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F
,
Perception of
Eknbedded
Figures after Induced
Cerebral Trauma
Robert L. Kahn, Ph.D. and
Max
Fink,
M.D.
1/?
"a
From
the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks,
M—927 of the National Institute of Mental Health, National
Institutes of Health, United States Public Health Service.
Aided by grant
Presented
11—27-57
at
American Psychological Association, New York, August, 1957.
NJ.
�Perception of
Embedded
Figures after Induced
Cerebral.Trauma
Studies of complex visual perception
man
are not always clear or consistent.
after cerebral
The
damage
in
disagreements may be due,
in part, to difficulties in evaluating the extent of the disease process
or the degree of alteration in cerebral function. In contrast, conditions
in'Which there is control of the degree of brain damage, as in electroconvulsive therapy (ECT), provide a unique opportunity
for studying this
problem.
While investigations of brain-injured populations have focused an
the role of location of lesion on behavior, current studies of
emphasized the
been shown
to
EDT.
have
factor of individual differences. marked.variability has
for perceptual (l), behavioral (2)
and physiological reSPonses
In addition, various personality (h) and social factors (5) have
1.
C. Landis, D. Dillon and S. Leopold, Changes
2.
M.
3.
R.L. Kahn,
'
ECT
in flicker-fusion
threShold are in choice reaction time induced by electroconvulsive
therapy, J. Psychol., bl, 1956, 61-80.
Fink, R.L. Kahn and M. A. Green, Experimental studies of the
Electroshock process, J. Nerv. & Ment. Dis. (in press).
M. Fink and E.A. weinstein, Relation of amobarbital test
to clinical improvement in electroshock, A.M.A. Arab. Neurol. &
PWChiato, 76’ 1956, 23-29;
Fink and R.L. Kahn, Relation of
EEG delta activity to behavioral
in
electroshock; quantitative serial studies, A.M.A. Arch.
response
M.
Neurol.
&
Psychiat. 78, 1957, 516-525.
h.
R. L. Kahn and M. Fink, Personality
5.
R. L. Kahn, M. Pollack ahd
factors in behavioral response
to Electroshock, Conf. Neural. in press).
F. Fink, Social factors in.the selection
of therapy in a voluntary mental hospital, J. Hillside Hosp., 6,
1957, 216-228.
�-2been related to differences
In the course of
an
in reSponse to treatment.
investigation of the perceptual
and behavioral
changes with ECT, a convulsive-subconvulsive control study was undertaken.
In this report, performance
on complex
visual tasks is presented.
Specific-
ally, the aim.was to determine whether perceptual change induced by ECT
is related to the degree of altered brain function and clinical behavioral
change; and whether the pretreatment perceptual pattern was related to
physiologic changes with treatment.
The method used
in the study
was the perception of embedded geometric
figures - a technique which has been Widely
studies of perceptual changes
accompanying
in recent years in
cerebral dysfunction (6).
employed
Lethe:
1) Population:
were
22
Fifty-three consecutive patients referred for
studied. These included
16 men and 37 women, with ages ranging_fran
to 66 with a median of h9 years.
into
ECT
The
patients
two groups. An experimental group of 29
were divided
at
patients (Convulsive
random
A)
received grand.mal electrotherapy with pentothal premedication three times
a week, using
C—h?
either a Medcraft alternating current instrument or a Reiter
electrostimulator.
A
minimum of 12
treatments were given.
of treatments was determined by the supervising
The number
psychiatrist in charge of
clinical criteria. A control group of
treated in similar faShion, except that only subconvulsive
the treatment unit on the basis of
2h
6.
patients
was
5. Battersby, H.P. Krieger, M. Pollack and M. B. Bender, Figure
ground discrimination and the "abstract attitude" in patients with
cerebral neoplasms, A.M.A. Arch. Neurol. & Psychiat., 76, 1956, 369-379;
H. L. Teuber and S. Weinstein, Ability to discover hidden figures
after cerebral lesions, A.M.A. Arch. Neurol. & Psychiat., 763 1956,
369-379; F. Pollack, W.S. Battereby and M. B. Bender, Figure-ground
discrimination in patients with cerebral tumor, presented at Eastern
Psychological Association, 1957.
W.
�"1
-3stimulation was given following the pentothal. Fourteen patients in the
control group
were subsequently given a
regular course of convulsive
therapy (Convulsive B).
2)
Perceptual task: In the week prior to treatment and on the
day following the 12th treatment each
patient was tested with a modifica-
tion of Gottschaldt's hidden figures developed
The
by Battersby
subject is presented with a page containing
geometric
figure,
figure is
embedded
it
and below
(fig. 1).
-a
simple
a complex figure in which the simple
The
patient is asked to trace a Specific
by
geometric figure from the background/outlining
~The
two fonns
gt 2;.(7).
it with a
colored pencil.
discriminations ranged in complexity from relatively simple to more
complex. There were 25 such discriminations.
was allowed
for each. Performance
of errors.
To minimize a
was
A
maximum of two minutes
scored in terms of total number
practice effect
two
equivalent forms of the test
were used.
3)
Evaluation of physiologic change:
Two
the electroencephalogram and the amobarbital
tests of brain function -
test
(8)
-
were given to
at weekly intervals during treatment.
each
patient prior to,
7.
Battersby, Krieger, Pollack and Bender, op.
8.
E. A. weinstein, R.L. Kahn, L.A. Sugarman and L. Linn, Diagnostic
use of amobarbital sodium ("amytal sodium") in organic brain
disease, Am. J. Peychiat., 112, 1953, 889-89h.
and
cit.,
The
703-712.
�.uelectroencephalogram was evaluated as to the degree of delta activity
induced according
to criteria previously published (9)°
’The
amobarbital
test for brain disease was noted as positive or negative according to the
standardized criteria (10). The results of these tests obtained during
the second, third and fourth weeks of treaunent furnished the criteria
for physiological change.
A
combined physiological index was obtained
by ascribing to each high degree delta
barbital test a score of one.
ranged from zero to six.
h)
EEG
record and each positive amo-
The range of
Behavior ratings: Each
physiological alteration thus
patient's behavior
was
evaluated
at
weekly
intervals. After the 12th treatment, a rating for the degree of behavioral
change was made according to
»..none.
These
ratings of
four classes: marked, moderate,
change were
minimal or
not value judgments as to the quality
of change, but rather quantitative estimates of differences in behavior
patterns under similar conditions of observation.
vpatterns as euphoria, paranoia or withdrawal might
[Thus such behavior
all
be
rated as equivalent
degrees of quantitative change, although the implications of each for qual-
itative evaluation of
9.
10.
improvement were
Fink and Kahn, op.
cit.,
quite different.
éin~pressl. 37$-5§fin.
'Weinstein, Kahn, Sugarman and Linn, op.
cit.,
889-89h.
�Results:
pre-treatment and treatment scores
The
number of
errors with treatment is
intragroup analysis
shows
shown
and the mean change
for
each group
that the subconvulsive group
in the
in Table I.
made
The
significantly
fewer errors during treatment, while the combined convulsive patients made
significantly more.
TABLE
I
Intragroup Comparisons for
Number
Before and During
ECT
Mean No.
Type of Treatment
Subconvulsive
Convulsive
A
Convulsive
B
Before
E}
ECT
of Errors
Errors
During
EDT
Difference p_*
2h
9.96
7.67
-2.29
4:1.02
29
10.59
12.62
+2.03
NS
7.36
10.1h
+2.79
‘=1.05
+2.28
“=1.02
**
1h
Combined Convulsive
h3
‘
* Intragroup analyses in this and subsequent tables based on
Wilcoxon's method of paired replicates.
** Patients originally in control group, then placed on convulsive
treatment.
group
is
period.
The score obtained during treatment
used here as the pretreatment score
Prior to treatment. subcgnvulsive patients
made
in the control
for the convulsive
approximately the
same
number of
errors as the original convulsive group. During treatment, however, subconvulsive subjects made fewer errors (7.67), while the errors in
convulsive patients increased to 12.62 errors - a difference significant
at better than the
1%
level of confidence.
�-6When
the data is analyzed with respeCt to physiologic change, significant
increases in errors are found only in those patients with the greater
degrees of physiologic change. This relationship is present in analysis
of the amobarbital
tests are
test
and the
combined (Table
EEG
as separate indices, and when the two
II).
TABLE
II
Intragroup Comparisons for Number of Errors Before and After
ECT in Relation to Degree of Physiological Change
.
Physiological Index
N
Mean Difference in Number of
Errors during Treatment
Amobarbital Test.
or
None
positive
one
13
-O.23
NS
28
+3.714
.01
23
+1.73
NS
18
+3.33
.05
3
21
+1.00
h to 6
us
20
+3.90
.01
Two
or three
positive
Electroencephalogram
or
None
one
High Delta
Two
or three
High Delta
.
.
Combined Physiological
0
to
The
in
relationship between
number of
flue degree
errors during treatment is
of behavioral change
shown
with no, minimal or moderate behavior changes
difference in
made
number of
errors.
in Table
III.
do not show an
and the change
Those
patients
appreciable
Those with marked behavior changes, however,
significantly more errors during treatment.
�TABLE
III
Intragroup Comparisons for Number of Errors Before and During
ECT in Relation to Degree of Behavioral Change
Degree of Behavioral Change
Difference Nnmber
Errors During Treatment
Mean
N
_
marked
2h
Moderate
1h
p
<1.0l
+3.58
+1.00
NS
-0.h0
NS
l
Minimal
or
5
None
Analysis of the pretreatment error scores in relation to the degree
of physiological change
is
shown
in Table
IV.
The
results
show
that subjects
with large pretreatment error scores manifest greater degrees of physiolog-
ical
change during treatment.
Patients with
little physiological
change
during convulsive therapy had a mean pretreatment score of 7.88, while
physiological effects,
had a mean pretreatment
score of 13.25 errors. The triserial correlation
the .05 level of confidence.
is +.3h, significant at
those
who developed marked
TABLE
IV
Relation of Pretreatment errors to Eventual Degree of Physiological
Change During Treatment
N
Mean Number
Errors Prestreatment
Physiologic Change:
o
to
211’
3/ and
my
16
7.88
19
11.21
�Qualitative Data:
Alterations in size of figure or in
minor aspects of form were common
types of error during both testing periods. Certain qualitative patterns
were
frequently noted during treatment,
however, which occurred only
or to a lesser extent in the pretreatment period.
patients to
.was
make no
It
was common
attempt to trace the more complex figures.
rarely
for
This response
often associated with a generalized withdrawal reaction in which the
patient
was unreSponsive to any stimulus or procedure.
Others became
hostile and negativistic toward the testing.
l
i
Patients
wifln
the greatest
amount of physiological change seemed to
difficulty following instructions. They would trace the lines indiscriminately without regard for the Specific figure to be outlined, repeated
have
‘
a previous figure despite changes in the
actually existed,
the
more complex
and impulsively, and showed
Such
little
drew
lines
where none
trace the stimulus figure while ignoring
and attempted to
test figure.
test figure,
patients were likely to respond quickly
concern about making an error even
they might spontaneously comment, "I
know
that's
not
right."
when
‘
�Discussion:
results of this study clearly danonstrate a relationship between
the degree of cerebral dysfunction and perceptual alteration. Patients
‘The
with subconvulsive stimulation
make fewer
errors
on
retesting.
A
slight
decrease or no change in errors occurred in those patients receiving
vulsive therapy
who showed
only minimal physiological changes.
vulsive patients, however, with the
showed a
significant increase in
alteration,
of errors. This interrelation-
number
is in
accord with studies of patients
with altered brain function due to head injury and brain tumor.
(ll),
The con-
most marked physiological
ship of brain fUnction and perception
and Weinstein
con—
Teuber
applying a similar technique in cases with penetrating
’brain,wounds, concluded that performance was unrelated to locus of lesion
but that aphasic patients
made
significantly more errors than a non-
aphasic brain-injured group.
Pollack gt §l3(12), using the identical
in this study, reported
relationship between perceptual errors
as
no
test
and
the location of lesion in tumor patients. They reported, instead, that
defective perception
related to the severity of other rental changes,
was
‘
such as
It
disorientation.
Should'be pointed out that the
all patients referred for
to that found by Pollack
ECT
was 10.35
total pretreatment
cit.,
Teuber and Weinstein, op.
12.
Pbllack, Battersby and Bender, op.
13.
Ibid.
score for
errors, a score almost identical
gt §l5(13) in thefi‘brain
11.
mean
369-379.
cit.
tumor
patients. Since
�the two populations are comparable in terms of other parameters as age
The
and education.
defects in figure ground discrimination cannot
be
’regarded as reflective of cerebral dysfunction as an isolated entity
abstracted from the totality of behavior. Rather than being in a
to one relationship, poor performance on such tasks
interaction of
many
there are
cases with cerebral
many
may
be due
to the
factors, brain dysfunction; being only one.
not
damage who do
show
one
Thus
defects.
Con-
versely, the present findings indicate that the inability to perceive
embedded
as
it is
The
figures
may be
related as
much
to certain types of mental illness
to brain disease.
!
relationship of perceptual alteration to behavioral
is clearly demonstrated.
treatment
The
patients
increase in errors during treatment were those
pronounced change
in clinical behavior.
who showed
also
who
change during
the greatest
showed
the most
They manifested such behavior
patterns as euphoria, hypomania, withdrawal, somatization or paranoia.
Comparable to these are the
embedded
figures test during treatment.
related to
paranoid
was
qualitative aspects of performance
an evasion
The
some
may
as well be
was
cases, and to a
lack of concern in correcting errors
associated with clinical patterns of euphoria
increase in errors
the
Failure to attempt the task
or withdrawal reaction in
hostility in orders.
on
attributed to
and hypomania.
change
The
in motivation or
attitude toward the task or examiner as it is to any Specific aSpect of
the altered brain function. Changes in performance on this complex perceptual task can thus be understood as
one
manifestation of changes in
the patterns of interaction with the environment.
The
relation between behavioral
this type of task, has been noted
and perceptual
by Witkin to be
patterns, using
true of persons without
9
�-11..
demonstrable cerebral dysfunction as well.
He
individual differences in the perception of
embedded
be
related to personality factors (15).
The
found
that the
wide
figures (1h)
may
finding in the present
study of the prognostic significance of the pretreatment score to the
eventual physiological reaponse is in accord with his observations.
7
Personality factors
may
thus be related to the degree of changes in
In a previous study (16) certain person-
brain function.with trauma.
ality patterns
were associated with the
ment following ECT.
short term behavioral improve-
basic characteristics of persons with a
favorable prognosis defined in that study were an inability to think
critically
The
or sensitively about
their
own
or other's needs or feelings,
patterns characterized by oversimplified generalizations,
,stereotypy and conventionality. The present data that persons with
greater difficulty in making the necessary analysis and figure-ground
and response
discriminations
on embedded
figures
show a
greater alteration in behavior
with treatment, is consistent with the previous observations.
Witkin,.Individual differences in case of perception of
figures, J. Pers., 19: 1950, 1-15.
15. H. A. Witkin, Nature and importance of individual differences
in perception, J. Pers., 18, l9h9, 1&5-170.
1h.
16.
H. A.
embedded
Kahn and Fink, op.
cit.
�.12Summary and Conclusion:
1. Fifty-three consecutive patients referred for electrotherapy
were studied before and
embedded geometric
after treatment
figures.
An
on
their ability to perceive
experimental group of
29
patients
received
A.
regular grand mal therapy wifla pentothal premedication.
control group of 2h patients received subconvulsive stimulation only.
2.
The
experimental group
made
significantly more errors following
treatment than did the controls.
I
3. 'Within the experimental group, however, there was considerable
I
variability. Increase in errors
was found
to
be
significantly related
to the degree of altered brain function, and the degree of behavioral
change.
h.
The
pretreatment error scores were significantly related to the
degree of altered brain function developed during treatment. The significance
in terms of personality factors is indicated.
5. Performance in this complex visual task mirrors the pattern of
of this
behavioral change observed clinically.
6.
one
It is
concluded
that performance
on a complex
visual task is
manifestation of a generalized pattern of interaction with the environ-
ment.
,4
Lu...
�.13-
Legend
Illustrations of test figures.
Fig. 1.
used to acquaint the subjects with the task
the task
is
The
is
preliminary sample
shown
in a. In
d
complicated by having the subject determine which of
the two simple figures can be found in the complex figure.
�
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Perception of embedded figures after induced altered brain function. American Psychologist, 12: 36, 1957.
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1957
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Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>
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