http://exhibits.library.stonybrook.edu/mfp/files/original/12764b529d79f1eb96174bc90f2534b6.pdf ca3411637648ce13d529a98dea9e5b2f PDF Text Text Behavioral Patterns in Convulsive Therapy MAX FINK. MD. AND ROBERT L. KAHN. Ph.D. GLEN OAKS. L. |.. N. Y. �Reprinted flow the Archives of General Psychiatry July 1961, Vol 5, [71). 30— 36 Copyright 1961,]1y Agzeiican Zl/[edical Association Individual differences in the behavioral response to convulsive therapy are marked. In psychiatric practice, patients with similar psychopathologic syndromes, and of similar sex and age, show a variety of clinical responses: Some improve and sustain such change; some improve, only to relapse quickly; and some fail to improve. These differences have been related to the degree and duration of induced neurophysiological change?“6 premorbid patterns of personal— ity,""11'15 sociopsychological characteristics,13' 15 and psychotherapeutic approaches.1 While these studies have emphasized ratings of improvement, the derivative nature of this evaluation and its dependence on staff attitudes, expectations, and family tolerance have been stressed.2""5'8 The manifest behavioral patterns provide the basis for the evaluations of clinical response. It is the purpose of this report to describe behavioral patterns in patients undergoing convulsive therapy and to relate these to problems of the evaluation of improvement and to an understanding of the convulsive therapy process. Behavioral Patterns in Convulsive Therapy Of consecutive patients referred for electroshock therapy during 1956-1957, seventy-three patients were subjects of the analyses described here. The patients were selected for treatment by the resident therapist and the supervising psychiatrist -——the investigators playing no role in their selection. These observations were made during a lllll|llllll|Illllllllllllllllllllllll|lllllllllllllllllllllllllllll|lllllllllllllllllllllllllllllllllllllllllllIlllllllllllllllllllllllll|lllllllllllilllllllllllllllllllllllllllllllllllllllllll MAX FINK, MD. AND ROBERT L. KAHN, Ph.D. GLEN OAKS, L.I., N.Y. convulsive-subconvulsive electroshock study in which subjects referred for therapy were randomly assigned to courses of subconvulsive or con— vulsive treatments. Electroshock was administered 3 times weekly under thiopental sodium (Pentothal) premedica— tion, using either a Reiter unidirectional or a Medcraft alternating current instrument. Grand mal or subconvulsive treatments were administered by altering the strength of current. Neither Submitted for publication Jan.6, 1961. From the Department of Experimental Psy— chiatry, Hillside Hospital. Present Address: Division of Psychiatry, Montefiore Hospital, Bronx, N. Y. (Dr. Kahn). Read in part, at the New York Divisional Meet— ing, American Psychiatric Association, November, 1957. Aided by Grant M- 927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service 52 �CONVULSIVE THERAPY 31 flecting the patient’s adaptation 2 to 4 weeks fol~ lowing the last treatment. patient, therapist, nor evaluating physicians was aware which course of therapy each patient received until after the evaluation period. Changes in brain function were measured at weekly intervals by tests of language patterns both clinically and after amobarbital and by the degree of slow-wave activity in electroencephalograms. The intercorrelation of these indices and their relation to behavioral changes have been reported previously?” The manifest symptom patterns of the referred patients were variable and included suicidal preoccupation, retardation, disturbances of mood and affect, excitement, agitation, panic and tension, delusions, ideas of reference, negativism, withdrawal, and somatic complaints. The clinical diagnoses were depressive psychoses of manic-depressive, involutional and reactive varieties, and schizophrenic psychoses of paranoid, mixed, catatonic, and pseudoneurotic types. Clinical behavior was assessed in weekly psychi— atric interviews, structured perceptual task situa— tions,“'15 and by conferences with the patient’s therapist. In these observations, the evaluation of improvement along the continuum of “recoveredunimproved” appeared inadequate and was supplemented by a rating of the degree of behavioral change. The degree of change in clinical and ward behavior was rated on a 4-point scale of “marked,” “moderate,” “minimal,” or “no change. H These evaluations were not value judgments as to the quality of the change, but rather quantitative es— timates of differences in behavioral patterns under similar conditions of observation. The assigned rating was based on changes observed during the treatment period and for 2 weeks post treatment. Evaluations of improvement response were made on the 4—point scale of “recovered,” “much im— proved,” “improved,” and “unimproved or worse.” These evaluations were value judgments, based upon the behavior of the patient, the therapist’s expectations, the tolerance by therapist and patient of those aspects of behavior often called “side— elfects of the treatment,” and the therapist’s judg— ment as to the family’s attitudes to the patient’s behavior. These evaluations were short—term, re- Observations A. Behavioral Change and Improvement. A comparison of the behavioral ratings and the improvement evaluations is presented in Table 1. That ratings of recovered and much improved were associated with high or moderate degrees of behavioral change is an expected observation. Similarly, that patients with minimal or no change in behavior were evaluated as unimproved or improved, is also expected. The significant relationship, however, lies in the patients showing high and moderate degrees of behavioral change and still rated as showing a poor clinical response. Of the 30 patients observed with high degrees of behavioral change, 17 were evaluated as recovered and much improved, and 13 as improved or un— improved. B. Modes of Adaptation—Analyses of the behavioral patterns of the subjects during and following treatment permitted the description of various modes of adaptation. For illustrative purposes we have described 4 behavioral patterns under the titles of euphoric—hypomanic, somatization, paranoidvuithdrawal, and panic modes. Euphoric-Hypomanic Mode: These subj ects appeared pleasant, affable, and friendly. They dressed neatly, spoke quietly, and participated in ward activities with increased interest. Occasionally they dressed gaudily and smiled and giggled excessively. Pretreatment symptoms were not manifest, and premorbid attitudes and behavior were again prominent. 0f Evaluations of Behavioral Change and Clinical Improvement (Convulsive and Subconvulsive Therapies) TABLE l.——C0mparison Improvement Rating Ichavioral Change High degree change Moderate degree change Minimal degree change No change F ink—K ahn Recovered (30) (17) (10) (16) Much Improved 9 6 0 0 8 3 0 L? 53 Improved Unimproved and Worse 8 6 2 5 5 1 15 5 �32 - In their psychotherapeutic interviews they described their illness in a detached manner, emphasizing “it” (illness) as having “dis— appeared.” They denied having been ill and facetiously suggested they were at the hos— pital for a rest, or that the institution was not a hospital, but a resort or a school. Symptoms were described in the past tense, and the quality of having been a different person during the illness was reiterated. Speech was marked by denial, displacement, evasion, qualification, and cliches.“ The third person mode was frequently used, as in such statements “the doctor says I am ill” or “my wife should have come here.” Gross changes in memory were either not apparent, or were described for the treat— ment period only. The patients expected and accepted these deficits, and neither connection with treatment nor apprehension was expressed. They looked forward to home visits and made realistic discharge plans. While conflicts with family members were described, these were minimized and expressed mainly in the past tense. Referential questions were answered in a referential manner and with— out an arousal of affect. For the more hypo— manic subjects, questions about home planning were responded to nonreferentially, with marked use of inappropriate clichés. When pressed with referential inquiries, they quickly exhibited anxiety and discom— fort, minimized their feelings, and changed the focus of the session. Such adaptations were sustained throughout the discharge planning period. The more hypomanic features were rarely sustained and within a few weeks were replaced by a more stable euphoric or somatization type of adaptation. Somatization Mode: In these subjects, in— cessant complaints about bodily symptoms and loss of memory, demands for reassur— ance and relief, and preoccupation with feel— ings of unreality and confusion dominated behavior. They remained unkempt and their rooms were untidy. When such an adapta— tion appeared early in therapy, further treatment was refused. ARCHIVES OF GENERAL PSYCHIATRY Speech was principally in the present tense and in the first person, with few third person references and a minimal use of clichés, denial, or qualifications. In psycho— therapy sessions, they were demanding and hostile, reporting their problems in terms similar to those used prior to therapy. They complained that the treatment caused addi— tional and more incapacitating difficulties. To referential questions, answers were gen— eraly correct, but associated with complaints of memory impairment. They described their family relations in pretreatment terms, with an occasional “I don’t remember” in response to experiential inquiries. Discharge planning was difficult, since they insisted that their new symptoms prevented any home adaptation. On the ward, their hostile demands for attention and relief of symptoms increased with treatment. Participation in group ac— tivities increased, however, for those sub— jects who had previously been withdrawn and seclusive. Memory complaints were preeminent. Pa— tients demanded reassurance that their memory would return and repeatedly asked if treatment would be harmful. They de— scribed feelings of derealization and con— fusion. Events, bodily feelings, and relations to friends and relatives seemed strange, fuzzy, unclear, and out of focus. While they complained chiefly of memory impairment, they also complained of back pain, headache, tingling of fingers and toes, nausea and weakness, and ascribed these to the treatment. At the end of treatment, the symptoms for which hospitalization had occurred were no longer present, and although complaints were many, their relation to the treatment and their transience was so universally ac— cepted by both the staff and the patients, that the results were evaluated as beneficial. This adaptive mode was sustained into the postdischarge period. Paranoid and Withdrawal Mode: Another pattern was the appearance of paranoid ideation, suspiciousness, hostility, ideas of reference, and delusions. These patients Vol. 5, July, 1961 �CONVULSIVE THERAPY failed to care for themselves and remained unkempt in their dress. Their rooms, in which they remained much of the day, were untidy. Speech was sparse and not spontane— ous. When questioned about their illness, they were hostile and demanded to know why they were questioned. They refused to answer inquiries or categorically denied or agreed to all specific questions. Experi— ential questions were answered referentially. When inquiry was insistent, they denied illness and minimized the symptoms which had resulted in their admission. They refused or avoided sessions with their therapist and insisted convulsive ther— apy be ended because it was harming them. When treatments were continued, they demanded release from the hospital, or pre— cipitated discharge by elopement, suicide attempts, or aggressive and destructive out— bursts. They were unable to discuss their relations with family or friends and focused on demands for either release or relief from somatic symptoms. Hostility was overt and engendered a fearfulness in the staff. On the ward, when coaxed out of seclusion, they were loud, aggressive, and demanding. They were suspicious of attempts at friendliness and expressed thoughts that others wished to harm them or talked about them. While insisting on discharge, no realistic discharge planning was achieved. Their View of the environment was grossly distorted and self—centered, preventing adequate care. In testing, they were uncooperative, and voiced angry suggestions of being experi— mented upon or abused. Complaints of memory impairment were infrequent and occasionally denied even when clinically manifest. On such occasions, they were en— raged at the implied deficit. Panic Mode: These patients became increasingly anxious, agitated, restless, sleep— less, and anorexic. In their dress, they were neat and cared for themselves. Speech pat— terns were unchanged and continued with emphasis on first person and present tense modes. Symptoms were distressing and prominently voiced. When asked about pre— treatment symptoms, these were expressed . Fink—Kuhn 33 in the same terms as those used earlier, with the complaint that treatment had made everything worse. Patients feared treatment and hid on treatment days, or pleaded with the staff to forego further applications. They threatened elopement and if this failed, submitted administrative requests for discharge. On the ward, they continued their pretreatment patterns of minimal participation. On treatment days, they were withdrawn, sullen, and negativistic, and cooperation was poor. They demanded to see their therapists and on such occasions insisted that treatment be discontinued. They were unable to discuss family situations or their attitudes to others, being preoccupied with their feelings of fear. In discussing their home, they insisted on immediate discharge, while stating they were severely frightened, anxious, depressed, and unwell. Ideation was unchanged with fearfulness as the principal affect. Fears of damage to the brain or mind was expressed, accompanied by the awareness that memory impairment may be a Sign of such damage. Complaints of memory impairment were infrequent and when present, were ex— pressed as a specific reason for discontinuation of treatment. Patients were uncooperative and fearful of testing and participated only if encour— aged that such tests may be helpful in the therapist’s decision about further treatment. Occasionally, when treatment was discon~ tinued, a more stable adaptation of relief, acquiescence, and denial appeared. C. Adaptive Mode and Improvement Ratings—Thus, for the various adaptive behavioral patterns, a range of short—term evaluations was observed. Those subjects who developed and sustained the euphoric— hypomanic modes were generally rated as recovered or much improved. Patients with somatization and panic modes were oc— casionally rated as improved, although unimproved ratings were frequent. The paranoid—withdrawal mode was evaluated as unimproved or worse, as were patients exhibiting the panic modes. The relation be— �34 ARCHIVES OF GENERAL PSYCHIATRY TABLE 2.—Adapti7/e Mode and Improvement Improvement Rating Modes Euphoric-Hypomanic Somatlzatlon Paranoid-Withdrawal Panic No adaptive change‘ ‘ Includes subconvulsive (36) (10) 7) ( 7) (13) ( Recovered Much Improved 11 14 0 0 0 0 l 10 5 0 0 0 2 2 l Improved Unimproved, Worse l 4 5 5 12 treated subjects Without second course of ECT. tween adaptive modes and ratings improvement is summarized in Table 2. of Studies relating physiological or psychological aspects of convulsive therapy to clinical outcome have reported inconsistent results}6 Thus, it has been reported that depressed patients respond favorably to convulsive therapy while schizophrenic or neu— rotic subjects do not; while other observers indicate that neurotic depressive patients re— spond badly, and that some schizophrenic subjects do have favorable outcomes. Vari— ous measures have been suggested as predic— tors of improvement, only to fail on more extensive testing. In such instances, the differences in results and discrepancies in convulsion can be related to the utilization of a variety of global estimates of improve— ment as the criterion of behavioral change, without adequate specification of the standards used in the evaluation. Such standards differ widely, depending on institutional populations and staff attitudinal factors. Varying attitudes toward “side-effects,” the use of global rating scales, and varying psychosocial attitudes affecting goals of treatment have each served to make results from different laboratories incom— patible. Thus, in our evaluations of con— vulsive therapy, the development of changes in memory, recall, and orientation have been considered as temporary manifestations of therapy and disregarded in the clinical eval— uations.3'19 Patients developing the euphoric or hypomanic modes, despite concomitant memory loss, have been rated as much im— proved. In a comparable study by Johnson et al.,10 the Lorr global ratings of behavioral change were utilized. In this type of evaluation the changes in memory and orientation are in— Comment These observations emphasize the variety of behavioral adaptations that occur during convulsive therapy and relate short—term evaluations of improvement to the type of behavioral change. Earlier observers of con— vulsive therapy have described a range of behavioral patterns, ascribing the changes to ego adaptive responses, to the trauma of the treatment, organic brain changes, or psychologic significance of the treatment.7' 9'21 These observations that subjects with similar psychopathologic syndromes receiv— ing similar treatment may exhibit discordant behavioral adaptations and be variously rated as recovered or unimproved, are of significance for an understanding of the convulsive therapy process. In earlier studies, the conclusion was reached that persistent alterations in brain function were a necessary condition for behavioral change in convulsive ther:«ipy.2""6 With changes in brain function, all aspects of behavior undergo modification. Percep— tion, mood, affect, judgment, attitude, mem— ory and recall are altered, and with these, the subject’s adaptation in the environment. Not all behavioral changes are viewed as improvement, however. Improvement ap— pears to be a special type of behavioral response, being the subjective estimate by an observer that the patient is “better.” It is based, not only on the patient’s behavior, but also on such nonspecific aspects as the observer’s expectations, and tolerances, and those of the family and environment. 56 Vol. 5, lily, 1961 �CONVULSIVE THERAPY cluded as negative scores in the improvement scoring, so that a high number of subjects were reported as “unimproved or worse.” Besides population differences, this single factor is sufficiently potent to alter the rela— tionships between the 2 studies and justifies the discrepant observations. The use of global estimates of behavioral change in evaluating therapy has other significant deficiencies. Psychiatric therapies are rarely focused, or effective in modifying a single symptom. The induced changes affect a spectrum of behaviors, with varying rates of change for different aspects. Global estimates tend to lose differences in individual elements within the medial designations necessary to define the whole response. In such situations changes in behavior which may be prominent, though not pervasive nor enduring, may dominate the evaluation as to overshadow other, potentially more signif— icant changes. Thus, alterations in memory and recall, or increased somatization or in— creasing withdrawal may dominate unim— proved evaluations; while explicit verbal denial, clichés, and euphoria may lead to recovered or much improved designations. The use of improvement ratings may be empirically justified as an early approxima— tion in studies of a new therapeutic meas— ure, but further analyses of the behavioral ‘ observations are required for understanding and adequately applying the treatment. The typologies described in this report are one approach—one that has been helpful in our understanding of the convulsive therapy process and one that is now being tested in studies of psychopharmacologic agents. In addition to the differences in improve— ment evaluations occasioned by attitudes to “side—effects” and the use of global ratings, there are differences due to the attitudes of therapists toward various sociocultural pop— ulations. The adaptation of explicit verbal denial in a lower class patient in a community institution is welcomed by therapists and family, but the same adaptation in an upper class professional in a psychothera— peutic hospital is considered poor or psy— chotic. The display of rationalization. Fin k—K01m 35 minimization and displacement, even when accompanied by a return to premorbid work levels, is considered marked improvement in one setting, but is viewed as a lack of improvement in another if goals of insight had been set by the therapist. Interference with memory and recall may be disregarded by therapists for one sociocultural group, but arouse empathic solicitude for patients of another social class. Such factors affect not only institutional attitudes, but within an institution, therapists of different thera— peutic orientations may have differing atti— tudes towards evaluations and therapies. The many recent sociocultural studies of thera— pists, and their attitudes towards selection of therapies, are indicative of these attitudinal differences.13'17-18'20'22 It is our impression, therefore, that im— provement ratings are no longer useful devices in evaluating psychiatric therapies. For the symptomatic therapies extant today, which are seemingly not directed toward the alteration of an etiologic factor, typologic descriptions have a greater applicability and empiric justification. Typologies based on concepts of diagnosis, target symptoms, or on dynamic—structural formulations have attempted to structure the pretreatment clusters in which therapies may be effective. Treatment and post—treatment symptom improvement scales have been used with utility. These are limited approximations, however, and there is a need for a broader approach to both the pretreatment and the treatment behavior, and a phenotypic, adaptive be— havioral typology, using multivariate tech— niques of data analysis, seems worthy of assessment. Summary An analysis of the variety of behavioral adaptations of 73 voluntary psychiatric pa— tients undergoing convulsive therapy resulted in the description of 4 major patterns. These are described as euphoric-hypomanic, somatization, paranoid—withdrawal, and pan— ic modes. The relation of these modes to clinical ratings of improvement is described. The �36 ARCHIVES OF GENERAL PSYCHIATRY derivative and generally nonoperational nature of improvement ratings is empha— sized. The difficulties in a communicative definition of this variable is seen as a major factor in the discrepant studies of indices predictive of improvement in convulsive therapy and in understanding the processes of somatic therapies in psychiatry. Therapy (With and W'ithout Atropine), Arch. Gen. Psychiat. 2:324-336, 1960. 11. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, edited by P. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126-139. 12. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Psychiat. 76 :23-29, 1956. 13. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings, and Diagnosis, A.M.A. Arch. Gen. Psychiat. 1:565-574, Max Fink, M.D., Department of Experimental Psychiatry, Hillside Hospital, 75—59 263rd St., Glen Oaks, L.I., N.Y. REFERENCES H Esecover, H.; Jafie, J., and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients, J. Hillside Hosp. 7:17-25, 1958. 2. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp. 6: 1. 1959. 14. Kahn, R. L.; Pollack, M., and Fink, M.: F igure-Ground Discrimination After Induced Altered Brain Function, A.M.A. Arch. Neurol. 2:547-551, 1960. 15. Kahn, R. L.; Pollack, M., and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. Ment. Dis. 130:187—192, 197-206, 1957. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electro— shock: Quantitative Serial Studies, A.M.A. Arch. Neurol. Psychiat. 78:516-525, 1957. 4. Fink, M.; Kahn, R. L., and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. Syst. 19:113~118, 1958. 5. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Afl'ecting Individual Differences in Behavioral Response to Convulsive Therapy, J. Nerv. Ment. Dis. 128 :243-248, 1959. 6. Fink, M.; Kahn, R. L.; Karp, E.; Pollack, M.; Green, M.; Alan, B., and Lef‘kowits, H. J.: Significance of Inhalant Induced Convulsions for the Theory of the Convulsive Therapy Process, Arch. Gen. Psychiat. 4:259-266, 1961. 7. Frosch, J., and Impastat, D.: The Effects of Shock Treatment on the Ego, Psychoanal. Quart. 3. 1960. 16. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and other Somatic Treatments in Psychiatry, New York, Grune & Stratton, Inc., 1952. 17. Kaplan, A. 1., and Lefkowits, H. J.: Influ— ence of Staff Attitudes and Environmental Factors on Treatment Selection, J. Hillside Hosp. 1961, to be published. 18. Klerman, G. L.; Sharaf, M.; Holzman, M., and Levinson, D. J.: Sociopsychological Charac- teristics of Resident Psychiatrists and their Use of Drug Therapy, Amer. J. Psychiat. 117:111-117, 1960. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Confin. Neurol. 16: 19.. 88-96, 1956. 20. McIver, J. and Redlich, F. C.: 17:226-239, 1948. 8. Frosch, J.; Impastato, D.; Ottenheimer, L., and Wortis, S. B.: Some Reactions Seen After Electric Shock Treatment, Amer. J. Psychiat. 102 Patterns of Psychiatric Practice, Amer. J. Psychiat. 115:692- 311—315, 1945. 697, 1959. 21. Millet, J. A. Glueck, B. C.: Psychopathologic Reactions and Electric-Shock Therapy, New York J. Med. 42:1553-1557, 1942. 10. Johnson, L. C.; Ulett, G. A.; Johnson, M.; Smith, K., and Sines, J. 0.: Electroconvulsive Psychosom. Med. 6:226-237, 1944. 22. Pasamanick, B.; Dinitz, S., and Lefton, M.: Psychiatric Orientation and Its Relation to Diag— nosis and Treatment in a Mental Hospital, Amer. J. Psychiat. 116:127-132, 1959. : P., and Morse, E.: On Certain Psychological Aspects of Electroshock Therapy, 9. 58 Printed and Published in the United States of America ��Putt-ran at Bohgvioral chant. and Inprorcnnnt 1n canvullivo rhcrapy In: Pink, x.n. and nobcrt L. Kuhn, Ph.D.* from the Dapartncnt or Expnrinontnl Psychiatry, ulna oakn, L.I., n.x. Hillside noupitsl, gratt K~927 of tho lattcnal Initituta a: nontal noulth, lutional Institutua a: Hatlth, United Status Puhlie Hualth survzoo. Reta in part, gt th.".!. 91'1319311 looting, American Payehintric Aidod by Association Northbor, 1951. : Btvfliomit o: Psych-try. Mutation 30-91%“. *Pruont Bronx, 1.1. VII: 1/61 “an" �Individuol flittoroncoo in tho bohoviorol roopouoo to oonvoloivo thoropy oro oorkod. In poyohiotric proctico, potionto with oanslor poyohopotholoxtc oyudroaoo, one or oililor varioty or olinieol rosponooo: oooo toprovo old ouotoin ouch chongo; oooo 1-provo, only to rolopoo quickly; ond oooo toil to taprovo. rhooo dittorooeoo hovo boon rolotod to tho dogroo ond duration or indoood nourophyoiolociool ehongo (3,6) prooorbtd pottorno or poroonoltty (5,11,15), ooulopoyeholoctool chorootoriotioo (13,15) and porehothoropontto opprooehoo (1). Vh11o thooo otudioo hovo onphooiood voting: 0: taprovooont, tho dorivotivo unturo or thin ovoluotion ond 1t: dopondonco on otort ottttudoo, oxpoctotiono ond tooily toloronco oox ond ago, ohow o has boon strooood (2,h,5,8). rho oonttoot bohoviorol pottorno provido tho boots tor tho ovo$uot1ono of clinical rooponoo. It 1o tho purpooo o: thto roport to doocriborbohovtorol pottorno 1n pottonto nndoraoinz oonvolsivo thoropy, ond to roloto tho-o to problooo of tho ovolootioo of taprovooont and to on ondorotondinx o2 tho coo- vuloivo thoronyIProcooo. �gethod: or consecutive pe$$en$e reterred for electreehoek therepy 63:13; 1956—57. teveatybthree pettente were subjecte e: the eaelyeee eeeeribed here. the patients were selected tor treeto sent by the reeident therepiet end the aupervteiuc peyohietrtefi - the inveetzceterp playing no role in their selection. These convulsive—euhcenvulaSve electroc 3 during were III. obeervettene eheok study a; whieh subject. referred tar enereyy were rendenly unsigned to entrees e: cuboenvuletve er convulsive treetnente. Electroeheek wee edginietered three tines weekly under pentethel preunedieetiea, using either e letter unidirectional er e xederett alternating entrent inattenent. arena eel or enbeenvnleive treetnente were eduin1utered by titering the etrongth of current. leither patient, therapist not eveluetinx phyeiaiene tee evere which entree e1 therapy each pétient received until titer the evaluation period. weeiiy intervals cheese: in urea: tunetion were neeeered at by test: of leagues. petterne both 011336.11: eta etter eneberbitel, and by the degree e: 310: were activity in electroencephelegrene. 2he interoerreletien e: theee indieee 3 �.3cooplointl. rho alinicol dioxnoooo woro doproootvo of nonio—doproooivo, involutioaol ond rooetivo and ooaotic poyuhoooo voriotioo; one oohioophrontc poyehoooo or poronoid, aixod, oototonto and pooudonourotie typoo. clinical bohovior woo oooooood in vookly poyuhiotric intorviovo, otrootorod porooptuol took oituotiono (1h,15) and with contorouooo tho potiont'o thoropiot. II thooo ohoorvo~ by tiono, tho ovolootion of :Iprovouont along tho continual of 'rooovorod-untnprovod' oppooroa inoaoquoto, and woo topplonontod by o roting of tho dogroo of bohoviorol ohongo. rho dogroo of chonzo 1n olinieol tad word hohovior woo totod on o four point ocolo or 'norkod', “nodoroto', 'nininol' or'ho chango'. Thooo ovoluotiono woro not voluo Judznonto no to tho quality of tho ohonxo, but rothor, quontitotivo ootinotoo o: ditforouooo in hohoriorol pottorno undo: oinilor condition: at otoorvotion. rho oooigood voting woo hoood on ohongoo oboorvod during tho trootnont poriod and for too vooko poot~ trootaont. lvolootiono or ingrovonont roopoaoo woro undo on tho four point ocolo or 'rocovorod', 'nuoh taprovod', fitnprovod', and “nailprovod or onroo'. rhooo ovolootaono ooro voluo Judgnouto, hoood upon tho bohovior of tho patient, tho thoroptot'o oxpoctotiono, tho toloronoo by thoropiot and potiont of thooo oopoeto of bohovior otton oollod *oido-orroeto of tho trootnont’, and tho thoropiot'o Judgnont on to tho tonily'o ottitudoo to the potioat'o hohovtor. fhooo ovolnotiono ooro abort-torn, rotlocting tho potiont'o odoptotion two to tour wool“ following the lost troutnOHto �gbaorvationo: (a) Donatioral chango and Ingrovonont coaparioon at tho bahavioral ratingo and tho iaprovoaont ovaluationo 1o proooatod in tabla I. that ratings at rocovorod and nuch iaptovod woro aaaociatod with high or moderate dogrooa at bohavioral change it an oxpoctod obaorvation. similarly, that patioato with ainiaal or no chango in behavior taro avalaotod ao uni-proved or iaprovod, io aloe oxpootod. tho aixaitioant rolatianahip, hovovor, lioa in tho patianta ohooing high and oodorato dogrooo or bohavioral ohoazo and atill ratod ao ohaoiaz a poor oliniaal roopoaao. at tho thirty patioato obaorvad with high dogrooa or hohaviaral ohango, aovontoon voro ovaluatod aa raeavorod and much iaprovod, and thirtoon ao inprovod or aainprovod. l .. --.. . ZLBLI (b) undo: at Adaptation I -“fl--. o: the bohavioral pattorna at tho oobaocto daring and tailoring traataont poraittod tho description or variauo today of adaptation. For illoatrativo purpoooa vo havo doaoribod tour bohoriorol pattorna undo: tho titloa a: oaghorie-hzgoaanio, oaaatiaation. garanoid-withdraoa; and Analyooo Rania nodoo. Bughorio-lzzoaanie Roda: Thooo oubjocta appoarod plaaaant, atrablo and friaudly. they are-sod neatly, opako quiotly, and participated in word activitioo with ineroaaod �Zlflfifi I atnpgrtann 0t Evaluationl Qt nohavttrnl change and clinical Inpruvcnont (c0uvu1317c and subconvnlutru 1h0r&pico) fitting XIErOVOIORt locovorod » _ Itch Inprdvod fininpruvod and Ingrovod 39:30 Bahaviorll Ghangc nigh dogroo change (39) fi lodorato (17) 8 9 8 5 3 6 6 2 Juana (‘10) o a 5 S (16) o 0 1 15 I. change ' ' I' �. ~5-. interest. 'oeeeeieeelly they dreeeed aeadily, end exiled end giggled excessively. Pre-treeteent eyepteee were net eenifeet end preeerbid ettitudee end hehevier were egeie prenieeet. In their peyohetherepeetie interviews they deecrihed their illueee in e deteched leaner, eepheeieieg ”it“ (illneee) ee they denied having-been ill end feeetieeely eeggeeted they were et the heepitel fer e reet; er thet the inetitutiee wee net e heepitel, but e reeert er e eeheel. Syeyteee were deeeribed in the pert teeee, end the geelity of keying been e different pereen during the illeeee hevins “dieeppeered’. reitereted. Speeeh wee eerked by deeiel,.diepleeeeeet, ereeiee, quelitieetiee end eliehee (11). the third pereen wee ' eede wee frequently need, ee in eeeh eteteeeete the doctor eeye 1 en 111' er *ey wife eheeld here eeee here.II Greee ehenzee in neeery were either not eppereat, or were deeeribed fer the treeteeet period only. the petieete expected end eeeepted theee defieite, end neither eeeeectiee with treeteeet her eppreheneien were expreeeed. they looked forward te here wieite end eede reelietie dieeherge pleee. While conflicts with feeily eenbere were deeeribed, theee were eieieieed end expreeeed neiely in the peet tenee. heferentiel qeeetieee were eeewered in e referential nearer end without en ereeeel of effect. for the mere hypeeeeie eebaeete, queetiene eheet here planning were reepended te nearefereetielly, with marked nee of inepprepriete eliehee. When preeeed with referentiel inquiries, they quickly exhibited �.5anxiety and dieeeatort, aiuiaieed their feelings and changed the teeua.e£ the eeeeien. Seek adaptatiene were euetained throughout the discharge planning period. The mere hypeaaaie features were rarely suetained, and within a for weeks were replaced by a mere etable euphoric er aenatizatien types of adaptation. ,8enatizetien Hades In theee_enbdeete, incessant eeaplainte about bodily eyaptene and lees e: eatery, deaands fer reaeeurenee and relief; and preoccupation with feelings of nnreality and eeeteeion doainated behavior. Ehey retained unkempt and their When each an adaptatien appeared early in were untidy. reels therapy, further treatment wee refused. speech nae printiptlly in the present teaee and in the first pereen, eith fee third peraen references and a ainiaai use at clichea, denial er qualifications. In peyohetherapy eeeeiene, they vere-deaandies and hostile, repertihg their prehieae in terae eiailar to these need prier to therapy. !hey eeaplained that the treatment eaaeed additieeel and mere incapacitating difficulties. re referential queatiens, answers were generally correct, but associated with eenplainte of aeaery inpairaent. they deeeribed their taaily relations in yreotreatneet terns, with en oecaaional '1 den't reaenber' in reepenee to experiential inquiriee. Discharge planning eaa dittiealt, as they insisted that their new eynptene prevented any home adaptation. their heetile demands for attentien and relief at eyupteas increased with treetaent. Participation in creep activities inereaaed, however, tar these eabaeete who had an the ward, �-7. previeaely been withdrawn and eeoleeive. Heaory eeaplainte were pre-eaiuent. ratioate deaanded reaaaaranee that their aeaery would return, and repeatedly asked if treatment would he hararul. they deeoribod feelinge of derealiaation and confusion. Erenta, bodily feelinge and relatiena to friends and relativee eeeaed etrange, teeny, unclear, and out of :oeue. While they oonplained ehietly e: book of alao ceaplained pain, headache, they iarairnent, aeaory tingling o: tinsera and teee, aaaaea and roakaoee, and aeorihed there to the troetaent. which end symptom: the for the at treatment, heepitalit iaatioa had occurred were no longer present, and although and to the treatment were relation their their aany, eoaploiate transieaoe eae eo univoreally aeeepted by both the start and the patients, that the rooalte rare evaluated or beneficial. !hie adaptive node wee eeetained into the peat-dieoharge period. Paranoid and Withdrawal lode: Another pattern tea the appearance or paranoid ideation, euepicieuaneea, hostility, ideae of reference and deleaiene. These patients failed to care for theaaolvee, and roaained unkeapt in their dress. Their reeaq.in which they reaained each or the day, were untidy. Speech eaa eparee and not epontaneeaa. when questioned about their illneae, they were hostile and demanded to know why they were queetiened. they retaeed to anewer inquiriee er categorieally denied or agreed to all epecixio queetiene. Experiential caeetiena were anewerod roterantially. When inquiry was ioeietoat, they doeidd illneea and ainiaieed tho ayaptena which �~8- resulted 3: their ednieeien. they retueed er eveided eeeeieee with their therepiet, end ineieted eenvuledve therepy he ended beeeeee iteee herningy then. When treeteente rere continued, they demanded releeee free the_hoepite1, or precipiteted dieeherge by elepeneut, euietde ettelpte er eczreeeive end deetreetdve outberete. They were uneble to diecuee their reletiens with relily or triende, and teeeeed either en deaende fer releeee or relief tree resette eynptoee. Ieettlity wee overt, end engendered e teertelneee 1n the etett. an the nerd, rhea eeexed out of see» Ineien, they were lend, eggreeetve end deeend1ng. They were eeepieieee e: etteepte at friendlteeee, end expreeeed theeghte thet other: edehed to here the: or talked ebefit then. while ineieting en dteeherge, no reelietie dieeherge pleating wee eehseved. their View er the envirtneent wee creeely distorted end eelreeeutered, preventing'edeqnete care. In testing, they were uneeeperetive, end rained angry eeggeetiene a! being experirented ugen or ebueed. Complaints at nenery impairment were intrequent, and occeeienelly denied when even clinicelly meniteet. on such occasione, they were eareged et the inplied deficit. Peale Bede: Theee'pettflate beeene increeeingly enzione, eglteted, reetleee, eleepleee end enorexie. In their dreee, they were neet end eered ror themselves. Speech patterns hed were unehegged end eontinued with eepheeie on tiret pereon and preeent tenee nodes. .synpteme were dietreee1ng end prentuentiy voiced. When asked about preetreetment eynptore, �.9. theee were expreeaed in the aaae terae ae theee need earlier, with the eaaplaint that treataent had aade everything weree. Patienta reared treat-eat and hid an treataent daye, er pleaded with the etatt to forage farther applications. they threatened elepeaent and it thie tailed, enhaitted administrative reqaeata fer discharge. an the ward, they continued their preatreataent patterns at participatien. 0n treataent daye, they were withdrawn, aalien and negativietie, and cooperation wae peer. they deaanded te aee their therapiete and on each eceeeiene ineieted that treataant be discontinued. they were unable to diecnee {anily eitaatiene er their attitudee to ethere, being preo eeeayied with their feeling: at tear. In dieeaeaieg their minimal heaa, they inaiated en iaaediate dieeharge, while atating they were aewerely trightened, anxieaa, depreeeed and unwell. ’Ideatien was unchanged with tearfulneae ae the principal . affect. reare te the brain er aied wae expreeeed, aeeeapaaied by the awareaeee that aeaory iapairaeet may be a sign at each damage. ceaplainta at aeaery inpairaent were in~ ex daaage frequent and when present, were expressed ae a apeeitie reason (or dieeeatinaatiea of treatment. Patiente were uncooperative and fearful at testing, and participated only it encouraged that such decision about further tests may be helpful treataent. occasion. in the therapist's ally, when treatment wae diacentinued, a more stable adaptation of relier, aeqaieeeenee and denial appeared. �' (3) 29:9" tivo H96. and rovunoat n;¢1 3 Thus, fo:_th¢ var1oua_gdaptivq bohnvitrnl ptttornl, a runs; or ihort term evaluations were obsorvad. thus: subjects aha devolaped and sustained the euphoric-hyponanie nodou were generally ratofi us rocaverod or nueh inpravod. Patients uith ponatizatian gnd panic modes were ocgusiantlly rated as improved, nithgugh uninprevod ratings were frequent. The paranoid-with. figural node was evaluated as unimprGVad or worse, as were model. The relation batucon the panic pn§;ontl czhibiting adaptive node and ratings or improvonent are Ialnnrilod in ' d‘ fable 1!. 1133! II -‘C- “CC- �tivo.flndc 3nd Ada rovonoat Ingrovcnont Rating Rtoovered 3.4.. anh Improved Inprovcd fininpravod, Horn. Euphoricvflyponanic (36) 11 1h 10 1 Selatinttion tiranotdniithdrauul (10) o 1 5 h ( 7) 0 o 2 5 Psntc ( 7) o o 2 5 ndaptivo ohtngoi (13) 0 0 1 12 I. alnoludas snbcenvulsivo trcntod unbaoctu without cocond course 01 not, �Bieeoeeien: fheee ebeervatiene eaphaeiee the variety of behavioral adaptatiene that-occur daring eonvaleive therapy, and relate abort tern evaluatieee or iapreveaeot to the type of behavioral change. larlier obeervere at oooveleive therapy have deeoribed a range of behavioral patterns, aeoribing the ehaogee to age adaptive reepenaee,to the traaaa of the treataent, organio brain changes, or peyehologio oigoifioanoe of the treataeot (7,8,9,21). These ebeervatione that subjects with eiailar peyohopethelegio eyndreaee receiving aiailar treatment aay exhibit dieoordaot behavioral adaptatiene, and be varioaely rated aa recovered or aaiaproved, ie o! eigoirieanoe for an onderetahding e: the eonvnlaive therapy prooeee. In earlier studies, the ooholoaioo val reached that pereietené alteratioea in brain tanotioo were a neoeeeary eonditieo to; behavioral change in oonvaloive therapy (2,h,6). With changes it brain tuaotioo, all aepeote of behavior undergo modification. Perception, need, affect, Jadgaent, attitude, aeaery and recall are altered, and with theee, the eabaeot'e adaptation in the environment. let all behavioral ebaegee are viewed aa iapreveaeot, however. Improvement appeare to be a special type oi behavioral reepooee, being the eobjeotive eetiaate by an obeorver that the patient ie 'hotter’. It ie baled, not only on the patieot'e behavior, but also on each oeo-apeoitie aepeeta aa the obeerver'a expeotatione, and toleraooee, and these at the taaily and eovirenaent. Studies relating physiological or peyehologioal aepeote �-12or oonvnloivo therapy to clinical inreported that deproeeed ontoone have reported been hae Thne, (16). it ooneietont roanlte eohiaowhile oonvnleivo therapy to patients reopond favorably oheorvore other while do not; oabjoota nonrotio phrenio or and badly, reepond patiente dopreeeive neurotic that indioate ontooaoe. do favorable have enhaeota that ooae aohiaophronio of inprovoaa predictora been enggeeted have Various noaanroe each inetanoea, In extensive tootinx. on aoro to lent, only tail can eonolneion in and diaoropanoioo in results the dittorenooe or oetiaatoe of global of a variety be related to the utilization vithoot behavioral change, of the criterion ilproveaent an evaluation. the need in etandarde of the adequate epooitioation Snoh etandarde differ videly, depending on institutional atatt attitadinal taotore. Varying attitudeand eoaloe of rating global the nae toaard 'aide-otteota', popelatione and o: treataent goale afteoting attitndee varying peyohoeooial have baoh eorved to lake reenlte tron different laboratorioe oonvnloivo therapy, o: ovalaationa in our fhne, inooapatiblo. and orientation recall in ohangee neaozy o: devolepaont the , and of therapy aanitoetatione have been considered ae teaperary dieregardod in the olinioal ovalaatione (3,19). Patients oonoonitant doepito aodea, hypeaanio the euphoric or developing anon been on ieproved. have rated neaory loee, In a ooaparable etndy by John-on gngg, (lo), the Lorr global of In type thie utilized.“ were change rating! of behavioral inolndod and orientation are in ohanxee the neaory evaluation �-13- negative oeoroa in the inprovenent nearing, no that a high nnaher or enhaooto were reported an 'aninproved or nerao.‘ Booidoe population ditterenoee, thia einglo factor in eattioiently potent to alter the relationehipe between the two etadios, and Justitieo the diooropant eboervationa. the nae or global eetinatea or behavioral change in evaluating therapy hae other significant detieieneiee. Psychiatric therapiea are rarely toenaed, or effective in modifying a single eyaptea. the induced ohanxoo affect a opeetrna oi hehaviera, with varying ratoa of change for ditterent aepoote. Global aetinateo tend to loae differenooe in individual ole-onto within the nedial deoignatione neeoeaany to define the whole reeponee. In oneh oitnationa ohangee in hehavier which nay he preninont, though not pervaaive nor enduring nay doninate the evaluation an to overehadoe other, potentially nore aignitioant ehanzee. than, alterationo in aenory and recall, or increaeed eonatination or inereaaing tithdrawal nay daninato nninproved evaluations; while explicit verbal denial, olieheo and euphoria nay lead to recovered or each iaproved designations. the nae o: inprevenent ratings nay he enpirioelly Jaatiried an an early approxiaation in studies of a new thorapeutio aoaonre, but inrthor analyoea o: the behavioral eboorva~ tiona are required for anderatanding and adequately applying the treatnent. rho typologiea deooribod in this report are one approaeh - one that hoe heon helptal in our nnderatanding or the oonvaloive therapy prooeea, and one that in non being teatod in etadiee o: payohepharaaeoloxie agento. on �ulhIn sddltlen to the differences in leprevesent evelestlens eeessieeed by attitudes to 'elde-effeets' end the use ef glebel due to the ettitedes ef thereplsts differences there ere retinls, tersrd rsrlees seeleesltsrsl peeeletiens. The edeptetien of explicit verbsl denial in s lever clues pstient in e eennenlty lestitntlee is welcomed by therspiste and really, but the seas sdsptstleu in en upper elese professional in e peyehethsrspeetle The displsy ef or psychotic. is hospital considered peer when and even nintnisstlen displscenent, retlensllsstien, eeeenpenied by s return to preeerbid work levels, is eensidered nsrked leprevenent in ens setting, but is viewed as e leek ef inpreveneet is enether if ceels of insight hsd been set by the thersplet. Interference with memory end reeell say he disregsrded by therspists fer ene seeieeeltnrel group, but sreese espethle eeliettede fer petlente ef endkher seeiel eless. Seek feetere effect not enly institutienel,%tt1tedee, but riteln en 1nst1ts~ tion, therapists of different therepeutie erlestétlees sey here evglestieae nsny thersples. towards sad the differing ettltedee recent seeiecnlterel studies ef therspists, end their sttitedes tevsrds eelsetion ef thersples, sre indiestive of these sttitndinsl differences (13,17,18,2o.22). It is our impression, therefore, thet inprevenent rstlngs are no longer useful devices in evslusting psyrhietrie therepies. For the eynptometie therapies extent today, which ere seemingly net direeted tewerd the slteretien ef en etiologic fecter, typelegte deecriptiens have s greeter spplleebility sud enpirie �-15. Justification. typologies haaad on concepts at diaxaaaia, targat aynpaaaa or on dyaaaio-atractaral formulations harattaaptad to atructara tho pra-traataaat clusters in witch thoraptaa nay be attaativa. fraatnant and paat—troatnant ayaytan impravaaant acalaa have haan used with utility. Thaao ara linitad approxinatiaaa, howavar, and thara 1a a naad far a broader approach to bath tho pra-traataant and traatnant bahaviara, and a phanotypio, adaptiva bahaviaral typolacy, aaing aaltivariata taohniqnaa at data analysis, aoana worthy a: aaaaaaaant. �w in enelyeie_er the veriety e1 beheviorelvudeptetiene or 73 velnntery peychietric petiente undergoing convulsive therepy reeulted in the description er tear nejor patterne. These are deecribed ee eupheric-hypenenic, eenetizetien, paranoid-withdrawal end penie nedee. the reletien er the-e nedee te clinical retinge e: ieprevenelt ie deecribed. the derivative end generally neu-eperetienel unture e: ieyrevenent retinge in enpheeieed. the difficulties in e cennunieetive detinitien e: thie veriehle ie eeen ee_e nejer teeter in the dieerepent etudiee et indieee predictive e: inprevenelt in cenveleive therapy, end in underetendinc the preeeeeee e: ee-etic therepiee in peywhietry. �-17- W' 1. Ieeeever, 1., latte, J. and Iain, R.L.: Peyehetherepeetie rechaiqaee with lieetreeheek Patiente. J. lilieide .3332..1; 17~2§, 1958. link, 1.: i fiaified theory of the ietiea e: Phyeiedyuanie rherapiee. J. lilleide legg. é; 197-206, 1957. BIG and of Delta Activity te telatien 1.5.: lake, link, I. lehavierel leepenee in lleetreeheek: Quantitative serial Stadiee. A.!.i. ireh. laurel. & Pezdhiat. 19: 516-525, 1257. n.: prerinental Studiee or «a. lleetreeheek Preeeee. Die. lerv. slat. 11: 113-119, and 3.1. Pellaek, a.a Payehelegieal rector. take, 3., tier, rant,§a.. lane, 1.1. and Green, 1958. Affecting Individual Differences in Behavioral Reapenee to canvaleive Therapy. J.l,!.B. 13g. 2k3-2h8, 1959. 6. Fiat, u., Kenn, 3.5., tarp, 3., Pollack, 1., Green, H., Alan, B. and Lei‘kewite, LL: Significance of Inhalant Induced neural-ion: tor the Theory er the convulsive Therapy Preeeee. L.H.i. Arch. Gen. Pezehiat. (in press). Preach, J. and Iepaetate, 9.: the Effects of shock Treataent on the 3:0. Pezgheenal. Quart. l1: 226-239, 19h8. Ireeeh, 6., Inpaeteto, 9., attenheiner, L. and Wartie, 8.3.: Some Reactions Seen After Electric Sheet Treatment. Amer. J. Pezghiat. 1021 311-315, 19h5. �.13- 3.0.: reyehepethelegie Reactiene end Bleetrie-Sheek Therapy.‘ 1.1: State J. led. g3. 1553-1557. 19h2. 10. Jehneen, L.c., Ulett, G.L., Jehneen, H., Snith, I. end Sines, 3.6.: Electreoeavuleive therapy (with end 9. alueek, Hithaut Atropine). Arch. Gen. Pazghie . g; 32h-336, 1966. 11. Kenn, 1.1. end Pink, l.c change: in Language Bering Elactroahock therapy. re ehe‘ethelo er colnunioetien, Ed. Roch, P. and Zubin, 3., Stuns e Stratten 126-139, 1958. 12. R.L., link, x. end Weinetetn, B.A.i Reletien of tnoberbitel rest to Clinical Inprevenent in Electroehock. Arch. neural. e rezehiet. lg: 23-29,'1956. 13. Kuhn, R.L., Pollack, H. end flag, 3.: Seeiepeyeheloxie Aspect; a: Peyehiatric Ireetnent in A Velentery Mental Hospital: Duretien or Hoepitelixetiea, Discharge hating: end Biegaeeie. 1.x.1. Arch. Gen. Pezehiet. ;} Kehn, 565-57h, 1959. 1k. Iehn, R.L., rolleck, H. end rink, H.a Figure-around Discriminetien After Induced Altered Brein Functien. A.H.L. Arch. lea-oi. g: 5&7-551, 1966. 15. Kuhn, R.L., Pollack, I. end tint, H.c Sociel Attitude (alliternie W ? Scale) end Convulaive Therepy. gig: 187~192, 1960. J.I.H.D. 16. lelileweky, L. and Heck, 2.: Shack trout-eats, Peychoeurgery end efiher Betetie Ireetnente 1n Peyehintry. Grtne end ___________._________________________.____ strn‘t.n. 3.1. , 1952e �lethed: 9t eeneecetire petiente referred fer eleetreeheek therepy during 1956-57, eeveety-three petiente were eebjeete of the ehelyeee deeerihed here. the pettente were selected fer treetnent by the reetdeut therepiet end the eupervieies peyehietriet the inveettsetere pleying he rele in their eeleetten. theee eheervetieee were nede during e eeeveletve-eeheeevuletve eleetreeheek etedy in which euhaeete referred for therepy were rendeely eeeirned to eeereee e1 eeheenveletre er eenreletve treeteente. Bleetreeheek eee edeiaietered three tinee weekly under pentethel pre-nedteetien, eeing either e letter unidireetienel or e heeerett elternetieg eerrent instreeeet. Greed eel or enheenvuleive treeteente were edninietered by eltering the etreexth a: current. [either petieht, therepiet her evelueting phyeieiene tee ewere which eeeree e: therepy eeeh pitieet received until etter the ewelnetiee period. eheugee in hreie tenetiee were neeeered et weekly intervele by teete e: leexeece petteree heth alerteelly end etter eeeberhttel, end by the degree e: elew eewe eetivity in electroencephelexrene. the intereerreletien e: theee indieee end their reletien te heherterel eheagee here been reperted prewieeely (3,1g). the senateet eyeptee petteree e: the referred pttiente were reriehle, end included euteidel preeeeepetien, reterdetieu, dieterheneee e: need end erreet, exeiteneat, egitetien, penie end teneaen, deleeiene, ideee et reference, hegettrien, rithdrewel 1 � 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 Behavioral patterns in convulsive therapy. Arch Gen Psychiat. 1961 Jul; 5:30-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-53-019 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the Archives of General Psychiatry July 1961, Vol 5, pp. 30—36. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published