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Experimental Studies of the Electroshock Process
MAX FINK, M.D., ROBERT L. KAHN,
In the last seven years, increasing study
by various authors“5 of the neurophysiologic alterations occurring in electroshock
has resulted in a re-assessment of the mode
of action of this form of therapy. The present neurophysiologic-adaptive hypothesisly2
states that an induced change in brain function provides the milieu in which behavioral
changes can occur, depending upon the characterologic predisposition of the subject.
This report summarizes the data of three
groups of studies which have been completed
in the continuing evaluation of the electroshock process in this laboratory. These include:
The relation of changes in neurophysiolog‘ic indices to behavioral change;
2. Types of psychologic response expressed and
factors in the evaluation of “improvement;”
1.
3.
and
The role of personality in the behavioral response.
and Method:
The studies have been carried out in
groups of consecutive, unselected electroshock referrals. The subjects are voluntary
patients in an open ward psychiatric hospital. All patients are treated by resident psychiatrists, who make the referral to the elec—
troshock therapy unit. The duration and
type of therapy, however, are determined by
the supervising psychiatrists in charge of
the treatment unit. Patients varied in age
from 20 to 66, and have been diagnosed as
suffering from depressive and schiz0phrenic
I. Subjects
illnesses.
(a) Tests of Brain Function: Two indices
of cerebral function have been stressed:
Quantitative measures of the degree of induced delta activity in the electroencephalogram,6 and changes in orientation and aware—
ness of illness after amobarbital sodium.7
From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y.
Aided, in part, by grant M-927, National Institute
of Mental Health, National Institutes of Health,
U.S. Public Health Service.
Read at the Twelfth Annual Convention, Society
of Biological Psychiatry, Atlantic City, N. J ., June,
1957.
PH.D., and MARTIN A. GREEN, M.D.
1) EEG: Electroencephalograms were done
weekly prior to treatment, and on a day following a treatment. Bipolar recording was
used, and selected leads were measured fOr
the degree of delta activity. The average
percent time delta for each of these selected
leads, the highest delta index in any one lead,
the highest amplitude and slowest frequency
of delta, and, the longest duration of bursts
were the measures utilized in the classification of the recOrds into “high degree]? "‘mod—
erate degree” and “low degree delta activity.”6
Amobarbital Test: This is a structured
interview, in which the patient is asked a
standard set of questions pertaining to ori—
entation and awareness of illness. Amobarbital is then administered intravenously, in
a concentration based upon body weight, at
a rate of 1 cc to every 40 seconds, until
nystagmus and slurred speech are induced.
In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc
per minute. Recently, to permit simultaneous estimates of the sedation threshold} the
procedure was modified to allow for weight
differences of subjects. The same questions
are repeated, and persistent changes in orientation, denial of illness, confabulation,
and reduplication are called “positive” and
are indicative of states of altered cerebral
function.7 Tests were carried out before electroshock, and at weekly intervals during
elestroshock on the day following treatment.
(b) Evaluation of Behavior: In addition
to the notes of the patient’s therapist and
supervising psychiatrist, all patients were
seen by the research psychiatrist at weekly
intervals during treatment and 2-4 weeks
after the last treatment. Evaluation of
changes in behavior induced by electroshock
were based on these descriptions. Ratings of
improvement 'Were based on the behavioral
response two to three weeks after the last
treatment, and reflect a short term clinical
rating. The patients were divided into three
groups: much improved, moderately improved and unimproved, based on criteria
2)_
described.2
Reprinted from Diseases of the Nervous System, Vol. XIX, No. 3, March 1958.
�(0) Evaluation of Personality .' The initial
method of personality assessment employed
has been a structured family interview. In
their original observations, Weinstein and
Kahn described the characteristics of the
maintenance of high degree delta activity
and short term clinical ratings.6 Of the pa—
tients who were rated much improved, 90%
had high degree delta EEG records in the
3rd and 4th weeks of treatment, While of the
unimproved patients, only 20% had such
records. The relationship between delta activity and clinical ratings is seen in Figure 1.
“explicit verbal denial personality.”9 To determine the significance of this personality
type for behavioral response, a structured
questionnaire was developed. In interviews OO
.— MUCH IMPROVED (u)
with two members of the family, the patient’s usual attitudes and interests in 15 90 .-—— moo. IMPROVENG)
UNIMPROVEDW)
.-.—
characEach
specific areas were explored.
80
teristic was rated as being absent, moderately present or markedly present. Scores 7O
of 0, 1 and 2, respectively, were assigned, '60
and added—the resulting score being termed
50
the “denial personality score.”1°
(d) Treatment: Electroshock was admin- 4o
istered on a schedule of three treatments 3.
30
12
week. A minimum of
treatments was
given, except in a few cases where a. severe 20
confusional state appeared earlier. The
course of treatment was determined by the
supervising psychiatrist in charge of the
lO-lZ
electroshock unit, based upon clinical criteria. Treatments were grand mal, using either a Medcraft alternating current instruobservations
In
these
series,
subsequent
ment or a Reiter C-47 electrostimulator. Pain
Based
extended
predictive
were
study.
a
tients were generally premedicated with inthe
earlier
it
on
was suggested
observations,
travenous Pentothal prior to the treatment.
those
the
much
that
were
improved
patients
In the past year, a subconvulsive therapy
been
in
had
whom
delta
high
activity
degree
group was instituted. Randomly selected induced
in
and
the
of
treatment
course
early
electroshock referrals received 12-42 suband
Records
second
sustained.
the
during
convulsive treatments, under Pentothal preweeks
of
third
treatment, therefore, were
medication. These patients were subjected
in
54
consecutive
The
results
assessed.
pato the same test procedures and the same bein
Table
Of
I.
the
noted
tients
patients
are
therevaluations
mal
havioral
as the grand
delta
who
degree
developed
activity
high
makthe
Neither
psychiatrist
apy subjects.
weeks
of
third
second
the
and
treatduring
ing the evaluation, the patient’s therapist,
while
much
rated
67%
improved,
were
ment,
nor the patient was cognizant of which pawithout
the
such
of
30%
aconly
patients
tients received which form of therapy. The
rated.
so
were
tivity
data for this series of patients is now being
evaluated, and reference will be made only
TABLE I
to the general observations.
Patients With High Delta Activity During
II. Observations:
Second, Third Weeks of Treatment
RATING
CLINICAL
in
Cerebral
Role
Function
of Altered
(a)
'8
>.
Behavior:
i’
75w:
a:
Electroencephalogram:
In these studies, we have emphasized the
degree of delta activity. In the initial series of patients a direct relationship was
noted between the early development and
a
1.
.c:
EEG Delta
Both High (18)
One High (16)
None High (20)
S
E
to.
E
5
8
a
5
12 (67%)
4 (25%)
6 (30%)
a; 8
’5‘
Q
sE
(22%)
8 (50%)
7 (35%)
4
a
D
2
4
7
(11%)
(25%)
(35%)
.
�Amobarbital Test
In the initial series of 24 patients, ‘previ:
ously reported,‘-’ eleven patients were rated
as much improved,,andall had positive aniobarbital test reactions after 7 to 9 treatments
and sustained this response. Of the unimproved patients, 15% had positive amobarbital responses in the third week and 28%
in the fourth week, but these were not Sustained.
A comparison of both the EEG observations and the amobarbital test data, as related to the eventual clinical rating is seen
in Table II. In 77 patients tested to date,
observations during the second and third
weeks of treatment were examined for the
presence of high degree delta activity and
positive amobarbital test results. Of the
much improved patients, 75% had both positive amobarbital tests and high EEG delta
activity during this period. Of the unimproved patients, however, 57% had neither
positive amobarbital tests nor high EEG
delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG
delta activity and much improved clinical
ratings is a significant one; and equally significant is the cluster of negative amobarbital tests, low and moderate EEG delta activity and clinical rating of unimproved.
TABLE II
EEG and Amobarbital Test Results During
Second, Third Weeks of Treatmenfit
2.
:,
.c:
8
2
8
Total .................................................... 33
.01
E
3 8
E
e s
E
Both Positive Amobarbital and High
EEG Delta Activity ........................ 25
Either Positive Amobarbital or High
EEG Delta Activity .......................... 8
Neither Positive Amobarbital nor
High EEG Delta Activity .............. O
*Significant at better than
2
2
Q
E
sD
10
3
12
5
3
11
25
19
level of confidence.
(b) Clinical Patterns of Behavior:
In these patients, we have observed varied responses to electroshock including the
absence of noticeable symptoms with a return of pre-morbid behavior; hypomania, euphoria, and denial; paranoid states with
ideas of reference and delusional formation;
confusional states with varying degrees of
memory disturbance; increased somatic com.plaints and pre-occupations, states of in—
creased panic, excitement and agitation and
varying degrees of withdrawal, and seclusiveness. The degree of’behavioral change
is seen to be related to the degree of alter'a}
tion in the neurophysiologic indices. During
electroshock, with the gradual induction of
states of altered brain function, and their
restitution in the weeks following cessation
of therapy, behavior shows characteristic
patterns. The following are but a few of the
gross patterns that are observed during the
period of increasing and waning states of
altered brain function.
An early change in behavior in retarded
subjects, for example, may be a change in
the degree of participation in ward activities and increased neatness and interest in
personal care. This is succeeded by a phase
of minimizing symptoms and displacement
of complaints, mild euphoria, denial of illness, and insistence upon going home. At
this time, the EEG shows the greatest degree of delta activity and amobarbital tests
are positive. With the cessation of treatment, the overactivity diminishes, and interest in the future becomes prominent. Premorbid patterns of behavior are in evidence,
and the EEG returns to normal and the amobarbital test becomes negative.
Other depressed subjects, however, become increasingly disturbed during treatment, withdraw from participation in hospital activities, and complain increasingly of
memory loss, physical distress and insomnia. Amobarbital tests and electroencephalograms may show the same degree of
change as in the first group. With cessation of treatment, there is either a return
to the depressed state, or a persistent emphasis on the memory loss and physical
complaints of the treatment.
Another pattern, seen in hostile, negativistic and withdrawn patients, is the development of hyperactive, hypomanic, and impulsive behavior. Memory loss is marked,
and clinical disorientation and confusion
may be noted at the height of neurophysiologic change. After treatment is ended, ideas
of reference, negativism and delusional for.3
�mation become prominent, to be followed by
withdrawal and mutism.
(c) Efiect of Subconvulsive Therapy:
The interdependence of these adaptive
patterns with the state of altered brain function is more clearly demonstrated by obser—
vations in the subconvulsive group. TWentyseven subjects received subconvulsive therapy instead of grand mal. Minimal changes
in the electroencephalogram and in amobarbital tests were induced, and the changes in
clinical behavior were limited. The electroencephalograms demonstrated either no delta
or a minimal amount of such activity. In no
patient were moderate or high degree delta
activity records observed. In the amobarbital tests, only three patients had positive
tests during treatment, and in each instance
it occurred only once. No change in symptoms or behavior was noted in twenty—three.
Nineteen were referred for a second course
of treatment. Grand mal electroshock in—
duced changes in brain function of high de—
gree delta activity and/or repeated positive
amobarbital tests in fourteen of these. All
fourteen showed significant changes in behavior; While of the five patients in whom
the physiologic indices showed only minor
changes, only two patients showed a definite
behavioral change.
(d) Role of Personality in the Adaptive Respouse:
Another variable in the adaptive response
of the patients is the personality—the habitual attitudes, patterns of perception and behavior and defenses of the patient. The
initial study of the role of personality related the characterological disposition of patients showing denial mechanisms to the
clinical result. The relatives of 47 patients
were interviewed, and denial personality
scores assessed. Scores ranged from 0 to 25,
with a median of 11. The scores were divided into two groups: scores from 11 to 25
were classed as the “high denial group” and
those from 0-10 as the “low denial group.”
Of the patients with high denial personality scores (Table III), 58% were in the
much improved group, and only one patient
(4%) was in the unimproved group. The
ratings of improvement for the patients with
low denial personality scores were random—'4
about one third appearing in each rating
category.
TABLE III
Relation of Denial Personality Scores to
Clinical Response to Electroshock
Personality
Score
11-25
0-10
Total
Much
Improved
14
Moderately Unimproved
Improved
7
9
9
1
7
21
18
8
Total
24
23
47
The difference in the denial scores between
the much or the moderately improved patients, when compared to the unimproved
patients, is statistically significant.
That the personality ratings were indeed
reflective of the patients’ adaptive response
under the conditions of altered brain function is noted in the correlation of these
scores with actual changes in language patterns which had been described11 as indicative of denial responses. As in that study,
changes in language in structured interviews
with the patient were studied. Each patient
was classified according to whether he
showed three or more explicit language
changes. The group of patients With high
denial personality scores showed a significantly greater number of language changes
than patients with low personality scores.
The coefficient of correlation is +.71, which
is significant at better than the 1% level of
confidence.
Discussion:
These studies of the neurophysiologic and
psychologic aspects of electroshock support
and amplify the hypothesis of electroshock
action initially expressed by Weinstein, Linn
and Kahn,1 and again by Kahn, Fink and
Weinstein,2 and the observations of Roth,3
Aird,4 and Ulett.5av Alteration in brain function is the central effect of electroshock
therapy, and is a pre-requisite to behavioral
change. We have emphasized delta activity
in the electroencephalogram and the patterns of disorientation, confabulation, and
denial of illness after amobarbital as indices
of altered brain function. Other measures,
applied in the same serial fashion, will, we
believe, demonstrate the same relation to
changes in behavior or alteration in brain
function.
Under the conditions of the induced
111.
‘0
�change in brain function, altered patterns of
adaptation are expressed.» The type of adaptation varies, apparently dependent upon the
personality organization. In these studies
we have noted the relationship of an “explicit verbal denial” personality type with
the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews.11 We have observed that patients
with high denial scores are those who are
more likely to be evaluated as “much improved” (Table III). The type of adaptation
is varied, however, as we have described
here. In this context, therefore, the conclusion is affirmed that electroshock is a means
of inducing change in cerebral function in
which altered patterns of adaptive-interpersonal behavior can be sustained.
We have emphasized “change in behavior”
in this report. In previous studies, we related our observation to “improvement.”
“Improvement” is a derivative evaluation of
the induced behavioral change, which is dependent upon the expectations of the therapist, the family, or the administrator, in the
milieu in which the behavior is observed.
When a depressed patient, who had been
withdrawn, crying, and had expressed suicidal thoughts, no longer is seclusive, and is
jovial, friendly and euphoric, denies his prob—
lems and sees his previous thoughts of suicide as “silly,” a rating of “much improved”
is made. To the extent that a schizophrenic
patient is perceived as less delusional, less
excited, and less Withdrawn, he is rated as
“improved.” When, however, the induced behavior is one of increased anxiety and fear—
fulness, or persistent complaints about memory loss, pain or other physical symptoms, or
excitement and delusional thoughts, a rating
of “unimproved” will be made.
These studies amplify the present neurophysiologic-adaptive hypothesis of electroshock action. Further studies, defining the
significant aspects of personality and of the
expectations of the environment on the patterns of behavior which are observed under
the condition of altered brain function are
suggested. Application of this hypothesis
to the effect of newer tranquilizing agents is
in progress. Finally, studies of individual
differences in the neurophysiologic response
to equivalent amounts of cerebral trauma
warrants exploration.
IV. Summary and Conclusions:
1. This report summarizes continuing experimental studies of the mode of action of
electroshock therapy.
2. Behavioral change in electroshock is
dependent upon an alteration in brain function as evidenced by serial changes in delta
activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital.
3. The pattern of behavioral alteration is
shown to vary markedly, depending upon the
degree of induced cerebral dysfunction, the
personality of the subject and the environmental situation.
4. “Improvement” ratings are seen as a
special case of behavioral change dependent
upon the type of adaptation elicited, the expectation of the therapist, administrator and
family, and the tolerance of the milieu.
5. The extension of this neurophysiologicadaptive hypothesis of electroshock action
to other forms of somatic therapies is suggested.
1.
REFERENCES
Weinstein, E. A., Linn, L., and Kahn, R. L.:
Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J.
Psychiat, 109:
22-26, 1952.
2. Kahn, R. L., Fink, M., and Weinstein, E. A.: Re-
lation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. and Psychiat., 76: 23-29, 1956.
3. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive
Treatment and Their Significance for the Theory of EST Action. EEG 01m. Neurophysiol., 3:
261-280, 1951.
4. Aird, R. N., Strait, L. A., Pace, J. W., Hernoff,
M. K., and Bowditch, S. C.: Neurophysiologic
Effects of Electrically Induced Convulsions.
Arch. Neurol. and Psychiat, 75: 371-378, 1956.
5 a. Ulett, G. A., Smith, K., and Glesser, G. C.:
Evaluation of Convulsive and Subconvulsive
Shock Therapies Utilizing a Control Group. Am.
J. Psychiat, 112: 795-802, 1956.
5 b. Ulett, G. A., Glesser, G. C., Caldwell, B. M.,
and Smith, K.: The Use of Matched Groups in
the Evaluation of Convulsive and Subconvulsive
Photoshock. Bull. Merm. Olin, 18: 138-146, 1954.
6 a. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Olin. Neurophysiol., 8: 158 (Abst.)
1956.
�6’ b.
.
.
Relation of EEG Delta Activity
to Behavioral Response in Electroshock: Quantitative Serial Studies. Arch. Neurol. and P31chiat, 78: 516-525, 1957.
Weinstein, E. A., Kahn, R. L., Sugarman, L. A.,
and Linn, L.: Diagnostic Use of Amobarbital
Sodium (“Amytal Sodium”) in Organic Brain
Disease. Am. J. Psychiat, 112: 889-894, 1953.
Shagass, C.: The Sedation Threshold. A Method
for Estimating Tension in Psychiatric Patients.
EEG Clin. Neurophysiol., 6: 221-233, 1954.
:
.
Weinstein, E. A., and Kahn, R. L.: Personality
Factors in Denial of Illness. Arch. Neurol.» and
Psychiat, 69: 355-367,
1953.
.
Kahn, R. L., and Fink, M.: Personality Factors
in Behavioral Response to Electroshock. Therapy. Conf. Neural. (In Press.)
11. Kahn, ;R. L., "and Fink, M.: Changes in Language During Electroshock Therapy in Psycho~
pathology of Communication (Hoch, P., and
Zubin, J ., Eds.). Grune and Stratton, N. Y., 1957.
(In press.)
10.
_
��.thv-
AyiAuu. .gypZZILu
Experimental Studies of the Electrcshock Process
Max
Fink,
14.13.,
Robert L. Kahn, 31.1).
and Martin A. Green, M.D.
From
the Department of Experimental Psychiatry, Hillside HOSpital, Glen
Oaks, N.Yo
of Mental Health,
part, by grant M—927, National Institute
Service.
Health
Public
U.S.
of
Health,
National Institutes
Aided, in
Twelfth Annual Convention, Society of Biological Psychiatry,
Atlantic City, N.J., June, 1957.
Read
Vo
at the
6‘27-S7
�-2Experimental Studies of the Electroshock Process
In the
last
seven years, increasing study by various authors
(1-5) of the neurophysiologic alterations occurring in electroshock has re-
sulted in a re-assessment of the
The
mode
of action of
this
fcnm of
therapy.
present neurophysiologic-adaptive hypothesis (1,2) states that an
induced change in brain function provides the milieu in which behavioral
changes can occur, depending upon the characterologic predisposition of the
subject.
This report summarizes the data of three groups of studies which
have been completed
in this laboratory.
in the continuing evaluation of the electroshock process
These
include:
relation of changes in neurophysiologic indices in
behavioral change;
1) The
2) types of psychologic response expressed and
evaluation of "improvement;" and
3) the role of personality
factors in the
in the behavioral response.
�II.
-3“
Subjects and Method:
studies have been carried out in groups of consecutive, unselected
The
electroshock referrals.
ward
subjects are voluntary patients in an
The
open
psychiatric hospital. All patients are treated. by resident psychiatrists,
who make
the referral to the electroshock therapy unit.
type of therapy, however, are determined by the supervising
unit. Patients varied in age from
charge of the treatment
have been diagnosed as
sufferina from depressive
(a) Tests of Brain Function:
have been
Two
duration and
The
psychiatrist in
20 to 66, and
and schizophrenic
illnesses.
indices of the cerebral function
stressed: Quantitative measures of the degree of induced delta
activity in the electroencephalogram,(6) and changes in orientation
awareness of illness after amobarbital sodium (7).
1) Egg: Electroencephalograms were done.weekly
ment, and on a day following a treatment.
selected leads
were measured
and
prior to treat-
Bipolar recording
was
for the degree of delta activity.
used, and
The average
percent time delta for each of these selected leads, the highest delta
index in any one lead, the highest amplitude and Slowest frequency of delta,
and the
longest duration
of
bursts
were the measares
utilized in the class-
ification of the records into "high degree," "moderate degree"
and "low
degree delta activity" (7).
2) Amobarbital Test: This
the patient
is
and awareness
asked a standard set of questions pertaining to orientation
of illness. Amobarbital is then administered intravenously,
in a concentration based
seconds,%
is a structured interview, in which
upon body weight,
until nystagmus
and
at
a
rate of
1 cc
slurred speech are induced.
to every
ho
The same
1"“.%
In the initial series, a 5% solution of amobarbital was administered at
the rate of 1 cc per minute. Recently, to permit simultaneous estimates
of the sedation threshold (8), the procedure was modified to allow for
weight differences of subjects.
�~12.-
questions are repeated, and persistent changes in orientation, denial of
illness, confabulation, and reduplication are called "positive" and are
indicative of states of altered cerebral ftnction (7). Tests were carried
at weekly intervals during.electroshock
out before electrodiock, and
day
on a
after a treatment.
(b) Evaluation of Behavior:
In addition to the notes of the patient's
therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and Z-h weeks after
the last treatment. Evaluation of changes in behavior induced by electroshock were based on these
on
descriptions. Ratings of
the behavioral response
reflect
a short term
groups:
much improved,
described
(
two
to three
clinical rating.
weeks
The
improvement were based
after the last treatment,
patients
were divided
and
into three
moderately improved and unimproved, based on
criteria
).
(c) Evaluation of Personality:
The
initial
method of
personality
assessnent employed has been a structured family interview. In their orig-
inal observations, Weinstein and
Kahn
described the characteristics of the
"explicit verbal denial personality" (9).
To determine
the significance of
this personality type for behavioral reSponse, a structured questionnaire
was
developed. In interviews with two members of the family, the patient’s
usual attitudes and interests in 15 Specific areas were explored. Each
characteristic was rated as being absent, moderately present or markedly
present. Scores of 0,
l and
2, reapectively, were assigned, and added
-
the resulting score being termed the "denial personality score" (10).
(d) Treatment: Electroshock was administered on a schedule of three
treatments a week.
A
minimum
of
12
treatments was given, except in a few
�cases where a severe confusional state appeared
ment was determined by
earlier.
The
course of
treat-
the supervising psychiatrist in charge of the electro-
unit, based upon clinical criteria. Treatments were grandznal, using
either a Medcraft alternating current instrument or a Reiter C-h? electro-
shock
stimulator. Patients
were
generally premedicated with.intravenous pentothal
prior to the treatment.
In the past year, a subconvulsive therapy group was instituted.
Randemxy selected electroshock referrals received 12-h2 subconvulsive treatthe
ments, under pentothal premedication. These patients were subjected to
same
test procedures
and
the
same behavioral evaluations as the grand mal
therapy subjects. Neither the psychiatrist making the evaluation, the
patient's therapist, nor the patient was cognizant of which patients received which.form of therapy.
The
data for this series of‘patients
being evaluated, and reference will be
made only
is
now
to the general observations.
�III.
Observations:
A. Role of Altered Cerebral Function
in Behavior:
1. Electroencephalogram:
In these studies,
we have emphasized
the degree of delta
activity. In the initial series of patients a direct relationship was noted
between the early development and maintenance of high degree delta activity
much
and short term clinical ratings (6). or the patients who were rated
weeks of
improved, 90$ had high degree delta EEG records in the 3rd and hth
treatment, while of the unimproved patients, only
relationship between delta activity
and
20%
had such records. The
clinical ratings is seen in Figure
1.
In subsequent series, these observations were extended in a predictive
much
study. Based on the earlier Observations, it was suggested that the
improved
patients
were those
in
high degree
whom
delta activity had been
in the course of treatment and sustained. Records during the
ant third weeks of treatment, therefore, were assessed. The results
induced early
second
in
Sh
consecutive patients are noted in Table 1.
veloped high degree delta
ment,
such
67%
rated
were
activity were
activity during the second
much improved,
so
while only
EEG
High Delta
and
who
de-
third weeks of treat-
of the patients without
I
Activity During Second, Third‘weeks of Treatment.
Clinical Rating
Much Imgroved
Delta
30%
the patients
rated.
TABLE
Patients with
Of
Mbderately'lrunnved
Unimproved
(11%)
Both High (18)
12
(67%)
h
(22%)
2
(16)
u
(25%)
8
(50%)
h (25%
None High (20)
6
(30%)
7
(35%)
7
One
High
(35%)
�a7;
2. AmObarbital Test:
In the
of 2h patients, preViouSly reported (2),
initial series
eleven patients were rated as
testreactions after
7
to
much improved, and
all
9 treatments and sustained
had positive amObarbital
this response. 0f the
positive amobarbital reaponses in the third week
and 28% in the fourth week, but these were not sustained.
A comparison of'both the EEG Observations and the amobarbital
test data, as related to the eventual clinical rating is seen in Table II.
unimproved
In
77
patients,
15%
had
patients tested to date, observations during the second
weeks of treatment were examined
activity
75%
and
had both
and
third
for the presence of high degree delta
positive amobarbital
test results.
positive amobarbital tests
Of the much improved
and high EEG
patients,
delta activity during
patients, however, 57% had neither positive
amobarbital tests nor high EEG delta activity. It is apparent that the
cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a significant one; and equally significant is
this period.
Of the unimproved
the cluster of negative amobarbital
activity
and
tests,
low and moderate EEG
clinical rating of unimproved.
delta
�9
..—--
m
TABLE
EEG
II
and Amobarbital Test Results During Second, Third Weeks of Treatment.*
Much
Mbderately Improved gnimprovsd
Improved
Both Pbsitive Amobarbital
and High EEG Delta Activity
25
10
3
Either Positive Amcbarbital
or High EEG Delta Activity
8
12
5
_£L_
L
(25)
Neither Positive Amdbarbital
nor High EEG Delta Activity
(33)
(Total)
B.
1.1
(19)
Clinical Patterns of Behavior:
In these patients,
we have observed
including the absence of noticeable
varied responses to electroshock
symptoms
with a return of yrs-morbid
behavior; hypomania, euphoria, and denial; paranoid states with ideas of
reference and delusional formation; confusional states with varying degrees
of memory disturbance; increased somatic complaints and preoccupations,
states of increased panic, excitement and agitation and varying degrees of
withdrawal, and seclusiveness.
The degree
of behavioral change
is
seen to
alteration in the neurophysiologic indices.
brain
During electroshock, with the gradual induction of states of altered
function, and their restitution in the weeks following cessation of therapy,
be related to the degree of
behavior
Shows
characteristic patterns.
The
following are but a few of the
are observed during the period of increasing and waning
gross patterns that
states of altered brain.function.
Anearly change in behavior in retarded subjects, for example,
rO-‘fi’lt.
* Significant
at hotter than
.01 level of confidence.
x»,-~-n---.'
~rmw-n.
may
it...“
�be a change in the degree of
neatness and
participation in
interest in personal care.
This
ward
is
activities and increased
succeeded by a phase of
minimizing symptoms and displacement of complaints, mild euphoria, denial
this time, the EEG shows
the greatest degree of delta activity and amobarbital tests are positive.
With the cessation of treatment, the overactivity diminishes, and interest
of
illness,
and
in the future
insistence
upon going home.
becomes prominent. Pre-morbid
evidence, and the
EEG
returns to normal
At
patterns of behavior are in
and the amdbarbital
test
becomes
negative.
Other depressed subjects, however, become increasingly disturbed
and
during treatment, withdraw from.participation in heapital activities,
Amocomplain increasingly oi memory loss, physical distress and insomnia.
barbital tests and electroencephalograms may show the same degree of change
as in the first group. with cessation of treatment, there is either a return
to the depressed state, or a persistent emphasis
physical complaints of the treatment.
Another pattern, seen
is the
loss
is
on
the
memory
loss
and
in hostile, negativistic and withdrawn patients,
development of hyperactive, hypomanic, and impulsive behavior. Memory
marked, and clinical disorientation and confusion may be noted at
thelieight o£1neurophysiologic change. After treatment is ended, ideas of
reference, negativism and delusional formation become prominent, to
be
followed by withdrawal and mutism.
C.
Effect of Subconvulsive Therapy:
interdependence of these adaptive patterns with the state of
altered brain function is more clearly demonstrated by observations in
the subconvulsive group. Twenty-seven subjects received subconvulsive
The
�~10;
electroencephalogram
therapy instead of grand mal. Minimal changes in the
behavior
and in smobarbital tests were induced, and the changes in clinical
limited. The electroencephalograms demonstrated either no delta or
were
a minimal amount of such
activity. In
patient
no
were moderate or high
activity records observed. In the amobarbital tests, only
each instance
three patients had positive tests during, treatment, and in
it occurred only once . No change in symptoms or behavior was noted in
degree delta
treatment.
twenty-times. Nineteen were referred for a second course of
degree
Grand mal electroshock induced changes in brain function of high
delta activity and/or repeated positive amobarbital tests in fourteen of
while of the
these. All fourteen showed significant changes in behavior;
five patients in whom the physiologic indices showed only minor changes,
only two patients showed a
definite behavioral change.
of Personalitywin the Adaptiverg‘e‘spggg:
the
Another variable in the adaptive response of the patient is
and behavior
- the habitual attitudes, patterns of perception
1). Role
personalitw
and defenses of the
patient.
The
initial
study of the role of personality
related the characterological disposition of patients
mechanisms
to the clinical result.
The
showing
denial
relatives of h? patients were inter-
Scores ranged from
viewed, and denial, personality scores assessed.
O
to 25,
scores were divided into two groups: scores from
and those from O - 10 as
11 to 25 were classes as the "high denial group"
with a median of 11.
the “low denial
The
gar-mp."
0f the ,.latients with high denial personality scores (Table
58%;
were in the much improved group,
and.
only one patient
(1%) was
III),
in
�911-
the unimproved group.
The
ratings of
for the patients with
- about one third appearing in
improvement
low denial personality scores were random
i
each
rating category.
lean;
Relation of Denial Personality Scores to Clinical Response to Electroshock
Much
Improved
Moderately
Improved
Unimpmved
Total
M9&1}EI., §9ar£
11
—
25
1h
9
1
2h
0
-
10
7
9
7
23
21
18
8
h?
Total
The
difference in the denial scores between the
improved patients, when compared to the unimproved
much
or the moderately
patients, is statistically
significant.
That the personality ratings were indeed
reflective of the patients'
adaptive reaponse under the conditions of altered. brain function
is
noted.
in the correlation of these scores with actual changes in language patterns
which had *een described (11) as indicative of denial responses. As in
that study, changes in language in structured interviews with the patient
were studied. Each patient was classified according to whether or not he
shone 6. three or more explicit language changes . The group of patients
with high denial personality scores showed a significantly greater number
of language changes than patients with low personality scores. The co-
efficient of correlation is +.7l, which is significant at better than the
1% level of confidence.
�IV. Discussign:
These
studies of the neurophysiologic
and psychologic aspects of
electroshock support and amplify the hypothesis of electroshock action
initially expressed by Weinstein, Linn and Kahn (l) , and again by Kahn,
(3), Aird (’4), and
Ulett (5a, b). Alteration in brain function is the central effect of
electroshock therapy, and is a pre-requisite to behavioral change. He
have emphasized delta activity in the electroencephalogram and the patterns
of disorientation, confabulation, and denial of illness after amobarbital
Fink and 'E-i‘einstein
(2),
and
the observations of
Roth
as indices of altered brain function. Other measures, applied in the
serial fashion, will, we believe, demonstrate the
in behavior or alteration in brain function.
Under the conditions of the induced change
same
same
relation to changes
in brain function,
The type of adaptation
altered patterns of adaptation are expressed.
these
varies, apparently dependent upon the personality organization. In
studies we have noted the relationship of an "explicit verbal denial"
personality type with the development
and maintenance of
clinical language
patterns of denial, displacement, and minimization in structured interviews (11) . We have observed that patients with high denial scores are
those
are more likely to
who
The type
of adaptation
be
evaluated as
is varied,
"much improved" (Table
III).
however, as we have described here.
In
this context, therefore, the conclusion is affirmed that electroshock is
a
in cerebral function in which altered patterns of
adaptive-interpersonal behavior can be sustained.
means of inducing: change
We
have emphasized " change in behavior"
vious studies,
we
in this report. In pre-
related our observation to "improvement."
"Improvement"
�:13-
derivitive evaluation of the induced behavioral change, which is dependend upon the expectations of the therapist, the family, or the administrator,
in the milieu in which the behavior is observed. When a depressed patient,
is
a
who had been withdrawn,
is seclusive,
and
crying, and had expressed suicidal thoughts, no longer
is jovial,
frienc‘ly and euphoric, denies his problems and
sees his previous thoughts of suicide as
is
made.
To
"silly,"
a rating of "Inuch improved"
the extent that a schizophrenic patient
delusional, less excited, and less
however, the induced behavior
one
is
perceived as less
rated as "improved."
When,
of increased anxiety and fearmlness, or
loss, pain or other physical symptoms, or
delusional thoughts, a rating of "unimproved" will be made.
persistent complaints about
excitement and
is
t-Iithdrawn, he
is
memory
studies amplify the present neumphysiologic-adaptive hypothesis
of electroshock action. Further studies, defining the significant aspects of
personality and of the expectations of the environment on the patterns of
These
behavior which are observed under the condition of altered brain function are
suggested. Application of this hypothesis to the effect of newer tranquillizing
agents is in progress. Finally, studies of individual differences in the
neurophysiologic response to equivalent amounts of cerebral trauma warrants
exploration.
�V. gunnery and. Conclusions:
1. This report sumarizes continuing esperimental studies of the
mode
of action of electroshock therapy.
2. Behavioral change in electroshock is dependent
upon an
altera-
tion in brain function as evidenced by serial changes in delta activity in
the electroencephalogram and disorientation and confabulation with intravenous amobarbital.
3.
The
depending upon
the subject
1;.
pattern of behavioral alteration is shown to vary markedly,
the degree of induced cerebral dysfunction, the personality of
and.
the environmental situation.
"Improvement"
ratings are seen as
a Special case
of behavioral
the type of adantation elicited, the expectation of
the therapist , adninistrator and family, and the tolerance of the milieu.
change dependent upon
this neurophysiologic-adaptive hypothesis of
electmshocl: action to other forms of somatic therapies is suggested.
S.
The
extension of
�m
REFEIUQI‘ICES
l.
Juno‘s—t
Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its relation to the Theory of Shock Therapy, Am.
J. Psychiat” 109: 22-26, 1952.
of Amobarbital
1. and Weinstein, E.A.: RelationA.I—-I.A.
Arch. Neurol.
Electroshock,
in
Test to Clinical Improvement
1956.
and Psychiat., IQ: 23-29,
Roth, 1-1.: Changes in the EEG under Barbiturate Anesthesia Proclucec‘v by
Electro-Convulsive Treatment and their Significance for the Theory
of EST Action, EEG. Clin. Neurophysiol., _3.: 261-280, 1951.
Kahn, R.L., Fink,
3.
h.
Pace, J.EI., Hernaff, M.K. and Bowditch, 5.0.:
Neurophysiologic Effects of lectrically Induced Convulsions, A.:-I.A.
Arch. Neurol. and Psychiat., 15: 371-378, 1956.
Aird, Ran,
Strait, L.A.,
.
G.A., Smith, K.
5a. Ulett,
Subconvulsive Shock
and Gleeser, G.C.: Evaluation of Convulsive and
Therapies Utilizing a Control Group, Am. J.
Psychiat., 112: 795-802, 1956.
5b.
Glasser, G.C., Caldtrell, B.M., and Smith, K.: The Use
of I'iatched Groups in the Evaluation of Convulsive and Subcommlsive
Biotoshock, Bull. Mann. 015.11.,
6a.
6b.
_1__8_:
138-1h6, 1951..
H. and Kahn, R.L.: Quantitative Studies of Slow Wave
Followi.n:_; Electroshock, EEG Clin. Neurophysiol” _8_: 158
Fink,
Activity
(Abst.) 1956.
EEG Delta Activity to Behavioral
and
___: Relation of
Response in hilactroshock: Quantitative Serial Studies, A.itI.A. Arch.
Eleurol. and Psychiat. (in press).
7.
E-Jeinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.:Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic
Brain F‘lisease, Am. J. Psychiatu .133: 889-89h, 1953.
8.
Shagass, C. : The Sedation Threshold.
9.
Weinstein, E.A. and Kahn, R.L.: Personality Factors in Denial of illness,
in Psychiatric Patients,
A.1-I.A. Arch. Neurol. and
EEG
A
Method
for Estimating Tension
Clin. Neurophysiol.,
Psychiat.,
_6_:
221-233, 1951;.
99;: 355-367, 1953.
Parsonality Factors in Behavioral
to Electroshock Therapy, Coni‘. Neurol., (in press)
Response
10 .
Kahn, R.L. and Fink, 14.:
11.
Kahn, R.L. and Fink, 141.: Changes in languAge During Té‘lectroshock
Therapy, in P cho tholo g; Comunication (Hoch, P. and Zubin,
J., 13623.), Grune and tratton, N.Y., 1957. (in press).
�
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Experimental studies of the electroshock process. Dis Nerv Syst. 1958 Mar;19(3):113-8.
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1958
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<a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A.
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[preprint] and reprint. Reprint from Diseases of the Nervous System, Vol.XIX, No.3, March 1958
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