http://exhibits.library.stonybrook.edu/mfp/files/original/6428428b2e8c8dd8c101b89ff0bcc16f.pdf 0dca1e713671d6e32179b0a6fd1afba3 PDF Text Text Electroencqahalographic Correlates of the Electroshock Process Max Fink MJJ. and Martin A. Green 14.3). ‘ .. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., in part, by grant M—927, National Institutes of Mental Health, National Institutes of Health, U.S. Public Health Service. Aided, Read at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. V:3-l-58 New York, N.Y. �Electroencephalographic Correlates of the Electroshock Process During the past few years, renewed attention has been given to the relation between changes in measures of cerebral function, and the behavioral changes induced by electroshock (l, 2). Alteration in various aspects of the electroencephalogram has been emphasized by various observers (3, h) in cerebral function. In an initial study in this laboratory, a significant relationship between the degree and duration of induced delta activity and clinical evaluation of "improvement" was observed (6). Subsequent studies have focused on as a sensitive index of changes ' various parameters of the EEG changes including frequency of type of current, age of subject and pre-treatment record It is treatment,' characteristics. the purpose of this report to assess the relation of these aSpects of treatment to changes in the EEG and in clinical response; and to describe the role of serial electroencephalograms in the rational management and study of convulsive therapies. �-2- man: One hundred and seventy-three consecutive electroshock referrals have been studied. Electroencephalograms were taken before treatment, after treatment at weekly intervals during and following the course of therapy until the record had achieved its pre-treatment and on a day characteristics. Patients in whom demonstrated slow wave or spike All the EEG delta activity. the pre-treatment electroencephalogram activity were excluded from the series. records were quantitatively measured for the amount of On the basis of the per-cent time, slowest frequency, highest voltage and longest duration of bursts of slow waves, in selected lead combinations, the records were classified into "high," "moderate" and "low" degrees of delta activity, according to criteria previously published (6). Three convulsive techniques were employed: suprathreshold alternating current, threshold alternating current current methods. The and parathreshold unidirectional alternating current suprathreShold (7) and unidirect- ional parathreshold (8) treatments followed established techniques. In the threshold alternating current method, patients without prior sedation received small amounts of current (90 volts for 0.2 second), usually sufficient for a petit mal response. intervals voltage, and if necessary, duration.was increased until a grand mal convulsion was inAt 20 second voltage and duration necessary to induce a grand mal duced. The minimal was the threshold value. In addition, a convulsive-subconvulsive control study was instituted during a period of these observations. Randomly selected patients referred . �.3for electrotherapy received subconvulsive therapy instead of grand mal. In this technique, patients were given pentothal intravenously until asleep, and then either low voltage unidirectional current fbr 60 seconds alternating current of 80 to 120 volts for 0.2 second were administered for one to three applications, for a total of 2h to 36 petit mal (8) or responses. Of the 173 electrotherapy referrals, lh6 received grand threshold alternating current, 57 by current and 63 by 26 by suprathreshold mal therapy - alternating parathreshold unidirectional current methods. Twenty- seven subjects received a course of subconvulsive therapy. All treatments were given three times a week, for 12-20 treannents. failed to develop a significant behavioral or clinical response, or middle or high degrees of delta activity in the EEG, were subsequently Patients Who treated five to ten times per week. Evaluations of clinical reaponse were trist ment and resident therapists on two occasions. At the supervising psychia- the height of the treat- effect, the degree of behavioral change was scored as ”marked," "moderate," "minimal” orfhone." in behavior in interviews These made by after treatment was terminated. and were based on the ratings were estimates of the change and on the ward from the Ratings of "improvement" were also weeks made by pre-treatment patterns. these physicians two to three These ratings were value judgments four-fold classification of "recovered," "improved” and "unimproved or worse" (2, 6). "much improved," �RESULTS: 1. Variability in Delta Activity'with Convulsive Therapy: variability in the degree of induced delta activity reparted in the initial 2h patients {6) is confinned in these series of convulsive therapy referrals (Table I). While the number of high degree The wide records increases with treatment, fourth week, are still rated as 27% ”low" degrees of TABLE Degree of EEG in the third week, and 18% in the delta activity. I Delta Activity with Convulsive Therapy (Per-cent of Group) Treatment Period h 28 h6 60 Moderate Degree 12 21 27 22 Lou'Degree 68 h8 25 18 16 3 2 o High Degree No Delta Activity 2. Role of Convulsion in The EEG Response: significance of the convulsion per gg in the EEG and behavioral response was assessed in the convulsive-subconvulsive study. Of the h? subjects*'who received convulsive therapy in this study, 9 had * These included 28 subjects who received grand mal therapy on a random selection basis, plus 19 subconvulsive subjects referred for a "second course" of therapy. �-5high degree delta records in both second, third and fourth weeks of ment, 12 during two of the three weeks, and 13 during one of the periods. Thirteen of the h? subjects failed to show a treattest high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta activity records during any week of treatment. Low degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. In concurrent behavioral ratings, 25 of initial 28 subjects in the convulsive group showed marked behavioral change; while of the subconvulsive group, Of the 21; of the 27 showed Bdnimal or no behavioral changes (Table latter group, 19 were referred II). for a second course of therapy. In 1h of these, grand mal electroshock induced high degree delta activity all significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroShock, all and showed a showed middle degree records; and change. three of the five Showed a behavioral Thus, of the h? convulsive therapy subjects, h2 showed a behavioral change. significant �—6— II TABLE Ratings of Behavioral Change: Convulsive - Sdbconvulsive Therapies (Fburth-Fifth'weeks of Treatment), Moderate marked Minimal yggg i Convulsive Therapy (A?) 27 15 5 0 O 3 8 16 Subconvulsive Therapy (27) In evaluations of the degree of "improvement" 51% of the convulsive therapy group were rated as "recovered," and evaluated as sustaining the "improved," and only however, but 70% 11% III). as "improved" (Table 32% 7% were rated same weeks after treatment, "much improved" On discharge, degrees of improvement, while were ”unimproved." in the tWo first two were “unimproved," two weeks or 51% were h2% were 0f the subconvulsive group, categories, 19% after treatment. As in the "improved," these were re- ferred for a second course of therapy, hosPital discharge evaluations do not reflect the effects of subconvulsive therapy. TABLE III Ratings of Improvement: CoHVulsive-Subconvulsive Therapies (TWO Weeks After Last Treatment) Recovered Much Improved Improved Unimproved, worse Convulsive Therapy (h?) 9 15 15 8 Sdbconvulsive Therapy (27) 2 l 5 19 �Convulsive therapy induced and more favorable evaluations The significantly greater behavioral change of improvement than did subconvulsive therapy. clinical observations thus parallel the electroencephalographic data. Also, patients who showed.neither an convulsive therapy, EEG Showed both EEG and or a behavioral response to behavioral changes when Sub- placed on convulsive therapy. 3. Role of Type of Convulsive Therapy: In view of the variety of electroshock techniques employed, the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock on EEG delta activity undertaken. The results are graphically presented in Figures first figure relates and 1 and was 2. The the treatment type to the percentage of records demon- strating high degrees of EEG delta activity in each treatment group during the second, third and fburth weeks of treatment. In each period, treatnent with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unidirectional current and with alternating current at threshold strength was less effective than the supra- threshold alternating current technique in each period; the unidirectional current treatment being method only more effective than the threShold alternating current early in the course'of therapy.* Subconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same relationship by measuring the per cent of each treatment group showing no delta activity or only low degrees * The differences between suprathreshold and threShold treatment methods are significant at .05 by chi square in the h-é and 7-9 treatment periods, but not in 10-12 period. Parathreshold treatment methods are not significantly different free the other two methods during any treatment_period. �-8of such activity. Here, the subconvulsive group is 100% for each treatment period. Suprathreshold alternating current techniques the least number of such records in eaoh period, with threShold show and parathreshold techniques in between. h. Freguenqy of Treatment: Another factor is the frequency in the rate of development of delta activity of treatment. While three times a week, a number activity were treated were given more who all patients and In nine such patients, treatments in each instance middle or high degrees of delta activity were induced. Similar previously demonstrated by Pacella 5. Factor of In the initially treated failed to develop high degrees of delta intensively. daily or twice daily, were at 31. (9), correlates were EEG and Callaway (10). V Age: initial series of'patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta activity during the first and second weeks of treatment; while older subjects developed such activity to a significant degree during the third week. By the fourth week of treatment, age no longer between the groups. Combining the data from supports this observation. all differentiated convulsive therapies During the Second week, h3% of records are in patients under the age of no; but only 30% in patients from h0-60, and 18% in patients 61 and over. In the third measured high degree delta and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects have high degree delta records times per week. when treated 3 �.9TABLE Variation in Per IV Cent High Degree Delta EEG Records with Age * 9 Treatment Period Second week Third week Fourth'week in. is. 2:2 nee ho years (28) 15% 61% 69% ’41-50 Years (28) 29% h0% 56% 51-60 years (28) 32% 56% 55% Over 61 years (18) 18% 50% 80% es To ' 6. Pre-Treatnent Record Characteristics: Previous reports, summarized by Chusid and Pacella (3), noted a significant relationship between pre-treatmnt reca» rd character- istics and the degree of induced "abnonnality." Predominant alpha rhythm, “abnormal" (3) or “borderline abnormal" (11) records were more develop alterations in the EEG liable to than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment'record demonstrated diffuse slow wave activity, spike or spike wave activity were not included in the statistical analyses. Eight such subjects were «- difference in incidence of hig1 degree records is significant at .01 level of confidence between the second and fourth weeks and .05 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. The �-10.. treated with convulsive techniques, high degrees of delta activity however; and seven of them developed earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre-treatment alpha . and the degree of induced delta activity was undertaken. Rank order correlations of the preetreatment per cent time alpha in selected leads (anterior temporaldvertex) with the degree of delta activity during the third and fourth weeks of treatment of +.2h and +.3S reapectively. The in h3 patients demonstrated correlations relationship in the fourth week significant at the .05 level of confidence; while that in the third fails of significance, although the trend is indicated. is week �.11.. DISCUSSION: aspects of these studies warrant discussion: the significance of the convulsion in the electroshock process; and the role of serial electroTwo encephalograms in the rational management and’study of convulsive therapies. In the early studies of convulsive therapy numerous authors, including Kalinowsky 23 El. (12) and Pacella and electroencephalographic gt.§£. (9), emphasized both the clinical differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes Similarly, electroencephalograms in grand activity, while in petit mal therapy, no in less than 25% of subjects. mal therapy demonstrate delta delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, and focal convulsive techniques in each, in.turn,,discarded in routine therapy. Bergman §§.§l, (13), for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records at 15 such "seizures;“ while 70-75% had "abnormal” records after have been described, and Ulettgt El, (1h), in a careful convulsive-subconvulsive control study,reported a significant difference in the clinical response of grand mal seizures. patients receiving convulsive therapies convulsive (33%), or controls (38%). reSponse in the He (60-80%) and those noted two groups, and emphasized the for the therapeutic effect. ReCent ﬁne discrepancy in the EEG significance of the seizure additional reports based on a variety of data further emphasize receiving sub- ﬂue by various observers, significance of the convulsion �.12.. in the therapeutic response (h, 15, 16). convulsions per g2 are, or which thus indicates that reflect, the significant physiologic events are the basis for therapeutic efficacy of convulsive therapies. If the convulsion is the essential element both in the the behavioral response, does the any The evidence EEG and in induction of the seizure play mode of role in.this reSponse?. In the studies reported here, small differences in both the degree of EEG delta activity and the rate of its development different methods of induction of grand mal seizure. Ulett gt 3;, (1h) reported an improvement rate of 57% for the alternating current cenvulsive technique, and 76% for the photo-metrazol were observed between technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulsive photoametrazol technique. In a discussion of this report, Kalinowsky noted.that metrazol convulsions have impressed various workers as being more efficacious than induced convulsions. convulsant drug, PM More electrically recently, Edwalds, (17) describing a 1090, ascribed to it new clinical results slightly better than electroconvulsive techniques. further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance~ we have of clonic or tonic phase, apnea, 332. All grand mal seizures are seemingly not equivalent; and a seizure is not an "all or Different seizure patterns occur and these may none" phenomenon. reflect differences in the physiologic effect of different treatment methods. Further studies of this problem are in progress (18). �-13 .- While this variability in clinical results is reported, it is clear that with repeated canvulsions, rates no matter how induced, improvenent per cent are observed. The differences between various types of treatment are small, and, for the most part, may be readily obviated by of 60 to 80 the simple expedient of increasing the frequency or number of treatments. We may conclude way that convulsive therapy is nonpspecific with regard to the the convulsion is induced. The significant element is the brain change subsequent to the convulsion, and not the agent used in bringing about this brain change. In previous reports (6, 19, 20) convulsive therapy we have noted that is also non-Specific with regard to its application in mental illness, and in its clinical effects. and behavioral The present studies, amplify , therefore, the previous conclusion of the non-Specificity of convulsive we have therapies. applied methods of quantitative, serial studies reported here. EEG analyses in the clinical estimates of behavioral While change have yielded similar data, such evaluations are more dependent on the attitudes of the observer (21), and less amenable to quantification than the EEG. Application of EEG analyses to problemsin convulsive therapies provides a rational basis for the comparison of different treatment techniques. “we have previously noted clinical management patients who that EEG analyses may be applied in the of patients receiving convulsive therapy (6). In fail to show a significant behavioral response on treatnent regimens of three times per week, an electroencephalogram may serve as a �guide for further therapy. In those subjects in.whom high degree delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a more effective oonvulsant method, may result in the neurophysiologic changes. If the degree of delta activity is high and sustained for a number of weeks, other factors as personality (22) or environmental (19) may be assumed to preclude a satisfactory behavioral response, even when the neurophysiologic substrate and further convulsive therapy application has been suggested EEG may well be discontinued. by Roth (5) A is assured; similar for thiopental activated records. The successful application of quantitative convulsive therapies, has led to dynamic EEG techniques to their application to other physio- therapies. Recent reports from these laboratories note a similar application for the rational psychopharmacologic agents (20). management and understanding of �.15sunnru AND CONCLUSIONS: Serial quantitative analysis of the degree of induced activity in were made 173 consecutive EEG delta electrotherapy referrals. Patients were treated by three convulsive methods: suprathreShold alternating current, threshold alternating current and parathreshold unidirectional current. Random electrotherapy patients received a course of subcdnvulsive treatment instead of grand mal, in a convulsive-subconvulsive control study. 1. An induced grand mal convulsion is essential both for the electro- encephalographic and the behavioral changes ascribed to ”shock" therapy. 2. The rate (a) two The EEG delta activity of seizure induction: suprathreshold Mode techniques induce techniques. and degree of induced EEG changes earlier and is dependent upon: alternating current to a higher degree than threshold results of unidirectional current methods fall between these techniques. (b) Frequency of treatment: increasing frequency inereases degree of EEG delta activity. (c) Age of subject: Patients under delta activity earlier than older patients, but ment, differences are insignificant. (d) Pre-treatment record hS develop by the greater degrees of fourth week of treat- characteristics: Patients with dysrhythmic records or high per-cent time alpha activity develop greater degrees of delta activityearlier than patients with low per-cent time alpha activity. 3. It is suggested that serial quantitative electroencephalography provides a rational basis for the study and the clinical management of convulsive therapies. �REFERENCES l. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. 1.92: 22-26, 1952. Psychiat. 2. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobartital Test 3. Chusid, J.G. and Pacella, B.L.: The Electroencephalogram in the Electric Shock Therapies, J. Nerv. & Ment. Dis. 116: 95-107, 1952. h. Roth, 14.: Changes S. Roth, to Clinical Improvenent in Electroshock, AMA. Arch. Neurol. in the under Barbiturate Anaesthesia Produced by Treatment and Their Significance for the Electro-Convulsive ECT EEG Clin. Neurophysiol. 2: 261-280, 1951. Theory of Action, Kay, D.W.K., Shaw, J. and Green, J.: Prognosis and Pentethal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG Clin. Neurophysiol. _9_: 225—237, 1957. 7:41., ’ Fink, EEG M. and Kahn, R.L.: Relation of Electroencephalographic Delta A.M.A. Arch. Activity to Behavioral Beeponse in Electroshock, Neurol. and Psychiat. Z_8_: 516-525, 1957. 7. Kalinowsky, L. and Hoch, P.: ghock Treatments, Psychosurgegy and Other Somatic Treatments in Psychiatry, Grune and Stratton, N.Y. 1992. 8. Alexander, L.: Treatment of Mental Disorder, W.B. Saunders Co., Philadelphia, 1953. 9. Pacella, B.L., Barrera, E5. and Kalinowsky, L.: Variations in the Ele ctroencephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Paychiat. 367-38u, 19u2. g: 10. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Neurophysio . a: 157-162, 1950. ll. Kennard, M. and Willner, M.D.: Significance of Changes in the Electro— encephalogram which Results from Shock Therapy, Am. J. Psychiat. 1L2: : 12. 13. Olin. uo-us, 19m. Kalinowsky, L., Barrera, Reaponse l9LL2. EEG ms. in Electric and Horowitz, W.A.: The "Petit-Mal" Shock Therapy, Am.J. Psychiat. 28;: 708-711, " P.5., Impastato, D.J., Berg, S. and Feinstein, R...‘ Electroencephalographic Changes Following Electrically Induced Focal Bergman, Seizures, Conf. Neurol. 12: 271-277, .1953. �W K. and Gleser, 6.0.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, A31: Jo MChiat. 112: 79S~802, 19560 Ulett, GA” Smith, 15. weinstein, E. and Kahn, R.L.: Denial of Illness, 0.0. Thomas, Springfield, 1955. 16. Fleming, “13.0.: An Inquiry into the Mechanism of Action of Electric J. Nerv. & Ment. Dis. 121;: th-hSO, 1956. Shock. Treatments, 17. Edwalds, R.M.: Intravenous Administration of PM 1090: Clinical Elmerience with a New Convulsant Dmg. Read at FLY. Divisional Meeting A.P.A. 1957. 18. Green, M.A.: Significance ‘of Individual Variability in "EEG Respome to Electroshock, J. Hillside Hosp. é: 229-210, 1957. 19. Fink, M., Kahn, R.L. and Green, “.11.: Experimental Studies of the Electroshock Process, Dis. New. 835 . (in press). 20. Fink, M.: 21. Fink, A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside M. and Kahn, 9: 197-206, 1957. R.L.: Behavioral Patterns in Induced States of Hosp. Altered Brain Function. 1957. 22. Read at N.Y. Divisional Meeting A.P.A. Personality Factors in Behavioral Response to Electroshock Therapy, Coni‘. Neurol. (in press). Kahn, R.L. and Fink, 14.: �ELECTROENCEPHALOGRAPHIC CORRELATES OF THE ELECTROSHOCK PROCESS MAX FINK, M.D., and MARTIN A. GREEN, M.D. From the Department of Experimental Psychi: atry, Hillside Hospital, Glen Oaks, .N. Y. Pro blem : In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment; on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varial, including unidirectional and alternating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12-20 treatments. Patients who failed to develop a clinical response, or EEG changes of signiﬁcant degree, were subsequently treated at 5-10 times per week. The EEG records were classiﬁed for degree of delta activity into “high," “middle” and “low" degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest amplitude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. _ Results .' ~ .4]; 3, 54 I ._ 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was signiﬁcantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subCOnvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional but by the 4th week of treatment, the di' erences were eliminated. '4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. ”ﬁruments, ‘ Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. . 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient 3) Early. and sustained high degree electroencephalographic delta activity is a necessary,, though not sufﬁcient, pre-requisite for improvement in the electroshock process. ’4 ; Avf" �TRQIW m Subuuowluve Conoubwc \\ d, AC. and u“ .. ﬁYc-‘Hol‘b _ Paiszélﬁftfl’l _ A “ \t W: 0 2a 3! 4¢v 93¢ {I to 057:0 7‘ �. t‘, “i. I 3 “fatig- ‘ ﬂcrld;é J 1’ 3547.79 5‘ ”WW 55/ (7.?” Mfl m- a; V Ear ﬂ<.a..ma'" 7”,... 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The limited a arrimy or mass pmduru is probably due to �Electmaephalagnphio many ' ﬂax 1* From ﬂak, 11.9., comma at the Prone“ Robert L. the Department at Experimental M3. 3“ IMO; i Electmhook m and H. Green, 3.9. mummy, Hillside Hospital, 613:: ��.3 I “,— “A May .— - ,. Mu may or ﬂu mam-m M's-3., Mn A. «ma. 3.»... m mm. 2., an. an». hm mammmwuuauuudumbmm mama hm Wumm mm meta-W MM mam; many bun W- mu 411 m; tmmt «www.mtmmmmwmmwm mm m We! pun-Wt Wam- mum www.mmmmwnmmmzw mum-m Was um mama-1 Mum Me for In many mum-ca it Wm as g dry their 33m- mock, ma M W“ 1240 mm“. atmum‘mwwmaamm.umwu mam-m.mnmmmmmammmma mmmmWWtwmamuwwm WHWW'WWNMWMWIWMW: nut-m tho pm mu; mam-*4... mu I“ awn“, amt V‘ IMWWdWhmw.mm-WM,M m'mM§ msmumWMWqu-y,mzomm “mm; M 3-95 1997;: 2 ‘s g 1 1 -§ 5 ��Electroencephalographic Correlates of the Electroshock H Max Fink, 14.13., W Process MW 1. . *- 14‘1” P: Green, H.D./ 1/ 4.. W. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. =,\ �Problem: In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral reSponse has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalogram before on a day after a treatment” mg card» oﬁuntime intervals during, and following IKE/MA retheir pie-treatment characteristics. treatment at weekly . cords had achieved ‘ .“ -~ 7 1-..9- ~. WW . ~~~~~ . mm ' ~ ' ~ . ”will. . Treatment was stituted at three times per week for 12—20 treatments. West-of atients who failed to develop a clinical response, or EEG changes of significant de- WM m gree, were At ated The EEG 9"“ M" /{“" records were classified for degree of delta abnomality ﬁih records/gang the following indices: “high" "middle" and "low" the percent-time delta; highest percent-time delta :1 wave in the record; highest amplitude ivity. ng * 5"“ Results: M 1) A W‘ -Ax/1 74 ' gs «Ede:94‘»!wa by the supervising M M fxwvm/ positive correlation was slowest delta; and duration of burst act- Kiwi” W W WM i/fal law/Mm a: fin oi‘ .0 lead; any M psychiatrist 3f 1‘41. W dan— Mﬂmdgmmzé “ﬁmmmal? A}. established between the development of ram I’lZunfgy ��In)" l- .J, nmmwmmuwuuunmbmm ammmwmmwammmm 7mm mmwmmgmawmaw ummmvmrmmwmummumw mmmmnmmmm; Wt”.- W mum‘mmammmwmmru-mmm mommimmmﬁwmummum mmmumwuamm.umwu mummmmmam ' ”T” . «mﬁwwwumm,mwmm I EMA : I/r/rp ��(“7 ,. ' 9/“ ;\\ KM 4/ 44(ég/7’M4 4% 4%”‘49444.44.44 /4u44.. ﬁod—n—«a— A: 44.4.44. 14 m @ 4 4 4 L?! («I , I er!) ,1 rd 449-64 -wmm.mm.mnu4— Md ‘chZJ‘M- if éw/AMM -4444 (24 [44/2444] 444 743444.444. ~ 4444424444; (4472442444,) 44 444444 4245/44“ maﬁa-,4 ﬁwjj/WJZM 444444 W \WW’W ‘ 44.4 I 44444444444444 44- £441,148 ‘43 44.474444744- 44.4444/‘ WU) Ker-44444.4. 447444.544” MMW //-/v -n $4244 77 rte—“4.44.4 1/ 44444 45/4 4 ’4 (I) @)(3) 4045': ...44. 4..."... ..... ~ £44444 {Que/7 5:7 82444444 44,444 4 K M444 4244 5447 47,424,, 4244444 ,. �1: 2/1/58 EEG Correlates of Electroshock Process During the past few years, incnasing attention has been given to the ic relation between changes in the electroencephalogram and the behavioral change induced by electroshock. The initial application of EEG techniques to the electr0310ck problem in the period l9hO-l950, was summarized in an excellent review of treatments in 1952, that the who noted rather than the degree of induced neurophysiologic (reflected in the peutic by Chusid and Pacella outcome. EEG) These was the primary number change factor related to favorable thera- studies, largely based on descriptive analyses of pre and post-treatment records, were followed by serial quantitative analyses. In 1951 and 1952, Roth analyzed the in patients during a course of was related to the process ECT and of recovery. In 1953, in the laboratories EEG activated by this- He concluded that thiopental delta noted that induced detal activity at Hillside Hospital, we analysis of neurophysiologic bases of electroshock, based " undertook an on a hypothesis expressed by Weinstein and his coaworkere in which they related improvement in electroshock to persistent states of altered cerebral function. Our �-2... first did studies utilized the amobarbital test show a provement. relationShip and these, parenthetically, between changes in language and Our second index was the ratings of delta index of the electroencephalogram. In our original review of patients, recently reported, significant relationship between the degree delta activity It is and im— and we noted a duration of the induced clinical evaluation of behavioral change and "improvement." our purpose tonight to review these findings; to describe subsequent studies in which various aSpects of the treatment process were the degree of EEG delta activity; and to conclude with a related to summary of the present neurophysiologic adaptive view of convulsive therapy. One hundred and have been studied. a day forty-eight consecutive patien electroshock referrals Electroencephalograms were taken before treatment, on after a treatment at weekly intervals during, course of therapy, istics. until the record had achieved and following the its pre-treatment character- Various treatment procedures have been used, including alternating current threshold and suprathreshold electrodhock; parathreshold unidirectional current electroshock; and subconvulsive techniques with pentothal premedication. �-3- alternating current suprathreshold The K ) and unidirectional parathreshold (Reiter) teChniques are well described in the threshold alternating current patients, without prior sedation, received a methods, for 0.1 second, which was usually sufficient for a petit 20 second second. intervals, voltage increased by 10 volts 90 until a grand mal absence. At up to mal convulsion was induced. just necessary to induce a grand 1&0 volts, 0.1 mal was the threshold voltage and The value. In subconvulsive techniques, patients were given pentothal intravenously asleep, volts Voltage was then reduced to 100 volts x 0.2 second, and increased by 10 volt steps time was current, low and then either low voltage . current of or alternating unidirectional current for ”a 80 nvolts x until 60 seconds; . . 0.1 second were administered for one to three applications. All treatments were given three times a week treatments. Patients who failed to develop clinical reSponse, or EEG changes of treated 5-10 times per All EEG a initially, for 12-00 significant behavioral or significant degree, were subsequently week. records were quantitatively measured for the degree of delta activity. This index was determined by measuring the per cent time delta �.uin 180 seconds of each of three lead combinations, and both the average _and the highest index in any one lead were used; the slowest frequency and highest amplitude delta; Records in the and the initial series duration of the longest burst were placed those with the greatest changes in slow Degree Delta Activity." Delta Activity" and "Low Degree week of The specific limits of ratings of Low degree treatment. 3) Evaluations of changes in behavior were and "High were "Moderate Degree following three slides demonstrate a High-Middle and psychiatrist upper third - earlier report. (Figs. 1, 2, weeks thirds Delta Activity." record obtained during the fourth The The activity - were called wave The middle and lower each range are described in the The into sequence. . made by the supervising resident therapist at the height of the treatment effect. "improvement" were made by these physicians two to after treatment was terminated, and were based on the three four fold "much improved," "Improved" and "unimproved classification of "re00vered," or‘worse." In our initial reports ( , ) we noted that patients who developed �-5high degree delta sustained, activity early, and in whom such delta activity was were evaluated as "much improved" or "recovered" with a greater incidence than those patients who failed to demonstrate significantly delta such activity. These observations are portrayed in slide h. (Slide h; These patients had been treated with a unidirectional convulsive therapy. In a subsequent series of 5b ~ in Graph EST #1) which the degree of patients, a predictive study was undertaken delta activity induced during the second weeks of treatment was determined. 0f the subjects in whom and high degrees of delta activity were induced during both weeks, 67% were eventually much improved; while of those either week, only 30% who did rated as not have a high degree record in were so evaluated. treated with a unidiructional current; third and Of these patients, half were half with a suprathreshold alternating current technique. Slide 5 - (Table I, Exp. Studies) Results: 1. Role of Convulsion§:in Therapy. In the most recent series of patients, randomly selected subjects �-5received subconvulsive therapies instead of grand mal; and both alternating current Of and unidirectional current techniques were used. the subjects who received convulsive therapy, ______had high degree delta records in both second, third and fourth weeks of treatment; .____ during periods. two of the three weeks, and ____ during only one of the Only _____ subjects failed to show a single high record test on con- vulsive therapy. Of 27 the/subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. Low activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. Concurrent analyses of the behavioral ratings showed _____ of the con- vulsive group rated as showing marked behavioral change; while of the suboonvulsive group, 25 showed no behavioral changes. were referred for a second course of therapy. In 1h of electroshock induced high degree delta activity and behavioral change. activity Of the five who all Of these, nineteen these, grand mal showed a significant failed to demonstrate high degree delta on convulsive electroshock, all-showed middle degree records; �-7and two of the five 2. Factor of Type showed a behavioral change. of Therapy: In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock in EEG delta activity was undertaken. The results are graphically presented in Figures 7. The first related the percentage of records in each treatment group during the second, third and fourth weeks of treatment high degrees of EEG current techniques The gave a lower percentage of high degree unidirectional technique was also degree delta delta records. less effective'than the supra- all these periods. Although effective than threshold alternating current course of therapy. who demonstrated delta activity. In each period,threshold alternating threshold alternating current technique, in more 6 and methods early in the Note, that subconvulsive techniques yield no high activity records. In the next figure, the converse is demonstrated. The relationship between type of treatment, treatment period and percentage of treatment group showing no delta activity or only low degrees of such activity. �-3Here, the subconvulsive group is for each treatment period. Supra- 100% threshold alternating current techniques show the least number of Such records in each period. 3. Frequency of Treatment: Another factor on the rate of development of delta frequency treatment. While convulsive therapies were treated given daily or twice daily. activity were initially treated three failed to develop high degrees of delta activity times a week, a number who on all patients activity is the In all more sudh intensively. Treatments were instances high degrees of delta were induced. u. Factors of In the Age and Diagnosis: initial series of patients, it was noted that younger patients, under #5 years of age, developedlgreater degrees of delta the first such activity during and second weeks of treatment; while older subjects developed activity to a significant degree during the third week. week of treatment, age was no longer a By the fourth differentiating aSpect between the groups. With increasing series of patients, utilizing various treatment techniques, the differences between successive groups is largely a matter of treatment technique rather than age. �.9Similarly, conventional discharge diagnoses bear to the rate or degree of delta activity induced. in young schizophrenics, no The relation either delta activity induced older depressed, older schizophrenic paranoid, younger reactive depressed subjects are similar in indidence of high, middle and low degrees not, of itself, a at different stages of therapy. The diagnosis is significant neurophysiologic factor in electroshock. and �combining the data from all convulsive therapies supports this observa— tion. During the second week,h3% of records are high degree delta in patients ho; but only 30% in patients from uo-so, and 18% 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3 of the subjects have high degree when treated 3 delta records times per week. TABLE Variation in % High Degree Delta EEG Records with Age Treatment Pe riod To ho years hl-SO (28) (25) h3% 61% 69% 29% h0% 56% 51-60 (28) 32% 56% 55% 61+ (18) 18% 50% 80% S. Pre-Treatment Record Characteristibs: Previous reports, summarized by Chusid and Pacella; a ( ) rated significant relationship between pre-treatment records characteristics the degree of induced "abnormality? Escords with predominant alpha rhythm or "abnormal" (Chusid and Pacella) or "borderline abnonnal" and �.10- liable to developé alterations in the (Bagchi §£.El) records were more EEG than those with predominantly low voltage fast activity patterns. Rank order correlations of the pre-treahent per cent time alpha in selected leads (anterior temporal - vertex) with the degree of delta activity during the third and fourth patients demonstrated correlations of +.2h The weeks of treatment in h3 and +.35 reSpectively rehationship in the fourth week is significant at the .05 level of confidence; while that in the third week the trend fails of significance, although is apparently indicated. Discussion: Two aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and ﬁne role of electro- encephalography in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the initial studies of convulsive therapy numerous authors, Kalinowsky including Kalmaasky at al,(l9h2), and Pacella gt_§l:(l9h2) emphasized both the clinical and electroencephalographic differences and petit-mal responses. provement in 60 to 80% While grand mal between the grand-mal seizures induced clinical im- of cases, petit mal induced changes in less than �.1125% of subjects. Similarly, the electroencephalographic reSponse to grand mal is one of delta activity, and to petit mal, is delta activity. no In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been described, and each, in turn, discarded in routine therapy. Bergman gt_§l”( ) for example, in describing the electroencquh- eIographic effects of focal seizure techniques noted that patients had normal records "abnormal" records after after 15 such l0% "seizures;" while grand mal seizures. Ulett gt §l° 20 of the - 75% had ), in a ( careful control convulsive-subconvulsive amdy, reported the significant differences in the clinical changes between the convulsive therapies (60-80%) and subconvulsive (33%), and noted the discrepancy response in the two groups, and emphasized the in EEQ significance of the seizure for the therapeutic effect. These studies emphasize the significance of the grand mal convulsion, both for the clinical therapeutic effect and the electroencephalographic reaponse. Recent reports by various observers, and based on a variety of data, support this conclusion. If the convulsion is the essential element in the EEG and �-12behavioral reSponse in electrotherapy, does convulsion is the induced?. In the studies reported here, small differences in both the degree of were observed. it matter in what way EEG delta activity and the rate of the development Clinical evaluation demonstrated concomitant greater degrees of clinical efficacy for the suprathreshold alternating current method to the two other convulsive techniques. 'Other studies have also for various convulsive techniques. shown differences in clinical results Ulett gt_§l. ( ) noted similar differences in clinical results in a study of patients receiving alternating current5'and photic-metrazole convulsive and subconvulsive techniques. He reported improvement rate of Sl%,'76% and concluded, 33% respectively; that the convulsive photoshock technique clinical efficacy. Epstein and Wender (1955) compared unidirectional current techniques, and reported no results but that unidirectional techniques required more had the than alternating current methods. More a new convulsant drug,.Hﬂ 1090, ascribed to greater than electroconvulsive techniques. and greatest alternating and difference in clinical one to two treatments recently, Edwalds, describing it a clinical efficacy slightly �-13while some variability in clinical results is reported, is clear that with repeated convulsions, provement rates of 60 and for the most part, treatment. regard to have noted we may its 80% are induced; may be no matter how induced, imThe differences are small, obviated by increasing the frequency of conclude that convulsive therapy mode of tat - it is non-specific with induction. In previous reports convulsive therapy (EEG is non-specific with Theory) we regard to their application in mental illness, nor is their clinical or behavioral effects. The present studies amplify, therefore, the previous conclusion that convulsive therapies are non-Specific. 2. Role of Electroencephalography in Convulsive Therapy: we have applied methods of quantitative, serial in the studies reported here. change may give similar data, such evaluations are the attitudes of the observer of EEG ( analyses clinical estimates of behavioral While on EEG ) than the EEG. more closely dependent Further application Analyses to other problems in convulsive therapies may provide a rational basis for comparison of different treatment techniques. �We have previously noted in the clinical management of that EEG analyses may be applied patients receiving convulsive therapy. of In our experience, the early and sustained induction of high degreaydelta _ activity provides the physiologic basis for behavioral vulsive therapy. a An electroencephalogram in patients significant behavioral response per week may subjects in change who in fail on treatment regimens of high delta to show three times serve as a rational basis for clinical management. whom con— In those activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a thera- peutically more effective convulsant If the physiologic changes. be maintained may ( ) for a or environmental ( havioral response, even and degree of delta number of weeks, other ) may be assumed to when further convulsive therapy records. result in the neuro- activity is high; and it factors, as personality preclude s satisfactory be- the neurophysiologic substrate is assured; application has been suggested EEG method, may may welllae discontinued. by Roth ( ) A similar for thiopental activated �.1 5.. lhe successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these application for the rational management pharmacologic agents Summary and ( Conclusions: ). laboratories note a similar and understanding of psycho- �to“ Win the Natalya”. Watmﬁmmbun gim nation bum inﬂamed by It: omwgek. _ than olectmnuplaham In 1953. in the and behavioral mum at. dung" mud. Hospital, We“ of ashram-1019a: upon“ at olmtrouhook m mm. swim: ( champs in )1n were band on which may a. Win mm by Romain and his muted imprmmt 1n 01.6mm to tho a» mom” Mom: of paraiamat sum at altered mmbml function. mmmmmmw< Luminanctwnmtmuump how the damn am mum a: ﬁn 1mm den-a activity and mum «alum of huh-mm damp and “W.“ this report to "view than ﬁnding” to describe mum nmrophyuiolom to nuggut aspect: of u. Almanac-1m or maps-oat. of minimum: 3%! On. W bun swans. 3nd It 1. at W at mt Media in mini: m mun-at woo.” In. ”mud; MWmm in mud!“ and and sum). mom“. {Wﬁt acne-anti" «hammock Marni: a". um um baton taunts-ant, and an ammrttmtatmmquadummfmmw-mm �4-2. of therapy meal the noon: Md «mum. 45* M‘ Pntimts- mﬁpn-matnnt or significant . bum its pwtmhmt m dual-tramw- 31w m a; mum activity, mm are «eluded from tho curios. Fm tmww madman «playing 611nm 1) umg/aumam W at. “mm: 3) MW“ mm mpnthnuhold It) mbommlsiva tonhmqwu‘ with pantothnl Wt 813de m tall dumrlhod. 5%: ( 9 ma pmdicttion. Tm ( gunman; ) hummus damning current. method patients, Mind 1w “mats, mu sufficient tor a phi: 3:1 mm”. and, (Maugham); ummmm lawman! In the thrown!!! ﬁtment prior «mum. ~ W of “dam he.“ M915 smug a) nun-mung «mm at. 3* mm“; (90 Volt. M 20 for 0.1 sound), mad Manila, may, it mam-,7, duration: in” 1mm mm a and m]. whim m mama. mmmomd timmcuurytojutincmma gmdmlmtho, thruhold value. In subconvulaiu m, m.( mu )3 and um mu” u {may maimﬁann mt. for co ornamtingmté mungvoltnxOJWurn “31.31th far on. 15mm. mam, puma“ mm 31m mm warmly to three Appnoatim, for a. total. of 21: to 36 ”ﬁt m1 �A11 tmtmubn an arm: thm tints a wok initially, for trauma“. Pantom- Ibo clinkai n‘spenn, or EEG tail“: to duolop a changes of 12-20 macaw behavioral or' signiﬁcant 4.3190, are subsequently mam 5-10 than m wok. m EEG Mord: were quntiutivoly manna for the dogma or délm mm: in. «data: at to mmr ﬂu: Man-mud ”M,“ activity. The "Manta“ or "lav“ 63M er delta activity, mowing to criteria pu- ‘ ‘ awn matched ( The ). mums; three slides (immune a high, maﬁa and 101! «n: Mord: duung tho fourth-ml: at twat-cut; W l (Figs. 1, 2, 3) Ivan-um or W m hamm- an and. by the mmmm Wm“ m6 random. therapist It. the Mia“. of tho treatment at ”mama-Int" Weaken: run and. by then physician:- two tn m tominatod, and were hand on ma “mound," “men In our initial “tact. tbs-0e four tam W,” M “W or mm." Wu ( g ) no The rating: mks utter dasﬁfiéum a! wind that patients me wanna �4‘" 1:131 damn 601%: activity . My, and in when m «1%: activity 1.! wow. wr- mlulud a “lunch Wmm or “uncured" with a grater muaow than than patient: activity. Thu. chomum who such delta m pawn-wed 1n and. h. (811* In Gnﬁ 511* s In the ta damn-tutu “mutant.” '1' M ”J (km. 1, nut wont. «run or puma“. ms Studio.) mm «new plum“ w tame m nmsmmmy mind .mmmvo thmpiu mm or mad Id; Ind both atom-$1M . W WW“ mt Man. RN and mod. at tho 1:? mm at: who mm mm ”mm haunt" than”. 9 hid high dome in both «ems, mm and fourth mks at truth-at] 1.2 wring hearth-thrum, mummly'motthlmtpoﬂm. thin-In “their? lubdwtlnuodto Muuuglchiwaogrudﬂumm convulnu thunpy. at tho 2? aubjootu who mum Wain mum, Wt, m �.5. dam-mud new or high down 4.11.: nativity mom or mutant. in! now of during both ﬂu my and: mu activity m not“ in than “hm new and third min at imam. and during the fourth elm-1n; in 8 ”Mo-ct: not. 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EEG an. activity. mutant um: daunting «mat It mmknshald high.” mom: In each period, otnncth and with numung mt at thmshou oft-cu" thin tho lupnﬁhnlhad alumnus mnem- m tho ‘ ' the tau-angst; m 1m mm, in out mar-cum; curl-mt. tmtamt being not: «mm than the tux-«hold 11th Suboomumn #:00QO yield no high dam «in: activity neural. cum-at. uthod only curly 1n the Mum WWW“: treatment the am come of mumpwmng pox-«near wh/mpwoungno «Inactivity such trut- ”may of my: (low mu mom. What with Winch 1m). nun-mt ported; of the «new. third and fourth molt: of mt Whiting mm dam of » a: nativity. Kin, tho «boom!» in map is WW- than ' «01:1:de 1005‘ for «ch tram �.7. ponod. “puma-«hold uunbor of man alumina current handgun chow th- but. rcmd: in «a: period, nth tun-had ma mmm “chum. in how. f Tm 3. ts Author factor on the truancy at tmtmont. tins a cock, u mater on convulsive nu of mama: of delta activity in tho While :11 who patents wore initially treated thm fund to therapnn vor- dculop mu! demo- or :1qu nativity tmud' non mun-may. In aim Inch uncut-,- an 3110:: an); or win any, and in «eh instant» ﬁddle or my: damn of 601%: activity an mm. 8mm- ma comm won prenatally dumtntod by mu. ﬁg... ( ). m1 cumu( mnmuta k. W' In tho )_. mun unit. or patina“, 1%. was mind that. younger patients, Mr 16 your! at ago, dmlepod grater dam of delta nativity during thnrst. and poems! activity to of & tnatnnt, m at “about; 111111. older subjects. donlopod inch signiﬁcant dogma during the third weak. 3: the fourth not m was no 10:15:01- : dittounuatiug ”poet bottom the groups. �~8— Gcnhdnmg “I. data from an. During tho undo:- mom convulsiv- m. h)! a! mm m raw demo dam in mutant: the as. of hot but only patina“ 61 and. thonpuu supports this obumum. mm no longer present. and 305 in ptﬁmto rm 1:040, In the third and fourth ”aka, the and 183 in antenna» an “mantel: 2/3 of the lubjlctl but high degree «It: «and: uhon trotted 3 tin” par wok. mu Yunnan 1n 1 8131. Dog“ mu ma mm with La * m m mm we no M 51+ 0 m be as) has (as) m (as) (13) W 1:2 as M 691 he: saw 32: 5a 95:: 18: 50: M no durum in 1mm of high dome mom 1: significant u .013 andhurthtruaunnd .OSShomthoummtndthird mic: or tun-em in patient: «or 50 your: at nan) but is not uwimny manna“ 61:1on for the“ put-1m in groups and» 50 yum. �.9. mum "pom, mm by Gama and mu“ )mm . IWmt mktimhip batman pmmst. aunt heard Mauritian and m m W “nbmlity.” new nu: mm: at or 'abnoml' (Ohmic! and alpha mm M113) or “bomﬂino ulnar-t3! (Hum 91 9;.) Wanmmummnunmummmmmum may In than 1w may tut activity ”than. «an or imam“, abduct: who“ pm-vbrnmcnt domain-1m um um «hazy apn- or space an activity nah mam.» Eight A manic mimic or the mush pro-Manta“ ﬁnality. talcum ,mﬁk order tin am in «new land: m pro-smut“ ”mutton: of an} mutton. alpha and pu-mamnt (anterior Mignon). worm) with the 601m activity during the third and tour «the cf gaunt: dalmatﬂm man of than and «It: antivity «run, and for more mm «It: activity an mandala-n dam. of or are not nausea in an gunman. Won. that in puma“ without par aunt mm... er mama-ac «any. m tmtod with emu”. taotmiquu dmlopod high amoe- at palm of a more! or +31; and «35 tmﬁmt mpoctinlm in h3 �.10. m mumumrmmmuummtn the 4351.701“ Widen“; thl while that in. tho third ‘at dwiam. although W6 a mum. W: M «poet- at” than the not an. that”... mt dimuon; tho Winn“ of, whim 1n the 01.6%!“th pm“; and the r910 at «an nontra- W! mopbnlomph (1) 1n the In the including mama: and may or convulsive therapies. mud and“: of cumulus." therapy lawman whim-c. hum-kw the clinical Ind «Mom: ‘ ﬁg. (19%), and Plum 5;. (193:2) aphasia! bah 01¢“ch diatom bum the grim n.1, mpoutm “WM mammmm-Wamm 1mm"mntinwtomofmu. ptﬁtnlindwod Weamhlstmaﬁof mycu. mm. ﬂu chem-pulmyhle mm. to m a! mu ”Univ, and {no pout m1, 1: In subsequent. you-I, various no delta grand an in mum. W131“, has! CW, mﬂmtiml “hunting, mopohr unwitting. foul contain" techniquu have been �.11. thd in mum. than”. Barman 33 3;. mum, and nah, in turn, ) tar example, in mung an cloutWaganc «not: or ( focal "inure manna-u Mad that art-r a), 15 inch "maumr' m1- "isms. Matt 93 g. study, repel-Md a halving ( of patients had - 753 had “abnormal" ), in a ammo-at autumn mm mom _ max-d: utter grand «ram comm). «muywmbeomhin 1n «mm-:1 roman "a! panam- amid" that-apt“ (W) ma theta minus abnormal-1v. (331). or control: (381). no tho two 70 70% mp3, and new tho war-may 1n the 3m noon-- in mum the signification at ﬂu loam for tho thanpuutic strict. Mint additional upon-h 17 various ohsarvm, band an a «ﬂaw of (Rain-“1n and an, alpha“ th- awinmaa at tho ”amnion. m, Roth, mung). rpm, the mm. mnem- um minim par a, an a:- mu tho signiﬁcant physiologic mu mm m the has for thirty-nut: If an. convulsion «fancy or 'oamluva than-qua." I both it tho mud chant/1n mu m and in tho behavioral "903380, does m node of inﬂation at the role in um “spam-7. In the chads." ”ported ham. uny “mama Min-mm in both the dam- ot‘ “ism play any Oman Em hut-.2 sun-u- mu activity �.12. the and at» of 11:»: “mu m abut-"d bum Miami mod: of imitation or grind u). m. m an m. pmidu but: far the mama Mm't tint .mpnthxuhold m @0an album-ting current “chum m mt “tutu. m We cmuloiva than”. “the: India ban the sham moms cumulus.“ “Wu”. exam in clinical results for 813% g 51.. ( ) mud 31:11.11- mum. ms; in mm:- mdiu or Mum waiving atom-um mt mmlpin and mumml mvulnm m! mbmvukin tech.- 1i: amen niquu. no "ported Wat. m. at $73. 763 ad 331 yumﬁuln mam ﬂat the Wain Manhunt: Wm bud tho amt.“ clinical «tinny. non may, W, doom-thing n m «walnut: and drug, a: 1090, named to it a clinical mam; unghuy gmur um dawns." wanna“. w studios an have mm mm m «Wm mam-d by Mom Wm» hm! um manna” of latency, duration, prom-mac In of claim: or tonic ammt phi“, am, two. um; not :11 mind In}, From that. Sundial, it has Mm him: at. minimum; and that : �:31)’ W; m mm a not an an or w“ cum and than my unset dim-mt. taut-mt aimed. Dunn-mo mum panama dutannm in Mahala «rout. of tho Mar mm" 01' this probhn an 11: 9'08“”- thn this "unmey in clinical 1:3qu in ”period, it in clear ma, ups-mt. raw or - in chum-d. m dﬂhmu human var-1m W or mutant m 3.311, and, for ma most part, be mm w increasing the 1:qu ﬂnt with rap-wad comma”. no author he! 60 305 may com!” may: in nonwith mum to ﬁlm W tho minim in Mad. The simiﬂmt or amber at mutants. it. any Mic «mm that amt u the bran W Mum. ta the uranium, and not an mat mamas-1mm mama“... Inwim mm (3m, Theory) in we: noted that commits.” map? 1: l1” 1%. application in with mam maul, m: in its clinical and with Wticity of convulsive. ﬂan-pin. to I bender-1 «facts. no pron-at studs.» «3mm winters, the pram» at the ”and comm �U. have appliad ”mode or quantitative, serial me the m1: studies} mporud here. We in clinical estimates at behainnl change ‘ may give of tho xinihr data, obumr ( ' ) than an m. Us lava dependent an tho m a prawn/mum]. buns for Miami tmtmnt technique“ pmionlly noted that mm mm: my be applied in the clinical magnum. or patients receiving oonmlsivo therapy tin I um tad» Wr applicttion at m analyse: to other pmhlm in convulsive thumps.” compariaon of am such evaluations am @mnua ”ported here, the curly and ( )- In sustained induction at high dam,» a! do“: activity provides the phyaiolagic bait for behavioral in cumulative mmpy. «mango fail to thm char 3 mu. increasing a electroencephalogram in patients uwﬂmt Wen]. times per week aunt. In An w when mutant. tummy, Mummiaogic more big: delta activity has withholding effective «walnut. If changes. it my be 31an for tmtmt ”31mm of norm as a rational basis for clinical manage» mbaem in thonpeutiany aspen”. on who o. tho dome of nmbor of not. been induced, pmdimtien, 0r shifting to mum, my resuli in the mm activl ty is 11139 mks, nth» future, and a punctuality �~15— ( ) or mama}. ( behavioral response, and ) my be can when the «me! to panama. a utiatactory Wide-go mbctrato is assured; further eomhivo therapy my will tion has bum suggested by an Ruth ( moons-tn]. application of convulsive therapies, ) be discontinue. m gaunt: similar applica- for buoyant-.1 activated 330 record» quantum." ‘m tachniquu to bu led to their application to nth“ hemp-us. accent reports from than laboratories not. for A as MW“ similar applicatim mum-1 moment and man-Italians of paychephameolom ( ). �416~ gagglnnianus 1.‘ In aerial qynntitativn analysis of aetitity in degroe of induced EEG delta anhjocta receiving variant convnlaivo therapies, a poaitdvu relationship betuoon the digrea o! indueod delta activity and bath tbs dagroe oi'bohavioral ehnngo and ratings of impruvamsnt 2. and induced grand mﬂl convulaian An is reported. 1: elscntinl for both the EEG behlviaral change. 3. Th3 rate a. and dogrcc‘of induced Hbdo dalta activity is dependent upon: at soiturc inductian b. Fruqunncy at treatment a. Ag. 0! lnb3oct d. Pre¢treatmsnt h. It is pmuvidoa a recommended EEG record characteristics that aerial quantitative electroencephalography rational basis both for the study and clinical managenant or variaus paychodynlmie therapies. �II: 2-5-58. 0131/11.!" Correlates of the Electroshock Pincess EEG During the past feW'years, renewed attention has been given to the relation between changes in the electroencephalogram and behavioral changes induced by electroshock. In 1953, an analysis of neurophysiologic aspects of electroshock studies ( in the laboratories at Hillside Hospital, ) in was undertaken. were based on a hypothesis expressed by Weinstein and which they related improvement The his co-workers in.electro$hock to the development of persistent states of altered cerebral function. In thii initial EEG study ( ), we noted a significant relationship between the degree and duration of the induced delta activity evaluations of tIhI=HIIEIEIIEZl=E=IIi§"improvement." It is and clinical the purpose of this report to review these findings; to describe recent studies in which various neurophysiologic aSpects of the treatment process were assessed; and to suggest the application of electroencephalography in.studies and rational management of physiodynamic One hundred and been studied. a day therapies. forty-eight consecutive electroshock referrals have Electroencephalograms were taken before treatment, and on after a treatment at weekly intervals during and following the course �-2- until the record of therapy ﬂag»! Patientsbﬂwyhgug‘pre-treatment IN EEG - . eggpktfd’ef’d .,,.,;‘""ﬂWh . activity, an...“ M"M ﬁignificant asymmetry were MW’O‘Mmmws-‘W pre-treatment characteristics. demonstrated slogwgave or spike . WW its had achieved series. from the { ‘ {V .up-w‘ . Four treatmentt procedures employing g different types of stimuli have ' i V . 1) been used; /alternating current at-threshold strength; 2) alternating current at suprathreshold strength; unidirectional current (parathreshold); 3)- h) subconvulsive techniques with pentothal premedication. The alternating current suprathreshold are well described. ( ) and unidirectional parathreshold ( ) techniques In the threshold alternating current method patients, without prior sedation, received low currents, (90 volts for 0.1 second), usually Sufficient for a and, if petit mal response. At 20 second intervals, voltage ,_ thewmwmm necessary, duration! were increased until a grand mal convulsion was induced. In subconvulsive techniques, patients were given pentothal intravenously until asleep, and then either voltage unidirectional current for ); or alternating current of seconds ( administered treatments . low l 80 (30 to 120 volts x 0.1 second were for one to three applications, for a total of 2).; to 36 petit mal �All treatments were given three'times a week Patients treatments. clinical response, who initially, for 12-20 failed to develop a significant behavioral or or‘EEG changes of significant degree, were subsequently treated 5-10 times per week. All records were quantitatively measured for the degree of delta EEG Ml WM! We! MM‘AWW activity Masada—WW ‘ delta activity, "moderate" or "low" degreet . l‘ . . I i 5 3 . The 30W week of (Figs. 1, treatment. 2,3) Evaluations of changes in behavior were made by the supervising psychiatrist resident therapist at the heigat of the treatment effect. The of "improvement" were made by these physicians tw0 to three weeks treatment "high, " following three slides demonstrate a high, middle and low degree delta record: during the fourth and M was In our after terminated, and were based on the four fold classification of _ "recovered," ratings ”va ”much improved,"nand "unimproved initial reports (' , ') we noted or worse." that patients who developed �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta such activity. These observations are portrayed in slide h. (Slide u: Est #1) Graph Ecsults: The “W etweeni“! relation neurophysiologic 5" . . and behaVioral response W111 be assessed according to five aspects: 1) 0 2) Type of Convulsive Therapy 3) Frequency of Treatment h) Factor of 5) Pre-treatment Record Characteristics ’Of Age the uz’subgacts’WHo”retaived‘ccnvuISive‘tnerapy, 7 nan nigh delta records in both second, third two of the three weeks, of the u? subjects and fourth weeks of treatment; and 13 during only one of the failed to show a UEgIEE" 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta sudh activity. These observations are portrayed in slide h. (Slide u: Graph Est #1) WWW Results: 1. convulsive vs Subconvulsive Techniques: In the most recent series eizpahaaaih randomly selected patients re— ferred for electrotherapy received subconvulsive therapies instead of grand mal; and both alternating current and unidirectional current techniques were used. or the h? subjects who received convulsive therapy, delta records in both second, third two of the three weeks, and show a had high degree fourth weeks of treatment; and 13 during only one of the of the h? subjects failed to 9 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �.5demonstrated middle or high degree delta Y3...” of treatment.§ x Low ( / activity records during any week degrees of delta activity were notedhiﬁwthree subjects during both tgexsecond and third weeks of treatment, and I“ .,.,_,_.,.-‘ ”mud,” Y , “W", v V .V,. inAB subjects ,, ’dmﬁgthefourth Week alli'lll=l==I-I behavioral ratings Concurrent subjects in the convulsive group rated as shining showed hZ of the h? marked behavioral change; hat ‘ while of the subconvulsive group, , ioral changes. of therapy. the Of latter 25 of the minimal or no behav- 27 group, 19 were referred for a second course In 1h of these, grand mal electroshock induced high degree delta n...» . 4,7,.“ .;...-....‘..,r,, 9...“; .. n .mm ., 3., ,. .~-wms...mu m-.. _,. ”a”. .. activity "Walnut... all showed a V.-.~...,..,..~..,.u.ma..~m.—.~..._..Mn...._,.m.. m failed all 4 f. ./ ..,,,.A. . .- significant behavioral change.#fgf the five t. ' to demgnstrate high degreewdeita “if I/VFI' My" : ’ activity a” , Thus, convulsive therapy induced showing on five . Mm)“.- . showed a behaVioral ”n,mmwm .,wmlumwﬂun. significantly greater behavioral changes neither an EEG EEG delta activity. Furthermore, or behavioral response to subconvulsive therapy, showed both the-EEG and behavioral changes therapy. convulsive”2lectroshock, delta activity, while subconvulsive therapy induced minimal behavioral change, and minimal patients 51/ Who~~ I” “(my We“ EEG ,4 .2 shdwed middle degreeprecords; and two of the associated with """ ------—--- 5"“ , /,/r ,//'change.; a r and when placed on convulsive r. e r. a 7.“, �-b2. Role of Type of Convulsive Therapy: In view of the variety of electrOShock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock undertaken. The first The delta activity on EEG results are graphically presented in Figures 5 was and 6. figure relates the treatment type to the percentage of records in each treatment group during the second, third and fourth weeks of treat- delta activity. In each period, ment demonstrating high degrees of EEG treatment with alternating current at suprathreshbld strength gave the highest percentage of high degree delta records. ieeetment'uéth-unidirect- ional current and*lith alternating current at threshold strength was less effective than the suprathreshold alternating current technique, in each period; a the udtﬁiEgﬁgie;;%reurrent treatment being more effective than the threshold alternating current method only early in the course of therapy. Subconvulsive techniques yield no high degree delta The next figure demonstrates the same activity records. relationship by measuring the treatment per cent of each/group showing no delta activity or only low degrees of such activity. Here, the subconvulsive group is 100% for each treatment �-7period. Suprathreshold alternating current techniques number of such records in each period, with threshold show the least and parathreshold techniques in between. 3. Frequency of Treatment: factor Another dn the rate of development of delta activity is the frequency of treatment. While times aweek, a number who on convulsive therapies all patients were initially treated three failed to develop high degrees of delta activity were treated more In nine such patients, intensively. treatments were given daily or_twice daily, and in each instance middle or high degrees of delta activity were induced. previouSly demonstrated by Pacella gt El. h. Factor of In the ( Similar EEG ), and Callaway ( ). Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta first correlates were and second weeks cf activity during the treatnent; while older subjects developed such activity to a significant degree during of treatment, age was no longer a ﬁne third week. By the fourth week differentiating asPect between the groups. . �-8data from all convulsive therapies supports this observation. Combining the During the second week, under'the age of ho; h=t===:;.30% ' patients "www-W” 9,.0. .. 1M 1‘ . at . on.» . , of records are high degree h3% M 61 and over. In the n.-“5.”. m1”- A, “W third in patients from delta in patients WW WM M ‘4 treated 3 ~ ‘ , W. W"; A .W‘ andﬁdpproXimately 2/;xtf the subjects n:/}pﬁger present M” when cue-yaw and fourth weeks, the differences arep ~ «idelta records in hO-CO, and 18% timéé per W99§° ,ffﬂ have wwww‘t4m HM\“ " ”a“ “by" ‘ high degree W“”w" ‘f" Mama.W ”Q h/‘ WWW, Wn.ﬁ,,,,.,-r..m TABLE Variation in % High Degree Delta EEG Records with Age * Treatment Pariod 5g: ' in is. 2:2 are 61% 69% (28) m ul-so (28) 29% m 56% 51-60 (28) 432% 56% 55% 61+ (18) 18% 50% 80% To no years * The difference in incidence of high degree records is significant at .Ol% between the second and fourth weeks and .05% between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. �S. \ Pre-Treatment Record Characteristics: In earlier studies, a relationship between pre-treatment record characteristics, notably degree of abnormality or predominant alpha, the degree of induced "abnormality" was noted ( , ). and g In these series of patients, subjects whose pre-treatment record demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniques and seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertakenjémk order between pre-treatment alpha and correlations of the pre-treatment per cent time alpha ée—Ge-lMed-ﬁeds—éea-teWﬂ—aemﬁ-with the degree of delta 4. patients demonstrated correlation‘ of . 95’ M activity during the third-and four weeks of treatment in M/Wima . 4'“ M +.35’ if ' I43 f5” 4d” �-95. Pie-Treatment Record Characteristics: Previous reports, summarized by Chusid and Pacella,( ) noted a significant relationship between pre-treat ment record characteristics and the degree of induced "abnormality." Records with predominant alpha rhythn or "abnormal" (Chusid and Pacella) or "borderline abnormal" (Bagchi 33 13;.) records were more liable to develop alterations in the EEG than those with fast activity patterns. predominantly low voltage ,1 In these series of patients, subjects whose pre-treatment record~ demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniquesﬂand seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertaken'éxk. per cent time alpha degree of delta order activity during the third—and patients demonstrated correlation( of 05’ correlations of the pre-treatment WWWWith a, , between pre-treatment alpha and M/W/mu . M the four weeks of treatment in 4'“ W +35) [a ' 1.13 ”(tyne/l @4’” �gr.“ 3 r% \ -1¢¥“""‘MI‘CWEHi ‘ — n—fJ‘r‘mWﬁ“ is” w? \\\\- r" ”y, wwﬂ:;¢"‘”w {awr rth geeﬁ'is Significant at the IQ§hlével of . the relatidﬁship in The , .10- ,_ PMW’MW v . . . > I? if“? f e . . iﬁcénfidence; while thatﬂin the . ”His" ”419"“ M third . a"? "’1’ if.” . ﬁx ,q/J’WNW lynx-"”61 (”fl ”M" . . ' . the trend rewindicated. ’71" a/«am “Mmmmmwmm“minim“..m“, Discussion: aspects of these studies warrant discussion; the significance of Two the convulsion in the electroshock process; and the role of serial electroencephalogragh in the rational management and study of convulsive therapies. (1) Significance of Convulsions:’ In the initial studies of convulsive therapy numerous authors, including Kalinowsky gt_gl. (19h2), and Pacella gt ﬁl‘ (19h2) emphasized both clinical the and electroencephalographic ‘3' petit and , .. “7:4!“{ "5 “vﬁﬂu.. “2. ‘ ., r , mal responses. ',>~'(:.w ’ i differences idwmaewa‘huwmmmm. I'“.ﬁ:W’"amhma-~vmmm~a While Sa-‘iukw‘ﬂ-‘Ih-m‘yow'wwmmmww“ ‘ anthem," between the grand mal. k» " qut‘w' cal 'mal seizures inducedngﬂmd c 12 prove- gﬁetrﬁ‘w afﬁx), ‘ ducedﬁphaﬁges MW“ in less than 25% 0 4745“ M M one of delta activity:‘and to petit mal, is no delta activity. . WW 7 mm M In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been �.11described, and each, in turn, discarded in routine therapy. ( gt al. for example, in describing the electroencephalographic effects of ) focal seizure techniques noted that 70% I after mal Bergman 15 such of patients had normal records 4 "seizures;" while seizures. Ulett 23 El. 70 - 75% after had "abnormal" records grand ), in a careful control convulsive-subconvulsive ( study, reported a significant difference in clinical reSponse of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive w” as; 6L. (33%).{es—eontrele-438%92J He noted the discrepancy in the . . EEG response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. Recent additidnal reports on a by various observers, based variety of data,&emphasize the significance of the convulsion. (Weinstein and Kahn, Roth, Fleming). Thus, the evidence indicates that convulsions per se, are’or reflectlgthe significant physiologic events which are 0 the bases for therapeutic efficacy of "convulsive therapies." . both If the convulsion is the essential element/in the . . behavioral reponse, does the mode EEG and in the of induction of the seizure play role in this reSponse?. In the studies reported here, small but cally significant differences in both the degree of EEG any dLr statisti- delta activity �-12— and the rate of its ' development were observed between different methods of induction of grand mal seizure. Ulett gt al, ( ) reported an improvement rate of current convulsive technidue, but and concluded 76% 57% for alternating for the photic metrazol technique, that the convulsive photo-metrazol technique had a greater clinical efficacy. convulsant drug, PM More recently, Edwalds, describing a 1090, ascribed to it a new clinical efficacy slightly greater than electroconvulsive techniques. "we have further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance of clonic or tonic phase, apnea, seemingly not equivalent; and a etc. All grand mal seizures are �‘ .13seizure is not an "all or occur and these may none" phenomenon. Different; seizure patterns reflect the differences in physiologic effect of the different treatment method: Further studies of this problem are in progress. While that with repeated convulsions, of 60 - 80% are obServed. The or number of treatments. We Specific with regard to the differences is the brain may way is clear no matter how induced, improvement are small, and, for the most part, element it this variability in clinical results is reported, may be between various types of treatment obviated by increasing the frequency conclude‘that convulsive therapy the convulsion is induced. change subsequent rates to the convulsion, The and is non- significant not the agent ‘ \ . 92;}, \‘> �-1u- 2. Role of Electroencephalography in Convulsive Therapy: have applied methods of quantitative, We serial EEG analyses in the studies reported here. While clinical estimates of behavioral change may give similar data, such evaluations are more dependent on the attitudes Wé‘v M30 Further application of Wt. of the observer ( 3 than the EEG.‘ EEG analyses to a (5M basis rer'ZZ‘ other problems in convulsive therapies'mey providﬁérational \ MM41$;r’.11.~:a"3"‘“é-e?fof we have clinical different treatment techniques. previously noted that management of EEG analyses may be applied patients receiving convulsive therapy ( in the ). In the experiences reported here, the early and sustained induction of high degrees of delta activity provides the physiologic basis for behavioral change fail to in convulsive therapy. show a three times per ment. An electroencephalogram in patients significant behavioral response week may who on treatment regimens of serve as a rational basis for clinical manage- In those subjects in whom high delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a therapeutically more effective convulsant method, neurophysiologic changes. If the it may number of weeks, be maintained for a degree of delta may result in the activity is high; and other factors, as personality �-15( ) or environmental ( behavioral response, even and ) may when further convulsive therapy tion has been suggested by , _. *MM‘ ,nm4.~~-> ....~,..~v~m be assumed to preclude a satisfactory the neurophsyiologic substrate is assured; may well be discontinued. Roth ( ‘) A similar applica- for thiopental activated «AW‘~ EEG records. V . The successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational agents.( ). management and understanding of psychopharmacologic ..,. awuwlw'uuw... �-16Conclusions: 1. In serial quantitative analysis of degree of induced EEG delta activity in subjects receiving various convulsive therapies, a positive relationship between the degree of induced delta activity degree of behavioral change and ratings of improvement 2. An induced grand mal convulsion and both the is reported. is essential for both the EEG and behavioral change. 3. rate The a. and degree of induced Mode of delta activity is dependent upon: seizure induction b. Eiequency of treatment _ c. . 'h. It is Age of subject d. Pre-treatment recommended EEG record characteristics that serial quantitative electroencephalography provides a rational basis both for the study and clinical management of S various pix-Lodynamic therapies. �EASTERN PSYCHIATRIC RESEARCH ASSOCIATIQNHINC. OFFICERS 1957-1958 DR. DAVID J. IMPASTATO. SEC'Y-TREAS. 40 FIFTH AVENU’ETNEW YORK 11. N.Y. DR. LEO ALEXANDER. PRES. ‘33 DR. LAWRENCE H GAHAGAN, ASST. SEC'Y-TREAS. 164 EAST 74TH STREET NEW YORK 21. NHY " MARLBOROUGH ST.. BOSTON. MASS. i DR. THEODORE R. ROBIE. PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. DR. DR . DR. DR. DR DR. WILLIAM L. HOLT. JR. ‘IST VICE‘PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICEsPRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. Y. 0 0.0 COUNCIL JOSEPH EPSTEIN EMERICH FRIEDMAN WILLIAM FURST' "' PASQUALE LgorE‘sA'rA NICHOLAS Locngeio '* EVELYN‘IV'EY ' w O .0 TWELFTH SCIENTIFIC MEETING; THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SgHARP NEW YORK UNIVERSITY MEDICAL SCHOOL ALUMNIHALL-‘HALLH AII 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) o '0. “O o 0‘ PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing Completion Test (An Incisive Interpretation of the Unconscious) Ferruccio (Ii Cori, M. D. Discussant: Dr. David Wechsler 3. Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detail do you use in your examination of patients and the recording of your findings? ��EASTERN PSYCHIATRIC RESEARCH ASSOCIATION. INC. OFFICERS 1957-1958 DR. LEO ALEXANDER. PRES. 433 MARLBOROUGH 5.," BOSTON. _ MAss. DR. DAVID J. IMPASTATO. SEC Y-TREAs. 40 FIFTH AVENUE NEw YORK N. Y .f'W‘" 1“" AssT I-I SEC‘-Y TREAs. DR. LAWRENCE GAHAGAN 154 EAST 74TH STREET NEw YORK 21. N. v. II COUNCIL DR. THEODORE R. ROBIE, PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. JOSEPH EPSTEIN DR.’ EMERICH FRIEDMAN DR. WILLIAM FURST DR. PASQUALE LOTESTA DR. NICHOLAS LOCA'SCIo DR . EVELYN IVEY DR. WILLIAM L. HOLT. JR. IST VICE-PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICE-PRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. V. , 0 0.0 .0. I ' ‘ L I O 0.0 TWELFTH SCIENTIFIC MEETIN‘C THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SHARP NEW YORK UNIVERSITY MEDICAI_,,SCI:IQOL ALUMNI HALL— HALL "A" 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) O 0.. M 9 0.. PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing CompIetion Test (An Incisive Interpretation of the Unconscious) F erruccio di Cori, M. D. Discussant: 3. Dr. David WechsIer Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detaiI do you use in your examination of patients and the recording of your ﬁndings? �”mm: W A! W R433. mm, W 8mm. an. «mm W Main ~me7 WMMaotmm mm, mm mw mum at can a, m. mi» mm mm. 3.1. mum-«math-Wwwmnmaumﬂum, Wéym. ��to to m m (as) 29: ms (as) m m am (at) mm M «a (13) W «pork, m M m sea: M W mmwmama mm. ma: (.3) wanton-«arm “Manna mmmmmtm, “W“ (3) or “box-during my (11) mm: m not: 1m 1w to «:1an aluminum in tum than than with mew voltme- M nativity mtma 9”»th rum m nmm mt. «Wm mun WWW mmmmdmtho gamma. mum: mam-m Wﬂthmmutnmmmawoftmmmwm at Mt: «ﬂier, for “W pom, m mama In than not-1» at Fatima, subjects nativity, activity mad mm vim m Wham; Witty. m 01m awe may“. at mam anm mmmwmmmuwtmtymmm. mm A 4!- this a: my: damn words Miami. It mm awmmehonmdmdfmmam .WMMQMW Tha diffemm in 19 mathmmdmamthmmmmrﬁemufmymu mmmwmrmntmrthmmmmmmmm. ��‘ mm Ammqmuutmmmemmwuwm mm ”tamer mm mm W WW. momma 5.» tommmetthaméfwmafmuﬂumm.m 1. mwmmmuummmmm ,3" mtnuwdwatmwmu ”£2,“qu memumm. mm: WWW“ wwamm M Huh b. a. 1300th m1. um Mam” mum“. W:- & both for the. candy and mm Wm at ��Electroencephhlographic Correlates of the Electroshock Process MB): Fink MOD. and Martin A. Green PM). From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, in part, by grant M-927, National Institutes of Mental Health, National Institutes of Health, [1.8. Public Health Service. Aided, at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. Read E: 2- 15- :2 New York, N .Y. �EEG Correlates of the Electroshock Process During the past few years, renewed attention has been given b relation between changes in the electroencephalogram and behavioral changes induced by electroshock ( l-h ). Based on a hypothesis expressed ﬂie by weinstein and his coaworkers (5% in which they related improvement in electroshock to the development of persistent states of altered cerebral function, analysis of the neurophysiologic aSpects of electroshock an was undertaken in the laboratories at the Hillside Hospital in 1953. In fig initial EEG study,” a significant relationship between the degree and duration of the induced delta activity and clinical evaluations of behavioral change and "improvement" was reportedayeThis study was based on convulsions induced by a unidirectional current instrument '(Reiter). Subsequent eXperiences with alternating current techniques demonstrated differences in the rate and degree of development of delta activity. Age of subject and frequency of treatment were also factors in the EEG reSponse to convulsions. It is the purpose of this report to assess the role of treatment method, age of subject, frequency of treatment and pre-treatment EEG record Characteristics in the EEG and clinical re- sponse to convulsive therapy. Method: : hundred and £e££f3i=irt consecutive electroshock One been a day studied. Electroencephalograms after of therapy Patients wave ﬂ a treatment were taken before treatment, and on at weekly intervals during until the record referrals have had achieved its and following the course pre-treatment characteristics. in.whom the pre-treatment electroencephalogram demonstrated slow AsymmeM/ or Spike activity, or significant aaaynetcy; were excluded from the series. �M Wﬂnﬁ rig/L Wm MW W Jam ”WWW- ﬁght/M4 W M WWW W (W) Jam MM WMWWW/ WWWW2AW W; Jaww W ,asJ—u—m 4/— .49 «3'44» :L WWWWW.%II: WWWWWMMW W ﬂéﬁw‘jﬂ. W’ W .WM MAJJA MM Wag/d �-2employing different eatments proceo Four ‘ van-us of stimuli alte .‘. ‘. current at t-- old strengthf" al - ‘ a current at suprathreshold ‘directio: current ngth; 4 w (parathreshold); t) s unvulsive techniques with -ntothal premedication. have been used' , ~. _ _ nat' The ‘ - ‘ alternating current suprathreshold (7) km W ﬁatients, unidirectional parathreshold and MW b‘ currenté’ ., without prior sedation, received for? second), usually sufficient for a petit mal response. odes second 3", (90 volts At 20 W intewals‘voltage, and; if necessary, duration! ale-re increased . . , until a grand to "Nu“ In the threshold alternating current (8) techniQues aae‘ well described. method ‘ mal convulsion was induced. mwmnl- The “voltage and induce a grand mal was the threshold value. be necessary In subconvulsive techniques, patients were given pentothal intravenously gor (>0 until asleep, either seconds (8); or alternating were administered petit and then for one to three low voltage, currentoi' 80 unidirectional current to l20 voltsﬁrézsecond applications, for a total of 2b to 3.6 mal All treatments were given three times a treatments. Patients week initially, for 12-20 failed to develop a significant behavioral or m m 55;, Mew $3 :13; gm W, were subsequently who clinical reSponse, or Jo treats (1% times per week. All activity. EEG ‘ b records were quantitatively measured for the degree of delta The "records were evaluated as to whether they demonstrated "high," "moderate" or "low" degrees of delta activity, according; to criteria pre- viously published (6). Evaluations of changes in behavior were psychiatrist and made by the supervising resident therapist at the height of the treatment effect) �, WWW WM/Jéw A?%MWW%4 /¢(WWW’MW” JKWWM HQWWWi ' ‘ �-3... and were scored as "marked," "moderate,"'hdndmal" or "none.” "improvement" were made by these physicians two ratings of The to three weeks after treatment was terminated, and were based on the four fold classifica— tion of "recovered,” "much improved," and "unimproved or worse.“ (6) Results: 1. Convulsive vs Subconvulsive Techniques: W MW, ' WW therapgrfglhad the h? subjectstwho received convulsive high degree Of delta records in-both second, third two of the three weeks, and of the )4? 13 subjects failed to the 27 subjects who and during Show a convulsive therapy. Of 6";gr one “a Low weeks of treatment; 12 during of the test periods. Thirteen high degree delta record on received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. fourth activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. neahJ-l’ 21‘ ln concurrent behavioral ratings, hirof the.ﬁﬂ subjects in the ‘ convulsive group showed marked behavioral change; while of the subcdn- vulsive group, (Table I). therapy. *» Y‘aab éacbndldb ham, ‘ ﬂ Of 2h of the the or 27 showed minimal latter group, 19 were no behavioral changes. referred for a second course of In lb of these, grand mal electroshock induced high degree delta .RE niekagd: uan W‘LWM ,_ AAAAaaeut "W wthwﬁ W ynxuduvuax “Gunrﬂ nta. waT‘5~/::L¢Gﬁe , . I �.uactivity and all showed a significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroshock, all WW m Showed middle degree behaﬂoral change. m. L *3 3 hawk»: records; and two of the five 47 I TABIE Showed a W! 4‘ 9““..44 b ' Ratings of Behavioral Change; Convulsive—Subconvulsive Therapies (Tourth-Fifth'weeks of Treatment) Degree of Change Moderate Minimal 27 15 S O O 3 8 16 Marked ConvulSive Therapy (h?) Subconvulsive Therapy (27) None In evaluations two weeks after-treatment of the degree of "improveof the convulsive therapy grongj::ted as "much improved" or "recovered," and 32% as "improved."qag% discharge, 51% were evaluatedileZS ment," 51% sustaining the and only were were 7% same degrees of improvement, while were "unimproved." rated in the first Of "unimproved;"ﬁgﬁgeiggége§:§§:$§%§:red do were "improved," the subconvulsive group, however, two categorie51’19% hOSpital discharge evaluations h2% in the "improved,“ but for a 11% 70% second course of therapy, not reflect the effects of subconvulsive therapy. II TABLE Ratings of Improvement: Convulsive-Subconvulsive Therapies (Two'ﬂeeks After Last Treatment) Recovered Much Improved Improved Unimproved Worse Convulsive Therapy (h?) 9 15 15 8 Subconvulsive Therapy (27) 2 l S 19 �W. .r -5... din=;.€onvulsive therapyinduced signiiicantly greater behavioral MM“ whichchange and eva uations of improvement thangsubconvulsive therapy We The parallel the electroencephalogr . Also, patients -EEG clinical I observations“ ”A“! who showed neither showed both or a behavioral response to subconvulsive therapy, and behavioral changes when placed on convulsive an EEG therapy. 2.- Role of Type of Convulsive Therapy; In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analgrsis of the was undertaken. 2. The effect The oi‘ type of electroshock on EEG delta actvity results are graphically presented in Figures first figure relates 1 and the treatment type to the percentage of weeks record ‘n each treatment group during the second, third and fourth tre:Egentgggégggggating:high degrees of EEG delta actigggi) In each of period, treatment with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unicurrent and with alternating current at threshold strength was directional less efi'ective than the suprathreshold alternating current techniquef.in each period; the unidirectional current treatment being more effective than the threshold alternating current method only early in the course of therapy.* Vsubconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same the per cent of each treatment group showing 7“: relationship no by measuring delta activity or only low ncés ..-»_. :v-n suprathe a‘, ent perins, tre Eur, .l-i-o . an. etho’.'5 - thre o'd reatv t si " Can at .05 by chi 7—9 “-3 ou- in} vDi7”e~' ces b tw-z para --12 0-" 0d“; no ignifican ' dWL- ‘ j . hold met‘ods, and for each method �at Mt“ M74 @WWAEW �-6Here, the subconvulsive group degrees of such activity. is lOO%_for each treatment period. Suprathreshold alternating current techniques show the least number of such records in each period, with threshold and parathreshold techniques in between. 3. Frequengy of Treatment: Another factor in the rate of development of delta activity is the frequency of treatment. While all patients were initially treated three ltimes a week, a number who failed to develop high degrees cf delta activity on convulsive therapies were treated more intensively. In nine daily or twice daily, and in each instance middle or high degrees of delta activity were induced. Similar such patients, treatments were given correlates were previously demonstrated Callaway (10). EEG h. Factor of In the by Pacella gt'gl. (9), Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta the first such and second weeks of activity during treatment; while older subjects developed activity to a significant degree during the third week. fourth week of treatment, the groups. Combining observation. and By the differentiating aSpect between the data from.all convulsive therapies supports this age was no longer a IMring the second week, h3% of records are high degree delta in patients under the age of no; but only 30% in patients from uo—oo, and 18% in patients 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects degree delta records when treated 3 times per week. have high �-7TABLE Variation in % High Degree Delta Suwd To DO years (28) Records With Age M ﬁlm k2 29% ' W % Treatment Period $9.213 69% 61% h3% (28) Lil-50 EEG lit-.9. £211 £59. III W W ‘ 31-66 (28) 32% 56% 55% (18) 18% 50% 80% ‘ 61+ 5. Pre-Treatment Record Characteristics: * Previous reports, summarized by Chusid and Pacella, ($3 noted a significant relationship between pre—treatment record characteristics and the degree of induced "abnormality." Predominant alpha rhythm, "abnormal" (3» or "borderline abnormal" (11) records were more liable to develop alterations in the EEG than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment record demonstrated diffuse slow wave were not included activity, spike or spike wave activity in the statistical analyses. Eight such subjects were saven of them developed high degrees ”treated with convulsive technique? and of delta activity earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre—treatment alpha and the degree of induced delta activity was undertaken, Rank order * The difference in incidence of high degree records is significant at .0 between the second and fourth weeks and .051 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. WW WM *7 �-8correlations of the pre-treatment per cent time alpha in selected leads (anterior temporalavertex) with the degree of delta activity during the third and fourth weeks of treatment in _tions of +.2u and +.35 reSpectively. week is significant at third'week N£L0 Two h3 The patients demonstrated correlarelationship in the fourth the .05 level of confidence; while fails of significance, although the trend that in the is indicated. aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and the role of serial electroencephalograms in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the éﬁéggél studies of convulsive therapy numerous authors, including Kalinowsky 2:". g. (12), and Pacella §_t_ (9)7 emphasized 3;]: both the clinical and electroenCephalographic'differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes subjects. Similarly, electroencephalograms in grand delta activity, while in petit mal therapy, no in less than 25% of mal therapy demonstate delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, been described, and and focal convulsive tedhniques have in each, in turn, discarded in routine therapy. Bergman §t_al, (13b for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records 70-75% had "abnormal" records after grand after 15 such "seizures;”'while J �-9mal seizures. Ulett gt a;. (1h), in a careful control convulsive-sub- convulsive study, reported a significant difference in the clinical response of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive (33%), or controls (38%). EEG He noted the discrepancy in the response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. W Recent additional reports by various observers, based on a variety of data further emphasize the significance, of the convulsion in the therapeutiC'responSe (1, l5, 16).fﬁeinstein—end thus indicates that convulsions per; are, or reflect, the significant physiologic events which are the basis The evidence se_ fortherapeutic efficacy of convulsive therapies. If the convulsion is the essential the behavioral reSponse, does the any role in this reSponse?. in both the degree of EEG mode element both in the EEG and in of induction of the seizure play In the studies reported here, small differences delta activity and the rate of its development were observed between differentxnethods of induction of grand mal seizure.jh/§ Ulett gt a}: (11;) reportedan improvement rate of 57% for the alternating current convulsive technique, and 70% for the phodio-metrazol technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulSive photo-metrazol technique. this repert, Kalinowsky noted 'various workers as being vulsions. Eh More more that metrazol convulsions have impressed efficacious than electrically induced con- recently, Edualds, (l7) describing a 1090, ascribed to it In a discussion of new convulsant drug, a clinical results slightly better than electro- convulsive techniques. 'We have further noted that the convulsions induced by various tech- niques have varying characteristics of latency, duration, preponderance �.10of clonic or tonic phase, apnea, not equivalent; and etc. "All grand mal seizures are seemingly a seizure is not an "all or none" phenomenon. Different reflect the differences inhphysiologic effect of the different treatment methodfp Further studies of this problem seizure patterns occur and these ‘are in progress. While this variability in clinical results is reported, that with repeated convulsions, 'of 00 may - 80% are observed. The differences element is the brain may way rates between various types of treatment benobv1ated byzincreagang the frequency we may conclude specific with regard to the is clear no matter how induced, improvement are small, and, for the most part, or number of treatments. it that convulsive therapy is the convulsion is induced. The DOD? significant change subsequent to the convulsion, and not the agent in bringing about this brain change. In previous reports (6, 18, 19) we have noted that convulsive therapy is also non-specific with regard to its application in mental illness, and in its clinical and behavioral effects.used The present studies amplify, therefore, the previous conclusion of the non- Specificity of convulsive therapies. 2. Role of Electroencephalography in Oonvulsive Therapy: applied methods of quantitative, serial EEG analyses in the studies reported here. While clinical estimates of behavioral change have we have yielded similar data, such evaluations are more dependent on the attitudes of the observer (20), and less amenable to quantification than the EEG. Further application of EEG-analyses to other problems in convulsive therapies provide a rational basis for the comparison of different treatment techniques. we have clinical previously noted that management of EEG analysis may be applied in the patients receiving convulsive therapy (6). In patients �.11Who fail to significant behavioral response show a on treatment regimens of three times per week, an electroencephalogram may serve as a guide for further therapy. In thise subjects in whom high degree delta activity has not been induced, increasing treatment frequency, withholding pre- medication, or shifting to a more effective convulsant method, may result in the neurophysiologic changes. If the degree of delta‘activity is high and sustained for a or environment#(18) number of weeks, other may be assumed factora',as personality (21) to preclude a satisfactory behavioral reSponse, even when the neurophysiologic substrate convulsive therapy is assured; and further well be discontinued. A similar application has been suggested by Roth (3) for thiopental activated EEG records. The may successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational management and understanding of psychopharmacologic agents (19). ��3;; Zn, ~ 6w WMMWL, _ ~ 4; �(«My REFERENCES 1. Roth, 1.: Changes in the EEG Under Barbiturate Anaesthesia Produced by W.Q Electro-Convulsive Treatment and Their Significance for the . Theory of ECT Action, 3: 251-280, 1951. 33. £5 Clin. Neurophysiol. Roth, M., Kay, D. W.K., Shaw, J. and Green, J.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG “a..- Clin. Neurophy61ol. :2, Chusid, J. G. and Pacella, B. L.: Shock Therapies, h. Ulett, G. and ,1 MM Johnson, _ J. Nerv. m M. W.: 225-237, 1957. 2_: The Electroencephalogram in the Electric:;> &:Ment. Dis. 116: 95-107, 1952. m" "' any...MA... mm:-W M and Scopolamine Upon Efiect of Atropine Electroencephalographic Changes Induced w”,// 1. By Electroconvulsive . Therapy, EEG.,Clin. Neurophysiol. 2: 217-22h, 1957. S. ‘Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Its Relation to the Therapy: Psychiat. 6. Fink, M. of Shock Therapy, and Kahn, R.L.: Relation of Electroencephalographic Delta Neurol. & EBSponse in Electroshock, A.M.A. Arch. Psychiat. Z§: 51o5525, 1957. Kalinowsky, L. and Hoch, P.: Shock Treatments, Psychosurgery And Oﬂier Somatic Treatments in_Psyohiatry, Grune 8. éﬂ:_i; 192: 22-26, 1952. Activity to Behavioral 7. Theory & Stratton, N.Y., 1952. Alexander L.: Treatment of Mental Disorder, W.B. Saunders Co. fhiladelphia, 1953. 9. Pacella, B.L., Barrera, E.S. and Kalinowsky, L.: Variations in the Electro- encephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Psychiat. g1: 307-38u, 19h2. �10° 11 . Callaway, 3.: Slow wave Phenomena in Intensive E1ectroshock,«Elootpa. tag; ennaphalggrﬁk'Clin. Neurophysiol. a: 157-162, 1950. t K)~u~uu¢,nk‘04+&.LUéQQNUM’ antm 3‘ v~n£.aax+ueB ox BK 33,; swam: n 3,. H AW“ um “3' W i?! p 12. Kelinowsky, L., Barrera E.S. and Horowitz, WA“ in Electric Shock Therapy, Am. The J. Psychiat. .y. i'c I 4"?“ use... "Petit-Mal" Response 2Q: 708-711, l9h2. 13. Bergman, P.S., Impastato, D.J., Berg, S. and Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Fbcal Seizures, Conf. Neurol. 11: 271-277, 1953. 1h. Ulett, G.A., Smith, K. and Gleser, 0.0.: Evaluation of ConvulSive and Subconvulsive Shock Therapies Utilizing a Control Group, gm;_g, szchiat. 113: 795-802, 1956. 15. Wéinstein, E. and Kahn, R.L.: Denial of Illness, C.C. Thomas, Springfield, i 1955. 16. Fleming, T.C.: An Treatments l7. Edwalds, Inquiry into the Mechanism of Action of Electric Shock 'Jidbnuav'nﬁuatJWor ,WO-ASO , 1950 . K.M.: Intravenous Administration of with a New Convulsant Drug. Read at PM 1090: Clinical Experience N.Y. Divisional Meeting A.P.A. 1957. 18. Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the ElectroShock Process, Dis. Nerv. Sys. 19. Fink, M.: A Unified Theory of the ACtion of Physiod namic Therapies, J. Hillside 20. Fink, M. and Hosp .__(_3_§ 19 7-200, 1957 . Kahn, R.L.: Behavioral Patterns Brain Function. 21. (in press). Read Kahn, R.L. and Fink, M.: at in Induced States of Altered N.Y. Divisional Meeting A.P.A., 1957. Personality Factors in Behavioral Electroshock Therapy, Conf. Neurol. (in press). Response to �mmﬁmu mumm. in M minions: W manta, mm mm am mm mu, 3.1. a: mm mm, mam mm mum mm M Mia mu: m“. &, M. at mutmmmummmmwmumamrmxm. VIM ��m W a: moo nativity «many to: tho uwmmthomw Migration“ (Miamimdmthouoomw the «Mo Wvomwmmuﬁml) Withomotmm room: Woo with Moment, Magenﬂ MWm«on ntod u “MAW of data. muty. yW WW 1 4- .. 11111 . . mammumuwumamuwmw 25mm W» W t mm ”mm Wt? 'W 28 12“ 21 8'! a 66." h“ 35 13 16“ 3 2 a M K 60 t wowmammmmgmmmw stumpWM Wommmmmmmlﬁm at m woman” mind Wm t1»npy*1n this M. m: who 34? 9 .3, ommamae monmmmmmmmmywamm 19 ”loom mu, plat tofu-rod for t «W W“ of thong, ' Win . ﬂ UWJOOM ��m Mm Mm am m 1%- M 61 M 1:: (28) W (38) M M W (28) 311‘ 565 (18) W 30% , thmum mwmmammﬂva thmm Wsmﬂmt Wampum “W" (ﬂw‘W W“ (n)mmmmmw mmnwpum. mmmerpmmmwmmm~mam ‘- _'mmunwmmu%%wapm§uwmw mmmwmmamummwa. thmmm �“Nuthmmw Mgr: than m 3mm of A. ma W,mm,W. mama“mmWWW pom, mu nativity without. such M for mm wan-«mam» Mutiny. WM maym at the man hum put-mm awn mmarwu1ummuymmm. mum mumaunpmmmmmmamnmmm (wwwm)uwmmdmummwmm m gm was « tantalum w a: mum. mm mum m at Nﬂbwhﬁmmunlyo mmumpmm comma mm“ mw3mmsmmmmm Wmum am at mum, among: an m u Mam. . ��Reprinted from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958. Electroencephalographic Correlates of the Electroshock Process and MARTIN A. GREEN, M.D. In the course of an evaluation of the role of a1tered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re—assessed. MAX FINK, M.D., Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment, on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varied, including unidirectional and alter— nating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12 to 20 treatments. Patients who failed to develop a clinical response, or EEG changes of signiﬁcant degree, Were subsequently treated at 5 to 10 times per week. The EEG records were classiﬁed for degree of delta activity into “high,” “middle” and “low” degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest ampli— tude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the Read at the meeting of Eastern Psychiatric Research Association, Inc., held Feb. 6, 1958. electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. Results: 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was signiﬁcantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subconvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional instruments, but by the 4th week of treatment, the differences were eliminated. 4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient. 3) Early and sustained high degree electroencephalographic delta activity is a necessary, though not sufﬁcient, pre-requisite for improvement in the electroshock process. - �mmmmm Garnish” at the mammoak Mam Hawaii‘s WWW at Moan rawhiam, 35.11.3169 363331981, men Oaks, m... mamas a: mm mm mums. w grunt 16-927: 33.131th um, in wt, M. ”03¢ M116 English From the Mﬂtﬁﬂﬂ Band at 131-13 Halal, mm at the Eastern mum autumn ”Manama, ﬁat York, Pcbmary 6,. 1953. Whip-$8 Saran. 3.1. �WWMMW.WMMMMﬁmhm Wmmmmmmammmwmmmm WWW.1IW (1.1).. 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Wu W. nativity that aw: 1w WWt ‘ � 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 Electroencephalographic correlates of the electroshock process. Dis. Nerv.Syst., 19: 227, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-32-009 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin 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 12 items. 1: [preprint]. 2: Edit page. 3: Hand drawn graphs. 4: Handwritten notes. 5: Drafts. 6: Program for Eastern Psychiatric Research Association, Inc. Twelfth Scientific Meeting, February 6, 1958 (handwritten notes on back). 7: [preprint]. 8: Final copies. 9: Reprint from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958 (one page). 10: [preprint]. 11: Discussion - NY Neurological Society 3-11-58. 12: [preprint]. 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