http://exhibits.library.stonybrook.edu/mfp/files/original/dcb2d198f268393b586365e8e34503d8.pdf f1412cf3717181597ffc25684c3fe518 PDF Text Text PREDICTION OF INDIVIDUAL PATIENT RESPONSE TO CONVULSIVE'THERAPY 1/ e i - i e ' . <-- Max Fink, M. D. l - E -ku'xs‘b The prediction of response to treatment is a necessary daily task of medical practitioners, who, after a process of clustering the symptoms and signs of illness of a patient, select a treatment regimen most likely to effect a salutary change in the patient. Where the classification of the disease is established by definitive criteria in syphilis. diabeas tes or malaria - the physician's problem is simplified. Where classification is not based on definitive criteria, as in heart disease, or mental disease - the physician's is problem complex. for he must resort to the recognition of pattern based on his individual experiSuch classification is not readily validated, and in the absence of specified external ence. criteria, errors in grouping for therapeutic purposes are frequent. ' wv'h"'" ‘ ' In the instanCes where remedies are established by their effectiveness. as in syphilis, or bacterial infections, or avitaminosis - treatment selection is readily defined. Where remedies are non-specific, as in the treatment of mental illness by environmental manipulation, psychotherapy and various physiodynamic therapies, the problem is complicatcd, not only by the non-specificity of treatment but by the probability that potentially effective therapies are applied to potentially responding and potentially nonresponding pop- -...-....'..-.-....-..—”.y—--—- ,.. ulations. The problem is further complicated b y a lack of evaluative criteria of salutary Various change. approximations are in use, as symptom rating scales, social adaptational measures, patient self-ratings, and changes in target symptoms. These indices are gencrally too broad, too inclusive and too non-specific to be useful. For example, in the target symptom approach, the assumption that anxiety in neurotic phobic, neurotic depressed, or paranoid schizophrenic subjects are equivalent processes is not valid. in Depression various subjects is no more the same phenomenon than is the fever in t mania or lung abscess. c . ' There are, therefore, three aspects to the problem of predicting individual patient response to therapy: the specification of populations (patient selection); the selection of therapy; and the specification and evaluation of behavioral change. These will be aspects described with reference to the convulsive therapy evaluation of the Hillside programs Hospital as studied during .the past seven years. Hillside Hospital is a voluntary, nonprofit, community supported institution in New York City. In these studies, the patients were referred specifically for convulsive therapy by staff psychiatrists to the special somatic treatment unit which was responsible for all somatic treatments at the hospital. .. ' I I mvvv’ ! . ' ; ~<~u .‘-~v- “tn“ a. ' ,,..~..‘..-.... i Observing the usual mixed group of subjects referred for convulsive thera py, we recorded a variety of behavioral adaptive patterns at the times when subjects had received the number of treatments sufficient to i nduce neurophysiological The changes. patterns ineluded euphoria, hypomania, denial, and minimization; loss and increased memory complaining; increased fearfulness, agitation and excitement; and withdrawal, paranoid and delusional ideation. In assessing these patterns, that of euphoria, denial hypomania. and minimization was prominently associated with clinical ratings of much improved and recovered. We termed this adaptive mode "euphoric-hypomanic" and set this as the criteria for the behavioral change which we would like to predict (l). \r I N. Y. ..~: “ Since treatment selection was defined by the institution, our studies focused initially the definition of parameters of change. 1/ From the De partment of Experimental ‘- aw.- 'V.¢§“-.~ Methods on ...._.-.,-..-,',.-»--—s.- Psychiatry, Hillside Hospital, Glen Oaks, L.I a. Aided, in part, by grants M-927 and MY¥Z715 of the National Institute of Mental Health, U.S. Public Health Service. 317 __W_ -_.. ”_.u' ‘U .—:r.. U..- ‘ �(and be therefore this show adaptive pattern to To determine the population prone terms usual diagnostic or the eschewed symp. we recovered) and rated as much improved these studies behavior. During of We measurable aspects more and sought tom check list. the termed which we neuroconvulsive-therapy process the of had develOped a concept a device to as convulsions seen are repeated view. In this (2). view physiologic-adaptive behavioral function brain adap. altered of such conditions the Under alter brain function. attitudinal and factors. sociocultural Thus, individual personality, based on tations emerge indices. attitude and predictive as personality we sought measures of pre-treatment defined that the we studies these had completed we after it was For the most part, of "much clinical ratings the earlier tables these on that "euphoric-denial" pattern, so with this be to equated be. View. in and our reported are, improved" and "recovered" are havioral pattern. Results Earlier of language patterns. was assessment Our first 3. Lan ua e measures. with brain dysfunction that patients demonstrated had (3) Kah and n Weinstein studies by after confabulation and intra. disorientation of denial, changes had characteristic language language these that same observed we study electroshock In one venous amobarbital. those that noted We patient. also of treatments. numbers with increasing changes occurred those not while recovered, evaluated as the ones showing these language changes were content A analysis linguistic unimproved. rated as generally exhibiting the changes were disminimization. denial. be to explicit the in study showed the language patterns rated of tense, of change third use comments, person, cryptic cliches, evasion, placement, (4). with question a and responding withdrawal, qualification, elecafter showed these who patterns language the subjects It seemed probable that treatment before such to . using patterns who have propensity a the be ones troshock would tested therefore. We. test. provocative some by changes if we could elicit the language adinterview, structured short in a questions each patient before electroshock by asking then and repeated and nystagmus. slurred speech until was there amobarbital ministered after amoof changes number language the for the We scored answers the questions (3). barbital (4). We noted a relation between the number of pretreatment language pattern changesthe during manifested clinically of changes number language the to following amobarbital between, also relationship a there was 1'). Furthermore. (Table of treatment week fourth imof much clinical ratings and term short changes the number of pre-treatment language proved and recovered (Table 2). TABLE 1 TO RESPONSE LANGUAGE PRETREATMENT BETWEEN RELATION AND CHANGES CLINICAL AND SODIUM AMOBARBITAL WITHDRAWAL DURING TREATMENT Three or more clinical language patterns“. Pretreatment response to amobarbital sodium pretreatment response to amobarbital sodium No *x2 +x2 318 4. 26; p< . 05. 6. as; p< . 01. Withdrawal reactions to amobarbital sodium: The scorn denial sc< We 1 cal rating score and �TABLE 2 “""“ RELATION OF PRETREATMENT LANGUAGE CHANGES WITH AMOBARBITAL SODIUM TO EVENTUAL CLINICAL RESPONSE V: «vs Change with amobarbital sodium‘I Much Improved 19 -~..-,..’. 68% .-.~.e. .. Moderately Improved _,_ ‘91- _ Unimproved *x2- 10. 30; P < .01 y-a-M-...‘;N -——vr-- b. Famil Interviews. Our second assessment was a denial personality As inventory. patients were referred for convulsive therapy, we interviewed a relative in an unstruc- exploratory interview. The questions were designed to determine the degree to which the patient approximated the explicit verbal described personality type Weinstein by and Kahn (3). On fifteen items, patients were scored on three a scale of l point and 2. 0, The scores were ranked and divided in half - those in the half termed were upper "high denial score" and those in the lower half, as "low denial score" (5). tured, vvvu—n- .vw- . . w».- w— v .AW observed a significant relationship between the denial score and short term clinical ratings (Table 3), In addition. there was a significant between relationship the denial score and the number of clinical language changes during treatment (Table 4). We . -pv TABLE .- 3 ..1..—. RELATION OF DENIAL PERSONALITY TO CLINICAL RESPONSE TO ELECTROSHOCK 'Much Improved Personality Score - ,ewv. .w-vv- Moderately Improved ,V, l4 s 7 u-....r.»-v 21 T,-..,'.«..fl_~. —.s.-—.— .--.-.. TABLE 4 RELATION OF DENIAL PERSONALITY SCORES TO CLINICAL LANGUAGE CHANGES DURING TREATMENT Personality Scores 11-25 (2.0) 0-10 (20) Number Language Changes 8 l7 ‘ 12 3 * . 319 �We the did Rorschach. was task Another not essayed Determinants. Rorschach c. look upon this test in the usual interpretive manner. but scored the number and patterns of Rorschach determinants following the schemata of Klopfcr and Kelley (6). It was observed that ratings of much improved and recovered were associated with the following Rorschach criteria; absent human movement (M). absent form color (PC). few responses, high form percentage (F ). presence of color (C) and color form (GP) or absence of all color. and low shading response. One schedule is reproduced in Figure l (7)- FIGURE 1 RELATION OF RORSCHACH PATTERN TO CLINICAL RESPONSE TO EST °/° NO M, no c M,CF AND [3 MUCH IMPROVED NO M, a\ MODERATELY IMPROVED AND no M,.cF/c M, NO c F6 AND M, FC UNIMPROVED. d. California F Scale. Still another attitudinal task is the California F Scale. This is the which to 10 subject statements of global of uncritical,’ series consists a task simple asked to express the extent of his agreement or disagreement. High scores reflect high agreement, and low scores, high disagreement (8). There was a significant correlation between high F scores and favorable clinical and (9,10) studies factors social out realso carried In we addition, 5). (Table ratings ported that favorable outcome was associated with few years of education. foreign'birth. and older age. ' » TABLE 5 RELATION OF SOCIAL FACTORS TO DISCHARGE RATINGS IN CONVULSIVE THERAPY . Recovered Much Improved Improved and Unimproved 320 Mean F Score 53.1 Mean Age Mean Years Education 7- 50 9. 4 / 10.6 12. 3 Foreign Born ‘ 35 17 �Conclusion summary, we have observed that a variety of pre-treatment measurable aspects of behavior, usually described as personality variables, are associated with the develop— ment of the euphoric-hypomanic adaptive pattern in convulsive therapy and are rated as much improved or recovered in our setting. These variables have been defined in language patterns, denial scores on family interviews, perceptual style reflected in the Rorschach. California F Scale measure of attitude, and the social variables of age, educational level, and birthplace. These personality and social variables provide the perceptual and attitudinal bases for the adaptive changes which occur under the conditions of altered brain function induced by repeated convulsions. Absence of these personality traits, in the presence ,of equivalent degrees of brain function leads to other adaptive patterns, usually rated as "improved" or "unimproved. " and not to the euphoric-hypomanic mode. In The same theoretical model of the neurophysiologic - adaptive interactional hypothesis is applicable to drug therapy (2, ll). We would suggest that different agents are psychopharmaceutically useful to the extent that brain function is altered systematically. These can be measured by the electroencephalogram, although not exclusively. Under the conditions of persistent altered brain function, changes in adaptation will occur, dependent on pre-treatment personality variables. These can be specified, and studies now in progress at Hillside Hospital are assessing this model for various psychotropic agents. References (1) Pink. M. and Kahn, R. L. : Patterns of Behavioral Change and Improvement in Convulsive Therapy. AMA Arch. Gen. Psychiat. (in press). (2) Fink, M. : A Unified Theory of the Action of Physiodynamic Therapies". J. Hillside (3) Weinstein, E.A. and Kahn, R. L. : Denial of Illness: Smbolic and Physiological Aspects, Springfield, Ill. C. C. Thomas, 1955. (4) Kahn, R. L. and Fink. M.: Changes in Language During Electroshock Therapy. Psycho atholo of Communication, Ed. Hoch. P. and Zubin. J., Grune & Stratton 1958, pp. l26-139. (5) Kahn, R. L. and Fink, M. : Personality Factors in Behavioral Response to Electroshock Therapy. J. Neuropsych. 545-49. 1959. (6) Klopfer. (7) Kahn, R. L. and Fink, M. : Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. J. Neuropsych. _1_: 242-245, 1960. (8) Kahn, R. L. , Pollack, M. , and Fink, M. : Social Attitude (California F Scale) and Convulsive Therapy. Jour. Nerv. Ment. Dis. L351: 187-192, 1960. (9) Kahn, R. L. , Pollack, M. and Fink. M. : Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp. 2: Zl6-228. I957. (10) 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. AMA Arch. Gen. Psychia . l_: 565-574. 1959. 1942. (ll) Fink, B._ and Kelley, D.: The Rorschach Technique. New York, World Book Co. . EEG and Behavioral Effects of Psychopharmacologic Agents. NeuroPsychopharmacology. ed. Bradley. P. . Elsevier, Amsterdam, 441-446. 1960. M. : DR. LASKY: .,- Thank you Dr. Fink. Do members of the panel have any questions or comments? 'r~ r- ”‘5 | 321 ”.“wnpm‘. �DR. KLERMAN: I Max, you presented with a fair amount of specificity, the personality and social fac. tors which characterize the patient. Iwas disappointed in that the other half of your neuro-adaptive scheme was left unspecified. Namely, is there any specificity in the alter. ation of brain function that is as predictive as these specific social and persouality factors? ‘ . patien1 adapta to tree will nc brain are co convul nnl, tt that hi . DR. PINK: answer to that is that we do have considerable specificity for the various treatments that we use. If I might have Figure 2. This Figure will show that we did use electroencephalographic measures. We were rating the EEG changes according to criteria which we called high degree-slow wave activity. This index could be specified and quantified. After determining which records were "high degree" slow wave activity, we were able to go back and look at the patients who had shown the much improved category, the moderately improved and the unimproved. It is apparent that of the patients who were in the much improved group, about 90% of the records of that group had shown high degrees of EEG change during the third. and fourth weeks of treatment. It is also clear that the pa. tient's who were "unimproved" did not show the high degrees of EEG change. We interpret these data to indicate that unless a patient has a high degree of EEG change he will not .show behavioral change. It is necessary to have changes in brain function and it is under the conditions of the brain change that adaptive change will ocdur. The type of adaptive change depends on these personality variables. In drug therapy we have other EEG patterns which can also be specified. I think the change 'shock. - DR ' L I schalk comm much crude with tl ' DR. F FIGURE 2 I . h. r . >‘ ,._ o—MUCH IMPROVED (u) E ..... moo IMPRovsom g S 3O ‘ - DR. 7 _ umumoveom (3 spe cif tional being . ‘ has s‘c UJ LL] as 0 0 $ DR. F LL! I reflec know \ “I": atric 6 5 u these more our e1 ber of E: we do much eupho: being: 2% if ‘ ' 4'6 7'9 “242 NUMBER OF TREATMENTS statin: . behavj which . . DR. KLERMAN. Is one difference between this kind of physiologic measure and the other measures in that they occupy different type predictive factor? Would you say here that unless the patient has this characteristic, EEG changes, he will not subsequently develop behavior and adaptive changes but can you predict before the treatment in any physiologic way whether or not a given patient will manifest these characteristic delta wave changes 7 In other words there is a difference between a predictive variable that you described as existing or .. characteristic with the patient prior to his exposure to the treatment and a predictive variable that says he must experience a certain kind of change under the influence of the so- matic therapy. 322 : ‘ - this a‘ $323: - ation This i ‘ :fifhfi hospit e ducai �PINK: I think what you are asking is whether we can predict the physiologic response of the patient. I think we can, although this is much more difficult than predicting the behavioral adaptation. We still do not know what the determinants are or how to measure them prior to treatment, to predict whether a person will or will not show a drug response or will or will not show a physiologic response. The question is not one of a sequence, where altered brain function comes first and then the subjects involuntarily adapt to it. These processess arc concurrent. At the time that brain function is changing under the influence of repeated convulsions or under the influence of repeated doses of drugs, the perceptual, the attitudinal, the conceptual and all the other aspects of patient behavior are undergoing change so that his whole view of life and his response to his environment is changed. The kind of change he shows depends on his pretreatment propensities, as we tried to show on electroshock. DR. ‘\ x v w -« ~ .rv-w--. "a... mv‘vo—‘w “ o...— DR. LASKY: 01-- - Dr. Fink, we'll ask another question or two. They are short ones. think Dr. Gottschalk and I have something rather similar in mind. Now, the one I had was--Could you comment On your criterion. You used a three level over-all clinical rating of recovery, much improved and improved. Now the question that comes to my mind is why use such a crude criterion when you are using rather quantitative measures as predicters and ties in with that, of course, what (ices this criterion mean that a man is "improved" 7 I DR. ”on mu w-wfinwvr'Vb-‘M FINK: Dr. Gottschalk, do you want to ask something ? w-vfimnmm DR. GOTTSCHALK: Well, I had a somewhat similar question, but I have focused on something a bit more specific than that--As whether Dr. Fink had any idea why those people with lower educational levels tended to have more improvement, was this possibly because of the goals being less as compared say to persons with higher educational levels, then of course this has some relationship to the question about the criterion for improvement. 'r-v-q—vruwm.“ - ‘ a ‘ Wm DR. ‘w FINK: .5 we‘rv .. think that both these questions are crucial ones.. I tried to indicate that our slides reflect early aspects of our studies. At the time that we did these first studies, we did not know what we were using as the eventual criterion of behavioral change. We used psychiatric ratings much as everybody else. This criterion was fairly effective. In the course of these studies, we learned that there were different behavioral modes, and these seem a more meaningful criterion. We are now in the process of assessing patients going through our electroshock program, trying to predict these various modes. Unfortunately, the number of patients referred for electroshock in 1960-61 has dropped off precipitously, so that we do not have a large enough sample. But, the statement of the slides on recovered and much improved reflects, ‘as we look back in our data, those patients who showed the euphoric-hypomanic adaptation. That adaptation can be characterized by a feeling of wellbeing; an attitude on the ward of being fine; dressing up, and participating; and on inquiry stating they are no longer sick or depressed and that there is nothing wrong with me. Such" behavioral changes are the ones that psychiatrists rate as much improved. In our hospital, which is psychodynamically oriented, there are a number of psychiatrists who have seen this adaptation and have said that this is not improvement, but explicit denial is a psy— chotic adaptation. There is, therefore, a problem of evaluating what we mean by much improvedor unimproved. The question about educational level is also related. The evaluation of "much improved" is dependent on the psychiatrist's or the evaluater's attitude. This is one of the reasons why the use of much improved characterizations across hospitals is almost impossible. We tried to show this yesterday in Dr. Pollack's report of our tri-hospital study where discharge ratings did not have the same meaning in the various hospitals. The educational level is important because. there is something about being well educated in the American culture which does not lend itself to the use of the, gross denial I , r‘tV‘W‘WW' mq— v'fT'V-a run-"Vera nrw— m. u~—WWWW—w—wm~n» l—"r'" le‘fp ”r" «- -m .» 1‘ i l t i l i V ‘323 i i i i �\Q institution is this in and reour them, we see as cultures ive The more primit response. who have and in may Europe who born were flected in the people in the older age group the adaptation use or such can people that in Europe, life sustained their early processes American Our younger. intelligent, denial. more verbal do use the adaptation of explicit born girls and boys just don't use gross denial. the for I on use apologize must and. is poor very The use of improved categorization The next studies. started our the we is that way the slides, but Ihad to use it because reflect will but an have not will that. two hence, series of slides, hopefully a year or that have teased think we which we predictors the" hope we Then adaptive mode typology. differences. those in demonstrating effective be will out using improving categories in ap procedure by investi; In or pharmacol lucidly, tc jsctive es; of familia: able dosa; 'age level not associ experimer pipradr‘ol tect: 47 ju : DR. LASKY: who A. 'Gottschalk. Louis Dr. is next Our speaker Fink. Thank you very much, Dr. Cinof Psychiatry. the Department at Coordinator Research and is Associate Professor to Individual Pay. Response is "Measuring his of title The paper cinnati General Hospital. Free-Associative) Behavior (or Verbal and Method a Introspective an choactive Drugs by Method. " Dr. Gottschalk. Fron the indivic a seconda: by pipradz themselve able to wo one thing themselve duced stin 1 AN BY DRUGS PSYCHOACTIVE TO RESPONSES INDIVIDUAL MEASURING INTROSPECTIVE METHOD AND A VERBAL BEHAVIOR (0R F REE-ASSOCIATIVE) METHOD 1] of accomp] , ‘ Louis A. Gottschalk, M. D. Introduction is a redrugs to psychoactive and individual idiosyncratic responses the Measuring of study and The systematic serious search area of increasing interest to investigators. the fact that the collective effect of such phenomena is made difficult and compounded by and the unique that time the at same the psychoactive drug has to be accurately measured for accounted plausibly whenever possible, and, observed individual effect is being validly at some level of organization. individual the for and accounting of measuring, Approaches to this problem detecting, and methof the Some principal ingenious. been have many drugs to psychoactive response different with major of to of patients a drug administration groups The ods have been: l) suband of behavioral different for patterns psychiatric nosological syndromes and looking psychoneuroschizophrenia, the , category, to diagnostic e.g. jective reactions according 1929; 1953; Bensheim, and 1952 and Pennes, sis, etc., (Beringer, 1927; Hoch, Cattell, of of the relationship Z) determination The 1960). Weinstein, 1953 and 1954; Kornetsky, beor profiles with different personality associated to a drug varying individual reSponses by measured etc. --as hysteria, depression, extraversion, havioral patterns--such as, and (Kornetsky evaluations clinical psychiatric various psychologic inventories or tests or individof the The 3) 1958). assessment a1. 1955; Laverty. , Humphries, 1957; Lasagna, et of defear such a conflict, as, with psychodynamic a ual reactions to a drug associated different The investigation'of 4) 1957). pendence (Gottschalk, et a1. , 1956; Sarwer-Foner, Kurland. 1955; and 1950 1956; et a1., Wolf, and 1955 a1. et . reactions to placebos (Beecher, the hence and effect placebo sometime of powerful the 1960), which provide an indication individual placebo component of the reaction to a drug. of Medicine. of College Cincinnati, of University the Department Psychiatry. 1/ From from (MY-1055) research in grant a by These investigations have been supported part and Welfare. 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Ritalin: it a thgntary, nonwprutxt. eon-natty anppcrtod 1ac$1tatzon 1n luv flirt 63". In that. tuanatomy "no Mum mu gum. a. nun» vulutvu thirty: by afint! pnythsstrtuts to the 19001.1 nu-nfito trastnnat :318 tits) at; roapaanthlu tor all tauntic sysataaut: at tic httpstul. mm: 513:. trantntnt coluctsca our cfimdaou or changn. initially tbcgacq III it datinod by thy Incitinttou. fit. dofiuttilm at ynvunatnvc �n53.» antarctic 5h: tunul atatd group a! Iuhstétu rcfttrfifi um tOOIrdId a itriuty at iuhiriaral ounvnlntvo tharnpy, it: udapttva pgtturnu 3t tho ‘tnnn when nuhsacto had roeoivtd .thc 383509 of troltnnntu Initiatont t0 induct naurtphyiiolocicul antagoa. 1h. pattarun 13011614 cughnriu, hypauuuit. X00. and tauranuad couwltiaw lnfi scumry aiuiniaatsan; atrial, 1am; inoraAI-d tourtulncuo, ugitutian and clattancnt; and withdrawn}, ptranatd and dnluntuual iauattau. In nsnassing than: unitarul, that at nuphartt. hyvonuuat. dupini and 3131315551.» van aroniutntly agitaatiod 81th clinical rattan: 01 Inch inprtvnd uni rnoovcrud. Ha tarnnd this snaptavo and. 'Ilphnriauhapouunxc' as! not fits. as $8. arifioraa (or tic hohtviornl Ihlnli thick at until 11:. ‘0 prodlat (I). in fiatarnino ‘hc p¢pultfitln 9:03. to that thin tdqptlvc puttura (and thorotura by ritad II 3:33 iuprcvui and r'covurcd) an uaahauud fin; Ic‘ul dingaantnu torn: or taught unrc honourabla anyocta at activiuw. Duran; thou. utuaica v. had dcvtlupad a stucopt or in. convultlvu-thornpy'praaist think an tarnnd tin nouruphrsiaiocismudapttva vita (a). In thin vicu, rnpoatad «intuitions urn lCfin a: u dgvtat to alto: brain truatiuug Undur it. atadttann: or tank llifirifi brush taxation h¢hsv1tva1 uasptttionn nuwtga tuned on indivtautl partuntltty, lactacultural and attitudtuul rin$pra. raga. an tomcat unalarna at prcatruasnnut pavnannltty «a: attitndn an pradtttlvu symptoa chock tadiait. liut, mad �.4... It: fit: unit part, It ran nttnr u. ind uolpldtud this. siuasot tint um cosine! tau ‘U‘Qhfitifihltfilil’ pgttaru. :0 ihtfi on than. tahlnu fit: ourltnr «lininal ratings 0: 'umuh auyrwvoafi and *rwcvvared' urn 20903104 and cit. in car vicw, it b: tqnztnd witk than bohmvtnrcl gust-ru- I a ; u: A. Ina-11w Langfiaga nannuran at: tarst gurus-nan! was of imaging. patt‘rnu. and“: by minute» and mm (3) m cum-tuna that pl‘tlfl‘l with basin dyml‘acttQI had churaatortatit lancuucu chanson u: tout-1. diaovtuntttlun and cuatnbulntsou it‘.’ iatruvuacnn an OhOOrVIO tint tnnbnrblfiax. In an. c1¢¢Qr9Ihntk study thcnu a... ltuculcc chtngns uacurrna It‘s 1302.531»; nuubnr3 at fiata‘luu‘a. Ho Ill. fitted tint that. ya‘toatu ohiuttgl‘hosc luncu;go chanson war. in. and. ovalultci an vucovnrtd, title than. nut annihitlag the .chnlgta tutu guncrully tutti an unimprovaa. A lingutnttc soatalt‘iathatu ahavud tbs languagu pntfiarna rntca in :3. Iiifly in he uxpllett £03131, Ianilisn£t¢u, dtuplacuutnfi, CVttiuu, clichcu, crypttu ocuanutc, II. of ttlrd purcun, lhlnxt or tonne, withdrtuul. qunlltiaatiun, :nd roupondxug with 3 citation (h). Xi aaauct probahzu that $3: Iuhsuotc It. august thin. Inusutcu puttcrnc utter aluo‘rcchuok vuuld be the fill any but! u prnpauatty to I‘tflg itch 9I$itlil burst. truatHOQt �.5g' II tait. 12 00:13 olacit sh. laacuago «haunt. by nous prcvcau£1vo no, uhurgtovo. tou‘od 0:0h putanut tutors ulnafircshank by acting qncstloan in t abort a‘rtttnrla intOtvtiu, Idntaiafiartd unohnrbtfial uu‘xl that: In: Ilnrr-d apo¢ah lad ayatngnnn, and #305 rtpuated tho quca‘iout (3). we luarcd tbs Innunrn {pr tho u‘ubur at luagulgc chanson altar mu»! alficd 0:). at u rolatlln butv.uu the ntnbgr or pru~ $I¢utuuai language puttnru chi-go: following :noharbttul ta £hn mutate a: luugnnao chtngcs Ianttuu£ad 311310311: during tn. fourth rock 0: tran‘nout (Tunic I). Furtharnnro, that. can :13. $ rolationohxp httfllfln tn. nuibcr or protrottlout linguoco chanson and about torn clinics: rating: find rtcovorod (tabla 11). or Inch ingrowcd fi‘-‘ .. O“ 40“ ‘ rabltu I, I! 3. ltully Iatorvituw : dautnl p¢raoa31tty rotorrcd it: touvulttvo thnrnpy, Our accond aunnolnnat at; savvniory. In patients worn no tltnrvinuod a ruxttlvu an an uanructurod, caploratorr £n$orvicu. fun qunatton: var! 60313306 ta actarline the vhtci 303:3. to tic pat10u% .pariualutcd tbs axpllost vvrbul plrsonnlity typc duccribol I7 “biacttin Ind tab» (3). an titties itnna, patients were t£09¢4 on & throa point tall. at o, 1 ‘nd 2. 1h. IIOFDI nur- rgnkod and �.75. dividcd in half . thlil in tho app»: htlt cur. taruod 'hxzh Junta: tact.“ and thtst an ‘3. lava: h:1!, us '10! innit! it!!!“ (5). aigaittulut rulutleulhip butauon tin short torn eliutcul rating: (table 111). no abacrvoa a dcnial ntoru and In afidation. chart was a siguztiuuut rulntsonshiy untrue» ‘hn «tutu! IOOIO and it. illhlr or clinical langunso GICIIOI daring £routunu$ (tabla It). D--“m““--‘ 215190 121, IV ..¢..~........ c. lartchnah nutcruanuntu Anothur task cunnyue In: in: lornchtch. 80 did u.% look uyou that tout in thc It!!! inturprctivo nuancr, hat scarce tho IIIbCf and pattcrnt a: Iorlchloh eatcruauv unfit following in. unhonstn 0! 110990: find tollty (6). It III Obaorvcd fihnt vstinga or tank improvud and rucovurad wort tauoain£od with the tailoring Inraohaoh crituric; thaini lunan havonunt (I), ubuuat for: 001.: (re), tut raupauuua. high for: ptroautnco (30), proscuco at atlor (6) Ind 0010: turn (or) if «haunt. a: .11 oolnr, 10' thufliug rulpcntt. can Iahudulo 1: rugrodtco‘ Inblo 1 {7).’ and fihlo V -Wd 1n �.7. a. culitoruia I aetistill anoint! attitudinal tint in tho caiitoruin r 80.1.. this ailpln tank eon-int: at n 0:21.: at 10 unoriiiaai, global sintonnntc to which in. Inbaoct in Ilkod to otprocl the cairn: of his agrcoaont or dinnarcosemi. list .3090. rotioct high tarocnnnt, and low amoroa, hick iiungrtclant (a). that. VII I liguiticuni curt-iniita hair... high r snort. and taverahio clinical rutinga (tail. '1). In addiiion, u. .1:- curriod out toainl factor. Italian (9.10) and roperiod ihai tavorahlo antenna val aaaociuicd with for yuaro or adiaution. tor-inn birth, und .16.: ago. -‘....” Tfiblt VI GQlCEVSIOls In Cilllfy, no but. oboorvcd this a varinty of pr.trottnaat lauuurabia aspect: at b-havior, unually douoribod .3 porooanlitw varinfiina, it. nauociniad with tho devoIOpr nant at tho ouphorieahypolnnio aduptivo pittcrn in unavainivo ihcrnpy and Ir. rated in luck inprcvod u: r-oovorod in our uniting. in... variuklou havo boon auxin-d in language pittorna, Gemini 30.9.. on 2:311: int-trio's, puroapiuni styl- rotlooicd in the nor-chuck, culitorain Sonia nannurn or nttitudc, and in. social variabiao 0: :30, educational 10701, and hirihvluca. r �“as this: permanality and utoitl vurtuhlnu yravtdu tha ptrauptutl and attitudinal bacon tar tug tdnptiva cunngon whiwh oaaur undur thn unufittitag a: Alcarsd Evita function induced a7 rnpcttnd canvulqtoan. tsunami of that. paracn~ alt$y truits. in th. pvncwuua a: aqu£V§lont duct... at Evita lunettun Illdl to 0th.: udtpsivn yu‘turna. attally an to m “mm-4'«ass-9W», a» am a. maman ’ hypluunic luau. the Inn. tha0r0£1oil natal a! tin acurnphyuialouic ¢ IdlpttVI znt¢ra¢tinnn1 hypcahc-is 1: nppliauqu ‘0 drug Gillan-at ig'n‘l ihcrnpy (2.11). "b woula sugguut at. yaynhupharnucnatsaally~1:0!!! tn tho extant that brain tuucslon In Il‘trfid ayataunttenklr. Yucca can bu nonsurud By tin olnatraanoaphulogrnn. althangh ant axalautvqu. Ulnar eh. eundttaouu at pcrnlntent n1£arn¢ hrgia run¢£1ou, ohtugua in aiuptntauu V111 ficaur, dcycnauut 0n prnutruutnwut tht pgrioanltty vurinhlus. 3!... «an h. apouttiaa, tad attitaa piogrunt law in ut lilllidt.‘0.vti¢1 av: nanotling thin nodal :0: variant ya:who$ropio Iz¢ntu. �1a iiuk; l. and tab». 3.3.2 rattcruu at iwhuvturtl nhnsun and Improvunous in auavu111Vt fhnrlpy. 5g; arch. 633: _!gzgg;gt. (in prnsu). a. tint, 5.: 1 Iaitsod fhnory at tho fiction 0! thytisdynnnta $303351... 2. la;§¢§da gang. g; 197*206, 1957. J. Unina£¢$a, 3.1. Ind Kuhn, 1.x.u 9593:; at ;;;ngtug 8M..; 4,“, ¢.c. rkants, 1955. laka, 3.5. and link, n.v' Ghatgct in » - ‘ s . l. A ; Satanic“, In. $nngungc During llocirauhuck Ihavtpy. r Ed. au¢n, 9. an: zubgn, a., Eran. s acrnttaa 1955, pp. 126-139. Ital, 3.1. tut rink. 3.: ruraouniity ructora 1a Behavinrtl laupnnio to Exactruahock Ikurayy. 3. xtnrgggzgh. 53 . &5«u9, 1959. tlnytar, a. raahtnh itchns nu. It! Ibrk, khrld Beak $6., lfiha. labs, B.L. and Fink, n.: Prsgnautit 731:: at Rartehnuh aritarAa in altuical lacyumau t0 cruvulsiwc thorapy. and £01101, 9.3. 2524“, 196a. $d§1fl1 an‘ Attattdo Pallusk, 2.: link, 3.1., u., Illa, {Bularornsu r sail.) ané euavultivv fhcrupy; gaggz_gggzg n¢n3, 23;, 329; xsr~191, late. 3.? una Social raatnra in lain, I.&., rilluck, x. rant, galactiua at Therapy in u Vtiuu‘nry lcnttl lbtpttll. a, :zzxsasg 5352, g; 21£~2¢a, 1957. 1, trauma”. 9» -ho 8 0 A: �13.. mm. 3.3... Mink, “put: 0: Psychiatric huugs and amt.» n. Mutton a: 91mm“. 565-515., 195’. In as an mu “on”. flak, 8.: Boominholuie tht banana“... it. and rank. is: a m alumina). Arch. “In-nun mm Mums. M: g mthat, y taut; a: antenna”. $3me Slum”, mum, mama, 1960. Mnualuz, «I. 11% . III-why, h, �153;! I Relatian Dotuvou Prttruatnnat Lfiuutnso Ambuhitnl Sodium and Withdrawal Io. ROIpOIuo clinical chant” atria: to an"? Truatuont then. or nor. aliniasl ltn- Hithdrawul rauc$103. ta that 2A». “A w.» Protrcstlcnt rnaponno to unotarbstll India: 39 EB 60 protrontncnt I.roapouoa to tits bnrbtt;1 nodttn )5 11 31 “x2 $12 . ' 13.26] ’ 6‘88, P < G91 < .05 . pct 00“ 21 10 12 3h .. m. per coat �153;; I! nun-n Mm. or Protruhmnt chann- Huh Sou“ to fight). 61131311 may; m: nut Input“ Hodn‘tolr ”mi Uni-pm“ «:2 - 10.30: 52: r «at. Q _ I with ”an“ m :8 19 68 22 8 3‘ 15 3 to .01 1 put out. «1m �mm lolattoa or again: rationality to eliuitnl g. tinctggghnak Rich thnrutclr gagrlrgd gggruvud Porlanggttz Swag. 11 to 25 0 $0 10 total icspmuac 33§EEI¢V0¢ rota! 15 9 1 2h -II ‘0 NI 23 11 13 0 h? �null-non mg If Maul res-nudity “on: to c1121”: Lluggagu Change. During treatment lumbar , a — 2 3 Or zutuong;gtz acgggu 11-25 (20) 0-19 (20) lutal B 12 11 3 25 15 not. �IA ‘ T Rolatton or Rorschach rusty»: ta clinical Icggoaau 1n cuuvuzuiva I Ind-rutaly Ilprcvvd tad lull taprovod Egagigggti novounat 39 11 (283) 28 (72!) laugh lwvununfi 58 28 (58$) 29 (hit) flu?;; I. rattan; :9 0 10: to ) For:tor: 001:: lo 3b 53 . 6.16. 7 32 p 21$ £601; :3 - 11.570 Both a and re re ” lotthor I nor ’6 num- a h 10 25 21: 25 38 xa awa‘h Xi‘an' ' 4.01 p 3.” {mi 661 “on, P uorrtuttuu {tr diocoatxnut‘r. 2? 21 <2 79% éhefi; .001 20 15 13 C4001 (83% $60!; 3h! �m1; Illntton at 8.31:1 rattorc to Discharge gg£iagl 1n convnlutvo lhurgzz I Iu‘n 1 833a 8 53.1 Itch turret-d 26 Inprcvod an! Uninptcvcd 23 Inc-vurod ,0 abnn that: 3 CV‘ I 1 retail! 3 9.h 10.6 so h1,8 51.6 h3.8 39;? 3!.) 11.3 17 35 � 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 Prediction of individual patient response to convulsive therapy. VA Cooperative Chemotherapy Studies in Psychiatry, 6:317-24. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-58-024 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> 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 Photocopy of publication with Q & A and [preprint]. 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