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. 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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. It my be 0.01““ an nth it is with]; as! n ”that without mwu mm diam to ”on I; ”out" mum. at “um ham “than with ma a nutuuully Ituutmt. “mu and «w In that. a! m 11" um [um mitt” rm!“ W W um "um 0! mm dam...umon patient t” In mum-um, 1n 1mm “warm I am“ cumulanu. an. u: an um. “mu” «- Wlmlmua am» 1.at the mm «a $13013. with. malt nu cm a on ”flat this study a ”11 u u m at tho ”than panama mac n a man an «11.5.»: “um A “no mun who m cm to you: at an. uncut. «um: “mm an have not ant to» a no on.“ a: u- n the min a!tutthismm.” mum In new mum. It a with)... to no than: u um am a tit m 1: on,» mm. “I not“ (7) m t. a th- wart“. if imlfim a! nun! ”in.“ with an“). “no m1“ «can! tut in g 0! flu in“ Ilth ~mum1" Wm thin II! to m '1“! «17 by tin ”pliant“ 0! nun a: in I“ m tam-nu tut utm a: ommtm. a» “muby and minus: (a) Ll. at ”mutual {mun m min a! mu Manna» an autumn he ”any“ 1: wt a: th W. man W cm man“ new m W.W W Watt �VF . «10~ "T diacloottc Iflrknl’ or ;.ann$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