http://exhibits.library.stonybrook.edu/mfp/files/original/cd19f1b46d47e649344f387e918358a2.pdf 402d7d717080af9c10d773a24db00fb9 PDF Text Text Reprinted from Journal of Neuropsychiatry, Vol. I, No. 1, Sept-Oct. 1959. Personality Factors in Behavioral Response to Electroshock Therapy ROBERT L. KAHN, PH.D., and MAX FINK, M.D. In previous studies”,7 we found that patients who were most likely to improve from electroshock treatment exhibited persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital test for brain disease.10 We reported, furthermore,7 that patients who improved with electroshock treatment had developed a language pattern similar to- that previously described by Weinstein and Kahn}3 in their studies of neurological patients with cerebral dysfunction. Weinstein and Kahn described a language pattern which they called “language of denial” and demonstrated the relationship of this language pattern to the premorbid personality of the patient. On the basis of these observations, we assumed that the patients most likely to benefit from electroshock treatment would be those who most closely approximated the “explicit verbal denial” personality.11 To test this hypothesis, we studied 63 consecutive patients referred for electroshock therapy. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. Thepatients ranged in age from 20 to 66, with a mean of 47, and included 21 men and 42 women. Prior to and during treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient’s family. At the opening of the interview, the relative was asked to describe, in his own words, the patient’s usual interests and attitudes. The relatives were encouraged to talk about any aspect they wished, and the interviewer followed the trend of their talk, rather than proceedFrom the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented at a meeting of Electroshock Research Association, Chicago, 1957. ing in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the “explicit verbal denial” personality. The number and; type of questions required'with each relative varied according to the degree of spontaneous production and the informant’s capacity to comprehend and communicate. The informant was encouraged to give concrete: examples of all statements. The patients were evaluated as to the pres ence and extent of the following character istics: whether they (1) stressed verbal symbols such as resolutions, homilies, cliches-and rationalization; (2) were prestige and; security conscious, and did not enjoy the in; trinsic benefits of health, work, leisure money and property; (3) regarded illnéSs: as an imperfection or disgrace, keeping it an; , secret from family and neighbors, and were reluctant to seek medical care; (4) tended) to “shake off” their own troubles and to be) regarded as practical persons who advise, others; (5) possessed much drive and coma pulsive energy and felt guilty or uneasy if not occupied; (6) were conscientious, with a high sense of duty and responsibility; (7) were sensitive to criticism, regarding it as an attack on their integrity; (8) were proud and tended to avoid help from others; (9) were reserved rather than openly affectionate or emotional; (10) emphasized being correct; (11) lacked imaginativeness and creativity; (12) were not considered by their relatives as dependent; (13) did not discuss sex openly; (14) did not have temper outbursts; and (15) were not “ludic”—a term taken from Piaget8 and used by Weinstein” and Kahn12 to denote comic, tragic or melodramatic behavior. After the interview, each item was rated on a scale of O, 1 or 2. A score of O was given if the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked ,» . , ' ' �' presence of the pattern. The scores for each item were added and, the resultant score termed the “denial personality score.” 2. Clinical Evaluation: Each patient was interviewed prior to treatment and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient’s behavior in the few weeks following the end of the course of treatment, and was based on the evaluation of the patient’s therapist, the therapist’s supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: much improved, moderately improved, or unimproved, following the criteria outlined previouslyf‘ 3. Language Study: In addition to. the clinical interviews, each patient was examined with a standardized series of questions directed at determining his attitude toward his illness. Two of the questions asked were “What is your main trouble?” and “If you had one wish, what would you wish for?” The patients were tested before and during treatment, and the verbatim responses were analyzed for changes in language, according to the method previously described.7 Treatment for all patients consisted of grand mal electroshock, using a Reiter elec— trostimulator or a Medcraft alternating-current instrument, on a schedule of three treatments per week. Of the 63 patients, we were able to- interview the relatives of 47; and the present study refers to this group. The denial personality scores ranged from 0 to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the “high denial” group, while those with scores from 0 to 10 were classed as low in denial tendencies. Personality Score and Clinical Response: Patients with high denial personality scores in these family interviews were most likely to be rated as much improved, and only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as unimproved. ') .« TABLE I Relation of Denial Personality Scores to Clinical Response to Electroshoclc Denial Much Personality Improved Score 11 - 25 0 - 25 14 Total Moderately Improved Unimproved Total 7 9 9 1 7 24 23 21 18 8 47 The difference in the denial scores between the much and moderately improved patients, when compared to the unimproved patients, is statistically significant (at 1% level of confidence by Mann-Whitney U Test). Although the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative Observations: Although there is a relationship between high personality scores and the clinical rating, 30 per cent of the patients with low denial scores were also evaluated as showing a marked improvement. While the group of seven patients is a small one, certain common characteristics can be described. Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or others’ feelings. They relate to the environment primarily by nonverbal forms of communication. They are described by their families as laughing or crying excessively and as showing anger by muteness— “going into a shell,” “walking out of the room in a huff”——or by violent tempers with table-pounding, throwing objects or direct physical assault. Personality Score and Changes in Language: By means of the technique of language analysis described in a previous study,7 the changes in language in clinical interviews ~were compared with the denial personality scores. Nine patterns of language change, such as explicit denial of illness or symptoms, displacement, qualification, etc., have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether �. qr nothe showed three or more explicit language changes. Patients with high denial personality scores showed a greater number of language changes than those with low denial personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes is +.71, significant at better than the 1% level of confidence. TABLE II Relation of Denial Personality Scores to Clinical Language Changes Daring Treatment Denial Personality Scores 11 - 25 (20) 0 - 10 (20) N 0. Language Changes 0 — 2 3 or more .................................. 8 .................................. 17 12 Total ........................................ 25 15 3 Illustrative Cases Case 1. High Denial Personality Score: A 61-yearold housewife was admitted to the hospital with a 15—month history of insomnia, abdominal. pain and fear of cancer. On admission she was depressed, retarded and seclusive, evincing little interest in her surroundings and wandering aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with much integrity. She had no hobbies or outside interests, and was unable to relax; as a consequence, she busied herself with chores at home. She was “mortally afraid” of doctors, minimized her illnesses and concealed ailments even from her husband. Very restrained, she showed no affection or emotion, never discussed sex and rarely lost her temper. She had “a long memory for little things if she felt that she was wronged,” a “streak of stubbornness,” and would “just as soon hold another person responsible for her mistakes.” She was proud and would “rather go- without food” than borrow or take money from others. According to the denial criteria, her score was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a “model” patient who, “while reluctant to discuss her personal feelings, asserted that she had no difficulties at home, had a wonderful husband who was very good to her, considered herself lucky and eagerly anticipated her discharge.” She was discharged with a rating of “much improved.” Case 2. Low Dental Personality Score: A 41year-old housewife was admitted to the hospital with a two-year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission it was noted that the patient paid little attention to her personal appearance, cried readily, showed psychomotor retardation and was circumstantial in speech. The patient was described by her husband as a “negative personality” with whom it was not easy to get along because she was opinionated and argumentative. He regarded her as “completely impractical, with no common sense.” She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. An excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, however, she Would become either completely mute or “very nasty, implying you just don’t know any better.” Although considered a “cold” person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was “naive” and “unrealistic,” believing, for example, that she had a flair for writing although others considered her amateurish. Her personality score was rated as 4. The patient received 18 electroshock treatments, which were terminated at her own insistence because she was too frightened to take any more. At the time of her discharge her doctor noted her as “quite depressed,” but felt it was doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for continued psychotherapy. Discussion The structured family interview was designed to test the Specific hypothesis derived from earlier observations that patients with the “explicit verbal denial” personality are most likely, with electroshock therapy, to show both the language and behavioral changes which are rated as much improved by the examiner. The data support this hypothesis and are also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952.9 They suggest tha “. . . the therapeutic eflicacy of electroconvulsive therapy . . . derives from the production of a. state of brain function in which the mechanism of denial is facilitated in characterologically disposed individuals.” The degree of explicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. On the basis of the present data and methods of analysis, a broader View of’ personality patterns in relation to improvement with EST is now possible. Those patients who are rated as clinically improved are character- ' �8va — _ ,r-Pff-‘wu ‘:_‘_":':'*'r‘-n-€"L ,V"-~.' -: < ,2 ized as: (a) nonempathic—unable to think critically or sensitively about the needs, feelings or communications of others; (b) nonintrospective—unable to think critically about their own feelings or needs, or to achieve insight even with the collaboration of others in the psychotherapeutic relationship; (0) relying heavily on nonverbal communication—even when they are talkative there is little referential communication, the words being clichéd, stereotyped or representative of feelings and emotions rather than transmitters of information; and (d) highly conventional—without imaginative or creative capacity, and with few resources to deal with stressful or new situations. With this pattern as the common background, two classes of patients who respond to treatment can be defined: the driving, conscientious, independent, successful, emotionally controlled person who can be characterized as the “explicit verbal denial” personality type; and the chronically inadequate, affectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short-term response to electroshock, preliminary followup observations indicate that the “explicit verbal denial” personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change shown with altered brain function, however, vary markedly in different patients. Some show mood changes and denial or displacement of symptoms, and are rated as improved. Others develop paranoid agitated states, become withdrawn or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality factors in those cases whose behavioral response was rated as improved. We have not considered the patients who were rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information 4.: in this regard is minimal, as this problem has not been approached with a specific hy-“ pothesis. These observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic premorbid personality. Abraham1 noted that states of depression occur in obsessional persons. Arnot2 described depressed patients as being overconscientious and perfectionistic. Hamilton and Mann,5 reporting various aspects of the personality in involutional depression, included such features as “followed a rigid pattern of behavior . . . displayed a lack of imagination . . . narrow range of interest . . . thorough, conscientious, meticulous devotion to duty . . . lack of feeling for point of view of others . . . hard, uncompromising drivers . . . oversensitive . . reserved.” Cohen et al.,3 in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having little capacity for communicative interchange; and unaware of other persons’ feelings toward them or of their feelings toward others. They emphasized the patients’ inability to communicate verbally and suggested that the therapeutic relationship should be in nonverbal terms rather than emphasizing the intellectual content of the exchange, These studies of the personality background of depression show a pattern that is most similar to those personality aspects which have been described as the “explicit verbal denial” personality. The factor of personality could thus explain the fact that depression is the condition that responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to nonverbal forms of therapy. These factors enable him to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism and prestige consciousness which produce a cat- ' > �.' respOnse in the individual faced astrophic 7 With the loss, of a partner, job, business or u'loiv‘ed one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed “improved” by the family and the therapist. Summary and Conclusions To summarize, we believe that our results show that aspects of personality can be differentiated, which are significantly related to the response to treatment. The basic personality pattern of the patients Who respond best to electroshock treatment can be characterized as (a) nonempathic, (b) nonintrospective, (c) communicating nonverbally and ((1) highly conventional and stereotyped, with little imaginative or creative capacity. Within the context of this common care, there are two main subdivisions of improved patients. One group is comparable with the “explicit verbal denial” personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to be chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are affectively labile and ludic. The same personality factors which contribute to a depressive reaction contribute to a behavioral change, under the conditions of altered brain function following electroshock therapy, which is evaluated as improvement. . . . REFERENCES Abraham, K.: Selected Papers on Psychoanalysis. (The Hogarth Press Ltd., London, 1949.) Arnot, R.: The Predepressed Personality. Arch. Neural. (G Psychiat, 76:617-618 (1956). Cohen, M. B., et al.: An Intensive Study of Twelve Cases of Manic—Depressive Psychosis. Psychiatry, 17 :103-137 (1954). Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock. Arch. Neural. c6 Psychiat, 78:516-525, 1957. 10. 11. 12. 13. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Hoch, P., and Zubin, J. (eds.), Depression, pp. 199-209 (Grune d2 Strattan, New York, 1954). Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neural. c6 Psychiat., 76:23-29 (1956). Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Hoch, P., and Zubin, J. (eds), Psychopathology of Communication, pp. 126. Piaget, J .: Play, Dreams and Imitation in Childhood (W. W. N ortau, New York, 1951). 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). Weinstein, E. A., et al.: Diagnostic Use of Amo— barbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112:889-894 (1953). Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol. (Q Psychiat, 69:355-367 (1953). Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease. J. Hillside H08p., 3:98-106 (1954). Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. (Charles 0'. Thomas, Springfield, Ill., 1955.) ' ��March 1957 £471.“. Personality Factors in Behavioral Response to ElectroShock Therapy Robert L. Kahn, Ph. D. and.Max Fink, From New WW. M. D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, York. Aided by M—92? of the National Institute of Mental Health, National of Health, United States Public Health Service. grant Institutes Presented to the Electroshock Research Association, Chicago, l. , l, , , gnu-H‘SVAmh-fiy, May 1957. �INTRODUCTION The behavioral response of patients receiving electroshock therapy variable. noted In previous studies of the factors related to that patients who showed is this variability early, persistent and relatively we marked degrees of altered brain function, as meaSured by the electroencephalogram and the amobarbital test for brain disease (10), were most response which was rated as improved (h) (6) (7). likely to The show a clinical present study is an investigation of the role of personality in the behavioral response. explicit hypothesis concerning this relationship has been derived An from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), patients patterns as explicit denial of illness; who develop such language we reported that personal, Spatial and temporal displacement of symptoms; and qualification, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) studies of neurological patients with cerebral dysfunction. in their They characteru ized this behavior as the "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "ex- plicit verbal denial" personality (11). the hypothesis was advanced On the basis of these Observations, that those patients this "explicit verbal denial" personality type the behavioral changes The purpose after EST who most closely approximated would be more likely to Show which are rated as improved. of the present study, therefore, was to determine: 1) whether personality characteristics related to the behavioral reSponse to electroshock therapy can be differentiated; and 2) whether patients with greater "denial" tendencies are more likeLy to show proved. behavioral changes after electroshock therapy which are rated as imp �~2~ POPULATION Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was asked to describe, in his interests and attitudes.. The relatives patient's usual encouraged to talk about any own were words, the aSpect they wished, and the interviewer followed the trend of rather than proceeding in a serial fashion. The their talk, interviewer asked questions, however, to obtain information in 15 Specific areas which have been described as characteristic of the "explicit verbal denial" personality. and type of questions required with each The number relative varied according to the de- gree of spontaneous production and the informant's capacity to comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence features: 1) stress verbal symbols such as rationalization; 2) are prestige and and extent of each of the following resolutions, homilies, cliches security conscious, intrinsic benefits of health, work, leisure, money and it a and and do not enjoy the property; 3) regard secret from family and neighbors,-and are reluctant to seek medical care; h) "shake off" their own illness as an imperfection or disgrace, keeping �-3troubles and are considered practical persons who advise others; 5) have drive and compulsive energy, and are guilty or uneasy if not much occupied; 6) are conscientious with a high sense of duty and responsibility; 7) are sensitive it to criticism, regarding as an attack on their integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly affectionate or emotional; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; 13) do not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25) After the interview, each item was rated score of O was given if on a scale of O, 1 or 2. A the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the each item were added and the resultant score pattern. The scores for is termed the "denial personal- ity score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The evaluation was determined by clinical the patient's behavior in the few weeks follow- ing the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist's supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: proved, following the much improved, moderately improved, or unimp criteria outlined previously (6). 3. lgnguagg §t_gy: In addition to the clinical interviews, each patient was examined toward his with a standardized series of questions determining his attitude illness. Two of the questions asked were, "What is your main trouble?" and ”If you had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim reSponses were anal- ized for changes in language according to the method previously described (7). �V «hRESULTS The relatives of scores ranged from h? patients were interviewed. to 25, with a O O denial personality statistical comparison Patients with scores ranging from 25 were consiRered the "high denial" group, while those with scores from to to For median of 11. the patients were divided into two groups. 11 The 10 were classed as low in denial tendencies. Patients with high denial 1. Personality score and clinical reSponse: personality scores in these family interviews were most likely to be as much improved, and only one case was considered unimproved (Table patients with a chance 30% I). In clinical reSponse rating occurred low scores, however, the basis, with rated on of the patients being regarded as unimproved. I TAJLE Relation of Denial Personality Scores to Clinical Response to Electroshock Moderately Much Unimproved Total 9 1 2h 9 7 23 18 8 h? Improved Improved Personality Score - 25 1h 0 ~ 10 7 11 Total . 21 The proved difference in the cenial scores between the patients, significant. % when compared to the unimproved much and moderately im- patients is statistically Although the much improves patients have a higher mean score than the moderately improved group, this Jifference is not significant. 2. Qualitative observations: Although there is a relationship between high denial personality scores she the clinical rating, low denial scores * Significant at ‘1 30% of patients with were also evaluated as showing a marked improvement. 'Hhile 1% .0 ' level of coniidence by HannAWhitney U Test. �-5the group of seven patients be described. and security is a small one, certain common characteristics can Although these Subjects lack the competitive drive, prestige ne ds of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings» They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying excessively; and as showing anger by muteness, "go into a shell," "walk out of the room in a huff," or bv violent tempers with table-pounding, throwing objects or direct physical assault. patients are "ludic," - a term used These by Heinstein and Kahn (12) to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were compared with the denial personality scores. patterns of language change, such as explicit denial of illness or Nine symptoms, displacement, qualification, 323' have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial personality scores showed a greater ality scores ality scores number of language changes, than those with low (Table II). The denial persen- coefficient of correlation between the person- and the number of language Chan es is + .71, significant at better than the 15 level of confidence. * This terizwas taken from Piaget behavior of young children (8). who pplied it to the play and imitative �-6- II TABLE Relation of Denial Personality Dcores to Clinical Language Changes During Treatment Number Language Changes - 0 2 3 or more Personality Scores 11-25 (20) 8 12 0-10 (20) 17 3 Total 25 15 h. Illustrative Cases: Case 1. A month High Denial Personality Score: élayear-old houswife was history of insomnia, abdominal nain admitted to the hospital with a 15 and fear of cancer. she was depressed, retarded, and seclusive, evincing On admission little interest in her surroundin s, and uaneering aimlessly about the ward. The patient was described responsible person with and was unable to home. She was much relax. by her husband as a conscientious, dependable, integrity. She had no As a conseguence, she hobbies, outside interests, busiee herself with chores at "mortallv afraid" of doctors, minimized her illnesses and con- cealed ailments, even from her husband. Very restrained, she onenly showed no affection or emotion, never 6iscusse€ sex had "a long memory for little "streak of stubborness," sible for her mistakes." than borrow or take things and would if she and felt that According to the denial She she was wronged," a "just as soon hold another person She was proud ane would money from rarely lost her temper. "rather go reSponu without food" others. criteria, hrr score was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor �-7called her a "model" patient feelings, asserted that band who was very good her discharge." who, "while reluctant to discuss her personal difficulties at home, had a wonderful husto her, considered herself lucky and eagerly anticipated she had no She was discharged with a Case 2. Low "much improved." Denial Personality Score: hl-year-old housewife A rating of was admitted to the hOSpital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission the patient was showed attention to her personal appearance, cried readily, psychomotor retardation and was circumstantial in speech. The whom He little noted to pay patient it was was described by her husband as a "negative personality" with not easy to get along because she was opinionated and argumentative. regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would ative person, she liked to sations. When put herself out for others. engage An excessively talk- in long, intellectual, pretentious converu angry, however, she would become either completely mute, or "very nasty, implying you just don‘t "cold" person, she was able to know any better." Although considered a talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "un- realistic," believing, for example, that she had a flair for writing although others considered her amateurish. rated as h. Her personality score The patient received eighteen electroshock treatments, which were term» inated at her was frightened to take any more,, At the time of her discharge her doctor noted her as "quite depressed," but felt that ital. it was own insistence because she was too doubtful that she could benefit from further treatment at the hosp- She was discharged with the recommendation for continued psychotherapy. �-8- . DISCUSSION The structured family interview was designed to test the specific hypo— thesis derived from earlier observations that patients with the "explicit verbal denial" personality are most likely to havioral Changes the examiner. show both the language and be- to electroshock therapy which are rated as The data supports this hypothesis and much improved by is also consistent with the theory of the mode of action of electroshock therapy advanced by'Weinstein, that "....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain Linn and Kahn in 1952 (9). They suggest function in which the mechanism of denial is facilitated in characterologically disposed individuals." The degree of explicit verbal denial is, however, only aspect affecting the behavioral reaponse to treatment. one personality the basis of the On present data and methods of analysis a broader view of personality patterns in relation to improvement with rated as clinically empathic - ~ improved are unable to think EST is now possible. Those own who are characterized by such features as: 1) non- critically or sensitively about the needs, ings, or communications of others; 2) non-intrOSpective critically about their patients - — feel- unable to think feelings or needs; unable to achieve insight even with the collaboration of others in the psychotherapeutic relationship; 3) rely heavily on nondverbal Communication little referential -- even.when they are communication, the words being cliched, stereotyped, or .representative of feelings and emotions action and h) highly conventional .. .. rather than transmitters of informp withoutimaginative or creativecapacity, y'and,with few resources to deal with stressful or With talkative there is this pattern as the common new situations. background, two classes of patients who "‘respond to treatment can.be-defined: a) the driving,.conscientious, independent, �.9can be successful, emotionally-controlled person who plicit verbal denial" personality type; b) the chronically inadequate, coming from an impoverished ively labile and ludic, dependent person, cultural background. characterized as the "ex- 'While both types are rated as improved affectsocio- in their short term reSponse to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical reSponse, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change'with electroshock therapy. The kinds of behavioral change shown with however, vary marcedly in different patients. denial or diSplacement of symptoms and paranoid agitated states, become withdrawn, altered brain function, Some show mood changes and are rated as improved. Others develop or show ory complaints, and are rated as unimproved. In additional somatic or memp this study we have stressed the personality factors in those cases whose behavioral reSponse was rated as improved. We have not considered the patients who were rated as only moder- ately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information in this regard is minimal, as These this problem has not been approached with a specific hypothesis. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic predepressed personality. Abraham (1) noted of depression occurred in obsessional persons. Arnot (2) describes that states depressions as being overly Conscientious and perfectionistic. Hamilton and Mann (5), reporting various aSpects of the personality in involutional depress- ion, include such features as "followed a rigid pattern of behavior....dis~ played a lack of imagination...narrou range of interestS..thorough, conscientious, �.10.. meticulous devotion to duty...1ack of feeling for point of view of others... hard, uncompromising drivers...oversensitive...reserved." Cohen, §t_§l'(3) in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige-conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having communicative interchange; and unaware of self or of his feelings toward others. to be little capacity for other persons' feelings toward him- They emphasized the patients' inability that the therapeutic relationship should in non-verbal terms rather than emphasizing the intellectual contents of communicate verbally and Suggested the exchange. studies of the personality background of depression Show a pattern that is most similar to those personality aspects whidh have been described These as the "explicit verbal denial" personality. The factor of personality could thus explain the fact that depression is the condition which responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to non-verbal forms of therapy. These factors enable him to reSpond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, convention- ality, perfectionism, and prestige-consciousness, which produce a catastrophic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed "improved" by the family and the therapist. �.11SUMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for e1ectro~ shock therapy were studied by means of a structured family interview. 2. which are 3. be The results show that aspects of personality can be differentiated significantly related to the reaponse to treatment. The basic personality pattern of the patients who respond characterized as a) non-empathic, b) non-introspective, c) non-verbally, and d) highly conventional and stereotyped, with best can communicate little imagin- ative or creative capacity. h. ‘Within the context of of improved personality, patients. One showing such and emotional control. ically inadequate grounds, uho are this group is core, there are two main subdivisions comparable to the "explicit verbal denial" common features as drive, conscientiousness, independence The oflaer group and dependent, coming consists of persons apt to be chron— from deprived Socio-cultural back- effectively labile and ludic. 5. The relationship between these personality patterns and descriptions of the personality of depressed perSOns is noted. The same personality factors which contribute to a depressive reaction, contribute to a behavioral change under the conditions of which altered brain function following electroshock therapy is evaluated as improvement. �.12.. FERENCES 1. Abraham, K.: Selected Papers on Psychoanalysis. London: Press Ltd., 19h9. Arnot, R.: The chiat., 3. Cohen, h. Fink, Predepressed Personality, Zé: 617—618, 1956. A.M.A. Arch. The Hogarth Neurol. & Psy- B., Baker, G., Cohen, R. A., FrommpReichmann, F. and Ueigert, An Intensive Study of Twelve Cases of Manic-Depressive Psychosis, Psychiat., 11: 103-137, l95h. H. E. V.: M. and Kahn, R. L.: Quantitative Studies of Slow wave Activity EEG Clin. Neurophysiol., Q; 158, 1956. Following Electroshock, Hamilton, D. M. and Mann, W. A.: The Hospital Treatment of Involutional Psychosos, in Depression (Hoch, P. and Zubin, J., eds.), New York: Grune & Stratton, 199-209, 1952. L., Fink, M. and weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Kahn, R. 7. Language During Electroshock Communication (Hock, P. and Zubin, Psychopathology of Kahn, R. L. and Fink, M.: Therapy, in Changes in Eds.) in press. Piaget, J.: Play, Norton, 19 51. Dreams and Imitation in Childhood. New J., York: N. W. 9. Weinstein, E. A., Linn, L. and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Pey- chiat., 193; 22-26, 1952. 10. ‘Weinstein, E. A., Kahn, R. L., Sugarman, L. A. and Linn, L.: Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic Brain Disease, Am. J. Psychiat., 11g} 889-89h, 1953. 11. E. A. and Kahn, R. L.: Arch. Neurol. & A.M.A. ness, neinstein, Personality Factors in Denizl of Psychiat., éfi: 355-367, 1953. Ill- 12. Ueinstein, E. A., Kahn, R. L. and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp., 2; 98-106, l95h. 13. Ueinstein, E. A. and Kahn, R. L.: Denial of siological Aspects. Springfield, Ill.: Illness: Symbolic and Phy- Charles C. Thomas, 1955. �--.f\ ._ Personality Factors in Behavioral Response to Electroshock Therapy Robert L. Kahn, Ph.D. and From Max Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented to the Electroshock Research Association, Chicago, May 5/59 195”. �INTRODUCTION .The behavioral response of patients receiving electro— shock therapy is variable. In previous studies of the factors related to this variability we noted that patients who showed early, persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital most likely to show a test for brain disease (10), clinical response were rated as investigation which was present study is an of the role of personality in the behavioral response. An eXplicit hypothesis concerning this relationship has been derived from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), we reported that improved (h) (6) (7). The develop such language patterns as explicit denial of illness; personal, spatial and temporal displacement of symptoms; and qualification, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) in their studies of neurological patients with cerebral dysfunction. They characterized this behavior as the patients who "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "explicit verbal denial" personality (11). On the basis of these observations, the hypothesis was advanced that �-2- closely approximated this "explicit verbal denial" personality type would be more likely to those patients show who most the behavioral changes after EST which are rated as improved. purpose of the present study, therefore, was to determine: The - 1) whether personality characteristics related to the behavioral response to electroshock therapy can be differ- entiated; and 2) whether patients with greater "denial" tendencies are more likely to show behavioral changes after electroshock therapy which are rated as improved. EQPULATION: Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was 1. �-3asked to describe, in his interests and attitudes. own words, the The relatives patient's usual were encouraged to aspect they wished, and the interviewer followed the trend of their talk, rather than proceeding in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the "eXplicit verbal denial" personality. The number and type of questions required with each relative varied according to the degree of spontaneous production and the informant's capacity to talk about any comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence and extent of 1) stress verbal symbols each of the following features: resolutions, homilies, cliches and rationalization; 2) are prestige and security conscious, and do not enjoy the intrinsic benefits of health, work, leisure, money and such as regard illness as an imperfection or disgrace, keeping it a secret from family and neighbors, and are reluctant to seek medical care; h) "shake off" their own troubles and are considered practical persons who advise 5) have much drive and compulsive energy,.and are others; guilty or uneasy if not occupied; 6) are conscientious property; 3) with a high sense of duty and responsibility; 7) are sensitive to criticism, regarding it as an attack on their �-u- integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly.af£ectionate or emotuonal; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25). After the interview, each item was rated on a scale of 0, 1 or 2. A score of O was given if the aspect was noted 13) do to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the pattern. The scores for each item were added and the resultant scoretns termed the "denial personality score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient's behavior in the few weeks following the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist’s supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. into three groups: much improved, unimproved, following the Patients were classed moderately improved, or criteria outlined previously (6). Study; In addition to the clinical inter~ views, each patient was examined with a standardized series 3. Language �-5of questions determining his attitude toward his illness. Two of the questions asked were, "What is your main trouble?" "If you had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim responses were analyzed for changes in language and according to the method previously described (7). �-6RESULTS relatives of interviewed. The denial personality scores ranged from O to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the "high denial" group, while those with scores from O to 10 were classed as low in denial tendencies. 1. Personality score and clinical response: Patients with high denial personality scores in these family interviews The likely to were most patients h? rated as be were only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as much improved, and unimproved. TABLE I Relation of Denial Personality to Clinical Response to Electroshock Much Moderately 25 1h 9 1 2h to 10 Total 7 9 7 23 21 18 8 h? Improved Improved Total Unimproved Personality Score 11 0 to The difference in the denial scores between the and moderately improved unimproved * patients, when compared much to the patients is statistically significant.* Although Significant at 1% level of confidence by Mann-Whitney U Test. �-7the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative observations: Although there is a relationship between high denial personality scores and the clinical rating, 30% of patients with low denial scores were also evaluated as showing a marked improvement. While the 2. group of seven patients is characteristics a small one, can be described. certain common Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings. They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying excessively; and as showing anger by muteness, "go into a shell," "walk out of the room in a huff," or by violent tempers with table—pounding, throwing objects or direct physical assault. These patients are "ludic," - by Weinstein and Kahn (12) a term used to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were the denial personality scores. Nine patterns of language change, such as explicit denial of illness or compared with * This and term was taken from Piaget imitative behavior of young applied it to the play children (8). who �-8displacement, qualification, 323. have been described as characterically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial symptoms, personality scores showed a greater number of language changes, personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes is + .71, significant at better than the 1% level of confidence. than those with low denial TABLE II Relation of Denial Personality Scores to Clinical Language Changes During Treatment Number Language Changes 0 - 2 Personality Scores 11-25 0-10 (20) (20) ' Total h. Illustrative 3 or more 8 12 1? 3 25 15 Cases: gigh Denial Personality Score; A 61-year-old housewife was admitted to the hospital with a 15 month history of insomnia, abdominal pain and fear of cancer. On admission she was depressed, retarded, and seclusive, evincing little interest in her surroundings, Case 1. aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with and wandering much �-9- integrity. hobbies, outside interests, and was a consequence, she busied herself with She had no unable to relax. As chores at home. She was “mortally afraid" of doctors, minimized her illnesses and concealed ailments, even from her husband. Very restrained, she openly showed no affection rarely lost her temper. She had "a long memory for little things if she felt that she was wronged," a "streak of stubborness," and would "just as soon hold or emotion, never discussed sex and another person reaponsible for her mistakes." She was proud and would "rather go without food" than borrow or take money from others. According to the denial criteria, her score was 20. electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a "model" patient who, "while reluctant to discuss her personal feelings, asserted After that she 20 had no difficulties at home, had a wonderful husband very good to her, considered herself lucky and eagerly anticipated her discharge." She was discharged with a rating who was of "much improved." Denial Personality Score: A hl-year—old housewife was admitted to the hospital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social aetivities, found it increasingly difficult to take care of her Case 2. Low suicidal thoughts. On admission the patient was noted to pay little attention to her personal appearance, cried baby and had �readily, showed psychomotor retardation and was circumstantial in speech. patient was described by her husband as a "negative personality" with whom it was not easy to get along because The she was opinionated and argumentative. He regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, An either completely mute, or "very Just don't know any better." Although however, she would become nasty, implying you considered a "cold" person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "unrealistic," believing, for example, that she had a flair for writing although others considered her amateurish. personality score was rated as h. The patient received eighteen electroshock treatments, which were terminated at her own insistence because she was Her too frightened to take any more. At the time of her discharge her doctor noted her as "quite depressed," but felt that it doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for was continued psychotherapy. �-11- Elialfiilgli structured family interview was designed to test the specific hypothesis derived from earlier observations that patients with the "explicit verbal denial" personality The are most likely to show both the language and behavioral changeswfiflxelectroshock therapy which are rated as much data supports this hypothesis and is also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952 (9). They suggest that "....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain function in which the mechanism of denial improved by the examiner. The is facilitated in characterologically disposed individuals." degree of eXplicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. 0n the basis of the present data and methods The of analysis a broader view of personality patterns in relation to improvement with EST is now possible. These patients who are rated as clinically improved are characterized by such features as: l) non-empathic - - unable to think critically or sensitively about the needs, feelings, or communications of others; 2) non-introspective ~ - unable to think critically about their own feelings or needs; unable to achieve insight even with the collaboration of others in the psychotherapeutic rely heavily on non-verbal communication they are talkative there is little referential relationship; even when 3) - �-12communication, the words being cliched, stereotyped, or representative of feelings and emotions rather than transmitters of information and h) highly conventional - - without imaginative or creative capacity, and with few resources to deal with stressful or With new situations. this pattern as the common background, two classes patients who respond to treatment can be defined: a) the driving, conscientious, independent, successful, emotionallycontrolled person who can be characterized as the "explicit verbal denial" personality type; b) the chronically inadequate, effectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short term response to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. of Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change slacwn with altered brain function, however, vary markedly in different patients. Some show mood changes and denial or displacement of symptoms and are rated as improved. Others develop paranoid agitated states, withdrawn, or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality become �-13- factors in those cases as improved. We whose behavioral response have not considered the patients was rated who were rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relation~ ship between personality and the behavioral reSponse in patients who are rated as unimproved. Present information in this regard is minimal, as this problem has not been approached with a specific hypothesis. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic These predepressed personality. Abraham (I) noted that states of depression occurred in obsessional persons. Arnot (2) describes depressions as being overly conscientious and perfectionistic. Hamilton and Mann (5), reporting various aspects of the personality in involutional depression, include such features as "followed a rigid pattern of behavior.... diaplayed a lack of imagination... narrow range of interests.. thorough, conscientious, meticulous devotion to duty...lack of feeling for point of view of others...hard, uncompromising drivers... intensive study of manic-depressive psychosis, reported their patients oversensitive...reserved." Cohen, sflngg (3) in an as being highly prestige-conscious; problems of little concerned with interpersonal relatedness; stereotyped; conventional; little capacity for communicative interchange; and unaware of other persons’ feelings toward himself or of his having �~1h- feelings toward others; They emphasized the inability to verbally communicate therapeutic relationship should be patients' that the in non-verbal terms rather and suggested than emphasizing the intellectual contents of the exchange. These studies of the personality background of depression show a pattern that is most similar to those personality "explicit verbal personality. The factor of personality could thus the fact that depression is the condition which responds electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are aspects denial" explain best to which have been described as the those which make him responsive to non-verbal forms of therapy. These factors enable him to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism, and prestigeconsciousness, which produce a catastrOphic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed "improved" by the family and the therapist. �-15SQMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for electroshock therapy were studied by means of a structured family interview. 2. The results show that aspects of personality can be differentiated which are significantly related to the reSponse . to treatment. basic personality pattern of the patients who respond best can be characterized as a) non-empathic, b) non-introspective, c) communicate non-verbally, and d) highly conventional and stereotyped, with little imaginative or creative capacity. h. Within the context of this common core, there are two main subdivisions of improved patients. One group is comparable to the Wkplicit verbal denial" personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to 3. The chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are effectively labile and Indie. 5. The relationship between these personality patterns and descriptions of the personality of depressed persons is noted. The same personality factors which contribute to a depressive reaction, contribute to a behavioral change under the conditions of altered brain function following electroshock therapy which is evaluated as improvement. be �116REFERENCES 1. Abraham, K.: SelecteguPafiers on The Hogarth Press Ltd.,‘l9h9. 2. Arnot, R.: The Predepressed Personality, A.M.A. Arch. Neurol. and Psychiat., 1g: 617f618, 1956. Cohen, M.B., Baker, 6., Cohen, R.A., Fromm-Reichmann, F. and Weigert, E.V.: Antintensive Study of Twelve Cases Psychosis, Psychiat., 11: 103-137, 1ofsfianic-Depressive 9 3. Psychoanalysis. London: 5 o R.L.: Quantitative Studies of Slow Wave Activity Following Elastroshock, EEG Clin. Neurophysiol., g: 158, 1956. Fink, M. Hamilton, and Kahn, The_Hospita1 Treatment of D.M. and Mann, W.A.: Involutional Ps choseg, in Depression (Hash, J., 6. 933.5, New Stratton, FT and Zubin, 199-209, 1952. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Kahn, R.L., Fink, A.M.A. Arch. 7. York: Grune E M. Neurol. & Egychiat., lé‘ 23-29, 1956. Kahn, R.L. and Fink, M.: Changes in Language During Electro— shock Therapy, in Psychopathology of Communication (Hoch, Zubin, J., eds.) New York: Grune & Stratton, 1958, P.6and 12 ~139. fi J.: Play) York: W.W. Piaget, 9. Norton, l9Sl. Imitation in Childhood. New Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, 10. Dreams and Am. J. Psychiat., 109: 22-26, 1952. Weinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.: Diagnostic Use of Amobarbitai Sodium ("Amytal Sodium") Am. inSOrganic Brain Disease, ""‘ J. Psychiat., 112: 889-89h, 19 3. 11; Weinstein, E.A. and Kahn, R.L.:’Personality Factors in Denial of Illness, A.M.A. ArCh. Neurol. & Psychiat., £2: 355-367, 1953. 12: Weinstein, E.A., Kahn, R.L. and Sugarman, L.A.* Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp. 2: 98-106, 195h. Weinstein, E.A. and Kahn, R.L.: Denial of Illness: Symbolic and Physiological Aspects. Springfiél’, 111.: Charles i 13. UT Thomas, 1955. � 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 Personality factors in behavioral response to electroshock therapy. J Neuropsychiatr. 1959 Sep-Oct; 1:45-9. 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