated as unimprGVad or worse, as were model. The relation batucon the panic pn§;ontl czhibiting adaptive node and ratings or improvonent are Ialnnrilod in ' d‘ fable 1!. 1133! II -‘C- “CC- �tivo.flndc 3nd Ada rovonoat Ingrovcnont Rating Rtoovered 3.4.. anh Improved Inprovcd fininpravod, Horn. Euphoricvflyponanic (36) 11 1h 10 1 Selatinttion tiranotdniithdrauul (10) o 1 5 h ( 7) 0 o 2 5 Psntc ( 7) o o 2 5 ndaptivo ohtngoi (13) 0 0 1 12 I. alnoludas snbcenvulsivo trcntod unbaoctu without cocond course 01 not, �Bieeoeeien: fheee ebeervatiene eaphaeiee the variety of behavioral adaptatiene that-occur daring eonvaleive therapy, and relate abort tern evaluatieee or iapreveaeot to the type of behavioral change. larlier obeervere at oooveleive therapy have deeoribed a range of behavioral patterns, aeoribing the ehaogee to age adaptive reepenaee,to the traaaa of the treataent, organio brain changes, or peyehologio oigoifioanoe of the treataeot (7,8,9,21). These ebeervatione that subjects with eiailar peyohopethelegio eyndreaee receiving aiailar treatment aay exhibit dieoordaot behavioral adaptatiene, and be varioaely rated aa recovered or aaiaproved, ie o! eigoirieanoe for an onderetahding e: the eonvnlaive therapy prooeee. In earlier studies, the ooholoaioo val reached that pereietené alteratioea in brain tanotioo were a neoeeeary eonditieo to; behavioral change in oonvaloive therapy (2,h,6). With changes it brain tuaotioo, all aepeote of behavior undergo modification. Perception, need, affect, Jadgaent, attitude, aeaery and recall are altered, and with theee, the eabaeot'e adaptation in the environment. let all behavioral ebaegee are viewed aa iapreveaeot, however. Improvement appeare to be a special type oi behavioral reepooee, being the eobjeotive eetiaate by an obeorver that the patient ie 'hotter’. It ie baled, not only on the patieot'e behavior, but also on each oeo-apeoitie aepeeta aa the obeerver'a expeotatione, and toleraooee, and these at the taaily and eovirenaent. Studies relating physiological or peyehologioal aepeote �-12or oonvnloivo therapy to clinical inreported that deproeeed ontoone have reported been hae Thne, (16). it ooneietont roanlte eohiaowhile oonvnleivo therapy to patients reopond favorably oheorvore other while do not; oabjoota nonrotio phrenio or and badly, reepond patiente dopreeeive neurotic that indioate ontooaoe. do favorable have enhaeota that ooae aohiaophronio of inprovoaa predictora been enggeeted have Various noaanroe each inetanoea, In extensive tootinx. on aoro to lent, only tail can eonolneion in and diaoropanoioo in results the dittorenooe or oetiaatoe of global of a variety be related to the utilization vithoot behavioral change, of the criterion ilproveaent an evaluation. the need in etandarde of the adequate epooitioation Snoh etandarde differ videly, depending on institutional atatt attitadinal taotore. Varying attitudeand eoaloe of rating global the nae toaard 'aide-otteota', popelatione and o: treataent goale afteoting attitndee varying peyohoeooial have baoh eorved to lake reenlte tron different laboratorioe oonvnloivo therapy, o: ovalaationa in our fhne, inooapatiblo. and orientation recall in ohangee neaozy o: devolepaont the , and of therapy aanitoetatione have been considered ae teaperary dieregardod in the olinioal ovalaatione (3,19). Patients oonoonitant doepito aodea, hypeaanio the euphoric or developing anon been on ieproved. have rated neaory loee, In a ooaparable etndy by John-on gngg, (lo), the Lorr global of In type thie utilized.“ were change rating! of behavioral inolndod and orientation are in ohanxee the neaory evaluation �-13- negative oeoroa in the inprovenent nearing, no that a high nnaher or enhaooto were reported an 'aninproved or nerao.‘ Booidoe population ditterenoee, thia einglo factor in eattioiently potent to alter the relationehipe between the two etadios, and Justitieo the diooropant eboervationa. the nae or global eetinatea or behavioral change in evaluating therapy hae other significant detieieneiee. Psychiatric therapiea are rarely toenaed, or effective in modifying a single eyaptea. the induced ohanxoo affect a opeetrna oi hehaviera, with varying ratoa of change for ditterent aepoote. Global aetinateo tend to loae differenooe in individual ole-onto within the nedial deoignatione neeoeaany to define the whole reeponee. In oneh oitnationa ohangee in hehavier which nay he preninont, though not pervaaive nor enduring nay doninate the evaluation an to overehadoe other, potentially nore aignitioant ehanzee. than, alterationo in aenory and recall, or increaeed eonatination or inereaaing tithdrawal nay daninato nninproved evaluations; while explicit verbal denial, olieheo and euphoria nay lead to recovered or each iaproved designations. the nae o: inprevenent ratings nay he enpirioelly Jaatiried an an early approxiaation in studies of a new thorapeutio aoaonre, but inrthor analyoea o: the behavioral eboorva~ tiona are required for anderatanding and adequately applying the treatnent. rho typologiea deooribod in this report are one approaeh - one that hoe heon helptal in our nnderatanding or the oonvaloive therapy prooeea, and one that in non being teatod in etadiee o: payohepharaaeoloxie agento. on �ulhIn sddltlen to the differences in leprevesent evelestlens eeessieeed by attitudes to 'elde-effeets' end the use ef glebel due to the ettitedes ef thereplsts differences there ere retinls, tersrd rsrlees seeleesltsrsl peeeletiens. The edeptetien of explicit verbsl denial in s lever clues pstient in e eennenlty lestitntlee is welcomed by therspiste and really, but the seas sdsptstleu in en upper elese professional in e peyehethsrspeetle The displsy ef or psychotic. is hospital considered peer when and even nintnisstlen displscenent, retlensllsstien, eeeenpenied by s return to preeerbid work levels, is eensidered nsrked leprevenent in ens setting, but is viewed as e leek ef inpreveneet is enether if ceels of insight hsd been set by the thersplet. Interference with memory end reeell say he disregsrded by therspists fer ene seeieeeltnrel group, but sreese espethle eeliettede fer petlente ef endkher seeiel eless. Seek feetere effect not enly institutienel,%tt1tedee, but riteln en 1nst1ts~ tion, therapists of different therepeutie erlestétlees sey here evglestieae nsny thersples. towards sad the differing ettltedee recent seeiecnlterel studies ef therspists, end their sttitedes tevsrds eelsetion ef thersples, sre indiestive of these sttitndinsl differences (13,17,18,2o.22). It is our impression, therefore, thet inprevenent rstlngs are no longer useful devices in evslusting psyrhietrie therepies. For the eynptometie therapies extent today, which ere seemingly net direeted tewerd the slteretien ef en etiologic fecter, typelegte deecriptiens have s greeter spplleebility sud enpirie �-15. Justification. typologies haaad on concepts at diaxaaaia, targat aynpaaaa or on dyaaaio-atractaral formulations harattaaptad to atructara tho pra-traataaat clusters in witch thoraptaa nay be attaativa. fraatnant and paat—troatnant ayaytan impravaaant acalaa have haan used with utility. Thaao ara linitad approxinatiaaa, howavar, and thara 1a a naad far a broader approach to bath tho pra-traataant and traatnant bahaviara, and a phanotypio, adaptiva bahaviaral typolacy, aaing aaltivariata taohniqnaa at data analysis, aoana worthy a: aaaaaaaant. �w in enelyeie_er the veriety e1 beheviorelvudeptetiene or 73 velnntery peychietric petiente undergoing convulsive therepy reeulted in the description er tear nejor patterne. These are deecribed ee eupheric-hypenenic, eenetizetien, paranoid-withdrawal end penie nedee. the reletien er the-e nedee te clinical retinge e: ieprevenelt ie deecribed. the derivative end generally neu-eperetienel unture e: ieyrevenent retinge in enpheeieed. the difficulties in e cennunieetive detinitien e: thie veriehle ie eeen ee_e nejer teeter in the dieerepent etudiee et indieee predictive e: inprevenelt in cenveleive therapy, end in underetendinc the preeeeeee e: ee-etic therepiee in peywhietry. �-17- W' 1. Ieeeever, 1., latte, J. and Iain, R.L.: Peyehetherepeetie rechaiqaee with lieetreeheek Patiente. J. lilieide .3332..1; 17~2§, 1958. link, 1.: i fiaified theory of the ietiea e: Phyeiedyuanie rherapiee. J. lilleide legg. é; 197-206, 1957. BIG and of Delta Activity te telatien 1.5.: lake, link, I. lehavierel leepenee in lleetreeheek: Quantitative serial Stadiee. A.!.i. ireh. laurel. & Pezdhiat. 19: 516-525, 1257. n.: prerinental Studiee or «a. lleetreeheek Preeeee. Die. lerv. slat. 11: 113-119, and 3.1. Pellaek, a.a Payehelegieal rector. take, 3., tier, rant,§a.. lane, 1.1. and Green, 1958. Affecting Individual Differences in Behavioral Reapenee to canvaleive Therapy. J.l,!.B. 13g. 2k3-2h8, 1959. 6. Fiat, u., Kenn, 3.5., tarp, 3., Pollack, 1., Green, H., Alan, B. and Lei‘kewite, LL: Significance of Inhalant Induced neural-ion: tor the Theory er the convulsive Therapy Preeeee. L.H.i. Arch. Gen. Pezehiat. (in press). Preach, J. and Iepaetate, 9.: the Effects of shock Treataent on the 3:0. Pezgheenal. Quart. l1: 226-239, 19h8. Ireeeh, 6., Inpaeteto, 9., attenheiner, L. and Wartie, 8.3.: Some Reactions Seen After Electric Sheet Treatment. Amer. J. Pezghiat. 1021 311-315, 19h5. �.13- 3.0.: reyehepethelegie Reactiene end Bleetrie-Sheek Therapy.‘ 1.1: State J. led. g3. 1553-1557. 19h2. 10. Jehneen, L.c., Ulett, G.L., Jehneen, H., Snith, I. end Sines, 3.6.: Electreoeavuleive therapy (with end 9. alueek, Hithaut Atropine). Arch. Gen. Pazghie . g; 32h-336, 1966. 11. Kenn, 1.1. end Pink, l.c change: in Language Bering Elactroahock therapy. re ehe‘ethelo er colnunioetien, Ed. Roch, P. and Zubin, 3., Stuns e Stratten 126-139, 1958. 12. R.L., link, x. end Weinetetn, B.A.i Reletien of tnoberbitel rest to Clinical Inprevenent in Electroehock. Arch. neural. e rezehiet. lg: 23-29,'1956. 13. Kuhn, R.L., Pollack, H. end flag, 3.: Seeiepeyeheloxie Aspect; a: Peyehiatric Ireetnent in A Velentery Mental Hospital: Duretien or Hoepitelixetiea, Discharge hating: end Biegaeeie. 1.x.1. Arch. Gen. Pezehiet. ;} Kehn, 565-57h, 1959. 1k. Iehn, R.L., rolleck, H. end rink, H.a Figure-around Discriminetien After Induced Altered Brein Functien. A.H.L. Arch. lea-oi. g: 5&7-551, 1966. 15. Kuhn, R.L., Pollack, I. end tint, H.c Sociel Attitude (alliternie W ? Scale) end Convulaive Therepy. gig: 187~192, 1960. J.I.H.D. 16. lelileweky, L. and Heck, 2.: Shack trout-eats, Peychoeurgery end efiher Betetie Ireetnente 1n Peyehintry. Grtne end ___________._________________________.____ strn‘t.n. 3.1. , 1952e �lethed: 9t eeneecetire petiente referred fer eleetreeheek therepy during 1956-57, eeveety-three petiente were eebjeete of the ehelyeee deeerihed here. the pettente were selected fer treetnent by the reetdeut therepiet end the eupervieies peyehietriet the inveettsetere pleying he rele in their eeleetten. theee eheervetieee were nede during e eeeveletve-eeheeevuletve eleetreeheek etedy in which euhaeete referred for therepy were rendeely eeeirned to eeereee e1 eeheenveletre er eenreletve treeteente. Bleetreeheek eee edeiaietered three tinee weekly under pentethel pre-nedteetien, eeing either e letter unidireetienel or e heeerett elternetieg eerrent instreeeet. Greed eel or enheenvuleive treeteente were edninietered by eltering the etreexth a: current. [either petieht, therepiet her evelueting phyeieiene tee ewere which eeeree e: therepy eeeh pitieet received until etter the ewelnetiee period. eheugee in hreie tenetiee were neeeered et weekly intervele by teete e: leexeece petteree heth alerteelly end etter eeeberhttel, end by the degree e: elew eewe eetivity in electroencephelexrene. the intereerreletien e: theee indieee end their reletien te heherterel eheagee here been reperted prewieeely (3,1g). the senateet eyeptee petteree e: the referred pttiente were reriehle, end included euteidel preeeeepetien, reterdetieu, dieterheneee e: need end erreet, exeiteneat, egitetien, penie end teneaen, deleeiene, ideee et reference, hegettrien, rithdrewel 1 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Behavioral patterns in convulsive therapy. Arch Gen Psychiat. 1961 Jul; 5:30-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-53-019 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the Archives of General Psychiatry July 1961, Vol 5, pp. 30—36. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0f6719a23fdc7ec86b84e3ad0121dcb7.pdf 2c174223139f67b6ca449ef570bd2067 PDF Text Text SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY K MAX POLLACK, PH.D. Reprinted from THE Vol. 132, N0. L 2 Copyright © AND MAX FINK, M.D. JOURNAL OF NERVOUS AND MENTAL DISEASE by The Williams Printed in U.S.A. 1961 & February, Wilkins C0. 1961 �JOURNAL or NERVOUS AND MENTAL DIsEAsE Volume 132, No. 2, February 1961 Reprinted from THE Printed in U.S.A. SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY MAX POLLACK, PH.D.1 The growing recognition of the relation of social factors to referral for and response to somatotherapy in psychiatric treatment has stimulated increased study of “drop-outs”— patients who refuse to start or to continue treatment. Although the problem of “dropouts” is a major one in somatotherapy, it has received little attention. In convulsive therapy it is considered one of the most fre— quent “complications” of treatment (1) yet it is infrequently discussed (3, 7) and no systematic studies have been devoted to it. Systematic studies of “drop-outs” have been limited for the most part to patients in psychotherapy in out—patient facilities (4, 5, 9, 19, 20). These studies have consistently shown marked differences in social and psychological characteristics of patients who remain in psychotherapy and those who fail to continue. Those patients who remain in therapy have more years of education and who those class social than of higher are leave. In addition, their social attitudes, as measured by the California F Scale, show “less so—called conventionalism, stereotypy and less of an uncompromising insistence that ‘right’ and ‘wrong’ can be distinguished” (20). In sociopsychologic studies of the patient population of Hillside Hospital (12, 13) age, education, place of birth and degree of stereotypy, as measured by the F Scale, were related to selection for, and response to, convulsive therapy. Those patients who were older, had fewer years of education, were foreign-born and who manifested high scores on the F Scale were most likely to receive convulsive therapy, be hospitalized for Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., New York. 1 and MY—2715, National Institute of Mental Health, U. S. Public Health Service. Aided by grants MY—2092 AND MAX FINK, M.D. a shorter period, and be rated as improved at time of discharge. In contrast, patients who were younger, better educated, native-born and who obtained low scores on the F Scale, most often received psychotherapy as their sole form of treatment, were hospitalized for a longer time, and were more likely to be discharged with a rating of unimproved. Thus, the determination of psychiatric treatment was viewed as an interactive process, and related to the background, cultural values and communicative pattern of both therapist and patient. In view of this relation of psychosocial factors to selection for and response to treat— ment, it was postulated that in a psychotherapeutically—oriented hospital patients who refuse or fail to complete convulsive therapy would be significantly younger, better educated, and be less stereotyped and conventional than patients who completed a course of therapy. This study was undertaken to test this hypothesis. PROCEDURE The seventy-five consecutive iii-patients (27 males and 48 females) referred for con— vulsive therapy at Hillside Hospital during the one year period from October 1, 1957 to September 30, 1958 were included in this study. Hillside Hospital is a non-profit institution for the treatment of voluntary patients. Psychoanalytically-oriented psychotherapy is regarded as the primary method of treatment, with various somatotherapies available when necessary. All pa— tients are seen for individual psychotherapy three times a week, with psychotherapy continuing when other treatment, 6.9., convulsive therapy, is administered. Three social (age, education and nativity) and one psychological measure (the Cali153 �154 POLLACK A ND FINK fornia F Scale), were employed. A ten-item modification of the F Scale (6, 14) was administered to 53 referrals prior to treatment. In this task, the subject reads 10 statements and indicates whether he agrees or disagrees with each statement, and to what extent. The score given for each item ranges from one to seven and the range of total scores is ten to seventy. The greater the subject’s agreement, with the statement, the higher the score obtained. The statements themselves are extreme, conventional and stereotyped expressions. lr‘or example, one statement is, “If people would talk less and work more, everybody would be better off.” Patients were referred for convulsive therapy by the psychiatric resident with the ap— proval, frequently at the suggestion, of his supervisor. The referral form requesting treatment was sent to the psychiatrist in charge of the convulsive therapy unit for medical examination and the institution of treatment. Thus, it was possible to determine those patients who were referred for treatment but who refused to start. Convulsive therapy was generally administered three times a week, and grand mal convulsions were induced with the standard Medcraft alternating current instrument. RESULTS Of the 75 referrals for convulsive therapy, 13 refused treatment. Of these, seven failed to start and six refused to continue treatment. In the latter group, the number of treatments ranged from three to eight— short of the generally prescribed course of at least twelve treatments. TABLE 1 Mean Age, Education and F Score by Group N Group ' Acceptance Refusal Mean Difference (One—tailed t p< test) 62 13 (figs) Educa- 0:325) 40.3 11.6 29.7 13.7 — 10.6 +2.1 2.5 1.9 .01 .025 F Score 48.7 37.7 — 10.0 2.2 .025 Social and Psychologic Factors: The group of patients who accepted a full course of convulsive therapy was significantly older, less educated and manifested a higher mean F score than the group that refused treat— ment (Table 1). Furthermore, 37 per cent of the acceptance group were foreign-born as compared to eight per cent of the refusal group. While there was considerable overlap between groups with respect to these factors, the refusal group was more homogeneous than the acceptance group. Thus, there were no patients in the refusal group who had less than ten years of education (69 per cent of the group had attended college) and none were over fifty years of age. In contrast, 27 per cent of the acceptance group never went beyond grade school (eight years or less) and 31 per cent were fifty years or older. Differences in occupation between groups paralleled the differences in education. Thus, none of the patients in the refusal group were unskilled or manual workers. They were in clerical, professional and business vocations, Whereas ten subjects in the acceptance group were unskilled workers. Housewives were excluded from this tabulation. Relation to Diagnosis: The discharge diagnoses of seventy-three patients fell into four major categories: psychoneurosis, schizophrenia, manic-depressive, or involutional psychoses. Two patients were classified as “psychotic depression” without further specification. Although there was no statistically significant difference in diagnostic composition between the group accepting and those refusing treatment, the groups were dissimilar with respect to the incidence of the involutional psychoses (Table 2). No patient in the refusal group was discharged with a diagnosis of involutional psychosis, whereas 24 per cent of the acceptance group were so diagnosed. There was also a high positive correlation between this diagnosis and the sociopsychological factors studied. Thus, the mean age (56.7 years) and F score (61.4) were higher while the years of educa- �155 REFUSAL OF CONVULSIVE THERAPY tion (9.2 years) was lower than that for the total refusal group (Table 1). Relation to Improvement Ratings: At the discharge conference held by the Medical Director each patient is assigned one of four improvement ratings: recovered, much improved, improved or unimproved. The incidence of recovered and much improved ratings was significantly lower in the refusal group (Table 3). Six patients, all in the ac— ceptance group, were rated as recovered. The hospital discharges were more closely associated with refusal or discontinuation of treatment in the refusal group. DISCUSSION The present study confirms and extends previous findings in this laboratory (2, 12, 13) in demonstrating the importance of social factors and their psychological correlates in the selection for and response to psychiatric treatment. It supports the hypothesis that in a psychoanalytically-oriented hospital patients who refuse convulsive therapy would more closely resemble those who remain in psychotherapy and differ from those who are selected for and treated with convulsive therapy. The lower 1“ scores in the refusal group than in the acceptance group are correlated with a less compliant attitude toward authority and a more analytic approach in interpersonal activities. Review of the patients’ hospital records revealed that negativism, belligerence, uncooperativeness and attempts to manipulate the staff were more common in the refusal group. For example, 38 per cent of the refusal group as compared with only 17 per cent of the acceptance group formally petitioned the Medical Director for discharge from the hospital. (Almost all these patients withdrew their request for discharge shortly after the initial request). Referral for convulsive treatment was more often associated with problems of management, e.g., disturbing the ward or eloping from the hospital, than for depressive or confused thinking. In contrast, a higher TABLE 2 Discharge Diagnosis by Group Group Manic. Depressrve Psychosis Schizo. - Psychoneurosls phrenla Acceptance7 (11%)25 (40%) 2 (15%) 7 (54%) Refusal X2 13 4 Involu. tlonal Psychosis (21%) 15 (24%) (31%) 0 (0) = 2.28, p = n.s. TABLE 3 Discharge Improvement Ratings by Group Group Acceptance Refusal X2 Recoveredfi Much Improved 34 (55%) 3 (23%) Improved Unimproved (31%) 5 (38%) (15%) 5 (38%) 19 9 = 6.41, p = .05 percentage of the acceptance group were referred for convulsive therapy for alleviation of depressive symptoms. There is increasing evidence that accept— ance or rejection of psychiatric treatment is related to learned attitudes toward treatment by both patients and therapist (8, 9, 16, 17, 21). Most often these attitudes which correlate with socio-economic status are formed far in advance of treatment, and are most likely an intrinsic part of the person’s repertoire of behavior. Thus, patients from lower class backgrounds more frequently view psychiatric treatment as nonverbal and in physical terms whereas typically “the middle class patient is predisposed toward the acceptance of psychotherapy even before he arrives at the clinic” (9). In the sample studied there were many expressions of a negative attitude toward convulsive therapy long before the referral for convulsive therapy had been made. One patient, in treatment for several years prior to her current hospital admission, terminated treatment and transferred to another psy— chiatrist on each occasion when convulsive therapy was recommended. Another patient asked to sign the voluntary certification form on admission, appended the following note. “P.S., If I am given shock treatment �156 POLLACK AND FINK I’ll either kill myself or leave the hospital.” Other patients, particularly those who have been in individual psychotherapy prior to hospital admission, state that their previous therapists instructed them not to submit to convulsive therapy in that it would be harm- ful. Perhaps more important than either attitude of the patient or the psychiatrist is the factor of consistency of attitudes. Klerman et al., (17) have reported that young resident psychiatrists with psychoanalytic orientations frequently have unfavorable attitudes toward somatic therapy and are ambivalent about prescribing such treatment. In the present study there were many indications that referral for convulsive therapy was not the “free” choice of the resident physician but was made only after considerable pressure by administrative and nursing person- nel. A recent study by Kaplan and Lefkowits (15) of staff and environmental factors associated with referral for drug therapy in this hospital demonstrated that the psychiatrist’s tolerance for disturbed behavior was much higher than that of nurses and other personnel. Frequently the resident physician placed a premium on helping the patient modify his behavior without resort to somatotherapy. A similar observation was made by Sabshin and Ramot (21) and by Klerman (17) who found that “psychiatrists treating a patient with psychotherapy were unusually reluctant to add drug therapy.” Such attitudes may be conveyed to patients either overtly or covertly. Such observations reinforce the findings of Pasamanick, Dinitz and Lefton (18) that “despite protestations by clinicians that their reference is always the individual patient, clinicians, in fact may be so overly committed to a particular psychiatric school of thought, that the pa— tient’s diagnosis and treatment is largely predetermined.” The studies here would suggest that the psychiatrist’s ambivalent attitude toward treatment is not a general attitude but is related to the “social distance” of the patient to himself. The psychiatric resident frequently has less difficulty in recommending somatotherapy for a lower class patient but is indecisive when it comes to making a similar treatment referral for a patient who is culturally more like himself. The findings that objectors to convulsive therapy were more often discharged from the hospital as clinically unimproved is consistent with previous observations (7). Gordon (7) classified objectors into two categories—poorly oriented catatonic subjects who offered resistance to the treatment and responded with clinical improvement; and a better oriented group who objected to treatment on an attitudinal basis claiming they were “not in need of them.” This latter group were refractory to the clinical benefits of the treatment. Almost all of the patients in the refusal group of the present study could be classified in the latter group. It is of interest that most of the patients who refused convulsive treatment were prognostically poor selectees for convulsive treatment. In previous studies (2, 10, 11) we have shown that the incidence of ratings of improvement at discharge in young, welleducated, low F score patients was signifieantly lower than in the older, less educated, more stereotyped patients. The refusal group is part of that group of patients who are neither “ideal” patients for convulsive treatment nor are they very responsive to milieu treatment and psychotherapy. While referral for convulsive therapy in this and other hospitals has been markedly reduced within the past few years, the problems associated with attitude toward treatment, of which treatment refusal is but one aspect, are of persistent importance. In the absence of specific therapies for the majority of psychiatric disorders the further study of decision-making in psychiatric treatment may help delineate the forces associated with selection of therapy. �157 REFUSAL OF CONVULSIVE THERAPY SUMMARY 8. HAEFNER, D. 1’., SACKs, REFERENCES Treatment of Mental Disorder, p. 223. Saunders, Philadelphia, 1953. 2. FINK, M., KAHN, R. L. AND POLLACK, M. Psychological factors affecting individual differences in behavioral response to convulsive therapy. J. Nerv. Ment. Dis., 128: 243— 1. ALEXANDER, L. 248, 1959. 3. FLESCHER, J. The “discharging function” of electric shock and the anxiety problem. Psychoanal. Rev., 37: 277-280, 1960. 4. FRANK, J. D., GLIEDMAN, L. H., IMBER, S. 1)., NASH, E. H., JR. AND STONE, A. R. Why patients leave psychotherapy. A.M.A. Arch. Neurol. Psychiat., 77: 283—299, 1957. 5. FREEDMAN, N., ENGELHARDT, D. M., HAN— KOFF, L. B., GLICK, B. S., KAYE, H., BUCHWALD, J. AND STARK, P. Drop-out from outpatient psychiatric treatment. A.M.A. Arch. Neurol. Psychiat., 80: 657—666, 1958. 6. GALLAGER, E. B., LEVINSON, D. J. AND ERLICH, I. Some sociopsychological charac— teristics of patients and their relevance for psychiatric treatment. In Greenblatt, M., Levinson, D. J. and Williams, R. W., eds. The Patient and the Mental Hospital, pp. 263—285. Free Press, Glencoe, Ill., 1957. 7. GoRDON, H. L. ()bjectors to electric shock treatment are refractory to its therapy. New York J. Med., 46: 407—410, 1946. AND MAsoN, A. S. Physicians’ attitudes toward chemotherapy as a factor in psychiatric patients’ As part of a continuing investigation of the relation of sociopsychological factors to psychiatric treatment, the present study was concerned with the sociopsychological characteristics of patients who refused to start or to continue convulsive therapy. Thirteen of the 75 consecutive voluntary patients referred for convulsive therapy refused treatment during a one year period in a psychoanalytically-oriented institution. These patients were younger, better edu— cated and had lower scores on the CaliforniaF Scale than the group that accepted convulsive therapy. The diagnosis of involutional psychosis was absent in the refusal group, and patients in the refusal group were more often discharged as unimproved. The acceptance or rejection of psychiatric treatment is discussed in terms of learned attitudes toward psychiatric treatment by both patient and doctor. J. M. . responses to medication. J. Nerv. Ment. Dis., 131: 64—69, 1960. IMBER, S. D., FRANK, J. 1)., (,iLIEl)MAN, L. H NASH, E. H. AND SToNE, A. R. Suggesti— bility, social class and the acceptance of psychotherapy. J. Clin. Psychol., 12: 341— 344, 1956. 10. KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock 11. therapy. J. Neuropsychiat., 1: 45—49, 1959. KAHN, R. L. AND POLLACK, M. Prognostic application of psychological techniques in convulsive therapy. Dis. Nerv. Syst., supp. 20, pp. 180—184, 1959. 12. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in the selection of therapy in a voluntary mental hospital. J. Hillside Hosp, 6: 216—228, 1957. R. L., POLLACK, M. AND FINK, M. Sociopsychologic aspects of psychiatric treatment. A.M.A. Arch. Gen. Psychiat., 13. KAHN, 1: 565—574, 1959. L., POLLACK, M. AND FINK, M. Social attitude (California F Scale) and convulsive therapy. J. Nerv. Ment. Dis., 14. KAHN, R. 130: 187—192, 1960. 15. KAPLAN, A. AND LEFKOWITS, H. J. Influence of staff attitudes and environmental factors on treatment selection. J. Hillside Hosp. In press. Staff attitudes, decisionmaking and the use of drug therapy in the mental hospital. In Denber, H. C. B. Research Conference on the Therapeutic Community, pp. 191—214. Thomas, Springfield, 16. KLERMAN, G. L. 111., 1959. 17. KLERMAN, G. L., SHARAF, AND LEVINSON, D. J. M., HOLZMAN, M. Sociopsychological characteristics of resident psychiatrists and their use of drug therapy. Amer. J. Psy- chiat., 117: 111—117, 1960. B., DINITZ, S. AND LEFTON, M. Psychiatric orientation and its relation to diagnosis and treatment in a mental hospital. Amer. J. Psychiat., 116: 127—132, 1959. 19. ROSENTHAL, D. AND FRANK, J. D. The fate of psychiatric clinic out-patients assigned to psychotherapy. J. Nerv. Ment. Dis., 127: 18. PASAMANICK, 330—343, 1958. 20. RUBENSTEIN, E. A. AND LORR, M. A. A com- parison of terminators and remainers in outpatient psychotherapy. J. Clin. Psychol., 12: 345—348, 1956. J. Pharmacotherapeutic evaluation and the psychiatric setting. A.M.A. Arch. Neurol. Psychiat., 21. SABSHIN, M. AND RAMROT, 75: 362—370, 1956. ��We. lama-b.1031“! at tutu. cantata norm In: rum rum. and “no“. at. In rm IJ. no What a: mum»: manna-y ' mum mum ' In. v.1. at... at... a» 18-1715. ”-10,! of In“: an lulu-.1 mu it Intuit. put '0’. 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Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sociopsychological characteristics of patients who refuse convulsive therapy. J Nerv Ment Dis. 1961 Feb; 132:153-7. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-54-020 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Pollack, Max; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Vol. 132, N0. 2 February, 1961 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/c1a1aa6de811d0a1630b2188051d512d.pdf a467aa19b75ccf3c7353e27cd875e8ef PDF Text Text M. FINK From the Department of Experimental Psychiatry, Hillside Hospital 7 Glen Oaks (N. Y.) Meeting on the Techniques for the Study of Psychotropic Drugs Bologna 1960 DISCUSSION OF THE REPORT OF Prof. MARCEL MONNIER Reprinted from the: of Acta of the International Meeting on the Techniques for the Study Psychotropic Drugs» - Bologna June 26-27th 1960 « MODENA —>SOCIETA TIPOGRAFICA MODENESE �Dr. Monnier‘s excellent review presents a vivid picture of neurophysiologic techniques in the study of drug effects. From monosyna‘ptic and poly— synaptic to organismic patterns the methods of study appear rich in promise. One phase of these studies, that of cortical EEG analysis, has been of considerable interest to our laboratory, Changes in EEG patterns induced by pharmacologic agents are generally considered to be poorly related to changes in clinical behavior. Yet, from the extensive experience with anesthetics, alcohol. sedatives and convulsants, and the theoretical views ascribing to brain function a central role in conscious behavior we would expect that psychotropic drugs may also have significant electrographic behavioral relations. The difficulties in such studies lie in inter—species differences in physiologic response, the range of inter-individual and intra—individual variability in both neurophysiologic and behavioral parameters, and the wide variety of events which must be measured to obtain a reasonable image of mammalian interactive behavior. A further difficulty has been a lack of reasonable theo— retic models of brain function-behavioral interrelations. Recent suggestions, however, may be helpful, including the synaptic models of Marrazz‘i (l) amongst others; the brain stem models of Magoun, as elaborated by Hi‘mwich (2): and the general neuro‘physiovloglic~adaptive views of Wlikler (3), Weinstein (4‘) and our laboratory (5). In 1954. Wikler (6) stated that drugs that alter human behavior in the direction of EEG desynchronization are associated with behavioral excite— ment. alertness, illusory sensations, and hallucinations; while drugs which induce EEG synchronization, with or without increased slowing, are associa— ted with sedation. tranquillization and decreased excitement. In our studies in psychiatric patients, this hypothesis has been substantiated. The following compounds administered in physiologic dosage ranges have been shown to decrease synchronization of the EEG: mescaline, LSD—25, amphetamine; anticholinergics as diethazine, benactyzine. JB—318, JB-336; and local anesthe— tics as cocaine, procaine, and lidocaine. The following agents increase synchronization of the EEG: barbiturates, chlorpromazine and similar pheno— thiazines. meprobamate, and anesthetics as ether, chloroform. etc. In addi— — tion, various compounds without significant clinical behavioral efi'ects have been studied, including phenyltoloxamine, WY-3149 and deanol - and these have inconsistent or indefinable EEG effects. In these studies we have observed. however, that the continuum of synchronization-desynchronization is an oversimplified generalization. In our present view, two other EE‘G pattern changes have assumed considerable prominence. One is a shift of dominant frequencies either to the slow (theta or delta) or the fast (beta) ranges; and the second, the presence of such figures .as burts, spikes or spindling. These latter two patterns were significant in �2 describing the EEG behavioral relations of imipramine (7). Examples of these paterns may he found in publications from this laboratory and elsewhere (8. 9, 10, 11). It is our impression, therefore_ that further EEG analyses of new compounds in man is indeed warranted. We would suggest that the number of quantification procedures be extended to include, in addition to frequency analysis, the techniques of topographic analysis, chronologic analysis - and these techniques may be augmented by computer techniques of summating evoked potentials. In studies of drug effects. not only is it important to define neurophysiologic parameters, but the behavioral parameters are equally significant. The equation of change in rates of animal pole-climbing. bar pressing or jiggleand is inaccurate and excitation human with tranquillization movement cage inappropriate. There is no evidence that such tasks in experimental animals and of to interaction physicians human in significance related to changes are psychologists. Indeed, if one impression dominates the session today, it is that the behaviors studied by pharmacologists are not the behaviors of inte— rest to the clinicians. Further study of the relations between the laboratory tasks highlighted today and human behavioral measures are needed. In this regard multivariate pattern analyses of behavior and the newer applied psycholinguistic techniques may be helpful in defining the changes in human behavior patterns. In conclusions. I wish to reenforce Dr. Monnier’s review, and indicate that increased attention to EEG analyses may be profitable in understanding the mode of action and the significant differences and similarities in psycho— pharmacologic agents. REFERENCES 1) 2) 3) 4) 5) 6) 7) 8) Marrazzi A. S., Science 118, 367 (1953). Himwich 11., Rinaldi F., Brain Mechanism and Drug Action, 115-44 C. C. Thomas, Springfield, 1957. Wikler A., The Relation of Psychiatry to Pharmacology. Wm. Wilkins, Baltimore, 1957. Weinstein E. A., and Kahn R. L., Denial of Illness: Symbolic and Physiological Aspects. C. Thomas, Springfield, Ill. 1955. Fink M., A Unified Theory of the Action of Physiodynamic Therapies. J. Hillside Hospital 6, 197 (1957) Wikler A., J. Nerv. Ment. Dis., 120, 157 (1954). Fink M., Canad. Psych. Assoc. J. 4, 1668 (1959). Fink M., Neuro-Psychopharmacology, ed. Bradley, P., Elsevier, Amsterdam, 441446, 1960. 9) Kink M., EEG. Clin. Neurophysicl. 12, 359 (1960). 110) Verdeaux G., Marty R., Rev. Neurol., 91, 405 (1954). 11) Bradley P. D., Elkes J., Brain. 80, 77 (1957). ��� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource EEG techniques in study of psychotropic drugs. Acta of the International Meeting on the Techniques for the Study of Psychotropic Drugs, Bologna, 1960. Societa Tipografica Modenese, Modena, 1961: 3pp. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-55-021 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource DISCUSSION OF THE REPORT OF Prof. MARCEL MONNIER. Reprinted from the: Acta of the International Meeting on the Techniques for the Study of Psychotropic Drugs, Bologna June 26-27th 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/f9143989b4f022343ed9672f34b2d359.pdf 1500dfbcc8282737a3c8c3677182eaf9 PDF Text Text WITHDRAWAL SYMPTOMS FOLLOWING DISCONTINUATION 1 OF IMIPBAMINE THERAPY JOHN C. KRAMER, M.D.,2 DONALD F. KLEIN, M.D.,3 AND MAX FINK, M.D.‘ [Reprinted from THE AMERICAN JOURNAL OF PSYCHIATRY, V0]. 118, No. 6, December, 1961] �, . 0 i ~ I I‘NG- DISCONTIN'UATION OFIMIPRAMINE THERAPY 1 . V IOHN _'.-KHAMEH, M.D;,2 c: DONALD “E KLE‘I‘NQMD.) mMAXFIN‘K, Mgn.4 r v I ' �1961 1 CLINICAL NOTES 549 WITHDRAWAL SYMPTOMS FOLLOWING DISCONTINUATION 1 OF IMIPRAMINE THERAPY JOHN C. KRAMER, M.D.,2 DONALD F. KLEIN, M.D.,3 AND MAX FINK, M.D.4 On discontinuation of imipramine 5 treatment some psychiatric patients reported nausea, vomiting, dizziness, coryza, muscuAided, in part, by grant MY—2715 of National Institute of Mental Health, National Institutes of Health, USPHS. 2 Post Doctoral Research Fellow, USPHS, 19601 1961. Mental Health Career Investigator, USPHS. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I., N. Y. 5 The cooperation and assistance of Ceigy Pharmaceuticals is gratefully acknowledged. 3 4 lar pains and malaise. The symptoms were first regarded as conversion phenomena, but after several repetitions were considered due to physiological withdrawal. Of the patients treated with imipramine 45 had been observed within the hospital during withdrawal of medication. Treatment was instituted with oral doses of 75 mg. daily and usually increased each week in 75 mg. steps. The daily maintenance dose was 300 mg./day in 34 patients, more than 300 mg./day in 3 patients, and less than �550 CLINICAL NOTES 300 mg./day in 8 patients. We reviewed our interview records and the daily nursing notes, noting reports of withdrawal symptoms within 48 hours of cessation of medication in 25 of the 45 patients. Most prominent were nausea with or without vomiting—16 subjects, headache— 10, giddiness—lO, coryza—8, chills—6, weakness and fatigue—5, and musculoskeletal pain—4. Twenty—two of 26 patients treated for 2 months or longer reported withdrawal symptoms, while only 3 of 19 patients treated less than 2 months reported similar symptoms (p< .001). The 25 patients who had been treated for more than 2 months were rated for severity of symptomatology. The reaction was scored as “marked” if subjects reported more than 2 different symptoms with significant distress and as “minimal” if they reported fewer than 2 symptoms causing minor distress, or no symptoms. Of 13 patients with a medication tapering and termination period of less than 2 weeks, 8 had marked withdrawal symptoms and 5 mini— mal. Of 12 with a medication termination period longer than 2 weeks, only 2 subjects demonstrated marked withdrawal symptoms (p:.05). These results are in keeping with the general experience that the intensity of physiological withdrawal symptoms is directly proportional to the duration of drug administration and the abruptness of withdrawal. We could not relate the withdrawal syndrome to the size of the maintenance dose, since our range was too small. However, our modal schedule of 300 mg. per day is larger than the usual clinical schedule of 100 to 150 mg. per day and may account for the inconspicuousness of this phenomenon in other studies. We observed that allowing a period of 2-4 weeks for withdrawal was prophylactically effective. When symptoms on imipramine discontinuation occurred they could readily be treated by resuming imipramine at 50 mg. daily and gradually decreasing over a 1-week period. [ December DISCUSSION A physiological withdrawal syndrome following the termination of treatment with opiates, demerol, barbiturates, glutethimide, alcohol, chlorpromazine and meprobamate is well known. Recently withdrawal symptoms with methaminodiazepoxide(2), nialamide(1) and alpha-ethyltryptamine(5) have been reported. Kuhn( 3) and Mann and Macpherson(4) have also reported symptoms on abrupt imipramine withdrawa1. Until recently the physiological withdrawal syndrome was considered restricted to CNS “depressants” such as opiates, barbiturates and alcohol. This was confirmed by the absence of such a syndrome with “stimulant” drugs such as cocaine, d-amphetamine, marijuana, mescaline and LSD. The occurrence of such a syndrome with imipramine, nialamide, and alpha-ethyltryptamine is of considerable interest, therefore, since these drugs have been loosely referred to as “psychic energizers” with energetic effects similar to “stimulant” drugs. It is apparent that a simple depression—stimulation dimension is inadequate to describe the complexity of drug effect both physiologically and behaviorally. The withdrawal syndrome complicates the evaluation of patients after drug discontinuation since both patients and physicians often interpret the onset of symptoms as an upsurge of “anxiety” related to incipient relapse, and resume treatment with the gratifying subsidence of the “anxiety.” This may cause both patients and physicians to overvalue the importance of the medication to the patient’s stability. BIBLIOGRAPHY 1. Hollister, L. E., Motzenbecker, F. P., and Prusmack, J. J. : J. Clin. Exp. Psychopath., 21 : 212, 1960. 2. Hollister, L. E., Motzenbecker, F. P., and Degan, R. 0.: Psychopharmacologia, 2: 63, 1961. 3. Kuhn, R: Schweizerische Medizinische Wochenschrift, 87: 1135, 1957. 4. Mann, A., and Macpherson, A. : Canad. Psychiat. Assoc. J., 4: 38, 1959. 5. Turner, W. I., and Merlis, S. : J. Neuropsychiat., 2 : 1961. ��Htth¢r¢wnl Symptonu ralluvtnz Discontinuation at In1pran1uo fhurtpy {can 6. {rt-st, H.D.#, nonald and r. Kissn, x.n.u‘ In: link, 3.9. from tho Departnont of Exporincntal rayohigtry, 3:110:40 lalpltal, Olen 00kt, 5.1., [.1. floatorll Raconrch fallow, 88,38, 1960~1961. oqnontnl lunlth euro-r Iavuatagutor, ssrus. Aided, in part, by grant l1~2715 or Intionul Institute 01 Hantnl Health, Int1¢n¢1 Iu|t1tutoa at laulth, yarns. the caoportttou and aauiutanoo ot_6.1¢y Pharancauttcal: O P98? 52.301111: nekuuvlcdaod. VI: 6/29/61 13 �discontinuation of iliprsniss trsstnsnt sons pstissts, ands: obssrvssisa ts: s vsristy a: psychistric sysdrssss, rsportsd nsssss, vssiting, dissinsss, ssryss, ssscslsr psins sad Islsiss. Ens sysptsss ssrs first rsgsrdsd ss osmvsrsisa phsnousns, but stisr ssvsrsl rspstitisns vs sonsidsrsd thsss to be dss to physiological withdrsssl sad an sttolpt vss nsds to dotsrsins their trsqusaoy sad varisty. o: the pstisats trsstsd with isiprssins during sn sightoon nsnth psriod, forty-11's hsd bssn observed within the hospitsl sstting during withdrawal of ssdissties. In thsss subsects trsstnsnt was instituted with arsi dosss st 75 s; dsiiy sad ssnsliy issrssssd sssh sssk in 75 as stsps. Ins dsiiy‘ssistsnsaes dsss ass zoo aglsay in thirty-tour puss-ntsg loss than 300 ltldly in tires pstisass; and loss thin 300 Is/dsy in sight 0n pstisats. rsvisssd our intsrviss rssords and fits dsily ssrsiac notss, noting rspsrss o: uithdrsssl symptoms within k8 hours of ssssstisa or sodiostion in 25 of tho h! pstisnts. (rsbls I) Vs n“.-.IABLE I -D.-”- �2.510 I aynptonl Within an Intro 01 cunna$1on or Iniprnnino therapy’ Pnttontl conning theft?! Patients reporting Iynptonu hS 25 azggtons l:unou (and/or vomiting) 16 Houdnoho 10 GiddinOII . 10 Darya: chill: taintnuuu HIIoqu-Ikolotsl pain Hoaknosu or rmma �.29 ovidoat whoa tho aurorolottonohip otguitioont ttoo o: trootlont and tho oppooroaoo of orlptono oro oomporod. (Toblo I!) toasty-too of tvonty-otx patients trootod for two ooutho or longor roportod withdruvol oyuptono, whilo only throo of ntnotoon potionto trootod loo: than too nontho roportod otnilor oynptono. 1o A II O .‘O--.. fAILB to dotornino tho rolotion of tho obouptaooo ot nodiootton withdrovol to indoood oyuptouo, tho twentyrtvovpottonto who bod boon trootod for noro thou two ooutho ooro rotod to: oovortty o: oynptoootoloay. rho rooottoo woo ooorod oo 'norkod' 1: lobaooto roportod ooro thou two dittoroot oynptono with otgaitioont diotrooo and to "minimal“ at tho: roportod towor than two oyoptono oonoins lino: atotrooo, or no symptolo. Too groupo ooro doriaod according to otothor tho poriod or Iod1oot1on rodootton woo looo thou too rook: or too uooko t or longoo. (foblo III) “-Qfl‘..-. TABLS III �Ink}: 1! nurution of Iniprnltno Therapy w1%hdr¢vn1 Symptoms It Withdrawal Symptonu (lubaootl) (subjects) in. isn‘t. I 16 fun South: or hangar 22 h Lon. thin x9 .- 23.91. P < .001 2gblo £51 rurtod or 3:3: Gestation In Patients rruatcd st Lcnlt fro abnthn Withdrawal 8232t¢nl lurked . Lon. than rug minimal VIDEO 6 5 fun with: or Long.» a 10 p ~ .05 (Fisher) (h) �~3- !haaa raaalta art in kaaping vita fiha can-val asparianaa ihat tho iataaaity a: phyaiolocical withdrawal aylptoua is directly proportional in tho duration at drug adaiaiatration and tha abruptaaaa at vifihdraaal. Va scald not ralata tha appaaranaa of at: withdrawal ayndroao to tho aiaa o: tho aaiatauanea doaa, ainoa our ranaa uaa too shall. flovavar. our natal aahadala a! 300 I; ha: day in largo: than tho aaaal clinical aahadala a: 100 ta 150 a. par day and nay account for an. inaauapioaaaaaaaa a: thin phaaaaaaaa in Qatar atadiaa. It Iaat ha aataa that withdrawal aylpiaaa was. unvaried by aaa patiaat aha III traataa la: tua lantha at 75 In; par «7. a marina. daaa at abaarvad that alluviag a parted at 3-h wacktar withdrawal ran prayhylaatiaally attaetiva. ihan ayaptaaa an iaipraaiaa diaeoatinaatiaa acaurrad they coal! readily be treated by raaaaing iaipraaiaa at Ha , 56 a; daily aid gradually aaaraaains era: a parted. one tack �9h. accurrcauc a: a vhf-1010:1931 utthdrnnal lyndronc tollcrtlg the tor-tnutton o: troninoat with optntcl, duu.rol, burhtiurltcn. all$othilado and 1100301 1! wall kntln¢ looantly withdrlvul Irlgten- attachlsrptonnsaao (2), Isthnatnodinuapcxtlo {1). nialnuldo (5}, alpha-oihyittyp‘anlno (9) and nuptniiluto (1,3,6) lav. icon rcporfiod. tan: (8) ha; ciao obstrvod lyuyton‘ on abrupt znlprnltno withdraanlo Until riotatly it. phytiologteal iithdruu:1 cyadrono was coalidtroi routrtetcd to 618 'dcpréunsatn' Inch OI splat... barblfiurnsos and alcohol. this was contirnod 57 Sh. tbacnco of such a cyndruno with “stannlsnt‘ drugs tank .3 cocgtno, d-tlphotanino, unhealino and £39. In. accurronoc at such antisulan, a syndrcnn with tulprlltnu,43131anldn, and alpha.ihrltryptaazno 1- or etalldnrahll Satori-t, ‘horutorc. can-o thus. drug: havn baa: 1.90.17 rtrorrcd to a: 'payuhao 0303:1302.“ 11$) unaruo‘tc o£1¢ctn 01-11:: ' human an to u .1»:am... It 1.- .pnmt Canto-liaa-stxlnlatioa dincnulun 1: tnnlcquat. to donoribu tho.¢olploxtty or drug effect hath phyuso« logically and behaviorully. in. at withdrawal 9:362:30 conpl1oatbn tho avnlunttou pcttcutn utter drug dicooutsnuatton, both oltniually . �hoth and patina“ an” maximum, punch:um 1“.»er tn ant a mu», (mans, to. u a: spur" a: ‘uuaotyfl "1am to menu“ "up“. and hum a mum ”amt an m ”any“. «bum» a: a. 'mtoty'. m. any at!" ”a and plantain: to ova-van tho moral» of a. plum“ noun“... to tho grunt“ gummy. and �m 1. no taunts-u at «1pm» ”um“ product. phyutoIocto-l withdruwnl uynptonu, which arc rolutod to luasth of ‘rontnaut and abruptuocn o: withdrivui. aylptonn may also be rolntad to douaco luv-1o I. H1thdrar¢1 lyyptons any h. militia-d qr oltntuutod by running fitchuaquol. I it. aneurraaac of : withdranul syndrong lath tnlprgnluo to porttnoafi ta tn. coucoptunltus$1.: or its paynhowhnrnaaolocical notiviflr, and to 3. prabltna I: clinical Isaac-hunt. �1. mu, 3.1., at. an... Ida W. ’- 33.3,. 1. 1023, 1955. Inch. 3-.» 9.3.: Mac, 3.3. and 833. 1958. lulu, 1.3.: m: a, J, 931. 1959. 'mnfi: MI 801301, id. 8.. vgumMe autumn, m ncfirtI-ltll, It! tort, 1956, 96. 5. lanai", In!” ”summer”, hr. and Pam-suck, 3.3.: 3 lmhflnfih, 3;: 212, 1960. g, nun: L“ 6- lolltltor, L.R. and fllcsanar, !.8.s £3!3§22§£££££2¥3‘§2& 196°. 3”, ;. 7. amour, In!” Runabout», LP. and Baa, the” It. ”that, BA” in W a W. I. ma. M 2- ‘3: 1951. 1135, 1957. 9. Mar, m1. ad lit-r110, 373, 1961 (app)... 1) 8.1 J, Inn-3mg; . g: 9.1: � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Withdrawal symptoms following discontinuation of Imipramine therapy. Amer J Psychiat, 118:549-50. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-56-022 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Kramer, John C.; Klein, Donald F.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint (Clinical notes) and [preprint]. Reprint from THE AMERICAN JOURNAL OF PSYCHIATRY, V0L. 118, No. 6, December, 1961 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/07a3d1b2eec1cf62891da3ff4c4049c8.pdf f5bf70eb575371f639319602e2837d97 PDF Text Text EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, M.D. Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume X ° Nos. 3-4 ° July-Oct. 1961 �EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, MD. The dedication of Hillside Hospital as a Research Institute has been a dream of many of its students—a dream that may achieve realization in this decade. Dr. Tarachow was an early proponent of this view; and both in his sponsorship of the Journal, and in his encouragement of research studies, he presaged this development. He was also the inadvertent sire of the research studies in experimental psychiatry. While I was a resident in psychiatry in 1952, we collaborated in a study of the relation of the early separation of child from a parent to the adult choice of neurosis. Reviewing the hospital records of five previous years we concluded that there was, indeed, a relation—— neurotic patients with obsessional neuroses had a significantly, greater incidence of separation than patients with hysterical neuroses (2). This report was the beginning of the patient population studies described here. Since 1954 the various programs in experimental psychiatry have been devoted to an understanding of the mode of action of the psy- chiatric therapies of the hospital. The techniques have been adapted from descriptive and dynamic psychiatry, neuropsychology, electroencephalography, linguistics, pharmacology, and sociology. This report reviews these studies and presents support for the creation of a Research Institute at Hillside. PAST STUDIES In our early studies of convulsive therapy, instituted with the 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. The studies reported here have been aided by the Board of Directors Research Fund; the National Institute of Mental Health (Grants M-927; MY-2092,-27l5, -4798; MF-12,033); Foundations Fund for Research in Psychiatry (FFRP 56-151); Kaufmann, and Dazian Foundations; and numerous pharmaceutical concerns including Geigy, Bristol, Wyeth and Smith, Kline 8c French Laboratories. 159 �160 MAX FINK aid of a grant award of the National Institute of Mental Health, evaluations of patient improvement were shown to be dependent both on changes in brain function and on psychological factors. As our understanding of convulsive therapy developed, a general neurophysiologic-adaptive view of somatic therapies emerged (6). A change in brain function was seen as a necessary condition for behavioral change, with the type of change varying, depending upon psychological and sociological characteristics of the subject (22, 25). Thus, the mode of action was not seen as either “organic” or “psychological” but rather as the interaction of neurophysiological changes and individual patterns of response and behavior. This hypothesis was sustained in studies of convulsive and in sulin coma therapies (21, 22); and the mode of action of the new psychotropic agents was expressed within this hypothesis. It was suggested that psychotropic drugs would be effective to the extent that persistent changes in brain function were induced; and that the type of behavioral response would be related to the type of brain change, and to individual premorbid psychologic (personality) patterns (6, 28, 40). Convulsive Therapy Process: Seeking a measure of altered neurophysiological change that was sensitive and suitable for repeated retests, various measures were studied including changes in the face-hand test (1, 10, 13, 35), memory tests (17, 35), amount of slow-wave activity in the EEG (16, 23) and confabulatory and denial language patterns after amobarbital (3, 15). The latter two, EEG and amobarbital tests, were the most sensitive indices of change in convulsive therapy subjects. In one experiment, clinical ratings of improvement were correlated with high degrees of change in these indices (15, 16). These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to either convulsive or subconvulsive therapy. High degrees of electrographic slow-wave activity and positive amobarbital tests were observed only in the convulsive group; improvement rates were significantly higher in this group, and when subconvulsive subjects were retreated by convulsive applications, the improvement rate was similar to the convulsive group (22). In subconvulsive applications, considerable electric current passes between the electrodes. It was postulated that the therapeutic agent was not the total electrical current per se, but the “all or none” quality manifested by the grand-ma] seizure (9, 23, 42). The signifi1. �EXPERIMENTAL PSYCHIATRIC RESEARCH 16] cance of the grand-mal seizure was examined in a comparative study of the inhalant convulsant, hexafluorodiethylether (Indoklon), and electrically induced seizures. Similar degrees of electrographic change, improvement rates, types of behavioral adaptations, and changes in neuropsychological task behavior were observed in both the inhalant and in the electrically treated groups (49). However, not all subjects manifesting high degrees of physiological change were evaluated as “improved.” In a descriptive typologic study, five adaptive modes were described, empirically termed “eu— phoric,” “hypomanic,” “somatization,” “paranoid-withdrawal," and “panic.” While the first two patterns were rated as “much improved,” the latter two were seen as “unimproved" or “worse” (50). In studies of psychological variables, it was reported that patients rated “much improved” and “recovered” frequently manifested personality patterns akin to the explicit verbal denial personality type (37). These patients expressed the “language of denial” more frequently than unimproved subjects, exhibiting such aspects as explicit. denial, minimization, displacement and clichés (27). Other psychological indices also related to favorable outcome included high F Scale score (42), Rorschach determinants of color, absent movement and absent form-color (30, 45), and low educational achievement and foreign birth (31). 2. Anticholinergz'c Compounds and Convulsive Therapy: Seek-ing a way to augment the degree of postconvulsive EEG slow-waveactivity, an anticholinergic compound diethazine, was given intravenously at various stages of the convulsive therapy process (20, 24).. Unexpectedly, diethazine caused an immediate and sustained de-crease in EEG slowing, which was associated with marked changes. in language and mood. In patients with denial language patterns. (27), these could no longer be elicited. Instead of euphoria and wellbeing, the subjects became irritable, anxious, and complaining. In‘ subjects prior to convulsive or drug therapy, diethazine induced, ex-citement, tension, anxiety, and illusory sensations. Subsequent studies with other central anticholinergic compounds" and sympathomimetic hallucinogens showed behavior and electrographic patterns similar to diethazine. These observations led to the suggestion that an increase in the cholinergic activity of the central nervous system was the biochemical basis for the convulsive therapy process (38). Psychotropic Drugs and EEG: Following these studies, the: neurophysiological changes induced by drugs were testedwithinan. 3. �162 MAX FINK acute experimental-EEG setting. It was observed that phenothiazines induced EEG synchronization and a shifting of the frequency spectrum to the slow frequencies; meprobamate and barbiturates, an increased synchronization and a shift of the spectrum to fast frequencies; reserpine, an increased slowing with synchronization at low dosages, and desynchronization at higher levels (18, 26, 28, 40). Imipramine induced desynchronization with a shift of frequencies to the slow bands (33, 34). Each active psychotropic compound was thus shown to have a characteristic frequency pattern. Various other experimental compounds were also tested, and for these no consistent electrographic pattern was recorded. These compounds have since been shown to have either no or very limited clinical psychotropic activity. The absence of behavioral change with these compounds lent further support to the assumption that brain change is a necessary condition for the action of psychotropic drugs. These observations suggested that psychopharmacological agents provide a means for eliciting various types of altered brain function in contrast to the single pattern following convulsive therapy. Furthermore, the type of neurophysiological alteration, as reflected in EEG synchrony and frequency patterns, was found to be related to specified types of behavioral adaptation. The advantage of EEG techniques for the assay of new psychotropic agents and the technical merits of electronic frequency analysis were assayed and described (47, 52). 4. Insulin Coma Therapy: In our insulin coma studies we con- firmed earlier observations that persistent alterations of brain function were related to prolonged coma and spontaneous seizures; and saw in this relationship support for a neurophysiologic-adaptive hypothesis. With the availability of the new psychotropic agent chlorpromazine, a controlled chlorpromazine-insulin coma study was undertaken in September, 1955. As patients were referred for insulin coma they were randomly assigned to courses of either oral chlorpromazine for at least three months in doses adjusted to fall short of toxicity; or insulin coma, induced by a standard technique at least fifty times in each patient. While a number of minor differences were noted in comparing the two therapies, the results at time of discharge showed no statistical difference in the effectiveness of both treatments. Neither treatment seemed to affect the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management (21). Concurrently, following the suggestion by the Creedmoor workers that �EXPERIMENTAL PSYCHIATRIC RESEARCH 163 divided insulin doses were superior to single insulin doses, Blumberg and Laderman (39) essayed this problem and demonstrated no significant merit to the multiple-dose technique. (In 1958, following the general confirmation of these observations, insulin coma therapy was discontinued at Hillside). 5. Neuropsychology: Various psychophysical tests were adapted from neuropsychology, where their significance in brain-damaged subjects had been demonstrated. The early studies assessed these tasks as indices of altered brain function (35), and measured the range of performances of psychiatric patients, who are generally assumed not to be brain-damaged. Thus, memory function was assessed on immediate recall, after various interpolated learning tasks (17, 35), as well as during convulsive therapy (17). Tactile perceptual tasks were first examined in the clinical population (1). Later, with more sensitive electrical tactile stimuli, Korin (10) observed the range of thresholds in different body parts, the changes with altered brain function (10), and the influence of set (instruction) on performance (36). We also studied the perception of embedded geometric figures (43), tachistoscopic presentation of embedded color figures (55), perception of the visual upright (55), critical flicker frequency (49), and interference in reading time by delayed auditory feedback (55). For each task, the degree of decrement in task performance was found to be positively correlated with the amount of EEG slowing. Following treatment completion, with the return of physiological indices to pretreatment levels, performance in these psychological tasks also returned to pretreatment levels, or higher—a betterment of performance ascribed to practice effect. Concurrently, assessment of various psychological measures as indices predictive of behavioral change during convulsive and drug therapies led to studies of the Rorschach determinants (30, 45), California F Scale scores (30, 42), language patterns after amobarbital (27), denial scores on interview (37), and the perception of the visual upright and auditory feedback (55). 6. Psycholinguistics: Concurrent with the syntactic language studies (27), analyses of other language patterns were undertaken, both in a search for more objective indices of behavioral change and to gain experience in the technical problems of tape analysis for psychotherapy research. An index of variability in the vocabulary of speech, the type-token ratio (TTR) of consecutive samples of dyadic speech, was extensively studied (7,41, 44, 46, 56, 57). In convulsive therapy patients, significant changes in TTR mean �164 MAX FINK and standard deviations were related both to the degree of induced EEG slow-wave activity and to syntactic language patterns obtained in independent structured interviews. It was noted that speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (41). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents which produced predominant synchronization patterns on the EEG were related to a decrease in mean TTR and an increase in the standard deviation of scores, while desynchronizing compounds elicited greater variability in speech patterns and decrease in variability of consecutive scores (44). Other language measures studied included distress-relief quotients, self-reference, and alterations in tense and person. It was suggested that these psycholinguistic measures are useful techniques for the operational analyses of physiological and psychological effects of psychopharmacological agents (44, 46). 7. Brain Damage and Schizophrenia: Following his studies at Ittleson Center, Pollack reviewed the relationship between age of hospitalization, intellectual functioning and prognosis in schizophrenic children and adults. He noted that initial hospitalization in childhood and adolescence was related to I. Q. scores in the subnor— mal range, deviant performance on psychomotor tasks, and more frequent ratings of “unimproved” at hospital discharge than was initial hospitalization as an adult. The early and insidious onset of the behavioral syndrome “schizophrenia” was thus related to brain dysfunction (54). Findings suggest that different subgroups of schizophrenia may be classified on the basis of neuropsychological deviancy. 8. Sociological Studies: Considerable interest in the family organization to which discharged patients were returning, the relation of social factors to choice and results of psychiatric treatment, and the specific problem of the relation of these factors to treatment referral patterns led to a series of population studies. In one study (8), education, age, place of birth, and score on the California F Scale were significantly related to the type of therapy received and the utilization of adjunctive hospital services. In a second study (3]), duration of hospitalization, discharge evaluation, and diagnosis were related to the same social factors, while in a study of patient refusal of ECT, similar relationships were observed (51). These observations suggested a comparative interinstitution study, and among three hospitals the relationships between social class and other demographic variables (age, sex, education) to the clinical �EXPERIMENTAL PSYCHIATRIC RESEARCH 165 variables of patient classification (diagnosis), duration of hospitalization, selection of therapy, and discharge evaluation have been assessed. Three teaching institutions were selected in which all therapies are equally available to all patients—Menninger Foundation Hospital (upper-class, Protestant), Massachusetts Mental Health Center (lowerclass, Catholic), and Hillside Hospital (middle-class, Jewish). In such a comparison we have found the differences in designations of treatment, diagnosis, and discharge evaluation so marked as to make comparisons difficult. While many relationships between social variables and clinical variables were observed in each hospital, no social variable was found related to the clinical variables in every hospital (53). In an outpatient department study, sex, age, and marital status were found to be related to the acceptance and rejection of patients and failure to complete the application process (55). These observations in population samples led to concurrent studies of staff attitudes in the selection of therapy (ll, 12). In a series of ward observation studies, Kaplan and Lefkowits indicated the significant role of staff attitudes (especially nursing personnel) in the referral for subjects for somatic therapies, and in the transfer of patients from one ward to another. (To study the influence of stafi attitude on patient selection for drug therapy, we requested one ward be designated as a “no-movement” unit. This was adopted in September, 1959 and shortly thereafter by the whole hospital.) PRESENT STUDIES During the period of the convulsive therapy studies, many new psychotropic compounds were assessed clinically (5, 21), electrographically (34, 40, 48), and psychophysically (48). The present psychopharmacology evaluation program, based on these studies, was designed to answer the following questions: 1. Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? 2. Are there pretreatment clusters of psychiatric, physiological, and psychological variables which are related to the type of behavioral adaptation? 3. Are such clusters related to the type and degree of physiologi- cal change? As an initial approximation, a double-blind, fixed dosage, ran- �166 MAX FINK dom assignment drug study was undertaken. Based on our clinical experiences three types of compounds were selected on the basis of their EEG patterns. In this study, 203 subjects were referred, and 149 have completed the testing program, from October, 1959 to July, 1961. l. Behavioral Change: In a survey of the behavioral adaptations of patients receiving various psychotropic compounds during 195859, a behavioral typology based on the treatment response and on pretreatment psychiatric profiles was developed (55). In the present study, the typologies are being tested, and various measures of behavioral change studied, including therapist ratings, self-ratings, and various ward observation scales. 2. Neuropsychology: Psychological tasks have been viewed both as indices of behavioral change and as predictive guides in convulsive therapy. Each of these tasks and a selected group of motor tasks are now being assessed for both their capacity to reveal change with various drugs and their capacity to predict change with the drugs in. this program (48). 3. Electroencephalography: In the convulsive therapy studies, the degree of EEG slowing was measured by counting the consecutive waves in selected samples (16). When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques (48), and electronic frequency analysis was introduced in August, 1959. By measurement of the pen deflection for various frequencies from 3 to 33 cps in ten-second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are obtained (52). Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood pressure response to mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. 4. Data Analysis: To analyze the data generated in this study, we have sought the aid of complex statistical methods and computational facilities. Analyses of covariance, correlation matrices, factor analyses, and discriminant function analyses are computations now in progress with these data at the NIMH Psychopharmacology Service Center’s Biometric Laboratory in Washington. THE NEXT STEPS Favored by a national research climate and a cooperative hospital staff, these studies have proceeded vigorously. The assets for research in this setting have been great—a selected, intelligent patient popula- �EXPERIMENTAL PSYCHIATRIC RESEARCH 167 tion resident from six to twelve months, without individual economic limitation of hospital stay; a sophisticated administration tolerant of controlled studies; and approval of a Board of Directors who desire “research” as an institutional function. As Dr. Lewis Robbins noted in his first hospital report in 1959, a specialty hospital can make little impact on the mental illness problems of the community by treatment alone. The successful treatment of 350 patients a year is but little comfort to the 40,000 resident patients in the state hospitals of Long Island. Nor will the annual training of twenty or thirty physicians in the arts of psychotherapy do much to help these unfortunates or the many thousands of ambulatory mentally ill resident in the nation. No, a therapeutic goal alone is salutary but inadequate to our needs. As he proposed, the answer may lie in the dedication of a “research hospital,” as it is here that a specialty hospital can truly excel. The charter has been written in the Board’s assertion of research as a hospital goal. With the assets of an exemplary therapeutic facility, such rededication can provide the stimulus for the continuous study of the cause of mental illness and of methods of therapy. Such dedication would provide the stimulus for comparative and controlled assessments of different therapeutic techniques. Continued study is urgently required of the selection of patients for various therapies; the application and mode of action of the therapies; and the role of social and milieu factors in supporting the effects of our ther- apies. Assessments require a meaningful classification of subjects. The behavioral variables alone, which are the basis of our present diagnostic schemata, are unsatisfactory. Study is urgently required of the applicability of social and demographic variables; psychological task performance profiles; typologies based on behavioral response to defined stresses or drugs; and physiological reactivity measures. Such classifications are also essential for any biochemical, physiological, or evaluative study to provide homogeneous samples and comparable controls. Assessments also require meaningful indices of evaluating change. Present global “improvement” ratings and socialization measures are inadequate. Whether the intervening variable be milieu therapy, psychotherapy, drug therapy, or time, the criteria of behavioral change require definition. The applicability of rating scales, language tasks, self-ratings, psychophysical change scores, family assessments, etc., require study and evaluation. Recent studies of psychotic subjects have provided the suggestion �MAX FINK 168 that there is a neurologic factor in a group of the schizophrenias. The high incidence of electrographic and neurologic dysfunction, the lack of behavioral response to all therapies, and the relentless course of the illness suggest an “organic” involvement in this cluster. Such a substrate must be clearly sought by the application of biochemical, neurophysiological, and epidemiological techniques to various clus- ters of young psychotic subjects. These are broader views of some of the questions studied in the programs in experimental psychiatry of the past seven years. These programs, and the contemporary projects in biochemistry and in medicine, provide models of bootstrap studies undertaken with limited support. A dedication of Hillside Hospital as a Research Institute will provide the needed focus and impetus for the scientific and humanitarian forces of the community to join in a common endeavor to resolve the problems of the mentally ill. Acknowledgment: Participants in these programs include the present members of the Department of Experimental Psychiatry: Ira Belmont, Martin A. Green, Abraham Kaplan, Eric Karp, Donald F. Klein, John C. Kramer, Max Pollack, and Arthur Willner. Former associates included Karl Andermann, Joseph Jaffe, Robert L. Kahn, Hyman Korin, George Krauthamer, Nathaniel Siegel; and Research Fellows Barre Alan, Fred Coleman, Harold Esecover, Stanley Friedman, Henry J. Lefkowits, and Robert Shaw. The cooperation of Arnold G. Blumberg of the Department of Medicine in the present program is gratefully acknowledged. The reports listed here are the result of the collaboration of these workers and the professional staffs of the hospital who gave unstintingly of their time and their good-will. REFERENCES' (1) This Journal, 1:21, 1952; (2) ibid., 2:67, 1953; (3) ibid., 4:3, 1955; (4) ibid., 4:134, 1955; (5) ibid., 5:67, 1956; (6) ibid., 6:197, 1957; (7) ibid., 6:207, 1957; (8) ibid., 6:216, 1957; (9) ibid., 6:229, 1957; (10) ibid., 6:241, 1957. This Journal, 10:84, 1961; (12) ibid., 10:97, 1961; (13) Neurology, 4:211, 1954; (14) Arch. Neurol., Psychiat., 72:233, 1954; (15) ibid., 76:23, 1956; (16) ibid.‘, 78:516, 1957; (17) Conf. Neurol., 16:88, 1956; (18) EEG Clin. Neurophysiol.,9:180, 1957; (19) ibid., 10:162. 1958; (20) ibid., 10:207, 1958. (21) J. Am. Med. Assn., 166:1846, 1958; (22) Dis. Nero. Sys., 19:113, 1958; (23) ibid., 19:227, 1958; (24) Arch. Neurol., Psychiat., 80:380, 1958; (25) ibid., 80:73, 1958; (26) Neurology, 8:682, 1958; (27) Psychopathology of Commum'cation, New York: Grune 8c Stratton, 126, 1958; (28) Psychopharmacology Frontiers, New York: Little, Brown, 325, 1959; (29) Proc. XV Int. Cong. Psychol., North Holland Publ., 238, 1959; (30) J. Nerv. Ment. Dis., 1281243, (11) 1959. (31) Arch. Gen. Psychiat., 1:565, 1959; (32) EEG Clin. Neurophysiol., 11:398, �EXPERIMENTAL PSYCHIATRIC RESEARCH (41) (51) 169 1959; (33) ibid., 12:243, 1960; (34) Canad. Psychiat. Assn. 1., 4:166S, 1959; (35) Proc. Int. Cong. Neurol. Sci., Pergamon, 613, 1959; (36) Am. J. Psychol., 72:384. 1959; (37) J. Neuropsychiat., 1:45, 1959; (38) EEG Clin. Neurophysiol., 12:359, 1960; (39) Am. J. Psychiat., 116:839, 1960; (40) Neuro-Psychopharmacol., 1:441, Elsevier, 1960. J. Nerv. Ment. Dis, 130:235, 1960; (42) ibid., 130:187, 1960; (43) Arch. Neurol., 2:547, 1960; (44) Dynamics of Psychiatric Drug Therapy, Springfield: Thomas, 29, 1960; (45) ]. Neuropsychiat., 1:242, 1960; (46) Am. J. Psychother., 15:46, 1961; (47) Neuro-Psychopharmacol., 2:30, Elsevier, 1961 ; (48) ibid., 2:381, 1961; (49) Arch. Gen. Psychiat., 4:259, 1961; (50) ibid., 5:30, 1961. J. New. Ment. Dis., 132:153, 1961 ; (52) Medicina Experimentalis (in press); (54) Arch. Gen. Psychiat., (53) VA Conf. Psychopharmacology (in press); 2:652, 1960; (55) Unpublished manuscript; (56) Psychiatry, 21:249, 1958; (57) Comparative Psycholinguistic Analysis of Two Psychotherapeutic Interviews. New York: Int. Univ. Press, 1961. ' Due to the length of this Bibliography, it is presented in an abbreviated form. ��IIPRIIIBIIAL PBIGIIATEIO 13831303 A! IILLBIBI noiiow and Proapoct HI: Pink, 3.9. Iron tho Dopsriuont of Export-cutnl Psychin$ry, 31113160 Hospittl, clan Oaks, L.I., 1.!. 2h. Itud1fil roportod hart hi1. baa: ntdud hr tho Board Dir-ctoro Research Fund; thc lttiannl Instituto or I: Honttl nutlth (Grants l-927; I!-2092,-2715,-h7983 nr~12,033); POIndationl Fund for honoureh 1: Psychiatry (373? 56-151); xuutnan§, tad Dalian fantastical; and lustrou- pharnao ooutionl cost-rap tncIudinx 60131, Briatbl, Wrath and Snith, K1130 a Iroach Lnboratorioa. 1': 10/1/61 �Exporinontol Poyohtotrio Rooooroh ot Htlloido lovtov ood Proopoot tho dodtoottou of 3111-14. Boopttol oo o Rooooreh Inotttoto boo boon o drooo o! nony or 1to otudooto - o drool that nay oohiovo rooliootion in thin dooodo.< Dr. 3. toroohov woo on oorly propoooot of thio vtow, ood both in hto oponoorohip of tho Joorool, ond to his onooorozonont or rooooreh otldtoo, ho prooosod thio dovolopuoot. no woo oloo tho toodvortoot oiro at tho rooooroh otodtoo 1n oxporioontol poyohtotry. “halo 1 woo o rootdoot 1n poyohtotry to 1952, no oolloborotod in o otudy or tho ro~ lotion of tho oorlr ooporotsoo of child tron o ohotoo tho poroot to odolt of uoorooto. notion13¢ tho hoopttol rooordo o: ttvo proviomoyyooro no oonolodod thot thoro woo, todood, o rolotioo nourotto pottooto with otooooionol oouroooo hod oigoitxoootly xrootor tooxdoooo o: ooporotioo thou potiooto with hyotoriool oonroooo (a). rhto roport woo tho boctooinc of tho potioot popolottoo otodxoo dooorabod horo. stnoo 19Sh tho vortooo progrooo 1o exportoontol poyohiotry hooo boon dovotod to on ondorotoodtog of tho undo o: o U �.2.- antioo of tho poyehiatric thoropioo of tho hoopitol. rho tochniquoo hovo boon odoptod tron doooriptivo ood dylooio payohiotry, oouropoyoholou, olootroonoopholonophy, linguiotiuo, phoroooology, ood sociology. Ihio roport roviowo thooo otudioo ond prooooto support for tho erootion or o nooooroh lootitoto ot lilloido. PIS! SIFDIBS In our early ttudioo or oonvoloivo thoropy, inotitotod with tho oid o: o grout oword of tho Iotionol Institoto o: nontoi Roolth, ovoluotioal o: potioot iaprovonont woro ohown to to dopoodont both on choocoo in broio function ond on poyoholociool tootoro. AI our Indorotondioz of oonvoloivo thoropy dovolopod, o gonorol nooropnyoioloxio~ odoptivo viow'o: ooIotio thoropioo ooorgod (6). i cholgo in brain function woo oooo oo o noooooory condition for hohoviorol ohonuo, with tho typo or chooco, houovor, voryiu; dogoadin; upon poyoholocicol oud oooio— logiool chorooto'iotioo ox tho outjoot (22,25). thou, tho oodo o: ootioo woo not too: oo oithor “orgooie' or ”prlyoholouinl' but rotbor oo tho iotoroction or non-ophyoiologiool chooaoo nod individual pottoroo o: rooponoo oud bohovior. fhio hynothooio ' woo oootoiood in otodioo or convulsivo old insulin oono thoropioo (21,22); and tho oodo or action of tho now psychotropic oconto woo ozprooood within thin �.3. payohoiropic'drugn that It would bu urinativo to tho uxtnn‘ thu‘ pcrllutcnt ehgugon k.— fiypo or tho tad induncd; that brain Inuation ugro in hnvtoral reopens. would bu rolntcd to tn. iypo o: br¢1a hypothosta. wan unggun‘od chnnga, and to individual pro-norb1d psychologie (par-caulitr) vtttnrns (6,28,ho). consu1;1v3 thcrngz Draco-s: Soaking a noncaro of gltorcd nourOphgstoleglogl «hangs that w:- annuitivo 1. tnitnblo for rcpol#od rutolta, various nan-urns wort studigd inpludinx chanson in tho ts¢o~hand tout (1,10,13,35), nanory tout; (17,35), anoant .1 slow utvn activity 1» tit :30 (16,23) tld contnbulatory and duaial languago pfit‘Orll attur nuebarbitul (3,15). an. llttor two, EBB und unubnrbittl touts, Hit. tbs nest oonlttlvo indie.- o: chaulc 1a convulnivo thgrtpy subjects. In on. uxpcrincnt, clinical rating: a: taprcvcfiont var. carrolatod wi‘h high 6.320.! of chungo in than. indicol (15,16). 2)... oblcrvutlon: wore touted 1n n doublo-bltnd study in which p;titntl tutorrod tor oloctroahock worn rindauly ‘3313306 to oithor convulsivo cr anhconvnlsivu and . therapy. nigh dour-on o£_oltetrogrnphic Ilcw wave :otivity and pastfiivg nnfibarbttnl tout: warn obsorvod only 13 the convulaivc group3~1nprovcutnt titan were algntticuntly highQr in this group, and whnn subconvn1I1Vt aubjccto var. retransod by convulnsvo applications, (he tnprovogout rat. way 31:31.: to tho ooarulstvo ureup (22). �.3. In sibeonvuluivo applications, nousidornblo oloatric current pgaau: botwugn the cleatrudou. It wan pontulntod that tho ihcrapoustc tguut was nut tin $Otl1 olootrt¢:1 current, r so, but_thu ":11 or nonn' quali$7 llhiftl‘td by tho crana 331 Ittluro (9,23,h2). 2h. Itcniriounao o: tut [rand 3:1 .oisuro was «an-$306 in n ounparuttv. study of sh. 13ha1:nt oonvulutut, lnxaflnnrodiothylathnr (Indckloa), :nd clnotrtotlly inducad soituroa. 81:11:: dour... ct olcatrtcrnphao chango, improvuuunt rat‘s, typo. or bohnviornl ndtptntionn, Ind ohnnxcn in Inuropcychnltgiotl talk hchavior war. ohocrvod 1n bush tho inhalant And in tho alcctraa;117 tronfiod crouy: (k9). Kuvonr, not ‘11 Iibaootl auntie-ting high dccroo: or phyttolbgiaal thugs. var. avnluttcd .3 “improved“. I: n doncrtp‘tvo typologia Ifindy,_£1vo .dnptivn aldol war. dusoribod, cupirxcslly torund “ouphorto', ”hypunnaic‘, "nmuuuon', 'mmnld-wtthdravnl', Vial. ‘h. strut tun pattcrnn ltttcr worn ratcd and ”pan“ . an 'uuoh inprovnd', var. loan as 'undnpruvod' or “war-0' (So). In utudloa at plynholoaicnl varinblou, it was ruportod that pationtn ratod “much inpravcd’ $36 'rocovorod' troquently nanitultnd parloatlttw pattern: :kin t. tho explicit vurbal dcntnl parnonnlity type (37). 2h... pattoutn cxproslod tho ”innauago a: 6.3151“ nor. troguontly than uninprov‘d aubjoctl, antibiting such asp-oil a: tho two �-5- explicit deeiel, einieieetiee, dieyleeeeeet eed oliehee (27). Other perchelexieel indieee else releted te fevereble eeteeee included high I fleele eeere (ha). nereeheeh deternieente ex eeler, ebeent eeveeeet eed ebeeet rereneier (30,h5), eed lee edueetieael eehieveeent eed rereice birth (31). 2. Aetiohelieer ie cenmeuede end Geeveleive There seeking e we: te enceeet the degree at peet-eeevuleive EEG e10? were eetivity, en eetiehelieergie deepened dietheeine, wee given intreveueeely e. verioue etegee or the ceavuleive therepy preeeee (20,2h)Q Unexpectedly, dietheeiee eeeeed en ieeediete end eeeteined deareeee in EEG elewiec, ehieh wee eeeeeieted with eerked cheagee in lengeeae end need. In petieete with deeiel leeteege petterne (21), theee oeuid no longer be elicited. Ineteed e! eupherie eed well 'heing, the subjects beoeee'irriteble, enxieus end coepleiuinn. In eebjeote prior to convulsive or drug therepy, dietheeine induced exeiteeent, teeeiee, eexidty end illeeery eeeeetieee. Subeeqeeet-etediee with ether centrel entiehelinergie cenpeeede end eyepethenieetie helleeieegeee ehewed behevier end electregrephic petteree eieiler to dietheeiee. the-e ebeervetieee led te the eeaxeetien thet ee ieereeee ie the ehelieergic eetivity at the eentrel eerveee eyetee wee the bieoheeieel beeie to: the eenveleive therepy preceee (38). �-6Iad‘filat Fallowing thtli Itudiou, tn. neurophyliolosic‘l august: induond by drugwar! touted within a. acito oxporiadnt.1 EEG Iotttng. It run obitrvod Butt phnuothinuianu induced BIG synchronxuuticn and a Ihittlnc at tun Iroqunncy spectrum to tbs slew Iroqunuotons taprobannfic and barbituratoa, tn agar-1:04 lynchruatagsgon ;nd a ahttt of thy spectrum to tact troquaauiau; rosorptnu, an iuaruatod slowing with uynohrcn3. ?a tutttoa at chair: is ,r law dontgua, gnd doqynohronitasion IIVOII (18,26,28,ho). at hiahur Iazprnliao induced douynchronination with a sun .1 trauma to the now bud: (33,310. Each ‘otivu psychotrnpia compound wgu #hu: about to ant. a charactnriatic trnqnoacy patturn. Vtriouo 9th.: axpcrtncafisl coipounda wort also tantad and tar than.. no noafiistcnt ulcotrogruphic pattart was rooordod. In... ounpuinds bl?! Gino. boon nhawa to have dittor no ¢r vary limitad clinical psychotropic :ctivity. rho .bIOflei of bahaviurul chins. with than. coupoundo loot turthor uupport Sc tho anlunptton that 32.1: chnnco is a accosstry condition far the nefiion of puyehntrOptc drugs. 2h... obncrvnfisons auccoattd thnt psychophgrnncou 10310.1 tannin provide a noun: icr niioitin; vnriou- typgs or altarod brain function in coltrnst to tho $13319 pattcrn following canvalniva tharupy. furthermora, tn. type a: luurophrliolocionl altorution, an rallcotod in EEG Iyuohrcay �.1and traqucncy patfiorns, val round rcln‘cd to 0’0011106 a: bohnvicrul adaptation. 2h: ndvnntazu 0: £80 toohnancs to: tho ‘Icay at new psychotrOpic taunt. sad types fihy toohntcnl tarts: or aloo‘rontu Iroquanoy tally-t- «or. unnarcd and dolcrihod (£7.52). h. Insulin can: fhnragz: In our inluliu can: studies we ocuttrnod anrlaor observations that porutntout alfiorntiona or brain tunottom were taint-d to prolonsud «one and upcntanaonu nuilnrou; and tau in this rolntioanhtp suppert for n nitroplyltologtc~ndapttvo hwpothontl. With thc grailnbtlitr 01 ‘h. ncv psychotropic asant chlnrprunasinn, a ountrollod?chlorprunaltao Insult: can; atudy was undartnkon in Sop‘anbgr 1955‘ AI patiaata war. rotorrod for insulin aim: tun: get: rundonly unsignod fin couraos or nithor oral chlorprcualino for at IQlIt 3 months in dosoa adJuIt-d #0 1111 short of toxicity; or'tnnultn cans, induoud by s uuhmd «chateau at last» so was 1: «ch pattont. Vh110 a uI-bur or ulnar distoroncou worn noted in comparing the two thgrnpigs, thn results at tile or dicohtrac chewed no stutilfitonl ditrorcnco in tho offsettVQBQnI at both traatncntl. loithnr troutunat £00.06 to affect tn. bantc nonsquhrcnto procons, but chlorpro-asino had tn. advantagot boing 3:202, tacit: to adniniator, lad hotter suited so long torn unnnzunont (21). concurrontly, following the 0“goutton by £ha Or-odnoqr worker. thtt dividod insulin �.3. doooa woro aofiorior to olaglo insulin doooo, Bloabor; and Ladoroao oooayod thin probloo and donorotratod no significant oorit to tho oulttplo dooo toohoiquo (19). (lo 1958. £91 ral courtroa too at hooo oboorvotiono tho a , 5. floor woro adaptod oho :' Various poychaphyoloal tooto tron oooropoyoholozy, whoro thoir signitioaooo to brain da-agod onbdocto had boon dononotratod. 1h. oarly otodioo aooooood thooo took: on lodlcoo a: altorod brain rotation (35), aod ooaaurod tho ranzo of portornaocoo or poyohtotrlc patiooto, who oro conorally aooonad not to to brolo dana‘od. Into, looory function woo aooooood on inoodiato roooll, artor vorlouo tutorpolatod loorninc tooko (11,35), aa roll ao aorta: coorulolvo thorapy (1?). rootilo porooptoal tooko voro tirot oxaninod to tho clioioal population (1). Lator, with ooro oonoitivo eloctrioal tootilo otlaoli, Karin oboorvod tho raafio o1 throoholdo 1a dittoroot body parto (10), tho ohaogoo with altorod . brain function (10) and tho inflooooo or oot (inotrootloo) on porforaanoo (36). Ho also studied tho porooption o: ooboddod gooootrio figuroo (h3), toohiotoooopio prooootatloo o1 ooboddod color rigoroo (55), porooptloo of tho vzoual oprlsht (55). orltlool illokor froqaoocr (h?) and 1ntor~ toroooo 1n roadtag tioo by dolayod auditory toodbaok (55). For oooh took, tho dogroo of dooroaoat 1» took portoroaooo �-9- gastttvaly oarralatad with tha anoint at 386 aldwtas. Folluuina troatnoat couplattan, with an. rota»: at partialoatoal tadtaaa ta pre-traatlaat lavala, partaraauoa in thaaa paychalagioal tanks also rataraad to prautraataant lavala, or tight: -.a battaraanfi a: partoraaaoa aacribad to practiaa afract. waa found $0 be concurrautly, aaaaaanant or varioua payoholaxtcal aaaauraa an indicaa pradictiva or behavioral «hang. daring convulsive and drug tharaptaa lad to studiaa of the Rorschach datarninanta (30,h5). calitornia F Seala nonra(30;h2), languaco pattern. attar atobarbital (21), daatal acarae an antarviaw (3:) and tha paroapttan of tho visual upright and auditory taadback (55). 6. razehalég‘uiattoa: concurrant with an: syntactic studio: languaua (27), analyaaa of othar languaga pattaraa warn andartakan, boat 1: a aaarch tor aura objective xadiaaa a: bahavtaral chaaua and to gain oxparianca in the taehnioal pwablana of tapa aaalyaia tar payahatharapy research. La . influx of variability in the vocabulary of apaaoh, tha typo- tokaa-ratio (if!) of eonaacufiavo Iaaplaa of dyadic apaaoh, wu “unholy atudiod (1,h1,hh.h6,56). In convulsiv. aharapy patxanta, aigaiftoant chanson 1n TIE naan hué standard daviationa war. ralatnd bofih to the dagraa or iadaaad 280 slow wave activity and to ayniactic �~10- lcnlicsc puitarnl abicincd in indcpcndcnt tircotnrcd intnrvicvn. It was cocoa that uptick bola-o norrepetitive (lav-rod not: III) an! acre varinblo in colaocntiVb cunplc: (kl). In intnrviowl infur- nnd cttor tho intravenous administration or ccntrclly active agents. ainiIcr chanson war. ohlcrvcd. input: which produced prcdo-iaact synchronisation pattorun on tho EEO ware rclctod to a docrctso in «can 1!! cad an incronno in flu: smdcrd duration or ...m. while «synchronising ccapcuada clicitod groatcr variability in cpccch pcticruc and dccrocnc in variabilifir at consecutivu acorn: (hh). 0thcr 1:33:53. Iltlflrlfl atndicd included diatrclc~rclict quoticntc, colt-rotoroncc, and altar:ticnc in till. cad patina. It VIC snag-ntod that than. paychcliuguictic accsuro- arc usctnl techniqnoc for thc operational caclyscl c: phyniolcgical and psychological uttcctc or psychopharnncclcgiccl cgcnta (hh,h6). 7. ling; B‘llli gud Schinaghrcgil: rollcwiug his ' Itudicl at Ittlsccn Ccntnr, PoIlnck ruvicwod th. rclcticnu chip bctwcon can 9! hospitaliscfiicn, intollcctucl tunationils and prognosis in cchincphrcnic childron ind nttad that initiil bagpitalilltica cdclta. H: in childhood cad Idoloaccncc was rclatcd to I.Q. secret in tko cubncrncl tango, dcvicnt pcrxcrnancc on psychanctcr ttlkfl, and nor. �.11; troqasat ratings or 'uaiaprsvsd” ai hospital discharge than was initial haspihaliaaiioa as as adult. rho aarly sad insidious sasst st iha hahsvisral syndrsss “sohissphrsaia‘ was ihas rslatsd to brain dysfunction (5?). Findings saggsai that say ha olsssitiod on davianoy. diffsrsat suhrroaoo s: aohisophrsoia tho basis at asarspsyohslogioal in Considarahlo iotorssi Studios: aooiols‘ioal tho family organisation to vhioh disohargsd patisnhs ohoios‘ wars rotsraing, tho ralatioa a: social factors to sad rssults o: pevohiatrio irsaiaaat, and ihs spaoifio prohlaa of tho ralatioa at thasa factors to irsatasot rorsrral paiisras lad to a ssrisa of population studios. Ia oas study (8), soaoatiao, ago, plaoa at birth and soars on tho California I seals wars significantly rslaisd to tho hypo or thorapy rsasirsd ass tho utilisation of adaaaotivs hospiial ssrviosa. In a ascend study (31), darstioa or hospitalisation, dischargs avaluaiioo and diagnosis wars rslatsd to tho sans social factors, whila in a study of patisht rafuaal of BOT, sitilar relationships wars ohsarvad (51). Thass ohssrvations suggastad a_conparativs and tho three among hospitals study, min-institution batwssn othsr demographic social class and rslationahips 8. ‘ variables (ago, sax, sdooatioo) to tho clinical variablos �.12. at patanat cltulixtcttscn (ataanonal), auruttoa o: inapttuln tuttton. soloctiqn or thornpy and dtuohnrgu uvaluntion 5.1. 3.0: unlocuod. Into. touching tuntttuttolu were :11 thortptcc arc oqaa11y avatlnblo to I11 pntiontl, - nonnincor Foundation Hospital (uppor-clusc, .Protoctant), uttsaohuontta ncntnl lualth Contor (loverclnll, Cathnlic) ind £111.16. Boaptttl (niddlo-claul, Jow1ah). In hack a canytrtton w. turn round tho dittorcaoul 1n duotgnntiona of trontnnnt, diagnoliu tad dtuehargo cvnluatton so dafforbnt an to ugh. nonpartnean difficult. Vhtla III: rolttionnhtpu tatvton Iodill varinblon 1nd 91131c31 Virilbltl var. oblarvad in each heapitnl, to 1001.1 variablo was fauna rclstcd to thc clinical variablo. 1- "01-7 hospital (53?. In an Out-Pattont Departnont utndy, sex, 8‘. 3nd narttallatata: var. found to ho rc1atod to tho acceptancand roawetion at patttuts tad fuilnr. to couplcto tho upplionttuu pIOGOII (5h), that. abatrvnt1¢nl 1; population Ianploa 10d ta coa— current Itmdios or start attituia: 1: tin Iolootion at thorapy (11,12). In a aortas o: ward obnorvation studiol; Kaplun and Lotkawttn indientsd tho significant :01. or otntt attitudes (oupocta11y turning porcannol) in thc rerorrgl tor lubaostn for lunatic thtrcp1on, and in tho tranutcr at pztiontl tron out ward to unothur. It stud. Icloctod ' 1n whaen �-13. fit. tn£1u ca .1 :finxt attitndo t1§n$ soloattoa for drag thorngz, w. g33u03$nd can ward be dontgagtnd an a "ago-avnusas' unit. 2):! van ndagtad in 8:233:34: 1259 and an shor‘lz fihornuttqr 3: the whole hangatul.) mum 8E1“ buriug *ho parioa at the convullivc thsrupy studios, man: nun psychotropic 00:90:36: were attained clinically (5,21) alootrographzgally (3h,h0,h8) ‘fid psychophrttcnllr .(aa). rho pro-ant payehophntuncology cvaluattoa progrta, b;sod on ‘hoao u§udion, was designed in gnaw-r tbs follow- ing'qunltions: I 1. fiber. ; rclntion botvooa COIII9I§XI &lt.rlttga in brcin function tad bahaviurnl Chtflflfl with psychotrOpic drug: on circuic :d-intstrntton? Ar. that. prb-troatnoat cluttcrl of plyohtatric, phy1101031ca1 and psycho- logiotl variablnl which are rolatod to ‘ho flypc at bohnvtoral adaptation? Arc ouch olultcro rclntad to thy typo and dogroo or physiolextcll chango? LI an iatt1;1 upprqxin&t19n, a doubln-blznd, fixed detach, vandal aunt‘s-ant drug study was undartakcn. Blood on our c1131ca1 cxporicaenl throo tIpCI a: compound: var. �Du. oolootod on tho boots o: thotr EEO pottoroo. 1: thin otody, 293 onhjooto woro rotoirod old 1&9 hovo oonplotod tho touting progron, tron ootohor 1959 to July 1951. 1. lohoviorol Chog‘oa In o ourvoy of tho bohoviorol Adoptotioao o: potiouto roooivin; voraoao poyohotropto compounds during 1958-59, o bohoviorol typology boood on tho arootnont rooponoo one on pro-trootnont poyohiotrto protiloo dovolopod (55). In tho pro-out otndy,tho typoloatoo oro botng tootod, old various oooouroo of bohoviorol choogo otodtod, inolnd1n‘ thoropiot ratings, coll-ratingo old various word ohoorvotaoo oooloo. woo 2. ggnr o cholo : Psychological tooko hnvo boon viovod both on indiooo of bohoviorol chonuo and on prodietivo goidoo to convulntvo thoropy. Koch o: thooo tooko and o oolootod group or uotor tooko oro now bozo; oooooood for both thoir oopoaity to rovool ohongo with voriouo drug: ood thotr oopooity to prodiot ohongo with tho drugs to this -pro.ron (hB). 3. Blootrooooogholg‘goggln In tho ooovuloivo thoropy ' otodiot, tho dogroo of slowing woo loooorod by counting tho oonoooutivo wovoo in oolootod oonploo (16). whoa tho noro oubtlo ohongoo or drug ottooto are studied, 1a noooooory to opplr loot todiouo tochniquoo (ha), ond EEG it olootronio froquonoy ontlyoio woo introdocod in August, 1959. I: nooourouont of tho pon dotlootioo for voriouo �.15- ' sooosd is_ton opoois, ropid trsqssssiss tron to nosslrsnsat or oppsrsstly sssll ohsncss is total activity and trout-soy upsets: or. sttsisod.(52). ethos physiological vsristlos stadiod in this 3 33 bps yrogron include tho rooponso of 830 to istrsvsnoos chloru ~pro-suns, blood prosaoro rospouso to nooholyl, tho EKG, radioactive iodine optsko, and saslysss or various blood tad urine olsnsnta. h. hots Ansgzgisx rs onslrso tho dots goosrotsd in this otndy, as hsvs sovxtt tho aid or complex ststisti- colon-thud: and computational tsuilitios. Analyses or notorious, osaj‘rslstioo ”trio", factor analyses and disorisintst function onslrsoo ore connotations new in prouross with this dots at tho III? Psychophsrnsoology aortic. contsr's Biolstris Laboratory in Washington. Ill-l!!! STEPS Favorsd by s notional rososroh ' clissto and s ooopor- stivo hospital staff, thsso studio; hows proooodod vigorously. Rho ssssts for rososroh is.this sotting hi7. toss arsst ~— s solsctsd, intslligont pstisst popnlstiou rssinsnt from six to twolvo months, without individual economic linitstios of hospital stay; a sophistiostsd sdninistrstioa tolorsst or controlled studios; sud spprovsl o: s 30:26 or Birootors who dosirs 'rssosroh' as on institutional function. �~16- eeted 1n hie tiret heepitel repert 1a 1959, e epeetelty heepitel eee eeke little tepeet en the eeetel illeeee prehieee er the seeeehtty by treet— eent elehe. the eeeeeeetel treeteent e: 350 petteate e contort to the h0,000 reeident petteete in but little yeer 1n the etrte heepzltele a: La; Ieleed. I» will the eeeeel treieie. or twenty er thirty phveieieee in the erte e: peyehetherepy do exeh to help theee untertnnetee or the reeident 111 theeeende of in the mentally enbnletery nee: eetiee. he, e therepeetle [eel eleee 1e eelutfiry bet teedeqeete to ear neede. he he prepeeed, the eeewer eey lie in the deeieetiee or 'reeeereh heepttel”, ee it 1e here thet e epeeielty heepttel eee truly excel. the eherter hee been written in the neerd'e eeeertlee er reeeereh ee e heepttel ceel. with the eeeete or en exeeplery therepeette teeility, each rededteetlee eee previde the etieelee tor the centieeeue ether 9! the eeeeee er mental zlheeee end at eethode e1 therepy. Seek dedicatiee ueeld provide the etteulee tor cenperetive and controlled eeeeeeeeete e: dittereet therepeette teehniquee. Centteeed etudy 1e urgently required of the eeleettee e: petseete ter verieee therepiee; the epplieeteee end eede er eetlee e: the therepiee; end the role of eeetel end ntltee :eetere in euppertte; the exteete Le Dr. Levin hehhtee & �.17- o: oar tharaptol. tubjoctl. the hohavioral Vtrtnblou OIOII, which are tin halt: a: on: profiont ditcznltso Ichtnstn, arc taunts-raotcry. at:dy is urgtntly requirod at tho upyltonbtlltr a! aootnl tad dulnarnphtc i:riab1¢a; paybholoutcal t:§k pcrfornancu protilun; twpologinc bnaod ca b-havxoral response to dozinnd Itroaaun or drug.; and physiologicall roactivity measures. such olaantticatioan arc also oniéntial for any biochemical, phyainlogioal or tvnlunttvo study to pravado ha-nzonous 33:91.! and campgrablo outrun. ‘ Alloa§nantu tlnd requsro moaningtul indtcoo of evaluating 05833.. Pros-at global 'tnpro.uncnt“ rating: tad loeaalitttton noctur-n arfi inadequate. Whathor tho 'iatorvuuing variablo bu nilihn thnrnpy, psychothnrapy, sino,‘§héleri£irii at bohhvioril chant. max... «anti-.1»; in.” 3592;131:1511”: a: rung-«1n, drug therapy 0r ' ladguaao #:028, idlt€r££1n3n,wpsyohéphyatéal"ch:n¢cVaéufca. . family CUIOIIIO§$I5I2E2- raqniru study :33 cviilatién; Roount attains of p¢y§hottc hubjoeta has proiidcdv tho succession thit thfirs in a notrolosic factor 1a.: group a: eh: ichisophroainn. The h1¢h tacidoneo er citatro"graphic and aauroloxie éysiunetian, the 153k or behavioral Vidnficulc to all thoripiol, and tut rclontlcna course a: �-18 o illncts nascent: involvontut in thin clustcr. Such a substrate aunt bo-olourly sought by tho app11egt19n of biochemical, nourophyniolegioal and opia daiiologionl toehuiquu to Vitus elation or you; pcyohutio hubgccta. 5: Eh. quontiona broador or 110:. than. arc son. Ittdiud in thc prosrtlz in cxyurimontul psychiatry ot-tho pant aovan yéura. than. programs, and the cantonporury projaots-in hiaahuniatry and in medicino, providc nod-1s It hootuatrgp studios andor;lkon with linitod uupport. ‘A dodieltion at lilllidOIHinitll as a ncaonrch Institutc I111 providc tho neodca £96“. and impetus for tha Iciontltia and hunnnitcriun forces at the oonnnntty to Join in a connea endeavor to roaclva the problems or the tantally £11. fiho 1n “orznn1¢* �LGRROUIOG‘OIIi‘ Participanfil in than. procraua inalndo thprouont ac-bcru a: fih- Dopartnnnt or Expnrtnoutnl tuyohiatry: Its lalnoat, acrtln A. Orton, thrthna Iaplnu, Brio Karp, Beunld 1. £1.13, Joha 0. truncr. an: Pollack and Arthur 33113.3. turner associntad includod Kurl tuner-nun, Joseph 4:230, lobart L. Kahn, Hyman Koran, Goircu Kruathunor, ln£h3n101 81.3.1; and angry J. Lorkauats, untold Intonvur, lid ntrrc Alan. It. couporn$1on 0! Arnold a. Blunborc ot~ Bopartaont of Hodictnn in the protont program in srqtntully the ropor‘s liltod horn are the roault at tun collnboratian of this. tartar. and fit. prutoastonll atQtta a: $h| h0upita1.vha an?! unnttnttnxly or tuttr tin. acknuwlodgnd. and that: nooduw111. �W J. innum- mug. 3:21, 1. was, 67, 1956; 6. 1953; 3. 3. 1955; ha 1952; 93.59201, My 1951; 10. £535.21.» aggmh, man, 53339229, 33539216. 7. 1957; 9. 1951; wgaév. 2. 1951; 1955; 5. 19575 gnu“ 12. 1961; and 35;: 33:81:, J. gag. 13. ”surfing, £3211, 195k; 1!... Arch. Home)... 16. 1956; 15. 195!“ 33311923, 353 3:233, 11. 91, 1961: and. ”an“. 13.516, 1951; can. gut. . 33:88, 11. human-.101. 3:180. 1957! 19. 10:207, 1958; 21. 22. 91!. 21;. Arch. and. Im. haul. 733, 19583 ' Jon. “or. M Ann. 1956; 18. no 011:. 32:162. 1953; 20.3113 }_6_§:18h6, 1958; 23. 3333.21221, 1958; 25. 1958; and £9: £33380, . cg ’E‘L‘E 26. Iowa. 33682, 1958; 21. Pazohoutholqz 323. 323113. 1958; w. at Gal-Inna», Brno & Suntan, 126, 1958; 28. PatchesGo. 1959; 325, a Iron Luna, , zbnrnuohg nation, 29. Pros. xv 139. can. Pulp»)... lath fioluud Pthln 238, 1959: 30. 3921.3, 1959. 31. Arch. 00:. PI:«but. $3565, 1959; 32. Egg cm. lam-gm“ . M 531668. 1959: 35- Pros. 33:398. 1959; 33. 6256. Porch. Luna. .1. 0.3.. Install. 501., Forum, 613, 31;. Plzchn . 133381;, 19595 31. J. 1959; 300911011. 35.2w. 36. 1960.: I“. nor. J. 11155, 1959-; �38. Ila 3113. "‘£32Ez.1.13 $30359, 1969; 39. Aunt. J. Plzdhzut. ;;§t839, 19601 ho. lonro~rozghgzhurnneologzll: n(‘) kl. Jeur. Harv. Rant. 31-. $§91235, 1960; ha. ibid $293187, 1960) h}. Arch. H.353 . 3.5h7. 1960; bk. nganien or Puyuhintrio Brag rhorugl, $9, 0.8. rhonnl, 19603 £5. 3. retrogjzoh. $3252, 1960; hé. 130:. J. Pazchuthor. $3; h7. Intro-tszghaghuguncolagz‘gc30, Elsovicr, 19613 hB. than 3:381, 1961: M9. Azeh Gan. rqzuhil . 5:259, 1961; 50. thid 2130, 1961. 56, 19611 ' orv. Rant. 91.. £2gn153, 19613 52. 535:, taint Eggorinontalcs (in prosl)£ 53. '5 can :wggvahogharuneo » (1n 5h. 890111 pro-I): 2‘; Inn‘s; (in prose); SS. Bupub~ lishoa §anulcript3 56. Pszohiltrz 3;:2h9, IQSB; 5?. Arch Gen. Paychiat. 23652, 1960. 51. Jour. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental psychiatric research at Hillside: review and prospect. J Hillside Hosp. 10:15969. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-57-023 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprint from JOURNAL OF THE HILLSIDE HOSPITAL Volume X Nos. 3-4 July-Oct. 1961 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/dcb2d198f268393b586365e8e34503d8.pdf f1412cf3717181597ffc25684c3fe518 PDF Text Text PREDICTION OF INDIVIDUAL PATIENT RESPONSE TO CONVULSIVE'THERAPY 1/ e i - i e ' . <-- Max Fink, M. D. l - E -ku'xs‘b The prediction of response to treatment is a necessary daily task of medical practitioners, who, after a process of clustering the symptoms and signs of illness of a patient, select a treatment regimen most likely to effect a salutary change in the patient. Where the classification of the disease is established by definitive criteria in syphilis. diabeas tes or malaria - the physician's problem is simplified. Where classification is not based on definitive criteria, as in heart disease, or mental disease - the physician's is problem complex. for he must resort to the recognition of pattern based on his individual experiSuch classification is not readily validated, and in the absence of specified external ence. criteria, errors in grouping for therapeutic purposes are frequent. ' wv'h"'" ‘ ' In the instanCes where remedies are established by their effectiveness. as in syphilis, or bacterial infections, or avitaminosis - treatment selection is readily defined. Where remedies are non-specific, as in the treatment of mental illness by environmental manipulation, psychotherapy and various physiodynamic therapies, the problem is complicatcd, not only by the non-specificity of treatment but by the probability that potentially effective therapies are applied to potentially responding and potentially nonresponding pop- -...-....'..-.-....-..—”.y—--—- ,.. ulations. The problem is further complicated b y a lack of evaluative criteria of salutary Various change. approximations are in use, as symptom rating scales, social adaptational measures, patient self-ratings, and changes in target symptoms. These indices are gencrally too broad, too inclusive and too non-specific to be useful. For example, in the target symptom approach, the assumption that anxiety in neurotic phobic, neurotic depressed, or paranoid schizophrenic subjects are equivalent processes is not valid. in Depression various subjects is no more the same phenomenon than is the fever in t mania or lung abscess. c . ' There are, therefore, three aspects to the problem of predicting individual patient response to therapy: the specification of populations (patient selection); the selection of therapy; and the specification and evaluation of behavioral change. These will be aspects described with reference to the convulsive therapy evaluation of the Hillside programs Hospital as studied during .the past seven years. Hillside Hospital is a voluntary, nonprofit, community supported institution in New York City. In these studies, the patients were referred specifically for convulsive therapy by staff psychiatrists to the special somatic treatment unit which was responsible for all somatic treatments at the hospital. .. ' I I mvvv’ ! . ' ; ~<~u .‘-~v- “tn“ a. ' ,,..~..‘..-.... i Observing the usual mixed group of subjects referred for convulsive thera py, we recorded a variety of behavioral adaptive patterns at the times when subjects had received the number of treatments sufficient to i nduce neurophysiological The changes. patterns ineluded euphoria, hypomania, denial, and minimization; loss and increased memory complaining; increased fearfulness, agitation and excitement; and withdrawal, paranoid and delusional ideation. In assessing these patterns, that of euphoria, denial hypomania. and minimization was prominently associated with clinical ratings of much improved and recovered. We termed this adaptive mode "euphoric-hypomanic" and set this as the criteria for the behavioral change which we would like to predict (l). \r I N. Y. ..~: “ Since treatment selection was defined by the institution, our studies focused initially the definition of parameters of change. 1/ From the De partment of Experimental ‘- aw.- 'V.¢§“-.~ Methods on ...._.-.,-..-,',.-»--—s.- Psychiatry, Hillside Hospital, Glen Oaks, L.I a. Aided, in part, by grants M-927 and MY¥Z715 of the National Institute of Mental Health, U.S. Public Health Service. 317 __W_ -_.. ”_.u' ‘U .—:r.. U..- ‘ �(and be therefore this show adaptive pattern to To determine the population prone terms usual diagnostic or the eschewed symp. we recovered) and rated as much improved these studies behavior. During of We measurable aspects more and sought tom check list. the termed which we neuroconvulsive-therapy process the of had develOped a concept a device to as convulsions seen are repeated view. In this (2). view physiologic-adaptive behavioral function brain adap. altered of such conditions the Under alter brain function. attitudinal and factors. sociocultural Thus, individual personality, based on tations emerge indices. attitude and predictive as personality we sought measures of pre-treatment defined that the we studies these had completed we after it was For the most part, of "much clinical ratings the earlier tables these on that "euphoric-denial" pattern, so with this be to equated be. View. in and our reported are, improved" and "recovered" are havioral pattern. Results Earlier of language patterns. was assessment Our first 3. Lan ua e measures. with brain dysfunction that patients demonstrated had (3) Kah and n Weinstein studies by after confabulation and intra. disorientation of denial, changes had characteristic language language these that same observed we study electroshock In one venous amobarbital. those that noted We patient. also of treatments. numbers with increasing changes occurred those not while recovered, evaluated as the ones showing these language changes were content A analysis linguistic unimproved. rated as generally exhibiting the changes were disminimization. denial. be to explicit the in study showed the language patterns rated of tense, of change third use comments, person, cryptic cliches, evasion, placement, (4). with question a and responding withdrawal, qualification, elecafter showed these who patterns language the subjects It seemed probable that treatment before such to . using patterns who have propensity a the be ones troshock would tested therefore. We. test. provocative some by changes if we could elicit the language adinterview, structured short in a questions each patient before electroshock by asking then and repeated and nystagmus. slurred speech until was there amobarbital ministered after amoof changes number language the for the We scored answers the questions (3). barbital (4). We noted a relation between the number of pretreatment language pattern changesthe during manifested clinically of changes number language the to following amobarbital between, also relationship a there was 1'). Furthermore. (Table of treatment week fourth imof much clinical ratings and term short changes the number of pre-treatment language proved and recovered (Table 2). TABLE 1 TO RESPONSE LANGUAGE PRETREATMENT BETWEEN RELATION AND CHANGES CLINICAL AND SODIUM AMOBARBITAL WITHDRAWAL DURING TREATMENT Three or more clinical language patterns“. Pretreatment response to amobarbital sodium pretreatment response to amobarbital sodium No *x2 +x2 318 4. 26; p< . 05. 6. as; p< . 01. Withdrawal reactions to amobarbital sodium: The scorn denial sc< We 1 cal rating score and �TABLE 2 “""“ RELATION OF PRETREATMENT LANGUAGE CHANGES WITH AMOBARBITAL SODIUM TO EVENTUAL CLINICAL RESPONSE V: «vs Change with amobarbital sodium‘I Much Improved 19 -~..-,..’. 68% .-.~.e. .. Moderately Improved _,_ ‘91- _ Unimproved *x2- 10. 30; P < .01 y-a-M-...‘;N -——vr-- b. Famil Interviews. Our second assessment was a denial personality As inventory. patients were referred for convulsive therapy, we interviewed a relative in an unstruc- exploratory interview. The questions were designed to determine the degree to which the patient approximated the explicit verbal described personality type Weinstein by and Kahn (3). On fifteen items, patients were scored on three a scale of l point and 2. 0, The scores were ranked and divided in half - those in the half termed were upper "high denial score" and those in the lower half, as "low denial score" (5). tured, vvvu—n- .vw- . . w».- w— v .AW observed a significant relationship between the denial score and short term clinical ratings (Table 3), In addition. there was a significant between relationship the denial score and the number of clinical language changes during treatment (Table 4). We . -pv TABLE .- 3 ..1..—. RELATION OF DENIAL PERSONALITY TO CLINICAL RESPONSE TO ELECTROSHOCK 'Much Improved Personality Score - ,ewv. .w-vv- Moderately Improved ,V, l4 s 7 u-....r.»-v 21 T,-..,'.«..fl_~. —.s.-—.— .--.-.. TABLE 4 RELATION OF DENIAL PERSONALITY SCORES TO CLINICAL LANGUAGE CHANGES DURING TREATMENT Personality Scores 11-25 (2.0) 0-10 (20) Number Language Changes 8 l7 ‘ 12 3 * . 319 �We the did Rorschach. was task Another not essayed Determinants. Rorschach c. look upon this test in the usual interpretive manner. but scored the number and patterns of Rorschach determinants following the schemata of Klopfcr and Kelley (6). It was observed that ratings of much improved and recovered were associated with the following Rorschach criteria; absent human movement (M). absent form color (PC). few responses, high form percentage (F ). presence of color (C) and color form (GP) or absence of all color. and low shading response. One schedule is reproduced in Figure l (7)- FIGURE 1 RELATION OF RORSCHACH PATTERN TO CLINICAL RESPONSE TO EST °/° NO M, no c M,CF AND [3 MUCH IMPROVED NO M, a\ MODERATELY IMPROVED AND no M,.cF/c M, NO c F6 AND M, FC UNIMPROVED. d. California F Scale. Still another attitudinal task is the California F Scale. This is the which to 10 subject statements of global of uncritical,’ series consists a task simple asked to express the extent of his agreement or disagreement. High scores reflect high agreement, and low scores, high disagreement (8). There was a significant correlation between high F scores and favorable clinical and (9,10) studies factors social out realso carried In we addition, 5). (Table ratings ported that favorable outcome was associated with few years of education. foreign'birth. and older age. ' » TABLE 5 RELATION OF SOCIAL FACTORS TO DISCHARGE RATINGS IN CONVULSIVE THERAPY . Recovered Much Improved Improved and Unimproved 320 Mean F Score 53.1 Mean Age Mean Years Education 7- 50 9. 4 / 10.6 12. 3 Foreign Born ‘ 35 17 �Conclusion summary, we have observed that a variety of pre-treatment measurable aspects of behavior, usually described as personality variables, are associated with the develop— ment of the euphoric-hypomanic adaptive pattern in convulsive therapy and are rated as much improved or recovered in our setting. These variables have been defined in language patterns, denial scores on family interviews, perceptual style reflected in the Rorschach. California F Scale measure of attitude, and the social variables of age, educational level, and birthplace. These personality and social variables provide the perceptual and attitudinal bases for the adaptive changes which occur under the conditions of altered brain function induced by repeated convulsions. Absence of these personality traits, in the presence ,of equivalent degrees of brain function leads to other adaptive patterns, usually rated as "improved" or "unimproved. " and not to the euphoric-hypomanic mode. In The same theoretical model of the neurophysiologic - adaptive interactional hypothesis is applicable to drug therapy (2, ll). We would suggest that different agents are psychopharmaceutically useful to the extent that brain function is altered systematically. These can be measured by the electroencephalogram, although not exclusively. Under the conditions of persistent altered brain function, changes in adaptation will occur, dependent on pre-treatment personality variables. These can be specified, and studies now in progress at Hillside Hospital are assessing this model for various psychotropic agents. References (1) Pink. M. and Kahn, R. L. : Patterns of Behavioral Change and Improvement in Convulsive Therapy. AMA Arch. Gen. Psychiat. (in press). (2) Fink, M. : A Unified Theory of the Action of Physiodynamic Therapies". J. Hillside (3) Weinstein, E.A. and Kahn, R. L. : Denial of Illness: Smbolic and Physiological Aspects, Springfield, Ill. C. C. Thomas, 1955. (4) Kahn, R. L. and Fink. M.: Changes in Language During Electroshock Therapy. Psycho atholo of Communication, Ed. Hoch. P. and Zubin. J., Grune & Stratton 1958, pp. l26-139. (5) Kahn, R. L. and Fink, M. : Personality Factors in Behavioral Response to Electroshock Therapy. J. Neuropsych. 545-49. 1959. (6) Klopfer. (7) Kahn, R. L. and Fink, M. : Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. J. Neuropsych. _1_: 242-245, 1960. (8) Kahn, R. L. , Pollack, M. , and Fink, M. : Social Attitude (California F Scale) and Convulsive Therapy. Jour. Nerv. Ment. Dis. L351: 187-192, 1960. (9) Kahn, R. L. , Pollack, M. and Fink. M. : Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp. 2: Zl6-228. I957. (10) Kahn, R. L. , Pollack, M. and Fink, M. : Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization. Discharge Ratings and Diagnosis. AMA Arch. Gen. Psychia . l_: 565-574. 1959. 1942. (ll) Fink, B._ and Kelley, D.: The Rorschach Technique. New York, World Book Co. . EEG and Behavioral Effects of Psychopharmacologic Agents. NeuroPsychopharmacology. ed. Bradley. P. . Elsevier, Amsterdam, 441-446. 1960. M. : DR. LASKY: .,- Thank you Dr. Fink. Do members of the panel have any questions or comments? 'r~ r- ”‘5 | 321 ”.“wnpm‘. �DR. KLERMAN: I Max, you presented with a fair amount of specificity, the personality and social fac. tors which characterize the patient. Iwas disappointed in that the other half of your neuro-adaptive scheme was left unspecified. Namely, is there any specificity in the alter. ation of brain function that is as predictive as these specific social and persouality factors? ‘ . patien1 adapta to tree will nc brain are co convul nnl, tt that hi . DR. PINK: answer to that is that we do have considerable specificity for the various treatments that we use. If I might have Figure 2. This Figure will show that we did use electroencephalographic measures. We were rating the EEG changes according to criteria which we called high degree-slow wave activity. This index could be specified and quantified. After determining which records were "high degree" slow wave activity, we were able to go back and look at the patients who had shown the much improved category, the moderately improved and the unimproved. It is apparent that of the patients who were in the much improved group, about 90% of the records of that group had shown high degrees of EEG change during the third. and fourth weeks of treatment. It is also clear that the pa. tient's who were "unimproved" did not show the high degrees of EEG change. We interpret these data to indicate that unless a patient has a high degree of EEG change he will not .show behavioral change. It is necessary to have changes in brain function and it is under the conditions of the brain change that adaptive change will ocdur. The type of adaptive change depends on these personality variables. In drug therapy we have other EEG patterns which can also be specified. I think the change 'shock. - DR ' L I schalk comm much crude with tl ' DR. F FIGURE 2 I . h. r . >‘ ,._ o—MUCH IMPROVED (u) E ..... moo IMPRovsom g S 3O ‘ - DR. 7 _ umumoveom (3 spe cif tional being . ‘ has s‘c UJ LL] as 0 0 $ DR. F LL! I reflec know \ “I": atric 6 5 u these more our e1 ber of E: we do much eupho: being: 2% if ‘ ' 4'6 7'9 “242 NUMBER OF TREATMENTS statin: . behavj which . . DR. KLERMAN. Is one difference between this kind of physiologic measure and the other measures in that they occupy different type predictive factor? Would you say here that unless the patient has this characteristic, EEG changes, he will not subsequently develop behavior and adaptive changes but can you predict before the treatment in any physiologic way whether or not a given patient will manifest these characteristic delta wave changes 7 In other words there is a difference between a predictive variable that you described as existing or .. characteristic with the patient prior to his exposure to the treatment and a predictive variable that says he must experience a certain kind of change under the influence of the so- matic therapy. 322 : ‘ - this a‘ $323: - ation This i ‘ :fifhfi hospit e ducai �PINK: I think what you are asking is whether we can predict the physiologic response of the patient. I think we can, although this is much more difficult than predicting the behavioral adaptation. We still do not know what the determinants are or how to measure them prior to treatment, to predict whether a person will or will not show a drug response or will or will not show a physiologic response. The question is not one of a sequence, where altered brain function comes first and then the subjects involuntarily adapt to it. These processess arc concurrent. At the time that brain function is changing under the influence of repeated convulsions or under the influence of repeated doses of drugs, the perceptual, the attitudinal, the conceptual and all the other aspects of patient behavior are undergoing change so that his whole view of life and his response to his environment is changed. The kind of change he shows depends on his pretreatment propensities, as we tried to show on electroshock. DR. ‘\ x v w -« ~ .rv-w--. "a... mv‘vo—‘w “ o...— DR. LASKY: 01-- - Dr. Fink, we'll ask another question or two. They are short ones. think Dr. Gottschalk and I have something rather similar in mind. Now, the one I had was--Could you comment On your criterion. You used a three level over-all clinical rating of recovery, much improved and improved. Now the question that comes to my mind is why use such a crude criterion when you are using rather quantitative measures as predicters and ties in with that, of course, what (ices this criterion mean that a man is "improved" 7 I DR. ”on mu w-wfinwvr'Vb-‘M FINK: Dr. Gottschalk, do you want to ask something ? w-vfimnmm DR. GOTTSCHALK: Well, I had a somewhat similar question, but I have focused on something a bit more specific than that--As whether Dr. Fink had any idea why those people with lower educational levels tended to have more improvement, was this possibly because of the goals being less as compared say to persons with higher educational levels, then of course this has some relationship to the question about the criterion for improvement. 'r-v-q—vruwm.“ - ‘ a ‘ Wm DR. ‘w FINK: .5 we‘rv .. think that both these questions are crucial ones.. I tried to indicate that our slides reflect early aspects of our studies. At the time that we did these first studies, we did not know what we were using as the eventual criterion of behavioral change. We used psychiatric ratings much as everybody else. This criterion was fairly effective. In the course of these studies, we learned that there were different behavioral modes, and these seem a more meaningful criterion. We are now in the process of assessing patients going through our electroshock program, trying to predict these various modes. Unfortunately, the number of patients referred for electroshock in 1960-61 has dropped off precipitously, so that we do not have a large enough sample. But, the statement of the slides on recovered and much improved reflects, ‘as we look back in our data, those patients who showed the euphoric-hypomanic adaptation. That adaptation can be characterized by a feeling of wellbeing; an attitude on the ward of being fine; dressing up, and participating; and on inquiry stating they are no longer sick or depressed and that there is nothing wrong with me. Such" behavioral changes are the ones that psychiatrists rate as much improved. In our hospital, which is psychodynamically oriented, there are a number of psychiatrists who have seen this adaptation and have said that this is not improvement, but explicit denial is a psy— chotic adaptation. There is, therefore, a problem of evaluating what we mean by much improvedor unimproved. The question about educational level is also related. The evaluation of "much improved" is dependent on the psychiatrist's or the evaluater's attitude. This is one of the reasons why the use of much improved characterizations across hospitals is almost impossible. We tried to show this yesterday in Dr. Pollack's report of our tri-hospital study where discharge ratings did not have the same meaning in the various hospitals. The educational level is important because. there is something about being well educated in the American culture which does not lend itself to the use of the, gross denial I , r‘tV‘W‘WW' mq— v'fT'V-a run-"Vera nrw— m. u~—WWWW—w—wm~n» l—"r'" le‘fp ”r" «- -m .» 1‘ i l t i l i V ‘323 i i i i �\Q institution is this in and reour them, we see as cultures ive The more primit response. who have and in may Europe who born were flected in the people in the older age group the adaptation use or such can people that in Europe, life sustained their early processes American Our younger. intelligent, denial. more verbal do use the adaptation of explicit born girls and boys just don't use gross denial. the for I on use apologize must and. is poor very The use of improved categorization The next studies. started our the we is that way the slides, but Ihad to use it because reflect will but an have not will that. two hence, series of slides, hopefully a year or that have teased think we which we predictors the" hope we Then adaptive mode typology. differences. those in demonstrating effective be will out using improving categories in ap procedure by investi; In or pharmacol lucidly, tc jsctive es; of familia: able dosa; 'age level not associ experimer pipradr‘ol tect: 47 ju : DR. LASKY: who A. 'Gottschalk. Louis Dr. is next Our speaker Fink. Thank you very much, Dr. Cinof Psychiatry. the Department at Coordinator Research and is Associate Professor to Individual Pay. Response is "Measuring his of title The paper cinnati General Hospital. Free-Associative) Behavior (or Verbal and Method a Introspective an choactive Drugs by Method. " Dr. Gottschalk. Fron the indivic a seconda: by pipradz themselve able to wo one thing themselve duced stin 1 AN BY DRUGS PSYCHOACTIVE TO RESPONSES INDIVIDUAL MEASURING INTROSPECTIVE METHOD AND A VERBAL BEHAVIOR (0R F REE-ASSOCIATIVE) METHOD 1] of accomp] , ‘ Louis A. Gottschalk, M. D. Introduction is a redrugs to psychoactive and individual idiosyncratic responses the Measuring of study and The systematic serious search area of increasing interest to investigators. the fact that the collective effect of such phenomena is made difficult and compounded by and the unique that time the at same the psychoactive drug has to be accurately measured for accounted plausibly whenever possible, and, observed individual effect is being validly at some level of organization. individual the for and accounting of measuring, Approaches to this problem detecting, and methof the Some principal ingenious. been have many drugs to psychoactive response different with major of to of patients a drug administration groups The ods have been: l) suband of behavioral different for patterns psychiatric nosological syndromes and looking psychoneuroschizophrenia, the , category, to diagnostic e.g. jective reactions according 1929; 1953; Bensheim, and 1952 and Pennes, sis, etc., (Beringer, 1927; Hoch, Cattell, of of the relationship Z) determination The 1960). Weinstein, 1953 and 1954; Kornetsky, beor profiles with different personality associated to a drug varying individual reSponses by measured etc. --as hysteria, depression, extraversion, havioral patterns--such as, and (Kornetsky evaluations clinical psychiatric various psychologic inventories or tests or individof the The 3) 1958). assessment a1. 1955; Laverty. , Humphries, 1957; Lasagna, et of defear such a conflict, as, with psychodynamic a ual reactions to a drug associated different The investigation'of 4) 1957). pendence (Gottschalk, et a1. , 1956; Sarwer-Foner, Kurland. 1955; and 1950 1956; et a1., Wolf, and 1955 a1. et . reactions to placebos (Beecher, the hence and effect placebo sometime of powerful the 1960), which provide an indication individual placebo component of the reaction to a drug. of Medicine. of College Cincinnati, of University the Department Psychiatry. 1/ From from (MY-1055) research in grant a by These investigations have been supported part and Welfare. 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In an. c1¢¢Qr9Ihntk study thcnu a... ltuculcc chtngns uacurrna It‘s 1302.531»; nuubnr3 at fiata‘luu‘a. Ho Ill. fitted tint that. ya‘toatu ohiuttgl‘hosc luncu;go chanson war. in. and. ovalultci an vucovnrtd, title than. nut annihitlag the .chnlgta tutu guncrully tutti an unimprovaa. A lingutnttc soatalt‘iathatu ahavud tbs languagu pntfiarna rntca in :3. Iiifly in he uxpllett £03131, Ianilisn£t¢u, dtuplacuutnfi, CVttiuu, clichcu, crypttu ocuanutc, II. of ttlrd purcun, lhlnxt or tonne, withdrtuul. qunlltiaatiun, :nd roupondxug with 3 citation (h). Xi aaauct probahzu that $3: Iuhsuotc It. august thin. Inusutcu puttcrnc utter aluo‘rcchuok vuuld be the fill any but! u prnpauatty to I‘tflg itch 9I$itlil burst. truatHOQt �.5g' II tait. 12 00:13 olacit sh. laacuago «haunt. by nous prcvcau£1vo no, uhurgtovo. tou‘od 0:0h putanut tutors ulnafircshank by acting qncstloan in t abort a‘rtttnrla intOtvtiu, Idntaiafiartd unohnrbtfial uu‘xl that: In: Ilnrr-d apo¢ah lad ayatngnnn, and #305 rtpuated tho quca‘iout (3). we luarcd tbs Innunrn {pr tho u‘ubur at luagulgc chanson altar mu»! alficd 0:). at u rolatlln butv.uu the ntnbgr or pru~ $I¢utuuai language puttnru chi-go: following :noharbttul ta £hn mutate a: luugnnao chtngcs Ianttuu£ad 311310311: during tn. fourth rock 0: tran‘nout (Tunic I). Furtharnnro, that. can :13. $ rolationohxp httfllfln tn. nuibcr or protrottlout linguoco chanson and about torn clinics: rating: find rtcovorod (tabla 11). or Inch ingrowcd fi‘-‘ .. O“ 40“ ‘ rabltu I, I! 3. ltully Iatorvituw : dautnl p¢raoa31tty rotorrcd it: touvulttvo thnrnpy, Our accond aunnolnnat at; savvniory. In patients worn no tltnrvinuod a ruxttlvu an an uanructurod, caploratorr £n$orvicu. fun qunatton: var! 60313306 ta actarline the vhtci 303:3. to tic pat10u% .pariualutcd tbs axpllost vvrbul plrsonnlity typc duccribol I7 “biacttin Ind tab» (3). an titties itnna, patients were t£09¢4 on & throa point tall. at o, 1 ‘nd 2. 1h. IIOFDI nur- rgnkod and �.75. dividcd in half . thlil in tho app»: htlt cur. taruod 'hxzh Junta: tact.“ and thtst an ‘3. lava: h:1!, us '10! innit! it!!!“ (5). aigaittulut rulutleulhip butauon tin short torn eliutcul rating: (table 111). no abacrvoa a dcnial ntoru and In afidation. chart was a siguztiuuut rulntsonshiy untrue» ‘hn «tutu! IOOIO and it. illhlr or clinical langunso GICIIOI daring £routunu$ (tabla It). D--“m““--‘ 215190 121, IV ..¢..~........ c. lartchnah nutcruanuntu Anothur task cunnyue In: in: lornchtch. 80 did u.% look uyou that tout in thc It!!! inturprctivo nuancr, hat scarce tho IIIbCf and pattcrnt a: Iorlchloh eatcruauv unfit following in. unhonstn 0! 110990: find tollty (6). It III Obaorvcd fihnt vstinga or tank improvud and rucovurad wort tauoain£od with the tailoring Inraohaoh crituric; thaini lunan havonunt (I), ubuuat for: 001.: (re), tut raupauuua. high for: ptroautnco (30), proscuco at atlor (6) Ind 0010: turn (or) if «haunt. a: .11 oolnr, 10' thufliug rulpcntt. can Iahudulo 1: rugrodtco‘ Inblo 1 {7).’ and fihlo V -Wd 1n �.7. a. culitoruia I aetistill anoint! attitudinal tint in tho caiitoruin r 80.1.. this ailpln tank eon-int: at n 0:21.: at 10 unoriiiaai, global sintonnntc to which in. Inbaoct in Ilkod to otprocl the cairn: of his agrcoaont or dinnarcosemi. list .3090. rotioct high tarocnnnt, and low amoroa, hick iiungrtclant (a). that. VII I liguiticuni curt-iniita hair... high r snort. and taverahio clinical rutinga (tail. '1). In addiiion, u. .1:- curriod out toainl factor. Italian (9.10) and roperiod ihai tavorahlo antenna val aaaociuicd with for yuaro or adiaution. tor-inn birth, und .16.: ago. -‘....” Tfiblt VI GQlCEVSIOls In Cilllfy, no but. oboorvcd this a varinty of pr.trottnaat lauuurabia aspect: at b-havior, unually douoribod .3 porooanlitw varinfiina, it. nauociniad with tho devoIOpr nant at tho ouphorieahypolnnio aduptivo pittcrn in unavainivo ihcrnpy and Ir. rated in luck inprcvod u: r-oovorod in our uniting. in... variuklou havo boon auxin-d in language pittorna, Gemini 30.9.. on 2:311: int-trio's, puroapiuni styl- rotlooicd in the nor-chuck, culitorain Sonia nannurn or nttitudc, and in. social variabiao 0: :30, educational 10701, and hirihvluca. r �“as this: permanality and utoitl vurtuhlnu yravtdu tha ptrauptutl and attitudinal bacon tar tug tdnptiva cunngon whiwh oaaur undur thn unufittitag a: Alcarsd Evita function induced a7 rnpcttnd canvulqtoan. tsunami of that. paracn~ alt$y truits. in th. pvncwuua a: aqu£V§lont duct... at Evita lunettun Illdl to 0th.: udtpsivn yu‘turna. attally an to m “mm-4'«ass-9W», a» am a. maman ’ hypluunic luau. the Inn. tha0r0£1oil natal a! tin acurnphyuialouic ¢ IdlpttVI znt¢ra¢tinnn1 hypcahc-is 1: nppliauqu ‘0 drug Gillan-at ig'n‘l ihcrnpy (2.11). "b woula sugguut at. yaynhupharnucnatsaally~1:0!!! tn tho extant that brain tuucslon In Il‘trfid ayataunttenklr. Yucca can bu nonsurud By tin olnatraanoaphulogrnn. althangh ant axalautvqu. Ulnar eh. eundttaouu at pcrnlntent n1£arn¢ hrgia run¢£1ou, ohtugua in aiuptntauu V111 ficaur, dcycnauut 0n prnutruutnwut tht pgrioanltty vurinhlus. 3!... «an h. apouttiaa, tad attitaa piogrunt law in ut lilllidt.‘0.vti¢1 av: nanotling thin nodal :0: variant ya:who$ropio Iz¢ntu. �1a iiuk; l. and tab». 3.3.2 rattcruu at iwhuvturtl nhnsun and Improvunous in auavu111Vt fhnrlpy. 5g; arch. 633: _!gzgg;gt. (in prnsu). a. tint, 5.: 1 Iaitsod fhnory at tho fiction 0! thytisdynnnta $303351... 2. la;§¢§da gang. g; 197*206, 1957. J. Unina£¢$a, 3.1. Ind Kuhn, 1.x.u 9593:; at ;;;ngtug 8M..; 4,“, ¢.c. rkants, 1955. laka, 3.5. and link, n.v' Ghatgct in » - ‘ s . l. A ; Satanic“, In. $nngungc During llocirauhuck Ihavtpy. r Ed. au¢n, 9. an: zubgn, a., Eran. s acrnttaa 1955, pp. 126-139. Ital, 3.1. tut rink. 3.: ruraouniity ructora 1a Behavinrtl laupnnio to Exactruahock Ikurayy. 3. xtnrgggzgh. 53 . &5«u9, 1959. tlnytar, a. raahtnh itchns nu. It! Ibrk, khrld Beak $6., lfiha. labs, B.L. and Fink, n.: Prsgnautit 731:: at Rartehnuh aritarAa in altuical lacyumau t0 cruvulsiwc thorapy. and £01101, 9.3. 2524“, 196a. $d§1fl1 an‘ Attattdo Pallusk, 2.: link, 3.1., u., Illa, {Bularornsu r sail.) ané euavultivv fhcrupy; gaggz_gggzg n¢n3, 23;, 329; xsr~191, late. 3.? una Social raatnra in lain, I.&., rilluck, x. rant, galactiua at Therapy in u Vtiuu‘nry lcnttl lbtpttll. a, :zzxsasg 5352, g; 21£~2¢a, 1957. 1, trauma”. 9» -ho 8 0 A: �13.. mm. 3.3... Mink, “put: 0: Psychiatric huugs and amt.» n. Mutton a: 91mm“. 565-515., 195’. In as an mu “on”. flak, 8.: Boominholuie tht banana“... it. and rank. is: a m alumina). Arch. “In-nun mm Mums. M: g mthat, y taut; a: antenna”. $3me Slum”, mum, mama, 1960. Mnualuz, «I. 11% . III-why, h, �153;! I Relatian Dotuvou Prttruatnnat Lfiuutnso Ambuhitnl Sodium and Withdrawal Io. ROIpOIuo clinical chant” atria: to an"? Truatuont then. or nor. aliniasl ltn- Hithdrawul rauc$103. ta that 2A». “A w.» Protrcstlcnt rnaponno to unotarbstll India: 39 EB 60 protrontncnt I.roapouoa to tits bnrbtt;1 nodttn )5 11 31 “x2 $12 . ' 13.26] ’ 6‘88, P < G91 < .05 . pct 00“ 21 10 12 3h .. m. per coat �153;; I! nun-n Mm. or Protruhmnt chann- Huh Sou“ to fight). 61131311 may; m: nut Input“ Hodn‘tolr ”mi Uni-pm“ «:2 - 10.30: 52: r «at. Q _ I with ”an“ m :8 19 68 22 8 3‘ 15 3 to .01 1 put out. «1m �mm lolattoa or again: rationality to eliuitnl g. tinctggghnak Rich thnrutclr gagrlrgd gggruvud Porlanggttz Swag. 11 to 25 0 $0 10 total icspmuac 33§EEI¢V0¢ rota! 15 9 1 2h -II ‘0 NI 23 11 13 0 h? �null-non mg If Maul res-nudity “on: to c1121”: Lluggagu Change. During treatment lumbar , a — 2 3 Or zutuong;gtz acgggu 11-25 (20) 0-19 (20) lutal B 12 11 3 25 15 not. �IA ‘ T Rolatton or Rorschach rusty»: ta clinical Icggoaau 1n cuuvuzuiva I Ind-rutaly Ilprcvvd tad lull taprovod Egagigggti novounat 39 11 (283) 28 (72!) laugh lwvununfi 58 28 (58$) 29 (hit) flu?;; I. rattan; :9 0 10: to ) For:tor: 001:: lo 3b 53 . 6.16. 7 32 p 21$ £601; :3 - 11.570 Both a and re re ” lotthor I nor ’6 num- a h 10 25 21: 25 38 xa awa‘h Xi‘an' ' 4.01 p 3.” {mi 661 “on, P uorrtuttuu {tr diocoatxnut‘r. 2? 21 <2 79% éhefi; .001 20 15 13 C4001 (83% $60!; 3h! �m1; Illntton at 8.31:1 rattorc to Discharge gg£iagl 1n convnlutvo lhurgzz I Iu‘n 1 833a 8 53.1 Itch turret-d 26 Inprcvod an! Uninptcvcd 23 Inc-vurod ,0 abnn that: 3 CV‘ I 1 retail! 3 9.h 10.6 so h1,8 51.6 h3.8 39;? 3!.) 11.3 17 35 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prediction of individual patient response to convulsive therapy. VA Cooperative Chemotherapy Studies in Psychiatry, 6:317-24. 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Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/aaac38fc36161269f14f4617b6ef620f.pdf 09f64ba46dc2ab1bcb50e506d78ad27a PDF Text Text v._, SOCIAL ASPECTS OF PSYCHIATRIC TREATMENT IN THREE HOSPITALS: METHODOLOGICAL PROBLEMS 1/ «- hoWCV‘ in Max Pollack, Ph. D. , Nathaniel Siegel, Ph. D. Robert L. Kahn, Ph. D. , and Max Fink,_M. D. - inst logic P hospit‘ same } scitiflg The generalization of findings from one population to another is basic to any science. Psychiatry. perhaps more than other medical specialties. is plagued with controversies concerning the non-reproducibility of results. One factor responsible for this state is the failure of investigators to adequately describe their populations and methods. The organ. ization of multiple hospital studies makes possible the detection and clarification of the" methodological difficulties. We would like to describe some of the problems we encountered in a recent tri-hospital study. with reference to the variables of type of treatment, discharge diagnosis, ratings of clinical improvement at time of. discharge and length of knoWiE tal dis A routin( at MM -ga. would hoapiti hospital stay. pang! Various social psychiatric studies of community and hospital psychiatric populations (1, Z, 6) have established the importance of sociopsychological factors in the type and incidence of mental disorder. the selection and maintenance of treatment and therapeutic evaluations. In these previous studies such selective factors as the patient's financial resources or the extent and type of available treatment facilities may have been more signi. ficant in the observed results than the social variables studied. A more critical test of the role of soda-psychological factors in treatment would be a study in a setting where the same therapeutic techniques and services are available to all patients, regardless of their ability to pay. This requirement is met at Hillside Hospital, and in 1957, we embarked out a program of assaying the relation of sociopsychological factors to the treatment of hospi. talized psychiatric patients (3. 4). Each patient receives individual psychotherapy and by request of his physician, somatotherapy (convulsive or psychopharmacological therapy). Our method of investigation was a census-type survey of all in-patients on a given day (3). In addition a brief modified California F Scale test (2, 5) was administered to all patients. We observed that age, education, sex, foreign-birth. and performance on the California I? Scale were significantly related to choice of treatment, duration of hospitalization, clinical discharge ratings and to clinical diagnosis. order to test the reliability of these findings, we repeated this study at Hillside Hospital in 1958, employing the same procedures and, concurrently extended it to two other institutions. the C. F. Menninger Memorial Hospital and the Massachusetts Mental Health Center (MMHC). These institutions are similar to Hillside Hospital in that both psychoanalytically - oriented psychotherapy and somatic therapies are available. They were selected for the additional reason that one serves predominately socioeconomic Class I and II patients (Menninger Hosp.) and the other. predominately Class IV and V. L soclat' the let that tr psychc of noti chothe basis' with tl tient c psycht chiatr reside I ciplin' .wn-w gists. view $ In (MMHC). Observations Dia n that tl behav the sa sent 5 charg classi these Hospital Structure ducin; reporting data from ones own institution. the structure of the hospital is taken for granted. and either ignored or briefly mentioned. When approaching a new institution._ .When distox Note the department of Experimental Psychiatry, l/ N.From Y. Hillside Hospital Glen Oaks, 1... I. . Aided. in part, by grant MY-Z715 of the National Institute of Mental Health; and the Nassau County Mental Health Board. The cooperation of the staffs of the Massachusetts Mental Health Center and the C. F. ' Menninger Memorial Hospital is gratefully acknowledged. . 202 ‘ and a five-f comp rion ( Disc}: the c: prove �r, 7' attempting to gather comparable data one is made aware of the differences institutions and the nature of the hospital organization is seen as one of the methodoBoth the MMHC and Menninger institutions have day logic problems affecting treatment. physician can care for the hospital units.and Hillside does not. At the MMHC the treating clinic. In such a in the and after-care in the hospital, day in-patient, an ”me patient as the at from an earlier date, hospital ,ctting’ the treating doctor can dischargeforthe‘patient in Hillside Hospiwhereas his patient's care; be he still responsible will that Mowing of the relationship. termination patient-doctor ux discharge means towcvcr- and in . "ru‘ ~1uwv1 different research programs. affecting clinical survey, approximately 20 percent of the patients been had and ill hospitalized for many years. Such a group at MMHC were chronically state would not normally have been in this hospital but they were transferred from another hospital for special study purposes. Designation of Type of Treatment In our assessments of specific variables, we encountered a variety of problems associated with the content of hospital records. For example, it was difficult to determine of time spent in the length of stay prior to referral for a somatic treatment, or the length that treatment. However, a major problem was to learn which patients were receiving psychotherapy. Our task was not to define psychotherapy, but the much simpler problem of noting Which patients were designated by the hospital as having been treated with psy- ‘ chotherapy. At Menninger Hosptial, psychotherapy was administered on a prescription basis by a staff psychiatrist for which the patient was charged an additional fee. Sessions with the psychiatric resident physician were considered part of routine administrative patient care and were not recorded as psychotherapy. At Hillside Hospital the definition of psypsychotherapy was limited to treatment sessions with the psychiatric resident. Staff the chiatrists did not treat patients directly, but restricted their activity to supervising Another problem was the presence of routincs- For example. at the time of the ..... . a. “syn a -w~a.u.r-- M -.M——-.— 5" t V_ . . ,. v.71 _ .I-uv-n- ‘-.p..o-i.m ‘W, runny-.9. -l residents. ‘4,"V‘OQ‘M'A'fi In contrast, at the MMHC psychotherapy was designated as a function of many disciplines - psychiatric residents, nurses. medical students, social workers and psychologists. To ascertain whether or not a patient was receiving psychotherapy we had to inter- view the resident physician in charge of the case. ‘71-'Nuo-nyap ..._...,. ,— —-— -vw“ Diagnosis -\» ,... a... assessment of diagnosis was another problem area. It is not surprising that there are institutional diagnostic “styles which reflect staff orientations rather than the behavior of the patient. Pasamanick and his associates (7) has shown that diagnoses within the same institution are vulnerable to individual differences among examiners. In our present study. there were differences in the terminology of the discharge diagnosis. Discharge diagnoses at Menninger Hospital were more descriptive and employed a multiple classification system. Table I illustrates several examples and shows how we converted these into more generic categories that could be applicable to all three institutions. In reducing multiple diagnoses to single generic ones, we were aware that we were introducing distortions through this maneuver. Table II illustrates the distribution of diagnostic categories within each institution. Note that at the Menninger Hospital there was a lower incidence of diagnosed schizophrenia and affective psychoses. while the diagnosis of personality disorder exceeds by three and five-fold that found in the other two hospitals.- We would emphasize that cross hospital comparisons of populations basedpn diagnosis as the single or the most important criterion does not insure comparability of populations. The .i-u.v.-.‘Mdh& M u--. , ~ ~m.va-»..... P... wv" 4 r .. R." s ~. , . —w . n—‘w—w-vw- \*_sm,~,-.w...—mp-- ' 7 ”avcuuuft Discharge Ratings of Improvement .- Similar problems exist for the equivalence of global ratings of improvement. As in the case of diagnosis, Menninger Hospital had the most elaborate discharge ratings of improvement and Hillside Hospital. the simplest. . 1 ~ A .w» wo-fi-‘v. - w- 2 203 l ': l . . T 1’ �TYPES OF DISCHARGE DIAGNOSIS Patient Discharge Rating 1. Depression Reaction Narcissistic Personality 2. Anxiety Reaction Narcissistic Personality 3. Narcissistic Personality 4. Narcissistic Personality Alcoholism Chronic Infantile Personality 5. Passive Aggressive Personality Alcoholism 6. Infantile Personality Schizophrenic Reaction Schizo-Affective Type Classification Rating Psychoneurosis Psychoneurosis Personality Trait Disturbance Sociopathic Personality Disturbance ' ‘ Sociopathic Personality Disturbance Schizophrenic Psychosis TABLE II DISTRIBUTION OF DIAGNOSIS (PERCENTAGE) Menninger Hillside MMHC Schizophrenia 41 52 52 Personalitybisorders 33 6 Psychoneuroses Affective Psychoses Organic Psychoses Transient Personality Disorder 14 18 8 21 16 5 l 5 2 2 6 100 173 N: 13 , 93 ‘ As shown in Table, III the discharge rating at Menninger Hospital was tripartite and a separate rating given for social, characterological and syndrome changes. Hillside and MMHC had similar global ratings and it is difficult to state how much weight was given to each of the three factors incorporated in the Menninger system. Such differences in systems makes it difficult to compare treatment results of hospitalization. Hospitalization Length of hospitalization for most illnesses, including psychiatric disorders, commonly denotes both severity of illness and response to treatment. As such. it is frequently used as an index for interhospital comparison. Table IV compares length of hospitalization by age at the time of the study. There was an observable relation between length of stay and age within each institution, with age being inversely related to length of hospitalization. Yet. among these three hospitals there were marked differences. When diagnosis is employed a similar pattern is obtained. At Menninger Hospital the over one percentage of patients with the diagnosis of schizophrenia who were hospitalised ' year was 91%. at Hillside Hospital 35% and at MMHC. 77o. 204 We 11: ' factor not generalizir , methodolog There single diag sociopsych difficulty. 5‘ ‘ Studiii: birth, edui nificantly 1. improvemc: choanalyti<- tures - one the other. ‘ �TABLE III ‘ RATINGS OF CLINICAL CONDITION AT TIME OF HOSPITAL DISCHARGE Hillside Menninger Improved Unimproved r. MMHC “'““”i“"‘ ,- «a..——q SOCIAL ADJUSTMENT , "VT'~M-» Recovered Recovered Much Improved Markedly Improved a. waw 9.9. «an::r:r;t?.'fi~'"'fi'f”“ o“ . Improved CHARACTER STRUCTURE Moderately Improved Slightly Improved ' ‘ Unimproved Improved Unimproved . .v-‘n. 1 . Unimproved ’ ~ ~VWT~I Regression SYNDROME .. V ' Complete Remission ””"1" Improved Unchanged (or worse) a'v‘r‘.':'§l':"t'.“"""""""‘ TABLE IV . HOSPITAL STAY BY AGE PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR A~-; _- Inf.) . .,i ~- -‘ .a-.<__. u- .,.I Age Menninger Hillside MMHC Below 20 20-29 30-39 40-49 81 42 14 73 36 6 61 30 6 30 20 0 50+ -_.-..-< vm r , 36 0 , ““*‘".'"‘-'-«rvm-AfiuvnrcM-mvr“ V" ' ' 0 u‘ "rm-J'W- V 12219122192 fl." j J.“ ~.. 4.... We have indicated that the philosophy and organization of institutions is an essential {actor not to be ignored in assessing observations and reports. Faced with the problem of generalizing our findings, how do we overcome these institutional methodological stumbling blocks to scientific activity? ‘.r‘a-..—..,._ differences that are the «4“le .-,... a... 5“ -.... 5hérv~naVvu .-- a .-.4 .. “4‘... «a; .v” .. . There is an urgent need for objective techniques to describe populations. The use of diagnostic terms is obviously inadequate. It is likely that detailed behavioral and sociopsychological descriptions of patients may be the best technique for overcoming this single «M-M~—,t...y.-.r, difficulty. Summary Studies of the in-patient population of Hillside Hospital indicated that age, foreignbirth. education and stereotypic attitudes as measured by the California F Scale were significantly related to choice of treatment, duration of hospitalization. discharge ratings of improvement and diagnosis. We have extended this study to other institutions offering psychoanalytically-orientedpsychotherapy and somatic therapies with different social structures - one the Massachusetts Mental Health Center. serving "lower-class" patients and the other, the C. F. Menninger Memorial Hospital. serving "upper-class" patients. . ‘vvw-WOv—u-wm-Mvr- . ws—vt‘v-~.o-‘- .-,. '< ' 205 u r ~-. . .- ”4...”.-. �,rm We have encountered a variety of problems in this comparison. including difference. in l) the type of hospital organization; 2) the definition of the treatment as in the designstion of which patients were receiving psychotherapy; 3) discharge rating systems of clinical improvement; and 4) diagnostic "styles” employed. ..... ~. a .w»-._.r ..x a The importance of these methodological problems in current psychiatric research are discussed. References (l) Hollingshead, A. B. , and Redlich, F. C.: Social Class and Mental Illness: A Commun. ity Study. New York, John Wiley & Sons. Inc. . l958. a...» .' (Z) Gallagher, E. B. : Levinson. D. J. , and Erlich, 1.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hospital. edited by M. Greenblatt, D.J. Levinson, and R. H. Williams, Chicago. Free Press. 1957. , Pollack, M. and Fink. M. : Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hospital 6: 216-228, 1957. (3) Kahn, R. L. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings. and Diagnosis. A.M.A. Arch. Gen. Psychiat. 1: 565-574. 1959. (5) Kahn, R. L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Neu. Ment. Dis.‘ 130: 189-192, 1960. (4) Kahn, R. (6) Myers, J. K. , and Schaffer. L. : Social Stratification and Psychiatric Practice: AStudy of an Out-Patient Clinic, Am. Sociol. Rev.l 19:307-310. 1954. (7) Pasamanick. B. , Dinitz. S. and Lefton. M. : Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. Psychiat. . l_l_6_: 127-132. 1959. DISCUSSION DR. KLERMAN: One of the ways to overcome the biasing factors related to length of stay is to calculate the mean stay for each hospital. In this way interhospital comparisons of the effect of such variables as age on length of stay could be compared in terms of quartiles. . r .4 g DR. POLLACK: .9101. .. ;v That's a good suggestion, however it still doesn't overcome the problem of differences in hospital structure. e. g. , the presence or absence of a day hospital facilities. in influencing length of hospital stay. «2' ‘Z uhwfifil'nl DR. OPPENHEIM: The finding that younger patients tended to stay longer at the hospital seemed to be at variance with experience at VA Hospitals. I ask what was it about the therapeutic programs at the three hospitals that led to these findings? What are the theoretical implications of these findings ? “AL. in \:A 9;.- .41: ..., s ——....-.-A..— .-..~u-....v-l-~ .e... “4...-..“ -.‘_......-c DR. POLLACK: The length of time a patient is hospitalized in a psychiatric facility is related to the particular function and philosophy of the institution. In those hospitals that stress psychoanalytically oriented psychotherapy, patients who are most like the therapists with regard to sociopsychological factors are kept in treatment for the longest period. In studies of out-patient clinics with a psychoanalytic orientation, it has been found that persons from higher social levels. as determined by education and income, are treated longer. In contrast. in state hospitals the results are quite different. Thus, it has been shown that state hospital patients with the least education will be institutionalized longer and are more likely to become the chronic patients. Consistent with the concept of state hospitals as largely providing long-term custodial care for lower class patients, the state hospital psychiatrist may be oriented toward a comparatively more'rapid discharge of those patients who come from a background most like his own. 206 v" .va —v : ��Social Aspects of Psychiatric Treatment in Three Hospitals: Methodological Problems Max Pollack, Ph.D., Nathaniel Siegel, Ph.D. Robert L. Kahn, Ph.D., and Max Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. fios Presented at the Sixth Annual Veterans Administration Research Conference, March 28, 1961, Cincinnati, Ohio. Aided, in part, by grant MY~2715 of the National Institute of From Mental Health; and the Nassau County Mental Health Board. The cooperation of the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully acknowledged. IV: h/17/6l �Social ASpects of Psychiatric Treatment in Three Hospitals: Methodological Problems generalization of findings from one population to another is basic to any science. Psychiatry, perhaps more than other medical specialties, is plagued with controversies concerning the non-reproducibility of results. One factor responsible for this state is the failure of investigators to adequately describe their populations and methods. The advent The of simultaneous multiple hOSpital studies makes possible the detection and clarification of these methodological difficulties. We would like to describe some of the problems we encountered in a recent tri-hospital study, and will consider the variables of type of treatment, discharge diagnosis, ratings of clinical improvement at time of discharge and length of hospital stay. Various social psychiatric studies of community and heapital psychiatric populations (1, 2, 6) had established the importance of sociopsychological factors in the type and incidence of mental disorder, the selection and mainten— ance of treatment and therapeutic evaluations. previous studies such selective factors as the In these patient's extent and type of available treatment facilities may have been more significant in the observed results than the social variables studied. A more financial resources or the �-2- critical test sociopsychological factors in treatment would be a study in a setting where the same therapeutic techniques and services are available to all patients, regardless of their ability to pay. This requirement is not at Hillside Hospital, and in 1957, we embarked on a program of assaying the relation of sociopsychological factors to the treatment of hospitalized psychiatric patients (3, h). Each patient receives individual psychotherapy and by request of his physician, somatotherapy (convulsive or psychopharmacological therapy). Almost all patients are non-chronic, as their admission to the hospital is associated either with first hospitalization or a recurrence of illness after a long period of remission. The case load is small, with at most ten patients to one resident physician. Our method of all in—patients on modified California all patients. birth, role of the We of investigation was a census«type survey of a given day (3). In addition a brief F Scale observed test (2, 5) was administered to that age, education, sex, foreign- California F Scale were significantly related to choice of treatment, duration of hOSpitalization, clinical discharge ratings and to clinical diagnosis. In order to test the reliability of these findings, we repeated this study at Hillside Hospital in 1958, employing the same procedures and, concurrently extended it to two other institutions, the C.F. Menninger Memorial Hospital and and performance on the �-3the Massachusetts Mental Health Center (MMHC). These insti- tutions are similar to Hillside Hospital in that both psychoanalytically - oriented psychotherapy and somatic therapies are available. They were selected for the additional reason that one serves predominately socialogical Class I and II patients and the other, predominately Class IV and V. �-hOBSERVATIONS Hospital Structure: When reporting data from ones own institution, the structure of the hOSpital is taken for granted, and either ignored or briefly mentioned. However, when approaching a strange institution and attempting to gather comparable data one is made aware of the differences in institutions and the nature of the hospital organization is seen as one of the methodologic problems affecting treatment. .Both the Menninger does institutions not. At the MMHC MMHC and hospital units, and Hillside the treating physician can care for have day the same patient as an in-patient, in the day hOSpital, and in the after-care clinic. In such a setting, the treating doctor can discharge the patient from the hospital at an earlier date, knowing that he will still be reSponsible for his patient's care; whereas in Hillside Hospital discharge termination of the patient—doctor relationship. Another problem was the presence of different research programs, affecting clinical routines. For example, at the time of the survey, approximately twenty percent of the patients at MMHC were chronically ill and had been hOSpitalized for many years. Such a group would not normally have been in means this hospital but they were transferred hOSpital for Special study purposes. from another state �-5Designation of Type of Treatment: In our assessments of specific variables, we encountered a variety of problems associated with the content of hoSpital records. For example, it was difficult to determine the length of stay prior to referral for a somatic treatment, or the length of time spent in that treatment. However, a major problem was to learn which patients were receiving psychotherapy. Our task was not to define psychotherapy, but the much simpler problem of noting which patients were designated by the hospital as having been treated with psychotherapy. At Menninger Hospital psychotherapy was administered on a prescription basis by a staff psychiatrist for which the patient was charged an additional fee. Sessions with the psychiatric resident physician were considered part of routine administrative patient care. At Hillside Hospital the definition of psychotherapy was limited to treatment sessions with the psychiatric resident. Staff psychiatrists did not treat patients directly, but restricted their activity to supervising the residents. In contrast, at the MMHC psychotherapy was designated as a function of many disciplines - psychiatric residents, nurses, medical students, social workers and psychologists. To ascertain whether or not a patient was receiving psychotherapy we had to interview the resident physician in charge of the case. �Diagnosis: The assessment of diagnosis was another problem area. It is not surprising that there are institutional diagnostic styles which reflect staff orientations rather than the behavior of the patient. Pasamanick and his associates (7) have shown that diagnoses within the same institution are vulnerable to individual differences among examiners. In our present study, there were differences in the terminology of the discharge diagnosis. Discharge diagnoses at Menninger Hospital were more descriptive and employed a multiple classification system. Table I illustrates several examples and shows how we converted these into more generic categories that could be applicable to all three institutions. In reducing multiple diagnoses to single generic ones, we are aware that we are introducing distortions through this maneuver. II illustrates the distribution of diagnositic categories within each institution. Note that at the Table Menninger Hospital there was a lower incidence of diagnosed schizophrenia and affective psychoses, while the diagnosis of personality disorder exceeds by three and five-fold that found in the other two hospitals. �We would emphasize tions based that cross hospital comparisons of popula- diagnosis as the single or the most important criterion does not insure comparability of populations. on Discharge Ratings of Improvement: Similar problems exist for the equivalence of global ratings of improvement. As in the case of diagnosis, Menninger HOSpital had the most elaborate discharge ratings of improvement and Hillside Hospital, the simplest. As shown in Table III the discharge rating at Menninger Hospital was tripartite and a separate rating given for social, characterological had and syndrome changes. weight was and MMHC it is difficult to state how given to each of the three factors incorpora- similar global ratings and much Hillside ted in the Menninger system. Such differences in systems makes it difficult to compare treatment results of hospitaliza- tion. Hospitalization: Length of hosPitalization for most illnesses, including psychiatric disorders, commonly denotes both severity of �-8- illness and response to treatment. As such, it is frequently interhospital comparison. Table IV length of hospitalization by age at the time of the used as an index for compares study. There was an observable relation between length of stay and age within each institution, with age being inversely related to length of hospitalization. Yet, among these three hospitals there were marked differences. diagnosis is employed a similar pattern is obtained. At Menninger Hospital the percentage of patients with the diagnosis of schizophrenia who were hospitalized over one When year was 91%, at Hillside Hospital 35% and at MMHC, 7%. DISCUSSION indicated that the philosophy and organization of institutions is a factor not to be ignored in assessing observations and reports. Faced with the problem of generalizing our findings, how do we overcome these institutional differences that are the methodological stumbling blocks to We have scientific activity? is for objective techniques to describe populations. The use of single diagnostic terms is obviously inadequate. It is possible that detailed behavioral There an urgent need �-9sociopsychological descriptions of patients best technique for overcoming this difficulty. and may be the �-10SUMMARY Studies of the in~patient population of Hillside Hospital indicated that age, foreign-birth, education and stereotypic attitudes as measured by the California F Scale were signifi- cantly related to choice of treatment, duration of hoSpitalization, discharge ratings of improvement and diagnosis. The same therapeutic facilities were equally available to all patients, predominantly middle-class, and ability to pay was not a factor in treatment. We have extended this study to Other institutions offering psychoanalytically-oriented psychotherapy and somatic therapies with different social structures - one the Massachusetts Mental Health Center, serving "lower-class" patients and the other, the C.F. Menninger Memorial Hospital, serving "upper-class" patients. We have encountered a variety of problems in this comparison, including differences in: l) the type of hospital organization; 2) the definition of the treatment as in the designation of which patients were receiving psychotherapy; 3) discharge rating systems of clinical improvement; and h) diagnostic The "styles" employed. importance of these methodological problems in current psychiatric research are discussed. �TABLE I TYPES OF DISCHARGE DIAGNOSIS PATIENT DISCHARGE RATING CLASSIFICATION RATING 1. Depression Reaction Psychoneurosis Narcissistic Personality \2. Anxiety Reaction Narcissistic Personality 3. Narcissistic Personality h. Narcissistic Personality Alcoholism Chronic Infantile Personality 5. Passive Aggressive Personality Alcoholism 6. Infantile Personality Schizophrenic Reaction Schizo-Affective Type Psychoneurosis Personality Trait Disturbance Sociopathic Personality Disturbance Sociopathic Personality Disturbance Schizophrenic Psychosis �TABLE II DISTRIBUTION OF DIAGNOSIS (PERCENTAGE) Menninger Hillside MEEE Schizophrenia Personality Disorders hl 52 S2 33 6 13 Psychoneuroses 1h 18 8 Affective Psychoses 5 21 16 Organic Psychoses S l 5 Transient Personality 2 2 6 100 173 93 Disorder N = �TABLE III RATINGS OF CLINICAL CONDITION AT TIME OF HOSPITAL DISCHARGE Menninger Hillside MMHC SOCIAL ADJUSTMENT Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved CHARACTER STRUCTURE Improved Unimproved SYNDROME Complete Remission Improved Unchanged (or worse) Improved Unimproved Regression �TABLE IV HOSPITAL STAY BY AGE PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Hillside yfifig Below 20 81 h2 lb 20-29 73 36 6 30-39 61 30 6 ho-h9 3o 20 0 50+ 36 0 0 ggg_ �REFERENCES Hollingshead, A.B., and Redlich, F.C.: Social Class and Mental Illness: A Community Study, New York, Joha Wiley & Sons, Inc., 1958. Gallagher, E.B.: Levinson, D.J., and Erlich, Y.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in Ehe Patient and the Mental Hospital, edited by M. Greenblatt, D.J. Levinson, and R.H. Williams, Chicago, Free Press, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Social Factors in Selection of Therapy in a Voluntary Mental Heepital. J. Hillside Hospital é: 216-228, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. A.M.A. Arch. Gen. Psychiat. l: 565-57h, 1959. R.L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Ment. Kahn, 2i§., Egg: 189-192, 1960. J.K., and Schaffer, L.: Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic, Myers, Sociol. Rev., 19: 307-310, 19Sh. Pasamanick, B., Dinitz, S. and Lofton, M.: Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. Psychiat., 116: 127-132, 1959. Am. ��Mmunattm of Patton Populations: Catapult-ability of 5mm 2!: Evaluating Thmpiu Mam Mutation! The Mam Fink. M. From A the D. Miami Its-mat. of Ptycmuy at 8:. Loans sum Hospital. 8t. Loni: hand an and“. madman: at tho mum. nuptial. New York in ramwith Du. R. I... Kuhn. N. 310901 and M. Pollack, and tar be puhmhod «Remnant 'smmyohtfloqtal Aspects at madman Truman m m mammary Hospitals“ uin 1863. �Recent community studies have demonstrated a between social factors and psychiatric treatment. relationship In their study psychiatric patient population, Hollingshead and Redlich reported significant relationships between an individual's position in the social class structure and the prevalence of treated of the New Haven illness, types of diagnosed disorders and kinds and duration of psychiatric treatment administered (3). The influence of patient economic status upon the availability of treating personnel, however, was not excluded in these studies. To test the role of social factors in the treatment of hospitalized patients independent of patient's finances and availability of treatments, undertaken at Hillside Hospital in 1957. variety of treatment In a survey was this hospital, a including individual psychotherapy and organic therapies are available to all patients regardless of their ability to pay. In the Hillside studies (h,5) it was observed that patients hospitalized for the shortest period were the oldest, had the least education and were most likely to have been foreign born. The older, modes, less educated patients were predominantly treated by convulsive therapy and received the more favorable discharge ratings. Younger, native born and more educated patients were hospitalized the longest, treated primarily generally received the poorer discharge ratings. The clinical factors were also related to a measure of stereotypy, the California F Scale (1,6). Higher F scores, i.e., greater stereotypy, were often found in patients by psychotherapy and �-2diagnosed as involutional psychosis who were referred for somatic therapy, hospitalized for a shorter period, and more often were rated as much improved or recovered. Another hypothesis developed at this time was that differences in various aSpects of psychiatric treatment among hospitals should show the same relationship to social factors as noted within Hillside Hospital. To test this suggestion it was decided to employ the procedures of the 195? Hillside study in three institutions ~— Hillside HOSpital, the C.F. Menninger Memorial Hospital of Topeka the Massachusetts Mental Health Center of Boston. These institutions were selected with the expectation that they served patients of different social classes. It was anticipated that in these hospitals there would be a similarity in attitude towards treatment and and education. is a teaching hospital with a full time superactive research departments. They emphasize Each visory staff and psychoanalytically-oriented psychotherapy but provide other treatments such as somatic therapies and active programs of milieu therapy. Each stresses short-term treatment of voluntary patients and does not provide custodial care. The specific aims of this study were to determine the population characteristics of the three institutions with respect to social class, age, education and F score: and to relate these characteristics to the treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions. �-3METHOD A census of institutions all voluntary, adult patients in residence in these undertaken in January, 1959. While Menninger and Hillside Hospitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic was schizophrenic state hospital group transferred for a Specific research project. These patients were excluded from the study because of their non-voluntary status. given the California F scale on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2~factor index - a weighted score of education and occupation - was used (2). The study population consisted of 173 patients at Hillside, 100 at Menninger Each patient and 95 was at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intrahospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intrainstitutional trends. These difficulties also led to missing information for some data, which is reflected in the varying population sample sizes in the tables. �4,. RESULTS A. Inter-hospital Comparisons l. Methodological Problems reporting studies from a home institution, the structure of the hospital is taken for granted and either ignored or mentioned briefly. However, in studying a strange institution and attempting to gather comparable data one is made aware of the many differences between institutions. While we selected these institutions as comparable in teaching, research and treatment programs, we found that they were unlike structurally in ways which influenced the data of the study. Specific problems were noted in the designation of type of treatment, diagnostic classes and the evaluation of treatment outcome. 3) Designation of Type of Treatment: The criteria for designating that a patient received "psychotherapy" differed among the institutions, making uniformity in classification difficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a fee. Sessions with the psychiatric resident were considered part of routine administrative patient care. At Hillside Hospital psychotherapy was defined as treatment sessions with the psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising the resident physicians. No additional fees were charged. When �-5the Massachusetts Mental Health Center psychotherapy was designated as a function of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students. Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident in charge of each case. b) Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative data scheme recommended by the American Psychiatric Association while both Hillside and MMHC followed unitary At systems. Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. Ratings of improvement at the three hospitals varied in format and detail. The discharge rating at Menninger HoSpital Was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the c) Discharge Ratings of Improvement: Menninger system (Table II). For this study the Menninger syndrome �~6— rating was compared to the global ratings of the other institutions. ----- ------Table II Sociopsychological Variables The distribution of the variables of social class, age, Jacation and California F Scale score among the three institutions 2. is presented in Table III. ------------a) Social Class: There was a marked difference in the social class composition of the three institutions. At Menninger Hospital the population was predominantly upper class; at Hillside Hospital, class; lower class. middle b) age: and at Massachusetts Mental Health Center, predominantly There were no differences in age distribution in the institutional populations. c) Education: The populations differed in educational attain~ ment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While bl per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduate. d) F Score: Significant differences in the distribution of scores on the California F Scale were observed. Fifty-one per cent �-7of Menninger patients had F scores below 30, and only eight per cent with scores of 50 or above -- the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside thirtyone per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30. Thus, the anticipated differences in the social class of the populations were observed, as well as significant differences in educational attainment and performance on the F Scale. These differences permit testing the hypothesis concerning the relation of sociopsychological factors to the treatment variables among the insti- tutions. 3. Psychiatric Treatment Variables a) Selection of Treatment: Among institutions, significant- ly fewer patients at Menninger Hospital (h3%) received somatic therapy than at Hillside (6h%) or MMHC (68%) as shown in Table IV. b) Duration of Hospitalization: The three institutions differed markedly with respect to patient's length of stay (Table IV). Hospital patients were hospitalized longest, with 65% of patients remaining for twelve months or more, uumynugd to 31 per baht of the Hillside patients and only 5 per cent of those at the Massachusetts Mental Health center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger �-9- either none or fewer than five cases, thus not permitting a satisfactory intrahospital test of the hypothesis. 2. Intra-Hospital Comparison With this methodological limitation some trends similar to that found in the earlier study were observed, although few were of statistical significance. With regard to selection of treatment, for example, age and F score were found related at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest period. While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over ho, but lh% of patients under the age of 20 remained longer than a year. Table V ----------- �-10DISCUSSION this comparison of three voluntary psychiatric hospitals we have observed significant interinstitutional differences of patients in the social variables of years of education and social class, but not age: in distribution of California F Scale scores: and in each of the treatment variables -- duration of hoSpitalization, selection of treatments and distributions of diagnoses and discharge evaluations. The expectation that the institution serving upper class patients In the longest duration of stay, higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, lower proportion of patients receiving organic forms of therapy, and poor- would have a est discharge ratings were each confirmed. Similarly, the institution serving lower class patients evinced shorter periods of hospitaliza— tion, low proportions of psychoneurotic diagnoses, and better dis— V charge evaluations. It is our impression that these differences in psychiatric treatment are more related to differences in staff attitudes than to differences in population samples. The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. These .stylistic differences cannot be dismissed as merely idiosyncratic since they follow a pattern related to social differences consistent with previous findings. �-11- population and treatment variable relationships appear to be interactive processes, determined both by the attitude of the physician and the administrative staff as by the constellation of Such history which patient may present. Such relationships will be most marked in those psychiatric conditions where diagnostic criteria are least specific, 343., where the objective criteria symptoms or a defining diseases of known organic impairment are absent, as in schizophrenia, psychoneurosis and personality and behavior disorders. Under conditions of perceptual or situational ambiguity the observer's attitudes and expectations become the basis for perception and classi~ fication. This view was clearly demonstrated by Pasamanick, Dinitz and Lefton (7) in their study of variations in diagnosis within a single institution. They observed that patients randomly assigned to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in diagnoses among the three wards and among three administrators on one ward. As it is highly unlikely that these differences were inherent in the population, we believe they are largely reflections of the attitudes of the examiners. It is clear that many of the present psychiatric concepts of diagnosis or clinical evaluation have relatively little meaning when transferred from one institution to another. If these concepts are taken literally the results become paradoxical. For example, Menninger Hospital has the most highly trained personnel conducting treatment, keeps its patients for the longest time and has fewest �-12- patients diagnosed as schizophrenia. And yet, despite these resources and favorable factors, it reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, which keeps patients for the shortest periods, and which has a higher proportion of the population classed asschizophrenia, the reported treatment results are the best. It is probable that this study does not reflect the relative therapeutic efficacy of the institutions. Our data furnishes no independent criteria for determining which heapital provides the better care; nor for assessing the comparability of the population in the degree of institution's own illness. Since the evaluations are based on the ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than any intrinsic psychiatric characteristics. In our initial Hillside study (5) it was postulated that different criteria of improvement were utilized for persons of different social background. It was suggested that the higher the person's social background the more complex the criteria employed. This has literally confirmed in the present study, with Menninger's using tripartite rating compared to the global rating of the other two been a institutions. considering the syndrome rating on which our comparative statistical analysis were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persbns the criteria stress such complex Even �~13- intangibles as "developing insight", or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been considerably impressed by the methodological problems of studies across institutions. These institutions were selected for their educational leader- ship and the expectation that the recorded variables would be clearly defined. But the differences in institutional style making it difficult to obtain comparable data are important cues to the problem of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to considerable error unless the institutions are clearly matched for social class patterns in patient population and for staff attitudes and style. These difficulties may also extend to the failures of scientists to confirm observations made in other laboratories, for the lack of confirmation may be as much a reflection of differences in populations and psychiatric criteria as to errors in the original hypotheses. The widespread use of such terms as "schizo— phrenia" or "psychoneurosis" to explore the changes in psychological or biological features with mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory, we do not have methods available to describe populations adequately to provide a sound confirmation. �-111- Increased attention must be paid to the methodological problems of classifying subjects by "objective" criteria rather than the present methods which appear to be so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the thera- pist-patient interaction. �-15.. SUMMARY and CONCLUSION In three psychotherapeutic-oriented teaching hospitals, population characteristics were related to treatment variables. 1. Populations were defined by social class, age, education and F score, and were related to type of treatment, duration of hospitalization, diagnosis and discharge evaluation. Significant interinstitutional differences were observed in characteristics of patient social class, years of education and distribution of California F scores, but not age. 3. The variations in treatment characteristics among institutions were found to be significantly different in the predicted direction. h. These variations in psychiatric practices follow a pattern consistent with social class differences among institutions and are not regarded as being idiosyncratic. S. The differences in institutional style make comparisons of diagnoses, duration of hospitalization, and treatment results between 2. institutions difficult and tenuous, and the need for more objective criteria of classification of populations is emphasized. �REFERENCES Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, R.N.: Authoritarian Personality, The New York, Harper & Brothers, 1950. Hollingshead, A.B.: graphed Two-Factor Index of Social Position, mimeo- publication. Hollingshead, A.B. and Redlich, F.C.: Illness: A Community Study, New Social Class and Mental York, John Wiley & Sons, Inc., 1958. R.L., Pollack, M. and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside £332., 9: 216-228, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Kahn, Duration of Hospitalization, Discharge Ratings and Diagnosis, Arch. Gen. Psychiat., l: S65-57h, 1959. R.L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. & Ment. Dis., Kahn, 130: 187-192, 1960. Psychiatric Orienta— tion and Its Relation to Diagnosis and Treatment in a Mental Hospital, Amer. J. Psychiat., 116: 127-132, 1959. Pasamanick, B., Dinitz, S. and Lefton, M.: �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Passive Aggressive Personality Sociopathic Personality Disturbance Sociopathic Personality Alcoholism Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of At Time of MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Clinical Condition Hospital Discharge HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE 1;; InterhOSpital Comparisons for Sociopsychological Variables Hillside Menninger Hospital Social Class 'v“ N (87) (133) I 31% 7% (72) 3% 20 28 III 17 3h 13 IV 1 3h 28 v o 5 28 x2=121.5; df=8z p<.001 'N (100) (173) (95) 19% 19% 15% 20-39 59 58 52 ho 22 23 33 + x3=3.9; df=h; p=n.s. (100) (173) <12 Education Center ' 51 N Years of Mental Health I II <20 Age Hospital Massachusetts i (91) 23% 32% h1% 12-15 Sh 51 h9 16 23 17 10 + v3=9.7; df=h; p<.os (92) (163) (76) 10~29 51% 33% 20% 30-h9 hl 50 50-70 8 N F Score 17 L i 2 I y3=39.2; df=hi p<.001 38 h2 . �TABLE IV InterhOSpital Differences in Treatment Variables ‘Menninger Hospital (100) N Type of Treatment Hillside Massachusetts Hospital Mental Health (173) Center (89) Psychotherapy 21% 36% 2b% Somatic h3 6h 68 Other 36 ~- 8 1 e a _ _u , xi:82.8: df=h: p<.001 N Duration of Hospitali— zation <7 months 7-11 months :il months (100) (173) (95) 22% 27% 67% 13 h? 27 65 31 S a ’ X2=9o.6; df=h§ p<.001‘ N Recovered, Improved Discharge Evaluation . Much (99) (172) (88) 1% 23% 28% Improved 80 62 61 Unimproved 19 15 10 lvwwy2=29.3; df=h; p<.001 m“ N Schizophrenia Discharge Diagnosis ” Affective Psychosis Psychoneurosis and Personality Disorder (95) (171) (85) h3% 52% 5h% 5 22 17 52 26 29 , X2=23-83 df=h; p<.001 �TABLE V Duration of Hospitalization BX,A§2 PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR £53 Menninger Hillside mag Below 20 81 h2 1h 20-29 73 36 30-39 61 30 h0-h9 30 20 50+ 36 �A? 9/7 . THE AMERICAN PSYCHOANALYTIC ASSOCIATION SUMMARY AND FINAL REPORT OF THE CENTRAL FACT-GATHERING COMMITTEE /f" ’4-4-‘"?;"é /L\ W2} The Central Fact—Gathering Committee was established by this Association in 1952 and charged with the responsibility Of setting up a method for pooling :the significant data of psychoanalytic practice. Starting modestly and testing a procedure that ensured professional secrecy, it was hoped that increasingly valid, meaningful data might be accumulated. However, the long-recognized difficulties -- diagnosis, nomenclature and measure of effectiveness -- all have led to increasing resistance and a resultant falling-Off in the number of completed questionnaires. Scarcely any reports are now being received. Therefore, it was recommended at the last meeting of the Association that this Committee be discharged and its materiel stored until such time as further developments warrant confidence in the use of the statistical method in psychoanalytic validation. \7 This summary of the material is being sent to you for your study and files. Although some members of the Committee thought otherwise, the Committee as a whole, the Executive Council and the membership at the last Business Meeting of the Association in December, 1957 approved the opinion that none of this material be published. It is not that the figures can be used to prove analytic therapy to be effective or ineffective, but that the material on which either opinion may be based is inadequately established, and controversial publicity on such material cannot be of benefit in any way. We trust that all will agree and will limit discussion of this ‘ material to those professionally qualified to recognize its serious limitations. is divided into two sections: Part I, the summary of the material from the Initial Questionnaires, and Part II, of the material from the Final Questionnaires. This summary ‘ PART I We received a total Of about 10, 000 Initial Questionnaires and 3, 000 Final Questionnaires, from about 800 participants. Of the 800, about 350 were members of the then total membership of 530, and 450 were senior candidates of the then total 600 senior candidates. SUMMARY OF DATA FROM INITIAL QUESTIONNAIRES 1. Sex: Male: 48%. 2. Race: v“ "114’ or i'TéIIW?“IMI—TNT 315' 51;; g L); (“lgflflIPV iflffl uuunwflkz ”v, jQihfijfiyrf HaAll. n F. F7! :~ , ,LCJHJE: . [2‘3 ,_ rf' 355:3 _ , White: 99%. Female: 52%. (U.S. Census: White: 89%. Colored: 11%.) �3. Age 9; patients: Percentage of total Up to 12 years: 2 2 13-18 14 48 27 19—25 26-35 36-45 ‘ 46 and over: 8 4. Highest educational level: 60% of all patients are at least college graduates. (25% college graduates, 8% attended graduate school, and 27% more completed (U.S.Census: 6% are college graduates.) graduate schooll) . : 5. income: 1—5 . % % ‘ 1 in analysis: in psychotherapy: 22 35 U.S.Census: 71 6-10 25 (In thousands) 11-15 28 16 13 23 6 ' 16-20 21-40 8 9 ' 1 16 13 41.69 4 2 Over 560,303 3 Z (over $10,000) 6. Previous treatment: Regardless of type of diagnosis, about 1/ 6 or 1/7 of all patients had had previous analysis. 1/3 of the cases of neuroses and 1/2 of the cases of psychoses had had previous psychotherapy. Some had had both. About half of the cases of psychoses had had previous psychiatric hospitalization, as did 1/10 of the cases of neurotic reactions and character neuroses. cases being re-analyzed (i.e. , 1/6 of all), only about 1/6 of them are being re.analyzed by the previous analyst. The other 5/6 chose another analyst . Of the group of. 7. Present treatment: 54% Of all cases in treatment are listed as being in analysis, and 46% in psycho. therapy. The percentage runs from 60-65% in analysis in the neuroses, to 40% in analysis in the borderline cases, and 20% in the schiZOphrenias, 8. Place of treatment: Private ofiice: 94%. Out-patient clinics: 9 4%. Psychiatric & general hospital: 1%. . {reguency of treatment: % % in analysis: in psychotherapy: Per week: 1 2 3 4 5 1 6 29 41 20 7 42 33 13 3 6 or more < 2' Q1 10. use of psychological projective tests: The tests are reported as being carried out in approximately 25% of the cases. In 75% of the cases given psychological tests, the clinical diagnosis was in agree. ment with the tests . �II. -3... 213929§§§ Initial diagnoses: The following diagnostic listings are presented with full appreciation of and emphasis on their inadequacy, invalidity, uncertainty and probable insignificance. It reminds one of Freud's remarks when chided about the lack of statistics in psychoanalysis, in 1913: "To compile statistics is at present impossible. To begin with, we work with much smaller numbers than most other doctors who devote so much less time to individuals. Then, the necessary uniformity is lacking which alone can form a basis of any statistics. Should we really count together apples, peas, nuts? What do we call a severe case? Moreover, technique changes and what about the numerous partially analyzed cases and those whose treatment had to be discontinued for external reasons? " ORDER OF FREQUENCY OF GROUPS OF DISORDERS Psychoneuroses Personality trait disturbances (character neuroses) Per sonality pattern di sturba nce s (borderlines) Psychotic reactions Perversions Addictions All others Psychosomatic disorders co-exi stent in: _ Percent of total . 39 33 1 l 9 5 2 1 11 ' ORDER OF FREQUENCY OF SPECIFIC DISORDERS Pas sive-aggres sive personality Compulsive personality, & Anxiety reaction (each) 16 14 Depressive reaction SchiZOphrenias Phobic reaction, Obsessive-compulsive reaction, personality (each) Perversions Conversion reaction, 9 7 & Schizoid Emotionally unstable personality (each) Dissociative reaction, Inadequate personality, Cyclothymic personality, Paranoid personality, & Addictions (each) Paranoia, & Manic—depressive reactions (each) & Psychosomatic disorders co-existent in: Some additional data: Of the neurotic 6 5 3 2 1 11 reactions, dissociative, conversion, de— pressive and phobic reactions were much more frequent to times more) in females than in males . Obsessive-compulsive reactions were somewhat more frequent in males than in females. The diagnosis of anxiety reaction was made equally in males and females. (2 3 diagnosis of borderline disorders, "schizoid", "paranoid", etc. , and of schizophrenia was equally distributed between males and females. Homosexuality was diagnosed two to three times as frequent in males as in females, as were the other reported sexual deviations. The �We have received about 3, 000 Final Reports. These were on cases that had been in treatment at the time the CFC- program began, or that began treatment thereafter. As it became increasingly evident that significant figures could not be obtained because of the previous mentioned lack of uniformity, we confined our study 110 a more intensive investigation of the neurotic reactions that had ”completed" treatment. We cannot say what happened to all of the cases that were in treatment during this program, because only about 1/3 to 1/4 of the cases were terminated during this period. The following information from the Final Reports may be of interest. sis, We found that out of 595 cases of neurotic reactions which undertook analy- 306 were reported as having been "completely analyzed”, that is, approximately years. (W ere this study to be continued, this figure might be higher, as there might be a larger percentage of longer analyses. However, it would not be lower.) Follow—up questionnaires were sent to the participants who had sent in these 308 " completely analyzed" reports. We received a return of 210 replies, that is 70%. Below is a summary of the supplementary information on the above Final Reports of "completely analyzed" cases of neurotic reactions: 50%, and the average duration was 3~4 Is there any doubt in your mind regarding the diagnosis? Did you think there was an underlying psychosis at any time? Had the patient been in analysis previously? Was the patient in standard, or classical, analysis? Of 28% 25% 18% 90% these "cured" cases. 45 Yes: Yes: Yes: Yes: 210 supplementary questionnaires received, 80 were listed as In 35 of these, all of the symptoms were reported as "cured", and in residual symptoms remained. In the 130 questionnaires received on "improved" was moderate in 74 cases, great in 46, and slight in 10. From the above, one might draw the conclusion cases, the improvement that about 97% of patients who undertake analysis for neurotic reactions and "complete" it, are "cured" or "improved" . Of the 50% who do not complete their analyses in this group of disorders, about half discontinue apparently because they were improved. The other half discontinue for "external" reasons primarily, because they did not improve, or were consid— ered untreatable, transferred to other analysts, or required hospitalization. The most frequent reason given for discontinuing, apart from being improved, was " external reasons". �-5RESULTS IN COMPLETE ANALYSIS OF N EUROTIC REACTIONS Final In Analysis Reports Analysis Completed Cured Improved Unimproved Anxiety reaction - ‘ 1,120 cases 335 183 90 35 52 3 70 38 26 11 15 0 cases 85 46 23 11 11 1 Phobic reaction 000-X04 - 500 cases 200 104 61 17 42 2 170 108 43 14 28 1 250 116 63 29 34 0 14110 595 306 117 182 7 50 37 6O 3 OOO-XOl Dissociative reaction OOO-XOZ - 175 cases Conversion reaction GOO-X03 - 250 Obsessive-compulsive reaction OOO-XOS - 500 cases Depressive reaction 000—X06 - 700 cases TOTAL Average Per Cent: REPORTED RESULTS IN Depressive Reactions Total Final Reports: In analysis: Cured Improved Unimproved 000-X06 Compl‘d 29 34 Discont'd 30 7 4 Untreatable Transferred Hospitalized External reasons TOTAL 250 116 Anxiety Reactions OOO-XOl Phobic Reactions 000—X04 335 183 200 104 Compl'd Discont'd Compl'd Discont'd 35 52 43 42 12 3 9 2 4 1 7 5 2 7 1O 29 2 1 2 1 63 53 90 93 12 61 43 �-5REPORTED RESULTS IN Obsessive-Compulsive Total Final Reports In analysis Cured Improved Unimproved Untreatable Transferred Hospitalized External reasons TOTAL Reactions, Compl'd 14 28 OOO-XOS 170 108 Disoont‘d Cured Improved Unimproved 1 441 232 Disoont'd 31 72 0 5 8 2 22 Compulsive PersonalityJ 000-X53 365 237 Compl'd Discont'd 29 77 62 3 l7 4 4 10 10 2 37 135 11 43 65 OOO-XZI Compl'd X29 — 234 42 97 Schizoid Personality 000-X42 Disoont'd 4 3 2 * Compl 'd 5 8 6 3 5 28 Homosexuality 000—X63 82 Disoont'd l3 9 1 7 i 33 1 34 128 101 4 9 35 109 185 HOSpitalized TOTAL Compl'd OOO-XSZ 6O 1 Untreatable Transferred External reasons Personality, 23 Schiz0phrenia Total Final Reports In analysis Passive—Aggressive 65 CompchL Disoont'd 8 13 1 1 6 10 4 3 3 5 2 8 9 48 22 43 Inall these eight reported cures of homosexuality, follow-up communications indicated assumption of full heterosexual roles and functioning. * Thinking it might be of some interest to gather the opinions and general experience of the membership on the expectation of results, the following questionnaire was submitted to the membership about a year ago: "Given a young person, whom one could analyze four years or more, with all conditions favorable, what would be your expectancy of result, in percentage, of cure, improvement and failure" -- for a list of neuroses, char— acter disorders, schiZOphrenia, schizoid personality and homosexuality. were the opinions: We received 120 replies from the membership of about 650. These �-71. 45% expected no cure in any of the conditions. 2. 35% expected a 50-100% cure in the neuroses, less in the character 3. disorders, psychoses and perversions. expected a 5~40% cure in the neuroses, less in the other con- 20% ditions . those that expected no cure or a low percentage of cure, 50% expected moderate improvement, 45% great improvement, and 5% slight improvement. Of those that expected some cures in the various condtions, the average expectancy of cure was: Of . 50% in anxiety, conversion and phobic reactions. in dissociation, obsessional and depressive reactions. in schizophrenia. 4. 20% in homosexuality. 1 2. 3. 33% 10% If these figures are combined with the reports of those expecting the no cures, percentage of cure would be about half, i.e. , 25% in anxiety cases and phobias, 15% in dissociation, obsessional and depressive reactions, 5% in schizo— phrenia, and 10% in homosexuality. Our "findings" suggest a higher percentage of ”cures" than the above opinions. (Please note quotation marks!) All of the foregoing have been presented before closed meetings of the Association and to a number of the societies. Details are available to those members who request them. As Chairman of the Committee, I should like to thank the members of the Committee, the membership, and the participating candidates for their cooperation, advice and criticism. Respectfully submitted, HIW:as 1/5/58 Harry I. Weinstock, M.D. Chairman Central Fact—Gathering Committee different times during the past five years the Committee has included: Drs. Leo H.' Bartemeier, Roy R. Grinker, David Kairys, Lawrence C. Kolb, Lawrence S. Kubie, Alfred O. Ludwig, Milton L. Miller, Milton Rosenbaum, and George W . Wilson, and our consulting Statistician, Jack B. Chassan, Ph.D. At �Janusry 15; 19590 é :9: Br. n. rink art. R.£. Kuhn and H. 51:111 sunancrs fineiul Payehidtrxa study gt manningcr reuadntien, 3.3“,’ 5‘10. 1959‘ yuan: arrived in rapuka rhmrudc ‘evnning, atnuary 7, ;nd ut tn. Paundttian nsrly t a nuxt sarning. Dr. Irving rupcrtud Kurt“: ta. Biractor of tho fi.¥. Xanainqur Munorial Baupital, .1 panel: zraaious and eaoparativa 1n urtry way. Eu bud Ill proyurod the stat: tad patients hatarahand in untiakput1an'at var visit. 8t:f£ coapsrfition at :11 1:101: wt: oxealltnt. rhnrn In: guaninc intsrcst in car :tudy and us had intnrusl Wu dincuaaiana with maths»: of tho stati. Br. Kurtuu Int us ans hi! 05:13: us air handgunrtcra In& and. nrrnnaauunfls tnr um kt lfififirfi :11 nppoin$n¢ntc and obtain ‘11 rouardn ind ropcrtn that I: filiirtdu Przar ta «at again; had tskud a: ta pruvidc him with ma iuiarufition uncut I. indinntin: I11 tun rocord data uttdifi for nut thudy. the nonienl runawaulibrtrinn and he: auatntuat Iptnt fair 6‘}! conp1¢$1ng taut. turn: ta dotnil. siuau sat: a! thin inturuatian was net raudtly avuiltblu in tho ehtrfis, fir. xtrtnu aunt t for: to all t». stat: «twist. in ob$u1n thin inxfirnnticn chart noqdnd. It w¢n1a havc takuu a: pnrh¢pl two nugka ta obtain :11.thu rneard intornfittan aurlclv¢t. ways. Thu a» “ the patiunts It! caninotud in two Iatull tasting of 60 worn aollantaé 1n the tharaday ubaut pttiantt $ha on and t¢utod an aging. :yuanuinn rlnuinlng attifiutu Pridny, tautcd indiviaunlly in thtir reams. baring the Friday tcnting tart a uflgtr nurt¢ nacnuytuiod at 3% all tinnt.ha that as short the various putauuta warn locatad and ta intradusu us ts Glah puticnt. Br. Kartun yartiaipatad in tha udniniutrafiioa at thg test an the dinturhad ward and gran It?! 1% ta a to: pittantn himself. Arrangancntu atrn undo tar tho raeaxflulihwnriun ta sand an tau disahnrxc data can: a manta during fihu next ynnr. an sgtarday neruxng, priar ta war dapnrturq, a: disuuaaod with m. 031‘an Murphy, Br. allay Gardner ”lurch tad Br. Rahart wallontttan. In tddi$1mn, aw dinunnnad garnet: z! ta: «linieal prusrnn with Dru. Rorbnrt auhlguingcr and Philip “that” “lfi‘finn or our Viuit thanks ortry objectiva to tha oxtrauraxntry eaaporttion a: tan manningar atntt, partinnlnrly Br. x;rtns. tun ltr¢et0r at tho huipxtnl and Eva. tauntu, thc modicul ruacrau 13hrnr1an. Ehuy war. ‘11 nuts xraaiaully httpitnblc and and. “a I‘ll-vulcanu and ut hunt. In unitary V0 uehiovod , 3&1143 �7‘, -. nay-u JIRU‘VV 1%: FRQH: Br. a. link art. svnaxata fi¢L. Kuhn and I. 15; 1959; 5103:! antatl Ptrahiuhria study Jlnuury 5‘10; 1959* ufi nhnninsar-rvunégtiqn. a. arrivad in Tapaku Ehnrtdu atoning, January 7, and rqpurttd ut tau runndnttun curly' a ncxt attains. Br. Irving Itrtus ta: Biruetar of fin. 6.3. thningar Hanurinl Balpitnl, was cx%rnmu1y grngiuuu mad weapcrntivn in OVQ?’ may. 30 hafl yrtynrtd sh: stuff gnu pat$nnt¢ butarokund an tnttaipntian ct an? vilit. fiturt aunyaratiaa at I11 Ivvalu in» axaalloat. tag». it: cnnutne inturast in an: Ifiuty lufl a: hlfl tatarnal dinausttvnn with unabcrn o: tha staff. fir. Kurtu: Int an nfio h1¢ oxttac I! an: hundquartorl aha and. arraugnnnnsa In: up %n tantra n11 uppaintncnts and abiain :11 rtearéu and ropnrtn that u: dusivgd.. trig? ta but G§I$fi8 ha had ankud.uu tn pruvidn bin with an iniurnntiun nhutt infiiotting n11 tun rianvd alt: uoaéod tar mar ntndy. 2h: uptufi :01: any: nudietl racirdnlibrnrinu and haw aasiat3nt «unwitting thcua turn: in datnil. $1300 can: 0: this information was nut ra:d£1y artil‘blc in sh. ahsrtc, nr‘ Rattan goat u tar: £9 :11 thc atatt dactarn ta abtuan than internatiun want. aci¢ad. I$~Vflfllfi hava fiakan 1‘ yarhupa tun wash: to obtain all tho roaord information ourscvaaa the aatual tuttinc at thu‘pnticntc wan gnuaucttd an in: nnyu. an fluvial: ukout 60 pntacntn vars eelltutaé in th. gylanpiun tag tpntoa gm amass. .an rrtany, «a; rcxnining'puttaatu thy wridty touting var. tantné ludtvadunlly in that: ragga. flaring saaw $0 no they. in: taunt fit neuonpnaicfi as all I uttti aura. variant patiuutl wart lfiflltid qua to intraduau as to naah patient. Br. tartan partiaipntgd in Eh. téuiniatrution at thp tun! an tbs diatarbod ward and gran ggvc at ta a In: pntiantl hinant. Arringauantt wart ugd¢ tor tho rgeerdtlihrnritn ta 30nd In the dinahlrxa data «an: a lauth fiuring thu nmxt ymar. on antardny-morniux. print ta gar d¢purtnrc nu digcuuand rtactr¢b nativitlna with nr.0%x§mma'nurphy, Br. £11.: euranar aaa 9r. iflhltt waxlumataia. In .dditiau, I. dinuuaaca anptati giltho ulinietl procran with Dru. Earhart achltaiagtr tad fihilip ‘fiflflfla In summary it anhicvnd_tvury ahagat1Vt or an: viast thunk: ta th: axtrtorainury anuparatgan g: tho Hunnincsr utatt, and Era. pnrtioulurly Br. Knrfimt. in: flirtator a! :5. hospital moa£ $3: wart rhuy nodisul-rnaorfis all librartua. xntntu, [racinuuly hatyttgblt and and. In Incl tblafllfi and at boat. ILK:JB ��wwwmgunm fiummfimmmhmmhwbmlw mswm‘mwmmmwwwmnwmw 2mm “WgLoW numm �Jun! 17’ 1959; Dr. Hilton Graanblatt, Haosachusetta Hontal Health Cantor, 72-7h Fonsood Road, Boston, 15, lane. Dear Kilt: I want to take thio opportunity to parsonally thank you and your Staff for the excellont cooperation shown the Billoide workers during their racont visit. They returned laden with considerable data and enthusiastic about the spirit and onthuaiasa manifested by your Staff. I an aoot grateful for your oooporation. / sincerely yours, , ,. éox Fink, H.D. foJB �����Q4: mmmnwm:mun.nm:mmw mamas ' " wMMummuanmmu _gm“, Mm. uuuwufiumnmuumazr- hunt“. " “mama. 7pm.; mm «m, a gm mm m mm: ' V»4,.fi,_,§.,..r* 3. Age" A tu Miamiwnuanhmmummumh‘ ��1/” [W W J7 fké, fax»: .7 .2 =_7 adv/O gala; ,Afuuzs a CH“; ; NV/ g xY/ A A3 / ‘3~*‘~/7::¢4 - ls- 925“ '0’? 4a 9 09% W [W751 13.9140 4 dew/9,567 ) M42 flF/fif. J adeN‘ > .7 Fm”. MM 5% F A?” flu— fink. fut. #mmduiui’ Fay: Q. �APR 5 I!!! HOSPITAL 1. nillnidt 2. nonningar 3. Hnn¢* nautil 2,3,k. PATIENT HUMBER 5. SE: 6,7. AGE Ectlth 1. Kilo a. Funnio --, on. Exact no Ago , intnrn;ti¢n RAGE 1. Whit. Euro 0th.:0. la inrornntien 2. 3. RILIGIGH 1. Pratauttnt 2. c;thalie 3. J¢ n 09. in“ r nu inxorattion 10. szArua‘ KARIYAL 1. Bingld 2. marriud 3. separated h. Divorecd 5. Widow‘d 6. la intaruttioa anueArIol 1. l¢n¢ 2. 1~6 yuarn 3. 7 h, . a s 9’11 ‘ o 6 . 12 7t 13-15 a . 16 9 . 17* e . nu internatiaa uma �«.2... 12. PLACE 1. 2. 0! 31313 USA reroitn tern: lagliah Bpatking ' ' 3. h. 5. 6. 7. 8. o. 13. 21‘38 1. 2. 3c . gammy ‘ ‘ 9‘- F‘ O C‘ U amrunwb 4t O . “”6 o‘ u 90 0. 15,/9 n * ' " I u * * fi : x H I t I 1 countricl Girntnia & Scandiuu tvinn Ittly Prune. & aplin slavie natiaun Latin Ancriet ethnr In internation I! 9.5.A. lativv beta Lap: thua 1*h 1 S~9 10~19 29.29 30+ 30 infatuation 69 at 79»?! 89-69 1... 90~99 16¢~199 110~119 120~12y 1 0‘13? 1 0* Ia intarmation 163 A? FIRE! PSYCHIATRIC 363156! -.. lxaet Ag. inrornltion PATIEIT'S sachL CLASS 1. 61:” 1 2. class 2 00“ He 3o 01". h. 81:” §.v 91:0: 5 9. 5113301“! IBHIIR : OF PRIOR HOfiPITALIfiATIONB «a murmur-i 9. 0. «I 8* Ho intomuntion �.3... TOTAL PERIOD OF PRIOR xxrxnxxxczs Lola than 1 nonth 1-5 not. 6’11 ‘0. t HOfiPITAL 1. 2. 3. h. 5. 6. 7. ‘Ow 0. 12~17 not. 1%-23 “58¢ 2h~35 non. 36-h? mac. h3~59 ”0‘. 5+ No year: internation COHDITION A? DISCHARGE 2. 3. Hueh‘inprovod; rocovarod Inprovod Unchangod or Ilightly wort. o. Ho 1. a. Docctncd informatien 913081861 OR DIAGH0313 l. 2. ESTABLISHED Psyahauis: Schiaephrcnic reaction Paychenia: Afroetiva rotations 3. Payehenifiz Dynamic h. Paychonnurotie Bisordcr 5. Pornonulity Dinardnr 6‘ Transient Situational Peranality ls 0 Ha inlermatian General Paychothornpy 30? TREATMEHT: +3 no internatian TREtTEEfiTT IRELTHEBT: 1. 2. easia#¢—— Psychotherapy Payeheanulyais Paychethnrapy: ”.9. Psychethortpyc 0th.: Gran; Thcrnpy Unlpoaiticd Ho psy¢hethorapy lo infatuatien �“aTREATMENT: 1. 2. Hoprob., dopral, oqunnil h. 1 + 2 1 + 3 2 + 3 1 + 2 + 3 3. S. 6. 7. 8. 29/ ORGANIG Phonothyaninou (OP,P,Tr11 9 C O O Tafranil Gthor organic trcatunnt Ne intermatian Ho LENGTH 6F HOSPITALIZATION BEFORE GRGAHIC TREATMENT Lo:a than t‘ 11- 2 M?“ weeks menths k' 5:6 78 9-10 omwmmru 1 waak u " " 11 + months No 25. infcrmation LE GTE OF CURRENT HOSPITALIZATIE Under 1 menth t v- t o wmwmmrwmwu I 2 3 manths months h-S manths 6 months 7~8 months 9-11 month: 12 month: (1‘. 2?, 2- . .‘ 13+ months No informtticn "F" SCORE —-. a exact 00. ~ Ha scorn information ) �0 \, $550014’o s 0% 'P ~_/”‘ A § PA- N A M H G H ‘1” a f ‘64, . , '_ «a V ’4L Rafi» Psychiatric Group Association for Health Insurance Inc. Mental Health Association PROJECT SPRINO7-6000. Ext. 399 RESEARCH 22' FOURTH AVNUE. NEW VORK3N.V- (Invettigation Into the Insumbility 0f Pch/aiatric Treatments) Helen H. Avnet, Proiect Director November 28, ADVISORY COMMITTEE l 960 Harvey J. Tompkins, M.D. CHAIRMAN lea Perlis VICE-CHAIRMAN A. Oakley Brooks Martin Cherkasky, MD. John M. Cotton, M.D. Jack Elinson, Ph.D. Sylvan s. Furman David Goldstein, MD. Clarkson Hill Paul H_ ”och, M.D. William A. Horwitz, M.D. Lothar B. Kalinowsky, M.D. Mack Lipkin, M.D. Henry B. Makover, M.D. Martin E. Segal Leo Srole, Ph.D. Partic£9ating PSYChiatri-Sts FROM: Harvey P J. Tompkins , M. D. and John M. Cotton, 1...; Participating Psychiatrists, the Project, covering a sample group Of 76’ 000 Persons’ has been operating satiSfaCtorll-y Since July 1,1959 HarrYl.Weinstock,M.D. Bernard Wortis,M.D. Attached msma is a report pating psychiatrists, REPRESENTATIVE COMMITTEE Int erest 1‘18- MANHATTAN: John M. Cotton, M.D. CHAIRMAN An on our survey of particithink you will find Which we address recently made by ArthurHH. Harlow, Jr. PrESident of Group Health Insurance, Inc., on the first, year' 5 experience under the Project, will be summarized in the December issue of the Bulletin of the New York State District Branches of the American Psychiatric KINGS: Morton H. Hand, M.D. BRONX, Jacobo. S-Jaeger,M.D. QUEENS: ArthurW.Schappe|l,M.D. Association. NASSAU: Irving Chipkin, M.D. If SUFFOLK: Robert Wagner, M.D. WESTCHESTER: Miltiades Zaphiropoulos, MD. write us r equ est. you would like additional information please and we will be happy to comply with your NEw JERSEY: David Flicker, M.D. DEPARTMENT EXPERifi'l {filial or ”ii PSYEW HILLSIDE HOSPITAL GLEN OAKS.N NOVZ 31960 M. D. sycuratric Research Pro;. ect Thanks to the cooperation of our S. APA T02 SUBJECT .. . . National American I 1 ulna! Illness (3 Me Financed by National Institute of Mental Health and Group Health Insurance, Inc. �QUESTIONNAIRE SURVEY OF PARTICIPAIING PSYCHIATRISTS possible aid in the eventual evaluation of results of treating Project professional qualifications and customs of participating psychiatrists. As a cases, a survey was conducted on the age, sex, and for participants, returned questionnaires. In addition, data on qualifications were obtained from the latest medical directories of the non-reSpondents. Of 1150 many 1008 In order to encourage the broadest possible response, the questionnaire was limited to one page with a dozen questions in all, mostly check-offs, and with space provided for comments. are: From the Project's point of View, the most important findings of the survey (1) The great majority of participating psychiatrists are well qualified, judging by accepted standards in the field. (2) Over three-quarters of participants regard themselves as primarily analytically and psychologically oriented in their approach to treatment. ‘ é‘EX, AGE;.,L9.CATION - (Tables 1 - 3) More than half the participants are between 35 and 49 years of age. About every tenth participant is a woman. The majority practice in Manhattan, although the suburbs are fairly well represented. TABLE 1 — SEX OFflgAgILQIPATING PSYCHIATR;§1§# Male Female TABLE 2 - AGE 1001 (88 per 138 (12 per cent) cent) Dl§IgIBUTION Age Group‘ Egmbgr 28-34 187 204 144 224 168 99 35-39 40-44 45~49 50-54 55-59 65 60-64 and over Total *excludes those who have resigned or in Group 71 42 1139* who have died ger Cent of Total 16.4 17.9 12.6 19.7 14.8 8.7 6.2 3.7 100.0 �Page 2. - AREA OF PRACTICE TABLE 3 Number Area Manhattan Brooklyn in Area Per Cent of Total 57.0 649 98 8.6 5.2 1.9 59 Queens Bronx 22 Staten Island New Jersey .4 5 6.4 73 7.0 79 Nassau Suffolk 4.3 5.8 49 Westchester 66 16 Rockland Other Total ~23 1.4 2.0 1139 100.0 TYPE OF PRACTICE participants confine their practice to hosPital work. The majority Forty-three per cent treat only in the treat office, referring their hospital cases to colleagues. Seven out of ten answering this question (1000) report that they also do out-patient clinic work. Only 17 both office and hospital patients. QUALIFICATIONS Of 1096 either participants for whom information is available, cent are 85 per Diplomates of the American Board of Psychiatry and Neurology or are ”Board per cent are qualified as psychiatrists, with an ”SI" rating, under the New York State Workmen's Compensation law. 0f the remaining 13 per cent, 6 per cent are accredited as psychiatrists by the New York State Department of Mental Hygiet e, with the "QP" rating, and 7 per cent meet the quali— fications for membership in the American Psychiatric Association. eligible." Another Table 4 shows TABLE two this over-all distribution, and Table 5 breaks it down by age: 4 - QUALIFICATIONS DPN* DPN ‘ . Number Per Cent Cumulative Per Cent 585 53. 4 31. 8 2.1 53.4 85.2 87.3 7.1 100.0 eligibility only* 349 23 SI rating only** 61 QP rating only*** 78 APA membership only Total Known 1096 5.6 9239 100.0 *Diplomate, American Board of Psychiatry and Neurology **Qualified as psychiatrist under New York State Workmen' 3 Compensation Law " " *** by New York State Department of Mental Hygiene - �TABLE 5 - QUALIFICATIONS Page 3. AND AGE Per Cent of Age Group with Boards or Eligibility SI Rating Only Age Group 28-34 90 40-44 45-49 50-54 55-59 89 - 60-64 65 and over 'All Groups (Total Reporting1096) *less than 1 * * 80 35—39 2 87 90 3 86 2 71 68 8 10 85 2 * per cent ORIENTATION invitations to participate in the Project were issued, reasons for nonparticipation were also solicited. Most refusals were based on the practitioner's analytic orientation: The 15 sessions provided by the Project were felt to be far from adequate in terms of the respondent's usual ”A-P” (analytic and psychological) When approach to treatment. Since the "D-0" (directive—organic) and eclectic practitioners were more apt to be optimistic about the effectiveness of short-term therapy, there seemed a possibility that enrollment from these groups might dominate the list of participants. This theory was effectively demolished by the survey. Of over 1000 respondents, 77 per cent checked ”analytical and psychological” as their primary orientation, 10 per cent checked "directive and organic,” and 13 per cent checked "other", usually specifying "both” or a combination of the other two such as "organic and psychological.” Although the majority with the primary A-P orientation exists at every age level, it becomes less of a majority with each age increment, so that what starts out as a 92 per cent A-P orientation, in the youngest group, comes down to a 53 per cent A-P orientation in the over-60 group, as shown in Table 6. TABLE 6 - PRIMARY ORIENTATION AND AGE . Age Group Per Cent of Each Age Group with Specified Primary Orientation Other A-P D-O Combination 28-34 35~39 92 89 2 3 40-44 85 3. 50-54 55-59 60 and over 76 61 10 21 45~49 All Groups(Total Reporting 1002) 6 8 12 53 25 14 18 23 22 77% 10% 13% 59 18 �Page 4. A primary orientation toward one approach does not of course mean that an individual will always use that approach. A psychiatrist who is primarily A—P oriented may use organic approaches on occasion, as shown below. ATTITUDES TOWARD DRUGS,gSHOCK THERAPY, GROUP THERAPY Drugs appear to be almost a universal tool among psychiatrists (98 per cent). 0n shock therapy and group therapy, there were far fewer answers, and it is impossible to evaluate whether a non-response indicates a negative attitude or an oversight. But a comparison of the number responding to each question may in itself be indicative to some extent of the degree of acceptance achieved by each method of treatment. The total responses and the percentage of affirmative answers follow: Total QEEEEEQE Do " H you " drugs? prescribe ” I! Per Cent Affirmative 98 952 693 shock therapy? group therapy? H Number of Answers 75 51 69". A cross-tabulation of the answers to these questions with the primary practice orientation of the respondent shows that the use of drugs and shock treatment is not a distinguishing characteristic of any group, although the non-A-P's are much more apt to recommend shock therapy than their colleagues. - PERCENTAGE OF REPORTING PSYCHIATRISTS TABLE 7 AND GROUP WHO PRESCRIBE SHOCK THERAPY, DRUGS, THERAPY, BY PRACTICE ORIENTATION Per Cent of Each Orientation Who Prescribe - Practice Orientation Shock Therapy 68 A—P D-O 92 90 Combination Drugs Group Therapy 100 100 50 54 34 97 There appears to be no dearth of personnel ready to administer shock therapy this) or to conduct group therapy (208 checked this). (247 checked FEES A question was asked as to differentiation between fees for initial consultatior Of 981 respondents, 45 per cent do differentiate, 55 per cent do not. and treatment. The question as to the respondent's usual fee for a private office session brought 987 responses, of which 789 were explicit, 198 stated a range. In other words, 20 per cent of the respondents do not have a set fee. For most of these, the range indicated was either $15-$20 or $20-$25, but there were instances of a twentydollar spread in the usual fee - e.g.,"$lS-$35" or"$30—$50". For those stating a definite usual fee, the distribution is as follows: Usual Fee $15 $20 $25 $30 or more Per Cent Charging 11 49 36 4 �Addendum: PSYCHIATRISTS AND THE OPERATION OF THE PROJECT Because of the enthusiastic response of psychiatrists to the Project, one of the disappointments of the first year's Operations was the relatively small number who actually saw a Project patient - fewer than a third of the participating psychiatrists. This includes cases treated by more than one psychiatrist, and multiple cases in the same family (usually treated by the same psychiatrist). The number of psychiatrists and patients* seen by each was as follows: Number of Psychiatrists Number of 201 1 Each 1 63 21 15 8 4 Patients 2 3 4 5 6 each 7 ,8,9,10,11 *Excluding cases having hospital care only. Psychiatrists having a in relatively short supply. number of cases are usually child psychiatrists, who are all participating psychiatrists, the psychiatrists who treated on the whole somewhat better qualified (91% vs 87% having Boards eligibility) and somewhat less primarily A~P oriented (67% vs 77%). The Compared with Project cases were or Board treatment. they rendered was mostly individual office psychotherapy. Four per cent of the cases were hospitalized; seven per cent received shock therapy (including hos— pital cases); three per cent received group therapy; seven per cent received psychological testing. Ig_thi£ty-five per cent of the office drugs were prescribed at one time or another during the course of treatment. cases, 0n the basis of the few (36) Project cases treated by two or more doctors, it would appear that psychiatrists are rarely in exact agreement about the diagnosis of a particular case. In 12 cases there was a basic difference as to the severity of the condition, with one doctor calling it a psychosis, the other something less severe. In four additional cases there was a difference as to major category (usually neurosis or personality disorder). In another six, there was a partial difference as to major category, with one doctor calling it a mixed diagnosis; and in another 9, there was agreement as to major category but differences appeared in the sub-categories. cases there were identical diagnoses in 5. 36 Out of Another demonstration of the individuality of psychiatrists emerged during attempts to classify frequency of treatment under the Project. Although six specific classifications were available for coding purposes, 42 per cent of the cases fell into the ”other” or non-classifiable category. Pursuit of this led to a fascinating variety of frequencies of individual office visits, each adding up to exactly 15 visits (the Project limit). There are combinations extending from two months (6 visits one month, 9 the next), to seven months (4,1,2,2,2,3,1; or and in between come all sorts of combinations spreading the visits overl,5,4,2,l,1,1), 3 or 4 or 5 or 6 months. far as is to the Project administration, there has been a negligible unfair advantage of the Certain difficulties inevitably arise with thbse who do not read their mail orplan. and there instructions, are occasional misunderstandings resulting from patients belatedly identifying them— selves as Project-eligible. As far as can be determined, broken appointments are not a serious source of difficulty. In general, the Project has generated the enthusiasm and cooperation which sometimes characterize pioneering ventures. So known amount of abuse, or attempts to take GHI’APA—NAMH RESEARCH PROJECT (for the period 7/1/59~6/30/60) �I: 12/26/60 Social Glaxo, Diognooio, ond Irootnoht In Throo Psychiotrio Hospital: In 1958, Bolliugohood and Rodlioh pahliohod on influontiol voloto, (1); in ohipn botvoon mat it tho: roportOd roiotion- social class) diognooio, tad tho troot- or loan]. dioordon. and Pink (2) which During 1958, Kohn, Pout ok roportod studill tt not lhOfln that who: oduootioh or oooiol slain, Hilllido Hoopitol vhoro woo it It! roiotod to toad who on to iodox on: rotorrod for convulsivo thoropy, one to tho thoropoutic rouponto to this trootnont inotrunont. Tho Bollinglhood ohd Rodlioh study It: oorriod out bororo tho oo-oullod 'tronquili:inz“ drugs oohiovod wido populority. thoropy ooooo oloo demo Tho Kohn, at a facility, woo hood. roportod, for CSflIplflg thot drug tho prinéipol thoropy in only b.31 of tho tho: otudiod.; thoropy won it: It won whoro Pollock o rink study woo ot tho tino, oonvultivo tho major organic thorlpoutio dovioo which �i3Tvvor the heepitele were well The third was the research hospital of a state hospital system etteohed to e its fietiente private facilities. known university medical center. Heat of were voluntary ednieeionl. Each of the heepitele were peyohoenelytieelly oriented and each institution maintained affiliations with local analytic institute. The hospitals were loceted reepectively in the aid-West. Riddle Atlantic, and The queetioee we e New England. wished to answer in relation to social classes for the different hospital settings were: (1) What is the relation of patient social class to (a) diagnosis, (b) treatment, and (o) length of he (2) hospitalisation. For these varieties, are there differences between heepitele vhioh treat different model close groups? Pppuletion a Hethodolegy: During the Winter 1958~1959, e research team each of the three hospitals. population of each hoapitfl. The who visited total adult in~petient were hospitalized on �~11» voluntary cartitieatan day. Each patient word was then at hi: hospitalizatien on studied in a given viaitatioh followed through the course and information regarding his treatmant, langth of hospitalization and discharge status was appended xjfilxiai to tha data ahaata for each patient studiad. All patients discharged tron this hoapital within aightaan months after the study began, were indluded in the sample. This included approximately minty per cent of the originally studied. Eollingahead position and was emphasised which aducational scores. farred to it two factor index of social utilizes Data for each Eollingshead cards to weighted occupational patient I? and V. trans~ on thc p u‘i.05 laval. Class Diatributian within Hogfiitala: In Hospital "A“; 311 or the classes I was facilitata statistical analyaas. Significanccs were computed Results: patiaata and II, 12$ to Class In Haapital Claaaes I and II, 3&5 '3', III, 271 in Class patients warn aaaignad ta and 571 to 615330: at the patients ware in III, and 39% in Clauses IV and I. �-5- '0', In Hospital III, Glass modion 82% and 1‘ in Class IV. class patients have I and II, worn in Classes of Viowod 17% in in turns of the its pationts, Hospital the highest status (Rd: Cleo: A's II), Hospital G's, the lowest (Ed: Close 1!) and Hospital B's petionts fall between tho two, (Nd: Cleo: 1119.10r purpuo of olooo~ ifiontion we visualize Hospital A no treating primarily upper close groups of patients, Hospital close group, and Hospital 0, a lower B, a middle class group. Hospital and Diggnosis: Comparing the proportion of its patients which ouch hospital diagnosed as oithor psychotic or non-psychotic, we found oigniticnnt diagnostic differences between institu- tiono (:2 - 12.73; df- 2; tended to treat p4 .01). In the hospital which predominantly lower close petionto, 75 For cont of-ull the patients were considered psychotic; in-tho hoopitol treating predominantly the middle class group, 7h! per cent were diognoood as psychotic, while in tin hospital trusting predominlily the oppor class grow), par cont wore oollod psychotic. 53 �.5. Social Glace and Dielgceiea It in interesting to note some of the diagnoetic differences in hoepitele, when In Classes I and constant. II the class factor we found patients were called neurotic, in Class neurotic, and in classes IV and V, 20% 36% or the III, 29% wc-e kept was were neurotic. The direction of these statistics tanded to support the observation of Hollinguhcad and Redlich but for the hospitalized patients never theleaa, did not reach significance (12 - 5.99, p on . the 15 level (12 ' 5.77; df - 2; p e 3.8.) .05). Hospitals and Treatment: We found differences in the employment of organic therapies, 1.0., the peychotrcpic coupenndc therepiee p 1n u.; .01). and convulsive the three institutions (12 - 12.12, a: In the clue: patients; hSS facility which tended to at the petiente received tract some - 2, upper torn or organic treatment; in the institution treating middle clues petiente, abs; clean pattente, and in the th hoepitnl treating prinerily lover received crgenic therapy. �.7Social Clan, Dugout: ndtrutnnt: In combined pooulntions or the three hoapitulo, thoro are differences between the major forms of troahncnt that psychotic and neurotic patients experience (12 d: - 2; p ~$.001). compared with 205 of In It! 115$ of the neurotic were administered to tho psychotic cacao. 32% tho go Organic thcaapios of the nourotica and Patients or psychotherapy, constituted 1nd kg of can: the psychotic tacos, psychotherapy the dominant trcatmont modality. wag ' 69-7; the paychotic cocoa. who 23% It I! 76% of received neither organic of tho neurotic cocoa has been shown thot within hospital settings studied, organic forms of therapy worn frequently given to psychotic than nourotic patients. morc In touting tho hypothocoa that a higher proportion of lower class than uppor class patients rocoivo organic forms of trootnont, we round the hyyothosia not to be supported for oithor the neurotic or psychotic groups. Within each oocial clot: group, psychotic patients received organic trootnont more was frequently than uon—poychotic patients but social class not aigniticantly rclntod to whether or not potionta �-3... who were either psychotic or noorotio would receive organic thorooy. Social Class and Length of Hospitalizotion: When no combined hospitals, we for Class I & found the populttions from the three that tho II potionto hospitalization period aoan III 9.2 months, Class was and Class IV and V, 7.2 months. We found no 9.8 months, statistical difference between the lungth of hospitalization or Class I, II III patients (t- 1.66, and div 196, p - H.S.) but found significant differences botvoon Class I, II and patients (t - 7.69, df- 221, ptmm) IV and V . ggopitalo and Length of Treatment: The figures are rotlootod in the different hospitalization periods that hospitals. patients were found in the three In Hospital A, the upper class hospital, were hospitalized for in Hospital 8, the middle class an average of ll institution, for montha, and in Hospital C, the lower S.k months. mean months, 8.9 class facility, for �“9- Rocapitnlation and Conclusion: The primary purooao or this ctudy ha: been to study the rolationahio of social class and psychiatric diagnosis and treatment in hospitals which have available conparablo facilities. troutmont differences, class which have We know members may that baoauso of «coconic gravitate toward institutions available different kind: of therapy, have selected three hospitals which and thus we employ comparable ranges of therapy and which tend to treat nonbors or different socioeconomic groups. “what In affect, what is the hospital experience of oocioocononic groups where all we are thus asking is: members of different forms of thorapy are equally available?" Within the social class was hospital cutting described, we found not related to whothcr a person diagnosed as psychotic or nonvpsyohotio. Ho that was also found aooial class to be unrelated to the employment of ergonio therapy. We believe that the relatively wide use that �-10psychotropic ooopoundo now enjoy nay toad to blur tho sharper diotinotiono whihh oxiotod non. yours ogo than organic treatment was identified with the shook tad con: therapies. We that lower class position found length of time doooribod.Lowo; o was related to tho patient spent in the hospital settings class patients (Glaoaos IV & V) were hospitalized for anorufiormas a: time than Class I, II 0r III patients. Major The difroronoeo were found between the throo hospitals. hospital treating upper class patients tended to diognooo the higher proportion of its patients as non-psychotic, tended to employ a lower comporativo percentage of organic thoropy, and left its patients period oz time. in treatment for the longest In contrast, the hospital which tended to treat patients primarily from the lower portion of tho ocononio ooootrnu had the highest proportion of psychotically diagnosod patients, onyloyod organic treatment more often than the other hoopitalo describod, and tort patients in treatmont for the shortest period of tins. �.11. In an tar us tau thrac hospitals studind arc construed, 300131 61188 woulé appear to ho lass intimataly rclutad to dingnosis and trantuent than scald the naturu at th. hospitzl itatltg and the sacinl gruup tauhieh it tddraascs itself. �1: 1/3/61 . soaihl 61:13, DiIIROIil whrct Paychtatrto und trtaincnt 1; Ht‘pit‘lfi IITRODUCTXOHa Iva hundrtd and ninety patients in $hr¢a uoau cuetadinl aetivu trcntiunt ptyehiatria haupitnln, which ortcrad multipln tharnpicn, primarily ta typur, niddlo a: lawn: clnta ficraoul var. Ifindaud during 1959*60. Questions utudicd were whothnr naninl clans £¢r haspitaltnad paticnta fiypm It: ralntod to (a) dingntsil, a: tr¢ntnen$, aha langfih at trautaunt tnd rahttamhtp at yum: suntan-nu» Cb) a nun “away", ’mifidla', and “tuner” «inns hospitals ta dznauuain, type a: treatment and longth a: traatnaat. W! Volautnurily udaittcd paticnta 1n thrtn kncvn xucxraphtnclly 47W“. u/Cc. f“ V: atpur:tc httntttll w¢11~ which itiflrlé �nan- : rung. if thnrup¢ut1¢ prnxruan. that. putioutu aura prtnnritr rdprutoutattv. at $§fi§upptr, 3:831. at lunar ulnauoa, turn atudiud t! s.aluu d:y in thy wintsr, n! a 311.3 heapittl 19$8~1959 tuilunod thruushaut tacit suntan and if a Putiontl vcro hospitalitutsnu detail: caacorninc that: buneruund, truutuant nud dtusnunin wart rncurdcd* 33831.93: Seats}. 6183! was tau“ ta ha r-alaud to lung“: at notivu truatnnn‘ within tha hotpitnl aettingn. 015': I? and charm Y putt¢nta rtlainad 1n truntnsnt for pox-ands a: an. than. an" x. I: or m paticntu. Signittctnt rolutanuuhipc bctwnun 1031‘; clans, diaguoail ana trtntucut warn mat uhaarvcd. sacniticnut rol‘ticnathn war. found bntwu.n p;t1§nt néubtrthip an upytr,xmiédla and Instr 01‘3t �influx: and dams“, “aunt. and has“ at hupiuluutom the nut» in tutwuomu mum at m "mun, "guitar at Vhflhtr a an: nutwumu m, that mm mm: tho "My“ ma M man.“ u magma-tun; mu rams." wan-am than”, and ”mi '56 Mpiullw tu- t!“ lmut yaw-1M at patio“ m I mum at ‘1‘. a a �1: 1/3/61 anuttl Gitul. nzlgntnia ;nd fruufincat 1a Ebro. Puyuhtatric notpxt;1: 111302301103: tin hundrtd nut ninnfir patlnusc in thran nth. custodial ac‘iis trca‘lnnt'ptrchtafirtu knupttnll, arrdrtd uvlfiiplo thnrnpioa, firtaartlr ta appur, which gladlo or Inuit «1‘3: pirlfifll 2‘3. atudand during ‘ 19$9~60. Quautsnas tindiod war. whithar 300151 31.0: hsnv1%nliutfi pntlcntu it: rnlntad in (I) din¢n¢nts. at trausnunt «:90 a! ircatunat, 3nd 1¢Ig§h raln‘aonshgp a: Fttitn£ llflhirihip a: and Inngth $34 th... ‘ntddlc'. ‘ud ”lower“ cln¢a hmlpttnIu-to flirt or £ruatnant tar (3) 'nppcr'. dianumwzt, a: trnatunnt. 930039332: Valuntslrily adsttttd pgtiunta knuwn geographiaally Iapnrttc 1n thr¢t wail- haipittll which uttarvd �.2. 3 ring. a! thnrtptutis progruun, Vhflri plttfiufii warn prtnlrlly roprcatntafiavu a: ifiiEnppor, ngdéau er lowcr alumnus, aura Uti‘iid an at n ctvuu hmapitui «call: any in tht‘wiufitr. tallauod thmaushtu‘ thttt and 6.13113 unncnrnxug and diltnllil l9$8~1959 BQIrlfi ¢ if Pnttonia var: hampttnlatuttuu that! h$ak¢round, trunfinnu‘ mutt ruocrfiad. Ilflfilg§x Benin: ulna: vat fauna to ht rulatcd to langth at asttro trcntnnnt wt‘han «a; hompttal Ittfiinsl. 015.: IV and V pattan‘u ruuutacd Ln trcntuont {or thurtar 9.3104: at téuo tuna clan! pttlthtl. Signifiauat I, I: at r¢1m§¢nanhapu 01:33, fltlflflfiflil nut tr‘aiuomt lira :11 bitwcun.taotn1 fiat dblorvnd. aacntttcant rolnfiiaalhtpa new: round bntugnn patsaat nadburahip an uyptr, 31441. and luau: «13;: �human and «awn; ”Miami and loan» at h§Ip1£u1tsatioaa 2h. srnttnr it: uaataaiaonuntc Ituiua a: the hanpiQal, rug&raluns a: whither a puticut any n ninbnr gmaup, aha mart a: a aiv¢n aacauuaacnumia 11ktly the pat1.n¢ wanié h: diaznaaed gs nanwpnychofiin, wauln rgaeivv neawurgania therapy, and would be hunpitnliangQr the $130. inngsst patina of �II: 1/10/61 Social Clean, Diegnoeie end Treetnent in Three Psychiatric Hoepitele INTRODUCTIOH: Recent etudiee have indiceted e reletionehip between eociel clean end peychietric diegnoeie end treatment. preeent etudy wee The designed to study whether social cleee for hospitalised patients wee releted to diegnoeie, type of treatment end length of treatment, in three institutions vith differing eociel cleee membership of the patient populetione. PROCEDURE: Two hundred end ninety voluntarily admitted patients to the C.F. Menninger Memorial Hospital, Hilleide Hoepitel end the Heeeechneette Hentel Health Center were etudied ea or e given hoepitel cenene day in the Winter, l958~1959. Petiente were followed by-e reeeerch teen throughout their course of hoepitelieeticn end deteile concerning their beckground, treatment end diegnceie were recorded. �.2RESULTS: Sooisl clsss was found to bs mars significant in coup-risans bstwssn hospitals than in intsr-institutisn analysis. Within institutions socisl class was saluted to lsngth at hospitalisstian snly; class signifiicsntly IV and V patients rsnsinsd in trustmsnt tar shorter psriods thsn III. those in clsssss I, II hespitsls significant rslstienships bstvssn social showsd sud Csnpsrison bstwssn class and disgussis sud trustusnt ss vsll ss lsngth of hospitslisstion. The higher tbs class status of tbs hospitsl, ths morn likely tho pstisnt would be diagnossd as nonpsychotic, vauld not rsssivs samstic thsrspy and would bs hospitslissd for s longsr psriod. hospital was mars Tho class status or ths importsnt than tbs inflividusl patisnt's clsss msnbsrship in dotsrmining thoss rslstionships. liIIIUQ �Junntry 10, 1961. Dr. Gurdnzr Kurphy, Diroctor of Research, Hunningcr Foundition Hoapitnl, Topeka, Kansas. Dear Dr. Murphy: stat: In 1959, Dru. Siogcl, Kuhn and Pollack at thin arranzod with Dr. Ksrtuu, ta undarttkc a canpnrativa population staple study at the in-putiontu Haulaahulitta Hunts! Hunlth Hospitals. Tho dtta colltction ph‘l. at this atudy VII conplotod in Soptunbor, and V. have prone-sad a large part or the atntiaticn and and. Ian. prolininary audguonts. It in our dosiro tn proscnt a comptrativc stnicuont a: the "Social Class. Dingnoui- ind Trontuant in Thruu Paychittric Hanpitalt ta tho incriesn Sociolozianl Sacicty in Augnat. rho dutu bl! bath intlysod according ta hypothcucn undtr otudy in tho in-pationt sorvico at Hillido Hospital in 1957 and 1958. An abutrnct or this initial roport in enclosed for your Honninger Hoapital, It Cbntur and Hilllidu internatian. urn plonuod ta credit the cooparatinu of tho ill thrto institution: in enabling this utndy to bo incomplilhud. I: that. it :ny additional connunicntion W. atattu or noogatngy new as for thc prancntntiou or this data, Du; Robbins and hipyy ycar. Join: us in withing you a Sine-roly yourc, Enel. HFsJB m iInE H05. would you lot anccoasrul �Social Class, Diagnosis and Treatment Jar/a ‘ in Three Psychiatric Heepitals 9s [4 N p as, "Axum If “lips: his 62%;}; s . d/mAM ,/ I INTRODUCTION: as g fag / AL»; 4 Kata, Xvi/5k. we ,4 A . _, Recent studies have .1 / ”wk indicated/a'relationshifi between social class l and psychiatric diagnosis MW“' treatment.I\ and The designed to study whether social class aunt for hOSpitalized patients was related to diagnosis, A type present study was oi—taeotment and length of treatment, in three institutions Withhdiffering social class membership,e£_:h¢_9a;§en¢_. popaiebffifis. PROCEDURE: Two voluntarily admitted patients hundred and ninety to the C.F. Menninger Memorial HoSpital, Hillside Hospital the Massachusetts Mental Health Center were studied as and of a given Patients hospital census day in the Winter, 1958-1959. research team throughout their were followed by a course of hOSpitalization and details concerning their background, treatment and diagnosis were recorded. 71.9.3th )7 5/2, ”mg r [£1 44M” ‘2 I (’- ’3 1,1,4"; at. & “4.4140,,51‘: , 2:3; f.a.Afi/_ 1.14931. 3 , j>gfl(‘""4" I) MM! 14.0741; 5&4: 4‘ I ”my 1:“ 2'33; 4» fall’g’ffrf (4“ {W4 / "w a? “3‘ ” . M was f. a a, ,x. aw Wm, f‘zl/“ié ”*Muwwt‘ .-' 7 “A,“ I ‘5 ’ 1,» . «min ad.“ an» g9 252‘. .6‘ - I J, £354 {V _ an , ' . �-k’ RESULTS: a . Social class was found comparisons between WM if ”54/ to be‘more significantnin hospitals than in inter—institution analysis. Within institutions social class was related to length of hospitalization only; class signifiicantly IV and V patients remained in treatment for shorter periods than 1132.? those in classes I,\II hospitals showed significant relationships between social class diagnosis and treatment as well as length of and hospitalization. The and Comparison between higher the class status of the hospital, the more likely the patient would be diagnosed as non- psychotic, would not receive somatic therapy and would be hospitalized for hospital was more a longer period. The class status of the important than the individual patient's class membership in determining these relationships. M �Mary 16, 1961. Dr. Hilton Greenbhtt, manhunt“ Rental Kuhn Center, 72-76 rammed Road, Bolton, Hen. Dear mm It In good talking to you in Wuhington. I think the meetings went very well and I eapociauy liked Shep Roma's raport location the VA, pnuont-paumt intonation. on also quite an Xurlmd and is little The many nit-moon in studios. more ammo good. bringing out the drug Comm oomtin and for phoebo control! now in and comparative efficacy tasks on saluting be who’s Mom to Encloud in our inltial abstract much to the Andean Sociological Society. we My best. regards. Sincerely you”, an: inn: mfi. Baal. HF: JB new drugs in order. am sending - �1. 3... W .‘ M753 . 2,3,8. z m» 5;. in. 5. 7 8 7. 4/44: m7 IAA/c M, m M4 n n "" If? ’é a , fl. "0 5 . .__n 22...} .JL A ~ MI Ag~nhfi ‘ 13. m. In" M ta man mum at “4.”. I. mmm ms WW!!!” m...“ “,.".“. -WA �at» mamount: ”a“ m I! 1: 'u‘n‘m 5. 19:19 6. 19-” 300 ,_ 15. N»?! 0M! 3. 5.a {@099 Ya 1'0‘1!’ #. ’1 a. 16. u km 6! .. ‘ ”-1” Rod” '9‘. h tumum Q‘tumfl sans. ems :1. 1 ’1 an. 3m. 5 "m m it ms mmum mm ii s g. 11,13. 316/”); I “a M‘. “O “1mm a A6311! as. 1’.”. ruemnn manna“ rm:is! ”I M‘ m. 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In our Why Wu "mu m. MW w.» mm m �«‘11-» u inn-1m an was. WM. mm mm mm m MI. 1 “mm“. 0M1 mm m that but than um mm “mm in” m M «harm Win W M ““hMg or m mast-3.: as ”mm; mu diam”. «mammain Mh I 1‘:.,u.z...c.4.,1;8 ems.» ”In. “um: um W‘. n It“ bid we mfi 01M!“ mm, Mm mm n: _m¢. 1: WIthan min-um a: must. manna. A: Ch ambit. a ml- :1. m Mum. mm a WWW»: mmnuuamu W! WW W. mmmmmsmarammnu mum. in nasal, and �nun mmtuouummmmmumumu wmmwmum.wmm. Intactumummmuumufium “0 ”film "an. ”31%“. OI’ at W In" «an mung m mutant. (mu “mm-nuns“), tmfiym mmuuuummmw.uuunm.um ”muucm1uu.mmnuutu¢Wfl. MmhIhu'. unmmm»m..uuu m). OWWMMUM‘WWMflmwnw-fl! ummmnm’umn. Atm.mmw1w �«na- ammglitmmt)m£~uum "flibmflfllhlflfilrwmmm M5 Mmummmumx mutual(”to”). mumummm flMflMWWM“WV-mwmfikc Warm. 'mmmumomom mautwmmumm W mfiwmmumumumm mamaammngm muwmmwmmmmu hmwmw.mmiuuwmmumm (mun). mhzmmnmnmnm uwmuummummwm.m mmwawstwmuummm munmnwmm. �db- mmummmu Immmtmhu). “inhuman Lma mm.nwmumwmm *MW'MW”.NWI§QMII§ manna-hm. “mun“.anyu ”mmnmflaamtm,auuwm ”mutton-an. mama-mama. mmurmmumm ”.msemhv. mmeuI-auu «mmmmumum magma-autumn. um.m mwmmuwmwrsm. mmmwummmaamm �.15. mum. m. Mam-I & mi. that mmumm:mmu MmumuHM-mumumu' mm m m an“ «nanny Wufim-flmmmf mums-Wwamnmt 'mmmmmwmum ). mumummmw .mmmatmsmmw. ”Mummmwnw mmnvudnammmuunamu stoma-mum. ttfiimflfltw W" «W . = '* a umwmm ~ WWW. ”QWthwm �mwmwuum.mummm: ”mummwpnmm nmumnmmmwmumm mummmummmtm :mumwtammnwmm uwumm.uummmram “Mm‘mquanuw Mfmfimw‘.mlmtmhhflm “RMCMJAMJAW. Mime mmm.~ nmmummmumim.wmu �Q1,” “Initial “It I rim with a um I «an an m»muuyumwmum. MG puinh‘MIom.umm-vvw.u but niobium" mmwumm'n mauwammmm. «mam m.uamuunlml tum. Sen-nub.” W W's. Wmmnmmmmuum but 1m» to WI.“ at unmtummmuuuuummum mum {Mk II). at “Imam w an“ m.mm.uuwwmtumum mumuuuummmmtunmw m.munmmuuanmmmum ammuwswmtumuw. “swam“,mmmmnmrmn m �.48.. m. W aux. WM“ mmwmumm d ”Hm“... mm «at manna-u m m m: m: and: “um u a mus-nun» mm In a. Wt yam Md. timzmmm.mum with“ mm mm ”W W m m W W. W, mmlwmmnmfl “4“an Influx rating! m um- A. In an .mm n 10.3,“ lacuna-u «- am an hr :2 mm a m n tho a minus" m pm W: mum“: u w. m tin-m am in ”mm a: mum“... or .1- am. in sum xx. in mm“ a ”new Wu mm um.“ m. m, catamaran. and a! minimal Win: mm, main: Mini. m1. W m «um um: Mm: um �A:- WWNnMWWth mutmnmmw.m‘m mamuamuunmwm. w- nmuummmnwwtmm mimmWflhflth.flfi mommuwrmnmm‘mawhu “wumnuumm. Mflkfliimm mum-hm. stWWMflIIlnflut nuutmIMMathkkh¢Wu u Wat-I” w 'mw mm“. m: an mmrmatmumhunumm amn$mu Wu'mm’. Minivan. “Mnmmfiarmdm. �om WHMIRM!‘WWWW uWth-“mmm', mmnmu'mw'. um. uws.flmmflmmm_muq H .l.,“,.Vl 1'5 mm» stamina-mum mtaummummmmtuwuum n‘wuuammu’w‘. vu‘uw W.W.nmtw'ummmt WW“W“M“O”WWamw asmuuw-amtmumw. At mmmammwmww,uas«m qmmun.mmmtmmumm www.mmuutmuww. mummmummmmu m1“. Asnmmmmeut-umm �~21» cmumuuummmmm. wwmhmskWIWtW'“ “W'umWa thm). mum.uwmmwomuuu *m W. ��«so unmet-mum“. um,umt. mumsmmmunwum mmmamw;mw.mm wammdawmwm. mwm‘mummm mmw:mmmm~m Mummnmmuum. wan-am mum mm mm Wt ). at 2.2 «mtwwc mum'ap'fihu‘ an mun-attain. m’WM-m an: unfit-Wlmdnutumm. Mm‘cmu mam”. ”mummmm',m. It. mt Win; it”. me WW �"35* mnunm u Mum mm mm «is: :W M w Imam” m t a M 3m: than was Mam u mad: mung: aunt's manna. MWWmflhfiflWFn/nua m W WfiflWbWMfll-de www.momzymmmu m Mm mMW‘fa a. mu» MWhhM‘WWan NuWWW. MW. “.mguummm nu WthuMW-mw. minim!» uwwmumtmmmmwm umwmmhawumw “WmmumuMMMu ��1. I. Wynn mmw W mat-tic Personality awoken“: ”in rmmmaa Eta-mu” W5 3mm 8.01m this, Fungal:V ' Mambm ‘. m Saginaw Pursuant: Far-a: misty Madam“ int mow- WW �I: CW, 15833 and» itiflili 9i fifilflififlisfifiifllflifliafii IZfiE flcxrtagiou �Wrww’ W ”mm m _.DEP.' RTMENT f“ GLEN 0M3: N. 1- - W w w— m" F’ .ma,, - 0! WEHRLHOSPITAL HILLS‘DE a a» -- rm , A fag—«m V ‘ ‘ U _ " �DEF'RTMENT OF ' ‘ .jy [mam-1231.1 Psvcflllm HgLleoE HOSPITAL . 1'be , fig“ - ,_ ¥ ./'I /1AW ‘3 I / / ff"? ”'"ZA 1 1 / .’ I / LzlsA/L. / / \ / I ( / ,I s./\_ ( /r"—/lw*<’ ’ i .— I! V “MM/t ‘ ‘ I ,4 g.” x_/,- i“ ;/‘_ ‘1 I ‘ fA / / j "j :J“;¢L.p (Lx/VL I ‘ ‘ ��’ ( .~ 4, �_.%:&: —3 2w 2m_.o% . _ m 6‘ 3‘5 ��r—r-mv—I- humility but mum MW: Wt: mm lemme many mum We 33mm �‘ (a v mun Ramswmmmmmmm ’” «mmmmm. 311nm nomad W W mm W W Inward My W Waxy Mme. Slightly 1mm �”w.” .-,,--a-wvrv~w“7 w—z-‘wv ammwwwvmrmmg~ ‘ :memum �w-mun—um wNW~l www-n-wn cm m—WAI'WV-vrwwu A,.m~mmtrv-mlw-wmvfl.wn-memW-¢ "‘xfi'rlr¢MrW.m-wywfl“~va 4” .. vn' (>2 �v ‘nwv—cu. ""v- 'n’“ . wv— >vIFNIV‘W-fl‘1-My—vlm uwrm. mW'IUF-ww.i' Ir-vw'I"-¥v‘~1www z; mm m—wflnmmJ—Fvw’flarxflv -uww:vml,m mlx.‘ mW'naM‘s-flrefiurvv-Iw-‘fwarwmrxlv-Iwumvw av»- ., ~rv- . ��awn-n. "-WYN/E' ; cum—n .1 nu-men—w - m-v—w mimmmmv -..~ w mnnwm lg m. arr Wm! :w ":N..iv-" . Wm 'w‘mnw'pmw Wm at frat-nut Interinstitutional Differences in 23 aim Pom-mt �.mmuw—v m MY 1 “Wu.W, .«nv ., r“ ass-rw-mw—w - . W wmmfn‘w 2? 75 33 100 <20 57 20-39 20 28 79 ���n :v Vw-“Vu ,v -_. .y v ,y. A“. ”w — wwwww~mwwruw :vmimn: rm: mrrwmw Wmmmwwm mm . firm-row mar—rm“,mwlmrmm‘“ Aw 8mm .i xfl 62 82 55 35 89 37 29 35 me -. 37 65 ����‘74.? 5634 7r.o �E 53 65 10.29 3049 i 30 20 80 �79.6 9/ 1&7 V? 1 4L 43m ax? 737 «<97 7; _ . ?7 I)! v}.3 fo.o up 2L ���._ “Nu-u": n- vuw—n-anmwasw“):-.a~—m:wwvwmmwwwmqWn.r:wfl-wauwmwmvw-xmv-uwnwnmwuu ‘, t i v x- 20. mura- gown—WW .n 19 '0 o 11 fig 17 1h 69 28 36 3h ,. . 11: 71 :u. ha 60 33 ' 20-39 59 . 20-39 5. ' <20 E ' 20-39 , 5 van-1 ‘w-n— our man �wwmmemI TABLE Munich V XIV and Duration of no v .mmtm am» in awaits]. ,rw—mqw gPu-‘cantz ‘ vamww Manon < W." 12 3 ~11 12* A 23 13 a 87 ’ w.~h.‘.w-, 12-15 51 20 22 £5 254 35 8 .. 12 21 5h 25 12-15 19 13 33 164‘ 9 21 21 w: 12 7h 17 9 may 57 39 h , ’ “Wm—r «gV\_..n..w_u_l_... w.” _._.._w MC 16*, c ���Wm.vwvlp.~ .- TABIE 1' . 1' Score 141' H ' 30449 33 10-29 30-119 50-70, m0 10-29 304:9 ’0» 0 Nation of 1mm < in. Ho Mimam ta; Paula 7.11 12+ 17 57 V 1“? 0-70 Score and IV m 33 ‘ 26 21 7 5 47h 4f: 1/ 1*: Ma? #3 29 15 33 17 69 6h 77 15 no 38 28 9 31 32 2 5 d4! 4 5!" g 93 US 214 O h o V 4 df 7? Or y‘ Y 05 ���" 3 . . u r." ~w-wm-aw‘m ' —L~"K'.uuhll a 'V'wlm m‘wmww.‘ -wmwmm ��M. +MI o I821. LC] 81.? K o 72.7 = 2. x" =/.-IO /:~s 20.9] 22.5 31.0 HH. 55%. “‘3 $8.6 =4 =5£7 X P = N5 MMHC ZED 49.4 25.3 22.2. 6!.0 w =3? x / =/VS 44.7 �������W“!- Aft-5 p< .061 N'- wmmm" ‘m'W-mmn“mm rum. V":I’fiwmfllflhm 1». ::-.. r u'< ����‘18.? 35’] 59,2. (0.0 . IA’. ‘2’ O 54,7. 52.7 9’51? MM (4C. 39% X’V 5/: / 1 r. P ‘ 77.0 91.8" 13.5’ 39,5- (47.3 53.8 9,/ . 9.7 7.7 ‘ .56 N3 ‘ V53 ����f 70 2 lé HEN” /.. / {’1’ 141.4 ' $29 2 ~- 32- é .5" �’<ZZ _ . 7" 1 I7 ' 7 '22 7 HS’ 5/ _______2__ . 39 ‘ ‘ FINN <7 o 7-— 6 . __ 0 " 3 I 11+ M?! [IQ 5‘ €=N3 5 33 4 7-" /$‘ ‘2. [If 5' O g I? a \\ NS ��W6’m 3 m mtmGoLfi. REE. 26. macalo 26. mam. mthnnhhmoflaimdmtommiw’mo' Hamnflquind,m'mw&m mu'nm.1,mtmmmwmca1.1.,nc. lawman analysis, the «en Gel. bum wmmm.29. 11m col. 29/ will b- mum-following 1,2,;th 29/6,?3 691.22/3 9.’ cal-dim“ 29/0 1111 m ho m. 5. ma far 29f]...2,3, ,5; 29/63; 29/5,? m and com «:3 an 601. 23 and 601. 26. aud-u Inmmamthath. mum‘s-um. WW 11:91»th Bogart-ant at Lunar Psychiatry, amino‘nybomm um, 61m Oaks, I. I. nmm. Rommel, 1: than. my difficulties um: um. any“, I my 3:. roach-d a mm. 3—7”, Monica 235. this mm, My“. to: Dr. shun}: yum-I. nth-ma. '3. mp1, mm. �iua1apuruhoxnclcnt Aspu¢1n or 311.21 L. Kain. rn.n.*, flhfifiauAul Ptrtiaitriu trcafinautle In: rulxauu, r119. 51.5.1, ra.n. tad film yank, «a. Buymrtntut a: r:«. 01¢: 8.3. Expurmsaneax Purch1a$ry, 3111116. cult, 1.1., I.!. AAdnt 11 putt. h; ‘11:! 31.209: at tug Iattsutx Ianiisato acuith. and 150 1.3113 Pabltc Buntth innpitnt. v.5 8.5115 lonrd. at 3.11:1 strvincz ”unfit! Unna¢uhurot§n $113!: Innis: the unaporufiitn-ox if It: ti. Icalth 6.31:: :31 1h. c.r. uonniusar fiaaorstl aaapatux 1: ¢9m313 cratnthllr aukunmloduufi1 ; it ’I& 31v1u1on Srozgatfitgdrutts 13 2/63 . at Ptyuhtntry, nontuttaro flcnpltal, �In innit liufir or sun luv pupuxmtttn, Rtlltacthmnd 5a! 83"; ynxuhzutrta patient ildlilh rtpnrtaa atnatttc£ut rolntioulhtpo bitumen In innavzdnaz‘a yactt£¢a in tha tuuinl clams Itrusfiura 3nd tan yrgv:13aan at trantnd illausu. typun or dilfififiltd aka-rduru Inn kind. and flurutiau a: puruhtntvxt trvutunut afistuxstgwod ( ). Char indimutté, tar txuupla, tht§l‘hig§ur vruyirttiu «f 1¢§nr alutn pufitinto in troutnunt wart alanattata yumitnma at It purnhntaa uppur 91:5: nae pcvtunnzity will. attairteuntzr high.» pmn¢ patiuuit Viv. eluaattioa at nauto‘ic etuurdtra. Far all vatltnts, psyahqfiharupy no: Ippitid 1n dalyriyoriiunutqu htnh itarnqa ta twp.» «Int. pattua‘a. within «tan dimgnfiat&e granfi, yqyuhatharnpy was apylzcd unfit-affine in npm§r ulna. yaiicmfia tad urinate fihtrtptnn tn lunar ulna: nuha‘ntn‘ fiiaimmr It. ligaxr1canuu at ¢uinanic fantara at traitius paruannal dgtaralaiag thn and availability abnorvgd disrurauman tiuld at! ht uxtludafi in $301: Ifiudiii. to tutu fiho #010 u! �-2. flfiflihl fact!!! in tap $r¢ttuaa£ at hutpttniistd patinuti nadir noadition: axnluaing sh. ruutara a: p¢ti¢nt'n rtuinata Ind availability 0! trcltnuatn, an: «adtriakta it a yaticnt can‘t: try: aurvay 3111114. unnpitul in 1957* yitti. t Viritty at triatntut awn... ind Irzouio thortpiua at. 1st. at thfilr ability $9 pay. In inglndinn pszuhothtrtpy available to «11 pgtiautn r.¢nrd~ an abachtd $hut nan. odnaatsfin and 913:. a:¢n£t1u:utly aaluciutod fiith fibfiifi. Quin hog. #3 at htrth tran‘naut, duratiun a! unflatt:11nnii¢a, altnzaul datahlrgc IvalunQiun daggnunta ( i. 91n¢r, iar'tgnwbara patiantu tarsal uduaattca wurn mart warn with find {a lit‘lu Itkolr tn ruccsv. qu‘tiu thurtpy. var. kupt in tha hnspital for nhurtar pcrioda at tint, aura titan rttaa .0 rancvurgd «r gawk Saerth And an ditchurga. In nanié;at. tho rsuncar, buttot uduoltud and n.ttvc born pafitonta airs at ertsuunt, stimn raeatvud puy¢hothurtpy an wot; haapituiisad it. 001: turn tar tong.» parioas tad rancivud �.3. t3: yearc: cliniuul diauharcu rutinut. Show: obsorvitivna attrautypr :culitarnin 3 rarlactofi final. C v.3. 1n £139 raintud to noniurau or lubjnet': roaponaea to ). Bichar F a nadiriad asorau wart unloointcd with ditgnaicu at 1nv¢1utianal payahnlis, uhartnr parioda or hanpitaliuutiun. and»: tharnpy ( It ). who h$shmr inoiélubc a: roturrul tar nouutia canclndod thtt the atroets patterfia trulfimant at aauiua algal (us dutinud my an ysyahiutria Halliaatho£a tad analluh). tau, advantiaa birthplncn and dogreo at statue» fiypy «tru 33% u result «I aconontc itcigtl or tvuiluhilitr a: uuagilttan an: «luau. trnitpsnt wan tha$ the oblervntionu tafiptutiou. rtrttcfiioa at ditturunt naagl a: 8.2. : tian and uxpruntian. It conuu31¢5w u:a poztnlatai that anhsucta cf 108a: would ROI. 313th :ud uduaattau 1001:: fortian Ioninl ulucunl, in maker nou~varhu1, ar mangory lynptunu ninirunt trcqututly puttnrnas while uyper 015a: subjunts vauld of .xprnulion. utiliip vurhal :¢nnt �.3... A n¢e§nd titaa to flho intirprttatlon, navthr, rc1:tnd th: tratinaat philauophicn tntiauul luadura and It wan anfi paraoanal. lantiiutioau what: ynyuhathhrapr Wfifi absurvuu ;ttitudu¢ at 13:81“ nuggsstod that in ilxhly vstund, uypcr Ginsu iudfividunln wauld rauntvu inordinatu ruprtlcnta$$¢n in ski! fihtrnyy. fianilnrly, dinahara. ovtluntiouu ¢ad duration at hanyattlxaatioa fitnld bu aflostté 195? «tat: at dittcring anciul ain‘t. unpnatntionn for individutln to twat this by nitraronaan in uu¢¢nd aucg¢utiou w. doaiicd Hillaido Iifldy; to naplvy ¢h¢ to rtpcat uh. It». lrotudurnig Ind uon* ¢h§arvati¢na «ataad the to ta ta: oth¢r iantitntiont, currently shn 0.). nannincur Ronarinl Boupttul a: laaaachaaatta Manta: noalth Tupakt tad tho Confiar 0: Boston. In theta thlfit hauptinlu, inlfiitutiaunl ptraonnvl nfxuot similar ttfiitadus in trsatuuut tad education. Eaah I fall tin: Inpurwinory stat: 1a a $¢¢ohins hasxital with uni tutivu rtnnureh dapurtneat. thuy amphaaiaa yaychnnng13t1enXXynarianttd glychntharafiy but �m5.u yrovide ufihor traataantn 1nolud1ng nonttxu fihortpiea «ad aetivp pragrlnt of utiiuu thurnyy. Bach ’trosuos chart- terfi traatmant of voluntary watiuuta, data tedial aura 39% provide gun» ta arav their pafiiont papulntian Ira: and tend: aimilur an; graupa, excluding ehtldrun and thy aunilc ug.d. flfijar inatiuuhznual dxtrcronaun 3:! gain in thoir cantata or iinnnaial anppart, airfarent institutional policies rnnnrd~ Sag lanath at stay find ntfiur¢¢tru. rho Huanuohuanttu Rental Health neuter (Mfific) in a publin Itfifit tundu: Killstdc Hospital institutien suppartud (RR) 1: a nan~pvot£t veluntary hospitui with a ns3ar partinn of its incanc durlvnd and other aonmunity funds; tad Kanningur pr1v¢ta inntitutiun. taliuntifin, «5:1. more Hfi at 33 tic: nit; nanpital (HIE) in a ha; I 90 day limit for haapiw I flotiblo on. yaar retina; kaharal attatuda. At urn $nd @ntpntiunt ulxaia urn while Thu Hana by mafia trail: trailnhla t and HIE, I dty hospital and to all vatznntag thdrela no 43a heapital and I uhopt tutu, limitld �45. tttovenrw proevnu is availabla to 2h: printry ruaaun I tun patinnts. far ouloettng tun tattitutaonu, havov¢r, lay in thy axpnctutiou thnt thuy vauld murvu pattants of differing acuinl alumnus {nae £5) lad that differuneui in this dtutaiicn vauld bu roxlnatad ta. ta trau$nnnt wurinblaa. rho speeifiu purpato cfl tutu stufly wt: ta dotcraina papilla t1en dittnrcnaas betuuan tun fibrin mustttnttant with raaptct to anclnl alman, :39, education and F utorc, na& to rolutn thaaa pttiunt chlraatcrtatica to sho trnntnnnt Ouvtnblun of type at treatmant, durntian or hospi$a111nt1an, diagnonau diuehawg. twilvatinn. Qua �.1. REEBOB A11 : pattoatn in rcaidcnco ia‘th¢un tnafiifiutiana givun dutu in January 1959 aura utuétod. R8 had mane on whiz. urn tan auuhar thoaa a at at duly, stall patients veluntlry Vtrt sultanua by an: uaurt: ta thu institutioa tor puynhiutria ovuluutian, or a chranis aahiuophrqula granp udn1t$¢¢ :nat. fro. in... a ottto hospitll for a Ip‘oific roaanrah pro- putisuta wit: oxuludud tron thy viva: bocauuc at thiir nan~vo1unttry ataxia. ntltnd a: 350h putt-nil fit an, 113 patient wan givun The 100 study popu1¢tloa cou- at urn tad 1h. culitnrnSn P cauln 95 It ( nuns. ) on the agatgnntaa dtxt. Paticntt' roeovdn aura analyutd fitter a ported at 15 nontha. which was the out~o££ vaint far the analyai: a! hut trontm¢nt vnrzuhloa. tor the dntcrninnuiau of toaitl clans, tau nailingthuad 2~ta¢tor inaux wua uncd ( ). �1. nutheaolegle Aaggata it fit: tuna uhlurvod thtfi thc vary tautor: an var: inturcltoa in studying afroatfid thi aollcotiou tad organizt~ tin-u o! tn dun. Via-tutu” in “iguana“: a: tarp: of trantmant and axprausiens auad far dtuguoaia and trottuant awnluatann, mad: aanlyauu attriault, tnfi rcguirad ooastdsrublu sanrtion for unitarnity. I} 1'- at u ut_!r, taint: Among thy tast1§u~ had a tha that the dtslgnataon pattnnt for crituria tionn, rocuivcd 'gnyahothurtpy' aiztavad narkndly. asking autturuity in cluas1rieat1nn difficult. At nrfi‘fiaychatherapy win dot1g¢ nttad ta trautaunt udn1n1;tar04 atnfr paychsatrtst, tar additional i... on a which tha proaariptian basis by a puttont was obtreod tn acasinnu with tbs psyahittric rwsia-nt wart cansifiarud part at routina adninintrative pati-nt earn. At an psywhath¢rtpy Vt! dcfiafid at trcatncnt anatiana with psychifitria rcaiafint. 8‘33: puywhiatraat: do not treat #hn �.9. rationia dircotly, but ruatrlntud that! activitius to uup'ru fitting the reticent th.rnpia$s. At the naac, 1n centrtat, paychotherapy Ina designatcd as a function at many diaciyliuua . payohiutric rustduuta, nurses, lidl¢§1 atudent¢, 3601.1 uorkorn 3nd piyuhalag1atu. Formal rueards at sneh nonstona warn ”Gt ruutfinc inaludgd in tun patannt': rauerd and to accurtttn watch patiynts were ranazving puynhethorapy, v1.3 the r-uadcnt in ohnrgo or each ta intcrw stat. Thor: aura individual b} migfiuouia: we hmd institutional aestza 18:10:, uhzah and. nonpartaans dirtianlt. dinu~ At urn ata¢hnrgo diagnoaaa unployid tn: multiglq clanuificntian rsynhifitrin Asaouantian whila both an tad nyittn.at tho shaving» nanc rallawad unitary indiganoua nywtims. at diagno¢ua tron urn goafiad convuruiona it. savcrul ax‘mplas Itutud in tabla , with *3: angu inté catcgoriaa campartble ta tn. athar tun inatitutiom, providing, how/var, an muvoidnbu sound: or d:stortian.. @iuilnr abaarvufiiona hit» bton rapartad and hit asaacintas ( ) who h&v& by Paanntniak chain thnt diaganac: within �411“ saniax aluau unngupition at thi karma institution: (Enhlt kt urn tho ycyulatioa artdoninantty‘uppar c1;ln with wan par cant of pntiuntn in annaea I at all»: 7. I»: «luau xv, and man. in 5% HR 82 i: uni! can viticut mafia!» «Inna praauuinttcd 31th acct patients in clnauan XII ind xv (éfi par cent}. At-HHHG, 57 It, ). pctianta «are «htafir from tha luwur a1u3;aa with pix eont la olnsans b) 532: Rhurc uué v. XV at: an ailturnaat in tan inutitatianal papnlnfiioan in mg: diatribntxan. a rung: afloat fifih sh» putiuutn an». undur the :3: at twnnty and on: quarter warn :orty yunru at oldgr. a} manuatagg: was populations éitrared 1n adunnfiianal nttainnunt, with patienga at tiau gt fihsn thguc 3x36 it KFH having worn yanra cflucau «use. Whit: k1 gar cunt at tho patiunfiu ruilod ta camylcto high auhacl, only an and 23 ptra¢nt a: at Krfi did sat graduxta. 32 par aunt at aux» Sanding in. cauuxntunt with the anciul clan: diffnraugt, claws the ceaiul �113 8 Intur:uut1tu%1onat countriinu. for aeasnplrahalosiaul Viritb1¢a m 512. 2. 51 an 23 3. h. 17 3h 13 1 3h 29 5. 0 5 28 19% 19 22 1. anti-1 G1!!! 26 Q 315 7% ”we 3% . I 9-.001 ‘ 59 58 333 22 23 33 23 32 bl um m. 2.2.15 51: 51 a9 16 * 23 1? 1o radorn to«29 51 33 20 Sowhfi hi 90 38 Sa~7a & 18 a: Ag. a “121 5 d£~8 39.39 he * 4.12 > 12-3.9 d£*h phn'fl'i ,2, mi .1 n~-0§ $g9.2 ;~.aox �.1a. alas» unnauru 1;, in part, buncfl an t6uani&§n. a) P Squat: 91:2.»¢ue¢¢ in tha diatrihution u: warn ubaurvc&‘ Fixiyuaun put buluw 30. and chi? It In cautraat. I aaala, A: ax tight par «an% at urn pntanutu fifty pi! want of the had accrua watiaatl 9:!" ma an“: a: 50 at mart. hna ? acorns in the hwe in: diaign «I an: study includad within stab r supra. sunk wath snarot mf an ar abuva. tad rurtyutwo par «ant "hum: had aunc tvaufiy gar cunt uura halww 30 on tha 31461: runga bntwaaa 30 «ad tho r Ewart; m nxnuinntion at m myohutric an» 1.: inititntiaa, ta wall as butacun inatiiutioat. tutu uiupuriteaa pruvua difficult, in putt buaauuo a! difrtrw aueid in thy dotinitiun a: fin: paychiatrac variabluu, finfi, in part, huaauau shins variables ranged so widuxy that «gnu parafiln answer: arxtfiria anmlé «at b: autdrniuad. Far umnmpla, ‘o-conpart tautitutican tn relatimn tu Innath a: �«13‘- htlpitnl atty, vuriout eut~¢t£ poriaal any: triod‘but nan: sllnuut tar at 165 At than luau «.11 3150:. urn, cqulvslout putiauta audfir ho yuan: ringinnd 15.0 thin 7 non‘hi. At sane, 70! of All Ind 39$ aura than 12 unathi. runnintd 1.3: than ? ninth». find 63 mar. thtn patilnti 12 manthn. Aauarfliugly, amphuaxa will bu pluaad on 1h; dirtcrunaul btawcan institutiana, with cttatiau wt rolcvnat intruuinuttw tatloatl rolntianthiyn. g) saw pnt1«nta 439 at xru i m: “autumn raw yuanivnd aauutiu thlrnpy than &t tan nthsr tau insfiltutaani. Manning.» ' Gauaurrintly a twnllor parcuntasu of patiautc warn attuned a: rac¢ivla¢ payuhothurnyy, with 3 lawn; aunts: (36 vcr want) r-euivtng niltnu turn. a: trtntaaut. an At KR that. antiautt Hamid hut: bo:a «Inluitiud fitting rgenived payahatyarupyfi x: can cuntruata tun pita owning. or 338 aamatac knurayy, reoniving patient: ahwvu oxanttieuntly lass than wither at tho fithur tun inatztntiano. �.11.. niltvu , (13 Ethics yarsittin: a «catwalk Wfithxu wank it and plyflhflthlvariifl wwrc cauhtuié. a: aunntlu :né taltituiion. trontaant at urn and F ?ut&unta why unto yuan: at pny¢h01¢¢1¢a1 thuruyivn.) nan wan waistla to nu10¢t£ua near: as xru $nd ER (Tablo ). uhnwa F a%oru VI! low rc¢c$v¢d pnyuhothurnyy with srcutnr trflqutaay $han gataouti who Vdra olétr or vha haé high F acoraa. Enua;t1¢nn1 achiavcnoa‘ and innit} eiaxn fiia not nigniticantlr atfcct soltutxan at ’30:: it any hauyéhnix Ana»: fihn yuyohtatrxc Ulrimblmt, within naah aitgnasia twia%* wax inttitut&cn, higfily tun want rulatvd varinhlo ta aaltetxon at itcn%annt. 91l¢hl¥3fi ovuluntiaa honpltuliuutana at 33 find name it urn and aur‘tiaa u: “are :13. rolatcd flu saloation at troatucnfi. than, aanataa truntaint an: :ataatafi for pa‘iiufia clataiiicd nu sanitaphrania and attaativa dincrdlr hart nttna fihnn urn; pafahaaanrntia. Lt that. «littnd an pufilunia rccaivtnc lattiifi arnatntnt (prudnninaatly that: �’15. alaauid an nahisuyhrtntu) rililwflfi dalnhnrsc rating: at minus. pmyuhnfihcruny rn¢a1v1nc p¢i$¢nsa than ngtuprovoé With hyapafinlu acupztuzx:xta¢n, ptticuta dtrtfiififl tn a: rtcnrd finnfi tar langcr ptrlldi b) wtrn that: rtcuivtn: nunutie thcrfigy. eoaniwtrnb1u dittortunau g' vurfi #huwn bfitwnan «a. fibrin inuttfiatfivna with waapaat so paxatufi‘a lungth a! stir 3; (rahlw 31a pasiuafia VI?! han- ta§a¢wt, with 65$ 0: pufi¢¢atfl runniniag pi‘nxasud naathn 0r aura, «savanna tud-unly 5 it 31 9a: aunt that: ut gut auu$ a! H336. 93 it! tar twmlvu the 33 patinafia aqua} ufiny Inuit: at thy while twawthirat EB nxuvun and batuuua savtn fifi! stony a: win within éiflfihflrafifi warn 3836 tan watasnta munQKa a: heapifialiautiong urn uafl fin I! at. wan its luadh 9t haupi§altfitfi$¢n for tha 1nugust veriad. At sauznl tunttr unit alumni: rtlaadd ~~ yauutcr yatxcufin rmmniutns Ovary :50 1Ith, hawavcr, that: �.16.. nt RIB rammiuud lanai: £hnn at an at Indand, an: mane. intnriuntihutiaanl diffuranous voru :9 grant that : putttat in the oldest as. group an: no». ltkniy to ho bospittlisud far trait. nanth: or yuanguat tau stony mart at tt Hana. urn thin war. pntinnta in an. At urn tad an tier. wan tile t aignificnnt relations batwenn durutiau a! honpitnlisutinn and F acara, tho lave: r uaora being atoneit‘od with lanai: in.» pitil atty. a) gigggniggu 1: thaw; t1. 1n rtblo 2h. diutribntion at diaehurgc attsnotnu . tar atatisttecl analysis three diagnaln fiery undue uabtsophranin, n£rautivv ditardfiru 3nd grvnpiugn psyvh¢nouroaaa Iflfl ynrsonultty «Quaraorn. portiona warn similar for the an and tha HFK muse rho é:ngnoci§a prou povulnttons, but pt%1cata warn rngurdoé as having raver urinativa and Iahiaophrania éiuordcrs, but I larger haiku: or paymhanoutotia or ehnrtatar dixardaro. Intrttnetxtationul analyntn chauoa this at as both as. �.1?. and 3 suort ”fir. rwlntnd to difignoaiu: at 3:3 as. clan: of tan sonata tgntart In: volataa to dinauouing whiz: at nuns a: tha senial variablnu war. trig vurinblgs, dingnoaaa can signifia&ntly so rolntcd. haupitnl ta unleatioa or trottmcnt &nd or mafia its rolttcd payouts- 1% «.mn durution at haapittilo nation; Ina val: at an tn aiaahtrgt ovuluutioa (gag: £££E£)~ a) 91353:: 0 Evuiuatiunt In sack heapital, nest patiouta ‘fi urtlnttud It A? the time a! disnharga as ”ingrovodfi (Tabl. ). 338. hatovnr, a higher ptreuatuga (19%) at patisntu warn ratad g. *uninprav¢d* and only I ainala puticnt wt: callud 'rucovnrod* er “hunk impru§ad'. rho highant porcantago at *rccovaro¢* at "Inch impruvod' rutxnga (28%) and thy lu‘nt haunt! at ”unimprovaéfi (165) wort $9334 at ”386. Anulyann within uaoh it an and Mann thqrt vitae haiku: than 1117 institution fine a teuéancy ahavad vuriuhln rlifiltl. for clan: pationta ta ywungcr ones, but thc b0 reunita urn Itntiatiaw significunt only at an. At a!“ that. run nu appositu trand, vita 014.! putxautt'uara liknly ta b. rutcd unimprovti. �__._._.._ u—mmmW__—m ��j w - 49:25 {0‘70 W “i a7 -31 2 5“ ”iii—“T- 7 '5 _ ��f ". ’qg" A comparactu a: Parahantwio truntnuut ta rant: Ybiuntary ntipstull nan-t an. an, Plum", nu mums, rum. lathgaxnl 81‘301. ?h.n. mu m: ’bwu Buapitul. nu, ma. Dmrtnoa‘ a: ta. #103 6th., L.I., znpnrtnnntux Plynhiuiry. laliuido l.!. II~2992 thy Inttunal Inntt‘utu grant a: by u.a. rublxu finnlth survtc.; &ad tho liuuau mfiuilth at Xantul fiuuaiy nuns:1 flutlth 30:96. a$ntt$ at tho lansnahsnntts luatnx I: it. ‘3‘ 0.3. Hummingur fibuuriul flutpifinl 1n In. comptruiatn finalth Busty: an! gratutully ntkuaulodx¢d. Afidraau: rrtltat 3.1. $7. 1.1. * 'VI: 3/5! niviuion a: rayuhautnr. Hau‘utinrc Bouptttl. �tn thoir 331$: at fihw It» fiavuu ptrfihtatrau patilnt flailingahund and anilinh rapovtla Itgntttnaui populnilon, valuisuauhipn baiwaun in xsdaviaumx‘: position in fin. tilill $ti§tad alum: ptruoturc Ina £3. pravuluu¢t at illnaua. twycu of attsuaaud atturamru and kinds and duratica.¢r payahAatrtc truutnuat :anantuiarad ( ). tkgr thattntna. for umaupla. that ; hiahor prupowfiann a: ions: aliin patient. in tvaatncat were alnncixtua Il~pl¥¢hfi§fii whaln‘uignzrinnutlr hithi? ptfi~ .purttons a: uppar ulna: p;t1¢nth var: alanuaxand an nuuraiio and puritanlitr dailrdora. It! all at: inpldrmfi is fliuyrnportaau:sity pnthonfiu. acyuhutharupy high ditrtli with at: ugyuw ¢1§Is pnyuhoni ouch within «inunnutat Iran», gutiyutaa thirty? tduxnzut.r¢d um. its; Otitn fit uppur exist p;t$amtt tad otntatu thnrupmuu in lunar 01a:- uabacatu. who cianiti‘nnst or ifliflfilifl tnc‘uvu at Granting «avid nah pavuunnnl dutaruinluc b. txaludod 1a and uvtilabaltiy it. obntrttd altxaruucau taunt ifiudaua. In tact tau rfilu a: �.1. watts: raster! in tin trontuntt u: hutpitalssd& vutiantc 'udur otndttllai quludtnl tut (natty; at pustanfi‘a £1uauuei and availability at trttfiuautly an! auditinknn t pISai. patlunfi acnaun sip: auvvqy at lillntdu niuptint 1a 1957. in $38: b0!» vnriuty a! firnntucut nudcu, Snalu¢1n¢ ptyfihmshuruyr or;¥nsc aha thnrwpiom irt a: fihutr ability ta §u¢u u wt dbauruud availahiu ka all patauntu rustedn why. that use, Odiatilin and 911a; uf‘birth acre ’atgatritafitmy automiftid with «intau «I trtutuon£. duration at hospitalautttua, arts: ( )a ultu1u¢x ninthnrtu cvnltatiom taa «luau furnaufiubnru nanny. pattcn‘. with littlu Input! giauttiaa war. at». minim: ta rucuavu taunts: taartpy, viva taps in in. hatpattl it» churfiar yariod. fl! $aun, and new. nt‘uu flirt vital in BIDUVIIid aw unit tuprtvcd on.d&nuh¢rtc. In Ionfirnta, tau yuuasur, buttur cfinuutod and natavm burn pasiunsa at»: titan ria¢1th purchaihurupy :3 tan saxo town a! trau*uou§. aura h¢3p£i511tvd 1hr teaser piriodi and tuuuivad �.3. fihc‘poovur ciiniail dinufiuran rfitingg. Ehita uthrvnfittun turn 31:. ruxattd fio'nauturat a: tiawnatrvy a: rurllctnd in nubaoais' vacuum... to a uyda~ {10¢ Gnltforuta I Butt. ( ). Haghnr 2 gotta: war: aasoaann tad v1$h ¢$uau0unl at tuvulutttaul psychouta. thawing purtoau a: htuyitnltl¢tian. and I highnr Lnuidcacu at votnrral 2i! aquatic thtrnpr ( ). 1t nun nanola¢u§ thnt thu uttuuta a: aoat‘z class. :31 Udllltilfl, biuhpinau and dcaroo at clarcaw Sway an purchaatrtc firuuinnat patturuc war. not a rouuit t: ataaautn :Iu‘¢ru or awnainbilitw a: trunungut ilflnic 9a: dbfiurvutiuna war. 3:3:tnttan val thus thg iudtviaunl astrircnnnl in and «uprtslian. X‘ month & ratlcutiou ax a: Iiuytutaon. nununaaaattan uni pcotulatcd that uwh3.¢tu t: taunt cocinl #Ifillflfl, lacinr‘wduuatiaa uaa turuttu birth wtuld aura trtquuutlr nanatalt lympiduu in nanwvorbul. tanner: a» II“? yt‘turuu, nfitn: whtlo upvav alas. If «upruisitnv Itbsattl wall uttiiiu varbnl �“a... t aanaud Lnturpritutiaa, huuuvor. ruluiud in; ubturutw taunt tn tht firnnfiusnfi philaaaphiul tad xsfttada; ct talttm tnsaaunl lucdaml and yawnunnul. tilt: audzv1d3313 nudfl runnivo It Uta aaacafitod that Ipptr inardiautn vupr.uwntahi¢n in psrahnthcrupr in 1a:t&%autoan what. yaymhntharanr vat highly vuluca. ataxitrly. flifilhtrtfi.§VIlfiifiifinfl and durailau a: knapitnlintfixan Imuld ha i33cttud u!pn¢$nt1¢nn tum Sflfl1VSdn§11 20 tons 195? allllléi my ditturaunh: in Ital! a: disrurtn; social «la... that scannd augguutioa an anulaad to ragga: the ntnay unplmrin: uh. u&nc pvuaafluria ind nan» aurr.nslr t0 «stand it» ohnurvut1¢na to tun 6.3. naauaugim armorial Hatpataz at sun ofihur Ebpaku and inatttn‘ltuu. tha untanahucnttl nausnl Hfl‘lfih cuntlr a: vastnn. In that. fihrao haupitnln, initttutianll piraunuol stitch :intlur tttttudai 13 traufinunt and udusntxon. a full llth 13 a itaahta: haupttal with twig auplrvilory nt¢££ find aetiva tumansh dvvarinont. rhuy lflphfitifit purehtanalrtafiallywtrltntnd pnyuhnihurnpr but �«6m H35Iflfi 111 vulnatarr. nanlt pafia-ntn tn rnitdauou in than. inntituianuu an a civun dt£a in Jtuutry flail: urn lad it than. it 1959 vurt ntuditd. an had volum$arr-patxtatn only, a R836 wart tcnigund hr It‘ll unnbur in. ataxia tar yuyuhittrtc avihnitin. or wurt sawhnrt at I otwouiu anhinwyhrunac ntntu haugi‘sl Irafig firtnliurrnd to! I sycatriu riannrth prajutt. that¢.paidnn&a war. umoluand tram thn aiudr hanuvn. a: that: nanwvulnniary abutat. 2h: study pnpuln$1un-etnnlctud at 113 p‘ttnuan ufi an, 190 at K18 titan satin £ha finittaruia F In! C 9E at mafia. ) an tho zach pa‘tau‘ 8t! datttugtta aatg. lithtnon Illihl taint in. knit-utn‘ rauurdn var: nualriad. Jar an. dutarutnataoa at :cetul exams, «an Hullsngahaua floatatar iadax may ntnd ( ). �“a. Autthur tritium of the prtlnnoc it: atrtur'nt ruataruh 1‘ tan itau rcutzaau. alaninit altacttu: grnuraut, sh. ¢£ nuns fix: at pavaunt vutiantn at tucaty upgrauanutaxr aurrny. wart ah:9a1u.lly 111 tad use Eta: hunptiulifiad far ulny Sfitfi a uwtap uuula «at annualir hnwu hunt inst tiny had Esau tranbturrnd tram yturt. in this hecpitu! inothtv skats.1uut1tu~ taou.tuw a Ip¢aiul uindr. rung. it vat anon apparant that £ht Vim: finiflfi war. inturauiod an Isndyiua ntrtcind thy atllua‘aon at nnfi in unite we». prdhlann flat éxtn. spaaarie urgiutswtiaa 9! st. varin‘xouu an finnigan*xnua a: twp: a: troatuuat and exprnualcaa qud tar diuguonin trantn-ut uvnlun‘iau watch aunt .n:1:~ W! at. disfiault 3) and dualguufitn: and viqntrid caaiiéovnblu wxorttau it‘s a puttuat than; sh: institutiouu, tut uni» m "um: for riuutv.d "unrahoth¢rupy* dittlrud making untSQrISty in clu:u$ti¢¢t$nn �.9. ditttailt. as an.par¢hoth¢rupr was davicuuttd nu trus‘uunt atlzulctornd on a yrnaurlyiton basis by tar thigh sh. A aunt: raruhtatrilt, pgfiicut nu: churned an additional (cu. with tho ptyahtgtrle retidant were uonntflursd part at rfiutiuu ti 3! wuywhn‘hornpy ill ulntntntrgttva pntxant oarc¢ to triatuont nunaionn with Station. fiha dart‘ud psychiatric rtnidcut. stuff paywhintritta did not tract pgtiunts diraetly, but raitrtutod thair sativitiom ta aapurviatns tau roaidoufi phywialnnn. Sb. lflfifi parehatharupr Wtfi a.t1gngz¢a g: a function Aluethiuoi-a~ parohtntrzu roatdouta. pmynholagittu. andauui xtudnnta. Formal workura. nuracu and station‘ war: not vau91noly ineiudod and fin unaariaiu which v0 and to ‘b) 1n at uni, «#6131 rieard. a: tank tau paeicut'n roger! patients wart rucotviag puythvthqripy, tutorviov $30 ruttdun‘ in chart. or 'uah oats. < Itylaa his» 5% “atlas Individu31 ialtitutionnl diuunontla mud: uomparioanu atrxicult. At $13 dinuhnrgs dtgtnvuua anplaymd tha mulfiapln awniuufitve data lfihlflfi �.19. ruccnuundol by it. Annrtcnn Payuhtntrzo Attestation uhtlo tellauad unitary syatcun. 5.1.9:: nuanplou bofia an :nd luau at fitnznalun Iron ark 3:. liutad in Tani. I, with our sug- gIatId uouvorniGnn into cathccrie: «caparablt to th. athar tua tuctztntlnna. 1h... canvosataau prcvido, hnwavur. an unuvotdahlt Ififltfi. a: dis#¢rt1¢n. (sinilgr obgorvutian: htva erortud boon ’allntntok by and dioata thus itaananuu within us: anneaiuucd $hn «an; ( ) who in- taut1tut1¢u arc 3130 vulatruhln to individunl dittornuaas nuang nxgntntra.; ‘ “U ”G“ .v."~.-fi fabll I ’ In a) Hunt vnracd :13 an: , tin ' a: I rovunnn I Rating: at zupravon in forum: ;nd actual. in. dischargc 1:113: tripattita with n tapnrgtc urulugtian churicturolocxual and axudrcn: chuncsa. global rbtluca 13 vital txihutlnn of ciah it tacit: HR it tar snaial. and Kane had In! dittiuult to saunas tan anu- 0! ‘ho Runniastr 3:06am (rail: 1!). �.11. tar tux; lwu&y sh: Hiuningar ta ta. slahnl rafiiugt or rating at: ealwnrad syndrome an and 3533. it. “a. .”‘*¢ *‘U’ Tiblt I! mafimflbfidhaou. that. in: 391131 013.0 a narkcd dittcrunoo in tho tanpoci‘ton or an; $hrt¢ tuntatutaoua (tab). :31). it. povnluttdn nun prgdauinuutly*uppar sluts uifih At urn pa! «tut O: pitiunin in dintucs 3 «lat: 1‘ an IV. :36 non. 1a «1‘0; v. rare in «1:539: 11! uavu'iu alannou fi) 53;: and IV nnd XV. whzle a: 9r 1!, only one pafiitnt 1: 3% 68 par onnt of patttat: $330 57 pcr aunt or pltisntt 9‘ rhura nut. no flixxartuot. 1n .3. distribution :3 sh» annt1$uiioual panulgtiaan. an. firth tug pafiiunta at»: this! tan use at tuuuty and one quart.» tor. tort: runrn or oldtr. e) ;:;i fan population: dittowad tn udlaatlaaul �Cwmf Mfl 2%} maxi?" ”an m“ 19$ 54cm 59 may £0 a?“ :- 2: _: ' 19s 53 a: 2‘33 3 13 33 , a:- fi 1:25;; « �.1}. tfifialllmnt, $1». ihnu putttutn at a?! haviag nmri v&§h that. ifi Illa. as Ilia 1.11.! In ca& $0 camplcia a) pat «out at 0inlxutunt while ht par aunt rat! in: a: %&0 a: fifiuflifl pt£1tuta blah iChOOI, tax: 33 par ctn‘ III as: at: u¢oaa1 IUIF£ nfi graauut¢. thin finding :- alga. dittorauua, :lnaa tho aoainl clan: nitsuru in, in putt, husta an education. a) g;§§gggs nirruroueon in the dictrabutiou at hoards «a th‘ salitavngn r Seal: an». ohuurvud. Pittyvonc par a¢a$ at mra patitnts kid with taunt: G! 59 i «mart: htluw J0, uud aux: at short .. an. Eight: r tith‘ pur aaa$ aeorta buing ntmun tinted with hiahav agaruuu a: uturuetypy. In ountraat. $336 flunnty par 91v oonfi fit. h.¢ «iii sworwa putaan$u has t var: hclnu 30 an at 50 or wars. ta. At an 9 it Quilt, and tartrwtua titty pt: aunt at 1009:: in tho mafia}. rung» botuaan 30 nna E9. 3. Wag It: Vggbxq candy inclnfiad .xauiautinn admin: ‘9 fin. a! th¢ rulutioua at 1!. ylythidttifl vfirinhlnn within nauh inatiaufiioa, �~13- I3 v.11 an Butane: inatitufiannu. Thwli noupnrilonn provud dixricult hangar. or dirtortnain in tho attiuitioa rtynhiatriq 1§v1nh1un. tn. *urxahlnu rung.d 01 th* tidal: @ and achw parnhlc wutaoxt ovltarin eeulfi an: by a¢t§r333td. and varying itarcta or ulsaingdntt. .rar'uaaupza, ta canparc tnofiltmfiiani in ralntian an xgugfih at hatp1%‘l stay, variant cutuott p¢rtodi auto triqd but man. allowed 33%. :5: aqutv¢1¢at «.11 11:... At an. gatrtaa of tha patituts ranatnad fawn: tug: 3".» nau‘hs. and sleuthzrfiu “‘3. than twozsa‘aonthu. aeutt$nt, 70$ at .11 aha auly d! any. fih;a #13:. thus: wax pa$iuufio runninad 1... at mass. 13 thin atvun Ioniht, twilia annthu. In fittuvuiutug social informatxan nvailnhlu far 292 a: 371 patioafifi. unalannitiahla at!!! at». flfilt otian flair! thu nduaatsuu at tbs knahnnd at in. {athar at a haaaowtxn «w ntnor wag nwt rnafirde¢¢ aonarainxzy, in the antiwaau cf ysywhzntrfic variable: euphaaaa H111 ha plmoad on the ditfmroueun botv~¢u inattfiutanls. �.15.. with citattun at vii-want tutruutut‘ituttonnl ralntannthipa (!Ih1c IV).' a) figggggggg_gg~gzgg!§gggs tutu: lnltltntianu, tawfir patatnsa it xx: r§a¢1v04 Inuitao fiharnpy fihnn tun institufisvuu (2:31. 1). canenrrantxy 3:: or launsngur plfiilnta instant, 8193 & anallnr parcau‘» act. allllid at rcaaavias paruhau lurta aunts: (as pursuit) raooavtu; allitu turn: at trautaoafi. I: t at $3. uthnr tt a 9:13.17 firuntnon‘ an patiunts r¢ciivanx then: ‘htr:ptua It! claaaltiofi to raaciving psyuhau thavupy utn¢u unuh 1- conventfiauttr again: taint. If on: ann‘rnat fihu aanufiau thgrupy. urn about t rniidals pnyuhtn- paranutlsa a: pt‘ltfltfl vttalvln; atauattuuuttr loan ‘83: 01th.: at tho 038:: in» institutinnu. tibia fltthsu V uncut harn ouuh xnu$1t1t&on, ‘30 I‘i ralntud fia=a¢1aat1uu �.15. a: trautunn‘ ut urn (I: Ihtln 1V, mitt-I and r taut. at both urn «ad I! (tibln If), and plynhnthurtptun aura semiautd, para hittsac a awntrnut u! inattaa Putatuta KFfi who W0?! yuan; it thtftpitfl.) ané puyuhclostnsl urn hr who‘s r nuara was 19: it or 33 ruoetvnd plychothnrxpy 91th sveltar rrnquanay than pattonil who var. altar or ihfi hid task achAQvunan£ and cua$u1 r ttfitti. Eduagtiannl alas: did not axgntxluanflly artist culucticn at tromfiuautlut nay huupit¢1. luau; in: plyuhittriu vurlablau within filah inntitnttuu, iigsnuuta figs fiha unit highly rnlattfl variabzo $e sultatioa a: traafinnkt. aquatic trot‘nnat wt: natcutud tar p‘tiuntn clunoittod t: auhtuoyhrauiu ind nttqctavo diaardur mare than the-y utttoud I! purchonn§r¢tl¢. Bituhtrfia avuiugtton n5 urn and aurgtioa at hanyitgliuat$uu at an rathid s. at trtntuant. ulna titan culmntion At and annc wow. MPH, p:t1natn rceoivtac anun$¢c trnnwn¢nt (pradunlnnntxy that. «lann§é as �“17. hnucvur. than. nt :33 rcnuluua lencur ihnu fit as Iudnnd. ‘3. 1nt¢rtunc1tut1au§1 dalxnruaupt n pataaafi ta ta. «lanai .2: pitalistd tar chIVd 1a the ytuncclt .3. at to :rtafi taut an: airy 112.1: cramp aonthn or new. group worn at at lHRGQ $0 ha ha». £18 than wuru pafiiuutl Hana. fluwtmfinuudafima «tr-bun an '- Emfilc v thwut hath a) Diuggggzgz 3h. d$a%ributtou o: dtnchuraa titanium! 1: shown $u lfiblu VII. Fur ututtutionl uuuiyail three diugv rustic grasping: warn undo: nahtiuphvania, attactlvn attoraara, aaa yirfihfih¢VFIi5§ and ysrioualtty fituordarn. 1k: diuunuutiu pvupovitoaa nur‘ ttntlnr for in. El tat popuxntiona, but H330 sh: urn pa‘imatd warn rncnrfiad at having f$WIr tttnattva and unhatuphrunit diavrdaru and a luvs.» nuuh‘r a: ptrahununrwtla a: pgrnannlity datnrdors. Intriinliitntiiuui and 3 unuiyuts nhnmnd near. cur. allitad ta «13:30.10: that it :t an bath mat urn us. glow: of �.18.. it. aaaaal tuufiuru «at ruiatad to atununoiug non; a: ‘h; I'd!!! VtrtlbIQi have ckintrta vaviabltu. diagnnuil tutu hmnpital ‘0 atlcofitoa pitalahntawn; and duty it. is um, r:%ad It at ham», it. 4; picniltuuntty rtln‘ufl at 711 tr huna (via. In ouch knupttul. rant pttttnts ”mm. um “ingrovnd' (ink). VIII). (195) 9: ”an“ 'tniupruvtd' lad calr a taunt. pltwtus ’rauovawad‘ at ihtut barn tau. at diuahurgi mum-v dwra‘lun £0 «Inuhnruv ovtlunfiaon d) gigggg;§g_§ggggg3§ggs ¢1tluutnfl u. rdlutcdt or ‘ha para a: $rotiuan$ Ian 1% H8 1:51: who that: at lure “math tupanvud'. mu van c.1125 the highest para-ntata a: ”rtcuvurad” at “unit isprovna' rating: (255) and tht luwaut (10;) with sauna at muse. prupawstcu a: "unimpruvwd‘ Antlynau vi‘han Utah anlfitfiuttan giant: varinhlb rulnlil. �.19” At 8! and Inna that: III C sinncuay tgr cldir putluafit if b. rutnd butt.» tan: ytuatar «uni. hut tut renal.» illr lilnitifliai Quty-ut us. At awn trend, with ulnar pttituti intrt an!» lxkuly tr. atatxnttuu vat tn upwtsitu is h. rufiud unimpravnd. �~29» m mum In ibis unvpar‘ntn at ihro¢ vuluutary garuhittric httpitala Vt havu-abttrVad sartoransua q: cannttlun and uninitiuaat tutarxnstituttounl varaubloa 3.61:1 tho in at yuavs a: pt‘itnti tutti: Illfli, but 00$ u¢.; ta diutriiustou a: fiulttuvniu I‘Eaalu trawli; and in unfit of tun triniulnt wart» $51.0 ditivtbxttnn a: aansuauuu sud dinohnrgu tvnlnafitana. In and quxinal atlltlai ‘33 in .. dnrnfiatn a! havpitaltsutzan. tdiauistn or transnaaia it: §1r£oraacou naapxtnl diner tbs «Enutha alyahtairac vtrlannu rut. nuarthnd ta airinruuaul an sunuclfiiud and wins: the nacial ttctarn at causatiun Ina utavio~ iapy n‘ raxlo¢tta in ya. v mourn. In fihn trimhgapttux atair, tntnrtautatattausl-afinyaritanu a: the pirahtttrta Vitib «big: I!!! thaw uiguitiannt sixtaruuogu, and §h§na rulluw nupuatsa «attributiaa thfi its. tars a: fit!&l1_.1flll, aduuntaaa tinnisiodnfi Vast at tat hryathutis 1a: inafiitut&nua1 caapuriaaat, wharc it um: and 1a Oh! r naorng in. iaflvuu tutiaiputgd {ant iocttl �.21” wartu in puythtu§r10 bu valntad ulna ulna: ditturtucau vault cvuravlltng uh: 1n ;ty1an. dxusnaaitu But vuranttdna whiuu. in3$1fiut£¢ua1 varlnttnnt 1n cud hamytiuiiuatxtu duratinu at Affautad anfl «unvaritau: thaiu vatautad diuchsvgu rattan: tho signatscun¢¢ 0% tbs inturhinuittutianil.aunpnrisauu 3! fin ifiliififliiifll'fl¢* aaltcttun at tracing: It? idlflfliid taint fihru: institution: a: bqing aduparuhid in “‘11; Int, acaaamta, rotuntitie nué th¢rap¢utia afi$aa£pattus rigor. printiynt ditttruntui ninth nampaaisAou await} in the thair putaaafia. run: were atrtaruni in whatnl alts! puttivni prfihiana aathafluiuczcal thu bu‘ nest Itriktus sure Vida dinsrdp;ua10u a: mm in: in tha atrialfituus a! tha plvuhtttrla wiriuhloa. can aaa¢1usian qoalé be that t§c dh‘nrvnd difzurauacc in purahiatric Viridhlut uqrfi littln act. 1dianyasr:a1n¢. wt: «untrant ta in hnapihglxsod urn ptttuatt ta; than aéninxntr‘ifion laughs ¢t tam: taut 33% 3nd name in an arm‘s, �n22» havuvir th¢$.1$ in $53 1£k01?‘§h be a raiiccfiiou a: mixturiuaui ta 5h: flip: in it «nah aduluiu§rut1va :avqufitiuu tanturcu an nouplunifiy u: diachiutta hnfi dtuahurnu avalaataon, tinny a: tharipiti lVI11£31l uni thy énfiaitlou and sauna “kink :: fin atttarnncut quuttfiy or uaatnl niiarahr. airiiuiaa at garchothurany are arcat dsxturunaoc £«11nu n gntturn. canttstant vath.9ruvioun randinxn A -. yatturu and hypuuhunal on tan ratafiann.at toaiai :actaxi $9 pxyuhst‘rzu «a»; at hampxifiln tlid fittinntt. It is palsahtu taan, that tau oabfiky a! fin inatitution in aawivnd ta t traufinnnt putt. stuntsiatnt uxtint sociajmyahalmaintl tautuvna fit in» pliiunfi Ivan thn prcdoutnant popnlntxan partly in rolatinn in the proatpticun, uttifiudcu. identificatian rulatian to darivud and asparntsaas {ha nxpcatationa thcir nuainl a: tha ntnrf and pnrtly 0: tbs patient: and that! 1n fililiti buekground. rhino nothfidalagical dittieultiou «nu the ntgnxtiaant arrant or gdmsniptrnfiivc and stat: uttttndua on pnyuhtatrto �.93” vuraiblcn «r. vuluvnni it She cauvunfitaaal was itVt utntavtacg. ugpa¢iu117 thuvapius. The rrtqnaut in: 1a may a: avu1§;fi$nn or aaup¢rn~ at ynynhtstrda 4£I¢hargQ vuiinga, diuwaantic algaanu or I-agth a! heaptttlixntioa us arisiria o: $h¢rtpvutlc valuua ar computability or aubzacts and pfififllltiaui 3.3% ta .xailutvo arrnr unlit: ugtahoé sawing It: fin: at. inatitttaena are olanrly aauini¢trattvc philoncphy uni l9¢1l1 «1:0: a! papulntiua nut variablgt .. ta nfiutznn 9:1: at that study. ruiluvt in naeiuat to: thilt litnral tatirprctution of Thu safiw fine in. paraéexiaal mast 91.13:. altar. at : variablus is in bu Cut abanrvatioa nonpu« noun 1: a at that atuiy. 1h. tub hawk highly trutand reactant! «and!¢t1as tyeaiuaut fi?!‘htn an or iiunx puriod: (unlinitcd) shiah is appliud tar aptiutl pepulntians with in: luau: prapcrtint alaguusnfi in In untuv¢r* uh1¢ pragnautic gravy (cdhisephruuiu) item a: ttvaruhls trvnfiuaut fflltl‘. .- and sat, «a. proparv it iho pomrtct. it Hand, in cantraci, «hat: tug 1¢nst trusuta tharnpiutt 13:1: trnntuaufio �u’hu to: tho attrt¢r periods, to a yapulutita with a higher pam- pnrtann daugucuta nchxsopkvautn (v‘po¢r yrngnosua 1) tau pvuportiou or ttvurt§10 Jiaahlxca rttiaga 1a artuturl ahibualr. thtta obturvutltan an act uizutfitaatlr rail-It thy itarapuuttc hfftcacr a: th¢au tantatntainu. but indiuutun tn. dartbwuat 1&1: critarta a: inprwvcnaat. Inc! or «barity in diagnostic unhona‘a sud incompar~ ability at paychtntrto trantnuat variation Ital: pants to :tttlwtud calpurattvu «$3613: or paywhigtric thavapiun. Iii I!» txanpla, thu vacant failure: by wiricua kaolactcnl natuut1¢ta to confirm ubuartatiana 3:66 in ether laburntlvan: hay'bu an much a raxluotian a! diffuranaiaa in populations, pavufitu atria «attoriu, 233. rha'waéaayraad asa at an £311u¢1oa 1n the numb original hypnthaucu. turn: ‘3 “Inhinophrantufi an '9»:ahou¢na¢sau* to unplaro eh. uhancot 1n payuhologsenl a: bialagiatl roaturca with anntnl illnouu h;n 1.4 ta a scaled. burdcnad by acautivc result: (3.11:3). hast u;rkaa rauuutly �.3... an in. tantztnting railing at tn. rnacc a: «taunts cud paywhulngatul a unrun ruvtav an cfihiiaphrnatn: fit in. whiz: thnripitu or fine transnatarinn if aauaatu inuuqruvakxltty.ot Git phywznzaganaz *~ huhnriuraz corvulattnun an aunt an (Fuuktnat§zn) and tadattan thruahala fiaaks¢ Erna it. uuaholrl «art : vaxtd fibulrvusiua in hi rtvurtad traa tug alxntt, do w: hhva nuthtd! avn$lub1n $9 «uteri»; yepalntfiaus.aduquataiy sauna num£Xraation? .Wu.ha11¢vu not, mad ta gravid: a nunnludo tron fihnfii «bairvatiuuu that incruuugd attuatiua aunt bu ynxd ta tha suathodnluwiani yrnblnud mm“, mm a: alunuzfiyias nubauaia by “ubgnafiavu‘ ma. um mum: mama no hfiahly fiuyaudunt on inatifintianal and and tau zun£ap¢y¢hu1nainal tapuwtx which «was: to to «bauwwir att1$afiula at in. fihurtpiahmyntimufi intirauatmng what aw tha ralmilan at again: fllfiifi t¢»psyeh1x%r1a trantnunfi an t§afla pdyulutiamx? afignzfitant dittiraaaaa it trcutwant anttavn taint betwoun thaau anntatu$aans, nné thqr ‘ �~26» ds-aufldr fig dilrgmnufl moat: Inuiul attuvam, utthfidalauiaal limitliauan umtlinafl wan-no gruufiar a dcfiawninuni hit with!» fihc ilviitv, iafiinl atuti pirkhtnfivia Sh! Vittthiun if «athin any inititutznu than «or: aha «flan» varidblam‘ fin «nuns «may. hauuvur, that m: away” 1» flay ianaiduraiaun «him «a. m we a: vctturna or at in. may, &&:¢nosin and flitting. tharimx unnuafi laniri I! it that-in that! haupxtalu, patiunt twain! tiara grafimhau thn phitnaqphy twcufinua% as an intruahaapisal thutar. 11 Ian: tutanttatr malttnd tn diigniflxl «nu try: bf firuiinuufi than int naturt a: vfiduti hfinpiial uni uh» iflflill canny aaaraaanu tum iaaim it wh£th it‘prtalriir :t-azr. an: paraaunbl a: mazxnaaa lbuyiiil, tantra», likb thmt a: in: sunningar‘fihnaraal awn: mm“ mm unsp1$a1 wad fin. laxtauhuutttu m: WIN: a In institution: with 31f£¢v¢ni fixmmm trt‘tntut iriunfiatifinu. pntaibta taut eitrarint witntiuhu hutw&ua it in theta vurtibtni �wa?fi any ”a ‘h“r“‘i In hntpitnli. gar ixuaplé. whfiwl trnutnant n‘=‘¢£&Iru¢ urn pvfinarilr auutnatuz or «um-tic, or «hurt nut: nuns” mun anagum m infliviauui tacit} alas» it in: in:$itt$&uu may aufi xxx cm Win-mat awn, diiifingfiiah‘firtihfitni grwapte x$ azatt uua afiministwuiivt attitgdat urn a firifiifil Vflrzabla in aufiarnintae tan pa‘iani‘n dinnnnitl; iraufinuut, qua tiawtk at haupiaaligafiica. �culpartnoa a: Suctopuyuhaloglcgl Virtublos nan Psychiatric frnniuunt 1n rite. 'blult‘ry laopltalu A ru.».‘; In: Rdbart L. xnhn. ramnnsk, rn.n. la‘hautcl 311.01. 95.9. and In: Iris 113k, 8.3. tho nontriuont or lxportncltnl Paychtntry, ltllaido loupatnl, Glen Oaks, 3.1., 1.2. £1404 in part, by grant nxuaoyz u: tho lhtlounl Innt1$u60 or lontal fiatl‘h, 8.8. P3511. Health survlco; and the luau.» county floutnl Ioal‘h Basra. tho oooporafitoa at tho stutto «t tho Intiuchuaotta flau$a1 lonlth Gout-r and tho c.r. loaning-r nunartul loapi‘nl 1o stat-fully : acknoulodcod. Division or Hvutcfloro Psychiatry, finnpttnt. ;;U:;ut'tgdruaas ! ’ I C v11: Q 3/62 �I: that: at in. law lav¢u psychiatriu put10n% populutauu, lollinxphcaa and iodlxch r-porfiud Iicn1ttonut utufiy rotatloanhlpc hair‘s: nu individua1’u pantttou in tho tacit! 01:3: struottro :34 tn. provalanoc It treat-d 111-03., £ypcn at diagnouod dalorduru and usual 03¢ duratxan a: puyahttfivtu trcntucut ndntatu‘orod ( ). tiny indicatod that proportionntoly nor. 10rd: 0130. pasxnutu in stout-cut vow. clalilfitd an psych-‘10 whtiu ‘ppar clas- pattcu‘a vow. Iflfllttil ulna-1ttod an noarotto nud parannnltir disordcra. n-unrdloll at digglouiu, plyuhciharupy was Inplcv.d 1a diaproyorttoaa$cly high 4.:rooa with tho uppor at... pntloutu. and annual. thtrnpto: with lcvcr clans subjects. 1h. Stilt-no. or cacnunio Ifint‘u :34 the availability §0I1d or firoa‘iug POIIOIIII not in cauludcd 1n £hou¢ t‘Idlfil. to tout the 901. or noctll_tnctoru 1: tin trcsiacut :1 ho:pitalxnod pufiaon‘a indopusdoat a: plutont's tinnncuu and :vuilubxllty at tro:tnon$u. n yntlca‘ turvoy val undtrtakuu 1951.,x: u:at nan-u. a «rut: :of treatment nod... including ildavsdual paychothnrapy ans orgnuau ‘hnrnpiou ‘90 nvnilnbln ta :11 ptt1ant: rccnrdlcsn mun: ct ‘htir ablli‘r maul, t. guy. In fihnfi tauplo. 33s. tduuutton and plant or birth var. otgnsrinnntlr luuoutntod with chain. ot.‘rautnont, durataoa at hilplfitllll‘illg allutnal discharge ivuluatiou ‘30 �lllfintlii ( ). it. gltatcul factor: war. 11-. ralltod to a non-Ira a: utorootrpy. tho calttorntu 1 Seal. ( ). ltxhcr r acoran tor. turn ur‘on round in pilliatl dauguoaoi a: tuvolntaouul parlhnlzl rctqrrod for sciatic thirty: and hours. taliiod to: a shortcr yuriod ( ). It It. concluded that ti. extant. a: postal altar, uno. ldi'ttiol. htrthplaaa and dagrco a: atarnotrpy on psyohtu‘ric firtatnca‘ pnt‘uvnu VII. uofi a roault at cannanta tno‘orn at availgbtlttr of troutlunt .10... On. tugxon‘iun was that 3001.1 :hcfi'rl tuIquu-od diagnouin :ad tronsncat by atrociing the varbsl and avg-vnrsnl nynptc- pattarnl at pats-It behavior. It was puntnla‘cd tha‘ nubauo£l at lcvor lusts! all-sou. Inna-r oduot‘tua :34 £03.13. Birth vault nartroqnontly'unuttcnt lynptuun non-Vtrbal. IOBIOPI or IOtO! pnttnruq cud «avast phyolonl nofisa or thurapy. Huger ulna. subject. will! utiltic Vtrhal non-n at gunman-10:, and patintputn paycholngioal turn: at troninun‘. A non-ad xn‘crprctataon rilnfiod plynh11$r1¢ trnutnont ‘0 tho philosophinn and uttxfinduu or individutl payuhtatrints and hatptttl ntat! nttttudou. II 1&3‘1‘n‘10ll what. patch.» thartpy Ill hluhlr vulucd. typo: 011-0 pnttunin vculd b. ‘rontod dispruyorttountcly with ptyuhath'rnpr. ataxllrly. dischargc ovuluattonn tad durut1on a: honpttalltntaon U'lld 1n it'll be uttcctcd by itttaroncol :u o‘ttt unpootutioau tor individlu all or distortu; noctal «13.3. �.3. In to“ m. «and menu“ I. «cum: u up.“ $0 lillaldo (ll) :tudy unploytns tin can. proctdurcl :ud tons-trout}: to attend thu diacrquIGnl to in. 0th.: taut:tu‘tonl. ‘hu 0.1. leanings! nuuurtnl inapltll at tarot. (If!) and tho llaunoinncttc lautal lcnlth cantor a: loaton tultt‘ufitann worn loloafiod in tho Impoo‘nttan (ulna). ‘In$ tiny servo putt-at: .8 ditrursux 30.1.1 clunuou and 1951 It... thnt ditfcrOIcoc an ‘hta dinanatuu uculd ho rofinotod in tho trnatucnt vurtdblou. In that. houulnlu $huro 10 a minim lnrlty 1n attitudo £OUIrdI ‘rcntnaut aad oduna‘tou. Inch 1: a ‘oaoltug haapt‘ox with n {:11 $hlo Inpcrvtaorr utntt and out£v0 research dapar€n0a$. tiny 0:93.013. plythae t-nlrttcalxy-orlontod payohttharupr but gravid. 0‘30: trcnt~ lint. inslnlan; taunts. thcrcptou and activ. prosrnss or I111fil £harnpy. Each :troinlt Ihlrtutarl troutnont or valuntnrr puttautl, does an‘ gravid. cuufiodial car. and toads t. d!!! 1‘: pu‘aont pcpnla‘tou trim 01:11:: as. groups. It. Ipouttio till a! £hxl study var. fit duttrntna popu13‘103 airfares-Ia tofivccu th- thrlc lun‘tfiltioan with roupcct to social 01..., a... cantatlol und 1 learn, and to roln$a ‘hunc patient attractorta‘tcn to tho troufiuca‘ variables c: twp. o: ‘rauinout. durut1on or hanpitaltua‘ton, ligament: Ind iililltta uvnlnniitu. �.5. am vuluntnry. adul‘ putiuntn 1n rustic... In ‘htll tuntttuttanl on a 31v.- dn‘c ta Ignutrr 1959 new. studiod. “£11. Ill and as had vnllntary 9a‘1cn‘l only. 3 0:311 nuniar a: ‘Inuc It also not. nultlnad by tho court: tor paychtntrtc ovulittton. or war. numb-r. a: a chronic achtsnphroatc utt‘o holpttul group transforrud for u upocltlo ranoarnh p30500‘. than. pataousn aura «natal-d tram tin Itudy b¢¢uulo of tuna: Ian-vnlunficry status. !Ia I‘I‘V population nountntnd a: 113 patinata at II, 100 a‘ Its sad 9S ut ulna. tutu pattcu‘ III ¢1vcn sh. calitorntn r 00.1: ( ) on tin doatgnntod data. Bastian: mouth: taint the pafitcntl’ rccurda war. anulynod (hr Oh: variant social and payshinfirl: taster. If sh. titty. 1hr tho dafiuruinatton a! social claua. t5. lulltngshaad autuc‘ar luau: was hand ( ). rho utudr thalidod ulnnxan‘aon a: the rolntacua or fihn 0001.1 to it; payahtafirtc vurtublot within tack tau.atu‘lon. .3 3.11 a: tutu-on tnuti‘attonl. otnpurtnonl pravnd dttttcnlt basin-o at littoral... 1: the dutinttton at the paychtnfiric vurinbloa. ‘Io variabloa ranged #11017 lad cnnparnhlo cutout: orttarta 00:16 30‘ to d0$urnanua, and varying dour-on at 31:31:. 41“. lb: uuunplo, to acnpnru tnctatuttonl in rola‘son to length of haupltnl u.ny. Vlrlitl oufioott potion. wore ‘raod but I... IIIIIOG for gilpurnbln dtnttlbuianun. At III, on. Q‘nrtnr or the pattuata tonuilcd raw-r this cart: nouths. tad wwvo‘hlrdo L11 it... �.5“ than twtivu nan‘hn. A: Illa. :3 contract. 701 at :11 61 only Inca ‘htu rauntnad nor. 00"! nath:. I.‘ pitiilil that finalv. mantra. I: inturututug coats: 01:1. ‘haro vac IGIO 08 89! for uVIilabll lltlrlafitul union accurrad what. thy 06‘3ct10n wit. .r in. tn‘hnr at I ulnar Pittoatl. Incluluttinhlo‘ of tho hm:hand of a not... 371 not ruccrdod. Anacrdtus, 1n fiho auolyann or payuhaasrto variation ouphunia will be glucod on tho asst-runaun botvacu sastzfiutlouu. with ostnttuu a! rutnvnnt antrn-tnttstnttaunl roln‘ioashtpa. was �~6- 3mm: I. tn no Whoa riparian; Itndtal 3:1: I hano’inlsatuttou, £30 ltruttlro if it. hanpt‘nl 1| takcu for nrnntod, and ui‘h-r ilflfif04 I? 8.fi*1‘ild brinrly. luvtvur. 1n atnaytuc a cuupnrabia Gut: 13¢ gather nttaupttag Itransn tlntitutian t. 1::51tn-V butt-an tho differ-nae: many 1at tflhrd 3.4: II. $103.. It. hosp1§a1 organisatsun a: a datnruianat a: grantnout in on: nothndolocie prohlcu. Far oxnnplo. bu‘h £h. mane and III havu dny houpttal unttc, while an doc. 39‘. A. name the fieottias phwuxciun can our. tar a patioat an In Qho and an sitar-taro any tbs in hacpt‘ul. tacpattuut, clinic. II Inch a ustttnn, ha 0‘! Ital tree t0 «tachnrgo the pntlont tron tho Ioupital at tn curlxsr «sit. kl¢V1lfl that he v11: still bu ranycnsitil £09 hi: pntxont's c;rn; what-an at In, dischargd lint! tnwuinnfiiou «I shut putiost- 1. I rclttionlhtp. tu-thar probluu an: cu. princnea «I dittoront ruuourch the .2 ‘15. routines. ¢1$i10a1 ti. attoctin: it progra-u. the 91810.1. at a: porcont tunity upprcutnatnly IIIVQI. sane acre chroszaally 111 and had but: haupl‘nlttoa for hnvo ban: in unrn:XIr u such act that! zrc‘p nan: y-arl. thin honpttnl hit tiny and icon trtatturrfid Iran anathur donfier Ittt- Anntttl§£un for That, it. t lytiill silty. vary tactqrn to war. tut-routed in Itn£rin¢ �.7“ situated ‘ho coll-ataoa and arguaisa‘:¢a .: tit dttn. ap.o::1- grails-l var. noted :- do.1¢ua.1¢an 0: try: a: trout-tut, (sag-nattc torn. and actlnntlouwor troutucnt outta... .) naggiggtigg at 3:23 2; rrggfiucntc 2h. crttorit tor looignntlng that I past-It r¢ouivud 'parohothornyy' dirtorod anon; tun tastttntioul, waking unitarnltr in olntlttscatsuu difficult. At Iii p:yohothcrnpy tru;;nant 34.1.II ‘ stat: paychintrtat, was dal13n1§od tttoroa on a pronurtpttoa banxl by lb: uhxch tin patiunt was citrate a ton. sonbaaan with the payohia‘rio rnnidoa‘ v.20 countdnrod part a! rcutxao nintnlutrattvv yafiinnt Giro. At In plythothcrtpy Ill dcttnod at trtntnqnt caution. vith ‘ho plyohto‘rtu raaiduat. Stat! payohattrtn‘o dtc not trgut pl‘ltufil. but rootrlcsad that: cctavt:aos to cupcrva-tag tho téfllflOi‘ phylacxaao. At tho lune pnythc‘hornpy val dalxcnasud an a (tactic; of Ian: diocipltaca ~~ pnyshtu‘rio rusadoatu, psychololiatu. Iactal Iurkorn, strata and nodical students. III-n1 accords at such stations vow. n9$ routtnoxy taclndoa 1n the pntlonfi'u rouurd and to :lcurtain thigh pu‘iontu roociv¢d piytho§lurapy, tn. rouidnn‘ tn charge at oath a... van lu‘trviovtd. h) Diagnaaaus ludividUll 1::‘1tn‘10na1 dtugnoittc atria. fill. and. ocupcrisnnn litticult. At K!B din-barn. �diagnouol nuptqycd tut nultipin cvnlnn‘ivn dn‘n sch-no raculncadod hr thy tntrtouu Paychlu‘rtl 1.00:11‘1uu whilc both in .36 male rolllvod unt‘ury ayutana. anvural 11:191.. at IJI arc iihlo I, vl‘h our in:sootcd convurliona tutu catuturica eunyurthlo to tho 0th.: 11.130000 tru— ltufiod in fags; convvrizoas provtdc, havcvar, tn unavnidabla taste: .3 diutartioa. (31:11:: aboarvntluau havb-nn roperfind by Pas-Inuit: and him tauoetstad ( ) wha indicat. that dilzuntaa Within tho tine tantitutloa Ira db. vulnnrnhlo to individunl titraruacua Ilia: examaacraa five lunfiifiufilouu. u--O-“.““. {thin I ”’W‘.fl u... c) gtlobnrlg Ragggln a: Ingggvcmcut: Rating: 0: invrQVOo aunt wart-é 1n (splat and dotall. It. discharge rating at nil was $r1purt$£o with a inparu§a cvaIunilun tor soatal. ottrac‘urololttal and Irndrona canteen. RI and tune End clubs: ratings in which 1‘ VII difficult ta attain the can. ‘rtbufiton at such tuct¢~ n: tn: 1!! Iyltuu (rnhic 11). Fur than ntuiy gt. 3!! lyndrawc rating van unwanted to it: global rgttuc' a: an and line. C-” t .“G‘”. Q Tibia XI ”“fl“Q‘O” a. Booicgtzphologgggl Virgabloc �‘9. Scotti amp-u; that. at: a ngrkad dixttrcuuu ta ta. .0013} alas! count-$Qton at ‘bn tire. annta$nttonl (tibia 111). g} at. .t as praduninnutly “pvt? 0130!; nxddlc .1333; and at mane, produatnauttr loan! 01‘33. h) figs: Thar. war. no daltcroiaul in 01' itl‘cihltina in tho tus£1sntiounl popula‘aonfi. o) pdn¢ufigggc The nopuln%toas dittarod in oduaataounl attstauant, with pniitu£l at If! havtuu not. glut: a: sinustiou than than: at 3:36. fihlin k1 per aunt of ‘hl pusiunfil 3‘ Hana tutled to aauplotn high cahool. only 32 par canfi at an tud 23 par cant afi urn did not grndutta. d) r Sacra: natturuuaaa 3. tin ata‘rlbnslcn a: metro. an tau calitnruiu ! 3131. war. oblorvcd. Itrth-oao pot ennfi at urn pattaafia had I soar-n hcldv 30, and eat: ctgh‘ not «out wi‘h start. 0! 50 or thaw. ~~ tn. highnr ? neuron 3.1:; .8..egatnd with higher 6.3!... at sgurcoiypy. In coa‘raut, at unnc tumufiy par ccnfi var. halo! 30 at tho 2 30.10, .Id fortytuo par cant hnd intro. 9: 50 or more. At an titty par coat 0! it. patiuatu hnd r an.rua in £hu utddln rgagc botutoa 30 and £9. 3. szph§ggg$g Vutiuhlgt In‘rnainutttuttunnl oonparinoau urn counotidatod 1: tabla 1', while tutaroinlt1£u§10nal unitartitul It. prancu‘od indivifinullr 1n llih not$tcn. In ttbl. IV, ntlbu and payohou thcrnptoo var. cnnbtnad, parntfitana I oontract a: 30-311: uni At 81! the population �pcycholcglaal tharaplnu. 3) 8.1.0.1.: or troatunu‘: ‘80:; inn$1tu.1ona, lunar 6% fOOOSVDd ulna, $hat naught. or thornny I! I?! at yl‘iontu (iuhlo V). OOIOIBIOC‘IV suallcr various... at tho urn pu‘tontl taro 31:35.6 :3 rootivis¢ paynhofihorapy, with u largo tank.» (36 putt-at) ratotvxna 31110: torso at ‘roa‘o tout. 1t an patsonta rocotvtn. nilxou thnrnptou at. Clflliltic¢ an raoniviu: plyluothoragy no i yrs-3:1 Iroatnuut ItIQO sank pattnntil cantonxtanily 3.01:; 3 3.014033 ply-htnsrict. 003331. or rnuctvtnx tho plfituu‘a pcrnonfitnc ion‘ruct on: I: thornpy, urn flhl'. nighttlctntly loo- thlu intact 02 .3. o‘htr tun anlfl1£itaona. . ”U“. d.-.”fi-‘.”.’..~” £311. 1 abuu‘ barn ao¢1a1«paynholoui¢a1 P Old acorn nun Alon; fuotlro, nannisieantly rolatad tn sraawnout nsloc‘ioa (0160» and highsr r Basra patzom‘a at ups; and 9 ant. froqucntlr'vccosvtna somatic therapy) 8.0:. can tainted to troaincnt ooloo‘ton n‘ 33. athar taa‘ora utrc Itgnaticaufi. Ian. of ti. '001n1psychological factor: II. rclntta ta try. at trottaon‘ at nuns (tabla IV). Luau. fin. purchx‘tric vurtabios vi‘hin ouch inntttutiou. diagnosit at: ntgnitso:ntzy‘rolntod 1a '11 tutu. hospital-x discharge ovaluntton ‘t I?! only. had dura$1an or hocyt‘nltunttoa I. �.11.: it an and nano. sonata. troaanan‘ nun aolaotol for pattunta clnnuittud nu ochisnphr-nta titan that $hoa¢ cluaaod tad attactivu diacrdar “or. a; paychgnnlzotio at oath htartt;1. urn. pataanfi: roootvinu acnatxn truafiuont (prudnnilaatly that. tlaa¢ad as Ichanophrontn) raeulvcd ditahnrso rattncu at Iniupruvud nor: artua than pntianta rnnttvini payohoth-rspy At nlonn. b) BI!&I&I! a: BIG 1it11 'zttat 1k. fir-c 11¢t1$ut1¢ul dittorod with roaptot to pnticu“: ltauth at utly (2‘51. 71). ”an“ was mat-nu: 19‘s.", um 65$ at gaunt. taunt-1n. tar traits «oath. .r usrc, compare: ta 31 par cnn£ at ‘ta 1! puttonta and only 5 par aunt 0! than. at nuns“ 2h. an andul afifiy st ‘30 In group it: bctvnoa save: and nl¢vnn noatha I311. tau-thirac at the anus pattun‘n var. diach§r¢od within '1! uoathl a: houpttnlinnfitou. 8.01.1 oinnu and 3 $3020 we». utt rnlutod id aurution at nay tultltutiou. ti. psy¢h1n£rio vurinblua. III! 613330.13 coula ht rtlntod . fig fihnao diuanantd ll achtsorhrouia utro bnlpttalaucd tar inncor puriafli .t each instii‘tscn. at «vary .3. 1.7.1, it... a: at urn ran-incd loagar tuna Qt 38 av Hana. Iadctd. tun lituriantieutiontl dirrcronuon turn a. gruat that a yattcnt in m clan-tn an» m m. lit-11 u be mutant“ “r tulovt manta: or more ut urn thug war. putaautn in fine "II‘II‘ ts. Irv!) at x386. Within initifiatfinns. as. andauducu‘1oa at xxx tad an �a“. war: wizntad ‘0 lsucht a: honpitnlifiatzuu -« runagir tad 1.0: olucutnd pstanntn rinninits for tho linxca‘ porioi tail. 1! dsdnt atrt a) Qgggggggg_gzg;33§;gga In ough hacpitnl. Kilt patient. .32 um um mum“ u. ”wwma" (ran. are cnlutoé u. (19%) 1; a" var. peanut panamWW. Ultli nu ”uninprovaa" and 0&1: ‘ 31331: patient Hus antlua 'rcgovnrod” or .Ififih taprovid‘. tum highcat pareaataec at 'rotovur-d“ a» ”tank inprovud' 31:13:: (20:) :51 an. tenant propurtion a: ”Ininyruvvd’ {101) «0:. Stand at aunc. Lnalyuua within such auntttnaioa uhcutn vurtnbln rouulto. A‘ an and nunc thsrc an: n tandungy IQ! )Iaar putauntn to ho Iltcd hctfior ‘3‘: yolaanr anal, but ‘kc ratnita tr: l‘a.1|$1t~ was m. ma on than n. may aimltisaant awn”. um rm‘cd to 5! with Iatupruvlla oléar likely an». pstinntu trend, tut ‘hia did not aahsava a‘sttltlcni tignittaanno. n m, an. mm a “‘3'“ :9.“‘fll”..”rhbgo VII wa-oonhwficumahha d) btgsnnuila Fur u‘atiattnul analytic $hrnn dinsnontal l¢h38iphliu1¢, arxostavc dsnurdaro. and poyzh¢ncnron15 and tflrlflnllltr ditirdlrt ($351. '11:). nuns and 31-11:: fit: I! disgn¢at1¢ proyorticnn It! It!» It. groupcinsu Ina. 544:: �.13. pcptlnttonn. but it. Ill ’ifiifilfifl «or. rcunrdod an invanu and and a 13:30: Iahtuophrcntc nttacttvo 1130:4023 tart: nn-pur a: purchanourofitc or per-duality dilornora. Intrailltitutlnutl ntalrlta Ibiuid that tt I! tot! l1. tad r loot. wore rolstad to It‘sntuan; 1‘ III an. at... a: £h. nacitl tltttrr was rolntca to dsnxnootng null. as 1386 iii? I! it. 30:13! vuradbla¢ war. no ralatod. at tho p31» Ohllttll var1thlos, it‘snoata val nignitiaantly rtlstnl gt enth hoiyital te tg1:¢tica 01 trnuitcnt llfi durati¢n of sad only at IE to diauh‘wxo artlaatiau. hanpt‘nltuation; .fluflwfi Q. .DI.C“M”O“ flhla V111 dbaut hart U-“OD‘““Om--.fi-“”“~.- �.15. n . 10! In this courtrtaon It fihroa vutun$nrr paychintriu houpa‘alt a. hat. dbuorvud tisaatlonat tn‘orinutitntionnl atttuvuunol I! rattantl 1. ‘ho noctnl vurtlblta a: rtura at oduca‘ioa and 1.01:1 slant, but not ugu; :- distribution at cnlstorutu r acalovan¢rnsy ‘nd 1: oath of tin truntnmat durntaon a: knapst:11uatton. ccluctton o: vurtlbluu trdut-c-tl and atltrtbutton at 1113.0... and danuhnrct ovuluattlua. It. tilt-routs: in ‘rontncnt variable. butt-nu £ho Lia‘stuttuns nay roc‘l‘ Iron man: flitlrl. including £ho 30.1.1 aspoo$o highlightod 13 an! tntfistl ain‘t-t. 2' dttinc tho r01: a: sedan! tho‘oro taro olonvly, vb IIICIiotk tho 1n£r‘~$nlttttt1¢nu1 nulparinOIt. Iron into. afiulyioa. fit» :gok a: cnlutltcnt ralaGloashtpu land: dent: n: in tho v.1. at putlcut nottal tuaiars u‘ priallpil actorntnnnta 1a £routnal£ vtlhln than. tittin... It via an‘tcipatud that wi‘hin ouch tusfiltnttoa. pnfilonin at hichur 00.1.1 clays, turn: r not». ans hat‘ar causation, would to croutud prcrcru tg‘luXXV by pcrthntb¢V£vrg clnsnttiod as nourotio, tuna:tnr shorter partodl and r:¢¢1v. botfi-r danchargo rats-an. wl‘hxn in. :uli1iut10n, an irrtstlnr unsootnfiloa bc‘vtta tn. 1;). (ram. mun-u «I wan. no sauna-n. it. Illa. not. at tin Inuit: $323.51.. var. rotatod tn any cum at: at. tacit! alga: Itliilttc;117 rotataa to 3:: trontnomt vnrlubln at otshcr I! or 313. o: a firoufiuout turtnblus �$3313 3 ___, by nun-qutuuml ”hunch”. Manta“ on Sam. ”I - haunt aolufl“ ' '- mun O: thuufll ' - Duncan 11“ch suit-nun mutton . man or Influuuuu I an" - ”can“ sun“." . Mam” " ii‘lfi 3;: - n. I. “nun-up in- ti mo. m «I» 4» am...» he mu: am0 u r: .05 p< .0). on W .001 �.15. pcccthlc he rclccaccchtpc hchucch ccctcl ccc trcctccnt vhrachlcc, clcvcn crc chctficttcclly nightttocat. fhc dirtcrcnccc 1c tho an cud It! dctc ucy hc a» rctlcchlcc ct thcir pcpclclhdch atttcrcccccu thc rclccicu at 13c cc d1cchcr;c cvclccttcn, ccd r cccrc tc 41c¢nccic at an rctlccticcihc htchcr prcpcrticn c: dcprcccivc illccccccp uhtlc hhc rclcctcc ct cuc cc hrcchucct cclccticn cc urn rctlccttcs choir highcr prcpcwttcc c: {cc-t pcrcccc clccciw tic! pcychcncurcclc cud chcrcchcr itccrdcr. rho ctnilcrthtcc :- I! and Ill much In: rctlcct ctnilcr trcchccut philcccphtcc, which crc littcrcct rrcn thct ct Illa. ccudtttcac c: clcchivc trcchucht ccd clccttvc dcrctxcn ct hccpitclxcchlch catch ct ll cud HIE. and th may hc thin tlcllhtlihy thch pcrcttc tho inhcrccticc ct tho cccicl vcrtchlcc. 1% lane, hcvcvcr. tho lththcd cccy cud cccd tcr rcpid trcctccch rcculhc ta h tctlcrc hc dchchctrchc cc 1ctcrcch1cc ct cccicl vcrichlcc vtch tho trcchhhct prccccccc. Similarly. thc rclchtcc ct cccihl clccc vcrichlcc hc trcchhcht varichlcc 1c hhc lcllxccchccd ccd nclltuh ctndicc Icy rctlcct hhctr dctc cclcchtca, vhtch vac cvcr thc hrccd rccxc ct c11 ccnuhcatw :cctltctcc cud cll trccthcah portcdc. within thcsahcttcnc, hcvcvcr, thccc cccthl thctcrc cppccr lccc «Incl-.111" ct trcchcct ruichlcc. accusing): cvmcvcrcd by tctrcccrcl cdhtctccrcttvc ct {sunsctcl ccccccthtcc. 1c hhc ccrltcr Iillctdc lccpthcl chcdacc ( ) thc rclcttcc ct �~16- vnrtubloc trooinant ‘0 thtad cit-atlas 0: u... r 3019:, 13 u rdlnation of the krona ndnantn‘rativu 1a£1ta¢ua avntlnhlo defined broadly lrtnfinout. var. tans. that a‘ tn pnfilnu‘ car. with cengfitc, nzltou :34 paychofihurnpautto undo. annuity ‘vniznhlo. ”III‘SOQ Ir Incpt‘nlinotton an. broadly duttnod Anni-lion policy 1 raga-atod. 19:31: or to up i: your, at was {113151. and thh taught and purntt‘od tun Ianxslaon or pafituu‘n ‘1‘» a I10. 933;. a: pcylhlatrxa laouraorc. the proacnt an Isudy than: (out: locial-trantnont'rctn‘tono con-fir‘o‘ttn 195? a parka»: ‘ha rollocttuc than s‘uay. nit»! Lu avgilabilifiy a! trcafiuont :hoiooa. ta popu1t£1on 33¢ a uniturn us‘cnnton-cl ditl‘lil at heapttcllulttoa. lit. new ad-tntn‘rnlifih a can‘nlyorcsoouslr thatlsltad pitta... with closer no narkud a Granting axillarity in clonal: $10., the Mt! nodal. Such administruttvo discus-10:. arc iosu no prtutcpal dctorntnlltl or tn. Clorfllllfl or dist-lutton a: social vurinbloa, n. ltl‘lrl ta tho trantncnt prostlu. A lacuna aspect at that. I‘udtoo an: tun Icthodoloctoul problems In 6011.13: tho ‘roatnon‘ Vtrtnbloo. That. last:tltSOan wort toloctod to: that: cantattouni loudnruhtp and be vanld roomrd¢d £ho vurtuono 01¢:rly tha‘ clygctattoa it. uglinod. OI: dirttcultzao in arriving at comparable Asia oouvuattonnl at a: $ht-prdblnn to one! in. tupcrtant tit at. OOIplrfifiiyi it;$ia£ion. 0330015117 1- £3. ovulustton a: psychiatric therapiou. rho trnquun‘ nu. at dilahnrco ratings, �-17- dtncnolttc .11.... or Iongth at houpisaltnatton an ortturta or thorlpputic vnluou at conpnrubtltty or nuts-ct: and poppItttona urn Iibaoct £0 can-031v. array pal... tho inuttfinctono puraduxtn naschnd adulatutrntivo patparuu. tar clourly It. It. cal uupuro at a :atluru ts anounat for this vurinhlo 1- to be 6511 dbucrvnfitoa ‘hc of a in tutprprctataon lttcrnl t: Iii! cindy. an. urn hi! it: most highly train! per-canal oondutttnu troainunt think is applxud for indivicunlly tottaofi,¢ptxan1 portods o: ‘llis it populations with it. 1...‘ propurtion danunouod 1p nu unfavorabls pritlll‘it group (achilophronin) - 1. uncultl (cvorlblo tracing-t a: rot. th. pOOIOIt. At Illa, 1n contranfi, tilt. in: lonat traluod shtruptacfi apply transient. for nu adutntutrativnly llutsnd patina, ‘0 t papnlattou ‘1‘! a tight! prcportlon dtnuuoacd Ichisophrpnia. tho proportten or tnvorablo itscharxt rating: in lixutticnutlr grouper: It 1- prubsblo thnt thun- ohlcrvuu £303: a. sop rutloc£ thy tharapcusac atticppy 0: photo snap:1n infitcatodb ortsorta o: tuprvvo~ attics-loan tu‘ttul, 3" ~- tad tho proportion uonfi. this lack a: alsritv in «tacuautta achcunfi¢ and lacunpnrtbiltfiy or psychiatric trou‘upnt variably. all. landpallc to th. t‘tcnptnd acuparupivc studio: or payohtntria thorpptca. Pb: asunplo. tho rank at rooont failurns or biolcgtcal Ioaonticsu to Courtru ubacrvutioan Ill. 1: «that labor-tartan rip he I: unch a rutloctinn 0: 11:10:03... In �.18. popnlnfisoul. paynhaatrin orssortu,lggg. an tullaniou it tho or131ua1 hip-thus... tin vtdnspmoad no. or tank turns :- ”Ichzscphroaiu' or "plynh'aamtoaiu' to unplarc £hn shuns-n 13 pnyubutagtoal or biological toninraa with noufiaz ilincsc has 106 it a Icioaea burdonod by ungattvu rctaign (Iellak), nont narkod rocuntly 1n tho nontliettng studio: at I tdrll false: in auhaauphroutn, :3d the tact-pur‘btltty or the yhyutologtoul -. hohnvtorcl corrcluttnn: scan in tun u0choly1 (Fulton-toau) and sedatiau thr¢lholfi tnakt. Esta nor. 3 valzd abourvn‘tou to be ropuriod :rcu on. clinic, dc a. havo' nothtdi available ‘0 deliriho poputlilonl manqua‘nzy £0 providc ‘ sound nontlrnatlon? w. haltovu hat, and nonoludc from thugs dbnurvuttcls that incranacd attention unst be paid to she uathodolaaaaal prnblun: o: alttsityina uuhjocta hy 'vb:oot&vo“ cratcriu, rather than fins prosoat untied! whack appear to b: a. hichiy dopoadont a: institutionnl ;ad otuarvar nttittana. In: the oouiopaychological 339.0%. .2 ‘3. thflllptltupl§103‘ tltcrtctiou. �IleI I can? a nu at Bil: WW 1. nnprunaav‘ rouctson Surciaozntlo Puruonnlitr 1: no: WM“ 1 61-1- “mm Payohcncnrostl 2. Auxtuty Roaution larttnntutia Parlounlafir Payohnaonrootl 3. larcttsiutia ?urlcan11my tartan-11:: $ h. lurcatfliutlc Par-annlstr. Alcohcttun chronic Intintilo PartinIISty I acuiuputhic Put-onaltty Btuturhusoo S. Pausivn Augrcuuive P¢rsoun1$fiy Alcoholiun Suctcpcthic Purcoanllty Disturhllco 6. Inthn‘iln rarncnnlzty Schauophrtntu Ronltton StuttOphronlo vaychoail , Suhifil-Afllofi1Vi*2¥pl frtit 31I£I§bnnio �TAELE c 1 5‘ 1 of I: on g; gaggs‘nl aacahnrgo 8a.: tin. Ii u , Illa floats: tgguai-ant Ruusvuroi luouvavud Inpmuvod Bach Inprvv‘d unrkodly InprQV'I Untaprovvd Invrdvnd lodurntolr Improvul alllprcvod 81133‘17 Inprovod Hltnprcvud couplate Ronanaign 2aprov.d v‘ahnugcd (u: wits.) �ans-$3 :33»! . i: on ., w W M . - V. ma w, ,-.M , u. x n Ha ‘ a WE w m V m Vino W4 m .w Vacs. gm H1 II ”Sup-32a a I'_I"II 3.33.. V mfiufififim .63. I; Eu. as PH. no in �EQELE V :2! an kl 173 we v’-82.8; 39 dtwhx p¢.061. ’ 21 h: 36 36 6h 0 ah 68 a ! principalxr lilies thsrtplio �me 95 x'.?0.6; “'1” V5.09! �331.8 quttt‘u I an g! m ‘ ’ Rum“, rum n '1; «huand d 1 c fi Imprond flux-yam! 99 1 an 1.9 17: 23 6: 15 as 61 10 mc- x*-29.3; «rub; p«.oat. �Y Ilstttntaau . V I WM). l achtgophrtnia Puyuhonguronia and E' 7 ml m1 male 171 . 85 t"13.8h1 43-h; pfioanl.‘ far-onalifiy O; !' J££o¢ttvo 33 $2 5 52 26 :92 SL 29 16 �A Couporioon o: sooioplyoholoaiool Voriobloo and Poyohlotrlo trootnout 1o Throo Voluntary Hoopitolo Robort L. Kuhn, Ph.D.', no: Pollock, Ph.D. lothoniol Siogol, Ph.D. oud m flak, um. tron tho noportuont of Suporinootol Poyohiotry, Hilloido Hoopitol, filo: Oaks, L.I., 5.1. Aidod, in port, by grout HI-ZOQI of tho lotionol Inotituto o: Kontol Koolth, 0.8. Publio BooIth Sorvloos ond tho loooou County Kontol Hoolth Hoard. tho cooperation of tho ototto of tho Hooooohuootto Montol Hoolth Contor and tho 0.1. Hoaninlor Houoriol Hoopitol 1o lrototuily ooknovlodcod. o Prooont Addrooo: Divioion o: Poyohiotry, Houtottoro noopttol, I.!. 67, 3.2. VII: 3/62 �In thair atndy a: tha lav lavas payahiatria patiaat populatiaa. lailingahaad and Badliah rapariad aignitiaant raiaiiouahipa batwaan an individuai'a paaitian in tha aohial aliaa airuatura and tha pravaianaa a: traatad iilaaaa, typaa at diaguaaad diaardara ind kinda and duration at payahiatria traatnaat adniaiaiarad ( ). Thay indiaaiad that prapartian~ ataiy aura lava: aiaaa paiiaata in traataant vara aiaaaitiad aa payahatia whiia uppar alaaa patianta vara naraattan alauaitiad aa naaratia and paraaaality diaordara. fiagardiaaa at diagnaaia, payahatharapy waa anplayad in diaprapartianataly high dagraaa with iha uppar alaaa patianta, and urgauia iharapiaa with iavar alaaa aahjaata. W” Tha intiuanaa at aaanaaia atatua tha availability aau‘gviat lfikaualndad in thaaa atudiaa. at traating paraanual fa iaat tha raia at aaeiai taatara in tha traatnant at hoaa finanaagfaui iadapaudani at patiant patiant' pitaliaad M“: JJ’availabilityat iraataauta;a patiant aarvay vaa undertakaa at Biliaida laapiial in 1951. In thia haapitai, a variaty at traatlant nodal, inailding individual payohatharapy and organic tharapiaa at. availabia to .11 patianta ragardlaaa 3”“ at thair ability to pay. In that ....!G. aga, adnaatian and piaca at birth var. aignitiaauiiy aaaaoiatad viih ahaiaa at traatuaai, duratiau at haapiiaiiaatian, aliniaal diaaharga avaiuatian and �.2diecneeie ( ). The elinieel teetere were elee releted to e eeeenre e: etereetypy, the celiternie F snele ( ). Higher r eeeree eere nere etten round in petiente diegneeed en invelntienel peyeheeie referred for eeuetie therepy end heepi~ telieed fer e eherter peried ( ).i 11..., mfiflfl‘iv W” It eee eenelnded thet the elGIItI-et eeeiel eleee, ege, education, birthpleee end degree or etegzgggpy en peyohietrie i:3§::§:7gi eeeienie treeteent petterne were not teetere er eveilebility er treeteent eleee. One eezgeetien wee thet eeeiel teetnre influenced dieueeeie end treeteent by etteetin: the verhel end nen-verhel eynpten petterne e: petient behevier. It wee peeteleted thet eehjeete et lever eoniel eleeeee, lee-er edneetien end tereicn hirth would eere frequently eeniteet eyepteee in nen-verbel, eeneery or enter pettnrne end would expeet phyeieel eedee e: therepy. Upper eleee eehjeete eenld etiliee verhel neene e: expreeeien, end eetieipete peyehelegieel teree er treeteent. A eeeend interpretetien releted peyehietrie treeteeet to the phileeephiee end ettitedee at individnel peyehietriete end heeyitel etet: ettitedee. In inetitntiene where peyehetherepy wee highly velned, upper eleee petiente would he treeted dieprepertienetely with peyehetherepy. Sieilerly, dieeherge eveleetiene end deretiee e: heepitelieetien weeld he etteeted by dittereneee in etet: expeetetiene for individuele of differing eeeiel eleee. ”Sikhs/W! �toot thio ooooad hypothuio no dooidod to "put to Hilloido (an) otody ouployinx tho Iona prooodoroo out l'o 1957 oonoorroatly to oxtoud tho oboorvotiono to two othor institutions, tho 0.}. nounio‘or Honoriol loopitol of fopoko (HIE) ond tho looooohoootto Hootol floolth Cantor of Bolton (ulna). rhooo inotitntiooo not. oolootoo in tho oxpoototioo that they oorvo potionto o! ditroriag oooiol olooooo and that ditrorooooo in thin di-oooiou would ho rotlootod in tho trootnont variation. In thooo hooptolo thoro in o oinia lority in ottitndo souordo trootooot and oduootiou. Each in o tooohinc hoopitol with a toll tin. ooporvioory ototr and ootivo rooooroh doportooot. rho: onphooino poyohoonolytioolly-oriontod porohothoropy but provido othor trottuonto including oonotio thoropioo ond ootivo procro-o o: nilioo thoropy. Book otrooooo chart-torn trootoont o: voluntary potionto, dooo not provido oootodiol ooro and tonde to draw ito potiont populotioo tron oinilor ozo croopo. tho opooitio tin; of this study voro to dotornino population dittoroaooo botwoou tho throo institution: with roopoot to oooiol olooo, ago, oduootion too I oooro, nod to roloto tho-o potioot ohorootoriotioo to tho trootnont voriooloo or typo or trootnoot, duration or hoopitolilotiou, diagnooio and dioohorxo ovoluotioo. �Uh. HEIIOD valaatary, adult pattanaa 1a validaaaa in thaaa taattauttaaa an a titan data in January 1959 wara aaad£ad. whsla 8!! and El had valaatary paataata only, a aaall nuabar a: thaaa at zinc vara aaatsaad by aha eaarta tar payahiatrta avalaaataa, at wara aanbara at a abrania aahtaaphraaio ataaa hospital group tranatarrad for a apaattia raaaarah proJaat. Thaaa patlanaa vara aaa}gaa§mgaan tho atudy baaauaa at that: aaa-valaafiary atataa. fha laud: popu1;‘1.§“;;hai§£;§”;g:§i3 tag-“ice at m and 95 at me. nub van W~_MM' W._~.»M~_~-w gtvan tha calitarnia I aaala ( ) an aha daaigaatad aaaa. is 0!“ ”Univ; MM Eightaaa aoutha later tha-pafitaata' raaar ‘Awara aaaiyaad. to. MMML and tho aha variaua aaatal taatara at payahtatria atady. )far a£3~3:::::2:;tton tar at aaazal alaaa, tho Ballingahaad 2-taatar tad-x was aaad ( ,). Tho atady inaladad aaaatnaaiaa at tha ralatiana of tha aacial ta tha payahiatrta variablaa within aaah inaattatian, as wall aa batwaaa inattantiana. ‘rhaaa aaaparlaana provad difficult baaauaa at airfaranaaa in tha dattataian of tha paychiatrta variahlaa, aha variablaa L11 mung"; pl;;t cut-at: aritaria could not ha dataraiuad, and varying dagraaa at ataatag data. Far axaapla, ta aaapara inatitutiana in ralatiaa to laacth a! haapital raucad widaly and camparahla atay. variaaa nag-or: pariada vara ariad but aana allowad rat aaaparahla diatributtaaa. At Hyfi, ana quartar a: an. pattaata raaaiaad ravar thaa aavan aaatha. aad awa-ahlrda a �.5. Into tuna twclvo acuthu. At ulna, in contract, 701 at .11 pation‘t rcnntnod 1... than IOVOI noaths. tad onzy 61 not. than 3201?. angina. In actor-intng 0.01:1 .1... that. van tarnrnnttou availnbll for 292 of 371 patiouta. Unclaucitxablo Ctlll accurrtd whoro tn. educ‘tion or the unaband or a honouwtto If the tathnr or a liner VII nut rouordod. Loonrdinu, 1n $ho nutty... a: paychiatrio vnrinblot inphllll V111 bu plaacd on tho dittcrcncoo botvoou tuititu‘lonn, with c1t:txon or rolovnnt tnttu-inatltnttonal rolntaonnhtpa. �Katharina“! “no.“ what! "parts.“ tn: hatun I tnutuuou, “at” 11 and “icon for of tho “that hospital crust“, "not”. 1. 4*“ 2y“ 1,: ,7) § )3 § Pg « § 3 studying in briefly. “attend flavour, {LR $ Q 1:”er 77W ', 0”] M and author Guplrlbli d». 44W stunting inflation 3:. fig .W' 3'. M” batvua tho undo 1at q dirt-rue” luuumm. any m\ an 3N M ”1:1” (Md “on. flu hospital. org-nuts.» u a dour-tun at twat-x § Q1: 9. 3* ”3%: both sh. pr-Obltl. 03mph, )W tumultuous hr no“ Q‘s an u ‘ Mflg 3 3g an do“ not. 7“ MM 1mm and am In" in: lupin]. nun, while (ft; Q 3‘ mfg?” At me the trotting phynuua u: can for a pttuu u a ‘E Q“k and tho as 1n é day the utter-nu hospital, W‘fijw Min-pun“, x i to In tool 1% In ;.1. 1,, no): a auburn «a in. “tuna. cunts. w k“ g M"; knowing tho at hoopla! the «run“to, patient in: ”file/:4 , a WV 15%”, 11111 ha hi: tar patint'u to ruponltblo «to; um can % 1;. 'bj’whuufi up») gt an, “sour” nun urination or “at puunA” MW auto:relation“?W M” Jr 1M Vb 5 0: the Authcr $4, III pubic: 51/” “than prune. running m. {Lu u} NM 5”” w” M. use tbs .2 _.., 011““). an. "nun“. ‘y prurun, “tuna: W” w g‘éflm w tho at approximately pan-nu “any para." u «may, W { to:111 had and bun chronically hospitals!“ mo var. “wwizof rb Mara would not normally 1: luv. bun Sun group I yuan. any fig Wu; MW" thin nuptial bit they had bun trmtornd tron author m O | 9' 1,. . |. “0: ax- . in 8 v 8 ”L e , A _ . Mk M ‘ 3 ‘35 ’ 3 \ g , . x ‘ W” ,5 l i ' W" . l at.“ human“ for a ”001.1 ““1. Thu, tho vary not." no In" int-tutu / in studying ,4"ch ‘ �~80 diagnssol unpluynd tho unltipIo avnl‘ativu d.ta Ichuuo rootuaondod by tin Anortcna Psychiatric LIIOOIQ‘itl will. both an and nuns rollovod Iaifiary nyufiunl. 8.7.!!! uxanploo a: dllfllllll tram I)! are liatod 1n Idblo I, with on: on;goutod oonvoruioaa into ottngoricn coaparablo so the cthor two institutiona. {hone aonvorlioul provide, horcvcr, an unavaidnblc neuron of dfstartaon. (31-11nr ebonrvntinln havban rap-rut! by Pun-nut and his uuetntoj ( ) who indicts. th.t diagnoous rifihin the can. tantikutiou arc die valuarnblo to individual ditturoncoc anon; anguinnr-J -“--I‘-----QTtblu I c) Dilahsr 0 anti 3 at In rovcm¢n%: Ratings at inpravc:ont varind in (grant and detail. the dischargo rating It KPH In: triparti‘o with a liptruto cvalustion for social, attractorcloliual and cyndrouo Chlnloto an and Kane had glob-1 ratings in which it was dirtiault to .0303: the con— trtbution or cash factor at th: urn tyntan (rubl- II). For this Itudy the urn urndrono rating VII compared to tho glqbll ratings of an and mane. T‘bla 2. Socioglzeholoitcal Variable. II �-9“ a) Socitl Gina-z that. val I narkod dittoronoc in tho lociil ulna: oonpouition of tho thro- iuttitttions (Table 111). 3% an BEE 01:00; tho produninaltly population uppar In. it niddia olaun; tad at axle. pradcninaatly lava: Ola-u. b) 5.3: Thor. turn as dittaruncun in In. dilirihutiou in the institutional popuiitiano. 0) Education: Tho populitionl dirtorod in cduantioual 1% HIE with having nor. yoirl or adieupaticatt utttinncni, tion than that. it HERO. While kl p02 aunt of tho pttiontl HERO ttilod to cosploto high annual, only 32 par cent at it KPH UK and 23 par cont it did ant ‘raduntc. d) F Sacra: Dittoruncon in the diuiribuiion of scar-I on tho Gilitornia r 80.1. not. obsorvod. ritth~ono par coat or urn paticntl had P score: below 30, cad only eight var cent with IBOrCI or 50 or abuvo -- the higher P acorns being O0..cintod with high-r dugrtul o: sturuotypy. In contrast, at 3336 tittty per cont not. Euler 30 on the F 30.1., and tort Knigz;::;pnr—ttnt $0 two per scat and IBOIII at or nova. it bb¢”»130 chad efinuau~ P&c&¢r véu<_z or the pntiuntl hid F 3002.: ia—ihn—nidd%¢arcntu-hufiwuuu—3O '0'”?ch My Sowua «Jan, 50m 0 3. Pozohiatric Variablu: Intrgoinutitutionnl «satirinonl urn connoiidatod in Tabla IV, wail. iuicr-inutituiional ounparinont are proacntad iadividquly in tack auction. In tibia IV, nirhu uni psychotherapi.a act. conhiuod, parlitting p «cairn-t or countie ind �.11. at an and rune. 3.3.310 two‘s-ant uni uolootna for pattea‘u clan-itlcd an achisaphroain and atfcotivo disorder not. titan than than. Illlflid an paychonuurmszo u$ Illh hoapitll. At HFH, pattou‘a rocolvtll unantio troaiannt (prodcninautly than. 01.8.06 an nthiaoyhrania) rocnlvod dinohsrso ratingot uninprevnd nor. ofton thus putiuata roooivina psychathcrapy alone. b) Duration of Boagitaliuttiona 23. turn. instituticua agitated with roapott t0 ptticnt'o longth of ctny (Tabla VI). MPH patients VII. haupitnliscd leascls, with 65$ of pat1¢atl runtiniag t0: twelvo lanth- or torn. cenpatua ‘0 31 par cont 0: patioutl and 0:1: 5 par coat a: that. it nuns. rho 3.4.1 ttay .1 it. i3 group was hottocn IIVOI and «lurch nonthn Hull. twenthirén of tho XHHC patioata wort diachuracd within six 393th: at hoapttnlisatton. 3031.1 «1::- and F acorn worn 30‘ rnlutod té dira‘ion at any institutian. or tea psyghiatrio variabloa, only diazuoaia 00‘1d b. taint-d - in. HE as tho». diagnonod a. achinaphron1n war. hospttnlaund to: longer porlodn It sunk inutttution. At avury at. 10701, that. at RFE rouninaé $0.30: th¢a It 33 or Mlle. Ind-oi, tho in‘cr- institutionul ditturonotl rat. to grant ‘hat 3 pttiont in th- oldut go pup nu It" 11h): up In lac-punts“ :cr tvlov. tenths cw not. at KPH ‘htl war. pntioats in tho yonncont as. graup at HXKO. Within ill‘iilt10nl..‘IO nudmodnoatton As xv: and an �-12u honpttnltnatiaa ~- youaxnr lid 10!: oducatod putt-at! rinutntng for tho lingolt period worn roln‘od to lunght of Q-.-“-O-QC“-- .O-”--. rabzo V1 abuut her. -U.---'...--’--Q-fi--.~ a) Diuoharlc Evaluation: In cash helpitnl, ants patiouta are ovnluatnd ut th. time o: disaharto :& "taprovcd" (Tabl. VII). 9: pattnntl worn a IIQEI. p¢t1¢nt who call-d At KPH, hoV¢vnr, u high-r porountaun (19$) rntud a: ”unimprovcd” and «317 ”gooovorad" or ”much improvad”. Tho hiahu:£ purncntago or ”roeovorod" or ”such 13336706" r;:1nsa (28$) :ud tha lowcat NHEC. (10%) "unimprvved” {tuna a: ct war. proportian Analya¢a within «ash institution Chalid Ttriiblfl roanltc. At an tad H336 thorn was t tondonay far 9140: puticuta to ho ratcd hatter than youaanr onus, but uh. results arc ut:ttlt1¢33. Afi H33 thorn wan II OppOlt$O anly at aixnirieant all? trund, with older pationta nor. ltkoly to ho rctcd nutupruvod; but this 616 net aahiove ntatiuticaI signiftclnao. -fl‘----‘-fi-“flflfl’.9351: VII -O.--’.-‘-.fi-¢--. d) Diauneais: Fer neltiutiaal annlyulu thrco diltnfii‘lt groupfingc were mudo: achisophrouit, tffottivo aiaordcru. disardora (Tublt VIII). Th. alcgnontie propertians «or. similar for tho an tad Hana und puychoneurcsin anfi pnr¢¢aa11ty �.13. purulntaonu, but it. It! patluuta wort tifllrdol s. h:v1:¢ tow-r atttattvo ate oohasophrcnto 1100:4013 and n.13rxcr author a: plyohcnonrotic or port's-11:; disordatl. Intrainatitutianal nnulylis abound that at RH both as. tad F 000:. not. rclatcd to ditcntats; &% HER use alone at thu nociul factorx uni ralstad to diaguoais; while at EMHG hfififi 0f file social varigbloa were so related. 0f ha payohzattiu variables, diagnoatl wan significantly rulnhad at Ollh hospital to solootion or tdnatnant aha auratian of and(§ging:iélta diucharge ev‘luttien. haspitalinttioag "'----’“-”-fl”. u-~u~q~a25310 VIII about barn u---~-‘n---—-h-~n”ca—umu—Mfln �~1hDISCUSSION In this comparison of throo voluntary psychiatric hospitals as havo obsorvod significant intorinstitntional dirtoroncos of pationts in tho social varioblos of yoars o: oducaticn and social class, but not ago; in distribution or California F Scalo scoros; and in oach of tho troatnont variablos -- duration of hospitalisation, soloction of troatnonts and distribution of diagncsos and dischargo ovaluatinns. pTho littoroncos in troatnont variablos botwoon tho institutions nay rosnlt from many factors, including tho social aspocts highlighted in our initial studios. To ,.__ Ar 7-“, dotino tho rols of social factors noro cloarly, no nndortook tho intra-institttional comparisons. Fron thoso analysos, tho lack of oonsistont rolationships londs doubt as to tho rclo o: pationt social factors as principal dotorninants in troatnont within thsso sottinss. It was anticipatod that within oach institution, pationts or highor social class, lowor F sccro and hottor oducaticn, would ho trootod proton-4 ontially by psychothorapy, classitiod as nourotic, romain for shortor poriods and roscivo bottor disshargo ratings. Within tho institution, an irro ular association botwoon tho (Tablo:;§;). variablos was obsorvod Within ono institution, tho HHHC, ncns of tho social variablos woro rolatod to any ...-- v troatnont variablo; nor was social class statistically ro~ latod to any troatnont variablo at sithor KB or MFR. Of a �-15- ’51, > possible h8 relationships between social and treatment variables, eleven are statistically significant. The differences in the HE and NPR data nay be at reflection of their popnlaltion differences: the relation of age to discharge evaluation, and Fiscore to diagnosis at hH reflectingthe higher proportion of depressive illnesses; while the relation of age to treatment selection at MIR reflecting their higher proportion of young persons classified psychoneurosis and character disorder. The similarities, in HR and HFH uata may reflect similar treatment philosophies, which are different from that at MHHC. Conditions of elective treatment and elective duration of hospitalisation exist at HE and MPH, and it may be this flexibility that pernits the interaction of the social variables. it HHHC, however, the limited stay and need for rapid treatment results in a failure to denonstrate an interaction of social variables with the treatment processes. Similarly, the relation of social class variables to treatnent variables in the Hollingshead and Rellioh studies may reflect their data selection, which was over the broad range of all community facilities and all treatment periods. Within institutions, however, these social factors appear less determining of treatment rariahles, seemingly overpowered by intramural edninistrative or financial necessities. In the earlier Hillside Hospital studies ( ) the relation of �.16. svoru, an: cducataul tn tin ‘routnnu‘ Vtrtttloc in t valuation a: fit. brand adntala‘rufitvo latitudes tvntlnhlo £011.04 broadly ltoutnon‘o not. tans. tn plttcnt 0.20 t‘ that with nonattu, natto‘ cad puythofilnrupuut1n Ind-I aquaixy i'ISXIUIGo Duro§aou at hingt‘ultsattou was tread}: tuttnod gs up ‘u 1 1I¢r, If longs: at rotunl$nd. hints-1's p.131: tun .1 and udnislttu and bath IOIIk$ par-titan (Icntblo II. dtnordorn. at var'hlasrto vtth runs. '1‘. I pattian f01§$$OI~ socxnlutronincn£ (out: In titan In: prtnott I‘l‘! constructxon a 1951 rotlac£1nl parity. Itndr. aha»: its: than tvusluhtlitr a: urinal-at ch¢1¢¢l. in pavulnttun and a intturu cu‘auliou at d§ru610| at hocrtttitlutxol. this with nan :dn:nlttracultauporaacauslr tuttxiutcd : prion-I. itfit clout: marina a Itntlnraty 070.11.: at tics. is nio-zlr adutaautrufiivo daucasaioua as Buck III! Iodci. 8!! It. tn. it. dinuolutltn at or Itficrnxnnnta thoracic. tr yrtnzcvll 0061.1 Vilil‘ltig ca titttri 1: tin trolmnont prcacal. A loalnd tlpoot c: that. Ituiica 3:3 tin nathodcloctonl prdfiloun In dottnln; tun traits-at vurtfibioa. Thai. tact:fiufiaous var. Iclootoa it! ‘hoir causatisngl ltuanrahty and ‘ho capacfia‘ton that tbs rooardul variable! wouId ho altar}: dofiutd. OI: dirttauiticc in Ittlvtts as Odlibrtilirdtil $h¢ cauvcatlosal'uno a: anon at ‘0 sh. gratin: .r. tap-rtaut cuuparntagu o‘ttintlnu. alpuntuIXI 1: fit. ovuluu£1oa a: purch3n%rlc thornpxnu. it: truancnt II. It diachnzao ratings. .3 ago. D �-17ae or criteria hoapiteliaation length diaguoetio cleaner/or of therapeutic valnee or oouparability or aubjeeta and populationa are subject to oxeeeoive error unless the inatitutione The paredoxipa+torna. adninietrativo notched for are clearly '7 be to ie oal nature of a failure to aooouht aeon in a literal interpretation of the observation or this HFH conducting boo personnel The highly the traini loot etudy. treatment which ie applied for individually defined,eptina1 periods or tine; in populatione with the least proportion diagnoeod in an unfavorable prognoa io group (aohiaophronia) ie roenlte treatment and the proportion yet, -o5\£avorabla the poorest. At HMKG, in contrast, where the laaet trained therapioot apply trootnente for an adniniotrativaly limited period, to a population with a higher proportion diagnosed eohioophrenia, the proportion of favorable discharge ratings in eignifioantly greater! It is probable that thoaa observationo do not reflect tho therapeutic ottioaoy or theoo inotitutiona, but indieatafli dittoronoee in criteria of improve- for@ Iont. Thie laok of clarity in diagnostic aohomata and incom- lendo a1ae variables treatnont e: payohiatrio peribility pauae to the attempted comparative etudioa of psychiatric t ranioe. For example, tho raeh of roeont failure: 0! made confirm other in to aoientiate ‘/h(c£jfiau!§iolozioal obaorvettfno laboratories may be as each a reflection of dittoronooa in �-18.. fallooioo in tho on such torus of The use widospzood hypothoaoo. original “oohioophronio” or "poyohononrooio" to oxploro tho chongoo in poyohologiool or biological rooturos with nontol illnooo hos lod to o ooionoo burdonod by negotivo rooulta (Bollok), noat marked roosntly in the conflicting studios of o serum factor in schizophronio, and tho inconporobility of the tho nooholyl in soon oorrolotions hohovioral physiological -(Funkonstoin) and sodation throohold tasks. Even were a havo' do wo from ono be clinic, roportod valid oblorvotion to nothodo available to doooribo populations odoquately to ooncludo Ho and holiovo sound confirmation? not, a provide from thaso obaorvotiona that increased ottontion nuot ho paid to hho nothodologiool problono of olooolfying aubjooto mothodo tho than presont rathor "ohjootlvo" by criteria, which oppoor to bo so highly dopondont on institutional and ohoorvor ottitndoo, and tho oooiopayohologiool oopooto of tho therapist-pationt intoraotion. populations, poyohiotrio oritorio, 323. Ufifi})*l 1" t no �”flu“ Wing mun. nupwum: 1V. Benefit.» Mun“. rmuw AnzacQV mm“ 3. magnum: Puumu‘y rum-nut. running mu h. l'mmuty mus-u: nub-1m em. f 8001me Imus)... Formula” S. 6. I'm“. Farm “mun in tau-nu rwmuw Batu” nun-pm. Baum-ulna" W - 1’me “than” Winn rumba“ Pmbmuw annual-n1. Ply-haul �z§gLs g; W W Ithovod Inst Inprovud Untnvrnvud coupluia nonalciao Ihwruvud Btuhtngad (or aura.) �am 1 M9 m. m “mu on mm ' i ‘ h). sa 5 want“ In".. cm W 33 3: mm“ an m �am um: 0) U) a g a: g . H auton,ann . .m.m So. E? So. 0&5» an a llllll'llglllllllll in CO E3 nonansao>m a“. o H‘ad .m.m Mina-«n can» an m “no no. 3E Hand pm a . an n 8. —:o«a~uwnu¢«.uom and. guaoflanncm .8. we ncvd.lomcuhnaH nodunuvm «uncanny . am «a So.“ ma mo. «nonvooua M. no. mm . nauaeadcm 3. mu . . «6 nuddo “;o«anu«n¢aumuom mouoaufiahm aoaaanuun Queen n«uo:uu«n ouudaunun newcauun “Canon a: h �m1 . u“ m �‘ * M1” .4 m H m . a: It 3? , 67 Innsh OM: $.00), ' 13 $5 a ’1 an s �ms X"2’a3i ‘ as «mush: mum. u a: 10 �Inattfiuttau I schlnophr-ntt rayuhtuanrosiu it}; m n me ‘ 171 - as x'-8)~3h1 firth; p¢.60m. Pursuant: and 8 .1. .. 1* _ 5’ 5’ 53 35 51; V art-1‘11. .99 s > 22 1‘ �ms]: Mutts-ant awn-«um: human on stun m" haunt 01' lap-11.13““!!9mm . ant-cum - " - W1- mum xumm at man mm "finalising " .. ~ 1 8m mud» " . n: - W 5.10.“..- uts-«mug W ti m. n- w m u m E ‘0' M 0" '3' m a a a 00 IWmfi tar man a... a 94. .05 H vs: .01 �IAflLE G0 vnasxox 0! 333313033 BISCRARGfl BIAGEEflES 1- n¢prota1v¢ raaatinn flarciiatatic Portannlity 2. Anxiofiy Rotation 6. I IfiCfiARGE E AflBBSEB GEIIRSL CL‘fifiIFICAT . ?nyohanaaraa15 narcissistic Forv¢aa11ty Plyahounurccfiw Hareienistzc rattannlity Faruuaultty fruit Diufiurbcuc. Strainalutia rtrlantlity Alcahaltsn 0hrnu1¢ Infantile Pattonalihr; Sflflififin$h1¢ Paaaiva Aggrnaaivc Parsonllity Aleeholian flociopnzh1¢ Parawnnlity . Infantila Pernanality schisephrenio finaniion s¢h$ao~1££¢ut1vo typo Parsannlity Disturhiuua Diuturbanca schizophrenia Payabalin �IABLE ‘Gnflraattlvz 8311308 0? OLIRIGAL fiDRBITIfifl oa- Rauniugor 39¢IAL ADJEEIEEYT 7 it QIKB 3 3a Killeida fiflfifi Raaavnrfié atauvartd Inprnvad narxodly Inpravud Improvwfi Rumh fininpravwfi Imyruvnd nodnrntuly Inpruvul flainprovod slightly Inpretnfl ‘~ stancruax Imarnvad Uniaproved agggaena. ¢auwlnfin Rtmianinu :upmuvsa fluthuaaud (yr werua) Uninprovid �Iutnrinatitutiuuul ntfturauea in Solaatiuu at Iggltmnng . - .wt_ _m1e . w. m 21 h: :5 I! 33 6h 6 mm as 53 a x2 «52.3 a: ”guru 9 .1, �taggg Infiorinstatution’l Ditrcrnneil (5 o! 1n itiliilti Duratiuu of not thjuatu) month: in gougital natitutian x? 7*11 1? 0 aka 22 13 65 ”K 27 h? 31 unac 6? 2? 5 :90.6 a: -k n �taggg Intarinatttutional Birrnrcnuau in Dinahargu Ditgnaoin Dingnaatte fiatcgarius (Par agnt) Iantitutlou fl at; me :3 '23.8h a: sh fi { t 001 Payahoncnroaia aha Purtunuiity Disardvr Atrsuttru b3 52 s 952 ‘ an schitophronis 171: 85 V ‘ 52 as 22 Sh 29 16 �fitgfifi Inttrinotifintiennl Ditruranuts X 1n niachar a Evaluattan niacharga Evaluatiau {?ar cunt) Institution W RIB fiflflfi x2 «29.3 df 'h p,§.001 linororeé, Inpravgd Buinpruvod 1 80 19 :3 62 15 nnd Each 1 srgvod �. I. . ,2 ' ‘1‘ ’ , . ' ‘ .. ' ‘ ‘ v I 6) z 'u m 1&1 tum-au< 2" ‘ �WW“ m m, rum. tuna, m my» my. Int-m 1.. mm, mm», “I 3.9. mmwwww maxim, “My m, hM;WMfl~mdfi-meam mammals-nun; m, mmmmmmam. lulu .10 mwammamwmmam ume.r.wmwmumw am.» am Palm mm, W ‘w W T 01’ n.’ : 4‘bv at 1.2. �MWWMuM“WMW¢(Mm mmmfl)mmmnmmmm nmmammmmmmmm, wmaummnmmmmumm umw,mwwmnummm “Mama-mm“). ummmam mnmwxmwm wthatwm‘w Wmmwwmmu ammmum. hmmmmmwortm mummmwwmumwuw. hmmswdmnnmmmmzmmm* «.me mwmm mu �“w- 'ml‘tvflivamu «mtmummmtmwm mawwm‘mmmmm I. “mummumummum. mmwuumummwmmu umumwmummmm,w' ¢J.rwmmmwm.u'mmm mummmnummmmm mmW-umummmammcm nmwmummmmum mm smwummmwmmm. mu. mmmuunwmmmumw mmmwwm m,mmmmmumwn~mm .am‘m. ”mmmammm “.mummm mmummmmuammumm, m,mm3m,mummmwmruuu ’ummmuwaw,mamm mtmmmum-m. mama-rum �mmmmmummmmm (an ummmmmmamm. mamm,mwmmmmm. mm~Wmemmalm,mu ::*:W~*”M1m*~” “WW MWWW:WWW,W3W «mmm‘umwm madam-Worm ,I. W W,um.mmummmm �mam-.nmmmmmumm. wmmmumuwum, t.) W ;_ :' 'm ”A a m “1% M W mmwummt ammmmmmum . . «mumu‘m mum-«mm mafia-Wum‘ mmmumm mm,mmmmmmumm «WWWWMxm-uuwmm Wuamuwmmmm, maummmmumutm mmmummmwmm'mu ‘ E§~ �lvmmm.—v m- n. 5) mm mmmmmmmmmm ummmmwmm mmmmmmmmmmw. meta-am. mmammwmmumuvm ww_mmwmwutnam mmmflm. MWWummm «um. nun-mm mm'mumowmnmum. uwmnmmmmuumuwlmmm. mummuaamw. mamumum mummammlmmmwumammmmt ummmmwamdmmwmmmmm mmmwmrmmmmm «mmmummrmmm. (1mm. WI! mmammamm,m,m �, mwrm—W“ W" mmrsuummmmmumum gammy. W: Mm‘mflflmuthmiu maximammmmm. mwmmm I») Wm'mumam;nmunmm Mgumwummum,mwm. a: mumummummmuw s) m: m,uummnwmmmmmormm mum-m umammmum ummmnmmmwww,maflmm mmmmmuW-mmm a) ' nummammnwmmm.(ma: (1)9393 . ”gm: awdmnmumm mma‘mWIMMW. mini-muse: mmmr'mwnatwmprmuu masoummmmrmcnummmnmm‘ “tn-“aw hm,anpx-mtd wmmmrmwwmnmm-Mmum mm”! m,m>mwmmmmmuenu mmumm,uwnu¢mmmmmum 1 mummmmmrm. WWW“ 'msmmmwummormmm �mwmmwmumm mammal WQMMiWMWM“ wmmmmmmmmum m, ma—mwwmmnmmmmm‘ mummmuu‘mmmmwu mmmm,mwmm. mmmwmm,mmwm“ mummm-Wmm,mmnmmw ummgmmmaomwwm. 'ummumuw, mm,murm mwmuwmm(mwm rmmwwmfimmmxrm «mummnw,uapnwmp WWW hummus.anme Wit:Mwumwmmmamum MM? Mawufiamfi #mée twat HS? MMWWWQ WWQM Wfiflflfl 9W“. �MI ‘ . o‘lo'u mammmmummammm vamwmu-Wnamhuwum WW,‘WM1§WIIW{WUMMW www.mm-ammmmmmwm;m. W? m mummammmm mummmmmmmmmmm mum y‘ ammmmmummmmsm. mm mwmmmmmm,mmwmmuw mmmmewmuw,ummm �WW # mustmwmumunutmormnw. mmnzaurwmuumumummuua, “snowman-Man. mmmumnmutum Wqummxmot-ounmuumuuu o: than 'wmm.m Willi-Ind mam, um mum m toners, It mthmnhtmumutmlmttmm M m,mmmmamxuutmuhrzmmu the of exam mid. new swam M, mm mswhmnmmwmsm'smm,emm, mmm‘m,um,m.,mwwmmu,mm tnmwmmmumumummmo: flu mam mm tom of W new new. th; 13 .mwumanmummmumrmmth-thum‘mmmmmmm “Wummmmnmmmuuutm mew,mmmmmwwmmu unmummmmwmmmtua wuawmumuummmmmmmw If utmmm-mumnmmutwmmmr. mwmmuummmummmm mam,mmmmwmtma mm. WQMtMW,h-mttmmmmmm �gm. anmuquw. Mmumwntmmmwm nm,umm,mnmmmfimmuum. um,uuuu MMWMtwnmmm,dmahusm deMW‘Ifi-Wamum m,mmmmm~mm«m mnmummtm Mmmumu mmmmmnnmmmmmm,n mmnw.m¢mmmmumm. hwmw tin-mmmmmmmmmuwm gamma mmmwmmm mmmumwa mummw mmm,uuwmmtmmummm ma “stumwmmm'wammnmmw ammuuxmmaw'm‘ammmmw WWMH‘WW,‘WWWWK �”V 1 “.17.. —-m_ — mmmmummmmum- -Wamwwmmm gunman -w—rv-v-rvv a. 7—WWVVWWW_W—.__. ummnmmmm ”.mumww,‘ mmwwwwuwmm 7m "— WWW—v N . 0w _ “A .W ..,_,.mw_.—....,.r,.,.- ww-v. ”u'mm*w “Mwumw (M‘m‘ m W‘i ”thawum W mmmnmmwm,mwwmmm mmamnmmmammm mmmmmmummmw «mnwammmm,m~wmm awmmm,m,mmum “at mmm,mmmmmumm J t; " �",wwww w .7"- wry—«W... ..”___,__, » «- .w‘ 3...; Amwmmmnmmwm, umamwmmmmnmm www‘wvwa WW «p—w‘wmmvw—WW mmammm,mmmum WWW-w ”.7“ ~ .— WW. �TABLE I - Redesignation of Discharge Diagnoses r . .m. ._...- in... Menninger Discharge Diagnoses 1. Depressive reaction Narcissistic Personality General Classification Psychoneurosis & reaction Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait 2. Anxiety Narcissistic Personality Alcoholism Chronic Infantile Personality Passive Aggressive Personality Alcoholism Disturbance ' Sociopathic Personality Disturbance Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction Schizo-Affectige Type ~ " Schizophrenic Psychosis *4 . r ., . ' ~ �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL HILLSIDE HOSPITAL ' Social Ad ustment Recovered ‘1’ MASSACHUSETTS MENTAL HEALTH CENTER Recovered Improved Much Unimproved Improved Moderately Improved Unimproved Slightly Improved Character Structure fiproved Markedly Improved Improved Unimproved Unimproved Szgdrome' Complete Remission Improved Unchanged (or worse) �TABLE III InterhosEital Comparisons for Sociogsychological Variables Hillside Massachusetts Menninger Hospital Mental Health Hospital Center 7% 20 Social ’=121.S df=8 p<. 001 3h Class 3b 5 1970 : . ‘ _ - Age 58 _ _ S2 Y3=3o 9 dfuh p- n.s. 12—15X2'9 <12 Years of Education 16 ” 32% df-h + p<. 51% F 7 OS X"3 2 df-h9 ‘ WWW Score hl SO p<. 001 8 -‘ - --‘” ~ ~ -~ .. x “hm-ave - x-r' row-'t-t'r. «ma-Iv: «cr-r\+:w.-:.wv-'--vvwz- ~‘rwrwg ,..\IQ‘W~("" w my 3‘"5‘WM»WMP �TABLE IV Intel-hospital Differences in Treatment Variables Heminger Hospital Psychotherapy Treatment Duration of Hospitalization Sanatic -(-19— 21% Hillside Hospital -fll)- Husachnsetts Mental Health Center —(-D 36% h3 6h 36 -- 7-11 months 27 11 months Discharge Evaluatim Improved Improved 80 62 Unimproved 19 15 Affective Psychosis Diagnosis 28% Psycheneurosis and Personality Disorder 61 10 �:5” HOSPITAL STAY K ONE YEAR ;P.sTA¥ING,OVER ‘Pfi 8‘1 . 20329 I ~ 6 36' “ ‘ M M - 73 A_ w Hillside Menhinger -‘ . , '61 in I ' BY AGE j :‘35 ~7f 6 I I ‘ 3,0 2.5,; - . 2’0 , 0 . . , 0 0 �7142b, ’- ”‘7‘; aceiopsyuhelogieal 13:11:00 of Pnyuhintric Trontnoat in fire. Voluntary loupttuls Robert L. Iain, P&.D.fi, in: Pollack, Ph.D. lathauxol stag-1, Ph.D. and an: Pink, 3.5. tho Bcpartlont of InpurtHOItal fuybhtntry, lillutdn fro. 61¢: Oaks. L.I., 3.1. loapttnl, Atdud, in parfi. by 29.3% lt-IOOI or the latiounl InItStn‘c’ of labial It‘l‘h. 8.8. ,ublic Inllth aorticag and tho Iguasu County Keats: Bealth Beard. the cacpcrntion of tho stuff. a: the nan-nonalctta mantel Italth Ccntar and the C.?. Hanninacr Nauorial flospital 13 grutctully nokaculodcod. irresant Address: Rivision of Paynhiatry, Haatofioro Hoapital. l.!. 67, l.!. 7!!!! h/62 �In pruvioua coat-payohologionl s‘udioa or leapitcl papulntion a. obncrvcd educatiou,plutu of birth aenlu rut. Iignitiountly 01 galact1on and th‘t scar. fit. 3:11.1do tuck a-pccta an :30, on the calitoruiu I Pointed ‘0 tbs trcntncut variation or trontumut. «11:10.1 disuse-1.. dura‘iou o: hacpitaliuatton gut treatment cytltation. It was ltggoutad at thut tins that tho can. influenco or noelal variation on the treat-cut process Inuit b. observed upon: institutions. to tact this auggontion a: wall as to roylieuto the stud: within inntitutiona, tho prusont study of three hoapitell val undattakta. In a. their study or flu Baron panhin‘ric mutant populsticu. Holliaguhoad and Budlizh rapertud alanifiiaat rtlntlonthlyu button» smut” an individual'a vanities 1n thu 0001.1 pmduu tented 111”". two: at amend uurdcra a: nu- ma «nu-n or pay-untu- duo troatnont cdnintutarod economic status or and tho ( upon tho ). fl. influoaeo o: patton‘ availability or trcnt1ag peruouuol �.-9. van nut fixalndod in this. :tudlua. 1b tact the :01. of coats: factors in tho triatunnt.or hoapttaltaod patients inflaptnddnt or puticnt'l tibiae-a 3nd dvcalnbillty of trnatacnta, I patiout burv.y In: undortakcn It lillolda 1§§7. in Ia thza‘hcapita\. a variaty’ct firockuuut Ibmyifitl ptychoéhnrnpy and organic Ind-n, including individual thorupiua are attllahlo to all pattints rlgardlosu or tags: abilzhy fie pay. In in. tillaido study. Ian. canonfiton and 31-00 at birth cur. utgnttlnuafily nouontatcd ut‘h chain. of trudaaont, duration at honpatglicntaan. alsuxeul diachnrxo aval‘ntiou Ind diagnonlt ( ). It Ill ohncvvod that patiuntn hounltnliuod for th- Ihortnus plrild aura the oldest, had tn. loant cane.» tic: :36 «are taut liktly to bats hut: foreign hnvu. The: wit. prudoulnnntly £rc-find by ouuvulutvo ‘horipy and rocuivnd it. not. fuvauahla diachnrsn ratinga. Ibnngur. unttv. horn and not. sdnaatcd paticnza.uuro hospitalinod fiho lenzuce. puyahofihcrnéy and goaorallr roaotvod trantnd prilntlly fir it: 90020! dischargo rattaga. it. 011310.: (Inter: 0‘3. 51:0 rtluted ta n I.nauru of starcatrpy, tn. culttornia r 80.1. ( ). lxahar I canton Int. tor. o:%ca tound an pu$1onts diagnccod an invalullannl pagthcutn, ruturrua far nonntto shorapy. and hasvttaltaad :91 unartor parted, and nor- Qtttu Uflfi vitae as much Anymovod or roger-rod. it in. 6.01301 to tupont tin 195? .111016. study uuployiug tha nan. procaaursu nnd nongurrtntly ta axteué who obstrvutaona I _ . �.3lnatitnttenu vtth roopact to social alsas. 33o. oduottioa and I to tho scorn. find to relate than. pats-at charactorlttica trtct-ont variahlqs of type if troutsont. duration at hospitalisation, diagnosis A and Ginsburg. evaluation. m enact: a! :11 voluntary. .dult patient. in roatdoaco in than. tuititattona was nadortakou in January 1959. flh$10 lcln1n¢¢r and Hillatdo Hospitals hnd ‘luatary pationta aalr. t 3:311 avatar at tho-e at Danton were anntguod by tho tor psychiatric avalnntton, or war. nc-bcta at aohisophroaxe stat. hounttql group tralalorrod 3 can’t- annual. ter a optoitia ruloarch product. Thane pationta war. cxoludad from the study banana. at tacit non-vuluntcry ntntun. Inch pnttent III :17.» th- cglitoraiu ligation tutti: lctar r 39.1. ( ) on the OOBIII any. the rooordo or dilohnrgod patient- voro untlyucd to dotorninu tho c.0131 and psychiatric factor- ar the otudy. For a mutant. of $03111 glass, the ficlliucahoud �.‘5- 2-tuetor ind-x was 3.06 t of 173 putllatn at ). Thu 81113140. zoo study population consisted at lbaalncor and 95 at ti. rnlationu or Untouchuootta Haltnl flcalth cantor (nuns). Tho study inelndcd «lamination a: in. social to th- paychlutrtu wart-hlcu within each institution, 2h... as wall as butunua inafiltatlons. difficult, hcunvor, boon-no fora-con discunncd below. comparisons were at variouqnnthodologlenl d1:- 9h... difficulttca var. nosQ Infkfld 1n the iatrnhaupitnl anupnrasean, and accordingly, in tin unnlynou a: p-yuhlntpta varinhloc emphasis will be lantttutiana, with citation plannd on tho daft-ronaus §atvoen or lb. intra-tnotltutiannl tronde. Whoa tho otruotnru rcportlnc studs-u fro! a lone institution, at tho houpltul 1- %ahoa tar grunt-d. and 01th:: ignored or Icnttunud briefly. Houwvur, in studying a atranco �a. institutien I“. “at will. I. and author t6 :ttcuptias canaarablo ant: ya. in of tho my allot-«cu but.” “autumn. tclcotod than. tuttituttont an eolpurablo in ‘bnchlag, rtaoarch, and troatunut pryxruuu, we tinc that tho: are unalika atrnct‘rolly in v.11 think influanca tn. data at the study. specific prohlona were notcd 1n dastgnatioul or type a: trnstu-nt, diaguont1a turns and avuluatiau or trontnnnt outcono. a) 90:1 ation a! a at cntlant: Th- critorin for danagatting that a paticut raceiv'd 'pcychotharupy' dirt-90¢ along an natiwtulu, Idling “Remus: «unification aux-nun. At floaningcr Hospital puyuhothurtpy use designated a trogtnaat qdninictcrod an a pro-criytiou ball: by a stat! pcyvhiafiriat, for which th- pattont via chtrgud a too. fienatone with tho ptynhintrta rnnidunt were considered or routine unaiaiutrattva pationt aura. part .0 �.j. it Hillside lsspiisl psyshsthsrspy was astinsd ss viih tho psychistrio rssidsnt. star! trsstasut ssssioas psychiatrisss.¢id not trssii patisuts, but rsstristsd thsir activities to supervising tbs residsnt physicians. it was ths Massachusetts xsntsl fisslth csntsr payohothsrspy assignstsd ss s functiea or many disoiplinss -- psyuhu istris rssidsnts, psychologists. socisi worksrs. nurses sad msdiasi studsats. Portal records a: sash ssssions wars nos routinely insiuded in the patisnfi's rscorfi and to ssesrisin which pstisnts rseoivsd psychotherapy. it was nocsssnrr for this study toss to intorviss tbs reaidsuis in churns washers of o: ssch cssa. b) n ' asis: individual institutionsl disguostic stylus slso Isds soupsrissns difficult. it lbsnisgsr lsspitsl disgussss supisysd ths sultipis svslustss fists caucus asses-sadsd by ths Aussiosn Psychisiric Association hsih Hillsids sad asstsu sun-piss sails toil-Ila usicsry systsss. assorsl st discussss tron lsssiussr sss listsd in 2:51. I, �-3with our ausgaatad aonvarazana into catacortaa nonparabla to that of tha nth-r tan inatttationa. Thaaa convaratona at. an unavoidahla aaaraa of distortion. (statlar abaarva- taona hava baan rapartad by Paaaaaatak and hia aaaocxataa ( ) who indicata that diagnoaaa within tho aaaa inatitatiaa ara alao valnarabla to individual dixtaraacaa anon: ataxiaara). Tabla I fi---“3) ntgoggg‘a gating; of Igggovaaaatn gravalant varied 1n Iattnga a: 1n— foraat and datatl. rho diauharga rating at nanninaar loapxtal aaa tripartite with a aaparata avaluattaa for social aharaatarolaalaal and ayndraaa ahanaaa. I111a1da > Raapttal and flaaaaahnaatta aantal Iaalth cantor had aloha: ntiuga I! in at aaeh which it "a difficult to aaaaaa the ontfibatton taetcr of tha Haaaiaxar ayutaa (Tabla II). for this atudy tho Iaaningar ayudraua rating aaa couparad to tha global ratinaa of tha athar iaatltattana. �.9. fibl. I! 2. aootgzgzggologiog; Vagiablaa Ina diatrtbattan at the variation of aooial 01a... aga, adacattoa and calttornia institution: in praaautad 1n r saala scar: along tha taro. tabla III. a) figg§.;_g;§ggn tiara uaa a Iarkad dittaranaa in tho aaaial clans coup-attic: at tho thraa inatttattona. Nautilus: loapttal tha reputation was At pradantnantly app-r class; at Hillatda laapttal Itddla alas-3 and at laaaaahuaatta lantal Baalth cantar, pvadaainantly 101a: alaaa. h) 553: that. war. as airfaronaaa in ago «attribu- patulattaao. tion in tho institutional a) Eduggtions rho populatzoaa dxttarad 1: tanta- ttaaal attatnlaat, 11th pattaata at naauiagar leapital having not. yaara at educattou than than. at Baa-annuaatta lautal laalth Cantat. 33110 kl ya: want at tho pattanta at also �-19- ha: aat couplutad high ottool, only and 23 per cent 32 par cont at Hillsidt nt loaningur did not graduate. Bittflrcnccs é) {nggggy in ‘3. distributtcu or can on tho annoy-nu I 80.1.. mo obs-nu. titty-cu V 9.: can: or lbnnancor puttautn had only night par cont I In coor¢n below 30, gnu scorn. of 50 or show. ~- thn higher accrue 5.13: associated with highor dcgruos or stereotypy. eaatraat, gt I Inuit, At '1‘! I Boston trout: 9.! coat unto hula: and forty-two par 3.9% had scores Hillside thirtybonc paw at 30 on tho 50 or nor¢. south! the vationta had I uaorol bolaw 30 sad otzhtatn por goat ubOVt 50. In nun-cry, .09131 class ' its a: the ptpllatiun val oblorvcd :3 uncut arr-nun on anticipatod dittorouetu in prudaninalt fit. r 30:10. 2h. 1a ago mutual dtutrlhatioa d1£rtrcnoon thus par-1t tho the institationa. hum-cat «14 not I011 on cigo an: mum“ 11:20:. Then. stair a: troutncut variables along �sum Wm fieduaigflgtion a; D§ge§gggg gag‘noggs M" an mmm nuproncivo reaction I. flnrczsaiatic Foraonality Payehanuaroniu 8. Anxiety reaction larezsalatto Personality 3. lavas-oistto Personality #- latoisoaltac Puruonaltty tlaoholiuu Chronic Infantilo Portolnlity S. Fusttvc Asgruacivc ’oroonality Alaaholxaa 6. Infantila Personality Sohiuophrunsc Ioaotaun antitanltfucttg. typo Psynhalturoais ' Poruouulity fruit niatnrhanco sociopathic Paraanality niufilrbunoo Seatapnthio Pirwnxrllfiy fiiaturbanao achisnphrauic Flywheels �aggzggattvo figttugg gt glgngog; geudition IIIIIHGII BOSPIZIL 33218132 HOSPITAL fillfllfiflflalfifl gg‘bffi CENTRE locovurnd loaovorod Each lproved Eark¢d1y Improved Ingrovod Hadnratoly Inprovod Unznprevod slightly Inprovcd Enimproved 60I§10to admission Ilprlvud Fuehnnged {or were.) HEHYIL �ammonia). muggy»souguzcholofiut 1'3; Yuan“ Hanna. ’nuluhmutn Ear-pun luau). Rum: liming" 30-pin). Gum 31$ 75 3% ' Saul c1». . Au 51 20 as 1? 35 13 1 3h 28 0 S 28 19$ 19! se 59 22 , p-n.l. 23 at Ian “mutton 33-9.? - ' 5.0!. W005 X..3909 did: 9‘ a 001 �m m. _ . i typo of '1'th Psychotherapy W mum t £10,111th manhunt:- mmani 215 Sal-nu 1:3 mm» 36 H1111“. Baum. ’ ; my. mm 36% 21a: 63; 68 - . B �.113. 7:23;;gt510 frogtysnt Vagiuhlog a) Soloetton or front-onto than: tultltucionn, taunt yattoutn 3‘ Ian-13:0: uoapttal rucctvcd sciatic thornpr than n$ flail-14. or "Ric, (fable 2'). caucnrron£1y a cnnllur parenting. or the nuaatuucr patttnia vita 013.004 to rocctvlng payche‘horupyp with a 132:. author (36 Iilica tor-- of treats-at. was an £111.14. lotpttnl - that. spacial doutcuataon tor Itliou therapies sud pationtn are 01:13:21.6 :- rocolvtuc payoho‘hcrapy Iont also. Iafih pattbnt psychiatrist for at nook. 1% pit cant) rteotving :- 10.1% II n priusry trout- tohcdnlod to so. u valid-mt tar... ouoohalt hour session: per 2h; pcrooafiacc 0: pa‘tou‘o rocotvtnu lunatic thorupy, at louatuscr natpltnl (3h!) 1. Isgntttcan‘ly 1-3: than n‘ ot‘hor at tho 0th.! in. houpttalu. lfibflt patient. ulnacad II cahtxophrcntn. thnr. was no atrrurunoo along houpltalo. for 10.30; a: such pationt' at each hospital recoivod notatio for.» of troatnont during �-13. It. hpnplltllsnfilon. 1: hated on $ho thé altroroaogu anon: laltlfiutloua dittorlng attitude. lounrdo gallant; oloacltlod a. puyohonourotlo, bahavlor diaordor sad dcprocnlvn payohoaln. its turn. llotltutlonl b)‘a3glgggg_g‘_lglg;§.;§g§§§ggs «11:09.4 with racy-ct lo pullout'n lcnuth 0: its: (2331. IV). loaning-r Hospital patlualo v.9. hocpltalluod least-t. with 653 a! pntlnnta rounlnlln for witlvu mouth. or loan. cou- ‘1 93304 to 31 par cant lb. 8111.140 pattcntl and only 5 91-: cast or £30.. Qt the lhcauohnnottn lontal loalth Ooutnr. fli- Iodd any of tho clovgn tenth: lull-id. group II but»: urea will. two-thirds of the diachgrsod within Boston and valiant: cor. .1: tenth: of hoayllalllatlaa. In cash hospital. tout pntlanta arc ovqltatod ufi tho tan. or discharuu ca 'lnprovcd* (tnblo 11). ll lounlugar loopttal. havuvur. a blunt: poroautnco (l9!) 0: pttluutn turn rated II 'Inluprovud* and only a tingle psfiluat �.13. woo oollod 'sosovosod' or 'sooh ispsovod'. rho hishost possontoso or “rooovosod' or “soon iopsovod' sstinas (881) sod tho ioooot provostioo st at ‘osiopsovod' (10$) ooso (bond Boston. d) ggg‘ggggg; For otstistissl ossiysis throo diogaostis groupings soso nods: sohioophrouis, ottostivo disosdoss, sad poyohonoorosis sud porosasiity disssdoss (roblo IV). tho diocoostio proportions of pstiosts within thoso groups loss sinilss tor lilisido sad lostoo in that slightly ovor holt discussod as sshisophssnio sad oppsouiootoiy oso-qoostor os psychooonrosio or ottootivo disordos. In sootssst ot Housings: loopitoi, poyoholsosooio sad possouslity dioosdor to: oooooatod . ovos n 1. lo titty pot O 0 o i coat of tho popslstion. 1 Probl Vsriols nothodoiosieol problsss vitistod intro-hospital ototi'otisol sou-potions. lost pro-issue. on tho has of loosinxtul out-or! ssitorio for subdivision or populstions. �-m- ft: oxaaplc. in ecuparo instituiioau in rpiniiou to Inacth or hospital Iiay, vuriouu eat-ct: varied: var. iriod uni n03. it lanaiacar lonvisui. Clio-04 for coupIr-blo distributioao. oat-quarto: at tho pationto runaiaod turn: Ina SII~thrdl taro than tunivo Inathu. its: auto: suntan, it Insoashtlottn ncnini laaiih easier, in couttuot. 70! at :11 paiioatu ro- ttinod 103! ill: ncvca months, and only 6’ :99. than tapivc Ionian. Anothtr aspect III tho oouatriotica of tutoroconoity or the population sulpic. In in. Boston group, tho crucial rooturoh patient. and th- uonrt roturrais sure hath dnlotod. in contra-tins tho_1957 and 1959 xiii-id. papuiutioa, II ob-orvad n uicaitieant accr.ano in it. an. o: oomvuinivo ihorapy its and an at pniiulia under tho :3. o: to. II. number a: cit-r patiouta, inure... in the coupurnhiiiiy a: as. group: in tho turn. halpitulo in this I‘Id’ lakes ihat similar pron-cunt lay lattes rumba! have oocarrod in it 113.17 in. fire-cat and lonuiacor populatioan. than ducrcioina tn. rang. �.13., e: file diecueetie, treatment In verieblee. end ecneetieuel elnttleu, Iteeiug tutorletlea eeelel oleee an lefierntuetaeqlee e teeter in vitietlng £ntre-heep1te1 eelperteeae with sate variable. In deteretetux eeetel eleee enere wee tater-eeiee W eveileble for 29! e! petieute. thleeetrteble eeeee 371 occurred where the edncetlen o: the huebend e! e heueea site Or the tether e: e miner wee ne‘ reeorded. alibi: these letheeelegteel ltnttettene. e number 0: the latte-heepltel eelperleele rare of eizatfleenee. With recerd to selection or treetleut. age end I eeere were significantly releted et Healteger Ieepltel (elder higher r aom pan-nu therapy) end 1 Score wee were frequently end unsung eon“. releted te zreetnen‘ eeleetion et I111e14e. In “eaten-u evaluation. t. ere an e teatime: tor older petten‘e te be re‘ed better then younger euee et lilletde' end Benton; but at leantncer there wee en eppeette trend. �-15... with oldcr ptttoato nor. likely $0 be rated tninprovud; finial: 0: .3. Loasth n: haupttalllnzttn and tho causation III. loup¢tols . rolutod st .ai Itll-tdo tho youugur IB“XCOI oduoatod putts-ta riulntu; tar tin luacont parted. that. dunonatrntod In in Danica (13b1pa$1sa$s Ind-r rilntionahipn 1% bo‘h tho Honnlatcr un‘ V) Whiz- such ruluttoanhtpn two hoart‘nla, riot. a. vnttcatl I 01:11:: it. trail 070: be. but 13 noted 1&1 a: as. to taunt: loucor than/n 70.2. 31.11:: It. for education, and for diacuousl. 30%04 abusinzor noupttcl the poroautaco at pationtn with fiho dinxnoain at ouhtaophrausu.uho wore hoapttalinod ova: an. yin: II. 911. at ltlllld. [capital laltal luulth cantor 7!. C...”rablo V 35‘ and at luaucshlcotto �# .W IGRPI‘I‘IL ”fill“a; 0: 53! an. Mon to 3H! 3'! £63 21! £32 6501!? 8131136 0785 W . ‘0 .35...“ M 81. ha 73 36 6 30*” 61 30 6 ho-M so to o 50 o 36 o o tan-29 11: �.17In thin nonpartgon of this. vquatary payhhtntria hocpt‘alc we have obs-trad significant tu$ar1act1tutzoanl diff-roast. or pufitcu:a tn ‘hc social vurxabznt or want. a: oduaa$1on tad .00131' .1305, But not .50: a: itafiribufiinu o: calitoruta r anal. sacral; Ind ta ouch a! fiho irnuIn-n$ variation ~~ duration at haupl‘oltunitaa, noloo‘ton at invaalsl§a and dia‘rtbutaona a: (taunt... uni dischargu Isuzunttnnt. in. oxpoctn‘ion fihat the institutton carving «99¢! G1.il pattnuts vault but. the long-at durattou o: otur: I uschu! pvoporttan a: payuholourotao Gianna... and nor: ooupluu diagnosfific nah-nuts; lunar preporttoa a! patients requiring organs. turn. or thavnpwa and peasant ditchuruu 1:31:30 use. each contarlnd. 81-41331!) tho tuctttution serving lav-r clan- putioata lvtnoad Ibortar purtoda at hocpttnllnutita, 10w proportaaua at pay-honaurotio cinema-us. and bot‘ar 41:03.13. uvnllafiaonl. In addition, tho diatrihitt-II at r 30.1. scorn. anon; tho that. hn0p1%aln tollaund tic arising: atllaidc it‘d: in that low accruuurc lost uhnrtn%¢rtnt1u at tho upper :1... group, and high score: at the lava! 0130-. 1951 mam. n: mu»by ropltoafiaon 3% Islamic; $fl 1959. a: null no tntvn—tua‘ttuttonal ‘ a. “mg a «m:- m am analysts 5‘ tbs ofih'r fin. holpttalo. '0 VII. intuucooutul. It. ‘33. tuttod to anhlcv: a‘a‘tn‘ionl Itgnittonacu. in part huaunuo at variomy or no‘hodologtcal prohluun. bnfi th- trcudu of tho lafia I?! 01-11:: to the ortxtaal study. . �.18. wall- theee etedlee have egeln eupheeleed the rele et eeeiel tedbre 1n peyehletrle tees-eat, we neat. have been lepreeeed by eke letheeelezleel preble-e e: etedleepereee laeeltetlene. theee leetltelleee were eeleeted tee their edeeetlenel leederehlp end eke expeetetlea thee the recorded vertehlee would be eleerly defined. our dirtteelelee 1a errlvtec et eoapereble dete ere invertent euee to the preblee o: the eeeventlenel eee e: eeeperettve eeetletloe. eepeelelly treqeene in the evelietlel e: peyehleerie thereplee. ihe eee e: dleeherze retinal, alecueeele eleeeee or length or heepltelleetlen ee craterle in therapeutic eveluetleue er ldeatltleetlen the e: eeepereblle populetloae ere enhaece te exceeelve error enleee eke tee stainletrettve peteerne. lnetlteeleee ere eleerly eetehed The peredexleel neenre e: e fellere te eeeeent for tneeltelleeel idleeyaereelee be eeea 1: e llterel :nterpretetlee e: the 1e to observation or sale etedy. fhe Refinance! neepllel bee the leet highly trelued �.19. par-onuol conducting trontuant thick to applied fur iudtvtda Optimal port-dd utlly Outta-a. ti. 10:33 propnrticn at tinny in population. with diagnaaud 1: an unfavorahlo prognostic grasp (nahtnophron1n1 . - and rut. tn. proportion of ruportod (ivornblc traatlont rouulta 1. tin recruit. It lintll lanlth 10.3% cantor, 1a contra-t, that. th-rnpiltn apply trout-nuts tor its atlluahunuttu an administruttvaly t'utnod lilatod potted, to a populntlou with a hithcr pruportton diagnouud an tahtuophrunta. the propor$1ou or Ihorco rafianaa :- than. dhnIrVn$£ann tarornhlc III-It: 41-- otgnatto-ntly grants!) 1‘ to yrobnhlo do not garlogs %hu% the thirapoutlo efficacy a! «a... tnltatuttann. but ludioutnn differ-aces 1n oritnrtn or ilprflvnncat. this luck of clarity in dilanos%1c Ichcuatn and 130.!- pnrthtlity or pnyuhiatrac truinant 1:31.310: :10. load. panic tn tn. attc-ptcd comparative stanzas 0: psychiatric tbcrapioa. for tun-win. tho rlIh or roounfirntlurcn o: �.26- hioleslatl caloutlltl to contlrn obnorvatloaa and. 1: othor laboratorlou In: bu as such a rotlcntlau o: dittoruaec. in popnlttloau. payehlnlrlo orltarln,'g§g, an fallout.- 1: the original hapothcuon. the widcaprhad “cohltophr'uln' or ‘puyahououroslu' II. £0 at Utah turn. as caplet. tho ohnngoa in payuhdbatonl or blclogluol tosGIrOI with mental 111:... ha. 1.! to a totals. burdcnod by nasatSVI result: (lullnk). coat Ijrkad ruouutly in lb. atatlletlng stadium at taste: in anhinophruals. physiological ~~ and tho lneonparnblllty bohuvlornl corrolntlona Icon 1. (runkuuulnln) and meantiou threshold tutti. Sven I It'll at the t3. Incholyl turn I 1.111 ohnurvntloa to b. roportod from on. allnlo. in v. is!- II‘hOdl twillablo to doccrlba povulctluno adoquntol: lo provido 1 00.34 ountlrun‘lon? 270: than. obocrvntiaal at icllavu ao‘, and concludn tint lucrtnuoa attention list to p.16 to the nothodlocloal problana of clnaaltylix substatby 'objoativo' criteria. rcthor thus ta. pro-oat lathe!- uhlnh,uppo-r to ho so highly dcponloat an inatttutlonnl �-g1. :ad ohatrvur nttiiudul, and tho nociepoyuhoiegieul nspuctc or it. thorupintapnsiont intcraction. studio: :13. highlight the situate of changing !hnuu populatidns on Iinilnr mind: than italics. lillnido lbnpitsl rho peasant that: rich! soaiopayuholocicai~troatlcat rclntioachipu it. 1957. rufloo‘inc. I. btliovu, a constriction in tho typo. fit trout-out. and th- .30 runs. at tho patiuntu. flora in; a nicnitiegnt rnduoiiou in the inure... in Icflocting anon oduontionai iovdi an 13010... in noun use, and as o: its population, it. nunbar of aJQIOlotnt and 33.33 aduli patients. baring in. in. yaw! purine, that. can 31.0 a untied voduoiion in tho incruasc in czalndnd was iii. it. nan u:- o: couvuluivv ihar:py chain. in the 1957 Itudy, wail. tho aoliacnt lunatic truatloat or thin study. at in. pvt-ant study, and a z: at poyuhatropic 4213!. art; ihorupy In. :- s irontlaat ‘OOOp‘QEQO and dittttcat ii had both a crcntcr it it the stuff psychological mooning than can. vulaivu incrlpr. Ind hearing, parhapc a diff-punt mulbioachip to attic! variablnn. its availability at an ottoctivcihorupy �9.2;. (or viauruua tout tor sinusitiaation) nay liaidbo in. intin-uco or uoeial «in-I vurinhlcu lliiin‘ahnad Ina lodiich (bund clans aad typo a: truttnayt did for tho oehiuophroaiaa. 317.3 dial-cu, than in n rolatittly ottaoiivu, n0 on iruatnnut. Etna. rulntion intros: loci-1 tar attentivt 'fhil payohoni: but tho: aficcontc that trail-at mils“. it, which inaxp-nnivu and tachaically for a i. lilplo. 01.0: ditfnruueun nay ho Podtcld, but not niiuiaafiod‘. 2:11. that. inter-hospital dittoroncoo 8‘! he loak¢d initial liliallc inirn-houpitai ‘ um. um peanuts.» and It. iatcrauiin DIOOOIIOI and expectation! of tho atndy. Xt_io our i-pr03Ii0I. tron-out mm “bun-hip. 1.9301: Invited iron tint: and authoriticu it. .ttiiudoo uiilil 0.83 institution.‘ thug. duration or patient tiny. Ginsburg. rating, type or transient anniniotcrod ind diagnosis are In �-52.. dutcrltuod an Inch by ‘30 attitude 6! the phyuiotnn and thy hanpttal niltcn 1a which tho‘pcsinlt rind: hilonlt. a: In: acuitollntion o: uyupttu or history which in In: pros¢nt. snob ralntionshapa ooaditlna tiara will he host lurkod in than. psychiatric that. diagnostic critnrin at. lunn‘ 39.01119. 5‘3‘, tho obaaoQavu «9:53:13 aloostntod with 4300.... hats: arcs-10 inpuirI-nt arc ahacnt, at an an achisuphrcuin. plynhancurolsn, and pcraouazt‘y and bohavior disordcrc. Vain: conditacnn or anbtcnitr tbs obcurvor'l internal can. (ntttwudal. alpoctttionl) hood-o and by clansiticatton hamlet, ( tic ball. for pyrotptton ). this via: 31.1%: and 1.1!“! 1!: was clonrly douonu$rutcd flair study of vandal in dingao¢1u within a £13315 institution. Th0: dbuurvod that 1: pnttnuts rials-1: assign-d to ditturoaf lords inns powulattonl d1! not 6111.: in sang it Idlllltin, Inrttal otntnn. vasecttla. as. or contain... stxusftoaa$ 41:211-300. 41¢ occur, hcvcvnr. 1- 13014030. of diagnoses anon; tItIO �5""? mg “m ammuuun- in on an. u that unman- mo notably at “he.“ in the mmu». I. an.“ they at largely "nuan- of tho “«Nu. and uts“: at the Ian-1:0". �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary HoSpitals Robert L. Kahn, Ph.D.*, Max Pollack, Ph.D. Nathaniel Siegel, Ph.D. and Max From M.D. the Department of EXperimental Psychiatry, Hillside Hospital, N.Y. L.I., Aided, in part, Mental U.S. ‘Glen Oaks, Fink, Health, Mental Health Board. by grant MY-2092 of the National Institute of Public Health Service; and the Nassau County cosperation of the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully The acknowledged. NOYI * Present Address: Division of Psychiatry, Montefiore HOSpital, NOYO 67, �Recent community studies have demonstrated relationship between social factors and psychiatric treatment. In their study of the New Haven psychiatric patient population, Hollingshead and Redlich reported significant relationships between an individual's position in the social class structure and the prevalence of treated illness, types a of diagnosed disorders and kinds and duration of psychiatric treatment administered (3). The influence of patient economic status upon the availability of treating personnel, however, was not excluded in these studies. To test the role of social factors in the treatment of hospitalized patients independent of patient's finances and availability of treatments, a survey was undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy and organic therapies are available to all patients regardless of their ability to pay. In the Hillside studies (h,S) it that patients hospitalized for the shortest period were the oldest, had the least education and were most likely to have been foreign born. The older, less educated patients were predominantly treated by convulsive therapy and received the more favorable discharge ratings. Younger, native born and more educated patients were hospitalized the longest, treated primarily by psychotherapy and generally received the poorer discharge ratings. The clinical factors were also related to a measure of stereotypy, the California F Scale (1,6). Higher F scores, i.e., greater stereotypy, were often found in patients was observed �-2diagnosed as involutional psychosis who were referred for somatic therapy, hospitalized for a shorter period, and more often were rated as much improved or recovered. Another hypothesis developed at this time was that differences in various aspects of psychiatric treatment among hospitals should show the same relationship to social factors as noted within Hillside Hospital. To test this suggestion it was decided to employ the procedures of the 195? Hillside study in three institutions -Hillside Hospital, the C.F. Menninger Memorial Hospital of Topeka and the Massachusetts Mental Health Center of Boston. These institutions were selected with the expectation that they served patients of different social classes. It was anticipated that in these hospitals there would be a similarity in attitude towards treatment and education. Each is a teaching hospital with a full time supervisory staff and active research departments. They emphasize psychoanalytically-oriented psychotherapy but provide other treatments such as somatic therapies and active programs of milieu therapy. Each stresses short-term treatment of voluntary patients and does not provide custodial care. The specific aims of this study were to determine the population characteristics of the three institutions with respect to social class, age, education and F score: and to relate these characteristics to the treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions. �-3METHOD these in residence in adult patients census of all voluntary, and Menninger While 1959. institutions was undertaken in January, of number small a only, Hillside Hospitals had voluntary patients (MMHC) assigned were Center Health Mental those at the Massachusetts chronic a of members Or were by the courts for psychiatric evaluation a for specific transferred group schizophrenic state hospital from the study excluded These were research project. patients A the patient because of their non-voluntary status. the months later F Eighteen California scale on the census day. social the determine to examined were records of discharged patients and psychiatric factors of the study. For a measure of social class, Each was given and education of score the Hollingshead 2-factor index - weighted 173 of consisted The study population occupation - was used (2). 95 Massachusetts the and at 100 Menninger at patients at Hillside, a Mental Health Center. social the of of the relations examination included study to the psychiatric variables within each institution as well as The between institutions. These comparisons were difficult however, These below. discussed differences because of various methodological and comparisons, marked the most in intrahospital difficulties were will emphasis variables of the in analyses psychiatric accordingly, be placed on the differences between institutions with citation of to missing led also These difficulties trends. intrainstitutiOnal information for some data, which is reflected in the varying population sample sizes in the tables. �RESULTS A. Inter-hosEital Comparisons l. Methodological Problems institution, the reporting studies ignored and either granted for taken is of the hospital structure institution a strange studying in or mentioned briefly. However, the of made aware is one data comparable and attempting to gather these selected we While institutions. between differences many pro— treatment and research teaching, in comparable as institutions wh ways in structurally unlike were they found that we grams, in noted were problems Sp‘cific the of study. influenced the data the and classes diagnostic of treatment, of type the designation outcome. treatment of evaluation desigfor The criteria 8) Designation of 212s of Treatment: the among differed "psychotherapy" received a nating that patient When from a home difficult. classification in uniformity institutions, making treatment as designated was At Menninger Heepital psychotherapy for a psychiatrist staff by basis a on prescription administered the psychiatric with Sessions a fee. which the¢patient was charged care. patient administrative of routine considered part were resident treatment as defined was At Hillside Hospital psychotherapy did Staff psychiatrists resident. sessions with the psychiatric to supervising activities their not treat patients, but restricted charged. were fees No additional the resident physicians. �-5At the Massachusetts Mental Health Center psychotherapy was designated as a function of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students. Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident in charge of each case. b) Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative data scheme recommended by the American PsychiaMMHC and both while followed unitary Association Hillside tric systems. Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. c) Discharge Ratings of Improvement: Ratings of improvement at the three hospitals varied in format and detail. rating at Menninger Hospital was tripartite with discharge separate evalua- The a tion for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study-tho Meaninger syndrome �rating was c Sociopsychological Variables age, of social class, variables the of The distribution institutions three the among F Scale score and California education 2. is presented in Table III. M social the in difference a) Social Class: Hospital Menninger At institutions. three the of class composition Hospital, Hillside at class; upper predominantly was the population There was a marked predominantly Center, Health Mental Massachusetts and at middle class; lower class. b) Age: There were no differences in age institutional populations. distribution in the attaineducational in differed 0) Education: The populations Menninger at education of more years having with patients ment, hl While per Center. Health Mental Massachusetts than at Hospital 32 only school, high MMHC completed not had Cent of the patients at not Menninger graduate. did cent at 23 and per Hillside at cent per of distribution the in differences F Score: Significant d) cent per Fifty-one observed. F were Scale California the scores on �-7cent and eight per only below 30, scores of Menninger patients had associated F being scores with scores of 50 or above -- the higher thirtyHillside at In contrast, with higher degrees of stereotypy. MMHC while at 30 below F had scores one per cent of the patients F 30. below were cent only twenty per the of class social the in differences Thus, the anticipated These differScale. educational attainment and performance of relation the concerning the hypothesis testing permit ences insti— the among variables treatment the to factors sociopsychological on the F tutions. 3. Variables Treatment Psychiatric Among Treatment: of a) Selection institutions, significant- therapy somatic received Hospital Menninger at fewer patients ly IV. Table shown in MMHC (68%) as than at Hillside (6h%) or differed The institutions three b) Duration of Hospitalization: IV). (Table of stay markedly with respect to patient's length longest, hospitalized were Menninger Hospital patients cent 31 to compared per months or more, twelve for remaining patients the of those at 5 cent of the Hillside patients and only per Hillside the of modal The stay Massachusetts Mental Health Center. the of two-thirds while months was between seven and eleven (h3%) group of months hospitalization. six within MMHC patients were discharged were most patients each In hospital, c) Discharge Evaluation: At IV). (Table “improved“ evaluated at the time of discharge as �-3(19%) of patients percentage a higher Menninger Hospital, however, called was patient a single and only were rated as "unimproved" "recovered" of The percentage highest "recovered" or "much improved". of lowest proportion and the (28%) "much ratings improved" or Health Mental Massachusetts the "unimproved" (10%) were found at Center. groupdiagnostic three analysis d) Diagnosis: For statistical and psychodisorders, affective ings were made: schizophrenia, The diagnostic IV). (Table disorders neurosis and personality Hillside for similar were these groups within of patients proportions schizophrenia as diagnosed were and MMHC in that slightly over half disorder. affective or psychoneurosis as one-quarter and approximately and personality psychoneurosis Hospital In contrast, at Menninger the of population. cent than per fifty disorder accounted for more B. Intra-Hospital Comparisons Problems Methodological l. by limited were comparisons The intra—hospital statistical lack the was Most prominent problems. methodological of a variety of subdivision the for criteria cut-off statistical of meaningful within the of population due to the homogeneity populations, in part analyses the In statistical size. each institution and to the sample had which obtained were cells several within a single institution �-9- either none or fewer than five cases, thus not permitting a satisfactory intrahospital test of the hypothesis. 2. Intra-Hospital Comparison With this methodological limitation some trends similar to that found in the earlier study were observed, although few were of statistical significance. With regard to selection of treatment, for example, age and F score were found related at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest period. While such relationships were trend two a in these was noted at the significant hospitals, similar MMHC (Table V) where no patients over ho, but lb% of patients under the age of 20 remained longer than a year. -—-_------- �-10.. DISCUSSION we hospitals psychiatric of voluntary three In this comparison of differences patients interinstitutional have observed significant but and social of education class, of in the social variables years of each and F in Scale scores; not age: in distribution of California hospitalization, selection of the treatment variables treatments and distributions of diagnoses and discharge evaluatimfih The expectation that the institution serving upper class patient! would have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata,10W6r proportion of patients receiving organic forms of therapy, aM'poorest discharge ratings were each confirmed. Similarly, the flfititution serving lower class patients evinced shorter periods of howitaliza— disand betwr low of diagnoses, psychoneurotic proportions tion, charge evaluations. It is our impression that these differences in psycuatric treatment are more related to differences in staff attitfles than to differences in population samples. The contrasts betweeninstituthccomplexity. tions in duration of hospitalization are great, as are of diagnostic formulations, discharge evaluations, definifions of details and amount of recorded data These and the psychotherapy, stylistic differences cannot be dismissed as merely idiosywratic since they follow a pattern related to social differences mnsistent with previous findings. —- duration of �-11- treatment variable relationships appear to be interactive processes, determined both by the attitude of the physician and the administrative staff as by the constellation of Such population and history which a patient may present. Such relationships will be most marked in those psychiatric conditions where diagnostic criteria are least specific, 343., where the objective criteria symptoms or defining diseases of known organic impairment are absent, as in schizophrenia, psychoneurosis and personality and behavior disorders. Under conditions of perceptual or situational ambiguity the observer's attitudes and expectations become the basis for perception and classi- fication. This clearly demonstrated by Pasamanick, Dinitz and Lefton (7} in their study of variations in diagnosis within a single institution. They observed that patients randomly assigned to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did view was occur, however, in diagnoses among the three wards and among three administrators on one ward. As it is highly unlikely that these differences were inherent in the population, we believe they are reflections of the attitudes of the examiners. largely It is clear that many of the present psychiatric concepts of diagnosis or clinical evaluation have relatively little meaning when transferred from one institution to another. If these concepts are taken literally the results become paradoxical. For example, Menninger Hospital has the most highly trained personnel conducting treatment, keeps its patients for the longest time and has fewest �-12- patients diagnosed as schizophrenia. And yet, despite these resources At treatment results. the poorest and favorable factors, it reports MMHC, in contrast, which is most inclusive in defining a therapist, which keeps patients for the shortest periods, and which has a higher the reported classed asschizophrenia, of the population proportion treatment results are the best. the does relative not reflect study this that probable is It Our no furnishes data of the institutions. therapeutic efficacy the which provides hospital for determining independent criteria better care; nor for assessing the comparability of the population the based on evaluations the Since are of the in degree illness. institution‘s own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than any intrinsic psychiatric characteristics. In our initial Hillside study (5) it Was postulated that different criteria of improvement were utilized for persons of different social background. It was suggested that the higher the person's has This employed. the complex the criteria more social background Manninger‘s using with the confirmed study, in been literally present two other of the the global rating a tripartite rating compared to which our on Even syndrome the rating considering institutions. contention our is were based, it analysis comparative statistical in improvement to we assess lower apt class are that for persons work, resume to capacity the symptom patient's relief or relation to while for upper class persons the criteria stress such complex �-13- intangibles as "developing insight", or "working through one's problems." investigations have again demonstrated the role of social factors in psychiatric treatment, we have been considerably impressed by the methodological problems of studies across institutions. These institutions were selected for their educational leader— ship and the expectation that the recorded variables would be clearly defined. But the differences in institutional style making it diffi— cult to obtain comparable data are important cues to the problem of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to considerable error unless the institutions are clearly matched for social class patterns in patient population and for staff attitudes and style. These difficulties may also extend to the failures of scientists to confirm observations made in other laboratories, for the lack of confirmation may be as much a reflection of differences in populations and psychiatric criteria as to errors in the original hypotheses. The wideSpread use of such terms as "schizoWhile these phrenia" or "psychoneurosis" to explore the changes in psychological or biological features with mental illness has led to a science burdened by negative results. Even were a valid observation to be laboratory, we do not have methods available to describe populations adequately to provide a sound confirmation. reported from one �~1h- Increased attention classifying subjects must be paid to the methodological problems of criteria rather than the present and on institutional dependent highly by "objective" methods which appear to be so of the and aspects the sociopsychological observer attitudes pist-patient interaction. thera- �-15.. SUMMARY and CONCLUSION hospitals, variables. treatment to related were characteristics population F and education score, social by defined age, class, were Populations and were related to type of treatment, duration of hospitalization, diagnosis and discharge evaluation. in observed were differences 2. Significant interinstitutional and education of characteristics of patient social class, years F of California scores, but not age. distribution 3. The variations in treatment characteristics among instituthe in predicted different be found to significantly tions were direction. a follow pattern practices in psychiatric h. These variations and are institutions among differences class with social consistent not regarded as being idiosyncratic. of make comparisons S. The differences in institutional style between results and treatment diagnoses, duration of hospitalization, need more objective for and the and tenuous, institutions difficult emphasized. is of populations of classification criteria 1. In three psychotherapantic-oriented teaching �REFERENCES l. Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, & New York, Harper Brotherg R.N.: The Authoritarian Personality, 1950. 2. Hollingshead, A.B.: Two-Factor Index of Social Position, mimeo- graphed publication. 3. Mental and Class Social F.C.: Redlich, & Sons, Inc., New John Wiley York, Community Study, Hollingshead, A.B. and Illness: A 1958. h. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a 1957. 216-228, g: 2., Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and Diagnosis, Ho 5. Arch. Gen. Psychiat., 6. l: 565-57h, 1959. (CaliM.: M. Attitude Social and Fink, Pollack, R.L., & Ment. Nerv. F Dis., J. and Convulsive Therapy, Scale) fornia Kahn, 130: 187-192, 1960. 7. OrientaM.: and Psychiatric S. Lefton, Pasamanick, B., Dinitz, Mental a in and Treatment to Diagnosis tion and Its Relation Heapital, Amer. J. Psychiat., 116: 127-132, 1959. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Impr oved Markedly Improved Improved Moderately Improved Unimproved Slightly WW- Unimproved Syndrome Complete Remission Improved Unchanged (or worse) ~———-————-—-——— Improved Unimproved �TABLE III Comparisons for Sociopsychological Variables Interhosgital Menninger Hospital ' Hillside Hospital t I Massachusetts Mental Health ! i t t Social Class EIII % 17 3h 13 i g § IV v 1 E t 28 �TABLE IV Interhospital Differences in Treatment Variables gMenninger Hillside Massachusetts Hospital Mental Health {Hospital Psychotherapy Somatic of Treatment Type 68 Other 8 1 . as”ii.ii.ii_wmm.mi“iiiiiiiiii.i,__ Duration of Hospitalization i:QfiiéimfiifAL_R$;991MW_WWWW“a. _-._~ _-_rmi...._i__.mwt 7-11 months 1 months “—W.W - came-u «rr Recovered, Improved Discharge Evaluation Much 61 Improved 10 'Unimproved I .. , m Discharge Diagnosis ..—W_-»lnw w-‘W a . df=h§ B<.OOl.~W___ y3é29.3; ..... Schizophrenia Affective Psychosis _ “p M 1? Psychoneurosis and Personality Disorde x2=23-83 df‘h? P<-001 29 *__,m_.__". �TABLE V Duration of Hosgitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR i» mm Below 20 Menninger Hillside 81 73 61 3O 30 20 2422219. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance ‘Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality AlcoholiSm Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �.0". m an.» "mm ”turn M m «trauma in a Want a mu “am“. m. to m: Imitation mums It“ ”'01:“! 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II. 3 0 O ~ A - D _ .. ~ - , . O , , . - H 4 ’9. {IV/J '11.: farm/1:22.— , , , , .16. , 9 69.19.2311... - . 2 .39.-. 3 S - -h- .0 o Reject MAL X 5‘3 // 2 not“ - .3 - .0 V J.» V. 5 . .35‘ - 0 8' 7 ‘ C? .o . m____9__ 0 f _. - Reflect - __ . . 43 ,a .0 _._V ., 3 , O A -601026/1 - limo), 001.29/8,9. Duh“ - ,, 55 .9— .V 9‘ - .. ,3- «wag—m... 53 / �-3Menninger Hospital, however, a higher percentage (19%) of patients called rated as "unimproved" and only a single patient was "recovered" or "much improved". The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health were Center. d) Diagnosis: For statistical analysis three diagnostic groupings were made: schizophrenia, affective disorders, and psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside in that slightly over half were diagnosed as schizophrenia and approximately one-quarter as psychoneurosis or affective disorder. In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per cent of the population. and MMHC -‘---------’ Table B. Intra-Hospital Comparisons l. Methodological Problems The a IV intra-hospital statistical comparisons variety of methodological problems. of meaningful statistical cut—off were limited by Most prominent was the lack criteria for the subdivision of populations, in part due to the homogeneity of the population within each institution and to the sample size. In the statistical analyses within a single institution several cells were obtained which had �Page 5. COMMENTS BY PSYCHIATRISTS Most of the unfavorable (1) (2) more insufficient " criticism can number of " " be divided into two complaints: sessions per patient paid for by Project patients point, many apparently feel the Project should advertise itself to its eligible subscribers, reminding them of the availability of coverage. 0n the second Favorable criticism was in general directed at expressing approval of the idea of testing psychiatric insurance. There were in addition a surprising number of complimentary remarks about the planning or administration of the Project. SUMMARY typical participating psychiatrist is a man between 35 and 50, practicing in Manhattan. He treats patients in the hospital as well as in his private office, and he also does some clinic work. He has his "Boards" in psychiatry. His usual office fee is $20 or $25. His primary orientation in his practice is analytical and psychological. This does not preclude his prescribing drugs or shock therapy. The interest in the Project is demonstrated by the fact of his participation. If he has some adverse criticism, it is apt to be directed at the number of sessions allowed, which he regards as insufficient, or at the small number of patients who have sought care, which he regards as a reflection of an inadequate educational program. In short, his criticism is generated by his tendency to view the Project as a social rather than an insurance experiment. He feels the Project, Operating in an area where the supply of private psychiatric time apparently exceeds the demand, is in a unique position to promote more psychiatry for more people, which is what he really wants - insurance or no. 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E fl m” he 4, ~ ' :'*13I:§ ‘ «a 9".”‘ 1“ 31-3 9 ”‘03:: at" .1 it'We” it”$001 “it" 90. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Social aspects of psychiatric treatment in three hospitals: methodological problems. VA Cooperative Studies in Psychiatry, 6:202-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-004-59-001 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Pollack, Max; Siegel, Nathaniel; Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 9 items. 1: Photocopy of publication with Q & A. 2: [preprint]. 3: Draft. 4: The Identification of Patient Populations: Comparability of Subjects in Evaluating Therapies Among Institutions by Max Fink, M.D. 5: The American Psychoanalytic Association Summary and FInal Report of Central Fact-Gathering Committee. 6: Correspondence. 7: Handwritten notes. 8: Social Class. Diagnosis, and treatment In Three Psychiatric Hospitals. 9: Research, drafts, and letters. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/9a3312b18cdf6e7ffc1390135fa8f24f.pdf 7ebf0740040bf69f9525e1f11a533ee3 PDF Text Text 20 Soci0psychological A3pects of Psychiatric Treatment A Report of Treatment in Three Voluntary Hospitals ROBERT L. KAHN, PhD, NEW YORK; MAX FINK, MD, ST. LOUIS; AND NATHANIEL SIEGEL, PhD, BETHESDA, MD IN THEIR STUDIES of the New Haven treated primarily by psychotherapy, and repsychiatric patient population, Hollingshead ceived poorer discharge ratings. These and Redlich reported significant relation— clinical factors were also related to a measscale.""5 California F the of in the individual’s stereotypy, ure position ships between an social—class structure and the incidence of Higher F scores, ie, greater stereotypy, were treated illness, types of diagnosed disorders, often found in patients diagnosed as inand kinds and duration of psychiatric treat— volutional psychosis who were referred for ment administered.1 The influence of the convulsive therapy, hospitalized for shorter economic status of the patient on the avail- periods, and were more often rated as much recovered. improved or of however, was personnel, treating ability It was suggested that differences in psy— not excluded. should chiatric hospitals treatment in the social factors of among Studies of the role social factors of influence in— similar reflect a of hospitalized patients treatment Hos— Hillside within noted for patients dependent of their financial status and the as decided it to this To was test suggestion pital. undertaken of treatments were availability 1957 Hillside the of the procedures 1957. employ this In in hospital, at Hillside Hospital Hosinstitutions—Hillside in three instudy a variety of treatment modes, including dividual psychotherapy, pharmacotherapy, pital, the C. F. Menninger Memorial Hosand convulsive therapies were available to all pital, Topeka, Kan, and the Massachusetts inThese Boston. Health Mental Center, patients regardless of their ability to pay. In our surveys 2'3 we observed that patients stitutions were selected with the expectation hospitalized for the shortest periods were that diverse treatment modalities were older, had less education, and were more equally available to populations of different often of foreign birth. These older, less- social classes. Each provided short—term educated patients were predominantly treated treatment of voluntary patients and did not by convulsive therapy and received more provide custodial care. Each is a residency favorable clinical discharge ratings. In con- training center with a full—time supervisory trast, younger, native—born, more—educated staff and active research units, emphasizing patients were hospitalized for longer periods, psychoanalytically-oriented psychotherapy. This study was designed to determine the Submitted for publication June 21, 1965. From the Department of Experimental Psychiatry, Hillside in— three the of characteristics population Hospital, Glen Oaks, Long Island, NY 1959-1962. Currently at the Department of Psychiatry, University of Chicago, social with class, to stitutions age, respect the of at the Psychiatry Department Chicago (Dr. Kahn); Missouri Institute of Psychiatry, University of Missouri and F score; and to relate these education, School of Medicine, St. Louis (Dr. Fink); and the National characteristics to treatment variables of type Institute of Mental Health, Bethesda, Md (Dr. Siegel). Reprint requests to 5400 Arsenal St, St. Louis, Mo 63139 of duration of hospitalization, treatment, (Dr. Fink). ' Arch Gen Psychial—Vol 14, Jan 1966 �EPIDEMIOLOGY—DUNHAM Small City,” in Epidemiology of Mental Disorder, B. Pasamanick (ed), \Vashington, DC.: American Association for the Advancement of Science, 1959, publication No. 60. 46. Hollingshead, AB, and Redlich, F.: Social Class and Mental Illness ew York: John Wiley & Sons, Inc., 1958. 47. Morris, ].N.: ealth and Social Class, Laneet 12303—305 (F 1959. 48. Dunham, Dis— “Anomie and Mental .. order,” in Anom and Deviant Behavior, M. B. Clinard (ed.), Ne k: The Free Press of Glencoe, a division of the acmillan Co., 1964. 49. Buck, C.; Wanklin, M.; and Hobbs, G.E.: Symptom Analysis of Ru l—Urban Differences in First Admission Rates, ] erv Ment Dis 122 280-82, ].A., and Kohn, M.L.: Social Isolation and Schizophrenia, Amer Soc Rev 20:265— 58. Clausen, 273 (June) 1955. 59. Stein, L.: Social Class Gradient in Schizo- phrenia, Brit J Prev Soc Med 11:181-195 (Oct) 1957. 60. Carstairs, G.M., and Brown, G.\V.: A Census . (July) 1955. M.B.: Al native Hypothesis for the Explanation of Some f Faris and Dunham’s Re— sults, Amer J Soc 47 48-52 (July) 1941. 51. Schroeder, C. : Mental Disorders in Cities, Amer Soc 47 :40-47 ( 1942. 52. @degaard, (3.: E igration and Insanity: Study of Mental Diseas Among Norwegian Born Population in Minnes , Aeta Psychiat Neural, 50. Owen, suppl 4, 1932. 53. @degaard, Incidence of Psychoses 0.31m in Various Occupations, Soc Psychiat, vol 2, No. 2 (Autumn) 1956. 54. Ekblad, M.; Psychiat c and Sociologic ‘ 19 , of Psychiatric Cases in Two Contrasting Communities, J Ment 5 ' 72—81 (Jan) 1956. 61. Dunha r .W.: Community and Schizo— phrenia : Epidemiological Analysis, Detroit: Wayne Sta University Press, 1965. 63. Leig lot: Comm Psychiatry, , lisher, 1960. 64. Leigh ger, New Y. 65. LClgh the Epidemi demiology bank Memori b , .H.: “A Proposal for Research in y of Psychiatric Disorders,” in Epi— ental Disorder, New York: Mil‘ o Fund, 1950, pp 128-135. 66. Krame M.; “Discussion of H. W. Dunham’s article”. 'n Causes of Mental Disorders: A Review of miologieal Knowledge, 1959, New York: Milban emorial Fund, pp 271—273, 1961. 67. Miles, H.C., et A Cumulative Survey of All Psychiatric Expe nce in Monroe County, New York: Summary of ata for the First Year (1960), Psychiat Quart 3| ‘ 58-487 (July) 1964. 68. Dohrenw , B., and Dohrenwend, B.: The Problem of Valio in Field Studies of Psychological Disorder, ] Abn Psyehol 70 :52-59, 1965. 69. Benedict, P.R., nd Jacks, I.: Mental Illness in Primitive Societie Psychiatry 17 :379—390 (Nov) . . ’ E.: Mental Ment Hyg (April) 1935. 55. \Vinston, M.; Compa t e Study of Disease Incidence in Admissions to ase Psychiatric Hospi— tal in Middle East, Men ei 922118—127 (Jan) 56. Simms, 1946. 57. JaCo, E.G.: The Social Isolation Hypothesis and Schizophrenia, Amer Soe Re-zv 19:567-577 (Oct) 1954. 1954. 70. Hollowell, Philadelphia 1955. : .A.: Culture and Experience, niversity of Pennsylvania Press, Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL diagnosis, and discharge evaluation among the institutions. Method A census of all voluntary, adult patients in residence in the institutions was undertaken in January While Menninger and Hillside Hospitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evalua— tion or were members of a chronic schizophrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their nonvoluntary status. The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead two-factor index—a weighted score of education and occupation—was used.“’6 The study population consisted of 173 patients at Hillside, 100 at Menninger, and 95 at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult, however, because of vari— 1959. ous methodological differences discussed below. These difficulties were most marked in the intrahos— pital comparisons and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intrainstitutional trends. These difficulties also led to missing information for some data, reflected in the tables by the varying population sample sizes. Results I. Methodological Problems—When re— porting studies from one institution, the structure of the hospital is taken for granted and either ignored or mentioned briefly. In TABLE 1.—Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction, narcissistic personality Anxiety reaction, narcissistic personality Narcissistic personality Narcissistic personality, alcoholism, chronic infantile personality Passive aggressive personality, alcoholism Infantile personality, schizophrenic reaction, schizoaiicctive type General Classification Psychoneurosis Psychoneurosis Personality trait disturbance Sociopathic personality disturbance Sociopathic personality disturbance Schizophrenic psychosis 21 gathering comparable data from multiple in— stitutions, however, the differences between institutions are accentuated. While these in— stitutions were selected as comparable in teaching, research, and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designa— tion of type of treatment, diagnostic classifications, and the evaluation of treatment outcome. Designation of Type of Treatment: The criteria for designating that a patient , received “psychotherapy’ differed among the institutions, making comparisons (lif— 1. ficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a fee. Sessions with a psychiatric resident physi— cian were considered part of routine ad— ministrative patient care. At Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising resident physicians. No additional fees were charged. At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines—psychiatric residents, psychologists, social workers, nurses, and medical students. Formal records of such sessions were not routinely included in the patient’s record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident physi— cian responsible for each case. 2. Diagnosis: Individual institutional di— agnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems. Several examples of diagnoses from Menninger are listed in Table 1, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. Arch Gen Psychz'al—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL 22 Discharge Ratings of Improvement: Ratings of improvement at the three hos— pitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological, and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table 2). For this study the Menninger syndrome rating was compared to the global ratings of the other institutions. II. Interhospital Comparisons—1. Sociopsychological Variables: The distribution of the variables of social class, age, education, and California F scale score among the three institutions is presented in Table 3. A. Social Class. The anticipated differ— ence in social class composition of the three institutions was observed. At Menninger Hospital the population was predominantly upper class; at Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. B. Age. There were no differences in age distribution in the institutional populations. C. Education. The populations also differed in educational attainment, with patients having more years of education at Men— ninger Hospital than at Massachusetts Mental Health Center. While 41% of the patients at MMHC had not completed high school, only 32% at Hillside and 23% at Menninger did not graduate. D. F Score. Differences in the distribution of scores on the California F scale were also observed. Fifty-one percent of Menninger patients had F scores below 30, and only 8% with scores of 50 or above—the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside 31% of the patients had F scores below 30 while at MMHC only 20% were be- 2.—Comparative Ratings of Clinical Condition at Time of Hospital Discharge TABLE 3. low 30. Menninger Hospital Thus, differences in social class, tional attainment, and performance on the F scale were observed. These differences permit a test of the hypotheses relating socio— psychological factors to the treatment variables among these institutions. 2. Psychiatric Treatment Variables: A. MM HC Improved Recovered Much improved Unimproved Improved Social adjustment Character structure Recovered Markedly improved Moderately improved Slightly improved Unimproved Unimproved Improved Unimproved Syndrome Complete remission Improved Unchanged (or worse) Selection of Treatment. Among the institu— tions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table 4). B. Duration of Hospitalization. The three institutions differed with regard to patient’s length of stay (Table 4). Patients at Men— ninger Hospital were hospitalized longest, with 65% of the patients remaining for 12 months or more, compared to 31% of the Hillside patients and only 5% at the Massachusetts Mental Health Center. The modal stay of the Hillside group was beComparison: for 'Sociopsychological Variables TABLE 3.——Interhospital ' Hillside Hospital Menninger Hospital N 87 31 % I II III Social class l 17 13 28 28 O 5 20-39 40+ x2= N <12 12-15 16+ 121.5, df = 3.9, dr= 4, 100 23 % 54 23 x2 = 9.7, df = 4, [ F score { I N Arch Gen Psychiat—Vol 14, Jan 1966 x2 51 P % 41 8 = 39.2, (if = <0.001. 173 19 % 58 23 95 15 % 52 33 173 32 % 51 17 91 41 P: NS 92 10-29 30-49 50-70 L P 8, 100 19 % 59 22 <20 education 28 V = 72 3% 2O 1 x2 M M HC 51 IV N Age 133 7% 34 34 L Years of educa— Hillside Hospital 4, P % 49 10 <0.05 163 33 % 50 17 <0.001 76 20 % 38 42 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL TABLE 4.—Inicrhospital Difi‘ercnccs in Treatment Variables Menninger Hillside Hospital Hospital MMIIC 100 Ty pe of treatment Psychotherapy [ Duration of hospitalization Somatic Other 21% 43 36 x2=82.,8 df=4, P <0.001 NMo <7 Mo >11 M0 7- 11 100 22 % 13 65 x3=90.,6 df=4, P RecoveNred,1 % evaluation much1m- proved Improved Unimproved x2=29.3, df= N Discharge diagnosis 80 19 4, 89 24 % 68 8 173 27 % 42 31 67 % 27 172 23 % 88 28 % 5 5 P 62 15 61 171 52 22 S5 54 10 <0001 95 43 % 5 Schizophrenia Affective psychosis Psychoneurosis 52 & personality disorder xa = 23.8, df = 4, P <0.001 % % 17 26 29 tween 7 and 11 months while two thirds of the MMHC patients were discharged within six months of hospitalization. C. Discharge Evaluation. In each hospital, most patients were evaluated at the time of discharge as “improved” (Table 4). At Menninger Hospital, however, a higher percentage (19%) of patients were rated as “unimproved” and only a single patient was scored “recovered” or “much improved.” The highest percentage of “recovered” or “much improved” ratings (28%) and the lowest proportion of “unimproved” (10%) were found at the Massachusetts Mental Health Center. D. Diagnosis. For statistical analysis three diagnostic groupings were made: TABLE 5.—Duration of Hospitalization, by Age Percentage of Age Group Staying Over One Year Age Below 20 20-29 30—39 40-49 50+ Menninger Hillside MMHC 81 73 61 30 36 42 14 6 6 0 0 36 30 20 0 schizophrenia, affective disorders, and psy— choneurosis and personality disorders (Table 4). The diagnostic proportions of patients within these groups were similar for Hill— side and MMHC, as slightly more than half were diagnosed as schizophrenia and one quarter as psychoneurosis or affective dis— order. In contrast, at Menninger Hospital psychoneurosis and personality disorder ac— counted for more than 50% of the popu— lation. III. Intrahospital Comparisons—The lack <0.001 99 Discharge 173 36 % 64 — 23 of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intrahospital comparisons. However, the trends appeared similar to those found in the earlier study. Age and F score were found related to the selection of treatment at Men— ninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals—the younger patients re— maining for the longest periods. While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table 5) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. Comment The patients of three voluntary psychiatric hospitals exhibited significant interinstitutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables—duration of hospital— ization, selection of treatments, and dis— tributions of diagnoses and discharge evaluations.7 Expectations based on our earlier intra-Hillside Hospital study were confirmed. The institution serving upperclass patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the Arch Gen Psychiat—Vol 14, Jan 1966 �24 SOCIOPS‘YCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL three institutions. Similarly, the institution serving lower—class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populations. The contrasts between in— stitutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, defini— tions of psychotherapy, and the details and amount of recorded data. While these stylistic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater de— pendence on social class variables than ordinarily acknowledged. Such population and treatment variable relationships are interactive processes, de— termined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients present. Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, ie, where objective criteria defining diseases of known etiology are absent, as in schizo— phrenia, psychoneurosis, personality and be— havior disorders. Under these conditions of perceptual and situational ambiguity, the ob— server’s attitudes and expectations become significant aspects of his perceptions, classi— fications, and decisions. A similar situation was clearly documented by Pasamanick et al 7 in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards (lid not differ in type of admission, marital status, education, age, or residence. Significant differences did occur, however, in the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the popula— tions were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners. Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another. Literal adherence to these concepts produces paradoxical results. For example, Menninger Hospital with more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizo— phrenia, and yet, reports the poorest treat— ment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results. In the absence of independent criteria for the quality of care or the assessment of com— parability of populations for degree of ill— ness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions. Since the evalua— tions are based on the institution’s own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psy— chiatric characteristics. In our initial Hillside study3 it was postulated that different criteria of improve— ment were utilized for persons of different social background. It was suggested that the higher the person’s social background the more complex the criteria employed. This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutions. Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower—class persons we are apt to assess improvement in relation to symptom relief or the patient’s capacity to resume work, while for upper—class persons the criteria emphasize such complex intangibles as “de— veloping insight,” or “working through one’s problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL were selected for their educational leader— ship and the expectation that the recorded variables would be clearly defined. But dif— ferences in institutional style made it diffi— cult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, di— agnostic classifications, or length of hos— pitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient popula— tions. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labo— ratories, for the lack of confirmation may reflect differences in populations and psy— chiatric criteria as much as errors in the original hypotheses. The use of the terms “schizophrenia” or “psychoneurosis” to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by “objective” criteria rather than our present methods, so highly dependent on institu— tional and observer attitudes and the socio— psychological aspects of the therapist—patient interaction. 25 Summary Population characteristics, defined by social class, age, education, and F score; were related to treatment variables in three voluntary teaching hospitals. Treatment vari— ables included type of treatment, duration of hospitalization, diagnosis, and discharge evaluation. Interinstitutional differences were observed in patient social class, years of education, and distribution of California F scores, but not age. The variations in treatment characteristics among institutions were significantly differ— ent in the predicted direction. The institution serving upper-class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses, and more com— plex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions. Similarly, the institution serving lower-class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diag— noses, and the better discharge evaluations. These variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hos— pitalization, and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasized. Aided, in part, by grants MY-2092 and MY-2715, of the National Institute of Mental Health, US Public Health Service and the Nassau County Mental Health Board. Dr. Max Pollack aided in gathering material for this study. REFERENCES Hollingshead, AB, and Redlich, F.C.: Social C lass and Mental Illness: A Community Study, New York: John Wiley & Sons, Inc., 1958. 2. Kahn, R.L.; Pollack, M.; and Fink, M.; Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J Hillside Hosp 6:216—228, 1957. 3. Kahn, R.L.; Pollack, M.; and Fink, M.; Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitali— zation, Discharge Ratings and Diagnosis, Arch Gen Psychiat 1:565—574, 1959. 1. al: The Authoritarian sonality, New York: Harper & Brothers, 1950. 4. Adorno, T.W., et Per— Kahn, R.L.; Pollack, M.; and Fink, M.; Social Attitude (California F Scale) and Convulsive Ther— 5. apy, J Nerv Ment Dis 130 2187-192, 1960. N.H., et al: Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals, Soc Problems 10 :191-196, 1962. 7. Pasamanick, B.; Dinitz, S.; and Lefton, M.; Psychiatric Orientation and Its Relation to Diagnosis and Treatment in a Mental Hospital, Amer J Psychiat 116:127-132, 1959. 6. Siegel, Arch Gen Psychiat—Vol 14, Jan 1966 �26 Families of Children Wit nia hi hood SchizoPhr Early Sc ected Demographic Informajion L IS HENDRICKSON LOWE, MA, INDIANAPOLIS PREVIOUS STUDIjS regarding the etiological importance of l‘family background in childhood schizophr ia have produced Kanner4 i ressions. and diverse findings has stated that autistic hildren are usually found to have intellige , sophisticated pareducational attaine high have who 3a ents level. In his populatio 10f autistic patients, grad— school high the we of parents 94% and 49% fathers of while 74% uates, of the mothers had co 'pleted college. In another publication,3 he ‘emarked on a low incidence of divorce :1 ng these families. Bender,1 on the other h d, has noted that 'ong the parents no such trends exist of schizophrenic childre seen at Bellevue, " t " wide variety of backgrou It has also been rep ed that a fairly in is a s common to of ratio boys high these that and ion, schizophrenic pop children are freq fly the firstborn in their male-fe— the lists nder2 sibling group. 1 in a group of 142 male ratio as 7 of under chil age. en years schizophrenic autistic 27 of ulation with a Phillips,6 is which boys, that noted were children, also He 6:1. ratio male—female 0 early a autistic of ition ordina data on presents children. In the general opulation, the ex— is 44.12%.6 children firstborn of rate pected In a group of 635 disturbed (but nonautistic) children, Phillips found that 27 the of while firstborn, 76.38% were autistic children, 81.5% were firstborn. that to data these suggest Phillips interprets autistic children differ from the normal population in matters of sexual ratio and ordinal position as do lesser disturbed chil:1 of the suggestion out dren. He points continuum, with more vere childhood dis— turbances appearing cw comitantly with a higher ratio of boys 'l girls, and with a ‘l stborn children. It higher proportion of should be noted that ny data on ordinal position can be undistood better when viewed in conjunctio with maternal age at the birth of the chi these various re— Discrepancies amo ports of data may be due to disparities in om which samples patient populations were drawn. Bender nd Kanner, however, drew their patient ample from different population groups ,' ith respect to socio‘anner’s probably came economic status. largely from peopl in higher socioeconomic groups in a unive ity community while Bender had a wide population to draw from in New York ci . Since this poten— tial error is compounc d by the relatively low incidence of c'dhood schizophrenia in the general . The p pose of the present paper is to make .available pertinent information collected etween 1955 and 1963 in the Chil— dren’s S :VICC of LaRue D. Carter Me— morial Ho' ital, Indianapolis. The data on children is compared with that schizophre obtained on y-\turbed children given diag— childhood schizophrenia. noses other Since LaRue Hospital is the only nit for disturbed residential treatmen youngsters in the stat of Indiana, the patient population is probably representative of all geographic areas of the state as well as a variety of socioeconomic backgrounds. t Ca Method Subjects.—Included in the study were the children whose preadmission diagnosis was one of emotional disturbance, whether or not the child was admitted Arch Gen Psychiai—Vol 14, Jan 1966 Submitted for publication March 18, 1965. From the Indiana University Medical Center. . Reprint requests to 64 Mercury Ct, West Springfield, Mass 01089. �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I. New York, 1959— 1962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts MEntal Health Center and the C. F. Menninger Memorial Hospital is gratefully acknowledged. The Aided, in part, by grants My—2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �In their studies of the New Haven psychiatric patient population, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure hand the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded, Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to payu In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birth, These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratingsa In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingso These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)c Higher F scores, i.e,, greater stereo— typy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recovered, In the survey reported here, it was suggested that dif— ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital, To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -‘ Hillside Hospital, the C. F° Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Bostono These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classes° Each provided short-term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psycho— analytically—oriented psychotherapy, This study was designed to determine the population character— istics of the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, �..2.~ METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside HOSpitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo— phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary statuso The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Centero — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intrathospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trendso These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample sizeso The �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or mentioned briefly. In gathering comparable data from multiple institutions, however, the many differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome, When 1. Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult. criteria for differed among At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising res~ ident physicianso No additional fees were chargedo At At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident responsible for each case. was 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger HOSpital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systemso Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono �Table I Discharge Ratings of Improvement: Ratings of im~ provement at the three hospitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)a For this study the Menninger syndrome rating was compared to the global ratings of the other 30 institutionsw Table B. II Inter—hospital Comparison 1. Sociopsychological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having mOre years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Manninger did not graduateo c) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty—one per cent of Menninger patients had F scores below 30, and only eight per~ cent with scores of 50 or above —- the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 300 d) F Thus, differences in social class, educational attain— ment and performance on the F Scale were observed. These diff— erences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables 2. among these institutions. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC Hospitalization: (68%) (Table IV), three insti~ tutions differed with regard to patient's length of stay (Table IV)9 Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per-cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization° b) Duration of The c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved"e The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centerm nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diag— disorders, and �psychoneurosis and personality disorders (Table IV). The diag— nostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one—quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per-cent of the population° Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsidec Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periods“ While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a yeare The Table —-—\ V �-7DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var— iables duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7), The —— Expectations based on our earlier intra—Hillside Hospital were confirmed, The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psy— chiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data, While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, gig}, where objective criteria de— fining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorderso Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his per— ceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners, Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another, Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment resultso In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions° Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background, It was suggested that the higher the person's social background the more complex the criteria employedo This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been great— ly impressed by the methodological problems of studies across in— stitutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hos~ pitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populations. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis'l to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective'' criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist—patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in— cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluationw Inter—institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted direction. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionsc \Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations, The variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. These differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasizedo Such �REFERENCES l. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. Sanford, Brothers, R. N. The New Authoritarian Personality° York, 1950, 990 pp. J. and Harper and 2. Hollingshead, A. B. and Redlich, F. C. Social Class and Mental Illness: A Community Study. John Wiley and Sons, Inc., New York, 1958, 442 pp. . L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216—228. Kahn, R. L., Pollack, M. and Fink, M. Aspects of Psychiatric Treatments in a Hospital: Duration of Hospitalization, G Ps h' Diagnosis. 1959, ., Kahn, R. Kahn, R. ifornia F L., Pollack, Sociopsychologic Voluntary Mental Discharge Ratings and is 565-574. Fink, M. Social Attitude (Cal— Scale) and Convulsive Therapy. .lefiflah_lkflflfi_Dlfi,, M. and 1960, lfifl: 187-192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. Ameri_la_£sxchiat., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete_Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE Interhosgital Comgarisons for Sociogsxchological Variables MEnninger Hospital N I Social Class III Hillside Hospital Massachusetts Mental Health Center IIIIIKEEIIIIIIHIIIIIEIIIIIIIIIIIIIIIHEIIIIIIII 31% 7% II 51 20 III 17 34 . . IV 1 34 V O 5 X 2 = 121.5; df=8: p<.OOl IIIIIIIIIIIIIIIIHNIEIIIIIIIIIIIHHIIIIIIIIIIIIIIIJBHIIIIIIII 19/ Ag e 20- 39 IIIINIIIIIlllllflflddflllllIIIIIIIHHEIIIIIIIIIIIEHIIIIIIIII Years of Educatio < 12 41% 12-15 49 16+ 10 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables jMenninger N Treatment Massachusett Mental Healt Center .m-m-mHospital Type of Hillside Psychotherapy Hospital Somatic Other =82 8 Duration of , Hospitallzatlon 7 df= 4 . .001 months 7-11 months ~11 months Discharge Improved Evaluation Unimproved X = Schizophrenia 29.3' df=4' .<.001 ' Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 52% 54% 22 17 26 29 23.8' df=4' -<.001 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Ass Menninger Hillside Below 20 81 42 20-29 73 36 30—39 61 30 40-49 30 20 50+ 36 MMHC 14 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Agg Below 20 Hillside 81 20-29 73 30-39 61 30 ho-h9 30 20 50 + MMHg �TABLE IV Interhospital Differences in Treatment Variables Menninger Hillside Massachusetts .m---Hospital N Psychotherapy Somatic of Treatment Type WW Other l Duration of Hospitalization Hospital Mental Health Center 9 21% 36% 2b% h3 6h 68 36 -- 8 » . _ . _..W.xi:82-8:.§_£:-hz P<-001 mud-Mm...“ w...» W 7-11 months x2=90.6; df=h; p<.OOl Recovered, Improved Discharge Evaluation f ‘> . 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Wwflmmmflm. 2. 3191131121“: inurhwfitutianl diffm m obscured in Wflmofpatimtsoahlelus,ymofodmutimm diuudbufimofcuifwml‘m,butmtago. mmmmmwummmum timmfmmbouigflfimflydifimtinmpmdicmd 3. dim. It. mmmmymammmnmnm mumtwithmmclusdflfmwmgimflmdmsmdm thuidiosynmtie. 5. matrmmmmmmummmof W,mumof)mpimnmim,mdmammultnbam mmwfimdtmmm,mmmdfmmobjwdw «imamimdmofmmfimsismim. �REFERENCES 1. Adorno, T.w., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, & New Brothers York, Harper R.N.: The Authoritarian Personality, 1950. Two-Factor Index of Social Position, Hollingshead, A.B.: mimeo— graphed publication. Mental and Class Social F.C.: Redlich, & New John Sons, Inc., Wiley York, Community Study, Hollingshead, A.B. and Illness: A 1958. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a 1957. 216-228, g: §g_p., Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis, Arch. Gen. Psychiat., l: 565—57h, 1959- (CaliM. M.: Attitude Social and Fink, Pollack, R.L., & Ment. Nerv. F Dis., J. and Convulsive Therapy, fornia Scale) Kahn, 122: 187-192, 1960. Pasamanick, B., Dinitz, Psychiatric OrientaTreatment in a Mental S. and Lefton, M.: tion and Its Relation to Diagnosis and 1959. 127-132, Amer. J. Psychiat., llé: Hospital, Siegel, N.H., Kahn, R.L., Pollack, and Treatment in Three M. and Pink, M.: Social Class, Diagnosis Psychiatric Hospitals, Social Problems, 10: 191—196, 1982. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved ~W‘_ Improved Moderately Improved Unimproved Slightly Improved Improved Unimproved Unimproved Syndrome .._.W Complete Remission Improved Unchanged (or worse) Markedly Improved W- �III TABLE InterhosEital Comparisons for SocioEsychological Variables Hillside Menninger ; Hospital Hospital Education 17 ’ (92) N 3 Score 1 i ’ F Massachusetts Mental Health ; 10-29 1 3o-h9 W7 51% i ’41 g (163) 33% 50 10 g i 76 20% 1 '1 38 } 50-70 8 1 i 17 g M �TABLE IV Interhospital Differences in Treatment Variables Massachusetts lHillside iMenninger Mental Health Center IHospital ‘Hospital ‘Psychotherapy of Treatment Type Somatic h3 Other Duration of Hospitalization 36 ’ 7-11 months 1 months Recovered, Improved Discharge Evaluation Much Improved 61 ’ . 'Unimproved 10 % I 9 . - _ mw.,,__,‘<2=29-3s df=1v fianQwawiwflj I Discharge Diagnosis tr-‘a-m-th-A _ ...-A.Wn‘.m Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde .W--- 85 Sh% 1? 26 29 ”- -.- —-”“— w- �TABLE V Duration of HosEitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Hillside Below 20 81 h2 20-29 73 36 30-39 61 3O hO-h9 3O 20 50+ M9 �‘— ‘7 -w vuwlr-u'rflmmm —-u-- “Tm—“vii W Hm: W. 21, man 911.13. Hill-M- Wu}. P. 0. Dan: 33 man Odes. the You: W81 , mm. mm mmmlht: MWWIMBWMbyaWo-n I whammmm'mmmmmmrmunm. Midwinbutlmzldlfluewrymm IMMMM Mtfizhfwwblmw . Wumflulntdmfimfm Wh.metMtoajml,ImflAlihto$smm-d Hm,I mmmmwmuwmmm. singlubmmtittoamoffiujwmmmwm to . 81 FILE. ‘ ‘ mm,mmmqumummxwmt mwmumwtm-mmdtmjmw. WWW. ma: �flv psychiatric treatment, haMflm and research December 2h, l96h Dr. Max Fink Missouri Institute of Psychiatry Shoo Arsenal St. St. Louis, Missouri Dear Max: (E) / (:> let, the have reread I In reply to your letter to and objections my original paper on sociological aspects the skirts I feel no altered. it in way this paper are whole problem of diagnosis which Nat in a previous paperwhich and than social class, has shown to be more ;important True, variable. be crucial a VA showed to I in the paper disturbed more severely younger same institution within the of time period a and longer for kept patients are treated and all this is relative to the philosophy of the the in not reported at all is This viewpoint institution. paper. form. in present its of in publishing favor not it I am Should you have some specific need for seeing it published, removed. was name my providing no objection I would have collaborate to want should you authormanship, of Speaking variables and psychological EEG and psychiatric on the findings I would have no objection. My best wishes to you, Martha and the kids for a Joyous New Year. have him I and Turan to tell Please give my regards ordered a copy of his book. Sincerely yours, of the 10m»; MP:gp Pollack, Ph.D. Senior Research Associate Max �m 21, 196‘! mmmrmtmmmgm-ormw;md fdfluMdmmm-Jmlofwmommfia Mfllhdmlafhyuhhm. mfiwmhfin ”magma-mum. hmmhmyw. and: Enema-mu cc: Pollack Ph.D. Nathmial siegel, Ph.D. Max �MONTEFHMHCHUSPVRHJAND MEDHLMACENTER 111 EAST 210TH STREET. BRONX, NEW YORK 10467. TELEPHONE: 212/TU 1-1000 January 19, 1965 Fink, Director max M.D. Missouri Institute of Psychiatry suoo Arsenal Street St. Louis, Missouri 63139 Dear Max: I think the paper is fine, and would touch it as little as possible. Your choice of Journal is excellent. For my part, go ahead and submit it. The only change concerns the here - "Mbntefiore Respital and Mbdical Center" and the revised address as revised name shown on this letter. It to see you and I pleased that you are doing well. was good am Best regards to Martha. Sincerely, RLK:FB Rdbert L. Kahn, Ph.D. Head, Section on Psyology Division of Psychiatry �DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE BETHESDA. MD. 20014 December 31, 1964 NATIONAL INSTITUTES OF HEALTH AREA CODE aoI TEL: ass—mo In reply refer to: M-TMR-SS AIRMAIL Dr. Max Fink, Director Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: I was pleasantly surprised to see the paper on "Sociosociological Aspects of Psychiatric Treatment in Three Voluntary Hospitals" again. I was really delighted that you resurrected it and have taken responsibility of submitting it to one of the journals that you listed. I have no real preference for one of various journals that you mentioned. I would think it would be most unlikely to be published in Psychiatry, but I am sure you share this opinion since you listed it last in your order. In all honesty, in rereading the manuscript, I found it to be much better than I remember it. Most of my comments are of a stylistic nature. Here, however, I would bow to you as the collator of the document to use the style that you prefer. My own penciled comments are, however, on the paper. V/ I think the main contribution that this paper has to make, and should make, has to do with the methodological problems that are involved in doing cross-hospital studies or in doing hospital studies within the same institution over a period of time. As you indicate in the paper, on page 4, that when one reports studies from one institution, the structure of the hospital is either taken for granted or ignored. Cer— tainly, we should be elaborating on this in great detail, and the methodological aspects of doing a study, such as the one we have done, Should occupy a major area of the report in its own right. For this reason, I am not sure I would report methodological problems as we have done on page 4. I think that it should either occupy a place of its own in the discussion or might indeed exchange status with "AH Interhospital Comparisons on page 4, and become the "A" category, or interchange and make Interhospital Comparisons the "#1" category. Most of the things that we want to say are in the paper but, as I have indicated, I am a �2. little unhappy about interweaving our "findings" with the "methodological not being our intent in the original investigation in the also, report. more I, important the I being think ...and, yet, would I of the author be try to should senior paper. believe that you own in and autonomy right its give problems it methodological the spotlight Section." "Discussion Section" the in "Results or done in be the whether this difficulties"...the latter Cole in Jonathan with be will visiting Please let us the evening want on spending us to plan I certainly Washington again. schedule I will on advance notice this have we a and if little together, know when you my time accordingly. My best to you and your family for a most happy 1965. Sincerely, Nathaniel H. Siegel, Ph. D. Acting Chief, Social Sciences Section Training and Manpower Resources Branch National Institute of Mental Health Enclosure �M L. W. liflunhfl.&hfln1,Ith" Kin. $.11... MI! nu! Nu m. 21.0.“ 31.9. �-n mmw — vvr-nwr w)v-x<v-'r v -, — 1‘... er—‘u‘ -~ ‘ m-vm.~—~v---ww—WVW-"— av uwvwx ':vtwv-‘uwvwav<< -... . >rv—zwv-Inl“ . wt. u-vww-wmw—m—m‘ vv'vi'fi‘mrr w 4w.—’wn’.~w—V'WWV MIMmm-Mhmumwa mwdwmm.mmm. 3.3.. mm. m. mummmc.r.mmwnwmhmmuy m,mm.wmm~mmm~m.dmm Mahatma). mmua. muss-mm; mun mwammme-m Lain. mmmwam. mmuumm.munmmm Cmm: wmsmnwzm. mm". a: mm mm mm mm. W. 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MWuwa-mw. mammmmwmmummw m.mawunuum.newmum mmmtum.mmmmmwmdw B. wwwmmamnw �REFERENCES 1. and D.J. Sanford, Levinson, Adorno, T.W., Frenkel-Brunswik, E., & New Brothers York, Harper R.N.: The Authoritarian Personality, ' 1950. 2. Hollingshead, A.B.: Two-Factor Index of Social Position, mimeo— graphed publication. 3. Hollingshead, A.B. and Illness: A Community Redlich, F.C.: Social Class and Mental & New John Sons, Inc., Wiley York, Study, 1958. h. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a Hos2., g: 216-228, 1957. S. R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: and Diagnosis, Ratings Discharge of Duration HOSpitalization, Kahn, Arch. Gen. Psychiat., 6. l: 565—57h, 1959- (CaliAttitude Social R.L., Pollack, & Ment. Nerv. F J. Dis., and Convulsive Therapy, Scale) fornia M. Kahn, and Fink, M.: 129: 187—192, 1960. 7. Pasamanick, B., Dinitz, tion Hospital, and 8. and to Diagnosis Relation Its Amer. J. Psychiat., 116: 127-132, l9S9. Siegel, N.H., Kahn, R.L., Pollack, and Treatment Psychiatric OrientaTreatment in a Mental S. and Lefton, M.: M. and Pink, M.: Social Class, Diagnosis in Three Psychiatric Hospitals, Social Problems, 10: 191-196, 1962 �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered A Markedly Improved Much Improved Improved A ! Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Unimproved Moderately Improved Slightly Improved Unimproved �TABLE Interhosgital Comgarisons for Sociopsychological Variables i I Social Class Years of Education III Menninger Hospital Hillside Hospital : I Massachusetts Mental Health �TABLE IV Interhospital Differences in Treatment Variables gMenninger Hillside Massachusetts Hospital Mental Health iHospital Center ' of Treatment ‘Psychotherapy Type 68 Somatic 8 Other 1 . _fl, __ Duration of Hospitali— zation 7-11 months 1 months Improved .--a-—u.~...w Much Improved 61 Unimproved lO a,” Discharge Diagnosis , months Recovered, Discharge Evaluation ~__imiu_i_.,i_.__.::- . ”13:29-33 W Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde df=h~ 5,1001 I ‘ ”WWW” 85 22 1? 26 29 ! I S2 1 �TABLE V Duration of HosEitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR £52 Below 20 Menninger Hillsidg 81 he 20-29 73 36 30-39 61 30 ho-h9 30 20 3422219. �' > %> This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hespital, Glen Oaks, L.I., N.Y., 1959-62. Pal/sue aux! KIRIM“ cooperation of the staffs of the Massachusetts Health Center the is The acknowledged. and C.P, Menninger Memorial Hospital Mental gratefully Aided, in part, by grants MY—2092 and MEI—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. ** Present Address: Division of Psychiatry, Montefiore Hespitalaw* ’ ' {hxxfirtfiF-itfifr IO‘NAZI g“ QM? 1.14: 0M yNL nan : National Institute of Mental Health, 'M, -flflqmam pn--~~r~Ognv m. Bethesda, Md. Department of Psychiatry at the Missouri Institute of Psychiatry ef-the-SChool of Medicine, University ot’ Missouri, suoo Arsenal Street, St. Louis) an, Ma, 6399'"! ,4 :9, �In their studies of the psychiatric patient population, Hollingshead and Redlidh have reported significant relationships between an' individual's position in the social class structure and the of treated New Haven illness, types of diagnosed disorders administered.(;%. treatment patient . The and kinds and duration W of psychiatric influence of the economic status of the the availability of treating personnel, however, was not excluded. Studies of the role of social factors in the treatment of hospitalized on #‘Ffi‘ . ' IflL srflwu‘ patients independent of pateent‘s finances and the availability of treatments were undertaken at Hillside Hespital in 1957. In this hospital, a variety of treatment modes, including individual psydhotherapy, pharmacotherapy and convulsive therapies were available to . . . . all patients regardless of their ability to pay. (Eglgé In these surveys we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birth. These older, less educated patients were predominantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratings. These clinical factors were also related to a measure of stereotypy, the ' California F ’15’ Scale (1333. Higher F scores, i.e., greater stereotypy, were often in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized fOr shorter periods, and more often were rated as much improved or‘recovered. hen, (gram) e' In thzs surveyglit was suggested that differences in psychiatric treat— ment among hospitals should reflect the influence of social factors as noted f0und fbr the patients within Hillside HOspital. To test this suggestion it was �decided to employ the procedures of the 1957 Hillside study in three institutions Hillside Hospital, the C.F. Menninger Memorial Hespital in Topeka and the Massachusetts Mental Health Center in Boston. These institutions were selected mm» Ww-Mans.:qum-W nag-MW : with the expectation that they served patients of different social classes.and- provide custodial care. Each supervisory staff and is a residency training center with a full active researCh units) time emphasiqgugsychoanalytically— They oriented psychotherqua This study was designed to determine the population characteristics of the three institutions with respect to social class, age, education and score; F to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the in— and stitutions. M'MWW,.,L..««Ila-mm?” W/ “”‘MW‘WWW ”‘W “’ m "' “ t4" "M" ‘flwwmwww ”‘ W “m «a , N, WWW‘W,MM —— �/ A METHOD census of all voluntary, adult patients in residence in the institu— in January, 1959. While Manninger and Hillside Hospitals had voluntary patients only, a small number of those at the MassaChusetts Mental Health Center (MMHC) were assigned by the courts for psydhiatric evaluation or tions was undertaken of a chronic schizophrenic state hospital group transferred for a from because excluded the These study were researdh patients project. specific of their non—voluntary status. The California F scale was scored for each were members patient on the census day. Eighteen months examined were of records the disdharged patients later to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingihead 2—factor index a.weighted score of education used(g;ii;.The and occupation was study population consisted of 173 patients — — at the Massachusetts Mental Health Center. social of the to the The study included examination.of the relations psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra— hcspital comparisons, and accordingly, in the analyses of psydhiatric variables emphasis will be placed on the differences between institutions with citation of at Hillside, 100 at Manninger and 95 intrainstitutional trends. These difficulties also led to missing infbrmation 1&6/34 6, #2, for some data, whidh is reflected in th varying population sample sizeslénrthe 4fififlxeu �RESULTS I Methodological Problems A‘ When reporting studies from one institution, the structure of the hospital maybe taken forgranted and either ignored or mentioned briefly. 'W 1,, e comparable gathering gr; m, _ M ”1111111....” institutions While were selected as these data from.multiple institutions, . in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific-problemscygf4LAt-Lk* comparable were prominent tions, in the designation of type of treatment, diagnostic classifica- and the evaluation of treatment outcome. criteria for designating that differed among the institutions, making come Designation of Eype of Treatment: 1) a patient received ”psychotherapy" [Sous parehti=ay The difficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a patient was Charged a fee. staff psychiatrist for whidh the Sessions with the psychiatric resident were con— sidered part of routine administrative patient care. 'At Hillside Hospital psydhotherapy was defined as treatment sessions with Staff psychiatrists did not treat patients, but No additional resident physicians. restricted their activities to supervising a psydhiatric resident. fees were charged. At the Massachusetts Mental Health Center psychotherapy was designated aucha‘ functiggrof psydhiatric residents, psydhologists, social workers, nurses and medical students. Formal records of such sessions as the many disciplines -— �which ascertain and record to in the included patient's were not routinely team members the of study for was received necessary psydhotherapy it patients to interview the resident responsible for eadh case. made comparisons diagnostic styles Individual institutional Diagnosis: evaluative the multiple employed diagnoses At Menninger Hospital difficult. 10 dlil the American Psydhiatric Association)while both followed different unitary systems. Several examples of scheme recommended by Hillside and MMHC conversions with Table suggested in our I, diagnoses from.Menninger are listed con— These two institutions. other of the that into categories comparable to versions provide a source of distortion. at the detail. The discharge rating at Menninger and format varied in three hospitals Hospital was tripartite with a separate evaluation for social, characterological 53) e Rat' Disc s of rovement: Ratings of improvement Hillside Hespital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study the Menninger syndrome and syndrome Changes. rating 3. jfiflv was compared to the global ratings of the other institutions. "A, .16 (’30 waft/mm Co I. Sociopsychological Variables The distribution of the variables of social class, age, education �and California F Scale score among the three institutions is presented in Table III. a) Social Class: The institutions composition of the three the population anticipated difference in social class was observed. was predominantly upper At Menninger Hospital class; at Hillside Hospital, middle Massachusetts Mental Health Center, predominantly lower class; and at class. There were no differences b) ége; in age distribution in the institutional populations. c) Education: The populations also differed in educational attain- ment, with patients having more years of education at than at MassaChusetts Mental Health Center. While Ml patients at per cent of the had not completed high school, only 32 per cent at MMHC Hillside and 23 per cent at Menninger did not graduate. d) F Score: Califbrnia F patients had 50 or above below 30. Differences in the distribution of scores on the Scale were also observed. Fifty—one per cent of Menninger F —- of stereotypy. patients had Menninger Hospital F scores below 30, and only eight per cent with scores of the higher F scores being associated with higher degrees In contrast, at Hillside thirty—one per cent of the scores below 30 while at MMHC only twenty per cent were �Thus, thl=a=pa===d.differences in social attainment and performance on the #40; F class, educational Scale were observed. RELA'H u a. These differences permit a test ofkhypotheses oamannrnngdflxrirfiefifixwrtn? sociopsychological factors to the treatment variables among these institutions. 12. Psychiatric Treatment Variables a) Selection of Treatment: Amongfiinstitutions, significantly at Menninger Hospital (”3%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV). fewer patients b) DUration of H05pitalization: The three institutions differed with regard to patient’s length of stay (Table IV). Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per cent of the Hillside patients and only per cent at the MassaChusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were disdharged 5 within six months of hospitalization. c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger Hospital, however, a higher percentage (19%) of were rated as "unimproved" and only a single patient "recovered" or "much improved". or "much The was patients scored highest percentage of "recovered" inproved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found d) Diagnosis: groupings were made: at the Massachusetts Mental Health Center. For statistical analysis three diagnostic schizophrenia, affective disorders, and psycho- neurosis and personality disorders (Table IV). The diagnostic propore tions of patients within these groups were similar for Hillside and MMHC, �as slightly more than half were diagnosed as schizophrenia and one- In contrast , at Menninger quarter as psychoneurosis or affective disorder. Hospital psychoneurosis and personality disorder accounted for more than fifty per cent of the population. 6. Intra—Hospital Comarisons lack of meaningful criteria for the subdivision of populations, 1......an size and 1:: the sample each within institution homogeneity their dgghb A $31“ Lou-T precluded adequate intra—hospital comparisons . everal groupings were The WW Jr”) W obtained which had fewer than five cases) . . . . 94 z 5/ the trends appeared similar to those found in the earlier study. Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher more and somatic therapy), receiving frequently F P score patients score alone at Hillside. both the related at and were chronological of age hospitalization length Hillside Hospitals - the younger patients remaining for the longest periods, While such relationships were significant in these MMHC V) where no (Table noted the was at trend similar two hospitals, a Menninger and patients over 40 , but 1% of patients under the age of than a year. ————_———_—— 20 remained longer �DISCUSSION Q , M daM SOClal variables—95 1:11: differences in Significant interinstitutional of distribution in not but age; years of education/W97 ; F ? {”1238 MN 3 WI } kw of eva‘aaeed periods shorter lower class patients the institution serving Eta and fieportions diagnoses of low psychoneurotic “better , hospitalization, discharge evaluations. \ ment are fiuw $7, memm‘ ; (M I and complex more diagnoses of psychoneurotic of stay, a higher proportion a forms somatic receiving of patients diagnostic schemataalower proportion “in Similarly, yere-eaeh-eonflmed. ratings and discharge of therapy, poorest r“ “3 {2/ MW W , ”fl 033°” “5: f Wtuw W —variables treatment the each of and F in California Scale scores; duration of hospitalization, selection ff treatments and distributions “MM: Mafia—5’ in— e of diagnoses and discharge evaluations. ..._v,.__~__~_.'/l\——".~W-v J! A . . . . duration the longest class patients stitution serVing upper ' f""\ 9’ «mean related Ato differences in staff attitudes than—to— “errences in populations . 'Ihe contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic and of evaluations psychotherapy, formulations , discharge , definitions lflese differences recorded data. amount and stylistic of details the W wwfi‘sfissed as slinky idiosyncratic1am they follow a pattern M, W related to social {W WW; meabmx/Wm fig “W434. differences] consistent7with . �-10- Such population and treatment variable relationships are Cf the physician attitude the both determined by interactive processes , and the administrative staff and by the Such constellation of symptoms or relationships are marked most history which patients present. least are criteria where diaglostic conditions those in psychiatric known of diseases defining criteria where objective i.e. specific, , fl personality schizophrenia, in psychoneurosis/ etiology are absent, as AAA-0L of conditions perceptual a: Under these disorders. and behavior and expectations attitudes observer's the situational ambiguity) Ak444~0u4, become 5 I4 v "uufi situation was Eris his perception classification) 6 . . . . study their and (1) lefton in Dmitz Pasamanick, clearly emanated-by observed They institution. within a single of variations in diagnosis in did differ wards not type different to assigned“ that patients g4en¢bh ' o dew S ’and' ~qu réaedéup _ M ’1 Significant residence. education, or age marital status, of admission, diagnostfié Cewif‘UI-Lflvarious of incidence differences did occur, however, in the among the three wards and m ' believe thefi reflect the among differences attitu W ward. one on administrators three As (“E in the populations/ we es 0 the examiners. ”atclinical evaluation Present psychiatric concepts of diagnosis par” another. to institution have little For results . roduces paradoxical literal adherance to these concepts meaning when example, Menninger transferred from one M mhighly trained personnel Hospital has—themes; con— 3% has “fewest the for longest patients its keeps time/and ducting treatment, the poorest Ad reports yI.’ yet, as diaglosed schizophrenia, patients I i I �-11- treatment results. ,fit'MMHC, in contrast, whiCh is most inclusive in defining a therapist, which keeps patients for the shortest periods, and whéeh-has a higher-proportion of the population classed as schizophrenia, OV’ quality of carefnnop the assessment of comparability of populations for degree of illness among the institutions)‘ Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of rather than.§gy intrinsic psychiatric Characteristics. In our criteria of initial Hillside it was postulated that different utiliZed fer persons of different social suggested that the higher the person's social improvement were It baCkground. study (‘) improvement was the more complex the cr1ter1a.enm3i?:§é*£lgis has‘::§&;1 background literally confirmed in the present study, WithAMenninger‘EluSIng a to the global rating of the other two institu— considering the syndrome rating on whidh our comparative tripartite rating tions. Even statistical compared analyses were based, it is our contention that fOr lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize sudh complex intangibles as "developing insight", or "working through one's problems." �-12_ demonstrated the role of While these investigations have again social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These selected for their educational leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable institutions were data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of disdharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populations. fikrtefiéeve——— difficulties also extend to the failures of scientists to clinical or laboratory observations made in other laboratories, lack of confirmation may reflect differences in populations and criteria as much as errors in the original hypotheses. The use confirm ’Ehese for the psychiatric of the terns "schizophrenia" or "psychoneurosis" to explore changes in psydhological and biological features of mental illness has led to-;:;1mnanadrthgr 6;Z;é science burdened by negative results. a valid observation to be “40W reported from one laboratory{ the methods armhamfiaafieélable—teéay to Judy.” «(no—c..- (adeduately)describe psychiatric populations for an=adiqnuta==nnfinm==éan. //*~—~.“www.m“imm. “WM.,.,.--M—«~~WW" c M 4;,Aaanéigzgedai7 . : 54; fggfi"JR;¢”;' 2%;7*"/;? E �~13. fzar Increased attention must be paid to thenaathedniogéoairprebiemSuei—-V4-’ 3 w, a by "objective" criteria rather than the present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist-patient interaction. $nn“ g cla881fyiag sub ects ‘ . o a 9 a �-1u- WW SUMMARY and “Wu-I 2 @1 MW VoLu u'! three CONCLUSION MWHw.» m...» (A a. teaching hospitals, W,~.mm~__1_ ""“"Wm.m...“ mmwv— vm l.»/ fiopulation characteristicsjig-ererelated to treatment variables W ,.. . ., wwmm MN defined by social class, age, education and F score , W type of treatment, duration of hospitalization, TfZM (W Washed-#0 W diagnosis and discharge evaluation. Z interinstitutional :da— differences were observed in patient social class , years of education and California F scores , but not age. distribution of @ variations in treatment characteristics among institutions were found—$0.435; significantly different in the predicted ‘2, The direction. '% 6 “Q variations in psychiatric practices follow a pattern among’f‘institutions withgocial and are consistent class differences These not regarded as idiosyncratic. 6g ‘Eae differences in institutional style make comparisons of between and treatment duration results of diagnoses, hospitalization, institutions difficult and tenuous , and the need for more objective criteria 4w 4C1 ff classification ( 0 ne‘kfi‘m‘v) emphasized. is pppulations A �REFERENCES Adorno, T. W., Frenkel-Brunswik, Authoritarian Personalitz. The 990 pp. 3. Communit238tudz. J. and Sanford, R. N. Harper and Brothers, New York, 1950, D. Class and Montal Illness: John Wiley and Sons, Inc., New York, T933, KHZ pp. Hollingshead, A. B. and A E., Levinson, delich, F. 0. Social L., Pollack, H. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Montal Hospital. J. Hillside Hos ., 1957, Q; 216Kahn, R. 228. h. Kahn, R. L., Pollack, M. and Pink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Montal Hospital: Duration of Hospi- talization, ;: 565-5714. Discharge Ratings and Diagnosis. Arch. Gen Ps hiat., 1959, S. Kahn, R. L., Pollack, M. and Fink, H. Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Mont. Dis., 1960, 1;_: 187—192. Pasananick, 3., Dinitz, s. and Lofton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. P hiat., 1959, gig: 127-132. 7. Siogel, N. H., Kuhn, R. L., Pollack, M. and Fink, H. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 19: 191-196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved -WM_W_ Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE InterhosEital III Comparisons for Sociopsychological Variables Menninger Hospital I Hillside Hospital 1 Massachusetts Mental Health s 2 § a 3 1 1 Social Class III E 17 3b ‘ z g i g 1 i i 3 i l ! z ~, Years of Education llZ—lS ; % i a 3 I F Score 5h '13 �TABLE IV Interhospital Differences in Treatment Variables ;Menninger [Hillside Massachusetts {Hospital [Hospital Mental Health of Treatment Type 'Psychotherapy Somatic 68 Other 8 I Duration of 7-11 months Hospitali— W zation months WWW..-”— mmm -w - 1 *- Recovered, Improved Discharge Evaluation Much Improved 61 Unimproved 10 . i Discharge Diagnosis . , I mewmm 001 -.......’32_.L.__.......B< _.... Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde (95) (171) I (85 5h% 17 �TABLE V Duration of HosEitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR l» mm Below 20 Menninger Hillsidg 81 he 73 36 61 30 3O 20 �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I. New York, 195941962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial " Hospital is gratefully acknowledged. The ‘ Aided, in part, by grants My—2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York *9': Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the psychiatric patient pop— ulation, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded, New Haven Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to pay“ In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birthc These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratings, These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i.e,, greater stereotypy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recovered. In the survey reported here, it was suggested that dif— ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital, To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -— Hillside Hospital, the C. Fo Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Boston» These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classesc Each provided short-term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapyo istics This study was designed to determine the population characterof the three institutions with respect to social class, age, score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions” education and F �-2“ METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside Hospitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo— phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary statusc The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center» — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trends" These difficulties also led to missing information for some data, which is reflected in.the tables by the varying population sample The sizes, fl... �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or men— tioned briefly. In gathering comparable data from multiple institu~ tions, however, the many differences between institutions are accentuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study, Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome; When *— 1. Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult, At Menninger criteria for differed among Hospital psychotherapy was designated as basis by a staff psychia— treatment administered on a prescription trist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident“ Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicians, No additional fees were charged, At At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psycho~ was necessary for members of the study team to interview therapy it the resident responsible for each case. 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and followed different unitary systemsa Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono MMHC �Table I 3. Discharge Ratings of Improvement: Ratings of imr provement at the three hospitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study the Menninger syndrome rating was compared to the global ratings of the other institutions. Table B. Inter-hospital II Comparison 1. Sociopsychological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table in. a) Social Class: The III . anticipated difference in social class composition of the three institutions was observed. At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduatec c) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty-one per cent of Menninger patients had F scores below 30, and only eight per— cent with scores of 50 or above -— the higher F scores being assoc— iated with higher degrees of stereotypy. In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 300 d) F Thus, differences in social class, educational attainment and performance on the F Scale were observed, These differences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables 2a among these institutions. Psychiatric Treatment Variables Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV). a) three institutions differed with regard to patient's length of stay (Table IV)Q Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside b) Duration of Hospitalization: The group was between seven and eleven months while two—thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV)o At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved” and only a single patient was scored "recovered" or "much improved"e The highest percentage of "recovered" or "much improved” ratings (28%) and the lowest proportion of "unimproved” (10%) were found at the Massachusetts Mental Health Centero nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV)w The diag— nostic preportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one-quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per—cent of the populationo Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital com— parisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsideo Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periods, While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. The Table V �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to anothere Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results, At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment resultso In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social backgroundo It was suggested that the higher the person's social background the more complex the criteria em— ployed° This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapiese The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other laboratories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist-patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables included type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions, ~Simi1arly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula— tions is emphasized° These �REFERENCES E., Levinson, D. J. and Authoritarian Personality. Harper and 1. Adorno, T. W., Frenkel—Brunswik, Sanford, Brothers, R. N. The New Hollingshead, Mental Inc., York, 1950, 990 pp. A. B. and Illness: A Redlich, F. C. Community Study° New York, 1958, 442 pp. Social Class and John Wiley and Sons, L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. Kahn, R. J. Hillside Hosp., . 1957, 6: 216-228. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and G Ps Diagnosis. A a ., 1959, A; 565—574. Kahn, R. Kahn, R. ifornia F L., Pollack, Social Attitude (CalScale) and Convulsive Therapy. ligjfiuabhlkuug_jn§,, M. and Fink, M. 1960, 13Q5 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental 1959, 116: 127—132. Hospital. Whig” Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosEital Comgarisons for Sociogsxchological Variables Menninger Hospital I Class "I“ Hospital 7% II 20 III 34 IV 34 V 5 x2 = 121.5; df=8: I Massachusetts Mental Health lllllflaiflllllllIlllflflflflfllllll N Social Hillside _ p:(.001 “M“-0__-____—_‘-.i-____.__..1-____—___ 19% 20- 39 Years of Educatio <12 41% 12-15 49 16+ 10 x2 = 39.2; df=4g p<.001 �TABLE IV Interhospital Differences in Treatment Variables §Menninger N T Massachusett Mental Healt Center mum-.mHospital Type of Hillside Psychotherapy Hospital 36% re atment Somatic Other =82 8 df=4 100 N Duration of Hospital— ization 7 months 7-11 months . ~11 months Recovered, Much .001 173 95 22% 27% 67% 13 42 27 65 31 5 90. 6 df= 4 X2= . .001- Improved Discharge Improved Evaluation Unimproved X = Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 2903' df=4. U<n001 52% 54% 22 17 26 29 23.8' df=4° .<.001 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20-29 73 36 30-39 61 30 40—49 3O 20 50+ 36 MMHC 14 �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I. New York, 1959— 1962. Pollack and the staffs of the Massachusetts Mental Health Center and the C. F. Menninger Memorial Hospital is gratefully acknowledged. The co.operation of Dr. Max Aided, in part, by grants My—2092 and MY-2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore .Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the New Haven psychiatric patient pop— ulation, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excludeda Studies of the role of social factors in the treatment of hosPitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including in— dividual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to pay, In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratingso In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingsm These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i;gf, greater stereotypy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredu In the survey reported here, it was suggested that differencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital» To test this suggestion it was decided to employ the procedures of the 1957 Hillside study in three institutions -- Hillside Hospital, the C. F, Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Bostono These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classeso Each provided short-term treatment of voluntary patients and did not provide custodial care. Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapya istics This study was designed to determine the population characterof the three institutions with respect to social class, age, score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutionsa education and F �METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside HOSpitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo- phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non-voluntary status. The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center, — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions, These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trendso These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample The sizes, �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or men— tioned briefly. In gathering comparable data from multiple institutions, however, the many differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific dif— ferences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome, When 1, Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult. At Menninger criteria for differed among Hospital psychotherapy was designated as basis by a staff psychia— treatment administered on a prescription trist for which the patient was charged a fee, Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident, Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicianso No additional fees were chargedu At At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical studentso Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident responsible for each case. was 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and followed different unitary systemso Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono MMHC �‘1 Table I Discharge Ratings of Improvement: Ratings of imw provement at the three hosPitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)o For this study the Menninger syndrome rating was compared to the global ratings of the other 39 institutions. Table B. II Inter—hospital Comparison 1. Sociopszchological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduate, c) Education: The Differences in the distribution of scores on the California F Scale were also observed. Fifty-one per cent of Menninger patients had F scores below 30, and only eight per— the higher F scores being assoc— cent with scores of 50 or above iated with higher degrees of stereotypya In contrast, at Hillside thirty-one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30, d) F Score: —— Thus, differences in social class, educational attainfi ment and performance on the F Scale were observed. These diff— erences permit a test of the hypotheses relating sociopsychological factors to the treatment variables among these institutionse 2. Psychiatric Treatment Variables Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV)c a) three institutions differed with regard to patient's length of stay (Table IV)O Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center, The modal stay of the Hillside b) Duration of Hospitalization: The group was between seven and eleven months while two—thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: PA In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved", The highest percentage of "recovered" or ”much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centero nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one-quarter as psychoneurosis or affective disorder, In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per-cent of the populationo Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periodso While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. The Table V �-7DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter'institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables -- duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7)¢ The ,r‘ Expectations based on our earlier intra—Hillside Hospital were confirmedo The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions” Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populations° The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data, While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, 3223, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorders, Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution, They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residenceo Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to another, Literal adherance to these concepts produces paradoxical results, For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results, At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions, Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background, It was suggested that the higher the person's social background the more complex the criteria em— ployed, This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating In our compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statis— tical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �f’. leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies, The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the original hypotheses. The use of the terms "schizophrenia" or "psychoneurosis" to explore changes in psychological and biological fea— tures of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the socio— psychological aspects of the therapist—patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in" cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso »Similar1y, the institution serving lower class patients did have the Shorter periods cf hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations, The variations in psychiatric practices followed a pattern consistent with the social class differences among the stitutions and are not regarded as idiosyncratic. These in— differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula— tions is emphasizedo Such �REFERENCES E., Levinson, D. J. and Authoritarian Personality. Harper and 1. Adorno, T. W., Frenkel—Brunswik, Sanford, R. N. The Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., . A. B. and Illness: Redlich, F. C. John Wiley and Sons, Community Study. New York, 1958, 442 pp. A Social Class and L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216-228. Kahn, R. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and G PS h 565—574. 15 Diagnosis. 1959, ., Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Social Attitude (Ca1- Scale) and Convulsive Therapy. .lLJkflubnlkflug_DLi-, 1960, 139; 187-192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. Am£I4_Ja_2£¥£hiaL., 1959, 116: 127—132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 195 191—196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosRital Comparisons for Sociogsychological Variables Menninger Hospital N I Social Class ‘“ Hillside Hospital Massachusetts Mental Health Center IllllflliillllllllIIIIIIIHEIIIIIIIIIIIIIIIIZIIIIIIIII 31% 7% II 51 20 III 17 34 IV 1 34 V 0 5 x2 = 121.5; df=8: p<(.001 “M 1IIIIiIifliiIIinjflfiniiiiifliiiifliijfiiiiiiIIIIIIIMIBIIIIIIIII 19/ 20- 39 = Years of Educatio 3. 9; df= 4; p=n. s. < 12 41% 12-15 49 16+ 10 x2 = 9.7; df=4; p<.05 IIIIEIIIIIIIIIIIIEIIIIIIIIIIIIIIIIIIIIIIIIIIIIIEflIIIIIIII F Score x2 = 33% 20% 50 38 17 42 39.2; df=4; p<.001 �W TABLE IV Interhospital Differences in Treatment Variables {Menninger Hospital N Type of Treatment Psychotherapy Somatic Other Duration 0t Hillside Hospital Massachusett Mental Healt Center 21% 36% 24% 43 64 68 36 -— 8 7-11 months Hospitallzatlon ~ll months Recovered, Much Improved Discharge Improved Evaluation nimproved X = Schizophrenia 2903. df=4.'<0001 52% Discharge Diagnosis Affective Psychosis 22 Psychoneurosis and Personality Disorder 26 X = 23.8. df=4. .<0001 54% 17 29 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Ass Menninger Hillside Below 20 81 42 20-29 73 36 30-39 61 30 40-49 30 20 50+ 36 MMHC 14 �Herch 12. 1965 Dr. Hetheniel Siegel. Ph.n. lecionel Institute of Hentel Beelth Bethesde. Ketylend Deer nets: I have sooepted ell your recommendations end heve redone this report. Enclosed ere e for copies which, while they still may hsve e typographiosl error, ere in e for: which ooold he sent to s publisher. I have taken the liberty of running this off on Colitho pletos. so the: if it is not published, we may still have some copies for our friends. Unless I hes: from you or receive s stop order. I will send e copy of this to the Archives of Geoersl Psychiatry. My best regards. Sincerely yours. Me: Pink. H.D. H131- Professor of Psychiecry �Hutch 12. 1965 Dr. Robsrt L. Kuhn, Ph.D. Division of Psychiatry antstiora Hospital and Medical Cents: Ill Esau 210th 8tssst Riv York, flaw York 10667 Dear Bdb: Following all tha recommendations in our last discussion, I have accepted the full responsibility for this draft. Recognizing the snotionsl problems involvsd. I hsvn deleted nsas. In this drsft. I have sssuusd tbs senior authorship insofar as you seen to be ralactsnt to do anything with the doeumsnt. It you would lihs, I will has. the first psgs radon. sad hsvs this subnictsd to tbs Archivss of Gsuarsl Psychiscry. with you ss senior author. st's It I tsctory. My do not has: from you. and submit ss is it it I will assume that this drstc is satisto Dr. Grinksr. best rsgsrds. Sincerely yours, Iink, H.D. frofsssor of Psychistry Ms: 31:3: �MONTEFIORE'HOSPPTAL.AND MEDICAL UHETHR 111 EAST 210TH STREET. BRONX. NEW YORK 10467. TELEPHONE: 212/TU 1-1000 March 15, 1965 Fink, M.D. Professor of Psychiatry Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5h00 Arsenal Street St. Louis, Missouri Max Dear Max: Thank you for sending me the draft of the "Three Hospitals" paper. I can understand your deleting Max's name since he never seemed able accept this organization of the material. I would appreciate however, if my name were restored as senior author when the paper is submitted for publication. I do not, in fact, feel "reluctant" it, to handle it, and if you wish, I am quite prepared to arrange for publication. I have no objections, however, if you wish to submit it to Dr. Grinker first with myself as the senior author. I notice from your letterhead that you are now a professor at the university of Missouri. I hope this change will be beneficial to your professional interests. You certainly have my best wishes. Regards to Martha. Sincerely, 34;, Hebert L. Kahn, Ph.D. Head, Section of Psychology Division of Psychiatry RLK:DCS to �April 1, 1965 Robert L. Kain, Ph. D. Division of Paydmiatzy Hmtefiom Hospital and Hndical Cantor 111 East 210th Strut Bronx, Haw York 10%? DurBob: Mummftisenclmod.andithasgmctonn Wrinthisfom Idohopohaceeptait,becauseit is me of tho intcmsting nm-biolofieal studies in m participated. MWMWMW.mImfindmlf inapooitimsimilartomatmichlheldinmsa. whidx we have Waterman burdms The are minimal and palate exclusively to mymstudiu. Immhawadaiewdawdmofindepondmca fwmamhwithamatdulofauflmvityoverpatimtn. staff.md£acilitius. WMIcm-mhemflxingofthis Ihaveafew excellent oomrkcm,but mlytimwill tell. have none the stimulation and imginatim that you exhibited. Max 14?: fun Fink, PLD. Professor of Pug/wintry �DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE BETHESDA. MD. 20014 NATIONAL INSTITUTES OF HEALTH AREA aoI TEL: ass—mo coo: March 17 2 1965 In reply refer to: M-TMR-SS AIRMAIL Dr. Max Fink Professor of Psychiatry Missouri Institute of Psychiatry ‘ University of Missouri 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: for the colitho copies of the "Sociopsychological" It looks fine and I hope that it will be accepted by Thank you paper. the Archives of General Psychiatry. I have been in touch with some of our training grantees in Missouri, making the Missouri Institute of Psychiatry more visible to them as a research source. I hope that some cooperative endeavor may result in the not too distant future. Please keep in touch, and give my best regards to Martha. Sincerely, Nathaniel H. Siegel, Ph. D. Acting Chief, Social Sciences Section Training and Manpower Resources Branch National Institute of Mental Health �April 1. 1985 Mamie). a. 31.91, PM). Acting Chief, Social 801m Sectian Training and Hammer Ramon Bunch National Institute of bats). Health Dapu'mmt of Health, Edtmtim. md Welfm Bethesda, Maryland Dar Nat: After- scnfing copies of the aociopsychological paper to Bob, he indicated apnfomce forbeing the scalar auflm. Implmodtocxooodtohiswish,mdmcloeediaaoopy offite “pm wiflatmmvisod fact sheets. Ampysimmrto this has gone to the Amhim. 811ml}; yaks, Max HP-zjn Pink, 1-1.1). Manor of. Psychiatry �March 30. 1965 lobbins, stis Msdicsi Dirscror Hillside Hospital Dr. P. O. Box 38 Glsn Oaks, Haw K. D. York Dost Lev: During ths wists: usstings discussed this study and esrion. we Bob Xshn, I for publi- Nst Sisgcl and ssrssd to prepsrs it linsl drsft is enclosed for your infornstian. Vs hsvs tsksn rhs liberty of sabnirring this to Dr. Grinksr for his A consideration for publication in tbs copy I! to Agghgve . it sdvissbls. I would be plesssd to ssnd you dssl snyons you sugzsst st tbs Heaninxsr Foundation. Sincsrsly yours. link, H. D. Protsssor of Psychiatry Ms: first, s �Hatch 30. 1965 Dr. Jack Ewslt, H. D. Prefessor of Psychistry Massachusetts Hunts! Esslth Cantor 72~76 Yenwood Rosd Boston, Hassschnsstts Dear Dr. Ewslt: s conpsrsttve study was undertsksn with the Massachusetts Mental Baslth Conner as s coopsrstins institution. A finsl copy of tbs ropes: of thst study is sneloscd. we have tsceLvsd psruisston to publish this inforustion from Sons years ago, Dr. Grssnblstt. WW- I an writing to tell for consideration I would bu by tho you tbs: us hsvs submittsd this drst: plssssd to hsvs your con-sacs. Sinesrsly yours. Ms: rink, u. D. Profsssor of Psychiatry lltkp �March 30, 1965 as. Roy R. Grinkar, Sr. lbpartnent of Psychiatry Michael Reese Hospital micago, Illinois 60616 Dear Dr. Grizflcer: I the opportmity to enclose two copies of a report "Socioysychological Aspects of Psychiatric Tmatmnt in Emma Voluntary Hospitals" for your consideration for publicatim in the Archives. am tall-dug We report mmmts a study mdertaken some years ago by my associates and myself at the Hillside Hospital. We have decided to submit 'ti'xis for publicatim, in View of the continued interest in the social aspects of diamonis and manhunt. Sincerely yours, Max Pixflc, M. I). Professor of Psychiatry 3‘? �Harvard Medical School Department of Psychiatry Boston Fenwood Road, 021 I 5 74 l l l Massachusetts Mental Health Center [plllllllllllllllllll3M“; ljlllllllllll!!llfllH . ugfifirflifi a: g 2:” l (Boston Psychopathic Hospital) ill Department of Mental Health W” ”H" u: ‘ Flak-.215 .-:::.!'1| " x2.mumuillméw JACK R. EWALT, M.D. 3mm PROFESSOR or PSYCHIATRY SUPERINTENDENT April 5, 1965. Dr. Max Fink Professor of Psychiatry Mi ssouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: Thank you for the copy of your study of the Hillside Menninger's MMHC. I found it very interesting and, considering the differences particularly between this place and Menninger's, I am impressed with the way you could tease out comparable elements. I would hope some energetic person would about ten years after the first study do a repeat on the same three institutions, using as near as possible the same criteria to see what directions or shifts if any had taken place be would directional changes that there I them. strongly suspect among in all three but the differences you found would probably persist. Si ely �w. -. m. .V 1n: vv “ quI’V—nw W", waw w':——'-1.17W . VF... s ”pamn— w...“ -mrmwmwv 4w-uw1-w‘rr ,_....v , . — Jun. 3, up. lbbart 1.. New . .4, , .«.—-~w "w ‘v.'rr .. «q many 1965 Rain Division of Psychiatry Hawaiian Win). and 1.11 East 210th 3m“: M York, ”fin—“W. hated. Cantor York 16%? DaanublndNat: Hm: Firm, 1!. 1). Professor of Paydfiatry many an: HAW Sign. Hm}. Mimi Imam of m1 Knuth m, mm a“ m:«mv-:~,<muvw; vn‘w‘u‘w‘rv v V .. ,... �PROCESSING OF ACCEPTED MANUSCRIPTS Each accepted manuscript is processed in the Chicago Editorial Offices of the Archives of General Psychiatry bringing together all elements of the printed pages of the final published article. You will receive a reproduction of the typescript, edited according to the official AMA Style Book, for final review and approval. There will be no galley proof. is accepted with the understanding that it may be necessary to make minor revisions, or to request changes in illustration or text. Your manuscript The Editors �SAMPLE DETACH SAMPLE AUTHOR(S) (AND ONE ADDRESS): R. K. Merchant and .I. P. Utz 1200 Blank Street, Chicago, Illinois 60610 TITLE: Familial Sarcoidosis (Name of) JOURNAL: Archives of Internal Medicine Sarcoidosis was observed in a mother and her daughter. The criteria for this diagnosis included (1) a compatible clinical picture, (2) granulomatous inflammation with little or no necrosis and the absence of demonstrable microorganisms to specially stained sections of biopsy material, (3) negative cultures, particularly'for acid-fast bacteria and fungi, of appropriate body fluids, exudates, and surgically excised granulomatous tissue, and (4) apositive Kveim test. These cases of sarcoidosis, together with 73 others involving more than one member of each 32 families, suggest the possibility that a complex hereditary trait is operative in the pathogenesis of Sarcoidosis. �w DETACH . INVITATION...TO PREPARE AN ABSTRACT OF YOUR COMMUNICATION WHICH WILL BE CONSIDERED FOR PUBLICATION .IN THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. Suggestions: .7. 1. Type name(s) of author(s) (also address of one of the authors), title of article and name of journal in which the original article appears. 2. Type abstract on attached card and mail promptly: a) Indicate purpose, extent, kind of study, materials and methods used. chiefly to new data—the high points—informational, not descriptive; criteria, technics, diagnostic new new new new statistics, apparatus, e.g., new evidence, new preventive measures, a new theory,new treatment.Do not use abbreviations. b) Refer 3. The abstract should not exceed 200 words. NOTE: Accepted abstracts will be printed concurrently with publication} of the original article. PLEASE TYPE THIS IS THE ONLY REQUEST PLEASE RUSH �DETACH PREPARE AN ABSTRACT OF YOUR COMMUNICATION WHICH I LL BE CONSIDERED FOR IiIVITATION...TO PUBLICATION IN THE JOURNAL OF THE AMERICAN EDICAL ASSOCIATION. Suggestions: 1. Type name(s) of author(s) (also address of one of the authors), title of article and name of journal in which the original article appears. 2. Type abstract on attached card and mail promptly: a) Indicate purpose, extent, kind of study, materials and methods used. b) Refer chiefly to new data—the high points—informational, not descriptive; e.g., new statistics,new apparatus, new technics, new diagnostic criteria, new evidence, new preventive measures, a new theory,new treatment.Do not use abbreviations. 3. The abstract should not exceed 200 words. NOTE: Accepted article. PLEASE TYPE abstracts will be printed concurrently with publication} of the original THIS IS THE ONLY REQUEST PLEASE RUSH �SAMPLE DETACH SAMPLE ——————————-———————‘_ AUTHOR(S) (AND ONE ADDRESS): R. K. Merchant and J. P. Utz 1200 Blank Street, Chicago, Illinois 60610 V. TITLE: Familial Sarcoidosis (Name of) JOURNAL: Archives of Internal Medicine Sarcoidosis was observed in a mother and her daughter. The criteria for this diagnosis included (1) a compatible clinical picture, (2) granulomatous inflammation with little or no necrosis and the absence of demonstrable microorganisms to specially stained sections of biopsy material, (3) negative cultures, particularly'for acid-fast bacteria and fungi, of appropriate body fluids, exudates, and surgically excised granulomatous tissue, and (4) apositive Kveim test. These cases of sarcoidosis, together with 73 others involving more than one member of each 32 families, suggest the possibility that a complex hereditary trait is operative in the pathogenesis of Sarcoidosis. �*Kahn, R.L., Fink, , dd d THOR s *‘blijvisioé 3f(?3yc?1'i%€ryf°figntefiore “ M. and Siegel, N. 10467) Hospital, St., TFFLE:Sociopsychological Aspects of Psychiatric Treatment in Three JOIHHWAL: Archives of General Psychiatry Voluntary HOSpitals. Population characteristics, defined 5y social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals, Hillside Hospital (N.Y.), C.F. Menninger Memorial 111 E 210 NY Hospital (Topeka), and Massachusetts Mental Health Center (Boston). Treatment variables included type of treatment, duration of hospitalizaThe and evaluation. institutions differed in discharge diagnosis tion, of education and distribution of California class, years patient social 1 but not age. EF scores, had the The class longest g patients serving institution upper p psychoneurotic diagnoses > quration of stay, a higher proportion of lower of patientg Idand a schemata, complex proportion more diagnostic (I) the dischar e of fo oorest an somatic ther rati receivi Eamong tfié three instfgfitions. €¥§i1ariy, thg institution sgrving “gs m of had the shorter hospitalization, periods class patients glower m lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. Psychiatric treatment and management practices differ among institutions according to the prevailing social class characteristics of their populations. �F‘ . “‘ ““ <4, FIRST CLASS Permit No. 1876 CHICAGO 10, ILL. VIA AIRMAIL MAIL REPLY BUSINESS No Postage Necessary if Mailed in the U.S. Postage . W111 be paid by— . American Medical Association 535 North Dearborn Street Chicago, Illinois 60610, U.S.A. Z. Danilevicius, MD _ — '— — — — — — — — — — — _ ~ �ARCHIVES OF GENERAL PSYCHIATRY EDITORIAL BOARD ROY R. GRINKER SR., M.D., Chief Editor American M€dical ASSOCiation June Institute for Psychosomatic andPsychiatticReseatch 29th Street and Ellis Avenue Chicago, Illinois 60616 EATON W. BENNETT, M.D., San Antonio EUGENE L. BLIss, M.D., Salt Lake City GEORGE E. GARDNER, M.D., Boston EDWARD O. HARPER, M.D., Cleveland M. RALPH KAUFMAN, M.D., New York HAROLD I. LIEF, M.D., New Orleans FREDERICK C. REDLICH, M.D., New Haven, Conn. MORTON F. REISER, M.D., New York DAVID MCK. RIOCH, M.D., Washington, D.C. JURGEN RUESCH, M.D., San Francisco 3 , 1965 Fink, M.D. University Of Missouri Max Medicine 5400 Arsenal Street St. Louis, Missouri JOHN H. TALBOTT, M.D., Director DIVISION OF SCIENTIFIC PUBLICATIONS SChOOl Of GILBERT S. COOPER, Managing Editor T. F. RICH, Assistant Managing Editor 63139 ' re: Manuscript Number 3836 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Fink, and Siegel Dear Doctor Fink: I am very pleased to inform you that your paper has been accopted by the Editorial Board for publication in the ARCHIVES OF GENERAL PSYCHIATRE, Yours very ROY truly, R. GRINKER, 311., NJ). Chief Editor iknczbr �’ ARCHIVES OF GENERAL PSYCHIATRY EDITORIAL BOARD ROY R. GRINKER SR., M.D., Chief Editor American Medical ASSOCiation Institute to: Psychosomatic andPsychiatticReseatch 29th Street and Ellis Avenue Chicago, Illinois 60616 EUGENE L. BLISS, M.D., Salt Lake City GEORGE E. GARDNER, M.D., Boston EDWARD O. HARPER, M.D., Cleveland M. RALPH KAUFMAN, M.D., New York HAROLD 1. LEE, M.D., New Orleans FREDERICK C. REDLICH, M.D., New Haven, Conn. MORTON F. REISER, M.D., New York DAVID MCK. RIOCH, M.D., Washington, D.C. JURGEN RUESCH, M.D., San Francisco June 149 1965 Max Fink, M.D . JOHN H. TALBOTT, M.D., Director DIVISION OF SCIENTIFIC PUBLICATIONS Department Of PSYChiatry Executive Managing Editor GILBERT S. COOPER, Managing Editor T. F. RICH, Asszstant Managmg Edttor ROBERT W. MAYO, Missouri Institute Of Psychiatry University Of Mi ssouri 5400 Arsenal Street St. Louis, Missouri 63139 re: Manuscript SOciopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Fink, and Siegel Dear Doctor Fink: I Number 3326 very pleased to inform you that your paper has been accepted by the Editorial Board for publication in the ARCHIVES am OF GENERAL PSYCHIATRY. Yours very ROY truly, R. GRINKER,SR., M.D. Chief Editor RRG3br P.S. We will, Of spaced throughout. Course, need three cepies of the manscript, doubled �re: Manuscript Number 3836 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Dear Author: et a1 Your paper has been received and is being considered by the Editorial Board. A decision will be given to you as soon as possible. Yours very truly, ROY R. GRINKER, Sr., MD. Chief Editor ARCHIVES OF GENERAL PSYCHIATRY �IS ROYR. GRINKER, Sr., M 5 c) Pan ‘ _HIS 29th STREET AND ELLIS AVENU CHICAGO, ILLINOIS, 60616 SIDE OF CARD FOR ADDRESS Fink, M.D. University of Missouri Dept. of Psychiatry at Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Max �June 15, 1965 Dr. Roy R. Grinkcr, Sr. , Chief Editor- Archivna of General Psychiatry Institute for Paymomtic and Psychiatric Paaeamh 29th Strut and Ellis Avenue Chicago. Illinois 60616 Dnar Dr. Grinkcr: Enclosed am thme copies of thc mmcxipt entitled "Sociopsycl'nlogical Mpocts of Psychiatric '15:!th in That. Voluntary Mitch," as mmtcd in ymr recent letter. I am also enclosing the Mical abstract card. I have pmvimuly cm to Dr. Dmilevicim, as he had rcqunstcd this about ten days ago. mt man: you very much for your interest. Sincamly yours, Pink, H.D. Professor of Psychiatry Max Hrzkp encloms �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �w. .-..w‘ww.."“mmmmn—pw MWCALWSOP WCWWWWWW mm L m. 31.9... ”I! My Katmai.“ Sing-1. Rub)“ “ODD... �Wt Oaks, Thisutudyunduuwmmnutmmassocimdatthe Hillside Hospital. Glen of L.I. Expodmul Pawmutry, New Yak. 1959452. MWmdfluataflsoffln meimofIr. CJ‘. «ad 1:): Manta). Henningnr Cantor hath Mutant“ mm l-bmitnl in gratefully W. Aidcd, in part. by grams M24092 and HY~2715. of the National Hulth, 0.8. Public malt}: Serving; and tho Instituu of mun Bond. Rum County mm m1 O Pun-mt Adams” East 210th York 1mm. “ I’m-mt Adan": W SM. mvidm of Psychiatry, Hmmfim 111 0mm, New Howitd and Wt ram New York. of Psychiatry at the Instituu o: Psyehhuy, Missouri School of of Mmity sum m1 Strut. Win... 8t. Inuit, Missouri 63139. no HIP 2/1/65 Present Adda-u; Nutimal Institutc of brutal Knuth, Wadi. mma. �. V.— ,___‘V ... auvn-m. rm. .whwwvr... _w.. .vaw.‘w 3w.-- - .-.—u--r.. .'>rlm' 'v' r q— “n... v-A‘Hnwwvwv‘V-vvv' )w-p—w' vrwumwrl—‘"W':"'V"V""-*‘VL'I'W-lw-v ‘.'._.,.._wv mmmdfluflummmcmmpop- ulntim. 8011111351356 and hdlich Imported significant relation- Mphmnmhmm'spmldminmsodalchssnmmtm mmmddmceofmatndillmas,typesof¢iagmoddism mmmmotmudammtmmmm. mainflumceoftmmcstmoffiumientmthe availabilityofmating pummel. m,mmtmm¢ Stmiasoffinmbofaodalfwminthomxmnof of their fixmial status and tho hospitalized paints Wt m mast-tam at Huma- Hospital in availability of mutant: 1957. In this hospital, anxiety of manhunt modes, incluling individual payabafinmpy, were WW thompiu available to all patients regardless of melt” ability to pay. and convulsive hmamys (mummizhat patimts hospitdiudforfln Wm‘iodsmmoldar.hadlmedtmimmdmmoftm 011mm. Mom,mmwmimmpm inmtlymmdbyomvulsiwfinmpymdmoeiwdmfavumbh WWW. mum W Myhypaydaathu‘pyujdmiwdpoomdim mm mm.mr.miv¢m. mhoopitlliud for Impurioda, tmtad ratings. Thuclmimlfwmwnmmmamof‘sumtypy, mmmnmrSa-hu.s).mwrm.w Mrstomn mmmofmmmdinmlmtadimduinvolutiaalpmis WWWMMWDMN thrupyfltocpitaliud‘fom amt- m,mmmmmumwwm. �_-..‘._ i It as ,. m." .... 7.." ‘r».:- — -~~-- um» 7.“ , suggested that differences in paydxiatr-io treatnmxt afloat a similar influence of social factors along hospitals should as noted for patimts within Hillside Hospital. To ewtion it was decided to wloy the Hillside study in three institutions cm. lhmin'ger Mental Health mm enter in - test this procedures of the 195? Hilleide Hospital, the Hospital in Topeka and the Maoeadmoetta Boston. Those with the expectation that diverse available to population of institutions were selected tnataent modalities diffemt social classes. were equally Each provided ohm—ten treatment of voluntary patients and did not provide custodial care. Each is a residency training center with a full time supervisory staff and active march mite, mixing peydnomalytioallycoriented psychotherapy. 'Ihia study wm designed to detemine thepopulatim character- ietioe of the three inetitutim with respect to social class. age, echoatim and 1' some; lid to relate these dmmcteriatios to treatment variables of type of treatment, duration of hospitalization, diamoeia and discharge evaluation mg the inetitutiom. tvwrw— w v �w J"- -A.».—. v ...v. m-uwwa. ... ,ur» In.‘,._(...._,..n .,.‘,.“___,‘ .- warm—Mr...“ . .VN.... .v- , ‘ ,7...” .... .... NM”, x..." ‘rwm'.tq'(1.'rm'“>1flr-r.ny\w ”rm—"w.“fivn v..._ mu Ammofmwlmtuy.am1tpafimtsinmimin mum adminidnflonpitalslndvolmtuypafimsmly,amnnmr WWquuminmeylaso. ofthoocatfluWMthfimethflflQmm mimdbyfinmtsprsymcovalmfimormm dadmionwimmicnmmitummfmdfwn specifiampmjwt. Mmflmflmmmfmflu studybocmofthcirmwmuy 3m. mmimeIMwasmndformImtimtmm mundu.‘ memmofdismdmimfi mummmmmmmwmmcrma 1110M. PornmofsoddclumflnfloWZ-fwtw im-aWMsdemmmmim-mmd of Hillside, at patients (3.“,7). mist-d M MORWWDSKWWWWMmCmtw. mmmmmflmoffinnmofflusml The W 173 mmmdmcmiabluwifldnmmnimflmumnm batman institutions. mu. maxim mm difficult. lunar, MmeofvuMBquiffWWbem. W www.mmwymoepaymcvamm diffimltiu were most mined These in the intm-hospital will be placid on the diffomw batman imtitutiau with citatim difficulties also no to o: mwmmmm m m. mummfomdmfwm‘dau,mfhmdintbeubmbythé ' vmpawmimsaploaigs. ‘ pvt—u u �A. WMCAL mums M Rpm ofthehoapitalis r studies from an. instituticn, tho stmctm fwmtedmdeimrimdorm~ tel-am timed bflafly. In suturing amenable data from nultiplc institutimo, hmwr, the durum between institutions are «mutated. R111- thele institutims were sol-cred as mental: invading, mom and Mt m. unlflm in ways which inflummd the data they a! the m 8m. fmctimdly Specific Mt, mutant «Item. differences were manhunt in the deeimtim of type of (lunatic mutants. and th- evaluation of m Raw designating that a pationt miwd of 1. the institutim, making 01' Mutant: The ”1:”de cum-rim difficult. oxitcria for diffemd mg hazing-r Hospital psychoflmpy was duimatod as mutant basis by a staff psychiatrist for Want-d on a At Mum mmpafimtwudmmdafui Wwithapsyddmic ruidunt physicim wen midst“ part a! rmtino mutmiw paint an. arm a Hillsid- ibopitn payMampy was mutant main»! with a psychiatric mid-at. Staff poydmictrim did not A1: matplthnta, mmmactivitiutowpoming midmtphysicim. Nomitimdfmwemmd. W mm MW 3 At tht th- mtivity Hum: Gutter pnyehothcrupy was ofmy disciplines --~- We �“am < -v u w“ -w “KN..." .... ,.. v... -. .7 r,r.,,..-....r...m~ rm.“ \w‘wur-m 7.. , .mvmwvrwmw—w ”v, w... H r. v. -_.'wm.-_..r.,.“,...m_,,‘,,.._w_..,. ,,._r_~‘l.,,_. w mm,pydnlosisu.sochlm,nms wwwwdzmsimmnmtmflmlyimmainm mdmdioal students. mt'smmmmmmummmm Witmmmfwmoffluammminm unmidmtplmidmmpmnibh farewells... W: Wm: 2. and. Indivichal imtitutimal difficult. At diamtic styles cums WWtal Whmlflphuvmmiwsmmdbytmmdw and music:we row mum diffmtufimaym. Scwnlmwofdimm W. W Wmmudinhbul,wmhmmsumutodmmm thWmMflfiWmhflmfim. Mmmmamflmm. 3- m WW=WMW mummmitmmwinrmmmm. m WWatWpritnmtdpar-dtewitham «31min: Max:111, W011 and syndm W. mmmimmmmmmmmmmam difficult to assess the ammunim of cad: it tutor offinlhminearsymfl'nblan). Pwfifiss‘mdyflnmmw rating making smmmmmmmmotwm intimation. m A... 7w.. �, .,__n..-. 7‘..-‘._._.‘._..-..W‘..v...‘ w...—,.,-v.,mx-,~_..V“-.."w.u "Wm.”w r9.w‘_v . .r,_..-——w.w ”w. ._»,.,.r,, — ._.__ .m‘...-..v..‘~,.\" »......—-....—-v— "m..- w w ——.~.. ".V...», v...“ - mmmmumoruummamum,m.m mmmrmmmmmmuumm in III. W Table I) W mattinmfiaipuaddflfnmin mm" mommmmormmmmmw. ”Wm-pimfiupwflaflmmpmuywm; «mumm.mm;mnmmmmm www.muymam. b) msnmmmdifminmdimibutim ammumwmmm. Wammmaflu‘dhm _mmm.mmmummmamdm «WWmmummmmnmmmm. mulmmammummmmmw 3M.uuya2parmtdtmmidcmd23permtatfllmimr c) didmtm. d) Wswfminmdlstfibutimat mmfinmifthSed-mmmd. Fifty-em mmtdmmmrmhlwm.mmy oimtmmwimmofSOwabw-wmhlmfm hum InWt. �, ”.7 . v Nv‘,—' ~ v , v... v. ‘v" —.~,~.~..-m ”11"!“ “we ,-.. ~.<.., .._ ~--r“~..,—a,<.»~mprv-. —. ~~pw~mmmw-w~mn m.” a... j." -r..-‘...,.1~.v» nymI-rznu at Hillside thirty-me per cent of the patients had 1" scores 30 while at WHO only twenty per mt mm belcw 30. mus, differences in social perfume: an the below clan, edumtional attaimxt P Scale were observed. and These diffexemee permit test of the hypotheses relating sociopsydsological factors to the mam-at variables mg these institution. 2. gleam-1c Than-ant Variables a n) Selectim of rm uimifimtly W: Manna the institutions, patimts at Naming” Hmpitel 043*.) received sciatic therapy than at Hillside (6%) or 11116 (68$) (Table IV). 1:) V Wm at Hoegiteliznticn: ‘lhe three insti— tutims differed with mm: to patient's length of my (m1. IV). Pedant: it Hlminw Mini was hospitalized lamest, with 65‘ cf patients mining far twelve month: or mated to m. alparwrtofflnflillnidepatientsMmlySpercmtatthe Pin-mm Hentnl thalth Center. 'Ihe mdal stay of the Hillside mmbetweeneemmdelmmfiu while tm-thirds ofthe WC patients were a) W Evalutim: diam Diem within six In and! petients were evaluated at the time of (Table IV) . At (191!) thinger Hoapitel. of patients wen rated patimt was a of hoapitelizatim. mini, mot dimmer-3e no "iuprmd" however, a higher percentage “miwmved” and only a single scared ”uncured" or “max iwmved." The percentage of ”mounted" an "mm harmed" rating him (2810 and the �_ _ v. “v ~_.v_..‘._.......p.r "anv “:wu—"mw-nr -17.": WNWV. ”.wuwwn mm My .-.._‘ n-wwn-y—wy ..~—r 7— —-,__.y vwri'ai.W"YV-wwmrnw. Mmportimofwumwd”(mt)wmfamdnmmuo mwmmm. W3 minimum: W, d) nostic For satiation analysis uffccdw Mmmiamdpomuuntymnflabh than: diag— diam, IV). Trading- Mamdmmmmmmm mmmm.usum1ymmmenaiW "Wmmrwmmhwdfwdw centrist. at paydmmia WW1“). disorder. In and memmdfwmflmfiftypwmdm W161. c. ’ m W.» mmammmmmmmmmmf ”Alum W.finflrhmpmiflwifldnudaimfituflm.mdm mm m].- siu (neural mine Maud: had was («or than than was) maimed significant intru-l’mpital mn- pm. Humor-.mmappomummtommmm thou-lineman MMmeMnWmm ulwddefatWHo-piulwwwhiMF accumumfmmuymaimwmm‘py).md Pamalematlfllhide. mamimmmm~ Wmmmnmnmmmmmmm Wm~mwmmmfmetm. mmmmmummtmmmmmm, �asmmmndwamudummmbuwmmmmn mummusotpmmmummmonomm Mam. W m DISCUSSIW mmormmmymmnmcmm mind significant inter-institutional cum in social mwmofmum.mtmtm;indiatflbutimof ammrsmammmmmormmmm win~mmothosp1unudm.ahctimo£mmts mammarmmamwmum maul-mm“. Hmpitnlatudy WWmmmmr (7). marina-d. 'nuimtitutimmvingwmpatiom mmmmmwmyummw paydmdodimmdmmdiwflcm,a �-rw .-,. a... h -... w ‘ purvm .. “.V 7—-.. w. tux—0.... V" - ,7". "7‘-.. - "\‘w' . -. -h. -Vw—l m.—....‘——wn~. V . m .w._-—zu—«——~....'_~Wm,- u...“ -10.. form of therapy. mtic mim and the poorest discharge ratings mg the three institutims. smmxy. the 1:31:in serving mg. class patients did have Mr proportion of patients the shorter pew of hoe:pi.t:eliaa1:i.tm,~ peydmmtic diamond, ad lover proportions bf the better discharge evaluations. Itumiwmeimflmtmdflfeminpeydumc W durum in staff ettitudes and are related more to lock]. alas variables than peydniatric differences in populetiom. The are We greet. as between m the mututime in dwetim 0f hapitaliutim mucky of climatic foundations. diam-rye evaluations. deflnitima of peydwthempy, and the detail- md aunt of differences W date. mm. these stylistic idiosynmtic, they follow! a social related to diffemoes, aid finir'miemncy mum with emeoteticm laments e meter dependence on social class may be dismissed as Wiedgad. Sud! mulatim and metnnt variable variables than outwardly intemtive processes, physicim and the of an 15th determined both by mum‘s staff relatimships are the attitude of the me! by the matellatim or history which patients present. Such relationships mined mat in than psychiatric conditions where diwtic criteria are leeet specific, a,an fining diseases of Imam etiology where objective criteria de- absent. as in schizophmie. peyoimmuis, personality md beluvior W. Under these �- ——-»~.—.. . 0 . .... Twp... -‘-- ~vv-ul'~w 5" 1m -.——.rw~‘~_.r “mp—m...“ "m”. . v~-_.v...‘.. ... m «um”www.m—mrwv.r.w-‘.,r-r.—,.m.~ Nut-aw..." I"-~nr~rl’-' Irav’r VW'FV‘wW-Pf'lm‘"- ._ mmwpomwthainiguity.m¢oh«mr's mmwmmmuwmumormm classified“, «Md-claims. osmium. 1:313:11»qu chalydoamudbyl’umidc,mnitxmdhfm (6)1ntha1r studyafmiatimiadimiuwithinasinghimtitutim. 'nuyobuzwdflutputiummimdatrmmdiffcmtm admtdifhrintypoofmm,mitalm,e¢mim. mermaid-non. Simiflcmtdiffcmasdidm,m,in “demmicwvimfimmm Mm “wwwmmmmwm. wtmmmmmmmmm.mumwm wmmammotdimmmmmitmIoffln W. WWWofmmismdmniml mmnnhmwmmfcmdmmimb tutimmmflm. unmmmammaemm mimic-insults. Farminlhmimmtdwiflxm Wyudmdpcmlmmfingmmnknpcimpmmto fwfinlamttiu,huflufmtpatiem$mdu W.mm.mflupmatmtmulu. Arm,inmt.miahismstimlmiwindufininga Wat.kmpaflmufwfindmtpoflw.Mhma mmamWWme Whhaatmammults. �mmmotmmmmmmqmny olmwflnmmtofmwutyofpopumamfw dogmofilhmsmgmeimtimfims, these {Wand We «fleet the mhtiva efficacy of the institutions. Simfincvalmfimsmbaudmtmmfimdm’sommfings, arm Mfmmmofimmmmrfiminmicpsyw- we mum that tho rennet variaticm in the criteria Mam“. Inwinimlfiflhidoatudym)itmpoamhmthat M WWW. mam criteria of were utilized {or mom of Itwmsuggastedfimttmmmr flumm'asodubwmdfinmmlexflthefiaw ployad. with mmmumlymmmmmtsm. flu cuff of flaming-r ibupital min; a tripartite rating Em Wmmemmgdmmmmum. mmmemmfingmmmmmmtiwamim fimnlmmbmd.itisourmumtmtorlmr duapommwapttcumiwinnuumto Wamfwfinpafimt's mpmitytomm wrigmile for uppor ulna panama the criteria aphasia: such mien intangiblmm”avnloping insight,"or"mfld.nng‘a pmbm." mmmmmmmmmmmmu ofwdnfminpaymem.mhmbemgrufly mmwmmmmmormm_mumm. �Midesmmwamedmflmllnad-nhip mamamimmmmmwmmnucmuy defined. But diffm in instituflmal style and: it diffimlt toebtlincmpambhdata. Mmdmisnmmmpmblm Wiml Wu meofwdxinmcmm. memormm of the use of statistics, «Many in W,mewmwlmnthm umitwiainmmwalmmwmidmfiflmimof Whpopuladmmauhdecttomiwmmnum institutions m charly mm for staff attitudu md atyla wmlluminmminpafimrtwpumm. Thu-o diffimltiwalaouflndtoflnfdlmdscimflahmomflm mmwmymmmmmMuMm-m. mmmammmwmmmu. mmmdfimmmuMqummm hypotm. flamofthcm”adfiaophmnia"or”paydw- W18” to explore chm in paydnologial and biological futuresofmtdfllmnhulodmascimww Manama oboewatimtobanpoma Mmmwzoday,mmmthmmmtom negatiw malts. paydkalc munitions Manly fwamfm tut of the be must paid, to the elusificutim Imam Music. mum m, wmymmmmmmmmnflmm of aubjwts by "abjectiw" criteria tamer than our present the oodnpoydxologiml aspects of fin unmist-padom: Wm. �v. ...., A. n. ‘v ....._.—ur————‘.v—. muw ‘ «m Two—u..— -..—.—v. .r. vvn<~>ww~wmfl‘rmew~——uir—I .—~ . am WMWW Was, Mmmdrsm,mm1mammamntvaflablaoin dufimd by social class, age, Fopuluflm on. ”may tanning hospitals. typo of mm. W variablas incluad dmutim of hmpitulimtim, diagnosis md diuduma evaluation. Imimtitmimal diffaranous mm in mint nodal class, yum of and distri- m mam Monofculifmiufums,butmtsga. Wins Thu tions m in W Gamma“ mg institu- uimifioumly diffamt in the pmdictad dimctim. The imtitutim sawing class patients did have the longest Minn of stay, a higher pmportim of paydxmam'otic diagnoses and W m min: diagnostic am, W, a lower proportion of diam and the poorest too-Mag mastic fans of ratings can; tho imtttutim. Similu‘ly, the m patina imitutim ummmmmdidmmmrpemcr houpitulisutim, 1m proportion of psydxmamdc diagnoses, and the discharg- evaluations. Wvariation on ma mm m muss with W mm not and Such dim, Wm hum institutimo objwmdam is in psychiatric practices followed u pattern class <11!qu mg thu momma. as idiosyncratic. in institutions! style make madam of of houpitalizatim and treatment mats {:1th ma tea-nuts, and the mad for m «item m:- the classification: of psymiati'ic populu~ mind. �REFERENCES and D. J. T. Levinson, Frenkel-Brunswik, W., E., Adorno, and The N. R. Harper Authoritarian Personality. Sanford, Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., A. B. and Illness: Redlich, F. C. Community Study. New York, 1958, 442 pp. A Social Class and John Wiley and Sons, M. M. and Social Factors in Fink, Pollack, L., the Selection of Therapy in a Voluntary Mental Hospital. Kahn, R. J. Hillside Hosp., 1957, 6: 216—228. M. M. and Sociopsychologic Fink, Pollack, L., Mental in Treatments a Voluntary of Psychiatric Aspects and Ratings of Discharge Duration Hospitalization, Hospital: Diagnosis. Argh, Gen Psyghia§., 1959, A; 565-574. Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Social Attitude (Ca1— Scale) and Convulsive Therapy. J4_Nexy&_mgntg_flls,, 1960, 1395 187—192. . Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental 116: 127-132. 1959, Ameza_J‘_£a¥£hiat., Hospital. 7. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191-196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved ______.____——————-——— Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Unimproved �TABLE Interhosgital Comparisons for Sociopsychological Variables Hillside Menninger Hospital Hospital N Class WM” Massachusetts Mental Health Center IllllfliilllllllIIIIEEEEHIIIIIIIIIIIIflflZflIIIIIIII I Social III 31% 7% 3% II 51 20 28 III 17 34 13 H IV 1 34 28 V 0 5 28 ”'1‘" " x2 = 121.5; df=8: p<{.001 ,,_-_1_A_s-__1.______ 19% 20— 39 =3. 9; Years of Educatio <12 41% 12-15 49 16+ 10 --—--—-— x2 = F Score df= 4; p=n. s. = 9.7; df=4; p<.05 §3z 20% 50 38 17 42 39.2; df=4; p<.001 �TABLE IV Variables Treatment in Differences InterhOSpital EMBnninger Hospital Treatment Psychotherapy 21% 36% 24% Somatic 43 64 68 Other 36 -— 8 x2 Duration . 0? HOSpltal— lzat1°n Hospital Massachusett Mental Healt Center IlfiflflflflllllIIIlflEflIIIIIIIIZIIIIIII N Type of Hillside = 82.8- df=4 -m** 7 months 7-11 months ' .11 months 22% 27% 67% 13 42 27 65 31 5 Discharge Improved Evaluation nimproved X = 29.3' df=4' -<.001 85 54% Schizophrenia Discharge Diagnosis Affective Psychosis 17 Psychoneurosis and Personality Disorder 29 X = 23.8' df=4‘ -<.001 �Duration of HOSpitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20-29 73 36 30—39 61 3O 40—49 3O 20 50+ 36 MMHC l4 �AMA SPECIALTY JOURNALS ' ' lC ' Am 6 r1 C a n M e d al A S S O C l at] O n 535 NORTH DEARBORN STREET - ' CHICAGO, ILLINOIS 60610 wa— AREA CODE 312 527-1500 910-221-0300 November 2 , 19 65 Archives of Dermatology . um 0 an i:Chialldr:n Sinse;ses Archives Of Envir nrnent al Heal I h .° Archives °f General Psychiatry Archives of internal Medicine Archives of Neurology Archives of Ophthalmology Arc ives o ‘0‘ o l a ‘V n g o ‘ o 3’ "_ Arcthes of Pathology A'c h'was ° f S“ '3 eW JOHN H. TALEOTT, MD, DIRECTOR DIVISION OF SCIENTIFIC PUBLICATIONS ROBERT W. MAYO, EXECUTIVE MANAGING EDITOR NORMAN D. RICHEY, MANAGING EDITOR Fink , MD Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5400 Arsenal St. St. Louis, Mo. 63139 Max Dear Doctor Fink: edited copy of your manuscript entitled, ”SociopsychoA Treatment: of Aspects Report of Psychiatric logical Treatments in Three voluntary Hospitals,” is enclosed for your final checking and approval. Also enclosed is a layout that shows placement of title, copy, and illustrations. Please indicate any necessary changes in a covering letter rather than on the edited typescript. we will be responsible for checking your material against proofs. An manuscript has been edited according to present AMA style. For example, most abbreviations appear without periods. The are currently striving for brevity in article titles. If the modified title of your paper is not satisfactory, please \/ supply another that will fit into two lines of no more than 40 characters and Spaces each. we L ,ZU Chi, for reprint purposes, the one Is address at end of article, you will be using on a relatively long-termlaasis? 1 Specialty Journals publish acknowledgments only to personsbfi1p P have aided in that a a study or organizations major way, as, for example, by supplying drugs or funds, making statistical analyses, or doing pathological studies. AMA references have been renumbered to conform to our rule requiring numerically consecutive citation. Your �Fink, St. Louis, Max MD -2- Mo. 11/2/65 According to our calculations,the paper will occupy 6 printed pages. Please note that any new material you may wish to submit at this time will be acceptable only if it can be compensated for by deletion of an equal amount of copy now included. have retyped the references so that an accurate copy estimate could be made. Although we have reread the typescript, we request that you also check for any errors of omissions that may have slipped through. we correction and return of your typescript will help us get it into print as fast as possible. Please return it, along with the layout, in the enclosed self-addressed envelope no later than November 9. For your convenience we are also enclosing a reprint order form with the correct number of pages indicated. Prompt Yours very amh , udith M. truly, Kiolbassa �. "luau—“new .- , . H- MW. -1 ~ »~v - we. w re ,-_....‘--—-~~w—~- «V... WP v,“ mm“- "WWW. w. 1“. - -.. .. . 5. 1965 Judith H. Kiolbesse Mariam Medical Association 535 North Deerbom Street Chicago, Illinois 60610 Dear flies Kiolbesse: Myouwrymdafcrymmletterofflovemrz. I shelltrytomreechitenineeqmnoe. The article title is satisfactory, elthcugh I think the "A Mt sub-heed should reed in Three Voluntary Report of Hospitals.“ 'me word "treetlsents" end "treetsent" are probably interminable, but in this inetmoe, I think the singular {on is preferable. However, both eve acceptable. While the address at the end of the erticle is one that will be used for e lmg~tem basis, I would prefer that you and that is the Depertnmt of change this for Dr. Psychiatry. University of axioego. Chicago, Illinois. m. edmouledgmt included the name of Dr. Max Pollack. In ell the studies done at Hillside, Dr. Pollack was e coper'tioipmt. In this study he was one of the three people she visited eech of the institutions. Hmever, in writing this report, there were some disagreements as to the omclusims, mdheelectednottobeeoo—euthoroftheetudy. Hy essccietes and I. wild, however, like to indicate his assistance, and for this meson, I think a statusent, "me cooperation of Dr. Mex Polleok is gratefully edmwledged" “me would be appropriate. met. numbered refermces are I m assuming thet the Jamel limits the timer of authors to three, and The metthieisthereesmmythatintwooftheoitetions the co~euthore are omitted. If this is not e gmerel rule, perhaps in this instance the oo—wthcrs could be listed. page la, in addition to the notation regarding the coopemtim of Dr. Pollack, would you please damage the address of Dr. Kern from Hontifiore Hospitel to: Department of Psychiatry, University of Omicego, Chicago, Illinois. On .uw vs.— ‘ =. 2.. .: “may.“ . .,.. �Miss Kiolbassa -2- Also, the dates 1959-1952 , which follow the statement donoeming the origin of the study, are immutable by themelvee. In our original report, we used the sentence, "his study was dorm when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital. 19594962." If 30m full sentence offluiekindionottobeinoluded,thmlwmldouggestthat the dates 1959-1982 be omitted. I have read the text carefully, and find two small corrections midxlhavemked. mm2,naarfimbotton, theoomotimo putaolashlinethmwfithemwerS, mdthiemaybemolmto 1’ the printer. It should read "the California Scale. 03,5) page 10, mfemoe 7 should be number 6, and mmked this copy. cm I have so is a table. and them is a symbol which I do not mderatmd. In the first oolm."omplete remission"is aplit with a synbol mien to me would indicate that the word “mission” should be under "ooeplete." If that is so, this may be molear. I do not know how this will be not, but ”oanplete minim," "amicedly homo," "mdemtely normed” are each word pairs that should not be split. If this is too long for the oolmn, than I hope you will indicate féthat "markedly mmved” fit Page 19 together by appropriate spacing. Tfiis is the first time that I have had the opportunity to edit a mmxmoz-ipt in this fashion, and I must say that I found it quite helpful. opportunity toworkwithyou, andI Myouforthe look forward to the final results. Sincerely yours . Pink, NJ). Professor of Psychiatry Max HP : in �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �~ This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I. New York, 19591-1962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial " is acknowledged. Hospital gratefully The . ‘ Aided, in part, by grants My-2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine,-University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the New Haven psychiatric patient pop— ulation, Hollingshead and Redlich hast reported significant relation— ships between an individual's position in the social class structure .and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded. Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to paye In anr thsae surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predominantly treated by convulsive therapy and received more favorable clinical discharge ratings, In contrast, younger, native born/aim? more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingsa These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i.eo, greater stereotypy, were often found in patients diagnosed as involutional psychosisf who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredo in-ehe-survey—rEpUTtEd-hETE)[it was suggested that dif— "’4”“’A“' ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for iht patients within Hillside Hospitala To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -¢ Hillside HosPital, the C. Fo Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Boston, These institutions were selected with the Fr:ec£3£ipn that hing-had diverse treatment modalities h’&Y‘ available,;d££:eoi¥ed-paeients of different social classeso equally Each provided short—term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapyo This study was designed to determine the population characteristics of the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, �_2_ METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside HOSpitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo- phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary status? The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2-factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Centero — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult/however, because of various methodological differences discussed below. These difficulties were most marked in the intraehospital comparisons/.and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra-institutional trendso These difficulties also led to missing information for some data, which—ie-reflected in the tables by the varying population sample The sizes, �RESULTS A. Methodological Problems repgfting studies from one institution, the structure of the hospital guanine taken for granted and either ignored or mentioned briefly. In gathering comparable data from multiple institu~ tions, however, the.mnny;differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcomeo When l. Designation of Type of Treatment: The criteria for designating that a patient received "psychotherapy" differed among the institutions, making comparisons difficult, At Menninger Hospital psychotherapy was designated as basis by a staff psychia- treatment administered on a prescription trist for which the patient was charged a feeo Sessions with the ‘2 psychiatric residentfiyere considered part of routine administrative patient care. fkysa4.¢ Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident, Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicianso No additional fees were chargedo At At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychowas necessary for members of the study team to interview therapy it the residentgresponsible for each case. fkjsKJAu Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems, Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono 2° Diagnosis: �Table I Discharge Ratings of Improvement: Ratings of improvement at the three hosPitals varied in format and detaily The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)o For this study the Menninger syndrome rating was compared to the global ratings of the other 30 institutionsa Table Q M’s _———"’ Inter-hos ital <:; B.fi~~,»n--__ "M..- {§_‘ 10 The Com II arisonSN Sociopsychological Variables distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observed, At Menninger Hospital the population was predominantly upper class; /AE Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—” cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduateo 0) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fiftynone per cent of Menninger patients had F scores below 30, and only eight per— cent with scores of 50 or above -- the higher F scores being associated with higher degrees of stereotypy, In contrast, at Hillside thirty-one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30. d) F Thus, differences in social class, educational attainment and performance on the F Scale were observed, These diff— erences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables \“"2. among these institutions. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside b) Duration of (64%) or MMHC Hospitalization: (68%) (Table IV), three insti— tutions differed with regard to patient's length of stay (Table IV)o Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization. The c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved"o The highest percentage of "recovered" or ”much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centerm nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one—quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty perncent of the populationo zx Table IV ‘“ CLJLRS ."” C: Intra—Hos s-‘wa. ~~ r“ e~ ital Com arisons ‘h53 lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital com— parisons, However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periodst While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year, The Table V �DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var— iables -- duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7)“ swudy Expectations based on our earlier intra—Hillside Hospitaufifi;;:’ confirmed. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. While these styl— istic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, Egg}, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disordersq Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward“ As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another, Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi- atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social backgroundc It was suggested that the higher the person's social background the more complex the criteria em— ployedo This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined, But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapieso The use of discharge ratings, diagnostic classifications or length of hos— pitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other laboratories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the socio— psychological aspects of the therapist-patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in— cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distri— bution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionse Similarly, the institution serving lower class patients did have the Shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The variations in psychiatric practices followed a pattern consistent with the social class differences among the in— stitutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasizedo These �REFERENCES 1. Adorno, T. W., Frenkel—Brunswik, E., Levinson, D. Sanford, R. N. The Authoritarian Personality. Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., Illness: New Redlich, F. Community Study. A. B. and A C. J. and Harper and Social Class and John Wiley and Sons, York, 1958, 442 pp. L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216-228. Kahn, R. . L., Pollack, M. and Fink, M. Aspects of Psychiatric Treatments in a Hospital: Duration of Hospitalization, Diagnosis. Arch, Gen Psychia;., 1959, Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Sociopsychologic Voluntary Mental Discharge Ratings and 1; 565—574. Social Attitude (Cal- Scale) and Convulsive Therapy. 14_lkuahhlkuxLL_Disu, 1960, llQ: 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. AmeIa_J4_E£¥£hiaL., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 1Q; 191-196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile.Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosEital Comparisons for Sociopsxchological Variables Menninger Hospital I Class 31% 7777 7 7 7% II 51 20 III 17 34 IV 1 V O 34 . 5 l||||||||||||||||||||||||||||||||||||||||||||||||||| x2 77 Hospital Massachusetts Mental Health IIIIIflBiflIIIIIIIIIIIIIIEIIIII N Social Hillside 7 7N7 777—777 7 = 121.5; df=8: p’{.001 7m__-— -77777777—77 20 39 Years of Educatio <12 41% 12-15 49 16+ 10 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables iMenninger Hospital Treatment Psychotherapy 36% 21% Somatic Other um— =82 8' N Duration 0? Hospital Massachusett Mental Healt Center IIIIIIIHIIIIIIIIKIIIDIIIHIIIIIIJJIIIIII N Type of Hillside 7 months 7—11 months Hospitallzat1°n .11 months df= 4 . .001 Z ' A 70 13 42 27 65 31 5 52% 54% 22 17 26 29 Discharge Improved Evaluation Unimproved Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 23.8' df=4' -<.001 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20—29 73 36 30-39 61 3O 40—49 3O 20 50+ 36 MMHC l4 �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance ‘Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �:0". mm»... can“ b. awn-u a mi: “tum-Ma in a M an“ ”MI "in“ am: tm‘nt It“ ”mm van-mm pap-nun ”humbly! m trams m um to but! up»: u “mun" pram-I. «Wu! h by no “at: m pints“: m “um. a n manna" u. wanna» .1 Wm at hum: mu 1 ”tint up mm“. In! mumm- Irin h nut mm in m than Mm m. pmmuu I!" ”not“ Mt “am“: Mm hut with, $1334, than “I “scan" ufinu «flung «In». or knu- uum Mum-mt an that. a n W“ mchm“ ”than”2le at numb”, nnflnn. “than” an and «mutton o: a“ nun»’M“” a: citation! «yuan-n tum v3.01: 2» a» mu pmmuu «a «mausuun. In. an flatly Imam“ hr tun-much, an“: and um (7) u that it“: of «than: as “was: um: a am. in“. huh. 3.; than“ it“. ”mm mum}! animal! to 551’:an an m mm in m. t: await», mm: sum, man, an 0: awn-mt «um-«m m mm. m m mthmulnhhiutmummd. u “unawaI“ am, bum, 11:01: «In “no in “and“ it. and. as! “St-rm mu tub-rut 1: m ywmfln. �SociopsydholOgical Aspects of Psydhiatrie Treatment in Three Voluntary Hospitals ;R0berrt L, .lfiahn, 1311313332! Nathaniel Siegel, Ph.D.*** ‘— NEIIIIiiiiIIiE§E¥§ �-7- ’4‘, DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter—institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables -— duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations {7}, The Expectations based on our earlier intra—Hillside Hospital were confirmeda The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionsc Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded datae While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged. a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, i;gf, where objective criteria de— fining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorderso Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sociopsychological aspects of psychiatric treatment in three voluntary hospitals. A.M.A. Arch Gen Psychiat. 14:20-5. 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