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Relation of Tests of Altered Brain Function to Behavioral
Change Following Induced Convulsions
Max
Fink,
McDo
Robert L. Kahn Ph.D.
and
Hyman
From
Korin Ph.D.
the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks,N.Y.
Institute of Mental Health, National
Health Service.
United
Public
States
of
Health,
Institutes
Aided by Grant M-927 of the National
(in part) at the Divisional Meeting A.P.A., Montreal, November, 1956, and
International Congress of Neurological Sciences, Brussels, July, 1957.
the
at
Read
12-3-57
“W5, $9;
WW7
A“!
�Relation of Tests of Altered Brain Function to Behavioral
Change Following Induced Convulsions
Numerous
studies have been.reported assessing the type, duration
and significance of mental changes following electroshock. These reports
vary widely in their descriptions and
meaningful conclusion regarding the
it is difficult to arrive at a
relation of such mental changes to
clinical response. Basic to these differences in observation are the
vexing problems of the definition and the ways of measurement of organictype reactions;
the time relation of the measurements to the treatment
process; and the definition of improvement following therapy. Each of
these factors bears an integral relationship to the final definition of
the problem.
In the present study, various
tests of brain function were
applied serially to patients in mhom‘behavicr was altered by repeated
inductions of grand mal convulsions (Electroshock).
The
data comparing
the serial changes in these indices are presented.
METHOD:
Definition of "organic mental changes":
conventional conception
The
of organic mental changes includes such behavioral changes as impairment
of
memory and of
the discrimination of differences on perceptual tasks;
disorientation for time, date, or place; errors
tractibility
and
inability to handle
perserveration in speech
on
more than one
and behavior; emotional
calculation tests; dis-
situation at a time;
lability;
and
loss of
interest in one's appearance and in the environment. Most studies assess
the relationship of memory loss or clinically manifest disorientation to
improvement following
by
tests of
simple
electroshock.
The memory
loss is usually measured
recall, information, personal events, digit
memory span,
�~2r
etc.: while disorientation is
place, date,
determined by questions
the examiner, 323,
name of
Such
tests of
relating to present
memory and
of
orientation, however, discriminate primarily only severe degrees of dysF
function.
In the present studies, cognizant of the difficulties inherent in
clinical assessments, we measured changes in brain function by four
different measures, hoping thereby to determine varying degrees, or even,
simple
types of dysfunction.
The
four'measures selected as being sensitive to
varying aspects and degrees of cerebral dysfunction.were:
a) The degree of delta activity in the electroencephalogram (1).
b)
in language and orientation following the administration
of amobarbital sodium - the "amytal test" for organic brain
Changes
disease (2, 3).
c) Alteration in perception of multiple simultaneous
d)
Changes
in tests of recall of
the interpolation of reading
Time
of Testing:
A
common
lists
tactile stimuli (h).
words, both with and without
of nonsense syllables (5).
second factor to be considered
is the
time of
application of these tests in relation to the treatment program.
Observers have reported the development of organic changes in the
Numerous
few
minutes of recovery following each treatment. Others noted the appearance
of mental changes during the course of treatment, and reported that treatments
at periods more frequent than the conventional three times per week induced
earlier and more severe changes. The transient nature of the changes are
frequently noted, so that by the second or third
at pretreatment levels,
orientation is re-instituted.
course of therapy the electroencephalogram is
memory changes have
disappeared and
week following an extensive
�-BIn the present studies, the electroshock treatment schedule was main-
tained at three times per week with
Reiter electroshock, during the
all
patients receiving conventional
initial three weeks.
In the fourth week,
treatment frequency was occasionally reduced to two times per week. All
patients received a
out
at
weekly
minimmn
intervals
of twelve treatments. All
on a day following a
tests were carried
treatment during the course
of therapy. Following termination: of therapy, weekly testing was continued
until the tests returned to their initial level.
third factor crucial to a study relating the
significance of organic mental changes to electroshock results is the
definition and evaluation of "improvement." The evaluation of clinical
Behavior Ratings:
response to therapy
A
is
a subjective value judgment by the therapist or
adninistrator which reflects a divergence of goals, judgments, and compromises. Significant variables in the evaluation of "improvement" are
the type, severity and duration of the pets“. ent' s illness, his premcrbid
personality, the sociologic (family) constellation to which he will return,
and the expectations (both conscious and unconscious) of the
institution, of the patient and of the family.
of the evaluation of the treannent result is also a
the
therapist, of
Furthermore , the time
most
sigaificant
variable.
The
parameters of evaluation have not been satisfactorily delineated.
In this study, the following
compromises have been made.
All evaluations
qualified psychiatrist who has no responsibility
for the selection of subjects or application of the treatments. Patients
are
made by an independent
are seen weekly
and conferences are
held with the therapist to assess the
�.Ll.
therapeutic goals before treatment and the therapist‘s estimate of the
respOnse
after treatment.
The
finai evaluation used here is the
clinical state of the patient during the second and third weeks following
the last treatment, and describe only changes in clinical behavior.
we have used a
three-fold classification of
improved" and "uninmuoved," with the
and "unimproved"
"much improved," "moderately
intent that the
categories respectively
"much improved"
would describe
patients at
the extremes of the response continuum.
The
patients rated as
those
"much improved" were
showed the symptoms which brought them.to the
who no
longer
hospital, their physicians
believed them to be better, and the nurses' notes confirmed such aspects
as being able to sleep without medication, better appetite and improved
capacity to participate in hospital activities.
The "unimproved"
patients were those
noticeable change in behavior
who
manifested no clearly
or'Who became worse.
The "moderately improved" patients showed some change
but continued to manifest signs of'mental illness.
some symptomatic
relief,
which was
transient.
They
in behavior,
typically showed
�.5.
RESULTS :
Twenty-four consecutive electroshock patients were studied.
these, eleven
and
were
Of
"much improved," seven as "unimproved,"
rated as
six as "nmderately improved."
(a) Electroencephalogrems: EEG records, using conventional leads,
were measured for the average per cent time
delta activity,
and
highest
per cent time delta in any one lead; the Slowest frequency in the record;
and the duration and amplitude of delta burst activity (1). Using these
measurements, the 180 records in the series were placed in rank order
according to the degree of delta activity.
The upper
1/3 of the records
were described as "high delta activity" and the lowest 1/3 as "low
delta
activity."
pretreatment records showed delta activity. During the course of
electroshock delta activity appeared in all records to varying degrees. It
No
was apparent within the
on the
third
with high
first
week following
EEG
week of treatment and
the
7~9
treatments.
The
usually reached a peak
results for those
delta activity are seen in Table I.
TABLE
EEG
-
%
I
High Delta
Activity
1-3
h—é
7-9
10-12
25
80
91
88
Moderately Improved (6)
0
16
50
ho
unimproved (7)
o
o
o
20
Treatment Period:
much Improved (11)
�~6(b) AmObarbital Test: In these
tests (2,
3) the patients are asked
series of questions relating to their illness and to orientation.
Sodium amytal is administered intravenously until nystagmus and slurred
speech are observed. The questions are then repeated. Changes in
a
orientation
and awareness
of illness are scored as "positive" amytal
response, reflecting a change in brain function ascribed to “organic
brain disease" (2).
The
results are noted in the next table.
TABLE
II
Amvtal Test -.%
Positive
Treatment Period: 1-3
11-6
7-9
10-12
13-15
Much Improved (11)
us
61;
100
89
100
Moderately Improved (6)
20
33
67
20
25
Unimproved (7)
1h
16
16
33
o
The
data of Tables
The congruence
I
and
II
have been graphically portrayed in Figure
of the observations of the degree of
delta activity
EEG
l.
and
test responses is demonstrated. (Fig. 1)
Tests: In this test (5) a list of three letter common
the per cent positive amytal
(c)
Memos!
words were presented
for
10
to patients by flash cards.
trials. After this, lists
interpolated.
The
of 3
recall of the first
The
cards were presented
letter nonsense syllables
list
were
of'wordStmas.then tested, and
the number of words recalled in each session was scored.
An
impairment
in recall function
decrement was maximal
in the second
was apparent
and
third
in all subjects. This
weeks of
sustained as long as treatments were administered
treatment,
3 times a week.
and was
�-7The
decrease in ability to recall the word
list is
noted
in the next
table o
TABLE
III
anaiment in Recall -
Marked Decrement
%
Treatment Period
1-3
1456
7-9
10-12
Improved (9)
o
11
33
o
Moderately Improved (h)
0
SO
SO
0
Unimproved (7)
0
1h
0
0
Much
the scores are compared with the mprovement rating, there is
no significant difference between groups. The rapid return of recall
ability to pretreatment levels when treatment frequency was reduced to
When
two times per week
indicates that this
more severe degrees
test is
a measure of only the
of cerebral dysfmction.
tests the patient is touched
by the examiner simultaneously on the cheek and the hand, and asked to
localize the stimuli. The tests are repeated for 10 trials using varying
combinations of cheek, hand, shoulder and thigh. Persistent failure to
(d) Tactile Perceptual Tests: In these
report
the stimuli or to mislocalize a stimulus beyond the tenth
indicative, in adults, of altered cerebral function (h).
one of
trial is
In all subjects, this test
was negative before
patients. In nine patients, two
observed, and of these, six were in the much
responses were observed in 19 of the
consecutive responses were
improved and three
treatment. Positive
21;
in the moderately improved groups.
�In the next table the positive responses were charted with relation
to the treatment period
and
of positive regaonses is to
the clinical evaluation.
be noted
in the first
A
high incidence
two groups, and many
fewer such responses in the unimproved group.
TABLE
Face Hand Test
IV
- % Positive
1-3
h-6
7-9
10-12
13-15
Much Improved (11)
16
no
in
h3
60
Moderately Improved (6)
60
1:3
2:3
30
o
o
16
12
11
o
Treatment Period
Unimproved (7)
�DISCUSSION:
Three aspects of these observations warrant elaboration.
sensitivity
and the
and
stability
The
of these indices of altered brain function
significance for a definition of altered cerebral function;
the relation of these indices during and
evaluation;
and
after treatment to the clinical
the relation of these observations for the theory of
electroshock action.
All
tests
showed changes during electroshock therapy,
indicating
that a state of altered cerebral function'was induced. Certain tests,
as the
EEG
and the amytal
test,
were altered
after a
few convulsions
persistently positive for one to three weeks fOIIOWing
treatment. In this regard the electroencephalogram manifested the
earliest and the most sustained changes. The recall and tactile perceptual tests also showed changes but these appeared late (in the 2nd
and remained
week of treatment) and disappeared
rapidly
when treatment frequency
was reduced.
Tests of recall function and
tactile perceptual tests, therefore,
are less sensitive indicators of the state of cerebral function. In
any evaluation
of the relation of an induced
to another‘variable,
it is important,
the operation (or
test)
and the
Because these
tests
have varying
change
in brain function
therefore, to clearly define both
sensitivity of the operation which forms
the basis for the estimation of altered cerebral function.
sensitivities, the frequency of
treatment and the duration of the treatment regimen become important
variables in any assessment.
EEG
changes are maintained by infrequent
�~10-
treatment, while changes in recall function and simultaneous tactile
perception are rapidly
0f the
function,
clinical
lost,
when treatment frequency
reduced.
correlations possible with these tests of brain
many
we have
selected the relation of these test results to the
improvement
rating.
‘With
the
EEG-and amytal
relationships between the appearance of test changes
improvement are
is
clearly observed. In the
positive amytal tests
and high degree
were more marked, and were sustained
EEG
tests significant
and
much improved
clinical
patients,
abnormality appeared early,
for longer periods (on the
treatment regimen) than in the unimproved patients.
The
same
moderately
improved patients were in between.
relation between altered brain function and clinical response
This
is noted only with the data obtained during the course of therapy.
There is no correlation of improvement ratings with post-ptreatment test
results. This divergence is related to the timing of test applications,
in the conclusions of other studies
and may explain the discrepancies
of this prdblem.
These Observations can also be
mode of
action of electrochock.
related to an understanding of the
In 1952,'Weinstein, Linn and
Kahn
(6)
postulated that the function of electroshock therapy was to "initiate
the production of a state of altered brain function in which the patient
his problems." These observations support the first part of
this hypothesis. namely, that a state of altered cerebral function is
can deny
induced by electroshock. Also, in patients who.improved, the altered
state is
more prominent, appears
earlier and is
more
persistent than in
�,
those
who
fail to
improve.
Of
the eleven
positive amytal tests (while
positive test); and ten had high
had
one of the unimproved
.11.much improved
patients, all
5 of the 7 unimproved never had a
EEG
abnormality records, while only
patients had such a record.
It is
our condlusion
significant degrees of altered cerebral
function are a prerequisite - a necessary, though not a sufficient
requirement - for improvement in electroshock therapy.
that early? sustained
and
�4.2;»
W:
In a study of the relation of tests of altered brain function
to improvement in electroshock,
of change
it
was observed
that while indicators
in brain function vary in sensitivity, all tests indicate
the development of organic mental changes during electroshock therapy.
The
reason for the conflicting results reported by others can be
accounted
for by the variations in the tests used, the time of study
difficulties in evaluating improvement.
It is our conclusion that clinical improvement in electroshock is
and the
dependent on
and
early, sustained
that electroshock therapy
and marked changes
may be
in mental function;
described as the non-Specific,
traumatic induction of states of altered cerebral function in which
the subject reacts with
new
patterns of adaptation.
�REFERENCES
1- Fink,
M. and Kahn, R.L.: Relation of EEG Delta Activity to
Behavioral Response in Electroshock: Quantitative
Serial Studies, A.M.A. Arch. Neural. & chhiatflfi:
516.525, 1957.
_
Kahn, R.L. and Malitz, 3.: Serial Administration
Test"
for Brain Disease. Its Diagnostic and
of "Anvtal
Prognostic Value, A.M.A. Arch. Neural. & Psychiat.
217-226, 1951;.
2. Weinstein, E.A,,
_’_?_I_:
3.
Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital
Test to Clinical Improvement in Electroshock, A.M,A.
Arch. jieurol.
8c
Psychiat" Zé: 23-29, 1956.
and Bender, M.B.: The Face-Hand Test as a
Diagnostic Sign of Organic Mental Syndrome, NeurologX, _2_:
h. Fink, M., Green, ILA.
h6—58. 1952.
H. , Fink, M. and Kwalwasser, 8.:
Memory and Learning to Improvement
Neuron-o, $6.: 88'96’ 1956.
5. Karin,
Relation of Changes in
in Electroshock, Conf.
Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy,
Am.
J. Psychiat., 109: 22-26,
1952’.
�--- .. anEu’mlJ-Jfial
from
,
“T'he FLSL
, ,.. -n
Congress of Neur-ofogical
’, Brussels, 1.;7. Vol. III.
EEG, Clinical Neurophysiology
ces
-pllepsy. Pergamon Press; London, New York & Paris 1959
"Emmi
,
RELATION OF TESTS OF ALTERED BRAIN FUNCTION TO
BEHAVIORAL CHANGE FOLLOWING INDUCED CONVULSIONS
DANS
CEREBRALE
FONCTIONNELLE
ALTERATION
D'UNE
ROLE
LE CHANGEMENT DE COMPORTEMENT SUCCEDANT A DES
CONVULSIONS PROVOQUEES
MAX FINK, ROBERT L.KAHN and HYMAN KORIN
New York, U.S.A.
Numerous studies have been reported assessing the type, duration and
significance of mental changes following electroshock. These reports vary
widely in their descriptions and it is difficult to arrive at a meaningful
conclusion regarding the relation of such mental changes to clinical
the
in
vexing
observation
differences
to
are
these
Basic
response.
problems of the definition and the ways of measurement of organic—type
reactions; the time relation of the measurements to the treatment process;
and the definition of improvement following therapy. Each of these factors
bears an integral relationship to the final definitiOn of the problem. In the
to
function
of
applied
serially
brain
were
various
tests
present study,
of
inductions
grand
altered
whom
behaviour
by
in
repeated
was
patients
mal convulsions (Electro shock). The data comparing the serial changes in
these indices are presented.
MET HOD
Definition of 'organic mental changes'
The conventional conception of organic mental changes includes such
of
of
discrimination
the
and
of
behavioural changes as impairment memory
differences on perceptual tasks; disorientation for time, date, or place;
handle
to
and
more
inability
caICulation
0n
distractibility
tests;
errors
than one situation at a time; per serveration in speech and behaviour;
emotional lability; and loss of interest in one‘s appearance and in the
environment. Most studies assess the relationship of memory loss or
clinically manifest disorientation to improvement following electroshock.
The memory loss is usually measured by tests of simple recall, informa: while disorientation is
etc.
tion, personal events, digit memory span,
determined by questions relating to present place, date, name of the
examiner, etc. Such tests of memory and of orientation, however,
discriminate primarily only severe degrees of dysfunction.
In the present studies, cognizant of the difficulties inherent in simple
clinical assessments, we measured changes in brain function by four
different measures, hoping thereby to determine varying degrees, or even,
to
sensitive
selected
four
being
The
as
of
measures
types dysfunction.
varying aspects and degrees of cerebral dysfunction were:
(a) The degree of delta activity in the electroencephalogram (l).
(b) Changes in language and orientation following the administration
of amobarbital sodium - the 'amytal test' for organic brain
disease (2, 3).
613
‘
�614
M. FINK, R.L.KAHN and H.KORIN
(c) Alteration in perception of multiple simultaneous tactile stimuli
((1)
(4).
Changes in tests of recall of common words, both with and without the interpolation of reading lists of nonsense syllables (5).
Time of Testing
A second factor to be considered is the time of application of these
tests in relation to the treatment program. Numerous observers have
reported the development of organic changes in the few minutes of recovery
following each treatment. Others noted the appearance of mental changes
during the course of treatment, and reported that treatments at periods
more frequent than the conventional three times per week induced earlier
and more severe changes. The transient nature of the changes are
frequently noted, so that by the second or third week following an extensive
course of therapy the electroencephalogram is at pretreatment levels,
memory changes have disappeared and orientation is re-instituted.
In the present studies, the electroshock treatment schedule was
maintained at three times per week with all patients receiving conventional
Reiter electroshock, during the initial three weeks. In the fourth week,
treatment frequency was occasionally reduced to two times per week. All
patients received a minimum of tWelve treatments. All tests were carried
out at weekly intervals on a day following a treatment during the course of
therapy. Following termination of therapy, weekly testing was c0ntinued
until the tests returned to their initial level.
Behavior Ratings
A third factor crucial to a study relating the significance of organic
mental changes to electroshock results is the definitiOn and evaluation
of 'improvement‘. The evaluation of clinical response to therapy is a
subjective value judgment by the therapist or administrator which reflects
a divergence of goals, judgments , and compromises. Significant variables
in the evaluation of 'improvement' are the type, severity and duration of
the patient's illness, his premorbid personality, the sociologic (family)
constellation to which he will return, and the expectatious (both conscious
and unconscious) of the therapist, of the institution, of the patient and of
the family. Furthermore, the time of the evaluation of the treatment
result is also a most significant variable.
The parameters of evaluation have not been satisfactOrily delineated.
In this study, the following compromises have been made. All evaluations
are made by an independent qualified psychiatrist who has no responsibility
for the selection of ‘subjects or application of the treatments. Patients are
seen weekly and conferences are held with the therapist to assess the
therapeutic goals before treatment and the therapist's estimate of the
response after treatment. The final evaluation used here is the clinical
state of the patient during the second and third weeks following the last
treatment, and describe only changes in clinical behaviour. We have used
a three-fold classification of 'much improved' , 'moderately improved' and
'unimproved' , with the intent that the 'much improved' and 'unimproved'
categories respectively would describe patients at the extremes of the
response continuum.
The patients rated as 'much improved' were those who no longer
showed the symptoms which brought them to the hospital, their physicians
'
�Relation of tests of altered brain fimction to behavioral change
615
believed them to be better, and the nurses' notes confirmed such aspects
as being able to sleep without medication, better appetite and improved
capacity to participate in hospital activities.
The 'unimproved' patients were those who manifested no clearly
noticeable change in behaviour or who became worse.
The 'moderately improved' patients showed some change in behaviour,
but continued to manifest signs of mental illness. They typically showed
some symptomatic relief, which was transient.
RESULTS
Twenty-four consecutive electroshock patients were studied. Of these,
eleven were rated as 'much improved', seven as 'unimproved', and six
as 'moderately improved'.
(a) Electro enc ephalogr am s
EEG
records, using conventional leads, were measured for the
average per cent time delta activity, and highest per cent time delta in any
one lead; the slowest frequency in the record; and the duration and
amplitude of delta bur st activity (1). Using these measurements, the 180
records in the series were placed in rank order according to the degree
of delta activity. The upper 1/3 of the records were described as 'high
delta activity' and the lowest 1/3 as 'low delta activity'.
No pretreatment records showed delta activity. During the course of
electroshock delta activity appeared in all records to varying degrees. It
was apparent within the first week of treatment and usually reached a peak
on the third week following the 7-9 treatments. The results for those with
high EEG delta activity are seen in Table I.
TABLE I
EEG -
%
High Delta Activity
Treatment Period:
Much Improved (11)
Moderately Improved (6)
Unimproved (7)
(b)
'W
.....'-.——-—-
a
.-
1-3
4-6
7-9
25
80
91
50
10-12
—-——————__.____—_~__
0
0
16
0
0
88
40
20
Amobarbital Te st
In these tests (2, 3) the patients are asked a series of questiOns
relating to their illness and to orientation. Sodium amytal is administered
intravenously until nystagmus and slurred speech are observed. The
questions are then repeated. Changes in orientation and awareness of
illness are scored as 'positive' amytal response, reflecting a change in
brain function ascribed to 'organic brain disease' (2.). The reSults are
noted in the next table.
�616
M. FINK, R.L.KAHN and H.KORIN
TAB—Ly;
Arnytal Test -
%
Positive
Treatment Period
Much Improved
(ll)
1-3 4-6 7-9 10-12
45
20
Moderately Improved (6)
Unimproved (7)
64 100
33 67
14
16
16
89
20
33
13-15
100
25
0
(c) Memory Tests:
In this test (5) a list of three letter common words were presented to
patients by flash cards. The cards were presented for 10 trials. After
this, lists of 3 letter nonsense syllables were interpolated. The recall of
the first list of words was then tested, and the number of words recalled
in each session was scored.
An impairment in recall function was apparent in all subjects. This
decrement was maximal in the second and third weeks of treatment, and
was sustained as long as treatments were administered 3 times a week.
The decrease in ability to recall the word list is noted in the next table.
TABLE III
Impairment in Recall -
%
Marked Decrement
Treatment Period
Much Improved (9)
Moderately Improved (4)
Unimproved (7)
1-3
4-6
7-9
10—12
0
0
0
ll
33
50
0
50
l4
0
O
0
are compared with the improvement rating, there
is no significant difference between groups. The rapid return of recall
ability to pretreatment levels when treatment frequency was reduced to two
times per week indicates that this test is a measure of only the more
severe degrees of cerebral dysfunction.
(d) Tactile Perceptual Tests
In these tests the patient is touched by the examiner simultaneously
on the cheek and the hand, and asked to localise the stimuli. The tests are
repeated for 10 trials using varying combinations of cheek, hand, shoulder
and thigh. Persistent failure to report one of the stimuli or to mislocalise
a stimulus beyond the tenth trial is indicative, in adults, of altered
cerebral function (4).
In all subjects, this test was negative before treatment. Positive
When the scores
�Relation of tests of altered brain fimction to behavioral change
61 7
responses were observed in 19 of the 24 patients. In nine patients, two
consecutive responses were observed, and of these, six were in the much
improved and three in the moderately improved groups.
In the next table the positive responses were charted with relation
to the treatment period and the clinical evaluation. A high incidence of
positive responses is to be noted in the first two groups, and many fewer
such responses in the unimproved group.
w
Face Hand Test - % Positive
Treatment Period 1-3 4-6 7-9 10-12 13-15
Much Improved (11)
16
Moderately Improved (6)
Unimproved (7)
60
O
4o
43
16
47
43
12
43
3O
ll
60
0
0
DISCUSSION
Three aspects of these observations warrant elaboration. The
sensitivity and stability of these indices of altered brain function and the
significance for a definition of altered cerebral function; the relation Of
these indices during and after treatment to the clinical evaluation; and the
relation of these observations for the theory of electroshock action.
All tests showed changes during electroshock therapy, indicating
that a state of altered cerebral function was induced. Certain tests, as
the EEG and the amytal test, were altered after a few convulsions and
remained persistently positive for one to three weeks following treatment.
In this regard the electroencephalogram manifested the earliest and the
most sustained changes. The recall and tactile perceptual tests also
showed changesbut these appeared late (in the 2nd week of treatment) and
disappeared rapidly when treatment frequency was reduced.
Tests of recall function and tactile perceptual tests, therefore, are
less sensitive indicators of the state of cerebral function. In any evaluation
of the relation of an induced change in brain function to another variable, it
is important, therefore, to clearly define both the operation (or test) and
the sensitivity of the operatiOn which forms the basis for the estimation of
altered cerebral function.
Because these tests have varying sensitivities, the frequency of
treatment and the duration of the treatment regimen become important
variables in any assessment. EEG changes are maintained by infrequent
treatment, while changes in recall function and simultaneous tactile
perception are rapidly lost, when treatment frequency is reduced.
Of the many correlations possible with these tests of brain function,
we have selected the relation of these test results to the clinical improvement rating. With the EEG and amytal tests significant relationships
between the appearance of test changes and clinical improvement are
clearly observed. In the much improved patients, positive amytal tests
�618
M. FINK, R.L.KAHN and H.KORIN
and high degree EEG abnormality appeared early, were more marked, and
were sustained for longer periods (on the same treatment‘regimen) than in
the unimproved patients. The moderately improved patients were in
between.
This relation between altered brain function and clinical response is
noted only with the data obtained during the course of therapy. There is
no correlation of improvement ratings with post-treatment test results.
This divergence is related to the timing of test applications, and may
explain the discrepancies in the conclusions of other studies of this
problem.
These observations can also be related to an understanding of the
mode of action of electroshock. In 1952, Weinstein, Linn and Kahn (6)
postulated that the function of electroshock therapy was to 'initiate the
production of a state of altered brain function in which the patient can deny
his problems'. These observations Support the first part of this hypothesis,
namely, that a state of altered cerebral function is induced by electroshock. Also, in patients who improved, the altered state is more prominent, appears earlier and is more persistent than in those who fail to
improve. Of the eleven much improved patients, all had positive amytal
tests (while 5 of the 7 unimproved never had a positive test); and ten had
high EEG abnormality records, while only one of the unimproved patients
had such a record. It is our conclusion that early, sustained and significant degrees of altered cerebral function are a prerequisite - a necessary,
though not a sufficient requirement - for improvement in electroshock
therapy.
'
SUMMARY
In a study of the relation of tests of altered brain function to improvement in electroshock, it was observed that while indicators of change in
brain function vary in sensitivity, all tests indicate the development of
organic mental changes during electroshock therapy.
The reason for the conflicting results reported by others can be
accounted for by the variations in the tests used, the time of study and
the difficulties in evaluating improvement.
It is our conclusion that clinical improvement in electroshock is
dependent on early, sustained and marked changes in mental function;
and that electroshock therapy may be described as the non— specific,
traumatic induction of states of altered cerebral function in which the
subject reacts with new patterns of adaptation.
REFERENCES
l.
2.
3.
Fink, M. and Kahn, R.L. Relation of EEG delta activity to
behavioral response in electroschock: quantitative serial studies.
A.M.A. Arch. Neurol. and Psychiat. , 1957, 78: 516-525.
Weinstein, E.A. , Kahn, R.L. and Malitz, S. Serial administration
of 'Amytal Test' for brain disease. Its diagnostic and prognostic
value. A.M.A. Arch. Neurol. and Psychiat. , 195.4, 71: 217-226.
Kahn, R.L. , Fink, M. and Weinstein, E.A. Relation of amobarbital
test to clinical improvement in electroshock. A. M. A. Arch.
Neurol. and Psychiat. , 1956, 76: 23-29.
�Relation of tests of altered brain function to behavioral change
619
Fink, M. , Green, M.A. and Bender, M.B. The face-hand test as
a diagnostic sign of organic mental syndrome. Neurology, 1952,
2: 46-58.
Korin, H. , Fink, M. and Kwalwasser, S. Relation of changes in
memory and learning to improvement in electroshock. Conf.
Neurol. , 1956, 16: 88-96.
Weinstein, E.A. , Linn, L. and Kahn, R.L. Psychosis during electro‘
shock therapy: its relation to the theory of shock therapy. Am. J.
Psychiat. , 1952, 109: 22-26.
Dept. of Experimental Psychiatry,
Hillside Hosp-ital,
Glen Oaks, N. Y. , U.S.A.
‘
��Relation of Tests of Altered Brain Function to Behavioral
Change Following Induced Convulsions
Max
Fink,
Rebert L.
IIOD c
Kahn Ph.D.
and
Hyman
From
Karin Fh.D.
the Department of Experimental Peychiatry, Hillside Hospital, Glen Oaks,N.Y.
Aided by Grant M~927 of the National
Institute of Mental Health, National
Institutes of Health, United States Pablic Health Service.
(in ,art) at the Divisional Meeting A. P .A., Montreal, November, 1956, and
at the International Congress oi Neurological Sciences, Brussels, July, 1957.
Read
12—3-57
�Relation of Tests of Altered Brain Function to Behavioral
Change Following Induced Convulsions
Numerous
and
studies have been reported assessing the type, duration
significance of mental changes following electroshock.
vary widely in their descriptions and
meaningful conclusion regarding the
it is difficult
These
reports
to arrive at a
relation cf such mental changes to
clinical response. Basic to these differences in observation are the
vexing problems of the definition and the ways of measurement of organic;
type reactions;
the time relation of the measurements to the treatment
process; and the definition of improvement following therapy. Each of
these factors bears an integral relationship to the final definition of
the problem.
In the present study, various
applied serially to patients in
whom
tests of brain function were
behavior was altered by repeated
inductions of grand mal convulsions (Electroshock).
The
data comparing
the serial changes in these indices are presented.
.
METHOD:
Definition of “organic mental changes":
conventional conception
The
of organic mental changes includes sudh behavioral changes as impairment
of
memory and of
the discrimination of differences on perceptual tasks;
disorientation for time, date, or place; errors
tractibility
and
inability to handle
perserveration in speech
on
more than one
and behavior; emotional
calculation tests; dis-
situation at a time;
lability;
interest in one's appearance and in his environment.
the relationship of
memory
tests of
simple
loss of
studies assess
loss or clinically manifest disorientation to
improvement following electroshock. The memory loss
by
Most
and
is usually measured
recall, information, personal events, digit
memory span,
�«2-
etc.: while disorientation is
place, date,
name of
determined by questions
the examiner, etc,
Such
tests of
relating.to present
memory and
of
orientation, however, discriminate primarily only severe degrees of dysfunction.
In the present studies, cognizant of the difficulties inherent in
simple clinical assessments, we measured changes in brain function by four
different measures, hoping thereby to determine varying degrees, or even,
types of dysfunction.
The
four measures selected as being sensitive to
varyinD aspects and degrees of cerebral dysfunction were:
delta activity in the electroencephalogram (1).
b) Changes in language and orientation following the administration
of amobarbital sodium - the "amytal test" for organic brain
a)
The degree of
disease (2, 3).
c)
Alteration in perception of multiple simultaneous tactile stimuli (h).
d)
Changes
in tests of recall of
the interpolation of reading
Time of
Testing:
A
common
lists
words, both with and without
of nonsense syllables (5).
second factor to be considered
is the
time of
application of these tests in relation to the treatment program.
observers have reported the development of organic changes in the
Numerous
few
minutes of recovery following each treatment. Others noted the appearance
of mental changes during the course of treatment, and reported
that treatments
at periods more frequent than the conventional three times per week induced
earlier and more severe changes. The transient nature of the changes are
frequently noted, so that
by
the second or third
is at pretreatment levels,
orientation is re-instituted.
course of therapy the electroencephalogram
memory changes have
disappeared and
week following an extensive
�.3In the present studies, the electroshock treatment schedule was main-
tained at three times per
all patients receiving conventional
initial three weeks. In the fourth week,
week with
Reiter electroshock, during the
treatment frequency was occasionally reduced to two times per week. All
patients received a
out
at
weekly
minimum
intervals
of twelve treatments. All
on a day following a
tests
were carried
treatment during the course
of therapy. Following termination of therapy, weekly testing was continued
until the tests returned to their initial level.
Behavior Ratings:
A
third factor crucial to a study relating the
significance of organic mental changes to electroshock results is the
definition and evaluation of "improvement." The evaluation of clinical
is a subjective value
administrator which reflects a divergence
response to therapy
judgment by the
therapist or
of goals, judgments, and com-
promises. Significant variables in the evaluation of "improvement” are
the type, severity and duration of the
patient's illness, his
premorbid
personality, the sociologic (family) constellation to which he will return,
and the
expectations (both conscious and unconscious) of the therapist, of
the institution, of the patient and of the family. Furthermore, the time
of the evaluation of the treatment
result is also a
most
significant
variable.
The
parameters of evaluation have not been satisfactoriLy delineated.
In this study, the following compromises have been made. All evaluations
are
made by an
independent qualified psychiatrist
who has no
responsibility
for the selection of subjects or application of the treatments. Patients
are seen weekly and conferences are held with the therapist to assess the
�.44..
therapeutic goals before treatment
and
the therapist‘s estimate of the
final evaluation used here is the
clinical state of the patient during the second and third weeks following
the last treatment, and describe only changes in clinical behavior.
reaponse
after treatment.
we have used a
The
three-fold classification of
improved" and "unimproved," with the
"much improved," "moderately
intent that the
"much improved"
and "unimproved" categories respectively would describe patients
at
the extremes of the response continuum.
The
patients rated as
"much improved" were
showed the symptoms which brought them
those
who no
longer
to the hospital, their physicians
believed them to be better, and the nurses' notes confirmed such aspects
as being able to sleep without medication,
better appetite
and improved
capacity to participate in hospital activities.
The "unimproved"
patients were those
noticeable change in behavior or
The
who became
"moderately improved" patients
manifested no clearly
Who
worse.
showed some change
but continued to manifest signs of'mental illness.
some symptomatic
relief,
which was
transient.
They
in behavior,
typically
showed
�-5RESULTS :
Twenty-four consecutive electroshock patients were studied.
"much improved," seven as "unimproved,"
these, eleven were rated as
and
Of
six as "moderately improved."
(a) Electroencephalograns:
EEG
records, using conventional leads,
highest
lead; the Slowest frequency in the record;
were measured for the average per cent time
delta activity,
and
per cent time delta in any one
and the duration and amplitude of delta burst activity (1). Using these
measurements, the 180 records in the series were placed in rank order
according to the degree of delta activity.
were described as "high delta
activity"
and
The upper
1/3 of the records
the lowest 1/3 as "low delta
activity.”
No
electroshock delta activity appeared in
was apparent within the
on the
activity.
pretreatment records showed delta
third
with high
first
week following
EEG
all
records to varying degrees.
week of treatment and
the 7-9 treatments.
delta activity are seen in Table
TABLE
EEG
.
%
During the course of
The
usually reached a peak
results for those
I.
I
Hiqh Delta
Activity
Treatment Period:
10-12
1-3
h—é
7—9
25
80
91
88
Moderately Improved (6)
o
16
so
ho
Unimproved (7)
o
o
o
20
finch Improved
(ll)
It
�a
(b)
~6-
Amobarbital Test; In these
tests (2,
3) the patients are asked
series of questions relating to their illness and to orientation.
Sodium amytal is administered intravenously until nystagmus and slurred
speech are observed. The questions are then repeated. Changes in
a
orientation
and awareness of
illness are scored as "positive" amytal
reSponse, reflecting a change in brain function ascribed to "organic
brain disease" (2). The results are noted in the next table.
TABLE
Amytal Test
-
II
%
Positive
Treatment Period:
1-3
h-6
7-9
10-12
13-15
Much Improved (11)
£15
61;
100
89
100
Moderately Improved (6)
20
33
67
20
25
Unimproved (7)
1h
16
16
33
o
The
data of Tables
The congruence of
I
and
II
have been graphically portrayed in Figure 1.
the observations of the degree of
EEG
delta activity
and
the per cent positive amytal test reSponses is demonstrated. (Fig. I)
(0) Memory Tests: In this test (5) a list of three letter common
words were presented to patients by flash cards. The cards were presented
for
10
trials. After this, lists
interpolated.
The
of
3
recall of the first
letter
list
nonsense syllables were
of words wens then
tested,
and
the number of words recalled in each session was scored.
An
impairment
in recall function
was apparent
in all subjects. This
decrement was maximal in the second and third weeks of treatment, and was
sustained as long as treatments were administered 3 times a week.
�.’
~7The
decrease in ability to recall the word
list is
noted
in the next
table.
TABLE
Impairment in Recall
III
-
%
Marked Decrement
1-3
Treatment Period
Mnch Improved (9)
Moderately Improved (h)
'
Unimproved (7)
When
h-é
7-9
10-12
O
11
33
O
0
SO
SO
0
0
1h
0
0
the scores are compared with the improvement rating, there
is
significant difference between groups. The rapid return of recall
ability to pretreatment levels when treatment frequency was reduced to
two times per week indicates that this test is a measure of only the
no
more severe degrees
of cerebral dysfunction.
tests the patient is touched
the cheek and the hand, and asked to
(6) Tactile Perceptual Tests: In these
by the examiner simultaneously on
localize the stimuli.
The
tests are repeated for
combinations of cheek, hand, shoulder and thigh.
report
one
10
trials
using varying
Persistent failure to
of the stimuli or to mislocalize a stimulus beyond the tenth
trial is indicative, in adults, of altered cerebral function (h).
In all subjects, this test was negative before treatment. Positive
two
responses were observed in 19 of the 2h patients. In nine patients,
consecutive responses were observed, and of these, six were in the much
improved and three
in the moderately improved groups.
�In the next table the positive responses were charted.with relation
to the treatment period
of positive responses
and
is to
the dlinical evaluation.
be noted
in the first
A
high incidence
two groups, and many
fewer such responses in the unimproved group.
TABLE
Face Hand Test
IV
-
%
Positive
Treatment Period
Much Improéed (11)
.
a
Moderately Improved (6)
Unimproved (7)
~
1-3
h-6
7-9
10-12
13-15
16
ho
h7
h3
60
60
h3
AB
30
O
0-
16
12
11
O
�DISCUSSION:
Three aspects of these observations warrant elaboration.
sensitivity
and
stability
The
of these indices of altered brain function
significance for a definition of altered cerebral function;
the relation of these indices during and after treatment to the clinical
and the
evaluation;
and
the relation of these observations for the theory of
electroshock action.
All
tests
showed changes during electroshock therapy,
indicating
that a state of altered cerebral function.was induced. Certain tests,
as the
EEG
and the amytal
test,
were
altered after a
few convulsions
persistently positive for cne to three weeks following
treatment. In this regard the electroencephalogram manifested the
earliest and the most sustained changes. The recall and tactile perand remained
ceptual tests also
showed changes but
week of treatment) and disappeared
.
was reduced.
Tests of recall function and
these appeared late (in the
rapidly
when
2nd
treatment frequency
tactile perceptual tests, therefore,
are less sensitive indicators of the state of cerebral function. In
any evaluation
of the relation of an induced
to another variable,
the operation (or
it is
test)
change
in brain function
important, therefore, to clearly define both
and the
sensitivity of the operation which forms
the basis for the estimation of altered cerebral function.
Because these
tests
have varying
sensitivities, the frequency of
treatment and the duration of the treatment regimen become important
variables in any assessment.
EEG
changes are maintained by infrequent
�{-10-
treatment, while changes in recall function and simultaneous tactile
perception are rapidly lost, when treatment frequency is reduced.
Of the many correlations possible with these tests of brain
function,
we have
selected the relation of these test results to the
clinical improvement rating. With the
EEG
and
clinical
much improved
patients,
relationships between the appearance of test changes
improvement are
clearly observed. In the
positive amytal tests
and high degree
EEG
tests significant
and amytal
abnormality appeared early,
were more marked, and were sustained for longer periods (on the same
treatment regimen) than in the unimproved patients.
The
moderately
improved patients were in between.
relation between altered brain function and clinical response
This
only with the data obtained during the course of therapy.
is noted
There is
results.
no
correlation of
This divergence
improvement
is related to the timing
of
test applications,
in the conclusions of other studies
and may explain the discrepancies
of
ratings with post-treatment test
this prdblem.
These observations can also be
mode of
related to an understanding of the
action of electroshock. In
postulated that the function
1952, Weinstein, Linn and Kahn (6)
of electroshock therapy was
to ”initiate
the production of a state of altered brain function in which the patient
can deny his problems." These observations support the first part of
this hypothesis, namely, that a state of altered cerebral function is
induced by electroshock. Also, in patients who.improved, the altered
state is
more prominent, appears
earlier
and
is
more
persistent than in
�.11..
those
had
who
fail to
improve.
Of
the eleven
positive amytal tests (while
positive test);
5 of
the
much improved
7
patients, all
unimproved never had a
and ten had high EEG abnormality records, while only
one of the unimproved
patients
had such a
record.
It is
our conclusion
significant degrees of altered cerebral
function are a prerequisite - a necessary, though not a sufficient
requirement - for improvement in electroshock therapy.
that early, sustained
and
�SUMMARY:
In a study of the relation of tests of altered brain function
to improvement in electroShock,
of change in brain function vary
it
was observed
that while indicators
in sensitivity, all tests indicate
the development of organic mental changes during electroshock therapy.
reason for the conflicting results reported by others can be
accounted for by the variations in the tests used, the time of study
The
difficulties in evaluating improvement.
It is our conclusion that clinical improvement in electroshock is
and the
dependent on
early, sustained
and marked changes
in mental function;
that electroshock therapy may be described as the non-specific,
traumatic induction of states of altered cerebral function in'which
and
the subject reacts with
new
patterns of adaptation.
�REFERENCES
l.
Fink,
Relation of EEG Delta Activity to
Behavioral Response in Electroshock: Quantitative
Serial Studies, A.M.A. Arch. Neurol. & PsychiatJfi:
M. and Kahn, R.L.:
516‘5251 1957.
Kahn, R.L. and Malitz, 5.: Serial Administration
of "Amytal Test" for Brain Disease. Its Diagnostic and
Prognostic Value, A.M.A. Arch. Neurol. Psychiat. 23;:
2. Heinstein, E.A.,
<3».
217-226, 19st.
3.
Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital
Test to Clinical Improvement in Electro shock, A.I'I.A.
Arch. Neurol. a Psychiat., 19: 23-29, 1956.
h. Pink,
Grren, HA. and Bender, H.B.: The Face-Hand Test as a
Diagnostic Sign of Organic Mental Syndrome, Neurolo fl. , _2_:
116—58, 1952.
1-1.,
H. , Fink, 1'1. and Kwalwasser, 8.:
Memory and Learning to Improvement
5. Korin,
I‘Ieinstein,
13.A., Linn, L. and Kahn,
shock Therapv:
Relation of Changes in
in Electroshock, Conf.
R.L.: Psychosis During Electro-
Its Relation to the
Theory of Shock Therapy,
�
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Relation of tests of altered brain function to behavioral change following induced convulsions. In L. van Bogaert and J. Radermecker (eds.), First International Congress of Neurological Sciences. Pergamon Press, London, 1959, 3:613-619.
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<a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Korin, Hyman
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Two [preprints] and one reprint. Reprint from The First International Congress of Neurological Sciences, Brussels, 1957, Vol. III EEG, Clinical Neurophysiology and Epilepsy. Peramon Press; London, New York & Paris, 1959
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