http://exhibits.library.stonybrook.edu/mfp/files/original/de95bf5b301da53b216f4fe5fa8c04dd.pdf c38414ee0bbef11434639b42d1daddd0 PDF Text Text Reprinted from the A. M. A. 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. MEDICAL DIR. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �, v—v—v flu ; {'ZflA/C’ , — S’s/"- 4—'-J-{/ , -:v»- mm- -- -< - - .» ,. - —~ :~- -~--7— «— u « , v-«wy— —— v~vn~~m~——.W»,M—->w— yw—W “H's—WW £46 4/? /7¢3 far]Flaw/t M(",qu ”may Webcw~aa M4£27%01;“, 6W f5 Wm awe/W m Moxie/M M W ¢m MJM WM W ’@.A.:f;4m «4% dw.;&%-m/: Midang/fvaf mam ”I‘M/MM 2/49“”{24414 WMMMWJW M41; {W MWMM W. I, r �“qua-7 r.l_~- ".w. v "/fl/Wd' Q/a 7 _.,;m,‘_<,,,,,..fi_ .mm. uvr...“ 4 ¥ 77“.. ,, Va- .._ , "W, ,V _._ .—-.~ .,. V .7 .,,.‘ ;....- . , .:__,<W dag ,u/ W WM W M ‘ _ ,_.,. . . , qr, .._.; x7443 A4414M4M 7’7 ’ “ 74' m WW/M .W We! l..— my MAJ WM W M :W mm _ . (NV, Aux-5&2; 7 fl £;W Jar/tamed 4 Ztaw a M..WA 2/ M44." 64;“..“4 92%] ”(“44ng l/amflv, (I , �. _. ~...v.;., , r“...— E , . V ~,~~—~ , »- . “-‘"‘ «(y—av“ .v. .r- . 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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. $1131.01. as: figumg _ Jg.P§Fdhiflta 105‘,h0*h53 19h5v Knott, , mum refluxing wnmlsiw shack mummy.” 1:7: 1009402“: 192:2. Go»; Wu, { G; Rn, Pma‘bor, IN Dr; and 600%, J“ E03 "Parallel psychologisal, psychiatria and Whalesinn). findings: in sahimphmnie patieats undar insulin ahcmk treatment." Am. J... Psychiatr.» 933 1422-4129. 121:1... lbriafiy, LB... and Siam, 573 112*.»718‘ 1913!. maevich, A" nut. and, shoal: therapy.” Arch. Neural. g mint. 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Jflm '2 ’1 wri-ryn 334/ m ; "‘ “ :~ <- W V 3K3»: -;M " HJWAM �Levy, N.A. and Grinker, and 8.3., ”Electroencephalogranhic and ElectriC9llylln- Clinical Studies Following Metrazol . duced Convulsime herany of Affective Disorders", Archives of Neurology and Psychiatryh7, 19h2. 1009-1099. L., "Variations Pacella, g. L., Barrera,.3. E,, and Kalinowsky, Electroshock Therany with Associated ~in El’ectroencenhaloggram Archives of Neurology Disorders." Mental of Patients with and Psychiatry A7, 19h2, pp. 367-38hk Sflnon, A., Yeager, C.L., and Bowman, K. 5., "Studies in Electronarcosis Therapy IV EEG Investigationsfl' J. Nerv.and Mental' Dis., 118, on. 131-1M33 "Clinical and Electrophvsiological 3.. Following ileotroshock". Am. J. Psych. 101, Proctor, D., and Goodwind, Observations laué, pp. 7a7-8a0. of Electricéghock TreatKarliner, W.,A "Neurolowic Comnlications review." J. of Nerv. and Mental Dis. 107, on. 1-10. ments: Rosen, A. R,, Secunda, L., and Finley, K. H., "Conservative In— Mental ' of Shock Therapy in Illness, Tracings Before, Electroenoenhalographic of cluding Study Therapy". Quarterly r"sychiatric and After ghack , During Approach 17, 19h3, to Use pp.6l7-6hl. Turner, W.J., Lowinger, Lg, and_Huddleson, J. 3., "The Correlation of Pro Electroshock Electroencephalogram and Theraneutic Results in Schizonhrenics? Amer. J. of Psych. 102, lghg, I fia+41?1 r8}+d*uw~ CZ-2§ (hfiwt lqfii ; :ryfugzo a9m~fl¢3 _ _ ”—4“; «-4 �’5? [Evy—q“ .. x“. 7v , “aw—.77“ . ...,-._:$.. .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. 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