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Borderland of Neurology —
BASEL (Schweiz)
Confinia Neurologica
Grenzgebiete der Neurologie - Les Confius de la Neurologie
Editor: E. A. SPIEGEL
S.
KARGER
NEW YORK
Separatum Vol. 16, No. 2/3 (1956)
Proceedings of the Eleventh Annual Meeting of the Electroshock Research Association
Atlantic City, New Jersey, May 8, 1955
Karin, H., M. Fink and S. 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.
The Electroshock Research Association is incorporated under the laws of Michigan as a non-profit corporation to promote
and coordinate research and clinical investigations regarding electroshock therapy and related therapies in mental diseases.
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Relation of changes in memory and learning to improvement in electroshock. Confinia Neurologica 1956;16(2-3):88-96.
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mfp-02-01-001-19-023
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1956
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Korin, H; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kwalwasser, s.
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[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.
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Basel; New York: Confinia Neurologica
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