http://exhibits.library.stonybrook.edu/mfp/files/original/a0dd669fe6ef80d3f920fa82ad004579.pdf 922f3407ada0d1bf7f975f2fcd3d0f5a PDF Text Text From the Journal of the Hillside Vol. VI October, 1957. I1oslojfoait, ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI1 HYMAN KORIN, PH.D.2 and MAX FINK, M.D.3 In the course of extensive investigations (1, 2, 3) into the perception of multiple simultaneous stimuli, the pattern of failure of subjects accurately to report one of two stimuli led to a concept of an “order of dominance” in cutaneous perception. Since then, the relationship of the observed pattern of dominance to biologic and psychiatric concepts of body image and body scheme has been the subject of considerable speculation (4, 7, 8, 14). The interrelationship of body areas was initially clearly demonstrated in simultaneous tactile tests of face and hand (2), in which it was noted that the stimuli to the hand were frequently not reported or mislocalized. These phenomena of “extinction” and “displacement” led to the inference that cheek area stimuli were “dominant” to hand stimuli. In subsequent reports (3, 10, ll, 12) a pattern of dominance for tactile stimuli was described in which the face and the primary genital areas were the most perceptive or dominant areas; the hand was the least dominant; and the shoulder, foot, buttock, breast, back, thigh and abdomen fell between these extremes in a mild gradient. These observations were made in normal adults and children and psychiatric patients, but were most clearly discerned in patients with brain disease. Indeed, the major portion of the data relates to a group of patients with severe diffuse brain dysfunction under observation in a general psychiatric hospital. 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M—927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. 2Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3 Director, Department of Experimental Psychiatry, Hillside Hospital. 241 �242 KORIN—FINK unclear. In a review of the problem (3) consideration was given to hypotheses ascribing signiﬁcance to anatomic, psychophysical, genetic, environmental and neurophysiologic factors. In their conclusions, Bender, Green and Fink of the organization “no explains that adequately theory one note this pattern. Learning and maturation are probably factors, but it brain with of studies In inherent.” be patients to mostly appears disease and normal young children, Cohn (4, 5) emphasized the rostral order of dominance and ascribed signiﬁcance to “an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain.” He also noted speciﬁcally that this pattern was primarily associated with “the over-all sentient function of the brain.” A more extensive elaboration of a maturational and developmental explanation of the order of dominance has been proposed (14). Taking the infantile patterns of sucking and feeding as a model, Linn ascribes dominance to the face as it is the oldest element in the body image; the dominant role of the genital area to the intensity of pleasurable sensation that the infant elicits from masturbation; and the subordinate position of the hand to its role as an second holds it wherein and appendage tension-relieving exploring place in awareness to its stimulation of the more exciting mouth and genitalia. A neurophysiologic view was advanced by Critchley (6, 7), who, after expressing a preference for the term “tactile inattention” instead of “extinction,” emphasized the rostral order of dominance. He stated that “strong stimulation of the healthy side suppresses the attenuated sensations on the impaired side,” and concluded that “tactile inattention in parietal patients is probably no more than an instance of local neglect or disregard, which may be demonstrated at times in many other spheres of consciousness besides the tactile—whether motor, visual or spatial.” A psychophysical explanation was eschewed by Bender, Fink and Green (3, 10, 11), who found no relation between the order of dominance and the tactile threshold for touch or pin prick. DennyBrown, Meyer and Horenstein (8), however, insisted that these patloss of alteration there when or was an only terns were apparent the that demonstrated exfurther discrimination. They two-point tinction of the hand stimulus by a stimulus to the leg could be cheek the of dominance hand. The the stimuli four to overcome by the stimuli altered to be ten by however, could hand the not, to hand in their subject. The basis for these phenomena is” �STIMULUS INTENSITY IN PERCEPTION 243 The following data further emphasize psychophysical factors in perception under the conditions of multiple simultaneous stimulation. These studies represent the initial report of an investigation into the application of simultaneous tactile stimulation tests to the problem of measurement of the alteration in brain function induced by electroshock therapy. In the course of this study electrical stimuli were applied to the cheek and hand of psychiatric patients. Stimuli were either at threshold or suprathreshold levels. Two aspects of the data are presented: (a) the effect of alteration of relative strength of stimulus in the order of dominance on facehand tests; and (b) relation of perceptual thresholds to the order of dominance. SUBJECTS AND METHOD The subjects were thirty-four consecutive psychiatric patients referred for electroshock therapy. The range of their ages was between 21 and 65 and the mean age was 45. Eleven patients were diagnosed as involutional melancholia, thirteen as manic-depressive, depressed, eight as schizophrenia, and two as psychoneurosis mixed type. All testing was done prior to a course of electroshock therapy and no patient had clinical or EEG evidence of altered brain function. Each patient was tested in one session for the purposes of this report. Two model S-4B Grass square wave stimulators were synchronized to deliver either single or two simultaneous electrical stimuli. An isolation unit was connected to each stimulator to eliminate artifacts and the output was monitored visually by an oscilloscope. A switch box inserted in the circuit permitted independent selection of the various body parts. An active and an indifferent electrode, required for each body part, were small 3%; inch steel discs placed 1 inch apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. The electrodes remained affixed to the selected body parts throughout the period of testing. The patient was placed on a couch in a relaxed and supine position. To alleviate undue anxiety the nature of the testing was described. It was emphasized that only a slight tap-like sensation would be felt. The electrodes were then placed on (I) the dorsum of the hands, (2) the mandibular area of both cheeks, and (3) the medial calf area of the legs. In the testing procedure, thresholds for the various body parts were ﬁrst determined. At a frequency of .3 cycles /second, and a pulse �244 KORIN—FINK duration of 50 milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, until the subject perceived 100 per cent of the stimuli. Increments of 5 volts were applied to the hand and increments of 1 volt to the cheeks. After a ten-second interval, the voltage was decreased until sensation disappeared. Following another ten-second interval, the voltage was gradually increased by 1 volt each six seconds until the patient again reported 100 per cent of the stimuli. This reading was considered the minimal voltage required to produce threshold sensation. Such stimuli, at threshold and 10 per cent above the threshold, are reported by the subjects as a “tap,” a “prick” or a “sting.” Complaints of painful perception were not elicited at these levels of stimulation. After the thresholds were determined, testing with a series of single and double simultaneous stimuli followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and left cheek (homologous stimulation). Both parts were stimulated simultaneously, or one part singly, in a mixed order for ten trials for each of the following conditions: (1) threshold, (2) suprathreshold (10 per cent above the threshold), (3) one body part at suprathreshold and the other at threshold, and (4) the reverse of (3). The order of presentation of conditions (1) and (2) was alternated for different subjects and the same was done for conditions (3) and (4). Similarly the order of presentation of the heterologous and homologous stimulation was alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. When this change occurred, stimulation was increased until a new threshold was determined and ten trials were started anew. RESULTS Threshold Values The threshold stimulation for perception was determined for the hands, cheeks and legs (Table I). The threshold values for the hands and legs are three to four times higher than the thresholds for the cheeks. While the threshold values in the legs are less than in the hands, these differences lack statistical signiﬁcance. Variability of the threshold is considerably greater in the hands and legs than in the cheeks. There is virtually no overlapping of thresholds, however, Where the cheeks and the hands are concerned. A. �STIMULUS INTENSITY IN PERCEPTION 245 I Mean Thresholds and Standard Deviations of Body Parts TABLE Mean Thresholds (volts) Standard Deviation Right Cheek Left Cheek Right Hand Left Hand Right Leg Left Leg 6.76 7.85 29.25 22.35 24.50 19.52 4.47 4.86 14.88 13.60 13.99 13.64 Extinction Patterns The difference between the number of extinctions of the right hand or the left cheek on stimulation of both parts with either threshold or suprathreshold stimuli was not signiﬁcant (Table II). Also, when both cheeks were stimulated with either threshold or suprathreshold stimuli, there were no differences in the number of extinctions in each cheek (Table III). In contrast to these observations, stimulating one body part with a suprathreshold stimulus and the other at threshold resulted in a signiﬁcant increase in the failure to report the body part stimulated at threshold. Thus the cheek was dominant over the hand, or the hand was dominant over the cheek depending on the body part to which the stronger stimulus was applied (Table II). Altering the relative strength of the stimuli applied to the cheeks resulted in a similar predictable change in the pattern of dominance (Table III). Further analysis of the data in Table II indicates that the hand B. TABLE II Mean Extinctions of Cheek and Hand for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Mean Extinctions Extinctions of Hand of Cheek Hand and Cheek at Threshold Hand and Cheek at Suprathreshold Hand at Suprathreshold and Cheek at Threshold Cheek at Suprathreshold and Hand at Threshold Difference Signiﬁcance 1.55 1.56 .01 NS. 1.02 .59 .57 NS. 2.30 .22 2.08 p<.01 .32 1.36 1.04 p<.01 �KORIN—FINK 246 was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.04) for the thresholdsuprathreshold condition. This tendency is also evident when both parts were simulated at suprathreshold. If it is considered that the mean threshold for the hands is approximately 30 volts, while for the cheeks the threshold is 7 volts, the difference in incidence of extinction may be explained. Suprathreshold stimulation was set at 10 per cent above the threshold value. The hand stimulus was TABLE 111 Mean Extinctions of Both Cheeks for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Extinctions of Left Cheek Mean Extinctions of Right Cheek Difference Signiﬁcance Threshold .39 .45 .06 N.S. Both Cheeks at Suprathreshold Right Cheek at .18 .37 .19 NS. .96 .14 .82 p<.05 .03 1.28 1.25 p<.01 Both Cheeks at Suprathreshold and Left Cheek at Threshold Left Cheek at Suprathreshold and Right Cheek at Threshold therefore increased by 3 volts and the face stimulus by only 1 volt above the threshold value. Such an increase, although proportionately equivalent, appears to have given greater relative strength to the hand stimulus. Extinction Regardless of pattern, the mean total of the number of extinctions was greater when heterologous body parts were stimulated at threshold than when these parts were stimulated with suprathreshold stimuli (Table IV). For these same conditions of stimulation the dilferences between the mean number of extinctions obtained on homologous stimulation of the cheeks lack statistical signiﬁcance, but the results are in the direction which indicate that a greater number of extinctions occur when two body parts are stimulated at threshold (Table IV). The failure to obtain a signiﬁcant difference in the latter instance is partly due to the fact that relatively few C. Incidence of �STIMULUS INTENSITY IN PERCEPTION TABLE 247 IV Mean of Combined Number of Extinctions For Varying Conditions of Threshold and Suprathreshold“ Stimuli Both Parts at Both Parts at A-Suprathreshold A-Threshold Threshold Suprathreshold B-Threshold B-Suprathreshold A-Cheek B-Hand 3.11 1.63 1.68 2.43 .85 .56 1.31 1.10 A-Left Cheek B-Right Cheek * Differences between the mean number of extinctions at threshold and the other three conditions of stimulation are signiﬁcant for the cheek and hand but are insigniﬁcant for both cheeks. extinctions are elicited when homologous parts are stimulated. These ﬁndings on the total number of extinctions are in agreement with previous observations (2). DISCUSSION The pattern of extinction followingelectrical stimulation of the skin with threshold and suprathreshold stimuli has been determined. In contrast to the ﬁndings of investigators (3) who used clinical (tactile) stimulation, the face stimuli were not reported more frequently than the hand stimuli. Under the conditions of the method of testing in this investigation, nevertheless, it is clear that the pattern of extinction for any two body parts can be readily altered by varying the relative strength of the stimuli. Thus a suprathreshold stimulus applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimulus intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand, in Simultaneous tactile testing, is due to an inherent factor, perceived body image, rostral dominance, developmental principle or a learned factor, are not supported by these observations under our conditions of testing. If any of these factors were involved, a pattern of face dominance should have been elicited when the hand and cheeks were stimulated with equivalent electrical stimuli at threshold and suprathreshold intensities, despite the methodological dif- �248 KORIN—FINK ference introduced by the procedure of afﬁxing electrodes to the skin. The ﬁndings in this study, namely that differences in the strength of the simultaneous stimuli can alter the pattern of extinction, supin differences inference, By hypothesis. stimulus-intensity a ports threshold also play a signiﬁcant role. That an intense stimulus elsewhere can raise the pain threshold and Wolf demonstrated been has by Hardy, 35 much cent as as per Goodell (13). This effect of a relatively intense stimulus on the threshold of another stimulus has also been found by investigators how however, still remains, The stimuli 9). problem (8, other using it is that a pattern of dominance may be elicited when presumably stimuli. touch stimuli by are applied equivalent The results of this study suggest an explanation. Stimuli of for sensation threshold elicit a to intensities are required differing various body parts. When these stimuli are increased 10 per cent, the resultant stimuli are proportional and are perceived as equivastimuli the two body in parts, touching clinically lent. In contrast, are disproportionate relative to the threshold value although apthe of Because their in of application. intensity equal proximately differences in threshold for the hand and cheek, the tactile stimulus the than threshold the above is more cheek the proportionately to stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and has been considered “dominant.” A threshold hypothesis was rejected (3) on the basis that the thresholds obtained by von Frey (16) for pressure and pain do not double the elicited order by dominance the to strictly correspond simultaneous stimulation tests. Most difﬁcult to reconcile is von which the of threshold penis, glans the that Frey’s ﬁnding pressure is second in dominance rank only to the cheek in a group of ten the while millimeter; 111 is tested, grams per square body parts 12 is is least dominant, only which at the grams of hand, threshold per square millimeter. feand male for the in area thresholds genital Unfortunately, thresholds of list Von determined. Frey’s been seldom have male (16) is based on a single subject. His more detailed observations (17), however, indicate that there is virtually no pressure sense in the and warmth of the pain, perception clitoris, although or penis glans cold is well developed. It is quite possible that the punctate presthe where touch with genital area correlate does threshold not sure is concerned but that instead some other sense or combination of senses is involved. �STIMULUS INTENSITY IN PERCEPTION 249 Thresholds for the dorsum of the hand and the cheek obtained by von Frey and other investigators indicate that the cheek is considerably more sensitive than the hand. These ﬁndings are in agreement with the thresholds obtained in this study. In a recent study of electrical thresholds at various body sites Sigel (15) reported that “leg areas including thigh and ankle, also dorsum of the hands and the palm showed a deﬁnite tendency for higher thresholds. Scalp, temple, forehead and face tended to have lower thresholds. The anterior chest and upper arm and anterior wrist areas showed a tendency for lower thresholds. Neck areas, abdomen and upper back showed no deﬁnite trend.” In this statement there is no disagreement with the clinically observed order of dominance. From the experimental results obtained here, it is proposed that the dominance hierarchy elicited under the conditions of simultaneous testing may be explained on the basis of the relative strength of the stimuli and the stimulus threshold. SUMMARY Using square wave electrical stimuli, the threshold for perception in the hands, cheeks and calves were determined in thirtyfour psychiatric patients. Simultaneous stimuli were applied in random sequence to combinations of cheek and hand and both cheeks, at threshold, suprathreshold and combinations of threshold and suprathreshold intensities. With simultaneous threshold, or simultaneous suprathreshold stimulation, the differences between the number of extinctions in either part were not signiﬁcant. With stimuli of unequal intensity (one stimulus at threshold and one suprathreshold), however, there was a signiﬁcant increase in the failure to report the threshold stimulus. The total number of extinctions is greater with threshold than with suprathreshold stimuli; and greater in heterologous than in homologous patterns of stimulation. It is concluded that the observed order of dominance in simultaneous cutaneous tests may be explained by psychophysical relationships. REFERENCES (1) Bender, M. B.: Disorders in Perception. Springﬁeld, 1952. (2) 111.: Charles Thomas, Bender, M. B.; Fink, M. 8c Green, M. A.: Patterns in Perception on Simultaneous Tests of Face and Hand. A.M.A. Arch. Neurol. é» Psychiat., 66: 855-362, 1951. �KORIN—FINK 250 (3) Bender, M. B.; Green, M. A. 8c Fink, M.: Patterns of Perceptual Organization with Simultaneous Stimuli. A.M.A. Arch. Neurol. (5" Psychiat., 72:233-255, 1954. (4) (5) (5) (7) (8) (9) (10) (11) Cohn, R.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation. 1. Nero. (5. Ment. Dis., 113:471-484, 1951. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: II—A Study in Rostral Dominance in Children. Neurology, 1:119-122, 1951. Critchley, M.: The Parietal Lobes. London: Edward Arnold 8c Co., 1953. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions. Brain, 72:538-561, 1949. Denny-Brown, D.; Meyer, J. S. 8c Horenstein, S.: The Signiﬁcance of Perceptual Rivalry Resulting from Parietal Lesion. Brain, 75:433-471, 1952. Duncker, K.: Some Preliminary Experiments on the Mutual Inﬂuence of Pains. Psychol. Forseh, 21:311-326, 1937. Fink, M. Sc Bender, M. B.: Perception of Simultaneous Tactile Stimuli in Normal Children. Neurology, 3:27-34, 1953. Fink, M.; Green, M. A. 8: Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects. ]. Nerv. 63'» Ment. Dis., 117:43-49, 1953. (12) Fink, M.; Green, M. A. 8: Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46—58, 1952. (13) Hardy, J. D.; Wolf, H. S. 8: Goodell, H.: Studies on Pain. A New Method for Measuring Pain Threshold: Observations on Spatial Summation of Pain. 1. Clin. Invest., 19:649-658, 1940. (14) Linn, L.: Some Developmental Aspects of the Body Image. Int. ]. Psychoanal., 3621-7, 1955. (15) Sigel, H.: Cutaneous Sensory Threshold Stimulation with High Frequency Square-Wave Current: 11. The Relationship of Body Site and Skin Diseases to the Sensory Threshold. ]. Invest. Derm., 18:447-451, 1952. (15) von Frey, M.: Beitrage zur Physiologic des Schmerzsinns. Ber. Sdchs. Ges. Wiss., 462185-196, 283-296, 1894. (17) von Frey, M.: Beitrage zur Sinnesphysiologie der Haut. Ber. Siichs. Ges. Wiss., 47:166-184, 1895. �JOURNAL of the HILLSIDE HOSPITAL VOL. VI, No. 4 l . l OCTOBER, 1957' * . . CONTENTS Papers» from the Department of Experimental Psychiatry A UNIFIED THEORY: OF THE ACTION‘OF- PHXSIODYNAMIC- THERAPIEs—‘——Max Fink - ’ A 19.7 AN OBJECTIVE STUDY OF COMMUNICATION .IN‘ PSYCHIATRIC, INmRyIEws—Jbseph Iaﬂe 207‘ SOCIAL FACTORS IN THE SELECTION OF THERAPY IN TA—RY MENTAL HOSPITAL—Robert and Max Fink L Kahn, Max Pollack SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN TO ELECTRosHOC'x—Martin A. Green A VOLUN- EEG .216 RESPONSE 229 ROLE OF STIMULUS INTENSITY IN PERCEPTION 0F SIMULTAN'EOUS‘ ELECTRICAL CUTANEOUS STIMULI—Hy‘mqn Max Fink Korzn and "241 ‘ NEWS AND NOTES -- "I ' ' I " " —— ——-——————_—. V , , V Published quarterly for the Hillside HOspit-al, Glen Oaks,- N. Y., by 7 ‘ 251 ' THESOCIETY 0F HILLSIDE HOSPITAL Copyﬁght_1957, The Society OE Hillside HOSpital, Inc. v” "V ' �Hillside Hospital is a nonsectarlan, nonproﬁt mental hospital for the treatment Of voluntary patlents sufferlng from early and curable mental illne-SS; regardless o'E the1r ability to pay. A special department for adolescents1's 1ncluded:1n the Hospital program. The Hospital teaches and trains" phys1c1ans ‘;in‘ psychiatry and psychotherapy, and also prOVidEs graduate training to graduate students1n psychology, social service and psych1atr1c nursing. Research programs are in progress in psychiatry, med1c1ne and1n the laboratories. The teaching and training program carefully organized and integrated with the clinical serv1ces and 1nvolves the participation of the administrative staff, a staif of superv1sors and the cooperation of a large psychiatric attendmg staff almost entirely psychoanalyti— cally trained. In addition to all the usual inpatient adjunctive therapies, the Hospital condiu‘cts anact’e extramural program including an aftercare clinic, an outpat1et1c11n1c afﬁliation with Adelphi College for the tralnmg'of’ psychologists, nurses and social workers, an organization of formerpatients; lectures to the general public, and a close afﬁliation with the LongIsland Jewish Hospital. The Hospital traces itsbegmmngsto orgamzatlonal meetings in 1917 held under the sponsorsh1p of Dr Israel Strauss which led to the formation of the Committee for Menta 'iI-Iealth among Jews, in 11919. Hillside Hospital was opened anddedlcated in 1927. Its original location was in Hastings-on-Hudson, mQVing' to its present location in 1941. It is an aﬂiliate of Federatlon oﬁ Jewish Philanthropies of New York, and has been growmg stead1lyin bed capacity, the present size being 200 beds. is " ' �JOUBNAL of the HILLSIDE HGSPITAL Published as a function of the Publications Committee of the Medical Board. The Hospital is an agency of The Federation of Jewish Philanthropies of New York. VOL. VI, No. 4 OCTOBER, 1957 Editorial Advisory Board MORRIS B. BENDER, M.D. DUDLEY SANDOR LORAND, D. SHOENFELD, M.D. MD. Editor SIDNEY TARACHOW, MD. Associate Editors M.D. JOSEPH S. A. MILLER, M.D. ABRAHAM S. LENZNER, M.D. M. DAVID EPSTEIN, M.D. SYLVAN KEISER, M.D. EMANUEL KLEIN, Distributed by INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street, New York 11, N. Y. �Information to Contributors Manuscripts—Original manuscripts should be sent to Sidney Tarachow, M.D., 123 East 80 Street, New York 21, N. Y. All parts of the manuscripts should be typewritten, double-spaced, on one side of bond paper. References should conform to the style of this Journal. Reprints—Orders for reprints should be addressed to International Universities Press, 227 West 13 Street, New York 11, N. Y. ANNUAL SUBSCRIPTION, $3.00, SINGLE ISSUES, $1.00 Editorial communications should be addressed to Sidney Tarachow, M.D., Editor, Journal of the Hillside HosPital, 123 East 80 Street, New York 21, N. Y. Business communications, remittances, subscriptions and advertising material should be addressed to the Administrator’s Ofﬁce, Hillside Hospital, Glen Oaks, N. Y. �EDITORIAL NOTE The Editors are happy to devote this issue to the work of one of the Hillside Hospital research departments, the Department of Experimental Psychiatry. While from time to time the pages of this Journal have carried reports of the various research activities within the Hospital, this is the ﬁrst time that an entire issue of the Journal has been given over to presenting a comprehensive picture of the activities of a single department. Future issues will carry reports of our other research activities, in different spheres and carried on with varying methodologies. In our next issue we expect to present a large report on the many activities of the in-Hospital and attending staffs in professional and public education. We turn this issue over to the Department of Experimental Psychiatry. It is a young department, its workers are searching for scientiﬁc measurable factors in psychiatry, and hope by their ﬁndings to contribute to the multidisciplinary approach in psychiatry. 195 �PREFACE The reports in this issue of the Journal are representative of studies now in progress in the Department of Experimental Psychiatry. The Department was established in September 1954 upon the initiative of the late Dr. Israel Strauss. The goal of its full-time research personnel was deﬁned as the study of psychologic and physiologic aspects of behavior. In establishing the operational, experimental principles of the Service we have leaned heavily on our previous experiences with Drs. M. B. Bender and E. A. Weinstein at the Bellevue and Mount Sinai Hospitals of New York. These studies are supported ﬁnancially by the Board of Direc. tors of the Society of the Hillside Hospital. In 1954 the United States Public Health Service, National Institute of Mental Health established their support of the program, which has continued. Funds have also been obtained from the Dazian and Kaufmann Foundations, and recently from the Foundations’ Fund for Research in Psychiatry. The Staff has shown rapid growth, and at the present time includes: Martin A. Green, M.D. Joseph Jaf‘fe, M.D. Robert L. Kahn, Ph.D. ' Hyman Korin, Ph.D. Max Pollack, Ph.D. Assistant in Neurophysiology Assistant in Psychiatry Senior Assistant in Psychology Assistant in Psychology Senior Assistant in Psychology —— —- — — — Technical assistants include Mrs. Hannah Mosquera (EEG), Mrs. Jean Kolodny (Psycholinguistics) and Mrs. Janet Bowie (Secretary). During the past year Dr. Harold Esecover, Senior Resident in Psychiatry, has been associated with the Department on a half-time basis. October 10, 1957 Max Fink, M.D., Director Department of Experimental Psychiatry 196 �A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMIC THERAPIES1 MAX FINK, MD.2 The proper role of the physiodynamic therapies (convulsive, insulin coma and lobotomy) in psychiatry remains poorly deﬁned. In part, this results from the lack of an adequate formulation of their mode of action. In the past six years increasing evidence for a neurophysiologic-adaptive View of electroconvulsive therapy has been presented (41, 32, 38, 1). This view ascribes the therapeutic process in electroshock to a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. The type of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, an awareness of a similar mode of action in insulin coma (31) and lobotomy (40) has developed. During the past four years we have studied the relation between alteration in various indices of brain function and the behavioral response of psychiatric patients to therapy. The neurophysiologicadaptive view of electroshock has been supported and ampliﬁed (1 l, 12, 13, 19, 21); evidence for a similar view of insulin coma has been presented (22); and recently the concept has been extended to the newer “tranquilizers” (9). These studies provide the basis for a generalization concerning the efﬁcacy of these therapies. It is our purpose in this report to examine the experimental evidence to determine whether or not the mode of action of each of these thera1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the 2nd International Congress of Psychiatry, Zurich, September 6, 1957. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 2Director, Department of Experimental Psychiatry, Hillside Hospital. 197 �MAX FINK 198 pies may result from their ability to induce sustained alteration in cerebral function; and the corollary question, whether measurable alteration in cerebral function is a necessary condition for the efﬁ— cacy of these therapies, or a “complication” or “untoward effect.” The indices of brain function used in these studies have varied. These include memory scales (26), visual (20) and tactile (10) perceptual tasks, and changes in language patterns of orientation both clinically (19‘) and after intravenous amobarbital (21). In electroencephalographic studies of this problem, changes in the delta index, both in routine records (11, 12) and after activation by intravenous thiopentone (32, 33), and in the beta index (16) have been applied successfully. For this review, two indices will be stressed: changes in the delta index of the unactivated EEG, and clinical neurologic signs. These indices have been selected because of their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities. OBSERVATIONS (a) E lectrosh ock The following notes summarize our experimental studies of the role of changes in EEG delta activity in the response of subjects to electroshock (11, 13). In these studies, electroencephalograms were obtained before treatment, and at weekly intervals on a day after a treatment in consecutive electroshock referrals. Grand mal treatments were administered three times a week, for twelve to twenty treatments. The EEG records were quantitatively analyzed for the amount of induced delta activity, and classiﬁed into categories of “high,” “moderate” and “low” degrees of delta activity. At the end of treatment, the patients were independently rated for their shortterm clinical response into the categories of “much improved,” “moderately improved” and “unimproved.” In the initial series of patients, a signiﬁcant relationship between the early induction of high degrees of delta activity, and clinical ratings of “much improved” was observed. Eighty per cent of the records in the much improved group were high degree delta by the fourth to sixth treatment; and the percentage was sustained at 90 per cent in the third and fourth weeks. In contrast, none of the unimproved patients developed high degree delta records in the ﬁrst three weeks, and only 20 per cent of the records in the fourth week were so classiﬁed. In a subsequent predictive study, the EEG records during the �THEORY OF PHYSIODYNAMIC THERAPIES 199 second and third weeks of treatment were analyzed. Of the patients who had high degree delta records on both occasions, 67 per cent were rated as much improved, while of the patients without such records, 70 per cent were in the unimproved and moderately improved categories. Roth (32, 38), studying the EEG delta activity evoked by intravenous thiopentone after electroshock, has related both the stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. He concluded that patients not attaining a speciﬁed delta activity level “have not acquired an adequate physiological basis for recovery,” and recommended measurement of delta activity levels after thiopentone as a guide to the clinical management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of delta activity that vary from low to high, subconvulsive therapy rarely alters EEG patterns or induces low degrees of delta activity (13). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Gleser (38) demonstrated a signiﬁcantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (13) recently completed here, twenty-seven patients received a course of subconvulsive therapy. Electroencephalograms, taken at weekly intervals, demonstrated minimal changes—none of the records were scored as middle or high delta activity. Of the twenty-seven patients, no change in behavior was noted in twenty-three, and of these, nineteen were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed signiﬁcant changes in behavior, while of the ﬁve who did not show the delta response, only two showed a behavioral change. (b) Tranquilizing Drugs When the newer drug therapies are studied from the viewpoint of their electroencephalographic and clinical neurologic effects, a meaningful classiﬁcation emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efﬁcacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly deﬁnable electroencephalographic patterns. Based on observations made in chronic admin- �200 MAX FINK istration of drugs in adult psychiatric patients, the EEG changes may be classiﬁed according to predominant changes in the frequency spectrum. There are three broad types: 1. Increased slow wave activity with hypersynchrony (“bursts”)——“delta shift” 11. Desynchronization with voltage and frequency irregularity and irregular theta activity—“desynchronization” III. Increased high voltage fast activity—“beta shift.” Of the group of drugs inducing a delta shift, the phenothiazine derivatives chlorpromazine, promazine, and perphenazine are clear examples. Each drug induces seizures in nonepileptics or exaggerates seizures in epileptic patients (7, 8, 15, 29, 37). Each drug induces clinical parkinsonian neurologic patterns when given in adequate dosage. In our laboratories, we have induced parkinsonism in all patients receiving chlorpromazine (14) and have observed seizures in 10 per cent of a group of psychotic patients without previous history of seizures. Induced delta activity, including burst activity, was observed in more than half the patients in this series. Reserpine also evokes delta activity when given in large doses (2). At high dosage levels, it exaggerates seizures in epileptics and induces seizures in animals (35). At the usual clinical dosages, however, reserpine induces desynchronization of frequencies with a moderate increase in theta activity (28), without seizure induction but with deﬁnite motor rigidities. In a series of patients treated here (39), parkinsonism was induced in all patients. EEG changes were limited to desynchronization only, without delta burst activity. The primary response of two other drugs, mepazine and benactyzine, is the induction of EEG desynchronization. Mepazine, a phenothiazine derivative, induces desynchronization with small amounts of theta activity (7). Delta activity has not been described, nor have we found reports either of seizures or parkinsonism in the clinical literature. Benactyzine, a potent anticholinergic compound, induces a blocking of alpha, ﬂattening of the record and occasional theta activity (5, 17). Neither seizures nor parkinsonism have been described for this agent. Meprobamate is the clearest example of the group of drugs inducing a beta shift in the EEG (3). This agent further differs from the phenothiazines and reserpine in not producing parkinsonism and not only are clinical seizures not induced, but deﬁnite antiepileptic activity has been described (30). Habituation is readily �THEORY OF PHYSIODYNAMIC THERAPIES 201 achieved, and withdrawal phenomena of agitation and seizures have been observed (42). In these actions, meprobamate is more like barbiturates than like the other new tranquilizers. If we determine the clinical efficacy of these agents, we note a parallel between the induced EEG effects and their potency in altering behavior. The drugs that most readily induce a delta shift in EEG frequencies—the phenothiazine compounds—are those with the greatest clinical efﬁcacy in the therapy of psychoses. The compounds with lesser activity in this direction are less efﬁcacious clinically. Insulin Coma Therapy The effects of insulin coma therapy on the nervous system are well documented. During each coma, EEG delta activity is induced, which usually persists for minutes to a few hours after gavage. Not infrequently, in approximately one third of patients receiving deep coma therapy in this hospital, seizures, aphasia or prolonged coma results. After such events, EEG changes of delta activity persist for days, and in cases of prolonged coma, for weeks and months (43). The relation between prolonged coma, altered brain function and behavioral response has been discussed at length. Revitch (31) reported eight cases of prolonged coma and concluded that improvement may be attributed to the induction of organic brain damage, similar to lobotomy. Yaeger, Simon, Margolis and Burch (43), describing twelve cases of prolonged insulin coma, noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (34), emphasizing EEG data, and Kwalwasser and Caplan (27) presented individual cases to support the same conclusion. We reported a similar relationship between prolonged coma and behavioral response in a case study (22). A 34—year-old schizophrenic patient with paranoid ideation developed a left hemiplegia during insulin coma therapy. With the onset of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and spatial inattention, there was a marked change in speech and behavior. He became lucid, loquacious and denied his illness. His former paranoid-withdrawal type pattern was replaced by a friendly cooperative attitude. These changes were accompanied by delta changes in the EEG, as well as language changes after amobarbital indicative of altered brain function. The neurologic symptoms resolved, but the behavioral changes persisted so that he was discharged two months later as “much improved.” (c) �202 MAX FINK (d) Lobotomy While we have not had the opportunity to study lobotomy patients from the point of view of this summary, the reports of numerous observers clearly document a similar relationship. EEG changes of delta activity are present in all subjects postoperatively (6) and persist for varying periods. Walter et a1. (40) in a study of 150 patients, found an 80 per cent persistence of abnormal EEG activity after three years. These authors also noted a relation between clinical improvement and the degree and extent of postoperative Slow wave activity. Postoperative seizures are a frequent “complication,” being variously reported as occurring in up to 20 per cent of subjects (25). Furthermore, there is a relationship between the extent of brain tissue cut and the therapeutic outcome. Circumscribed surgical lesions, regardless of locus, have an improvement rate lower than unilateral lobectomy; and these latter are frequently inadequate and are “improved” upon by a bilateral procedure (36). DISCUSSION When the various physiodynamic therapies are essayed from the point of View of an alteration in brain function, a common mode of action becomes apparent. These therapies represent devices which induce appreciable changes in brain function, with resultant change in behavior. Convulsive therapy and lobotomy induce measurable diffuse changes in brain function directly; insulin coma primarily when complications ensue; and the phenothiazine and reserpine groups of tranquilizers when given in adequate dosage. How persistent changes in cerebral function affect behavior is not clear. Psychotic behavior is not “reversed” or “obliterated.” Rather, with an alteration in the central nervous system milieu, there is an alteration in all aspects of behavior including perception, mood, affect, memory, judgment and attitude. The speciﬁc adaptive is and is each for variable dependent on numerous subject response historical and environmental factors. Premorbid personality (18), environmental situation and expectations (13), and the duration of the alteration in brain function (12) have recently been discussed as determinants of the behavioral response under these conditions. The induced changes in behavior are evaluated by the psychiatrist, administrator or family as to the degree of “improvement.” These ratings are value judgments, based upon such factors as the tolerance environmental the behavioral of induced response, type �THEORY OF PHYSIODYNAMIC THERAPIES 203 and the observer’s expectations. In this context, the physiodynamic therapies do not induce “improvement”-—rather they induce behavioral change which is secondarily evaluated as improvement. The alteration of cerebral function is therefore not a “complication” or an “untoward effect” but the desired goal of these forms of therapy. Of the many “organic" therapies introduced during the past thirty years, none apparently has been a speciﬁc agent for the therapy of psychoses (in the sense that penicillin is speciﬁc for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efﬁcacy in altering behavior by altering the cerebral milieu. In this context, the various physiodynamic therapies are not spe— ciﬁc for a type of psychosis. The early enthusiasm that reserpine or chlorpromazine was speciﬁc for schizophrenia, or hypotheses that ascribe signiﬁcance to an antagonism between these drugs and “psychosis” or “schizophrenia” are not tenable. Similar enthusiasm claiming a speciﬁcity of insulin coma for schizophrenia is also untenable, and support for this view is presented in a recent chlorpromazine-insulin coma control study (14). EEG analysis of these therapies permits a more explicit deﬁnition of the induced alteration in brain function. Changes in cerebral function reﬂected by a shift in the spectrum of EEG frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as “bursts” or “hypersynchrony” provide the change in milieu that is more effective in altering behavior. The signiﬁcance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the tranquilizers. That a delta shift has some speciﬁcity is seen in the analyses of the drug effects. Those drugs that induce the delta shift—the phenothiazines and reserpine—have been consistently reported as effective modiﬁers of psychotic behavior. Changes in brain function reﬂected by EEG desynchronization only, or a shift in frequency spectrum to the faster range, have a limited efficacy in altering psychotic behavior.3 The signiﬁcance of a delta shift is further seen in the limited efficacy of subconvulsive electroshock when compared to convulsive electroshock in the management of psychoses. Another aspect of the alteration in brain function which may be deﬁned is the change in seizure threshold. With the delta shift in These observations suggest the application of EEG screening of new chemotherapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. 3 �MAX FINK 204 the EEG, an increase in clinical seizures would be anticipated. This is indeed true. Seizures have been described following electroshock (4, 24); they are prominent after lobotomy (40) and a common “complication” during and occasionally following insulin coma therapy (23). With the tranquilizers, the parallel of clinical efﬁcacy and seizure induction is most striking. Phenothiazine compounds induce seizures commonly; reserpine rarely; benactyzine not at all; and meprobamate is a potent anticonvulsant! The lowering of seizure threshold parallels the extent of the EEG delta shift induced by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism—both potent indices of an alteration in cerebral function. The neurologic basis for the delta shift and increase in seizure frequency is unclear. Whether this represents a persistent change in function of some speciﬁc brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a delta shift, with or without hypersynchrony, it appears more likely that the EEG changes reﬂect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of speciﬁc cellular masses. SUMMARY The neurophysiologic and clinical neurologic aspects of convulsive therapy, “tranquilizers,” insulin coma and lobotomy, are 1. reviewed. The efﬁcacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent change in cerebral function, of which a delta shift in the EEG spectrum and an increase in 2. incidence of seizures are two indices. 3. Alteration in cerebral function is an essential prerequisite of behavioral change with each of these therapies. Such alteration is neither a “complication,” nor an “untoward effect,” but is the sine qua non of the mode of action of these therapies. 4. No evidence has been educed in these studies that the physiodynamic therapies are speciﬁc agents for the relief of psychoses; nor do they affect a speciﬁc segment of the nervous system; nor do they induce speciﬁc behavioral changes. 5. The therapeutic process of convulsive therapy, insulin coma, lobotomy and tranquilizers may be ascribed to the induction of a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. ' �THEORY OF PHYSIODYNAMIC THERAPIES 205 REFERENCES Aird, R. B.; Strait, L. A.; Pace, J. W.; Hernoff, M. K. 8c Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. A.M.A. Arch. Neural. (9 Psychiat., 75:371-378, 1956. (2) Arellano, A. P. 8: Jeri, R.: The Effect of Reserpine on the Scalp and Basal Electroencephalogram. EEG. Clin. Neurophysiol., 8:150 (abst.), 1956. (3) Berger, F. M.: The Chemistry and Mode of Action of Tranquilizing Drugs. (1) Arm. N. Y. Acad. Sci., 67:685-699, 1957. (4) Blumenthal, I. J.: Spontaneous Seizures and Related Electroencephalographic Findings Following Shock Therapy. J. Nerv. é» Ment. Dis., 122:581-588, 1955. (5) Coady, A. 8: Jewesbury, E. C. 0.: A Clinical Trial of Benactyzine Hydrochloride (“Suavital”) as a Physical Relaxant. Brit. Med. J., Mar. 3, pp. 485487, 1956. (5) Cohn, R.: EEG Study of Prefrontal Lobotomy. Arch. Neural. & Psychiat., 53:351-357, 1945. (7) Denber, H. C. B.: Discussion, Symposium on the Psychopharmacologic Approach to Schizophrenia. Second Int. Congress of Psychiatry, Zurich, 1957. (8) Fabisch, W.; Effect of Chlorpromazine on the Electroencephalogram of Epileptic Patients. J. Neurol., Neurasurg., (5» Psychiat., 20:185-190, 1957. (9) Fink, M.: Therapy of Schizophrenia: Role of Alteration of Brain Function in Behavior. Presented Second Int. Congress of Psychiatry, Zurich, 1957. (10) Fink, M.; Green, M. A. 8c Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. (11) Fink, M. 8: Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Clin. Neurophysiol, 8:158 (abst.), 1956. (12) Fink, M. 8: Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neural. (5» Psychiat., 78:516-525, 1957. (13) Fink, M.; Kahn, R. L. 8: Green, M. A.: Experimental Studies of the Electroshock Process. J. Nerv. 6} Ment. Dis. (in press). (14) Fink, M.; Shaw, R.; Gross, G. 8c Coleman, F. 8.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis. J. Am. Med. Assoc. (in press). (15) Hankoﬁ', L. D.; Kaye, E.; Engelhardt, D. M. 8c Freedman, N.: Convulsions <16) Complicating Ataractic Therapy, Their Incidence and Theoretical Implications. N. Y. State J. Med., 57:2967-2972, 1957. Hoagland, H.; Malamud, W.; Kaufman, I. C. 8c Pincus, G.: Changes in Electroencephalogram and in Excretion of 17-Ketosteroids Accompanying Electro-shock Therapy of Agitated Depression. Psychosom. Med., 8:246-251, 1946. (17) Jacobson, E.: Suavitil, et Nyt Stof Med Speciﬁk Virkning pa Centralnervesystemet. Ugeskrift for Laeger, 117:1147-1151, 1955. (18) Kahn, R. L. 8: Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy. Conf. Neural. (in press). (19) Kahn, R. L. 8c Fink, M.: Changes in Languages During Electroshock Therapy. In: Psychopathology of Communication. New York: Grune 8c Stratton, (in press), 1957. (20) Kahn, R. L. 8c Fink, M.: Perception of Embedded Figures After Induced Altered Brain Function. Am. Psychol., 12:361 (abst.), 1957. (21) Kahn, R. L.; Fink, M. Sc Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. A.M.A. Arch. Neurol. (5- Psychiat., 76:23-29, 1956. (22) Kahn, R. L.; Graubert, D. Fink, M.: Delusional Reduplication of Parts of the Body After Insulin Coma Therapy. This Journal, 4 :134-148, 1955. 8: �MAX FINK 206 (23) Kalinowsky, L. B. 8: Hoch, P.: Shock Treatment, Psychosurgery and Other Somatic Treatments in Psychiatry. New York: Grune 8c Stratton, 1952. (24) Karliner, W.: Epileptic States Following Electroshock Therapy. This Journal, 5:258-263, 1956. (25) Klotz, M.: Incidence of Seizures, with EEG Findings, in Prefrontal Lobotomy. A.M.A. Arch. Neurol. 65- Psychiat., 742144-148, 1955. (26) Korin, H.; Fink, M. 8: Kwalwasser, S.: Relation of Changes in Memory and Learning to Improvement in Electroshock. Conf. Neurol., 16:88-96, 1956. (27) Kwalwasser, S. 8c Caplan, M.: A Case of Prolonged Insulin Coma: Treatment. This Journal, 1:145-155, 1952. (28) Liberson, W. T.: Effect of “Tranquilizing” Drugs on EEG. EEG Clin. Neurophysiol., 8:523, 1956. (29) Liddell, D. W. 8c Retterstol, N.: The Occurrence of Epileptic Fits in Leucotomized Patients Receiving Chlorpromazine Therapy. J. Neurol., Neuro(30) (31) (32) (33) (34) (35) surg., (g. Psychiat., 20:105-107, 1957. Perlstein, M. A.: Miltown, Its Use in Convulsive and Related Disorders. ]. Am. Med. Assoc., 161:1040, 1956. Revitch, E.: Observations on Organic Brain Damage and Clinical Improvement Following Protracted Insulin Coma. Psychiat. Quart., 28:79-92, 1954. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive Treatment and Their Signiﬁcance for the Theory of ECT Action. EEG Clin. Neurophysiol., 3:261-280, 1951. Roth, M.; Kay, D. W. K.; Shaw, J. 8c Green, 1.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electro-Convulsive Treatment. EEG. Clin. Neurophysiol., 9:225-238, 1957. Shagass, C. St Rowsell, P. W.: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma. A.M.A. Arch. Neurol. 65Psychiat., 72:705-711, 1954. Sigg, E. B. 8c Schneider, J. A.: Mechanisms Involved in the Interaction of Various Central Stimulants and Reserpine. EEG. Clin. Neurophysiol., 9: 419-426, 1957. (35) Simon, A.; Margolis, L. H.; Adams, J. E. 8c Bowman, K. M.: Unilateral and Bilateral Lobotomy: A Controlled Evaluation. A.M.A. Arch. Neurol. (‘5' Psychiat., 66:494-503, 1951. (37) Stewart, L. F.: Chlorpromazine: Use to Activate Electroencephalographic Seizure Patterns. EEG Clin. Neurophysiol., 9:427-440, 1957. (38) Ulett, G. A.; Smith, K. 8c Gleser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group. Am. ]. Psychiat., 112:795-802, 1956. (39) Wachspress, M.: Blumberg, A. G.; Fink, M. 8: Miller, J. S. A.: Evaluation of High—Dose Reserpine Therapy for Relief of Anxiety. This Journal, 5 :67-77, 1956. (40) Walter, R. D.; Yaeger, C. L.; Margolis, L. H. Simon, A.: The EEG Changes in Unilateral and Bilateral Frontal Lobotomy. Am. J. Psychiat., 111:5908c 594, 1955. (41) Weinstein, E. A. 8: Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. Springﬁeld, Ill.: C. C. Thomas, 1955. (42) Wikler, A.: Personal Communication. (43) Yaeger, C. L.; Simon, A.; Margolis, L. H. 8: Burch, N. R.: Electroencephalographic Studies in Posthypoglycemic Coma. ]. New. 6’ Ment. Dis., 118: 435-441, 1953. �AN OBJECTIVE STUDY OF COMMUNICATION IN PSYCHIATRIC INTERVIEWS1 JOSEPH JAFFE, The clinical interview MD.2 is the psychiatrist’s primary tool for diagnosis of psychopathology, the modiﬁcation of behavior, and collection of research data. Only in recent years, however, have actual transactions which comprise the interview been studied the the the ob- jectively. Investigators of the interview have usually employed systems of content analysis (1), which are based upon various theories of psychodynamics. Currently, there is increasing emphasis upon formal aspects of interaction such as temporal patterns of speech (14), drastic change of subject (3), physiological relationships of the participants (2), grammatical patterns of language (5, 6, 9), and speech disturbances and silences (10). These aspects, in contrast to content categories, are relatively independent of theoretical preconceptions, and are more readily quantiﬁed and studied statistically. In many investigations of these formal variables, however, the patient’s communications are abstracted from the total context of the interview. These approaches neglect the fact that the psychiatrist is a participant observer, i.e., a signiﬁcant variable in the interaction (ll). Others have attempted to control this variable by means of structured interviews in which the doctor’s contribution is standardized according to a predetermined experimental design (6, 7, 14). These structured situations delete the very quality of living relationship that is the ultimate concern of the psychotherapist (7). 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the New York Divisional Meeting, A.P.A. November, 1957. Supported by Grant 56-151 of the Foundations’ Fund for Research in Psychiatry. 2Assistant in Psychiatry, Department of Experimental Psychiatry, Hillside Hospital. 207 �208 JOSEPH JAFFE We are in need of methods of verbal interaction analysis that neither preclude nor prescribe the doctor’s clinical responses. The purpose of this paper is to present a method of interview analysis which (a) is objective and quantitative, (b) preserves the natural patient-therapist relationship, and (c) treats the interview as an integrated system of interpersonal communication. This is accomplished by including the doctor’s usual clinical behavior in the data to be studied. The raw material is not the patient’s speech, but rather the total verbal output of the “two person” or “dyadic” group (8). METHOD The tape-recorded interview transcribed, without regard to the speaker of the words. Careful attention is given to subtle repetitions such as “I—I mean,” “Well as—as I say,” and to (i i, such “so as “you know,” to speak, interpolated expressions as I said,” etc. These have a tendency not to be heard since they are irrelevant to the content. The transcript is then arbitrarily divided into consecutive units of 100, 50 or 25 words, depending on the discreteness of the phenomena to be investigated. Thus a unit contains contributions of words from either doctor or patient alone, or from both in varying proportions. The measurement applied to these units of dyadic speech is the type-token-ratio (TTR). This is an index of the balance between repetition and variety of words (12). The TTR is the ratio of the number of diﬂerent words (types), to the total number of words (tokens), in a sample of language. For example, in a lOO-word sample the repetition of the identical word 100 times in succession would produce the lowest possible ratio of .01 (1 type/ 100 tokens). The highest possible ratio of 1.0 would result if every one of the 100 successive words were different (100 types/ 100 tokens). These extremes of stereotypy and diversity are rarely encountered, and then only in grossly pathological situations (8). The “word-type,” i.e., the numerator of the TTR, is arbitrarily deﬁned. All words are different which are pronounced or spelled differently. Thus, give, gives, gave, given and giving are considered different types, as are know and no. Vocalizations not clearly identiﬁable as words are omitted, with the major exception of “mmhmm” which is a frequent utterance of the interviewer in our records. Contractions are retained as single words, but vulgarisms such as “I dunno” are edited to read “I don’t know.” is precisely �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 209 The TTR is calculated for each unit and the pattern of consecutive scores is graphically plotted, as illustrated in Figures 1 and 2. For additional precision, the units may be overlapped; e.g., 50word units may be advanced 25 words at a time, so that each unit is composed of the last half of the preceding and the ﬁrst half of the subsequent unit. This often smoothes the resultant curve. The overlapping technique is illustrated in Figure 3. Previous studies of the TTR have dealt with the over-all average in a single person’s language (12). The present method studies the sequential pattern in dyadic language. OBSERVATIONS In the last eighteen months approximately sixty recorded interviews have been investigated by this method. The material includes forty patients in all diagnostic categories. The dyadic TTR patterns have been found to be sensitive to a variety of clinical phenomena (8). This report illustrates the changes in language interaction occurring during the course of hospitalization and therapy, as well as changes in rapport and defensive operations within individual interviews. TTR Pattern in Clinical Change Figure 1 shows the pattern of the ﬁrst 1500 words of three separate interviews during the clinical course of one patient. The doctor (a) Dyadic DYADIC TTR PATTERN WITH CLINICAL CHANGE (CONSECUTIVE PRE-TREATMENT T53 I. 25 WORD UNITS) POST-TREATMENT# I2 0N DISCHARGE .92 .84 .76 M M .68 ."-' — ‘ .60 I lo 20 30 40 UNIT NUMBER 5060 I I0 20 30 40 UNIT NUMBER FIGURE 1 5060 I I0 20 30 4O 50 60 UNIT NUMBER #40 #49 #59 I957 �210 JOSEPH JAFFE in each. This case was selected as an unequivocal example of gross clinical change. In the ﬁrst interview the patient was agitated and depressed. She refused to be seated and paced about the room, reiterating stereotyped self-recriminations, crying hysterically, with marked pressure of speech. At the time of the second interview, following a course of grand mal electroshock, the clinical picture was grossly altered. She was less agitated and more cooperative, although withdrawn and complaining of a memory deﬁcit. On discharge two months later, she appeared alert, poised, conversational and, at times, surprisingly insightful. She had been rated is the same clinically as “recovered.” The TTR of consecutive 25-word units of interaction, for each of the three periods described, is graphically represented in Figure 1. Consecutive points are connected by lines so that the ﬂuctuations in the graph reﬂect the difference between successive scores. The mean TTR for the complete interview from which these samples were taken is represented by a horizontal line through each graph. The pattern of scores demonstrates a ﬂuctuating equilibrium about the mean. ' The interviews at these three successive stages show a sequence of changes. The mean level of the interaction is seen to increase as the clinical status changes from psychosis to “recovery.” There is a concomitant restriction in the amplitude of the pattern, i.e., a decrease in variation about the mean. Comment: The sequence of change in the TTR pattern parallels the progressive improvement in interpersonal communication that was apparent clinically. This suggests an approach to the quantiﬁcation of clinical change, deﬁned as an altered pattern of verbal interaction in the interview. (b) Changes in Communication Within the Interview Figure 2 is an enlargement of the ﬁrst of the three interactions shown in Figure 1. Here the sequence of changes within a single interview is examined rather than comparing the patterns of successive interviews. As described before, the patient was speaking continuously in a disorganized affective outburst. The lower line indicates the 25-Word units in which the interviewer participated. Following the doctor’s introductory remarks, units 3-12 represent the patient’s uninterrupted speech. Wide oscillations of the pattern are prominent. From samples 13 onwards the doctor made repeated efforts to communicate with the patient. Two independent judges reviewed the transcribed protocol, and both identiﬁed three areas �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 211 in which there seemed to be an understandable, rational interchange between the participants. These periods are labeled “rapport” in the upper line. During these three periods the oscillations of the pattern are much constricted. Compare other nonrapport periods such as 23-24 and 39—41, in which the doctor’s participation ampliﬁed the oscillations. DYADIC TTR PATTERN (CONSECUTIVE 25 WORD UNITS) —— 'RAPPORT" TTR 36 DOCTOR'S PARTICIPATION l 5 l0 IS 3035 4045 20 25 UNIT NUMBER FIGURE 2 50 #40 I957 Comment: This illustrates a method of quantifying interpersonal phenomena, such as the degree of “contact” with a severely disturbed patient. The affective pattern in this patient represents the psychotic integration, and for this reason, the occasional occurrences of conventional, rational conversation are described as periods of “rapport.” The restriction in the amplitude which characterizes these periods is similar to the over-all pattern at the time of “recovery.” Complete Interview Figure 3 demonstrates the initial dyadic TTR analysis of a complete interview. This interview is the discharge evaluation of a patient who had been hospitalized following a bizarre suicide at(c) Analysis of a �JOSEPH JAFFE 212 tempt. After seven months of hospitalization, she had “improved” clinically. This took the form of a hypomanic mood and a gross denial of her severe emotional conﬂicts. The interview is scored by the method of successive 50-word units advancing by 25-word steps. The mean TTR for the interview is shown by the horizontal line drawn through the graph. The pattern falls into several natural segments. There are two areas in which ten consecutive points fall below the mean (areas 4 and 7). These are unusual in this interDYADIC TTR ANALYSIS TTR OFA PSYCHIATRIC INTERVIEW (OVERLAPPING so woao UNITS) .98 .94 .90 :3: ::2 I.I—'i—'.I—'Ij== .70 .r. III -. v. 255- -/1-’1 I II ~ JUL—I- ---.r I 4I—I—I—I----I----—I——-—I-—I—|*I—---|—I—I I 3 4 7 5 9 8 l0 II I2 it 54 |957 FIGURE 3 There are also areas of gross deviation from the mean (such as area 2). Thus we allow the objective pattern to determine our criteria for phenomena to be studied. In general, we look for per- View. sistent changes in the TTR level, gross trends or sudden shifts. Several of the deviant areas are described to illustrate the method. The interview begins with a hypomanic monologue in which the patient describes her successful visit home, her euphoric outlook and plans for a rosy future. Area 2 has been delineated because of gross deviation from the mean. The beginning of this period coincides with a change of topic to her plans for going back to her job two days hence. Her optimism is’interrupted by a period of confusion as she tries, with some difﬁculty, to recall one of the details of the job. The end of the gross ﬂuctuation coincides with the rationalization “I don’t think I’ll have too much trouble.” ‘ �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 213 Area 4 was delineated as one of the two sections in which ten consecutive scores fall below the mean. Its beginning coincides with a statement about her depression on admission to the hospital. This area ends with the lowest score of the interview, which precedes by only a few words a spontaneous reference to her suicide attempt. This large deviation at the end of area 4 embodies the main characteristics of the following area. Area 5 is characterized by large ﬂuctuations above and below the mean. The content of this area is completely on the theme of suicide. She attempts to prove how much she now wants to live. The doctor’s queries at the end of the period meet with increasing resistance. In the beginning of the next segment (area 6) she stubbornly refuses to discuss the subject of suicide further, at which point she changes the subject abruptly. Area 7 was delineated on the basis of two criteria. It begins with a precipitous drop in the TTR, followed by ten consecutive scores below the mean, and ends with an equally abrupt rise. Its beginning coincides with a change of subject by the doctor in the form of a question about her feelings at that moment in the interview. This content area, i.e., the “you-me” relationship, is pursued at a very repetitive level. The period ends when she abruptly changes the Area 9 is delineated because of an extremely low score enclosed by two large deviations. It coincides with a brief mention of a meeting with a young man who told her how well she looked. It ends with an embarrassed r'emark and her statement “I decided to get him off the topic.” These examples illustrate areas of disturbance or disequilibrium in the verbal interaction pattern. In contrast, 3, 6, 8 and 10 are areas of relative stability or equilibrium in the record. These periods are marked by a different quality of communication. They consist either of a euphoric, hypomanic monologue which avoids all stressful subjects, or of evasion of the doctor’s probing questions by superﬁcial rationalization and conventional cliches. Comment: Recent reports of objective interview studies using other techniques (10) have noted that the interaction goes through a series of deﬁnable phases, which may correspond to periods of stressful disorganization and successful defense respectively. The phases demonstrated here, and the events that delineate them, suggest an analogous formulation. The content areas that disturbed the pattern in this ﬁnal interview also did so on the initial interview seven months earlier. We anticipate that the discussion of a subject �214 JOSEPH JAFFE that had resulted in disequilibrium, but now no longer does so, may constitute an operational deﬁnition of “resolution of an area of conﬂict.” DISCUSSION AND CONCLUSIONS Diverse and highly personal interpretations of interview data limit the growth of psychiatry as a science. Systematic study of the actual transactions may lead to operational deﬁnitions of hitherto subjective phenomena. For example, it is likely that the patterns of verbal diversiﬁcation presented here constitute part of the subliminal cues to which therapists respond when making clinical judgments of anxiety, affect, etc. Objective investigations of the interview must encompass the behavior of both participants since the events observed are interpersonal processes. Gill, Newman and Redlich (4) deﬁne even the initial interview as the “diagnostic evaluation of an interpersonal relationship.” Ruesch (13) has recently stated that “observations made in social situations do not have the characteristics of a scientiﬁc procedure in which one aspect is studied in detail while all other variables are held constant.” The method presented here is an attempt to convert these concepts into practical research methodology. It permits a quantitative statement of various clinical phenomena occurring either within single interviews or in the course of therapy. Disturbances of verbal interaction are deﬁned operationally in terms of the conﬁguration of the TTR pattern. Applications to the deﬁnition of clinical change and transactions within the interview have been presented. The TTR is only one of many quantiﬁable aspects of dyadic speech. Pace of interaction, time reference, and relative amounts of participation by doctor and patient are also being measured. Further applications of these techniques are under investigation. REFERENCES (l) Auld, F. 8c Murray, E. J.: Content-Analysis Studies of Psychotherapy. Psychol. Bull., 52:377-395, 1955. (2) Coleman, R.; Greenblatt, M. 8: Solomon, H. C.: Physiological Evidence of Rapport During Psychotherapeutic Interviews. Dis. New. System, 17:2-8, 1956. H.; Hamburg, D. A.; Inwood, E. R.; Salzman, L.; Meyersburg, H. A. 8c Goodrich, G.: A Procedure for the Systematic Analysis of Psychotherapeutic Interviews. Psychiatry, 17:337-345, 1954. (4) Gill, M.; Newman, R. 8c Redlich, F. C.: The Initial Interview in Psychiatric Practice. New York: International Universities Press, 1954. (3) Eldred, S. �COMMUNICATION IN PSYCHIATRIC INTERVIEWS (5) 215 Goldman-Eisler, F.: A Study of Individual Differences and of Interaction in the Behavior of Some Aspects of Language in Interviews. ]. Ment. Sci., 100:177-197, 1954. (6) Gottschalk, L. A.; Gleser, G. C. 8c Hambidge, G.: Verbal Behavior Analysis. A.M.A. Arch. Neural. 63'» Psychiat., 77:300-311, 1957. (7) Grinker, R. R.; Sabshin, M.; Hamburg, D. A.; Board, F. A.; Basowitz, H.; Korchin, S. J.; Persky, H. 8c Chevalier, J. A.; The Use of an AnxietyProducing Interview and Its Meaning to the Subject. A.M.A. Arch. Neural. (5* Psychiat., 77:406-419, 1957. (3) Jaffe, 1.: Language of the Dyad: A Method of Interaction Analysis in (9) (10) (11) (12) (13) (14) Psychiatric Interviews. Psychiatry (in press). Lorenz, M. 8c Cobb, 8.: Language Patterns in Psychotic and Psychoneurotic Subjects. A.M.A. Arch. Neurol. (5. Psychiat., 72:665-673, 1954. Mahl, G. F.: Disturbances and Silences in the Patient’s Speech in Psychotherapy. ]. Abn. é» Soc. Psychol., 53:1-15, 1956. Mandler, G. 8c Kaplan, W. K.: Subjective Evaluation and Re-enforcing Effect of a Verbal Stimulus. Science, 124:582-583, 1956. Mowrer, O. H.; Verbal Behavior in Psychotherapy. In: Psychotherapy: Theory and Research, ed. 0. H. Mowrer. New York: Ronald Press, 1953. Ruesch, 1.: Disturbed Communication. New York: W. W. Norton, 1957. Saslow, G.; Matarozzo, J. D. 8: Guze, S. B.: The Stability of Interaction Chronograph Patterns in Psychiatric Interviews. J. Consult. Psychol., 19: 417-430, 1955. �SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL1 ROBERT L. KAHN, PH.D.,2 MAX POLLACK, PH.D.,3 and MAX FINK, M.D.4 Recent investigations have indicated a relationship between inci— and with to disorder class and type social respect psychiatric dence of mental illness (3, 5, 6, 13, 14), selection and maintenance of treatment (2, 6, 15), and therapeutic outcome (10). The present in of selection the in factors social therapy is with concerned study a voluntary mental hospital. In the studies reported by Hollingshead, Redlich, and their coworkers (3, 5, 6, 13, 15), the population of New Haven was divided into ﬁve social classes on the basis of weighted criteria of education, under who residents the Of were residence. of and place occupation freclasses social more were the from those upper psychiatric care, quently treated with psychotherapy, while organic treatment or custodial care was more common among the lower classes. Of the the restricted two to was entirely psychoanalysis psychotherapies, of the determinant the class Social was predominant upper groups. held conthe when was diagnosis selected even of treatment type is that “. found it follows: results . . as their summarize stant. They determedical and psychological does on not depend treatment well. the of as the patient status but position minants alone, on Psychotherapeutic methods are applied in disproportionately high 1 Glen Hillside Hospital, of Psychiatry, Experimental the From Department Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, U. S. Public Health Service. 2Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 4Director, Department of Experimental Psychiatry, Hillside Hospital. 216 �SOCIAL FACTORS IN SELECTING THERAPY 217 degree to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist” (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's ﬁnancial resources or the extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques and services are available to all patients. This requirement is met at Hillside Hospital. It is a nonproﬁt, nonsectarian institution for the treatment of voluntary patients with “early and curable mental symptoms” (4), who are admitted regardless of their ability to pay. One of the main criteria for accepting patients is their ”ability to participate proﬁtably in psychotherapy.” Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment with organic therapies available when needed. The average length of hospital stay is six months, although some patients remain for as long as a year. The present investigation is an outgrowth of several years of study of electroshock therapy. In previous work it has been shown that certain aspects of personality were signiﬁcantly related to patient selection and therapeutic efﬁcacy of electroshock (8). The purpose of the present study was to determine whether electroshock patients differ from those receiving other forms of treatment in regard to cultural background, including such factors as education and place of birth, and personality as measured by the California F scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. METHOD Population: The entire inpatient adult population of Hillside Hospital as of March 7, 1957 was studied. This constituted a total of 172 patients, ranging in age from 16 to 68 with a mean of 34.6, and including 58 men and 114 women. Procedure: (1) The population was subdivided into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only.5 5All patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data were included in both groups. In the results this makes a total of 179 subjects. �KAHN—POLLACK—FINK 218 (2) birth. The groups were compared for age, education and place of (3) All patients were tested6 with a ten-item modiﬁcation of the California F scale suggested by Levinson (9). The F scale is a questionnaire (see Appendix) which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to What extent. The score given for each item ranges from one to seven and the total score range is 10 to 70. The greater the agreement the higher the score obtained. The statements themselves are extreme, uncritical or stereotyped expressions. (4) The population was subdivided in regard to utilization of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing and creative therapy. The latter is a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psycho— logical testing and creative therapy were selected for this study because both require a speciﬁc referral from the therapist. RESULTS The data were analyzed as follows: comparison of the treatment groups for age, education, F scale scores, and place of birth; (2) comparison where diagnosis is held constant; (3) signiﬁcance of length of hospitalization prior to treatment; and (4) comparison between groups referred for adjunctive hospital services. (1) Comparison of Treatment Groups For each of the three treatment groups the means and standard deviations for the F scale scores, age and years of schooling are presented in Table l. The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These diﬁerences were statistically signiﬁcant for F score and age but failed to reach statistical signiﬁcance for education. The failure of years of education to differentiate the groups was due, in part, to the fact that the electroshock 1. 6As part of an ongoing study all the EST patients were tested with the F scale prior to treatment. In the case of‘ those patients who were actually on EST on March 7 their pretreatment scores were used in the statistical comparison since it had been found that EST signiﬁcantly affects the score during treatment. �SOCIAL FACTORS IN SELECTING THERAPY 219 - .550 ammvaom §3« 50m $.32 o ammuuoh mo REE 55 :Eduamo ﬁwmouom onesm .ummm.50m $32 Aﬁoozw ﬁvwwvm £me 50m -0332 «a ﬁvgvmm $592 ﬁaéww :25 83m mo .Esnamo 8m: 35 -Gwmuuom Son $52 $55“ ﬁmwvvv $392 $82 “Staggm 088 .vm GMV @8va How mo .Ssﬂamo 658% 98on H 53H. h mBOBm J/ SK $2; $5: ﬁx: l/i If!!! 3320 6M Gm «0 28> 582 EwEuuﬁh 3 3 g NM 2: 2: OS "~on .qu :53 9: «E MN S 2 :33. 1&3 fill!!! “59$th Qm q: 3 3; n: 3w mum u w? um< x0 :82 Gav: £5 .2: 3w a 3%...“ 3 :oﬂkﬁﬁcu Gm 92 3; 2: ::.m m2. :32 E2 28m h 582 3% ﬁne: 2m we”. a5 3 3: mm mo. 8. 32 So. 3 a a so: 8% 385:me 285:? 385:3 t 1 .onoxmmézsmcu £35me 339% @380 532: -onuwmm Saga -935-.me 38% 3&2: 1:. �220 KAHN—POLLACK—FINK group contained many foreign-born patients whose education was difﬁcult to evaluate accurately. When treatment groups were subdivided into number of patients above and below eight years of education, the difference was signiﬁcant at the .01 level. The insulin and psychotherapy groups did not differ statistically for any of these factors. Both somatic groups had a higher percentage of foreign-born patients than the psychotherapy group, with the electroshock group being highest of all. Among the foreign-born patients, those who came from Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe received psychotherapy alone. Comparison of Treatment Groups in Relation to Diagnosis The diagnostic categories of the patients in this study are com— parable to those reported in previous studies of the hospital popution (12). Of the 172 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and 2 with other diagnoses. As expected, a larger proportion of the depressed patients (52%) received electroshock than did those with other diagnoses. To control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those who received electroshock and those who were given psychotherapy alone. The results are shown in Table 2. While the two groups were comparable for age and education, the electroshock patients had a much higher mean F score, a difference signiﬁcant at the .02 level of conﬁdence. It is also demonstrated that a signiﬁcantly higher proportion of the electroshock patients were born in Eastern Europe. 2. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment While the electroshock patients, as a group, have been shown to differ from those receiving insulin or psychotherapy, there were still considerable intragroup differences. To account for some of these differences it was postulated that the same factors involved in selection of treatment were also related to the readiness with which a given patient was referred for electroshock. While most of the patients who received EST were placed on treatment less than three months after admission, about 40 per cent were referred after a period of three to twelve months. In Table 3 the patients are compared according to the period of hospitalization prior to electro3. �SOCIAL FACTORS IN SELECTING THERAPY .830 ax”: $.va vacuum 133$ $2; ﬁhm “225355 «0 583m ainamo 83m «so .033 50m $32 @5th $.ng @8va Z ”REE 208 23$th a; how «0 comumuswm Envy. Mano Sign“ waoﬁum N ﬁg; @E: 23 .vm HEM—NH =32»:qu Qm 3 can: 3: mo $3on 3 2: GNU: a $5 a5 86 a mg umucxuaﬁm Gm mi «NH 3.2; vm< 582 3:“ Gm 32 3* Que: mg £5 ﬁtubum kc a ﬂ: *Nwm 88m goutumwﬁcu h 532 3* non 5N0: Em: a5 8d me. a as 3% 285:? -oﬁwmmémm -oauwmm 322: 382: Ha a. 221 �KAHN—POLLACK——FINK 222 ﬁé .850 N a o .83 5.85 $me mo 583m @888 uneasm 8 8me H o m «Eu EuEEush -0332 3 58m $88 $85 $8: 2 5 2 ﬁg $89 $83 mm a : BER 988 How we tetanacﬁﬁwem 8.8 H 8098sz any? «Eu 183 wBBom x0 $2: a m m SMEVN 6mm 559 3 Qm E :82 3 «o 928% 3 ca 5.: 8.8 8 88 :2 8.8 :82 .85 cm: Sn a; fill!!! Mﬁﬁkouuvx Gm 8.2 25.36% 98 8.2 a :4 :88 gm :82 .85 83. $4: 8...: a 8.8 :8.“ :2 %< 8.8 582 8% :3 Ram 88 Qm Q: w: mm; 38m :oﬂtiﬁcu BE :52 :8 rm :32 Sim -mNzﬂmmmom “cued—88H. 622.: aa dawned .88 :05 8.8 a; 9 mo E« $va .88 m m .85 $8 288 EMS“ 2c m 52: o 3 :82 88 who: 8 $04 a; 2.2 8 288 .88 8 8 m 8. S. 8. m 52: 80A .89: 5:: 988 885.85 88:88.,” Gmﬂu .888 c 8 m UHOE .888 a.“ I �SOCIAL FACTORS IN SELECTING THERAPY 223 shock. Patients who had higher F scores and were older were treated earlier than the younger and lower F scale groups. Place of birth is also a signiﬁcant factor. While 44 per cent of those treated within three months were foreign-born, all patients referred after a period of six months were born in the U. S. The data on education just fails of signiﬁcance, although 28 per cent of those treated earlier had less than eight years of education. 4. Use of Adjunctz've Hospital Sewices Comparison of the patients referred for creative therapy and psychological testing is shown in Table 4. It is clear that those referred for either of these procedures had signiﬁcantly lower F scores, were younger in age, had more education and more were nativeborn than patients who were not referred for these services. DISCUSSION The results indicate that the factors of education, age, place of birth, and F scale score were signiﬁcantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients who were younger, better educated, native-born and had lower F scores. Such patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated and foreign-born, particularly in Eastern Europe, were most likely to be referred for EST. These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still signiﬁcant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich, and their co-workers (3, 5, 6, l3, 15) who demonstrated that social factors are related to the type of therapy received in a community. The present study demonstrates that such factors are also signiﬁcant in a hospital setting where ability to pay is not a criterion of therapeutic selection and where all forms of therapy are equally available to the entire population. With ﬁnancial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations be conmay sidered. The social factors may relate directly to the empirically established criteria for choice of therapy. On this basis a patient is �KAHN—POLLACK—FIN K 224 550 .35an «REE $5; $5.: @2va $5: 153$ $3: Axwwvwa $.8va @583 $.me @me $3 5me «0 532%.“ vacasm ﬁw: ﬁvﬁvmw H awwuamu «Eu 82m 323.5 -0332 3:3 1E3 Eom a wumtuh EOE $38 kg How «0 N £038st *Nmenamo man“; ~e£m£o£uaam «Eu . 33:5 ARR“: waoﬁum ﬁéw ﬁévﬁ u8 w. 8.9.5wa it’ll; .wm 539 if} 3. m.» Qm a.» a 8N ***h.w mm: mo 28> 2: 3: :82 wﬁ w: :82 a5 A: AWN 233::va .8“ Qm 2: 3: «.2 :82 EN 3m Sun «.2 a mg :52 .Em ***©N.m fwawowé om< wmtukum 0.“. ﬁoa Scwtek it$©m6 Gm kc 2: QB inomﬁ H as 2: :32 :32 28m h :82 982 3w 5.3 soy 32V 3.» iv 55 m.w mg: A5 s. so. a a a 23.23%:80 O>UNQHU mo. :52 Esme? 385:? $3389 385:? Aonuwmm 3:80 .rH.U 03330 322? 3225 Oz Jonowmm .Hoaowmm and. oz -Hd OZ * oZ i I; �SOCIAL FACTORS IN SELECTING THERAPY 225 referred for electroshock because he is older, poorly educated or foreign-born, clinical experience having shown that such persons respond best to this type of treatment. This explanation is inadequate since half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communication. Thus, a patient is not referred for electroshock because he is foreign-born or poorly educated, but rather these factors provide the difference in cultural background between patient and therapist which makes successful communication less likely in the psychotherapeutic relationship. Robinson et al. (15), in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic relationship. In the present study, similarly, the patients who received psychotherapy alone were more like the therapists with regard to the factors studied.7 Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have shown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are likely to receive electroshock (7, 8). Such language patterns appear to be more frequent in persons with poorer sociocultural backgrounds. Social and cultural factors, in addition to their effect on com— munication patterns, may also determine the manifest symptomatology. Opler (11) has noted that, among patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank et al. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those who remained had ideational symptoms. In a study of personality The therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen per cent were born in Eastern Europe. Their mean years of education was 7 20. 18 over �KAHN—POLLACK—FINK 226 factors in electroshock patients (8) we have noted that certain patterns of symbolic value and communication were more likely to be associated with the development of a depressive psychosis. The relationship between communication pattern and symptoms indicates that symptoms themselves are a mode of communication. The F scale furnishes a quantiﬁable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethnocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. In the present study the F scale was the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical signiﬁcance. lowthat indicate in from observations study a progress Preliminary scorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing their social differences, by matching them more closely for age and place of birth. Of possible greater importance is the necessity for developing new modes of communication when treating conventional psychotherapeutic apwho to refractory are patients proaches. While epidemiological studies have clearly structured some of the indicated have and of selection in involved treatment, problems the direction of further study, it still remains for more processoriented research to provide deﬁnitive answers. / SUMMARY In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of and of birth, education, place available, age, were equally therapy score on the California F scale were signiﬁcantly related to the type of therapy received and to the utilization of adjunctive hospital 1. services. Patients who were older, poorly educated, had higher F scores and were foreign-born, particularly in Eastern Europe, were most likely to be referred for electroshock. Psychotherapy was the treat2. �held constant. 4. Among the electroshock patients the same factors found to be signiﬁcant in choice of therapy were also related to the readiness with which a patient was referred for electroshock. 5. It is postulated that treatment selection is the result of the communicative interaction between patient and therapist. Social factors may be important in so far as they are related to different modes of communication. APPENDIX F SCALE FORM Below are a number of statements. For each statement we want you to give us your personal opinion of whether disyou or agree agree. Answer each statement accordi ng to one of the following: I AGREE A LITTLE I DISAGREE A LITTLE I AGREE PRETTY MUCH I DISAGREE PRETTY MUCH I AGREE VERY MUCH I DISAGREE VERY MUCH I. No sane, normal, decent close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and wor k more, everybody would be better off. pe and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. 8. The best teacher or boss is the one wh 0 tells us exactly what is to be done and how to go about it. 9. Young people sometimes up they ought to get over them and settle down �KAHN—POLLACK—FINK 228 weak the classes: distinct into divided two be 10. People can and the strong. REFERENCES 8c Sanford, R. N.: D. Levinson, J. E.; Frenkel-Brunswik, (1) Adorno, T. W.; 8: Brothers, 1950. York: New Harper The Authoritarian Personality. St: Stone, A. R.: E. H. S. Nash, D.; L. Imber, H.; (2) Frank, J. D.; Gliedman, (33» 77: Neurol. Arch. Psychiat., A.M.A. Leave Psychotherapy. Why Patients 283-299, 1957. (3) Freedman, L. Z. 8c Hollingshead, A. B.: Neurosis and Social Class. Am. ]. Psychiat, [13:769-775, (4) (5) (5) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) 1957. Hillside Hospital: 29th Annual Report, 1956. 8c Redlich, F. C.: Schizophrenia and Social Structure. A. B. Hollingshead, Am. ]. Psychiat., 110:695-701, 1954. Disorders. Class and Social Psychiatric 8: C.: F. A. B. Redlich, Hollingshead, Disand Psychiatric Environment Social the Between In: Interrelations orders. New York: Milbank Memorial Fund, pp. 195-208, 1954. Kahn, R. L. 8c Fink, M.: Changes in Language During Electroshock Therapy. 8c J. Zubin. New York: P. Hoch ed. Communication, In: Psychopathology of Grune 8c Stratton, 1957. to Behavioral in 8c Response Factors M.: Personality L. Fink, R. Kahn, Electroshock Therapy. Conf. Neurol. (in press). Levinson, D. J.: Personal Communication. 8c Johnson, N. A.: Failures in Psychiatry: The Chronic HosC. N. Morgan, 1957. 113:824-830, Am. Patient. ]. Psychiat, pital 197:103—110, American, Scientiﬁc Culture. and K.: M. Schizophrenia Opler, 1957. 8: Rachlin, L.: A. Lurie, M.; Gurvitz, G. S.; Goldman, Rachlin, H. L.; 1950. in Hillside from Hospital 317 Patients Discharged of Follow-up Study This Journal, 5:17-40, 1956. Redlich, F. C.; Hollingshead, A. B.; Roberts, B. H.; Robinson, H. A.; Disorders. and 8: Social K.: Structure Psychiatric Z. L. J. Meyers, Freedman, Am. J. Psychiat., 109:729-734, 1953. Rennie, T. A. C.; Srole, L.; Opler, M. K. 8: Langner, T. 8.: Urban Life and Mental Health. Am. J. Psychiat., 113:831-837, 1957. Robinson, H. A.; Redlich, F. C. 8c Myers, J. K.: Social Structure and Psychiatric Treatment. Am. ]. Orthopsychiat., 242307-316, 1954. Titus, H. E. 8: Hollander, E. P.: The California F Scale in Psychological Research: 1950-1955. Psychol. Bull., 54:47-64, 1957. In: Verbal in Factor Therapy. Ethnocentrism as Limiting a R.: R. Tougas, 8c R. F. Dymond. C. ed. R. Rogers and Change, Personality Psychotherapy 1954. 196-214, Press, of Chicago pp. University Chicago: Creative of Utilization 8c and E.: Therapeutic Structure E. Zierer, Zierer, Activity. Am. ]. Psychother., 10:481-519, 1956. �SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN EEG RESPONSE TO ELECTROSHOCK1 MARTIN A. GREEN, MD.2 The assumption is often tacitly made in studies of nervous system function that the capacity for neurophysiological change is similar for animals or humans in the groups under study. Differ- ences in response are ascribed to different parameters of the stimulus or to differences in the location and extent of lesions, either spontaneous or experimentally produced. Such an assumption may not be warranted, however. Perhaps another factor in the variability of response under these conditions is an individual variability in neurophysiological reactivity or responsiveness. The initial “base line” may not be similar in all individuals. The possibility of different inherent patterns of reactivity has been suggested by the studies of the alterations in the EEG during electroshock. We have been impressed by the high degree of variability in such alterations both in their quantitative and qualitative aspects. Although this variability has been described by previous investigators, it has not been stressed sufﬁciently; nor have possible explanations been advanced or systematically investigated. The present report concerns a description of the changes in the EEG during electroshock in the Hillside Hospital material. The concept of neurophysiological reactivity is presented and studies that may clarify this problem are suggested. MATERIAL AND METHODS Eighty-nine patients who received electroshock for psychiatric illness were studied. The patients were voluntary admissions to 1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. 2Assistant in Neurophysiology, Department of Experimental Psychiatry, Hillside Hospital. 229 �230 MARTIN A. GREEN Hillside Hospital and the majority had not received electroshock previously. The diagnostic groups included psychotic depression, manic-depressive psychosis and schizophrenia. The largest group was patients with depression. Ages ranged from 20 to 68 years with a median of 47 years. Treatments were given three times weekly, each patient receiving at least twelve treatments. The Medcraft instrument (alternating current) was used for twenty-eight patients and the Reiter instrument (unidirectional current) for sixty-one patients. Electro— encephalograms were taken prior to, at weekly intervals during, and two weeks following the course of treatment. Patients Whose pretreatment EEG was abnormal were speciﬁcally excluded from study. Tracings were done on a nontreatment day (from 24 to 36 hours following the previous treatment) with an eight channel Medcraft machine using needle electrodes. Frontal, motor, parietal, occipital, anterior temporal, posterior temporal, vertex and earlobe placements were employed with scalp to scalp and scalp to earlobe combinations. RESULTS Delta Activity A. Quantitative Diﬁerences: The delta activity was analyzed according to the method described by Fink and Kahn (7). The duration of burst activity, the lowest frequency, the average delta index in several leads, the highest amplitude, and the highest per cent time delta in one lead were measured. Records were classiﬁed as showing a low, middle or high degree of delta activity (Fig. 1) according to criteria previously described (7). All patients developed delta activity during the course of twelve treatments, but differences in the amount of the slow activity and its rate of development were very apparent (Table I). Some patients developed “high delta activity” early in treatment, whereas other patients showed only “low” or “middle” changes even after twelve treatments. These latter patients were followed further with serial EEGs. As treatment was continued, a high degree of delta activity did not develop in some of these patients until twenty or more treatments, or until treatments were given on a daily basis. They were resistant to neurophysiologic change. This individual variability in EEG response was independent of the type of electroshock current employed, being present both with alternating and with unidirectional current applications. 1. �INDIVIDUAL VARIABILITY IN EEG UPON ECT 231 WWW WWW WWW’VW’WW WWW WWW WWW "WWW WWW-«MW WWW WWW LF-LO RF-RO .,, LC-LMT RC-RMT RP-E LAT-LPT WWWWWWWVW ”W ISECOND RAT-RPT PRE- ELECTROSHOCK FIGURE la 24 HOURS AFTER EST 150 W 4%: l2 Degree of Delta Activity—Low From Fink and Kahn (7) Qualitative Diﬂerences: Although the total amount of delta activity may be similar, records differ as to type, frequency and voltage of delta activity. One prominent qualitative difference is the ratio of irregular delta activity to bursts of slow activity. Nearly all B. W WW LF‘ LO WWWMWMWW LC-LMT R C -R MT L P-E RmANWMMW-E LAT- LPT ' WNW/“WWW WWW/MW Ison "WWW WWW WWIMMMMMMWNVWMMWWMMMMMHM £59932. RAT-RPT PRE-ELECTROSHOCK FIGURE 1b 24 HOURS AFTER EST #10 Degree of Delta Activity—Middle From Fink and Kuhn (7) �MARTIN A. GREEN W W W mm 232 LWW WWW «WWW - L MT T ELEM“ Mwmwwaw MR LP'E RP-E ”WWW “H” WWW lSECOND RAT- RPT' PRE-ELECTROSHOCK 24 FIGURE 1c {5,on HOURS AFTER EST =11:” Degree of Delta Activity—High From Fink and Kuhn (7) records show burst activity during a course of twelve treatments. In some patients the initial delta change is in the form of bursts which become more frequent, slower and of higher voltage as treatments are continued. The irregular delta activity in such records is much less prominent and usually occurs at faster frequencies. In other patients the reverse occurs. Delta activity appears chieﬂy in an irregular and scattered form. Although burst activity is also present, it is not conspicuous. In a third group of patients the amounts of irregular delta activity and bursts are approximately equal (Fig. 2). These differences in the form that the delta activity assumes are usually constant during the course of treatment. At times, TABLE I Degree of Delta Activity in Serial Electroencephalograms during Electroshock (2-4 records were taken for each patient) No. of Records in Each Treatment Period EEG Activity No change Low delta activity Middle delta activity High delta activity EST 1-3 4-6 7-9 10-12 5 l 1 37 0 21 7 20 28 22 45 10 25 16 3 1 �INDIVIDUAL VARIABILITY IN EEG UPON ECT 233 however, burst activity will become more prominent than the irregular delta only during the latter part of the course of treatment; or burst activity which appears prominent early in treatment may be overshadowed and obscured in later records by a large amount of continuous irregular delta activity. WWWW A HH I486 WWW AT‘VERTEX R 5 HH F-VERTEX 1392 WWWNWWVWWW R WWWWWWWWW ‘3 HH l599 AWWWWWWWMMMMWNWWW D HH 50 mv. I572 |____ SEC. l FIGURE 2 Qualitative Changes in Delta Activity A—Irregular Delta C—Rhythmic Runs B—Delta Bursts D—Asymmetry The slow activity is maximal at the anterior temporal and frontal electrodes and less pronounced at the more posterior electrodes. Often it is asymmetric, being of higher voltage, slower, and in greater amounts at the left anterior temporal and frontal electrodes as compared to the right (Fig. 2). Only rarely is the reverse true, i.e., accentuation on the right side. This asymmetry occurs during treatment both with alternating and with unidirectional currents. Another type of abnormality is the appearance of rhythmic runs of delta activity which may continue for 10 to 20 seconds (Fig. 2). �MARTIN A. GREEN 234 The regularity of the frequency and voltage of the slow waves in these runs is very striking. These runs are usually infrequent, but may be the most prominent alteration in the record. In many records the amount of delta activity ﬂuctuates during the tracing. At times, some portions of a record may appear nearly normal, while in other parts of the same record the delta activity may be quite pronounced. This variation is independent of the electrode combinations employed. or Spike-Wave Activity A large number of records show single spike activity of low, moderate or high voltage. Most often such spikes are slower and not as prominent as those present in patients with seizure disorders. A small number of records show spike—wave activity. This is usually at irregular, mixed frequencies and, again, does not resemble the regular rhythmic bursts commonly seen in patients with seizure disorders (Fig. 3). 2. Spike 3. A lpha Activity The alpha activity shows changes both in amount and frequency. As the amount of delta activity increases the amount of alpha activity usually decreases. Changes in frequency occur but are not proHH A F I40! a ~wvv~uu~vv*1qJJWV’V‘r 0 W “H 3‘ WWW AT-VERTEX TO EARLOBES AT VERTEX '5“ P-EARLOB ”PT 50 mv.| I SEC. FIGURE 3 Spike and Spike-wave Activity �INDIVIDUAL VARIABILITY IN EEG UPON ECT 235 nounced. The frequency will be slowed by 1-2 cps but at times will remain the same as in the preelectroshock tracing. In a small number of patients the amount and voltage of alpha activity increases during treatment. This change persists during the posttreatment period after the slow-wave activity subsides (Fig. 4). F-O HHI484 L R WW PRE-EST HH |597 WWW’WWWWWMMWWWWMAMWMWW L F-O 2 wxs. POST-EST FIGURE 4 50 mv.|_ l SEC. Change in Alpha Activity Beta Activity The fact that many sedatives, particularly barbiturates, induce fast activity in the EEG and the difﬁculty in controlling the administration of these drugs in the population studied makes it difﬁcult to evaluate changes during the course of treatment. In most instances changes in fast activity are minimal. The most frequent change, when present, is a decrease in the activity. 4. DISCUSSION The problem being raised is that of the individual variability in the type and degree of EEG alteration during electroshock therapy. AS described, this is manifested in: (1) the amount of slowwave activity and its rate of development; (2) qualitative differences in the slow-wave activity (amount of burst activity vs. irregular delta activity, symmetry, ﬂuctuating appearance of slow activity, runs of rhythmic Slow activity); (3) presence of Spike or spike-wave activity; and (4) changes in alpha and beta activity. Previous investigations (2, 4, 5, 10, ll, l2, l4, 17, 18, 19, 20, 25) have stressed possible correlations with age, sex, frequency of treatment, type of current employed, psychiatric diagnosis, and clinical �236 MARTIN A. GREEN change. Increasing the frequency of treatment, for example, will increase the degree of alteration in the EEG. However, when patients of similar sex, age and psychiatric diagnosis are given treatments at the same frequency with the same type of electroshock current, variability in the rate of development of changes in the EEG and their type and degree are still very prominent. One explanation for this variability might be the distribution of the electroshock current in the brain. Perhaps minor differences in the resistance of the skull, in the distribution of blood vessels and their permeability or in the arrangement of nerve tracts create differences in the pathways taken by the current. Under such circumstances, different portions of the brain may receive more or less current in one patient as compared to another. Differences in the type of electrical activity generated by these variously affected areas might account for variability in the EEG. Available studies employing direct intracerebral measurements indicate considerable diffusion of current throughout the brain (6, 9, 16, 21). However, a concentration of current anteriorly and along large neuronal pathways, such as the corpus callosum, has been demonstrated. No further information is available as to amounts of current received by more speciﬁc cerebral areas. Due to the high resistance of the skull only a small portion of the applied current actually reaches the brain. The amount of current entering different portions of the brain is said to be determined by the resistance of the skull overlying these areas, the anterior concentration of current being the result‘of the thinness of the temporal bone with its consequent lower resistance as compared to other parts of the skull (9, 21). Several considerations, however, indicate that individual differences in these factors of resistance and amount of current reaching different areas of the brain are of minor, if any, importance in the EEG response during electroshock. It is the occurrence of the generalized seizure per se, rather than the passage of electricity, which is the primary factor. During a course of grand mal therapy induced by nonelectrical means such as metrazol, EEG changes occur which are similar, in general, to those seen with electroshock (13, 14). Diffuse slow-wave activity, accentuated anteriorly, and spike or spike-wave activity are described. The amount of slow-wave activity increases during treatment'but shows individual variability unrelated to the number of treatments. Another observation is that electroshock therapy which induces petit mal (8, 18) or focal (3) seizures rather than grand mal does not produce the characteristic �INDIVIDUAL VARIABILITY IN EEG UPON ECT 237 build-up of slow-wave activity. In addition, there is no increase in the degree of delta activity in our patients in whom mal grand therapy is given with high suprathreshold stimuli as compared to those in whom threshold stimuli are used. Factors of current cannot be entirely dismissed, however. Even with grand mal therapy, the type of current employed may inﬂuence the EEG change. We have conﬁrmed a previous study (20) showing that the rate of increase of delta activity is slower in therapy with unidirectional current than in that with alternating current. Similarly, brief stimulus therapy is said to produce smaller degrees of alteration in the EEG as compared to alternating current therapy (15). The other theory to be considered in explaining the variability in EEG responsiveness, and the one which is probably more decisive, involves inherent differences in neurophysiological reactivity. By this is meant both the quantitative and qualitative aspects of the inherent capacity of the nervous system to respond to stimuli or injury. Not only the degree of response, but also the type of response, may have these determinants. The type and degree of EEG abnormalities developed during electroshock therapy to be appear the reﬂection of such inherent individual differences in neurophysiological reactivity. Several types of investigation may serve to test this hypothesis. Methods other than electroshock known to produce EEG alterations could be applied prior to treatment. These might include lowering the blood sugar by parenteral insulin, intravenous administration of convulsants such as metrazol or Megimide, photic stimulation, or the intravenous administration of drugs such as barbiturate. In addition, perhaps the actual electroshock seizure threshold or the pattern or severity of the seizures may be a measure of nervous system responsiveness. Data from such investigations could be correlated with the degree and types of EEG change during electroshock. In this manner it might be possible to demonstrate different patterns of neurophysiological reactivity and to classify individuals accord- ingly. Such studies may not only help in understanding the variability in the EEG alterations during electroshock but would have wider application to other problems in clinical electroencephalography and neurology. For example, the basis for the development of spontaneous seizures secondary to traumatic, vascular, or neoplastic lesions of the nervous system is not known. Patients with lesions �238 MARTIN A. GREEN comparable in type, size and location may or may not develop seizures. As previously described, some subjects show spike or spikewave activity during electroshock. This suggests an inherent difference in the capacity to develop clinical seizures or EEG seizure activity following “injury” to the nervous system, whether the injury is spontaneous or induced. Differences in this capacity may be reﬂected in varying patterns of neurophysiological reactivity. Differences in neurophysiological reactivity may also be manifested in the pretreatment EEG. Patients in whom the pretreatment record is abnormal (ll), “instabile” (22), or shows a predominant alpha rhythm (5) are said to develop the greatest alteration in the EEG during electroshock. Other investigators have not conﬁrmed these observations (2, 23). Actually, such correlations depend on the method of analysis of the pretreatment record employed and the criteria used for “abnormality.” Further investigation of this relationship is necessary. Suggesting that neurophysiological reactivity is an inherent process does not imply that a physiological basis does not exist or cannot be investigated. This may reside in the central nervous system itself, consisting of individual differences in neurochemical systems or in the permeability of cells or blood vessels; or it may be outside the nervous system. Individual differences in hormonal or other humoral substances produced during the stress of electroshock may serve to “sensitize” or “desensitize” the cerebrum with regard to developing different amounts and types of electrical activity. That such factors may be operative is suggested by the following studies. Trypan red injected intraperitoneally in cats before a course of electroshock decreased the permeability of the blood-brain barrier and reduced the degree of EEG changes as compared to control animals (1). Atropine and scopolamine administered during a course of electroshock in man blocked the development of the usual slow-wave activity (24). Electroshock therapy affords an excellent opportunity for the experimental investigation of the problem of an inherent neurophysiological reactivity. One is able to apply studies directly to man rather than animals. The stimulus to the central nervous system can be standardized and the degree of neurophysiological change controlled, within limits, by changing different parameters. Tests of EEG responsivity can be given before such changes are induced as well as during and after treatment. Restudy of patients is often possible when subsequent courses of treatment are necessary. I ‘ �INDIVIDUAL VARIABILITY IN EEG UPON ECT 239 SUMMARY Individual differences, both quantitative and qualitative, in the EEG changes during a course of electroshock treatment in eighty-nine patients are described. 2. These differences are pronounced and are not explainable by age, sex, type of shock current, frequency of treatment, psychiatric diagnosis, or clinical change. 3. An inherent capacity for neurophysiological change that has both quantitative and qualitative aspects may be the primary determinant of these differences. 4. Variation in skull resistance and in the amount of current reaching the brain appear to be minor factors. 5. Investigations that might serve to test the hypothesis presented are described. Such studies may lead eventually to a classification of individuals as to different patterns of neurophysiological reactivity and clarify other problems in clinical neurology and electroencephalography. 1. REFERENCES Aird, R. B.; Strait, L. A.; Pace, J. W.; Hrenoff, M. K. 8: Bowditch, S. C.: Current Pathway and Neurophysiological Effects of Electrically Induced Convulsions. J. Nerv. (‘5' Ment. Dis., 123:505-512, 1956. (2) Bagchi, B. K.; Howell, R. W. 8: Schmale, H. T.: The Electroencephalographic and Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders. Am. ]. Psychiat, 102:49-61, 1945. (3) Bergman, P. S.; Impastato, D. J.; Berg, S. 8c Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Focal Seizures. Conf. Neurol., 13:271-277, 1953. (4) Callaway, E. 8c Boucher, F.: Slow Wave Phenomena in Intensive Electroshock. EEG. Clin. Neurophysiol., 2:157-162, 1950. (5) Chusid, J. G. 8c Pacella, B. L.: The Electroencephalogram in Electric Shock Therapies. ]. Nerv. €7- Ment. Dis., 116:95-107, 1952. (6) Delgado, J. M. R.; Alexander, L..& Hamlin, H.: Effects of Electroshock on the Cortical and Intracerebral Electroactivity of the Brain in Schizophrenic Patients. Conf. Neurol., 13:287-294, 1953. (7) Fink, M. Sc Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Re» spouse in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neurol. (‘3‘Psychiat., 78:516—525, 1957. (8) Fink, M.; Kahn, R. L. 8c Green, M. A.: Experimental Studies of the Electroshock Process. J. Nerv. &- Ment. Dis. (in press). (9) Hayes, K. J.: The Current Path in Electric Convulsion Shock. Arch. Neurol. é} Psychiat., 63:102-109, 1950. (10) Hoagland, H.; Malamud, W.; Kaufman, I. C. 8c Pincus, 0.: Changes in the Electroencephalogram and in the Excretion of 17-Ketosteroids AccompanyElectroshock ing Therapy of Agitated Depression. Psychosom. Med., 8:246251, 1946. (1) �MARTIN A. GREEN 240 Willner, M. D.: Signiﬁcance of Changes in the Electroencephalogram Which Results from Shock Therapy. Am. ]. Psychiat., 105: (11) Kennard, M. A. 8: 40-45, 1948. ' (12) Klotz, M.: Serial Changes Due to Electrotherapy. Dis. Nerv. Sys., 16:120-122, 1955. (13) Knott, G. R.; Gottlieb, J. S.; Leet, H. H. 8c Hadley, H. D., Jr.: Changes in the Electroencephalogram Following Metrazol Shock Therapy: A Quantitative Study. Arch. Neural. (5" Psychiat., 50:529-534, 1943. (14) Levy, N. A.; Serota, H. M. Sc Grinker, R. R.: Disturbance in Brain Function Following Convulsive Shock Therapy. Arch. Neurol. 1027, 1942. (‘5' Psychiatu 47:1009- (15) Liberson, W. T.: Current Evaluation of Electric Convulsive Therapy. Res. Publ. Ass. Nerv. Ment. Dis., 31:199-231, 1951. (16) Lorimer, F. M.: Sega], M. M. Sc Stein, S. A.: Path of Current Distribution in Brain During Electroconvulsive Therapy. EEG. Clin. Neurophysiol., 1: 343-348, 1949. (17) Moriarity, J. D. 8c Siemens, J. C.: Electroencephalographic Study of Electric Shock Therapy. Arch. Neurol. é» Psychiat., 57:712—718, 1947. (18) Pacella, B. L.; Barrera, S. W. 8c Kali'nowsky, L.: Variations in the Electro- encephalogram Associated with Electric Shock Therapy of Patients with Mental Disorders. Arch. Neural. E} Psychiat., 47 :367-384, 1942. (19) Proctor, L. D. 8c Goodwin, J. E.: Clinical and Electra-physiological Observations Following Electroshock. Am. J. Psychiat., 101 :707-800, 1945. (20) Proctor, L. D. 8: Goodwin, J. E.: Comparative Electroencephalographic Observations Following Electroshock Therapy Using Raw 60 Cycle Alternating and Unidirectional Fluctuating Current. Am. ]. Psychiat., 99:525530, 1943. Wegener, C. F .: On Electric Convulsive Therapy with Particular Regard to a Parietal Application of Electrodes Controlled by Intracerebral Voltage Measurements. Acta Psychiat. et Neural, 19:529-549, 1944. (22) Sulzbach, W.; Tillotson, K. J.; Guillemin, V., Jr. 8: Sutherland, G. F.: A Consideration of Some Experience with Electric Shock Treatment in Mental Diseases, with Special Regard to Various Psychosomatic Phenomena and to Certain Electra-technical Factors. Am. J. Psychiat., 99:519-524, 1943. (23) Taylor, R. M. Sc Pacella, B. L.: The Signiﬁcance of Abnormal Electroencephalograms Prior to Electroconvulsive Therapy. J. Nerv. (S; Ment. Dis., (21) Smith, J. W. 8c 107:220—227, 1948. - Johnson, M. W.: Effect of Atropine and Scopolamine Upon Electroencephalographic Changes Induced by Electro-convulsive Therapy. (24) Ulett, G. A. 8c EEG. Clin. Neurophysiol, 9:217-224, 1957. (25) Weil, A. A. 8c Brinegar, W. C.: Electroencephalographic Studies Following Electric Shock Therapy. Arch. Neural. é" Psychiat., 57 2719-729, 1947. �ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI1 HYMAN KORIN, PH.D.2 and MAX FINK, M.D.3 In the course of extensive investigations (1, 2, 3) into the perception of multiple simultaneous stimuli, the pattern of failure of subjects accurately to report one of two stimuli led to a concept of an “order of dominance” in cutaneous perception. Since then, the relationship of the observed pattern of dominance to biologic and psychiatric concepts of body image and body scheme has been the subject of considerable speculation (4, 7, 8, 14). The interrelationship of body areas was initially clearly demonstrated in simultaneous tactile tests of face and hand (2), in which it was noted that the stimuli to the hand were frequently not reported or mislocalized. These phenomena of “extinction” and “displacement” led to the inference that cheek area stimuli were “dominant” to hand stimuli. In subsequent reports (3, 10, ll, 12) a pattern of dominance for tactile stimuli was described in which the face and the primary genital areas were the most perceptive or dominant areas; the hand was the least dominant; and the shoulder, foot, buttock, breast, back, thigh and abdomen fell between these extremes in a mild gradient. These observations were made in normal adults and children and psychiatric patients, but were most clearly discerned in patients with brain disease. Indeed, the major portion of the data relates to a group of patients with severe diffuse brain dysfunction under observation in a general psychiatric hospital. 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. 2Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3 Director, Department of Experimental Psychiatry, Hillside Hospital. 241 �242 KORIN—FINK The basis for these phenomena is unclear. In a review of the problem (3) consideration was given to hypotheses ascribing signiﬁcance to anatomic, psychophysical, genetic, environmental and neurophysiologic factors. In their conclusions, Bender, Green and Fink note that “no one theory adequately explains the organization of this pattern. Learning and maturation are probably factors, but it appears to be mostly inherent.” In studies of patients with brain disease and normal young children, Cohn (4, 5) emphasized the rostral order of dominance and ascribed signiﬁcance to “an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain.” He also noted speciﬁcally that this pattern was primarily associated with “the over-all sentient function of the brain.” A more extensive elaboration of a maturational and developmental explanation of the order of dominance has been proposed (14). Taking the infantile patterns of sutking and feeding as a model, Linn ascribes dominance to the face as it is the oldest element in the body image; the dominant role of the genital area to the intensity of pleasurable sensation that the infant elicits from masturbation; and the subordinate position of the hand to its role as an exploring and tension-relieving appendage wherein it holds second place in awareness to its stimulation of the more exciting mouth and genitalia. A neurophysiologic View was advanced by Critchley (6, 7), who, after expressing a preference for the term “tactile inattention” instead of “extinction,” emphasized the rostral order of dominance. He stated that “strong stimulation of the healthy side suppresses the attenuated sensations on the impaired side,” and concluded that “tactile inattention in parietal patients is probably no more than an instance of local neglect or disregard, which may be demonstrated at times in many other spheres of consciousness besides the tactile—whether motor, visual or spatial.” A psychophysical explanation was eschewed by Bender, Fink and Green (3, 10, 11), who found no relation between the order of dominance and the tactile threshold for touch or pin prick. DennyBrown, Meyer and Horenstein (8), however, insisted that these patterns were only apparent when there was an alteration or loss of twopoint discrimination. They further demonstrated that the extinction of the hand stimulus by a stimulus to the leg could be overcome by four stimuli to the hand. The dominance of the cheek to the hand could not, however, be altered by ten stimuli to the hand in their subject. �STIMULUS INTENSITY IN PERCEPTION 243 The following data further emphasize psychophysical factors in perception under the conditions of multiple simultaneous stimulation. These studies represent the initial report of an investigation into the application of simultaneous tactile stimulation tests to the problem of measurement of the alteration in brain function induced by electroshock therapy. In the course of this study electrical stimuli were applied to the cheek and hand of psychiatric patients. Stimuli were either at threshold or suprathreshold levels. Two aspects of the data are presented: (a) the effect of alteration of relative strength of stimulus in the order of dominance on facehand tests; and (b) relation of perceptual thresholds to the order of dominance. SUBJECTS AND METHOD The subjects were thirty-four consecutive psychiatric patients referred for electroshock therapy. The range of their ages was between 21 and 65 and the mean age was 45. Eleven patients were diagnosed as involutional melancholia, thirteen as manic-depressive, depressed, eight as schizophrenia, and two as psychoneurosis mixed type. All testing was done prior to a course of electroshock therapy and no patient had clinical or EEG evidence of altered brain function. Each patient was tested in one session for the purposes of this report. Two model S-4B Grass square wave stimulators were synchronized to deliver either single or two simultaneous electrical stimuli. An isolation unit was connected to each stimulator to eliminate artifacts and the output was monitored visually by an oscilloscope. A switch box inserted in the circuit permitted independent selection of the various body parts. An active and an indifferent electrode, required for each body part, were small 5%; inch steel discs placed 1 inch apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. The electrodes remained afﬁxed to the selected body parts throughout the period of testing. The patient was placed on a couch in a relaxed and supine position. To alleviate undue anxiety the nature of the testing was described. It was emphasized that only a slight tap-like sensation would be felt. The electrodes were then placed on (1) the dorsum of the hands, (2) the mandibular area of both cheeks, and (3) the medial calf area of the legs. In the testing procedure, thresholds for the various body parts were ﬁrst determined. At a frequency of .3 cycles/second, and a pulse I �244 KORIN—FINK duration of 50 milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, until the subject perceived 100 per cent of the stimuli. Incre1 volt of increments and the 5 hand volts to of were applied ments to the cheeks. After a ten-second interval, the voltage was decreased until sensation disappeared. Following another ten-second interval, the voltage was gradually increased by 1 volt each six seconds until the patient again reported 100 per cent of the stimuli. This reading was considered the minimal voltage required to produce threshold sensation. Such stimuli, at threshold and 10 per cent above the threshold, are reported by the subjects as a “tap,” a “prick” or a “sting.” Complaints of painful perception were not elicited at these levels of stimulation. After the thresholds were determined, testing with a series of single and double simultaneous stimuli followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and left cheek (homologous stimulation). Both in mixed singly, a one stimulated or simultaneously, were part parts order for ten trials for each of the following conditions: (1) threshold, (2) suprathreshold (10 per cent above the threshold), (3) one body part at suprathreshold and the other at threshold, and (4) the reverse of (3). The order of presentation of conditions (1) and (2) was alternated for different subjects and the same was done for conditions (3) and (4). Similarly the order of presentation of the heterologous and homologous stimulation was alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. When this change occurred, stimulation was increased until a new threshold was determined and ten trials were started anew. RESULTS A. Threshold Values The threshold stimulation for perception was determined for the hands, cheeks and legs (Table I). The threshold values for the hands and legs are three to four times higher than the thresholds for the cheeks. While the threshold values in the legs are less than in the hands, these differences lack statistical signiﬁcance. Variabiland hands the in legs is threshold considerably the of greater ity than in the cheeks. There is virtually no overlapping of thresholds, however, where the cheeks and the hands are concerned. �STIMULUS INTENSITY IN PERCEPTION TABLE 245 I Mean Thresholds and Standard Deviations of Body Parts Mean Thresholds (volts) Standard Deviation Right Cheek Left Cheek Right Hand Left Hand Right Leg Left Leg 6.76 7.85 29.25 22.35 24.50 19.52 4.47 4.86 14.88 13.60 13.99 13.64 Extinction Patterns The difference between the number of extinctions of the right hand or the left cheek on stimulation of both parts with either threshold or suprathreshold stimuli was not signiﬁcant (Table 11). Also, when both cheeks were stimulated with either threshold or suprathreshold stimuli, there were no differences in the number of extinctions in each cheek (Table III). In contrast to these observations, stimulating one body part with a suprathreshold stimulus and the other at threshold resulted in a signiﬁcant increase in the failure to report the body part stimulated at threshold. Thus the cheek was dominant over the hand, or the hand was dominant over the cheek depending on the body part to which the stronger stimulus was applied (Table II). Altering the relative strength of the stimuli applied to the cheeks resulted in a similar predictable change in the pattern of dominance (Table III). Further analysis of the data in Table II indicates that the hand B. TABLE 11 Mean Extinctions of Cheek and Hand for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Mean Extinctions Extinctions of Hand of Cheek Hand and Cheek at Threshold Hand and Cheek at Suprathreshold Hand at Suprathreshold and Cheek at Threshold Cheek at Suprathreshold and Hand at Threshold Difference Signiﬁcance 1.55 1.56 .01 NS. 1.02 .59 .57 NS. 2.30 .22 2.08 p<.01 .32 1.36 1.04 p<.01 �KORIN—FINK 246 was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.04) for the thresholdsuprathreshold condition. This tendency is also evident when both parts were simulated at suprathreshold. If it is considered that the mean threshold for the hands is approximately 30 volts, while for the cheeks the threshold is 7 volts, the difference in incidence of extinction may be explained. Suprathreshold stimulation was set at 10 per cent above the threshold value. The hand stimulus was TABLE 111 Mean Extinctions of Both Cheeks for Varying Conditions of Threshold and Suprathreshold Stimulation Both Cheeks at Threshold Both Cheeks at Mean Extinctions of Left Cheek Mean Extinctions of Right Cheek .39 .45 .06 N.S. Difference Signiﬁcance Suprathreshold Right Cheek at Suprathreshold and Left Cheek at Threshold .18 .37 .19 N.S. .96 .14 .82 p<.05 Left Cheek at Suprathreshold and Right Cheek at Threshold .03 1.28 1.25 p<.01 therefore increased by 3 volts and the face stimulus by only 1 volt above the threshold value. Such an increase, although proportionately equivalent, appears to have given greater relative strength to the hand stimulus. Extinction Regardless of pattern, the mean total of the number of extinctions was greater when heterologous body parts were stimulated at threshold than when these parts were stimulated with suprathreshold stimuli (Table IV). For these same conditions of stimulation the diﬂerences between the mean number of extinctions obtained on homologous stimulation of the cheeks lack statistical signiﬁcance, but the results are in the direction which indicate that a greater number of extinctions occur when two body parts are stimulated at threshold (Table IV). The failure to obtain a. signiﬁcant difference in the latter instance is partly due to the fact that relatively few C. Incidence of �STIMULUS INTENSITY IN PERCEPTION 247 TABLE IV Mean of Combined Number of Extinctions For Varying Conditions of Threshold and Suprathreshold‘ Stimuli Both Parts at Both Parts at A-Suprathreshold A-Threshold Threshold Suprathreshold B-Threshold B-Suprathreshold A-Cheek 3.11 1.63 1.68 2.43 .85 .56 1.31 1.10 B-Hand A-Left Cheek B—Right Cheek Differences between the mean number of extinctions at threshold and the other three conditions of stimulation are signiﬁcant for the cheek and hand but are insigniﬁcant for both cheeks. * extinctions are elicited when homologous parts are stimulated. These ﬁndings on the total number of extinctions are in agreement with previous observations (2). DISCUSSION The pattern of extinction following electrical stimulation of the skin with threshold and suprathreshold stimuli has been determined. In contrast to the ﬁndings of investigators (3) who used clinical (tactile) stimulation, the face stimuli were not reported more frequently than the hand Stimuli. Under the conditions of the method of testing in this investigation, nevertheless, it is clear that the pattern of extinction for any two body parts can be readily altered by varying the relative strength of the stimuli. Thus a suprathreshold stimulus applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimulus intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand, in simultaneous tactile testing, is due to an inherent factor, perceived body image, rostral dominance, developmental principle or a learned factor, are not supported by these observations under our conditions of testing. If any of these factors were involved, a pattern of face dominance should have been elicited when the hand and cheeks were stimulated with equivalent electrical stimuli at threshold and suprathreshold intensities, despite the methodological dif- �248 KORIN—FINK ference introduced by the procedure of affixing electrodes to the skin. The ﬁndings in this study, namely that differences in the strength of the simultaneous stimuli can alter the pattern of extinction, supports a stimulus-intensity hypothesis. By inference, differences in threshold also play a signiﬁcant role. That an intense stimulus elsewhere can raise the pain threshold as much as 35 per cent has been demonstrated by Hardy, Wolf and Goodell (13). This effect of a relatively intense stimulus on the threshold of another stimulus has also been found by investigators using other stimuli (8, 9). The problem still remains, however, how it is that a pattern of dominance may be elicited when presumably equivalent stimuli are applied by touch stimuli. The results of this study suggest an explanation. Stimuli of differing intensities are required to elicit a threshold sensation for various body parts. When these stimuli are increased 10 per cent, the resultant stimuli are proportional and are perceived as equivalent. In contrast, in clinically touching two body parts, the stimuli are disproportionate relative to the threshold value although approximately of equal intensity in their application. Because of the differences in threshold for the hand and cheek, the tactile stimulus to the cheek is proportionately more above the threshold than the stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and has been considered “dominant.” A threshold hypothesis was rejected (3) on the basis that the thresholds obtained by von Frey (16) for pressure and pain do not strictly correspond to the dominance order elicited by the double simultaneous stimulation tests. Most difﬁcult to reconcile is von Frey’s ﬁnding that the pressure threshold of the glans penis, which is second in dominance rank only to the cheek in a group of ten body parts tested, is 111 grams per square millimeter; while the threshold of the hand, which is at least dominant, is only 12 grams per square millimeter. Unfortunately, thresholds in the genital area for male and female have seldom been determined. Von Frey’s list of thresholds (16) is based on a single subject. His more detailed observations (17), however, indicate that there is virtually no pressure sense in the glans penis or clitoris, although the perception of pain, warmth and cold is well developed. It is quite possible that the punctate pressure threshold does not correlate with touch where the genital area is concerned but that instead some other sense or combination of senses is involved. �STIMULUS INTENSITY IN PERCEPTION 249 Thresholds for the dorsum of the hand and the cheek obtained by von Frey and other investigators indicate that the cheek is considerably more sensitive than the hand. These ﬁndings are in agreement with the thresholds obtained in this study. In a recent study of electrical thresholds at various body sites Sigel (15) reported that “leg areas including thigh and ankle, also dorsum of the hands and the palm showed a deﬁnite tendency for higher thresholds. Scalp, temple, forehead and face tended to have lower thresholds. The anterior chest and upper arm and anterior wrist areas showed a tendency for lower thresholds. Neck areas, abdomen and upper back showed no deﬁnite trend.” In this statement there is no disagreement with the clinically observed order of dominance. From the experimental results obtained here, it is proposed that the dominance hierarchy elicited under the conditions of simultane— ous testing may be explained on the basis of the relative strength of the stimuli and the stimulus threshold. SUMMARY Using square wave electrical stimuli, the threshold for perception in the hands, cheeks and calves were determined in thirtyfour psychiatric patients. Simultaneous stimuli were applied in random sequence to combinations of cheek and hand and both cheeks, at threshold, suprathreshold and combinations of threshold and suprathreshold intensities. With simultaneous threshold, or simultaneous suprathreshold stimulation, the differences between the number of extinctions in either part were not signiﬁcant. With stimuli of unequal intensity (one stimulus at threshold and one suprathreshold), however, there was a signiﬁcant increase in the failure to report the threshold stimulus. The total number of extinctions is greater with threshold than with suprathreshold stimuli; and greater in heterologous than in homologous patterns of stimulation. It is concluded that the observed order of dominance in simultaneous cutaneous tests may be explained by psychophysical relationships. REFERENCES (1) Bender, M. B.: Disorders in Perception. Springﬁeld, Ill.: Charles Thomas, (2) Bender, M. B.; Fink, M. 8c Green, M. A.: Patterns in Perception on Simultaneous Tests of Face and Hand. A.M.A. Arch. Neurol. (9 Psychiat., 66: 1952. 355-362, 1951. �250 (3) KORIN—FINK Bender, M. B.; Green, M. A. 8: Fink, M.: Patterns of Perceptual Organization with Simultaneous Stimuli. A.M.A. Arch. Neurol. 67- Psychiat., 72:233-255 , 1954. (4) (5) (5) (7) (8) (9) (10) (11) Cohn, R.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation. J. New. 6» Ment. Dis., 113:471-484, 1951. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: II—A Study in Rostral Dominance in Children. Neurology, 1:119-122, 1951. Critchley, M.: The Parietal Lobes. London: Edward Arnold 8c Co., 1953. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions. Brain, 72:538-561, 1949. Denny-Brown, D.; Meyer, J. S. 8c Horenstein, S.: The Signiﬁcance of Perceptual Rivalry Resulting from Parietal Lesion. Brain, 75:433-471, 1952. Duncker, K.: Some Preliminary Experiments on the Mutual Inﬂuence of Pains. Psychol. Forsch, 21:311-326, 1937. Fink, M. Sc Bender, M. B.: Perception of Simultaneous Tactile Stimuli in Normal Children. Neurology, 3:27-34, 1953. Fink, M.; Green, M. A. 8c Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects. J. Nerv. 69'» Ment. Dis., 117:43-49, 1953. (12) Fink, M.; Green, M. A. (13) (14) (15) (15) Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. Hardy, J. D.; Wolf, H. S. 8c Goodell, H.: Studies on Pain. A New Method for Measuring Pain Threshold: Observations on Spatial Summation of Pain. J. Clin. Invest., 19:649-658, 1940. Linn, L.: Some Developmental Aspects of the Body Image. Int. J. Psychoanal., 36:1—7, 1955. Sigel, H.: Cutaneous Sensory Threshold Stimulation with High Frequency Square-Wave Current: 11. The Relationship of Body Site and Skin Diseases to the Sensory Threshold. J. Invest. Derm., 18:447-451, 1952. von Frey, M.: Beitréige zur Physiologic des Schmerzsinns. Ber. Siichs. Ges. 8c Wiss., 46:185-196, 283-296, 1894. (17) von Frey, M.: Beitrage zur Sinnesphysiologie der Haut. Ber. Siichs. Ges. Wiss., 47: 166-184, 1895. �NEWS AND NOTES DR. MILLER ANNOUNCES APPOINTMENT OF DIRECTOR OF PROFESSIONAL SERVICES Dr. Joseph S. A. Miller, Medical Director of Hillside Hospital, has announced the appointment of Dr. Lewis L. Robbins of Topeka, Kansas as Director of Professional Services at Hillside Hospital, starting July 1, 1958. Dr. Robbins has been connected for many years with the Menninger Foundation, and has held many senior positions at the Foundation, including the Directorship of the Outpatient Depart ment, and up to about a year ago, the Directorship of the Department of Adult Psychiatry. During the past year, he has been Senior Psychiatric Consultant and Chairman of the Psychotherapy Research Project at Menninger’s. Born in Chicago, Dr. Robbins was graduated from the University of Chicago and received his medical training at the Rush Medical School. He interned at the Michael Reese Hospital, Chicago; and had his psychiatric residency training at the latter hospital as well as at the Menninger Sanitarium. He graduated from the Topeka Institute for Psychoanalysis. He is a Diplomate of the American Board of Psychiatry and Neurology and also holds the American Psychiatric Association’s Certiﬁcate as a Mental Hospital Administrator. Dr. Robbins has been an instructor in psychiatry at the Washington School of Medicine and a lecturer in psychiatry at the University of Kansas Medical School, the Menninger School of Psychiatry as well as a training analyst at the Topeka Institute for Psychoanalysis. He is a member of numerous national and regional societies, including fellowship in the American College of Physicians, the American Psychiatric Association, American Orthopsychiatric Association, the Group for the Advancement of Psychiatry; and he also holds important ofﬁces on the executive and other committees of the American Psychiatric and American Psychoanalytic Associations, and is currently the Secretary of the American Psychoanalytic Association. Hillside welcomes Dr. Robbins to its staff. The position of Directorship of Professional Services will include the general direction of the Hospital’s treatment, teaching, and some of the important research programs of the Hospital. 251 �252 NEWS AND NOTES SPECIAL INSTRUCTION FOR RESIDENTS DURING 1957—1958 We are pleased to announce that we have engaged the teaching services of three prominent psychiatrists and psychoanalysts for the special instruction of our Residents during the 1957-1958 season. These are: (1) Dr. Robert C. Bak, whose course will be on “The Psychopathology of the Psychoses, with Special Reference to the Schizophrenias.” The lectures will be given at the Hospital on Wednesdays from October 1957 through May 1958, from 12:00 to 1:00 P.M. (2)Dr. Paul Goolker, who will be giving the course on “Principles and Practice of Dynamic Psychotherapy for Hospitalized Patients.” This course will be given during the same period on Fridays from 12:00 to 1:00 RM. (3) Dr. I. Peter Glauber will be in charge of the course on “Important Readings in Psychoanalytic Psychiatry.” This will be given at the Hospital on Thursdays from 11:45 A.M. to 12:45 P.M. As has been the custom, these lectures to the total Resident staff will be preceded by three hours of special conferences including group preceptorship of a number of Residents and their particular Supervisor. A SPECIAL COURSE OF LECTURES ON GROUP PSYCHOTHERAPY We have the pleasure of announcing that Dr. Aaron Stein, the Director of the Group Psychotherapy Program at the Hospital, will be giving an introductory course of lectures to our Resident staff; and that all members of the psychiatric Attending Staffs and the Clinical Assistants of both the Manhattan and Queens Clinics are cordially invited to attend. The lectures will be held at the Hospital in Glen Oaks on Saturday mornings from 9:00 to 10:15 A.M., beginning Saturday, September 28 and up to Saturday, December 21. Dr. Stein is an Associate Attending Psychiatrist at the Hospital and an authority in group psychotherapy. He plans to cover the important practical aspects of the subject, including general principles, selection of patients, group psychodynamics. the role of the group therapist, relationship between group and individual psychotherapy, etc. J.S.A.M. �Recent and Forthcoming Publications INSTINCTIVE BEHAVIOR The Development of a Modern Concept Translated and edited by CLAIRE H. SCHILLER Introduction by KARL S. LASHLEY With contributions by Konrad Lorenz, Paul H. Schiller, Nicholas Tinbergen, Jakob von Uexkiill 120 illustrations, $7.50 EROGENEITY AND LIBIDO Some Addenda to the Theory of the Psychosexual Development of the Human Psychoanalytic Series, Volume I By ROBERT FLIEss $7.50 YOUTH AND CRIME Proceedings of the Law Enforcement Institute Held at New York University Edited by FRANK J. COHEN $6.00 ON THE UTILITY OF MEDICAL HISTORY Institute on Social and Historical Medicine, Monograph I The New York Academy of Medicine Edited by IAGO GALDSTON $2.00 ON NOT BEING ABLE TO PAINT New Revised Edition By MARION MILNER Foreword by illustrated, $4.50 ANNA FREUD or order directly from INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street New York 11, N. Y. At your bookstore 1] �THE INDEX OF PSYCHOANALYTIC WRITINGS ALEXANDER GRINSTEIN, M .D. 5 Volumes, sold as set only, $75.00 Volumes I and II, now available Volume III, Fall, 1957 The Index covers the entire psychoanalytic literature through 1952. Every book, article, review or abstract is listed in alphabetical sequence according to authors and titles. There are approximately 37,500 listings drawn from 25 psychoanalytic publications and some 75 journals containing articles by psychoanalysts or about psychoanalysis and closely related subjects. Psychoanalytic books and articles, published in 21 languages, have been included, and foreign-language titles have been translated into English. The most invaluable feature is a separate subject index with some 30,000 topical entries. In addition, there are a number of appendices. One of them lists nonanalytic books reviewed in psychoanalytic journals. The others are devoted to a chronological listing of the writings of psychoanalytic pioneers. Among them is the ﬁrst complete bibliography of Sigmund Freud’s writings and published letters. Dr. Heinz Hartmann says: “Psychoanalysis has reached a stage at which a truly comprehensive index of analytical literature has become a necessity. Many questions of principle had to be decided, on the methods of listing, on the degrees of inclusiveness, etc., in order to make this Index a valuable tool for research workers in psychoanalysis and related ﬁelds. Dr. Grinstein made these decisions with considerable wisdom and objectivity, guided by a lucid understanding of all the rather complex problems inherent in his tremendous task. This task might well have looked forbidding and frightened off many a less courageous man. Having become accustomed to using Volume I of The Index of Psychoanalytic Writings (other volumes are to follow soon), I can say that the obvious difﬁculties of this comprehensive venture have been successfully overcome and that this imposing work has proved of the greatest value to me, and without doubt to very many others.” At your book store or order directly from INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street New York 11, N. Y. . 1] �JOURNAL of the HILLSIDE HOSPITAL VOLUME VI 1957 NUMBERS 1-4 CONTENTS Scientiﬁc Papers Blane, Howard T. and Glad, Erik—THE PSYCHOLOGIST AND THE PSYCHIATRIC TEAM IN A RESPIRATOR CENTER . Boyer, L. Bryce—THE MEANING SCHIZOPHRENIC PATIENT Desmonde, William H.—THE ANIMAL SACRIFICE . . OF INSULIN THERAPY TO A . . 24 . . . . . . ORIGIN OF MONEY IN THE . . . . . . . . Devereux, George—THE CRITERIA OF DUAL CO‘MPETENCE IN PSYCHIATRIC-ANTHROPOLOGICAL STUDIES . 87 Fink, Max—A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMIC THERAPIES . . . . . . . . . Glynn, Eugene—THE THERAPEUTIC USE ADOLESCENT PAVILION . . . OF SECLUSION IN AN . . Green, Martin A.—SIGNIFICANCE OF INDIVIDUAL IN EEG RESPONSE TO ELECTROSHOCK . . Jaﬁe, Joseph—AN OBJECTIVE 1 9‘7 . . . . 156 VARIABLIITY . 229 . STUDY OF COMMUNICATION IN . 207 FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL . . . . . . . . . . 216 PSYCHIATRIC INTERVIEWS . . . . . . . Kakn, Robert L.; Pollack, Max; and Fink, Max—SOCIAL Karin, Hyman and Fink Max—ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI. . . . . . . . . . . . . 241 �Locke, N orman—REMARKS PSYCHOLOGY AND THE ON THE GROUP PSYCHOTHERAPY OF THE HARD OF HEARING 100 . M eerloo, ]oost A. M .—Kos AGAINST KNIDOS: AMBIVALENCE AS THE PSYCHIATRIC OUTLOOK ON MAN . . . . . 67 M ullan, H ugh—GROUP PSYCHOTHERAPY IN PRIVATE PRACTICE: PRACTICAL CONSIDERATIONS 34 Nz'ederland, William G.——THE SYMBOLIC RIVER-SISTER EQUATION IN POETRY AND FOLKLORE Reider, N OTman—TRANSFERENCE PSYCHOSIS Slap, Joseph William—PSYCHOTHERAPY 91 131 . WITH A CASE OF 43 MALADIE DES TICS Slap, [oseph William—SOME CLINICAL AND THEORETICAL 150 REMARKS ON CHESS Clinical Symposium OUTPATIENT TREATMENT VIA PSYCHOTHERAPY OF A CHARACTER NEUROTIC WITH IMPOTENCE Part 1: Case presentation by Lionel Blackmcm Part II: Discussion Book Review News and Notes 107 160 180 . . . . . . . . 55,121,182,251 �NO and YES on the genesis of human communication By RENE A. SPITZ $4.00 Dr. Spitz, well known for his original studies of the psychological ‘ i development of infants, devote-s a monograph to the beginnings of com~ munication. He tackles this most important problem from a broad basis, using the theoretical framework of pSychoanalysis; direct ob’servations of infants, both normal and abnormal; and the newest ﬁndings of animal ethology, experimental psychology, embryology and physiology. Skillfully integrating the dataiobtained by thesescience'sr Dr. .Spitz presents a most fascinating and thought-provoking theory of, the roots of communication, both verbal and nonverbal. Dr. Spitz eXa-mines the inherited or preformed motor behavior patterns whiCh have a function in the earl1est nursing situation. Both negatiOn as well as afﬁrmation have such early motor prototypes, which in the Course of deve10pment undergo a change of' function. Divorced, fromthe behavior they originally subserved, these motor patterns can now be utilized exclusively as signals of communication. Later, endowed with semantic meaning which the child acquires through identiﬁcation with the adult’s “No” gesture, they are used for communication proper. Though drawing upon the data and theories of other sciences, the framework of this monograph rests upon Freud's fundamental insights into human pSychological development. Its, major contribution is the minute examination of some of; the building blocks of‘Freud’s theory. This proc'edUre permits the author to throw light on hitherto unexplored interrelations between speCIﬁc aspects of behaviOr1n infants. these ﬁndings emerges the generally applicable concepts of From ‘ “organizers of psychic development" as well as a description of the origins of the Selfin infancy. These ﬁndings have the widest implications for clinical psychoanalysis as well as the study of human relations in general. . . ‘ .< .. .1 2...: .J _ ‘ ’ —.—___‘_____________________ At your bookstore. or order directly from ‘ 1] INTERNATIONAL UNIVERSITIES PRESS, INC. 227. West 13 Street 'New York 11, N. Y. . , ' �M THE PS’YCHOANALYTIC STUDY OF THE CHILD Volume XII, $8.50 Contents. of the Newest Volume ERNST KRIS, 1.9004957 Contributions to Psychoanalytic Theory Nature and Development of the Concept of Repression in Freud's Writings PHYLLIS GREENAcRE—The Childhood of the Artist EDITH JACOBSON—On Normal and Pathological Moods Pathoand Normal JEANNE LAMPL—-DE GRoor—On Defense and Development: ‘CHARLES BRENNER—The logical RUDOLPH M. LOE-WENSTEIM—eSomt} Thoughts on Interpretation in the Theory and Practice of Psychoanalysis SEYMOUR L. LUSTMAN—Psychic Energy and Mechanisms. of Defense ’ Aspects of Early Development CAsusoe-Anxiety Related to the Discovery of the‘Penis': An Observation. With an Introduction by ANNA FREUD MARIANNE KRIS—The Use of Prediction in :1 Longitudinal Study WILLIAM G. NIEDERLAND—The Earliest Dreams of a Young Child GABRIEL _ ‘ ANNEMARIE SANDLER, ELIZABETH DAUNTON and ANNELIESE SCHNURMANN— Inconsistency in the Mother as a. Factor in Character Development: A Comparative Study. With an Introduction by ANNA FREUD V Clinical Contributions PETER BLos—Preoedipal Factors in the Etiology of Female Delinquency ERNA FURMAN—Treatment of UndeﬁFiV'es by Way of Parents ELISABETH GELEERD—Some' ASPects cents of Psychoanalytic Technique in Adoles- BELA MITrELMANN—‘Motility in the Therapy of Children NATHAN N. ROOT—A Neurosis in Adolescence MARGARETE and Adults RUBEN—Delinquency; A Defense Against Loss of ObjeCts and Reality LISBETH J. SACHS—On Changes in Identiﬁcation frOm Machine to Cripple ‘ Applied Psychoanalysis the Salamander’ StanislaVsk-i PHILIP WEISSMAN—The Childhood and Legacy of ROBERT PLANK—On ‘fSeeing ______—__‘_____._______———————————or- order directly from {I At your bookstore INTERNATIONAL UNIVERSITIES PRESS, INC. 0 New York 11, ‘N. Y. 227 West 13 Street, . . �jam; Rah at smug/1n Pox-caption of Simultaneous mm. swam Pub}! m 2 Karin $.13. and 3"!“ Fink Kenn ”amt at emu“ in “armament until. puma“: ha m been the object at midst-able discussion was. it: «napalm by Bender and common and matron: wlmtim hm bun errand. Ema: 12h. threshold for perception 9150mm maand “mm, 3!; mm w psychiatric putienta. «in: mm, simianeoua stimuli are applied in madam nqumo to lamination: o! cheek md hand and both check: at 111mm, mthruhold and mama” cf throdwld and mmthruhold human. Bung aqua-o in ’01:. hands, Results: 40de 3mm: cinnamon” or supnthromold «imam, wmw, the differences between the number of “auctions in aither part. were not. nigaiﬁunt. Him «ml: or mummy (m sum“ at thmhold and one supmthmshold), Mater; then m a signiﬁcant meme in the £13,1an ta «part tho thruhom. with W Cancyuam Thou data suppert tho 1:: simultaneous cutaneous ‘o‘ono " ”Ix/57 mmnm: tint the obnmd nrdor of Wm mm are pmd upon paydmﬁysieal anaemia“. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Role of stimulus intensity in perception of simultaneous cutaneous electrical stimuli. J Hillside Hosp., 6: 241-250, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-26-001 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Korin, Hyman; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint From the Journal of the Hillside Hospital,Vol. VI October, 1957. Full copy of the Journal of The Hillside Hospital, Vol VI, No. 4, October 1957, Table of contents: A UNIFIED THEORY: OF THE ACTION OF PHYSIODYNAMIC- THERAPIEs by Max Fink; AN OBJECTIVE STUDY OF COMMUNICATION IN PSYCHIATRIC INTERVIEWS by Joseph Jaffe; SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL by Robert L Kahn, Max Pollack and Max Fink; SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN EEG RESPONSE TO ELECTROSHOCK by Martin A. Green; ROLE OF STIMULUS INTENSITY IN PERCEPTION 0F SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI by Hyman Korin and Max Fink; NEWS AND NOTES. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published