http://exhibits.library.stonybrook.edu/mfp/files/original/d7a08df9cf0427fc8180966376064147.pdf df0afef232047bc6a8f732705fc32387 PDF Text Text USPHS M—927 Final Report ALTERED BRAIN FUNCTION FOLLOWING ELECTROSHOCK (Perceptual Changes Induced by Drugs and Electroshock) the Department of Experimental Psychiatry Hillside Hospital From Glen Oaks, L.I., N.Y. September 1, 1959 �September 1, 1959 FINAL REPORT weal Department of Experimental Psychiatry HILLSIDE HOSPETAL 1., Glen Oaks, L. N. Y. 235$! 1 1. Acknowledgment 2. Summary 3. Summary,Five Years, 195k - 1959 27 h. Publications, 195k 32 5. Presentations 195k - 1959 1959 37 195h #h, 6. Summary #1, September 1, 7. Summary 3,52, January 1, 1956 #3, April 8. Summary - February 1, 1958 1, 1957 September 1, 1959 - 2 January 1, 1956 hZA - April 1, 1957 55A - February 1, 1958 70A Fink, M.D. Principal Investigator max Research Associates (Experimental Psychology) Robert L. Kahn, Ph.D. Research Associates (Neurophysiology) EEG Technician Secretary Hyman Karin, Ph.D. Eric Karp, M.A. Martin A. Green,M.D. 195k 195h-1958 1958 1956 - George Krauthamer,Ph.D.1959 Hanna Mosquera Janet Bowie ' Associates, supported through other grants: Research Research Research Research Associate Associate Associate Associate (Experimental Psychol.) (Psychiatry) (Psychiatry) (Sociology) 1956—1959 Joseph Jeffe, M.D. Donald F. Klein, M.D. 1959 Nathaniel Siegel, Ph.D.l958 - Max Pollack, Ph.D. 1957 �Acknowledgment These studies would not have been possible without the of Founder of Hillside Hospital, and the support interest faith, Dr. Israel Strauss, the Board of Directors, and the Administrator, Mr. Maurice Bachrach, who sustained this program during its early vicissitudes. are also indebted to the Henry Kaufmann and the Dazian Foundations of New York, the Foundations' Fund for Research in and the Nassau Board County of Health Mental the Psychiatry, following pharmaceutical firms: Smith, Kline and French and Laboratories Bristol Geigy Pharmaceuticals, Laboratories, We Wyeth Laboratories, whose support is gratefully acknowledged. �September 1, 1959. M-927 Altered Brain Function Following Electroshock Progress Report #h Max Fink, M.D., February 1, 1958 - September 1, 1959 Director, Department of Experimental Psychiatry Hillside Hospital, Glen Oaks, L.I., N.Y. Associates: Robert L. Kahn, Ph.D.-Research Associate (Experimental Psychology. y) Psycholo Eric Karp, M.A.-Research Assistant (Experimental (Neurophysiology% Martin A. Green, M.D.-Research Associate Hanna Mosquera - Technician Janet Bowie - Secretary �-3ALTERED BRAIN FUNCTION FOLLOWING ELECTROSHOCK SUMMARY: In the past eighteen months, the various studies of the convulsive therapy process were completed and extended, and The begun. agents of psychopharmacologic an investigation framework for these investigations has been the neurophysiologicand 1955; Kahn, (Weinstein view convulsive of therapy adaptive Fink and Kahn, 1957) extended to insulin coma and drug therapies in psychiatry (Fink, 1957). The following aspects of the convulsive therapy process were studied: A Convulsion: comparative study the of 1. gignificance of the neurophysIoIogic, psychologic and behavioral effects of electrical and inhalant (Indoklon) induced convulsions. 2. S Efie a tic Basis of Neuro h siologic Change: Further effects of acute administration of experimental studies of "normal" the both on and agents sympathomimetic anticholinergic and post—convulsive EEG. s There As Convulsive of ects ic 3. Sociopszcholo of the of factors Relation age, education, a. F Scale) the California by (measured and stereotypy nativity to the selection of therapy, duration of hospitalization, diagnosis and discharge ratings. b. Changes of F score with treatment, and relation of these changes to EEG indices. Thera : In supervisory chothera and Convulsive h. PsaIteratIons psychotherapeuggc in the relationship sessions, with convulsive therapy were observed. 5. Perception: Both patterns of change and individual differences on ac stoscopic figure-ground discrimination tasks and perception of the upright with induced convulsions. These studies were extended to drug therapies and the following studies undertaken: 1. Neurophysiologic: EEG of change on acute and chronic Relation a. administration of various psychopharmaceuticals to clinical behavioral change. III: 8/59 �potency. actiVityo b. EEG as a screening device for psychopharmacologic c. Relation of EEG changes to hallucinogenic effects of megimide. 2. Communication Patterns: Relation of induced neurophysiologic change to dyadic diversification and syntactic d. EEG language measures. 3. §pciopsychologic Studies: Aspects of the doctorpatient relationship affecting choice of somatic therapy. studies have supported and expanded the neurophysiologic-adaptive view of convulsive therapy, and demonstrated that such a hypothesis has applicability to our understanding of the mode of action of psychopharmacologic agents. These �~5- ‘mm PROGRESS REPORT A. THE CONVULSIVE THERAPY PROCESS; 1. Significance of the Convulsion: An earlier convulsive-subconvulsive control study had demonstrated that significant behavioral changes occurred almost exclusively in patients receiving grand mal convulsive therapy. The present report is an assessment of the neurophysiologic,behavioml, and clinical effects of two different methods of inducing convulsions - electrical and inhalant. Twenty-five consecutive patients referred for convulsive therapy were randomly classified into two groups with seizures induced in thirteen patients by the standard Medcraft alternating current instrument, and in twelve by the inhalation of hexafluorodiethyl-ether (Indoklon). In both groups treatment was administered three times a week for a total of 10 to 2b applications, determined by clinical criteria by the supervising psychiatrist. All patients were tested one to two days prior to the first treatment, following the 10-12th treatment, and two weeks following the last treatment. In addition to evaluations of behavioral change, tests included measures of intellectual function (five subtests from the Wechsler-Bellevue Intelligence Scale), perception (figure-ground discrimination using embedded geometric figures, the perception of pseudoisochromatic color plates at high speeds of tachistoscopic exposure, and the Street incomplete figures test), and social attitude (the Levinson revision of the California F Scale). An electro- �-6encephalogram was obtained during each of the testing periods, and measured for the per cent time slow wave (6 cps or slower) activity from a continuous 66 second sample. The results failed to show any significant intergroup test differences between the electroshock and Indoklon groups at each of the three test periods. Intragroup analysis, however, showed that during treatment both groups made increased errors on the intellectual and perceptual tests, and had higher scores on the F scale. By two weeks after the termination of treatment both groups returned to near pretreatment levels for most tests. Both groups were comparable for the degree of induced EEG slow wave activity after 10-12 treatments.v The per cent time slow wave activity for the Indoklon group was 51% and for the electroshock group h7.5%. Within each group individual differences in behavioral change were related to the degree of neurophysiologic change - those with the highest degree of EEG change showing the greatest behavioral change. Rank order correlations between changes in test performance and the degree of slow wave activity with treatment were positive for all procedures, except the comprehension subtest of the Wechsler-Bellevue, and reached a level of statistical significance for digit span (+ .61, p < .01), object assembly (+ .h6, pr< .05), F scale (+ .38, p (' .05), tachistoscopic perception (+ .67: P <: .01) and perception of embedded figures (+ .h3, p < .05). �-7Two different convulsant agents thus produced similar neurophysiologic and perceptual behavioral changes; and it was concluded that the behavioral change in convulsive therapy is related to the degree of altered brain function, and is non-specific for the type of agent used to induce the convulsion. (Presented, in part, at the Eastern Psychological Association, Atlantic City, April, 1959). 2. Biochemical“nu—On.“— Aspects of the Convulsive«non-mu...Therapy Process: The significance of high voltage EEG slow wave activity in the convulsive therapy process (Roth §t_al, 1951, 1957; Fink and Kahn, 19S?) and the report that this activity was blocked by the administration of such anticholinergic agents as atropine and scopolamine (Ulett and Johnson, 1957) provided the basis for these studies. As there were attendant unpleasant systemic effects with the administration of these agents, reports describing diethazine as an anticholinergic compound with potent neurologic but minimal systemic effects (Jenkner and Lechner, 1955; Lechner, 1956) led to studies similar to those of Ulett and Johnson using this compound (Fink, 1958). These observations with diethazine further led to the investigation of other experimental anticholinergic agents. Clinical and electroencephalographic responses to the intravenous administration of diethazine, Win-2299, benactyzine, JB-318, JB-336 and atropine in psychiatric patients at various �-8. stages of convulsive therapy were studied. Each is a potent anticholinergic agent in vitro. The subjects were ninety psychiatric patients referred for convulsive therapy, ranging in age from 18 to 67, with a A of diagnoses. total of 107 observations were made, variety as some subjects were studied with more than one compound. The observations were made in the EEG laboratory using a standard 8 channel instrument and needle electrodes. In each trial, the compound under study was administevhd intravenously at a set rate per minute until clinical behavioral or electrographic changes were observed. It was observed that administration of these anticholinergic agents was associated with a) desynchronisation of EEG rhythms with a blocking of post-convulsive delta activity; b) alerting, excitatory behavioral response with illusory, delusional and hallucinatory ideation, and c) systemic effects of muscular weakness, dryness of the mouth, dry skin and tachycardia. The electrographic, behavioral and systemic effects were concurrent. These observations are regarded as consistent with the suggestion that the physiologic basis of convulsive therapy lies in an increase in central nervous system cholinergic activity. Observations that LSD, amphetamine, mescaline and diphen- hydramine - sympathomimetic and antihistaminic agents - also induced EEG desynchronization, blocking of post convulsive delta �-9- activity and clinical excitatory activity support the suggestion that the behavioral and electrographic patterns of these compounds are also based on an alteration in synaptic activity. Increased synaptic activity (cholinergic, sympatholytic effects) is associated with EEG hypersynchronization, and clinical sedation and euphoria; while decreased synaptic activity (anticholinergic, sympathomimetic) is associated with EEG desynchronization and clinical excitatory and.ha11ucinogenic states, thus supporting a hypothesis initially described by Wikler (195h). It was also suggested in these studies that the discrepant observations of EEG slow wave activity after the administration of atropine was related to significant differences in dosage and to species specificity. (Presented, in part, at the Society of Biological Psychiatry, San Francisco, 1958 and awarded the first A.E. Bennett Psychiatric Research Award of that Society; and, in part, at American EEG Society, Atlantic City, 1958. Published, in part, A.M.A. Arch. Neurol. & 80: and 380-387, 1957; Psychiat. accepted for pufilication, EEG Clin. Neuropfiisiol.) 3. Sociopsychologic Aspects of Psychiatric Treatmen : a. Duration of Hospitalization, Diagnosis and Discharge Evaluation. In an earlier study of the Hillside Hospital population (Kahn, Pollack and Fink, 1957), it was noted that age, education, place of birth and social attitudes as measured by the California F scale, were related to the selection of therapy. Those patients who were older, had less education, were foreign-born and with high stereotypy scores on the F Scale �likely to receive convulsive therapy. In contrast, who and who native-born better were educated, younger, patients were more obtained low scores on the F Scale, received psychotherapy as their sole form of treatment. This study was extended to determine the relations of these sociopsychologic factors to l) the duration of hospitalization, 2) the clinical evaluations at time of discharge, and was final diagnosis. The entire in-patient adult population on March studied. This consisted of 171 patients, 57 men 3) the 7, 1957 and 11h 68 16 from to in women, ranging age years, with a median of 35 years. Patients hospitalized for the shortest period (1-5 months) were noted to be the oldest, have the least education, were most likely to be foreign-born, and have the highest scores on the F Scale. Younger, native-born, more educated, lower F score patients were hospitalized the longest (10 or more months). The same relationship of these factors to length of hospitalization was found when separate analyses were made according to diagnosis and type of treatment (convulsive therapy or psychotherapy). Discharge evaluations of improvement were significantly related to age - the older patients having the most favorable ratings. Analysis of the data by type of treatment, however, demonstrated that among the convulsive therapy patients ratings of recovered or much improved were given to those patients with �the highest born. F scores, least education and who were foreign- Diagnoses of schizophrenia or psychoneurosis were associated with lower F scores, younger ages, more education native birth. older, less educated, foreign-born, high F score patients were more frequently classified as involutional or manic-depressive psychosis. It was postulated that these relationships reflect the influence of social background and psychological processes, such as the behavioral patterns of communication and mode of expression; and that these relationships contribute not only to the pattern of mental illness, but affect all aspects of the patient—therapist interaction. (Presented at the Eastern Psychological Association, Atlantic City, and the Academy of Psychoanalysis, Philadelphia, April, 1959. Accepted for publication, Archives of General Psychiatry.) b. Changes in Social Attitude with Convulsive and The Treatment. earlier observations that the California F Scale is useful in understanding the reason for referral for convulsive therapy and the evaluation of clinical response Following following such treatment, further studies were undertaken with this scale in regard to the following questions: 1) What does the F Scale measure in a psychiatric population? 2) Do F scores change with convulsive therqay? 3) Are these changes related to the degree of altered brain function? �-12- entire in-patient population of the hospital was given the F Scale, and one month later, was retested with The a "reverse" F Scale, in which each statement was changed to the opposite of the original. The "reverse" scale was scored in the same manner as the conventional scale, with high scores reflecting greater agreement. It was noted that those patients who made low scores initially, indicating a predominant disagreement with the statements, showed an increase on the "reverse" scale, indicating a high degree of agreement. In contrast, patients who made high scores initially showed little change on retesting, agreeing with the statements to the same extent even though the meaning was reversed. It is evident that low F score patients are more critical and discriminating persons, while those with high F scores are more undifferentiating and stereotyped in their reactions. This observation is related to the process of selection of patients for convulsive therapy. A high degree of stereotypy of thinking and communication is incompatible with the establishment of a conventional psychotherapeutic relationship, thus inhibiting the psychoanalytically-oriented psychotherapy stressed at this hospital. It follows that the high F score patients will be unsuccessful in psychotherapy and most likely referred for convulsive therapy. In another study, sixty-nine patients were given the F Scale before, during (at 10-12 treatment period) and after �-13convulsive therapy. Ten patients, selected at random, constituted a control group and received subconvulsive electroF in score of +5.7 mean There increase was a stimulation. during treatment in the convulsive group - a difference 5% the level. In contrast, the control group at significant showed an insignificant change during the same period (+0.5). The extent of increase in the convulsive patients was related to the degree of cerebral dysfunction as determined by slow (more The with EEG. delta high the on patients wave activity +8.6. of had mean increase a record) h0$ of the sample than Those patients with low delta indices, however, showed an F the treatment scores were Following +3.h. of increase comparable to the pretreatment levels. These findings support and elaborate previous observations on the effects of convulsive therapy. Greater agreement with show conventional treatment during statements Scale the F in Changes discrimination. and in difficulty stereotypy of changes language the characteristic thus score parallel cliche; and of use increased denial, evasion, qualification, and stereotyped expressions (Kahn and Fink, 1958). It is also comparable to the increased difficulty in complex visual F and 1957) figureKorin, tactile ground discrimination (Kahn and Fink, 1957). (Presented at the Eastern Psychological Association, 1958; and accepted for presentation at the Divisional Meeting of the American Psychiatric Association, New York, November 1959). and perception (Fink, Kahn and �-1hh. Psychotherapy and Physiodynamic Therapy: Previous studies indicated that patients referred for electroshock in this hospital are of two types. The larger older age who have limited education and are foreign born. They tend to be non-introspective persons, stereotyped in their language and thinking, and verbally uncommunicative. Symptoms of depression, agitation, withdrawal and somatization are prominent. The second, and smaller, group of patients are younger,native-born, bettereducated, and verbally communicative with a capacity for introspection. They characteristically exhibit thinking disorders and overactive behavior, with lesser degrees of somatization and depression. Four patients, two from each group described above were studied to determine 1) reasons for referral, 2) whether different attitudes were required in psychotherapeutic 3) the relation of the psychotherapeutic management, and approach to the patient's clinical response to convulsive therapy. It was concluded that these patients were referred for convulsive therapy because of difficulty in communication in the psychotherapeutic relationship. In two cases this was a reflection of the patient's limited verbal and introspective capacity related to educational and social factors. In two instances, however, the impaired communication was reflected in acting-out behavior. group are patients of an �-15Following treatment, the older, less educated patients were able to sustain the behavioral change with a reassuring, supportive technique, amplifying tendencies to minimization ‘In the better and denial developed during electroshock. educated patients, the decreased acting-out behavior was associated with increased interpretive psychotherapy. It was suggested that the relationship of psychotherapy to convulsive therapy various with the communication pattern and adaptation shown by the individual patient. Published in the Journal of Hillside Hospital, 1: 17-25, 19 58 ). 5. Perception: have of procedures test perceptual-cognitive variety been studied in patients receiving somatic therapies. a. The Tachistoscopic Perception of Embedded Colored Figures: This task was studied in an experimental group consisting of 35 consecutive referrals for convulsive therapy, and "control“ groups of 20 patients treated with phenothiaains medication (thorazine and promazine) and ten patients receiving no somatic treatment, matched for age. All subjects were tested prior to treatment, and after four weeks; the convulsive weeks two time a following the third were tested patients A . cessation of treatment. �-15There was a statistically significant increase in mean errors with convulsive therapy, and a significant decrease from the pretreatment scores following treatment. "Control" subjects made significantly fewer errors at each succeeding period. There was a significant difference in EEG low between showing changes as classified errors patients (per cent time delta) when compared with high EEG changes. There were high retest correlations for all groups. There were marked individual differences in response patterns prior to treatment. With brain changes there was a reduction in perseveration, completion and confabulation in some patients, and an increase in others, with no unions Even in those to cerebral dysfunction. attributed patterns EEG with high changes, the "style” of his response patients pattern was maintained. Thus a patient showing completion type errors prior to treatment would continue to make such errors with convulsive therapy, although the threshold at number of which completion was shown might change. (Presented, in part, at the Eastern Psychological Association, Atlantic City, April 1959). b. Rod and Frame Test (Withinz: This task was administered to h? patients consecutively referred for somatic therapy. Marked individual differences in performance were correlated with age, education and score on the California F Scale. Patients whose judgment of the vertical was strongly influenced by the surrounding frame (field dependent) were more frequently �referred for convulsive therapy than drug therapy. No significant change was found with drug or convulsive treatment. For both drug and convulsive groups retest correlations were high (+.86 and +.88). It is considered that individual differences on the Rod and Frame test reflect personality factors that are of importance in psychiatric treatment. �-18B. PSIGHOPHARMACOLOGIC STUDIES; 1. Neurophysiologic Asgects: According to the neurophysiologic~adaptive view of the convulsive therapy process, the clinical efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in central nervous function, providing a milieu for changes in the subject's interaction with the examiner and the environment. In these studies the best index of neurophysiologic change has been those aspects of cerebral function reflected by delta activity in the electroencephalogram (Fink and Kahn, 1957). The efficacy of newer psychopharmaceuticals in altering psychotic behavior patterns has led to the suggestion of a similar hypothesis for the mode of action of these agents, and to studies of the relationship and specificity of altered behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of the psychopharmaceuticals tested in acute experiments an increase in synchrony with or without an increase in slow wave activity has been observed for chlorpromazine, promazine and triflupromazine. Behaviorally, these drugs were associated with a) increasing sedation, drowsiness, denial and euphoria; b) decreasing agitation, panic, excitement and delusional and hallucinatory activity; and c) minimization and displacement of symptoms. Barbiturates regularly induced an increase in fast activity with an increase in synchrony, with the associated behavioral changes of sedation, euphoria, denial and minimization. �-19Amphetamine and methamphetamine increased fast activity without increased synchrony and behaviorally were associated with alerting, hypomania, excitement and increased motor activity. Decrease in voltage and per cent time of slow wave activity in subjects with post-convulsive delta activity with LSD-25, benactyzine, Win-2299, JB-318, JB-336 and diethazine. Of these drugs, benaotyzine produced increased alerting, excitement, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional and paranoid ideation. was seen electrographic patterns were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, sedation and minimization of symptoms were associated with increased EEG synchronization and shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with desynchronization of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorpromazine and barbiturates, augmented the per cent time delta activity and enhanced the clinical patterns; agents that desynchronized frequencies, as diethazine, LSD-25 and benactyzine, minimized the clinical effects typically ascribed to repeated convulsions. The �-20. Various experimental psychopharmaceuticals were tested. In addition to extensive studies of b-b methy].ethylg1utarimide hexaflnarodiethylether (Indoklon) the following agents were studied; phenyltoloxanine(PRN-Bristol), methonalide (ELM-188, Bristol), tropin-h-chlorbenzhydryl ether (WY-21h9, (Megimide) and Wyeth), dimethylaminoethanel and varieties, Riker), its congeners (Deaner and JB-318, 329 and 336 (various piperidyl- benzilates, Lakeside) and imipramine (Tofranil, Geigy). Because significant behavioral and electrographic changes were observed, a more intensive investigation of imipramine (TofrEnil) was undertaken. In 28 acute experiments, consecutive patients referred for physiodynamic therapies were tested in the EEG laboratory at various stages of treatment. TofrEnil solution (10 mg/cc) was administered intravenously at a set rate (1 cc/ho sec) until electrographic or behavioral changes became prominezit, for a total of h0-125 mg (0.5-2.5 Behavioral observation and electrographic recording continued for one to three hours. In patients referred for pharmacotherapy because of manifest depressive, withdrawn or retarded behavior oral TofrEnil of 75-350 mg was administered. In the acute studies there was initial restlessness, associated with dizziness, dry mouth, "faintness," nausea, mg/kg). and on four occasions, vomiting. These symptoms persisted for lassitude, heaviness eventual drowsiness. Heart rate was 10-20 minutes, and were accompanied by of the extremities and unchanged or slowed. Blood pressure dropped by 20-h0% in �-21.. older (age > 60) patients. Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographoc patterns accompanying these behavioral changes were initiated by a gradual decrease in voltages during the injection. By ten minutes, the per cent time alpha had been halved. In patients with moderate amounts of beta activity, such activity occasionally increased in voltage and per cent time. By twenty minutes, in association with behavioral lassitude, low voltage (to 50 microvolts) random theta frequencies (5-? cps) appeared. In records with post-convulsive delta activity, there was a marked decrease in voltage and per cent time of slow wave activity. These % to two hours. for electrographic patterns persisted There was considerable individual variability in this acute EEG response. In patients who received 100 mg or more of TofrEnil, EEG and behavioral changes were observed in all but three. In six patients, dosage of TofrEnil less than 50 mg were associated neither with EEG nor with behavioral changes. In chronic Tofrénil studies, behavioral changes generally appeared during the second, and were maximal during the third, week of treatment. The most prominent behavioral adaptation was euphoric denial. Patients complained less of somatic displaced their illness became increasingly difficult to discuss symptoms, and denied, minimized or on inquiry. It �-22In six patients them. with significant life relationships and depressive increased and restlessness somatization agitation, restlessness, affect persisted. of cessation the to excitement, insomnia and vomiting, les five patients in noted were symptoms No in change therapy. In three, therapy. showed administration chronic on studies Electrographic Low modulation. record a decrease in voltages with poorer Well 10% appeared. to up cps) activity (5-7 theta voltage few. a in prominent more became defined fast activity after four weeks of NeuroInternationale (Presented at the Collegium the 1958; at September, Psychopharmacologicum, Rome, March, Montreal, Conference on Depression and Allied States, in Published, 1959. EEG Society, June, 1959; and American harmacolo chc Ps of s C.I.N.P.; Proceedin the in gamed. part, Ps Ass. cfiiat. 1959; 32§~332, N. Kline, ed. 19E8. Frontiers, 682-685, and Neurology __3. _E: 1653117159959; _8_: Relationship Therapist-Patient of the 2. Aspects Affecting Choice of Therapy. than other aspects involves The selection of therapy the In the of patient. the manifest behavioral patterns been have problem this further efforts to clarify past year therapist-patient and frustration that We have hypothesized relationship. and implicit relationship hostility in the therapist-patient have a significant environmental pressures or explicit the in factors emphasizing undertaken, influence in referral for somatic therapy. residents with interviews 76 structured In a pilot study somatofor requests and supervisors were initiated following �-23- therapy. These interviews were designed to elicit the basis of the referral. It was found that in only relatively few cases was there a change in the patient's clinical status which directly led to the referral. In most instances there had been no change or progression in the presenting symptoms. Factors contributing to the timing of the referral included impending discharge, avoiding administrative discharge, and pressure from the patient's family or ward personnel. .It was also noted that patients with similar behavior patterns were treated differently, some given somatotherapy and others none. The reasons for this ranged from "whim" to quantitative differences in symptomatology and individual preferences for type of treatment. It was concluded that factors other than clinical indication played a role in the referral in a significant number of cases. These same extraneous factors also influenced the timing of the referrals. As a result of these findings a "Somatic Treatment Referral Sheet" was developed (see Appendix) to be completed by the therapist whenever somatic therapy is requested. This study is continuing. �-2h. 3. Language Patterns as Measures of Behavioral and Neurophysiologic Change with Drugs. In previous studies of the convulsive therapy process, it was demonstrated that two language measures, a syntactic content analysis (Kahn and Fink, 1958) and dyadic diversifica‘ tion scores of unstructured interviews (Jaffe, Kahn and Fink, 1958) provided objective indices of behavioral change, and were related to the degree of altered brain function. In a further test of these language measures as indices of behavioral and neurophysiologic change, they were applied to interviews on acute administration of various psychopharmacologic agents. Seventy-two interviews with patients at various stages of drug therapy have been analyzed, using the following agents: amobarbital, benactyzine, chlorpromazine, diethazine, lysergic-acid diethylamide, and Win-2299. Following a routine electrographic recording, an unstructured psychiatric interview, with short periods of structured inquiry, was tape recorded. With EEG running, an intravenous injection was then given at a slow rate. When specific electrographic or clinical changes were induced, the interview was repeated. Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The EEG was measured for changes in synchronization, shifts in dominant frequencies, and per cent time of slow waves (delta) and beta frequencies. �.25tape recordings were transcribed and measured for the diversification of consecutive 25 word samples of speech of The both participants (dyadic) and for syntactic changes. In the dyadic analysis, the pooled verbal behavior of both participants was transcribed, divided into 25 word samples, for each sample the ratio of the number of different words to the total number of words (a diversification score) was calculated. The syntactic language analyses were based on the response to standardized questions using a method previously described (Kahn and Fink, 1958), scoring such changes as syntactic use of person, alteration in tense, evasion, qualification, displacement or verbal denial of symptoms, use of stereotyped expression or cliches, cryptic response, and withdrawal or silence. Consistent changes were observed in both the dyadic diversification and syntactic language measures in subjects classified according to the neurophysiologic and behavioral effects of the drugs applied. Amberbital and chlorpromazine are neurophysiologic synchronizing agents. Amobarbital regularly induces high voltage well synchronized fast activity at 20-2h cps, while chlorpromazine administration is followed by increased synchronization of the EEG record and a shift to slower frequencies including occasional slow wave burst activity. Behaviorally these drugs are associated with sedation and tranquilization. On the language measures there was an increase in stereotypy and �-26~ repetitiveness associated with increasing use of alterations in tense, displacement and evasion. and / cliches, Diethazine, benactyzine, LSD-25 and Win-2299 are neurophysiologic desynchronizing compounds. These drugs are characteristically associated with decreased voltage and per cent time of alpha activity and increased irregular low voltage fast activity. Behaviorally hallucinatory, excitatory or illusory activity are observed. 0n the language measures there was decreasing repetitiveness, wide diversity of words, less variability of diversification scores, and decreased use of cliches and alterations in tense. Further exploration of language measures are suggested as a rational basis for the understanding of the psychologic effects of the new therapies. (Presented at the Conference on Psychodynamic, Psychoanalytic and Sociamgic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April, 1958, and at the American Psychiatric Association, Philadelphia, April, 1959). �-27. SUMMARY lgsh - 1959 out-“n” laboratories of the Department of Experimental Psychiatry were established at Hillside Hospital in September, 19Sh. During this five year period neurophysiologic, and and perceptual), linguistic (personality psychologic sociologic aspects of "somatic" psychiatric therapies have been the principal foci. The Convulsive Therapy: The view of the convulsive therapy process as the induction of a non—specific state of altered brain function, similar to craniocerebral trauma was supported and amplified 1. cerebral Within subjects altered milieu, this 21). ll, were seen to respond in various ways (26), of which the most "successful" was explicit verbal denial (7, 31). This latter (10, adaptation was most prominent in characterologically disposed individuals (36). An alteration in brain function was pre-requisite to behavioral change (7, 8, 11, 26). Grand mal seizures were essential to this process (26) but electrical induction was not (B-h2). The alterations in brain function were measured in various ways including electroencephalography (6, ll, 12, 2h, 39), language patterns (b, 7, 1h, 31, h3; B-2h), perceptual tasks (2, 16, 17, 3?, h6; B-26, hl, h2) and tests of Reference numbers are to publications or presentations (Blisted in the appendix. ) �recall (8). It suggested that the neurophysiologic basis of convulsive therapy may lie in an alteration in central synaptic cholinergic - adrenergic relationships, with a predominant shift to increased cholinergic activity as the operationally significant pattern. Such interpretations were based on the was relationship of high voltage EEG slow wave activity to behavioral change (6, ll, 26) and the blocking of post-convulsive electrographic and behavioral changes by central anticholinergic agents (21, 3h, 35, bl, h2) and central sympathomimetic agents (h2). A variety of behavioral changes were seen during convulsive therapy (26; B-l7). Such patterns were viewed as adaptations to altered brain function, and were believed dependent upon characterologic and environmental factors (7, 25, 26, 36, ho). Clinical ratings of improvement were seen as value judgments by the observer of behavioral change in the subject (26). Adaptations characterized by denial mechanisms, both in behavior (B-17) and in language (7, 31) were seen as most favorably rated by the psychiatric staff. Such adaptations were related to habitual modes of conduct (character, personality} (36; B-ll, 32). The persistence of the altered behavioral nodes was noted as dependent upon the degree and duration of altered brain function, the environmental expectations, and the type and �+29- degree of family and medical support (26). Different varying types of behavioral patterns were best supported by psychotherapy (19). Measures of linguistic behavior in structured (7, 31) and unstructured (1h, 29; B-2h) interviews showed characteristic alterations towards increased denial, minimization, displacement, stereotypy and repetitiveness related to the degree of altered brain function (B-Zh). These changes were blocked or reversed by anticholinergic hallucinogens (21,h3). Various perceptual tasks provided indices of behavioral change and were related to the degree of altered brain function. These included the perception of simultaneous tactile stimuli (17), embedded (Gottschaldt) figures (37; 8-16), and tachistoscopically exposed words (37) and embedded color figures (hl). Sociopsychologic aspects of age, years of education, nativity and degree of stereotypy and conventionality (measured by California F Scale) were related to selection of therapy, duration of hospitalization, diagnosis and treatment response in hospitalized patients (15, 36, ho, hS). 2. Neurophysiologic-Adaptive Hypothesis of Somatic Therapy. Based on these studies, a hypothesis concerning the mode of action of other therapies such as insulin coma, leucotomy and psychotropic drugs, was expressed (10, 33, 38). This view holds that the efficacy of these therapies depends upon the induction of states of altered brain function, in which �varying adaptive patterns may become prominent. The adaptive pattern is related to the type, degree and duration of altered brain function, the personality of the subject, and tolerances and expectations of the environment. Examination of drug therapies MY—2092 3. is this hypothesis as applied to psychotropic now in progress, supported by USPHS grants and MY-2715. Insulin Coma Therapy. initial case study showed the significance of denial patterns and of persistent altered brain function for the An behavioral changes in insulin In an insulin coma therapy (3). - chlorpromazine control study, no coma differences in hospital improvement ratings were observed in the two treatment groups (27). Chlorpromazine was safer, easier to administer, permitted continued administration and allowed for greater degrees of concurrent relationship therapy than insulin coma. These observations led to a replacement of insulin some by psychotropic drugs in this institution. h. Pharmacotherapy. The ongoing program in evaluating various psychopharma- ceuticals is derived from these hypotheses. Electrographic and linguistic analyses of effects of acute intravenous administration and chronic clinical administration of various new compounds are in progress. EEG patterns, along such continua as synchronization-desynchronization and frequency shift, and various perceptual, perceptual-motor and personality �-31.. and h2) 3h, (21, behavioral bl, to related being tasks, are linguistic changes (21, h3). The neurophysiologic basis of experimentally induced hallucinogenic states has been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (h2). Initial work on this hypothesis (21, h2) is now being expanded. �.132-" PUBLICATIONS AND PRESENTATIONS 195k - 1959 A. Publications. 195h Patterns of Perceptual Organization with Simultaneous Stimuli. Arch. Neurol. & Psychiat., 72: 233- 255. Bender, M.B ., Green, E. andFFinE, M. 2. Standardization of the Face-Hand Test. “”""§z Neurolo , h: 1. 211-217. Fink, M. and Green, 1955. M. ' Delusional Reduplication of Parts of Body after Insulin Coma Therapy. J. Hillside Hos ital h: 13h-1h7. Kahn, R. L., Fin , . an rau er , h. The Amytal Test in Patients with Mental Illness. J. Hillside Hospital, h: 3-13. Kahn, R.L., Fink,'M. and Weinstein, .A. 3. 1956 Denial of Blindness Following Cerebral Angiography. J. Hillside Hos ital, S: 238-2h5. Fink, M. 6. Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Clin. Neurophzsiol. Q: 158 (Abst) Fink, M. and Ka n, R.L. 7. Relation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. & Ps chiat. 76: 23- 29. E. A. Kahn, R. L., Fink, M. and Weinstein, 8. Relation of Changes in Memory and Learning to Improvement in Electroshock. Conf. Neurol. 16: 88- 96. Karin, H., Fink, M. and Kwalwasser, §. 5. 9. Evaluation of High-Dose Reserpine Therapy for the Relief of Anxiety. Wachspress, Hillside Hospital killer, . 67- 77. J. S .A. M., Blumberg,'I'WG Fin E, fl. and �~33:. PUBLICATIONS AND PRESENTATIONS 1957 Unified Theory of the Action of Physiodynamic Therapies. J. Hillside Hos ital, 6: 197-206. Fink, M. 11. Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neurol. & Pszchiat..- 78: 516-525. Fink, M. and 10. A w Itajin, ROE. 12. Significance of Individual Variability in the to Electroshock. J. Hillside Green, M.A. 13. EEG An and Response Hospital, 6: 229-2h0. EEG Clinical Response to Megimide. EEG. Clin. Green, M. and Fink, M. Neurophysiol. 2: 180. Objective Study of Communication in Psychiatric Interviews. J. Hillside Hospital, 6: 207-215. J. Jaffe. Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hos ital, 6: 216-228. Kahn, R.L., Pollack, M. and Fink, M. 16. Perception of Embedded Figures After Induced Altered Brain Function. Amer. Psychol. 13: 361. Kahn, R.L. and Fink, M. 17. Role of Stimulus Intensity in Perception of Simultaneous Cutaneous Electrical Stimuli. J. Hillside Hospital, 6: 2hl-2SO. Karin, H. and Fink, M. 18. Perception Experiments in a Study of Ambivalence. Arch. Neurol. & Psychiat. lg: 167-176. Karin, H., Tarachow, S. and Friedman, S. 1958 with Electroshock 19. Psychotherapeutic Techniques Patients. " ‘J. Hillside Hospital, 1: 17-25. Esecover, 3., JaTTe, 3. and Kahn, R.L. 20. Lateral the Sedation Clin. Neurophysiol. l2: 162-163. Gaze Nystagmus as an Index of Threshold. Fink, Mo EEG. �PUBLICATIONS AND PRESENTATIONS 1958 21. Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. A.M.A. Arch. Neurol. & Psychiat. fig: 380.387. Fink, no 22. Effect of Diethazine on EEG and Significance for Theory of Convulsive Therapy. EEG. Clin. Neurophysiol. l2: 207-208. Fink, M. 23. Effect of Anticholinergic Compounds on Post-Convuhive EEG 776 and Behavior. (abst). Fink, EEG. E. Clin. & Neuroph siol. $2: Electroencephalographic Correlates of the Electroshock Process. Dis. Nerv. Sy . $2: 227. Fink, M. and Green, EXperimental Studies of Convulsive and Drug Therapies in Theoretical Implications. A.M.A. Arch. Psychiatry: Neurol. & Psychiat. fig: 733-73h (abet). Fink, M., a n, . . an reen, M.A. 26. Experimental Studies of the Electroshock Process. Dis. Nerv. Sys. l2: 113-118. Fink, M., Kahn, R.L. and reen’ 0 M. 27. Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis. J. Amer. Med. Assoc., 166: 18h6-1850. Fink, M., Shaw, R., Gross, G. and Coleman, F.S. 28. ' Clinical and Electroencephalographic Effects of Megimide in Patients without Cerebral Disease. Neurology, 8: ‘ 682-685. Green, M. and Fink, M. Psychiatry, 3;: 2h9-258. Jaffe, J. 30. Communication Networks in Freud's Interview Technique. 29. Language of the Dyad. Psych. Quart. 2g: hS6-h73. Jaffe, J. 31. Changes in Language During Electroshock Therapy. and Ed. P. of Hoch, Communication, Psychopathology Eratton. Kahn, R.Lo and Fink, u n, ., rune M. �-35PUBLICATIONS AND PRESENTATIONS 1959 32. Effect of an Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Biol. Psychiatry ed. Massrnan, J., Grune & Stratton, N.Y. pp. 1 -l9 33. Alteration in Brain Function in Therapy. N. ed. Kline harmacology Frontiers, E Co., Boaton, pp. 325-332. Fink, M. 3h. Significance of EEG . Fink, Psycho- Eittle, M. Brown ‘ Pattern Changes in Psychopharmacology. Clin. Neurophysiol. g: 398 (abst). Fink, M. 35. Electroencephalographic and Behavioral Effects of TofrEnil. Canad. Psych. Assoc. J. A: 1665-1718. Fink, M. 36. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy. JoNoMoDo 128: 2h3‘2h8- Fink, Mo, Kahn, Roll. and EEG. PoIIacE, HT" 37. Effects of Diffuse Altered Brain Function on Perception. Proc. XV . Int. Con . Psychol. Publ. North-Holland, Amsterdam, pp. 238-239. Fink, M., Kahn, R.L. & Karin, H. 38. Therapy of Schizophrenia: Role of Alteration of Brain Function on Behavior. Congress Re orts II Int. Cong. Psychiatry, I}: E9?-E§3 Kahn, R.L. and Korin, H. labstS. Fink, M., 39. Relationship of Threshold and Duration of Seizures to Degree of EEG Delta Activity Induced During Electroshock. EEG Clin. Neurophysiol. —2: 399 (abst). Green, M. ho. Prognostic Application of Psychological Techniques in Convulsive Therapy. Dis. Nerv. Syg. 32: 180-18h. Kahn, R.L. and Pollack, H. In Press bl. Effects of Psychopharmacologic Agents. szchotropic Drugs, 2: Ed. Bradley P. Fink, b2. Effect of Anticholinergic Compounds on Post-Convulsive EEG and Behavior of Psychiatric Patients. EEG Clin. EEG and Behavioral Neurophysiol. Fink, M. M. �PUBLICATIONS AND PRESENTATIONS In Press (contd) Interview Patterns. The D amics of Psvchiatric Drug There , ed.-3T arwer-Foner, C.C. nomas, Springfield, Ill. Fink, M., Jaffe, J. and Kahn, R.L. hh. Formal Language Patterns as Character Defenses: Implications for Psychoanalytic Technique. Pszchologz of Speech and Hearing Disorders, ed. Barbara, D. ., Grune & Stratton. Jeffe, 3. h3- Drug Induced Changes in Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. A.M.A. Arch. Gen. Pszchiat. Kahn, R.L., Pollack, H. an h6. n, o Set in the Perception of Simultaneous Tactile Stimuli. Am. Jour. Psychol.Korin, H. and Fink, M. The Role of �3. Presentations. 1. Relationship Between Altered Brain Function and Denial in Electroshock Therapy. American Psychiatric Association, Atlantic City. Delusional Reduplication of Parts of the Body after Insulin Coma Therapy. New York Neurological Society, and the New York Society for Clinical Psychiatry, New York. Relation of Changes in Memory and Learning to Improvement in Electroshock. Electroshock Research Association, Atlantic City. h. Quantitative Study of Slow Wave Activity Following Electroshock. Eastern Association of Electroencephalographers, Bethesda. Newer Drugs in Psychiatry. Nassau Neuropsychiatric Society, Long Island. 3. 1956 Changes in Language During Electroshock Therapy. American Psychopathological Association, New York. Electroencephalographic and Clinical Effects of Megimide. Eastern Association of Electroencephalographers, New York. 1957 8. Perception Experiments in a Study of Ambivalence. Section of Neurology and Psychiatry of the New York Academy of Medicine and the New York Neurological Society, New York. Individual Differences in EEG Responsivity. Metropolitan EEG Society, New York. 10. Criteria in Evaluation of Clinical Behavioral Change. Round Table Discussion, American Psychiatric Association, Chicago. 11. Personality Factors in Behavioral Response to Electroshock Therapy. Electroshock Research.Association, Chicago. �938PRESENTATIONS 1957 12. EXperimental Studies of the Electroshock Process. Society of Biological Psychiatry, Atlantic City. Effects of Diffuse Altered Brain Function on Perception. XV International Congress of Psychology, Brussels. Therapy of Schizophrenia: Role of Alteration in Brain Function in Behavior. International Congress of Psychiatry, Zurich. The Relation of Ambivalence to Aggression and Authority in Psychoneurotic Patients. American Psychological Association, New York. 16. Perception of Embedded Figures After Induced Altered Brain Function. American Psychological Association, New 13. York. 17. Behavioral Patterns in Induced States of Altered Brain Function. New York Divisional Meeting, American Psychiatric Association, New York. Objective Study of Communication in Psychiatric Interviews. New York Divisional Meeting, American Psychiatric Association, New York. Significance of EEG Frequency Shift for Psychiatry. Metropolitan EEG Society, New York. Effect of Diethazine on EEG and Significance for Theory of Process of Convulsive Therapy. Eastern Association of Electroencephalographers, New York. An 1958 Correlates of the Electroshock Process. Eastern Psychiatric Research Association, New York. 22. Significance of Individual Variability in EEG Changes During Electroshock Therapy. Eastern Association of Electroencephalographers, Montreal. 23. Experimental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretical Implications. New York Neurological Society and the New York Society of Clinical Psychiatry, New York. 21. EEG �-39. PRESENTATIONS 1958 Patterns with Altered Brain Function. Eastern Psychological Association, Philadelphia. The Relation of F Score to Behavioral and Psychological Response with Altered Brain Function. Eastern Psychological Association, Philadelphia. 26. Intensity of Stimulation and Perception of Simultaneous Stimuli in Cerebral Dysfunction. Eastern Psychological Association, Philadelphia. Communication 27. 28. 29. 30. 31. 32. 33. 3h. 35. SociOoPsychological Aspects of Diagnosis and Treatment: Theoretical Implications (Symposium). Eastern Psychological Association, Philadelphia. Drug Induced Changes in Interview Patterns. Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (Tranquilizing) Drugs in Psychiatry, Montreal. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy. American Psychiatric Association, San Francisco. Social Factors in Selection of Therapy in a Voluntary Mental Hospital. American Psychiatric Association, San Francisco. A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon". American Psychiatric Association, San Francisco. Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. Electroshock Research Association, San Francisco. Effects of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Society of Biological Psychiatry, San Francisco. Role of EEG Frequency Shift in Behavioral Effects of Drugs. Section of Neurology and Psychiatry, Queens County Medical Society, New York. Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior. American EEG Society, Atlantic City. �shoPRESENTATIONS 1958 Prognostic Application of Psychological Techniques in Convulsive Therapy. Eastern Psychiatric Research Association, New York. 37. EEG and Behavioral Effects of Psychopharmacologic Agents. Collegium Internationale Neuro-Psycho Pharmacologicum, Rome; and Eastern Association of Electroencephalographers, New York. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock. Eastern Association of Electroencephalographers, New York. 1959 Effects of Tofranil. International Conference on Depression and Allied States, Montreal. Sociopsychologic Factors Affecting Therapist-Patient Relationships. American Academy of Psychoanalysis, Philadelphia. Effect of Induced Cerebral Dysfunction in Man and on Tachistoscopic Perception of Embedded Color Figures. Eastern Psychological Association, Atlantic City. Behavioral Changes with Different Methods of Induced Cerebral Dysfunction. Eastern Psychological Association, Atlantic City. h3. Sociopsychologic Aspects of Psychiatric Treatment. Eastern Psychological Association, Atlantic City. hh. Language Patterns as Measures of Behavioral and Neurophysiologic Change. American Psychiatric Association, Philadelphia. EEG and Behavioral �C. Reports in preparation: 1. 2. 3. Experimental Studies of Convulsive Therapy - a monographic review. EEG Patterns and Synaptic Events in Experimental Hallucinogenic States. Comparative Study of Indoklon and Electrically Induced Convulsive Therapies. Studies of the Sedation Threshold. Effect of Induced Cerebral Trauma in Man on the Tachistoscopic Perception of Embedded Colored Figures. Individual Differences in the Perception of the Upright in Hospitalized Psychiatric Patients. Social Attitude (California F Scale) and Convulsive Therapy. Sociopsychologic Factors in Drug Therapy. Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function. �’os. Relation Between Altered Brain Function and Denial in Electroshock Therapy Robert L. Kahn, Ph. D. Max Fink, M.D. Edwin A. Read , at the Weinstein, M.D. Annual Meeting American Psychiatric Association, May 1955. the Research Service of the Hillside Hospital, and the Department of Neurology of the Mount Sinai Hospital, New York. From This investigation was supported in part by the Medical Research and Development Board, office of the Surgeon General, Department of the Army under Contract No. DA-h9-OO7 MD-3763 and grant M-927 from the National Institute of Mental Health of the National Institutes of Health, Public Health Service. �Although many theories concerning the mode of action of electroshock and psycholphysiological among the relationships been have offered, therapy (3,h,5,6) studies In previous understood (1,2). remain poor v ogical factors certain function, that was suggested of brain it of patients with alterations of effects the to therapeutic related of the observed patterns of behavior were electroshock. dis(3,6), anosognosia of or illness denial included patterns in and language, (8) changes time and (7), reduplication orientation for place that indicated was It (9). paraphasia misnaming or particularly nonaphasic These than rather of illness the stress to these phenomena were fonns of adaptation neural of milieu the In judgment. Specific defects in memonv, perception or motivations his the expresses damage, patient brain reorganization provided by the with modes of interaction changed of in new s,rmbolic patterns indicative of forms insuch denies the delusion patient In anosoynosic the environment. of an the and operation, fact blindness, of a limb, loss capacity as hemiplegia, as well as other problems in livinfi. In disorientation for place, the way in the symbolic as serves hospital which the patieit be need to the often traumatic situation, representation of some aspect of the the locates or of familiar place a name the he uses well and go home. Thus, misnames and mislocates the the outside hospital. a confabulates journey his to or close hospital academy" skating "roller a as the to hospital 'When a paraplegic patient refers names Mount the (Mount Cyanide, Sinai) hos the ital or a paranoid patient calls home symbolize the patient's feelings in dramatic fashion. In paraphasia, the ob- a to personal related usually are patient jects the Thus, patient and of hospitalization. illness that problem, particularly and and objects the of places body, selects aspects of the environment, parts which are misnamed by the in of his a feelings the exnression for them language his in uses n interaction. new mode of �.3. could be brought out by the administration of amytal sodium ("positive amytal test"). 'With a return of the complaints of pain these changes in behavior were no longer apparent either clinically or under amytal. This sequence of events were repeated during two Subsequent courses of electroshock. While this report supported the hypothesis regarding the therapeutic action of electro- test" in investigating the probdid not represent the usual condition for shock and showed the usefulness of the "amytal lem, it concerned only one case and is given. The theory is further tested in the present study in which a group of potients receiving electroshock for mental illness were given repeated amytal tests before, during and after the course of treatment. The purpose of the study was to determine the relationship between the clinical response to the which electroshock treatment and changes in behavior produced by the drug. theses tested were that those patients more likely to show: (1) evidence The particular hypo- improved with electroshock would be who of brain dysfunction on the amytal test and (2) behavior patterns indicative of denial. METHGD series of amytal tests. In this test, the patient is asked a standard group of questions pertaining to orientation and the patient Each awareness of was given a illness. The drug ution at a rate of .05 grams (1 is then administered intravenously in a cc) per minute until nystagmus, slurred drowsiness and errors in counting backward are noted. now repeated. The The same 5% sol- speech, questions are following changes, when persistent, are called "positive" and are deemed indicative of cerebral dysfunction. 1. Complete denial of illness. 2. Denial of major aspects of illness, such as attributing entry into hospital to a trivial or past illness. 3. Misnaming the hospital, either euphemism as "rest home." its proper name, or in terms of a �ah. Displacement of the location of the hospital, such as to another city. 5. Confabulated journeyt 6. Reduplication of the hospital, as stating that he is in another hos~ pital of the same or similar name. 7. Disorientation for time of day with confusion of day and night. misidentification of the examiner such as calling or an "entertainer". 8._ Gross him a "lawyer" 9. Disorientation for year. The patient was given his first test prior to treatment, and re-tested at weekly intervals. All patients in the series had negative amytal tests prior to the initiation of therapy. Treatments were administered three times a week, so that the patients were generally tested after every third treatment. A test after a treatment. Testing was continued after the termination of therapy until the result had become negative. of and records standard tests memory and learnElectroencephalographic ing ability were also given, but will not be considered in detail in this paper, was always given two days POPULATION Twentyufour patients at Hillside Hospital receiving electroshock with the Reiter Electrostimulator were studied. There authors. The patients were taken on the was no basis of consecutive referrals, and the determination of the necessity for treatment was Some patients were selection of cases by the made by the clinical necessarily excluded because their treatment staff. was terminated or interrupted before they were adequateLy studied. Another was omitted because he had manifestations of brain disease and a positive amytal to electroconvulsive therapy. thirtyvthree. Patients treatments. Some The number who showed test prior of treatments varied from nine to clinical improvement tended to receive fewer of this variability could also be ascribed to differences in the inclination of the resident psychiatrists to use this form of treatment. �~5One patient decided for himself that he had enough treatment and eloped. gnostically, the patients consisted of 1h with depressive schizophrenia and one manic reaction. There were 15 and the ages ranged from 2h series, to 68 reactions, women and 9 men 9 Dia- with in the with a median of h7. of response to E.S.T. Evaluation.Wa— M~~ All the patients were observed for at least eight weeks after completion of treatment. on Determination of the patient's response to electroshock was made staff opinion, the the basis of the resident psychiatrist‘s impression, nurses' notes and the clinical evaluation of one of us (M.F.) who supervised the treatments but was not aware of the amytaltest results. In this way the pat- ients were classified into three groups. gfiwwyarkedlv Improved; The 11 cases in this group were regarded as show- ing recovery or marked improvement. These patients no longer showed the ptoms which brought them symp into the hospital; their doctors felt they were better; and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite, and improved capacity to get along with the other patients and participate in hospital activities. B. Moderatelv Improvegz_ The six patients in this group showed some improvement but continued to manifest indications of mental illness. These patients typically relief, i;§:, acute depressive features showed symptomatic might be gone, but the dramatic change so evident in the apparent. Each patient continued to show some first group was not noticeable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation, C. Minimally or Unimnroved. In this group were placed seven patients in whom change was not ient improvement. somewhat improved. clearly noticable or Some showed But who showed only equivocal or trans- fluctuations in behavior, at times appearing the change was not sustained, so that by the end of �9-6- much did before. as they appeared treatment, they are aware of the difficulties in evaluating improvement. Others might In by these any case, of in patients. change estimates the have differed in and the between first the differences using this threefold classification, We third groups will be distincto OBSERVATIONS l. flggjggL Test Results of The number tests given amytal Reactions. of A. Distribution Positive -um-W from to three thirteen, ranged electroshock of the course each during to patient shown the data Table is In maintained. I, depending on how long treatment was . for the number of and number and percent posthe treatment tests given during The improved patients markedly each in the group. patients itive for all moderthe with unimproved the group, showed many more positive reactions than between these groups. Every markedly improved ately improved patients in On other the treatment. reaction during ient had at least one positive amytal cases unimproved of the and five hand, one of the moderately improved patients the of incaach A the results of comparison showed result. a positive never the than better at significant groups, using chi-square, is statistically level of confidence. TABLE I pat—_ 1% WWW DISTRIBUTION OF POSITIVE ANITAL TESTS DURING TREATMENT ” No. of tests given durinc treatment Markedly improved (ll) Moderately improved (6) Unimproved (7) Number positive % Positive 50 38 76% 39 15 38% hS 6 13% the In groups of Fig. treatment. each l stase at B. Positive reactions who had positive each in of group the patients percentage for are compared » �treatment. of each stage at results after reactions had positive Almost half the markedly improved patients nine to seven after reactions had positive and.all treatments, three only treatments. In the unimproved cases, on of number positive the hand, other the of the course during increase consistent no was and there small reactions was other the between to tends fall improved group moderately the Again, treatment. two. Although some than more received patients 15 treatments the data is not small too became each number in group the because presented beyond this point than more received unimproved patients of the Four of comparison. for purposes mode One the of with consistently negative amytal test results. 20 treatments occasionally an with only treatments 30 received over improved patients erately positive reaction. There were variations in the per- reactions. positive a .e-u' two consecleast at Using week. week to from sistence of positive reactions improved, markedly the of nine of persistence, criterion the as utive positives showed perunimproved group the of one and only two of the moderately improved C. Duration_3§ “-5 one but patients treatment all of termination the ,After sistent positives. The reconvulsion.. the last after nine days had negative amytal reactions treatment. week after second the by test negative a developed maining patient improved group markedly the in D. Factor of awe. Since the patients conceivis reactions, it from depressive suffering be older tended to persons to age be scley related might results test able that the difference in amytal assum— the is this Underlying improvement. clinical to coincidentally and only funbrain altered show of signs to more s likely i older the person that ption | shown. each is 2 for group mean the Table age In electroshock. when given ction �-8. TABLE 2 RELATIONSHIP OF CLIEICAL_IMPROVEMENT TO AGE Than Age Markedly Improved (ll) h7.6h 0' Moderately Improved (6) 50.00 Unimproved (7) 35-29 It is apparent that the first patients. two groups were older than the unimproved Yet, while the mean age of the moderately improved cases higher than the markedly improved group, theSe patients still show is slightly significantly fewer positive reactions. In Table 3 the number of positive reactions during treatment is shown of he over to age. limited years patients the analysis is for In this table the relationship of positive reactions in the different groups remains unchanged from that when the groups are considered as a whole. each group when TABLE 3 OVER hO PATIENTS IN AMITAL'TESTS DISTRIBUTION OF.EQ§EE;VE a... No. of tests given durine treatment_ Number positive % fpsitizg Markcdly Improved (1m) h6 35 76 Mederately Improved (5) 3h 15 hS Unimproved (3) 17 O O 2. Other Aspects of Behavior. were there and disorientation of denial illness explicit and the of drug influence the under both occurred changes in behavior that fashion progressive treatment is of significantly the course clinically during Apart from in those patients who improved. These aspects may be divided into verbal and non-verbal communication. A. can: Channes in Verbal Language. These consisted of denial expressed in �-99.. evasion and in the use of a syntactical pattern involving the third and second When person. asked about their symptoms patients gave such answers as "it's hard to say" or “I forgot" or "I don't know; I‘ve been waiting for the doctors tell as "it's to me." The change what they in syntactical person is illustrated by such remarks call a depression," "I‘m afraid answering the question "what trouble." Sometimes In patients patients is talk of a relative would there One to the start of treatment what will get hurt" or your main trouble" with "what who improved in the non-drug interviews. somebody was a who was is 3223 main sick. notable development of such patterns patient, for example, whenzisked prior his main trouble, said "I'm depressed." such was After two treatments he answered the question with "I don't get along well with my mother-in-law." After five treatments he said "I don't get what you he said know." After ten I that‘s "I all sick; get after eight, what 11 "in and said way after don't my see wife," "right now, it‘s that I do you mean" and "I don't know how to explain it." At the termination of given home" an followed by "I to want main get was as trouble his tr atment, mean," and account of how "good" his wife was. of these group, increased the use the other hand, on In the unimproved language patterns did not occur. They were not present in some, minimally or inconsistently noted in others. In some of the unimproved patients there was than the of drug the under effects of these language patterns actually less use there had been in the pre-amytal interview. ..B. clinical in Changes in Non-Verbal Behavior. and drug interviews most frequently the moderately improved and improved. Euphoric reactions occurred both in in the markedly improved, less least in the group which were considered un- In the unimproved patient classed as manic, euphoric behavior was present in his clinical behavior and was not changed by amytal. �-10—‘ of of four interviews the amytal in apneared Changes in sexual behavior other the of each in one in only but patient the markedly improved patients makthe examiner, caress hug to form of or This took the trying categories. ing remarks with sexual content or engaging in masturbatory ient in the unimproved group showed activity. this behavior both during are-drug A pat- inter— views and under the influence of amytal. Withdrawal or "selective inattention" was shown by nine of the eleven the amytal of the phase drug during markedly improved patients particularly about the questions answer to of failure consisted interview. This behavior fashion. and cryptic in dysarthric responding and hospitalization or illness the other each of groups. in once occurred only the drug under This reaction who appeared the category unimproved two in of that patients It was interest withdrawn before the test became more responsive under the influence of the drug. ravage: there is that indicate these in patients tests the of anwial results damage or brain of and the production improvement between clinical a relation method of determined this by particular an altered state of brain function as The examination. In patients who improve, the amytal test becomes consistently treatment. of the course in early positive In moderately improved or unimproved does not increase and frequency their reactions patients there are fewer positive such function brain methods of evaluating with more treatments. With other the in showed abnormalities All not patients present. close correlation was found frequently as was and * learning impaired record electroencephalographic damage The brain of effects who did not. those who improved as in in patients are not unitary and different methods of study show varying results. more analyzed_in being are these data in patients a The electroencephalographic the show that The findings preliminary be reported elsewhere. detail, and.will amytal the to comparable EEG improvement, to related abnormality is Wegree of test findings. �.11 - in to changes function brain of altered In relating the various aspects behavior after electroshock therapy defects in the formation of In the of language. first symbol it has been helpful to distinguish between patterns and defects in the adaptive uses category one may include such clinical phenomena as loss. of memory and certain types acalculia aphasia, apraxia, finger agnosia, cannot select he but wants he "know" to what say In aphasia, the patient may and movements and sounds of the appropriate elements from the entire category of elements excannot select the defects With patient memory integrate them. them temporal pata in and units arrange significant perience, class solving of problem manifested in tests commonly also tern. Such defects are fre— Such are patients scale. and in certain subtests of the Wechsler-Bellevue them into quently concerned with their and of marked anxiety degrees and exhibit defects frustration. Adaptive changes in language, on the other hand, relate to interaction They behavior. of motivational aspects the with the environment and concern The besame and disorientation. denial of are exemplified in the phenomena and other in defect a conditions as havioral element may appear under certain cases as a part of an be may example, for form of adaptation. Left~ri9ht disorientation, impaired and is of right which the left concept aphasic defect in a paralyzed able to identify seem not may Other however, patients, or lost. or and ear left arm their (non-paralyzed) Show right their left arm, but can relate not does and as long as it of right knowledge left similarly indicate a the not in electroshock of prois action therapeutic to their illness. milieu neural the in providing rather but formation duction of defects in symbol The in which altered forms of adaptation may be maintained. outcome of electroshock treatment by the psychiatrists predict the Other point treatments. the initial amount of "confusion" that occurs after The test amytal Leprovement. to not related was "confusion" where to cases Many �-12.. should be useful as a prognostic guide by defining the nature of these changes. In cases "confusion" some patients the amytal test mainly a matter of memory defect and in these may be negative. On the other hand, some patients imp such Clinical In of evidenae few without treatments "confusion." a after prove instances the amytal procedure may show an alteration in brain function. In may be this study almost half of the markedly improved patients had positive reactions In another case, treated privately by one of us (E.A.W.), within three treatments. after only two result prior to treat- marked improvement of a severe depressed condition was noted convulsions. Yet this patient, who had a negative amytal ment, showed a markedly positive reaction one day These results do not than patients brain damage ectly measure brain damage, but rem that mean who do improved not improve. rather after the second treatment. patients have a The amytal one deduces test greater degree of does not dir- the presence of braincianage the nature of the adaptive changes in communication. Thus patients with brain damaje who do not show such changes are considered to show a negative re- im~ methods of behavioral demonstrating other that sult. It is for this reason paired brain function may not distinguish between improved and unimproved patpositive do and not others amytal a Why some develop test, patients ients. despite many more convulsions is unclear, but factors and to the patient's habitual mode may be related to personality of adaptation to stress. It is be so function brain of altered state treated a that nevertheless, necessary, that these forms of adaptation or denial can be maintained. It is for these which electroshock methods of administering believed that reasons that it is be not seizures will generally unilateral as function brain minimally alter efficacious. Also it affords some explanation as to why electroshock often has a beneficial short term effect while evaluation of long ternleffects little difference between treated and untreated cases. show �-13In considering what constitutes "improvement," it is likely that such evaluations are dependent in considerable degree on the types of verbal and patient denies that imp he rated and is and uncomplaining, affable he has any problems, appears he has developed he that has or does mean not acquired insight that It proved. non-verbal adaptation that the patient uses. a more realistic understanding Thus, when a of his interpersonal relations. exemplified by the patient previously cited who said he This is well was "depressed" in third person when asked about his illness. While his behavior is rated as improved, actual analysis of his language shows that he is using different forms of symbolic the pre-treatment interview, but later used evasion and use of the adaptation. Recent mechanisms of studies have supported the findings concerning the development of denial in the improved patients. Carter (12) confirmed Janis’ (13) findings of consistent evidence of circumscribed amnesias in patients lowing electroshock. He that general memory impairment did not occur, "selectivity" in forgetting of unpleasant material concluded but rather, that there was a from the fol- patient's past life. Komgold (11;) likewise reports selective and "mechanisms of observes (15) Teicher similarly, sensitized forgetting. highly repression" for "emotional" stimuli after electroshock. Another aSpect of the difference between the improved and unimproved groups which may bear a relation to the therapeutic proved patients there were more changes in all not only in verbal patterns. Thus, a patient mechanism was that in in, types of symbolic adaptation, who appeared withdrawn both in the pre-drug and drug interviews had a poorer prognosis than the patient became withdrawn only under the who showed who effects of the drug, Similarly, the patient altered sexual behavior under the effects of the drug had exhibited this behavior during the prenamytal questioning as well, and did not improve with treatment, while the four patients manifesting sexual behavior only under �fill!" the effects of the drug, did improve. The importance of the change in symbolic pattern is also illustrated by the fact that the unimproved manic patient showed no changes in this aspect of his behavior during the amytal test. It is thus likely that the facility of changing symbolic patterns in a situation of added stress is an important one in determining response in all somatic therapies. �SUMMARY AND CONCLUSIONS ment treatelectroshock for consecutively referred (l) Twenty-four patients the during intervals and at regular during were given amytal tests before, courSe of treatment. (2) There proved to be a close relationship between the shorteterm tests. of the anwtal results treatment and.the to sponse patients showed early, persistent re- The much improved positive reactions during patients showed no positive reactions or and increasingly the course of treatment. Unimproved intermediate group who showed infrequently and inconsistently. unimproved the than reactions showed more positive moderate clinical improvement of reincidence positive the much in improved the of short group but fell far An showed them actions. (3) Changes in behavior forms of non-verbal and language were most consistent and pronounced related to denial in the improved group, even in interviews not employing drugs. (h) The improvement clinical that the hypothesis support observations function in of altered.brain milieu of a in electroshockzmequires the creation mainbe may of those denial, Which new patterns of adaptation, particularly tained. �mmmmggzg 1.) Gordon, Fifty H. L. : 2.) Kalinowsky, L. Shock Therapy Theories, Mil. Surg. $92: 397, l9h8. B. and Hoch, P. H. Shock Treatment, PBychosurgery and : Other Somatic Treatment in Psychiatry, (2nd ed.) 3.) ’Neinstein E. & 1..) Psggrchiat. A. and Kahn, R. L. _6}_1_: Syndrome : Ybrk, 1952. of Anosocnosia, Arch. Neurol. 772-791, 1950. 'E‘Jcinstein, E. A., Kann, R. L., Sugannan, L. A., and Linn, L. Use of Amobarbital Sodium in Organic Brain Disease, 889-8911., Am. : Diagnostic J. Psych., llg: 1953. S.) weinstein, E. A., Kahn, L., and Malitz, S. R. Its the "Amytal Test" for Brain Disease: A. M. A. Arch of 6) New weinstein, E. Serial Administration of : Diagnostic and Prognostic Value, “enrol. and Psychiatu 11: 217-226, A. and Kahn, R. L. : 1951.. Denial of Illness: Symbolic and Physiol- ogical Aspects, Springfield, 111., Charles C. Thomas, in press. 7.) Weinstein, E. A. and Kahn, R. L. Brain Disease, J. Neuropath. 8.) & : Patterns of Disorientation in Organic Clin. Neurol. l; 21h-226, 1951. and R. A. L. E. L. A.: Kahn, Sugarman, weinstein, , A. M. A. Arch. Neurol. uplication, 9,) 'weinstein, E. 0rg-tanic Brain Psychiat. M. A. Arch. Neurol. 10.) weinstein, E. A., Linn, L. and Kahn, R. L.: Its Relation to the Therapy: {31: 808-8111, 1952. L.: Non-aphasic Misnaming (paraphasia) in A. and Kahn R. Disease, A. & Phenomenon of Red- & Psychiat.,‘éz: 72-79,l952. Psychosis during filectroshock Theory of Shock Therapy, Am. J. Psych., $925 22-26, 1952. 11.) Mcinstein, E. A. and Kahn, A. M. A. Arch. Neurol. ness, 12.) Carter J. T.: Type convulsive Therapy, 13.) Janis, I. L. : R. & L.: Personality Factors in Denial of Psychiat. Ill- Q2; 355-367, 1953. of Personal Life Hemories Forgotten Following ElectroAm. Psychologist §; 330, 1953. Psychologic Effects of Electric convulsive Treatments Post-treatment Amnesias.) J. Nerv. & Ment. Dis. ill; 359, 1950. (I. �REFERENCESz 1h.) Korngold, M.: An Shock Treatment, 15.) Teicher, A.: Investigation of Am. The continued Psychologist Q; Some Psychological Effects of Electric 381-382, 1953. Effect of Electroconvulsive Therapy actions of Schizophrenic patients, Am. on the Visual Re- Psychologist, g, hhS, 1953. �] ONS I REACT. 90 ._” much Improved (11) '*~ Mod. Improved ‘ 80 ” Unimproved (6) /// (7) / t// ‘\\\\\\_ //////////’ “~. * AMYTAL POSITIVE 3o PERCENTAGE 20 / / / (“” \ " , ,/ . " / x,” I f 10 O ' h-é ,__.._..7..___.-_....-_,_....__.-..;}..-.__ 7-9 10.12 13.15 NUMBER OF TREATMENTS occurring reactions test amytal of positive Fig. I.-—- Percentage treatment. of stages different each at in group �{fw g; ,{1/,m»‘-‘ JUN 26 ”12!. :c. .M Altered Brain Function Following Electroshock H—927 Progress Report - February 1 1958 - September 1 1959 Summary: In the past eighteen months various studies of the convulsive therapy process were completed, a program for the investigation of psychopharnacologic agents consistent with the general hypothesis concerning the node of action of physiodynamic therapies was developed. The physiologic effects of nany interrelationship of the neuro- new compounds with the psychodynanic, perceptual, personality and sociologic aspects of patients' behavior provided the framework for tnse investigations. following areas of study were explained: l) of psychotherapy with physiodynanic therapy; The the interrelation 2) the elucidation of the synaptic chemical events which are the basis of the convulsive therapy process by the acute administration or experimental anticholinergic compounds at various stages of convulsive therapy; and behavioral 3) studies of the acute and clinical effects of a EEG variety of psychopharnacologic agents; h) the use or language indices, such as syntactic and dyadic~ 1959 �-2- diversification analyses, as measures of behavioral neurophysiologic changes with drugs; and 5) a comparative study of indoklon and electrically-induced convulsions in psychiatric therapy; duration of 6) sociopsychologic aspects related to hospitalization, discharge ratings and diagnosis in a voluntary mental hospital; 7) the relation of social attitude to the effects of convulsive therapy; 8) aspects of the therapist- patient relationship affecting aha: choice of therapy; 9) studies of individual differences in the selection of, and behavioral change with, convulsive therapy by perceptual aethods. These studies have supported and expanded the neuro~ physiologic-adapative view or convulsive therapy, and demonstrated that such a hypothesis has applicability to our understanding of the node of action of psychepharnacologic agents. �Progress Report: A; Psychotherapy and Physiodyganic Therapy. Previous observations have shown that two types of patients are referred for electroshock in this hospital. largest number are patients in the older limited education and are foreign born, age groups who have They tend to introspective persons, stereotyped in their thinking language and verbally unconmunicative. symptoms The The be non- and Their predominant are depression, agitation, withdrawal and sonatisaticn. second, and smaller, group of patients are younger, native- born, better educated, and verbally ccnnunicativo with a capacity for intropection. They characteristically exhibit thinking disorders and overactive behavior states, with sonatisation and depression occurring An to a lesser extent. oratory explanatory study was undertaken of four patients, two for each group described above, for the purpose of determining 1) reasons for referral for convulsive therapy, 2) whether the differences in patients required different attitudes in psychotherapeutic nanagenent with electroshock, and 3) the �-1... relation of the psychotherapsutic approach to the patient'e clinical response to electroshock. It was found that all of the patients studied were electroshock because of a failure of connunication referred for in the psychotherapeutic relationship. In a reflection of the limited verbal and cases this was two introspective capacity social factors. In the of the patientdue to educational and other two cases, however,-the inpaired communication primarily due wee to unmanageable acting out. Following treatnent, the older, less educated patients were able to naintain this improvement with a reassuring and to nininication the tendencies denial toohniqne,-supporting during developed electroshock. electroshock eeened to make In the better educated patients, the patients nore’anenable to an psychotherapy. torn of interpretive It or psychotherapy was concluded that the relationship to electroshock varies with the particular_type of communication pattern and adaptation shown by the individual patient. This �-5. the and been Journal written up published in material has or Hillside Hospital, 7: 17-25, 1958. B; Biochemical Aspects of the Convulsive Iherapz Process. The significance or high voltage the convulsive therapy process (Roth and Kahn, 1957) and the EEG 22.;l! delta activity in 1951, 1957; Pink report that this delta activity was 'blocked hy the adninistration of ahtioholinergic'compounds; atropine and scopolanine (Ulett and Johnson, 1957) provided the basis for these studies. As there were attendant unpleasant, 'systenio effects with the administration of these agents, .reports describing diethasine as an anticholinergio'conpound' (Jenknerwith potent neurologic but minimal systemic effects l956) Lechner, studies 19553 to.undertake led Lechner, us and sinilar to those of Ulett (Fink, 1958). and Johnson neing this'conpound These observations with diethasine led to the agents. of other antioholinergic experimental investigation Clinical and electroencephalographic responses to the intravenous administration of various anticholinergic agents �-6in psychiatric patients at various stages of convulsive therapy were studied. These observations were related to hypothesis covering the node of action of convulsive therapy and of hallucinogens. The subjects were ninety psychiatric patients referred for convulsive therapy, ranging in age tron Ivariety of diagnoses. since some The total or 18 to 67, with a 107 observations were made, subjects were studied with more than one compound. A drugs were administered at various stages of the treatment process. The observations were laboratory using a standard electrodes. In each intravenously at a trial, 8 made in the EEG channel instrument and needle the compound under star was adninistered until set rate per minute with clinical behavior or electrographic changes were observed. The compounds studied have been diethasine, Win-2299, benactyaine, JB~318, JB~336, and atropine. Each is a potent anticholinergic agent in vitro. It was observed that diethasine, Win-2299, benactysine, �-7; JB-318 or JB-336 administration therapy were associated with at various stages-of convulsive a) desynchronisatien of rhythms with a blocking of post-convulsive b) EEG delta activity; alerting, excitatory behavioral response with illusory, de- lusional and hallucinhtory ideation, and c)_systenic effects ‘drynessof muscular veakness, degrees of the mouth, dry skin and tachycardia. . The electrographic. behavioral and systemic effects were concurrent. These observations are regarded as consistent with the. suggestion that the physiologic basis of convulsive therapy lies in an increase in central nervous system cholinergic activity. Observations that LSD, amphetamine, nescaline and diphenhydranine- synpathoninetic and antihistaminic agents also induce EEG ~ convulsive of desynchronisation, blocking post delta activity and clinical excitatory activity support the suggestion that both the behavioral and electrographic patterns are based on alteration in synaptic activity. Increased synaptic activity (cholinergio, synpatholytic effects) is �-8. associated with 336 hypersynchronisation, and clinical eedation and euphoria; while decreased synaptic synpathominetxic) is associated with clinical excitatery activity (anticholinergic, EEG and hallucinogenic desynchronisation and states. Discrepant observations with the anticholinergic agents, atropine, are considered to be related to significant differences in dongs and structural chemistry. This material was presented EEG at a meeting of Society in Atlantic City, June 1h, 1958. the American �-90. Acute and Chronic EEG and Behavioral Psychophersscologic Agents. Iffects of According to our neurophysiologic~adaptive view of the clinical the convulsive therapy process, efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in central function, providing a nilieu for changes in the subject's interaction with the exaniner. In our studies the best index of neurophysiologic change has been those aspects of cerebral function reflected by delta activity in the electroencephalogram (Pink and Kahn, 1957). The efficacy of newer psychopharnaceuticals in altering psychotic behavior patterns has led to the suggestion of a similar hypothesis for the node of action of these agents, and to studies of the relationship and specificity of altered behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of the psychopharnaceuticals tested in acute experiments an in increase in synchrony with or without activity has an increase in slow been observed for chlorpronazine, pronazine and triflupronasine. Behaviorslly, these drugs were associated wave �-10with a) increasing sedation, drowsiness, denial and eqhoria; b) decreasing agitation, panic, excitement hallucinatory activity; of synptons. and and delusional and c) minimization and displacement Barbituratee regularly induced an increase in fast activity with an increase in synchrony, with the associated behavioral changes of sedation, euphoria, denial and minimization. Amphetamine and methamphetamine increased fast activity without increased synchrony; behaviorally they resulted in behavioral alerting, hypcnania, excitement activity. and increased motor Decrease in voltage and per cent time of slow wave subjects with pcst~convulsive delta activity activity in was seen with Lsnazs, benactysine, Win~2299, JB-BlB, JB-336 and diethasine. Of these drugs, benactysine produced increased alerting, excitenent, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional The and paranoid ideation. electrographic patterns were consistenthfiltered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, �.11sedation and minimisation of symptoms were conversely associated with increased EEG the delta range. and hallucinations synchronisation and shift of frequencies to Agitation, tension, panic, excitement, illusions were associated with desynchronisation of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorpronasine and delta activity barbiturates, and enhanced augmented the per cent clinical pattern; agents that chronised frequencies, as diethasine, minimised the LSD-25 and tine desyno benactysine, clinical effects typically ascribed to repeated. convulsions. Following these preliminary observations more intensive undertaken. was of an (Totranil), agent, inipranine investigation In 28 can3:§:::: acute experiments, patients referred for physio- dynamic therapies were stages of treatment. tested in the EEG laboratory at various Tofranil solution (10 ng/cc) was adninistered intravenously at a set rate(l'cc/h0 sec) until electroencephalographic �total of or behavioral changes became prominent, for a mg (.05«2.5 ng/kg). hO-125 Behavioral observation and electrographic recording continued for one to three hours. A second group of ve, withdrawn 16 patients nanifesting depressienl or retarded bdnvior and were whp referred for pharmacotherapy, received daily oral Torranil of 75-250 mg for four weeks or longer. In the acute studies there was initial restlessness, associated with dissiness, dry mouth, 'faintness," nausea, and on tour occasions, vomiting. These symptoms 10-20 minutes, and were accompanied by lassitude, heaviness of the extremities and eventual drowsiness. unchanged or slowed. persisted for Heart rate was Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographic pattern accompanying these behavioral changes were initiated the injection. halved. such In {our By by a gradual decrease in voltages during minutes, the per cent tine alpha had been ten patients with noderateonnouniiof beta activity, activity increased in voltage and per cent time. By twenty �-13minutes, in association with behavioral lassitude, low voltage 6 to 50 nicrovolts) randon theta frequencies (5-7 cps) appeared. In six records with poet-convulsive delta a marked decrease activity. two in voltage and per cent time of slow patterns persisted for These electrographic was wave 5 to hours. variability in the There was considerable individual acute of activity, there EEG response. In patients totranil, but three. who received 100 mg or more angptehavioral changes were observed in all In six patients, dosage of Tofranil less than 50 EEG associatedéwith were either EEG mg or behavioral changes. In the chronic Tofranil studies behavioral changes generally appeared during-the second, and were maximal during the third, week of treatment. The most adaptation was euphoric denial which They conplained or displaced prominent behaioral noted in eight patients. was less of somatic synptois, their illness on inquiry. It and ed ed denial. mininisetien became increasingly difficult to discuss significant lire relationships with then. �' ~1h- in three patients sonatiaation and restlessness increased and depressive affect persisted. In two of these, restlessness, insomnia and vomiting led to cessation of therapy. symptoms were noted change in in five patients after four weeks of therapy. Electrographic studies minimal changes. No on chronic administration shoved Voltages became lower and record modulation poorer. Well defined fast activity became more prominent, and in four subjects, low voltage theta (5-7 cps) activity noted. was Details of these studies were presented at the Collegiun Internationale Neuro«Psychopharmacologicum, at the Conference 1958, and Rone, September 12, on Depression and Allied States, Montreal, March l9~2l, 1959. D. Patterns as Measures of Behavioral and Language Neurophsziolegic Change with Drugs. In previous studies of the convulsive therapy process, was demonstrated analysis ( ) that two language measures, and dyadic syntactic content diversification in interviews ( ) provided objective indices of behavioral change, and were related to the degree of altered brain function. In a further it‘ �-15- test of language measures as indicea of behavioral and neurophysiologic change, they were next applied to recordings or interviews on acute administration of various psychopharnacologic agents. At the present time 72 interviews with patients at various stages of drug therapy have been analysed, using the following agents: anobarbital, benactysine, chibrpronazine, diethasine, lysergic~acid diethylanide, and Vin-2299. Following a routine electrographic recording, an psychiatric unstructured physiologic interview, with slow periods of structured inquiry, was tape recorded. With EEG running, an intaavenous injection was then given at a slow rate. specific electrographic or clinical changes interview was repeated. When were induced, the Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The EEG was shirts in (delta measureg'tor changes in synchronisation, dominant frequencies, and per cent and beta frequencies. tins of slow waves �-16The rthe tape recordings were transcribed and measured for diversification of consecutive 25 word speech and for syntactical changes.‘ samples of dyadic In the dyadid analysis, participants both of behavior verbal the pooled divided into total i;g., the ratio of the number of different number of words. . . The transcribed, samples, and for each sample a diversification 25 word score was calculated, words to the was syntactic language . analysis were based on response to standardised questions using the nothod previously described ( ), scoring such changes as syntactical use of person, alteration in tense, evasion, qualification, displacement or verbal denial or symptoms, use of stereotyped expression or clichzs, cryptic response, and withdrawal or silence. Consistent changes were observed in both the dyadic diversification and syntactic language measures in subjects classified according to the neurophpiologic and behavioral effects of the drugs applied. Anobarbital and chlorpronasinc are neurophysiologic synchronising agents; anobmrbital regularly induced high voltage �-17. well synchronised administration fast activity, at was followed by 20-2h cps, while chlorpronasine increased synchronisiation of the record and a shirt to flower frequencies including occasional EEG slow wave burst activity. Behaviorally these drugs are associated with sedation and tranquilisetion, there was an On the language measures increase in stereotypy and repetitiveness associated with increasing use or cliches, alterations in tense, displacement and evasion. Diethasine, benactysine, LSD~25 and Win-2299 of the neurophysiologic deaynchronising.compounds. characteristically induce decreased voltage of alpha activity and increased irregular are examples These drugs and per cent low voltage tine fast activity. Behaviorally they are associated with hallucinatory, excitatory or illusory activity. On the language neasures they induced ' decreasing repditiveness, wider diversity o: words, lesevariability of diversification scores, and decreased use or cliches and alterations in tense. neasures Further exploration of language are suggested as a rational basis for the understanding or the psychologic �-13- effects of the new therepies. Details of these studies have been presented at the Conference on Paychodynenic, Psychoanalytic and Sociologic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April 11—13, 1958, end Aeeocietion, American the Psychiatric et Philadelphia, April 27, 1959. E. Coupereble study or Indoklon and Electrica11y~ Induced Convaleiona in Pczchietric Therepz. A In our investigation or the-node of action of convulsive therapy we have previouslymnnducted a convulsive-subconvnlsive control study. This study demonstrated that e significant behavioral change occurred almost exclusively in patients receiving grand nel electroconvulsive therapy. The present report in an assessment of the relative neurophysiological behavioral and clinical effects of two different methods of and convulsions current) (alternating electrical inducing inhalent (indcklon). �Twenty—five consecutive patients referred for convulsive therapywere studied. They were randomly divided into two groups, 13 patients receiving grand nal therapy induced by the standard while convulsions were Medcratt alternating current instrument, induced in the renaining 12 by the inhalation of hexafluorodiethyl- ether (indoklon). In both groups treatment time a week for a on the total of 10 to 2h wee administered three applications, determined basis of clinical criteria by the supervising psychiatrist. All patients were tested one to two days prior to the first treatment, following 10-12 treatnents, and following the of lest treainent. The two weeks tests given included intellectual functioning (rive subtests measures ' from the Wechsler- perception (figure—ground Bellevue Intelligence Scale), figures, the perception discrimination using embedded.geonetric of peeuoisochronatic color plates at high speeds of tachistoscopic exposure, and the Street incomplete figures test), and social attitude (the Levincon revision of the California I Scale). An EEG was given during each of the testing periods. �-2066 from continuum slow wave cent a tine activity the per second sanple was used as the index of neurophysiologic change. results failed to The test differences show any between the electroshock and indcklon groups at each of the three test periods. showed significant intergroup Intragroup analysis, however, that during treatment both groups on the intellectual and peripheral on the F scale. By two weeks tests, made increased errors and had high scores after the termination of treatment both groups returned to near pretreatnent levels for most Both groups were comparable slow wave activity in the mean EEG after tests. for the degree of induced 10-12 treatnents. The s user per cent tine delta for the indoklon group was 51%, and for the_electroshock group h7.5%. Within each group individual the of behavioral were to related degree change in differences physiologic change, those with the highest per cent tine delta showing the greatest behavioral change. Bath between change in test activity with treatment and correlation performance and degree of slow wave were positive for all procedures, except the comprehension subtest of the Wechsler-Bellevue)and reached a level of statistical significance for Digit Span (e .61, p <-.Ol), �p( object Assembly (+.h6, .05), tachistoscopic perception (+.67, embedded figures (*.h3, p 4< F scale (+.38, p < p < .05), .01) and perception of .05). This study has denonstrated that two very different convulsant agents may produce similar neurophysiologic behavioral change. and It is concluded that behavioral changes in convulsive therapy are related to the degree of altered brain function, and are non-specific for the type of agent used to induce the convulsion. Details of this study were presented at the Eastern Psychological Association in Atlantic City, April, 1959. Sociopszchological Aspects of Psychiatric Treatment. F. In a previous study of the Hillside Hospital population, it was shown tht the factors or age, education, place of birth and social attitudes as measured by the California I scale, were related to the selection of therapy. ‘Those patients were older, had less education, were foreign-born and with high stereotpy scores on the F scales were more whp likely to receive �-22- convulsive therapy. 'In contrast, patients who were younger, the on low and obtained scores native-born educated, better as psychotherapy received scale, their sole F form of treatment. study the relation determine to was Further undertaken of duration hospitalto factors of eociopsychological 1)_th° 2) the isation, The Hospital 171 16 final diagnosis. 3) the and inspatient of Hillside population adult entire on March 7, 1957 was patients. to 68 57 nan and llh studied. This consisted of from in age ranging wonen, median of 35-years. with a years, It period clinical discharge, of time evaluations at was (1—5 shortest the for hospitalized that patients found the least education, were months) were oldest, had foreign-born, the scores andlad highest been have to most likely on the 1 scale. Iounger,native-born, more educated, lower r '(10 more or the longest score patients were hospitalised months). The sane hospitalisation factors of of length to these rdationship made were when analyses found separate was �-23according to diagnosis and type of treatnent (convulsive therapy or psychotherapy). Discharge evaluations of improvement in the population studied were total related to age, the significantly older patients having the nest favorable ratings. Analysis of the data by type of treatnent, however, demonstrated that the convulsive therapy patients ratings of recovered or among much improved were F given to those patients with the highsst scores, least education and who were foreign-born. Diagnoses of schizophrenia or psychoneurosis were associated with lower and high native birth. F The F scores, younger ages, more education older, less educated, foreign-born, score patients were more frequently classified as involutional or nanic-depressive psychosis. It is postulated that these relationships reflect the ingluence of social background on psychological processes, such as the behavioral patterns of communication, nodes or expression and symbolic values. These not only contribute to the pattern or mental illness, but affect all aspects of �~2h- the patient-therapist interaction. Details of this study have been presented at the Eastern Psychological Association in Atlantic City, Avril, '1959, and at the Academy of Psychoanalysis in Philadelphia, April 26, 1959, and has been accepted for publication in the Archives of General Psychiatry. 0. The Relation of Social Attitude to the Effects of Convuleive Therapz. As F indicated in the previous section, the California scale has been found ueeful in understanding factors related to the referral for convulsive therapy and the evaluation of clinical response following have been undertaken with questions: population? a treatnent. Further studies such this scale in regard to the following 1) What does the F scale neasure in our psychiatric 2) What are the behavioral changes induced with convulsive therapy? 3) How are theee changes related to the degree of altered brain function? �-25answer the To first question, in part, the entire in-patient population of the hospital was given the later One month they were retested with a "reverse" in which each statement original. The was changed "reverse" scale was F scale. F scale, to the opposite of the scuzred in the same manner as the conventional scale, with high scores this procedure reflecting greater to determine agreement. The purpose of whether the to the contents related patients' responses were was of the statements, or were a manifestation of a more general personality aspect, such as acquiescence. It was found that those patients who made low scores originally, indicating predoninant disagreement with the statenents, indicating who made showed a large increase the "reverse" scale, on In contrast, patients a high degree of agreement. high scores initially showed little change on retesting, agreeing with the statements to the sane extent even though the meaning was reversed. low I score patients are while those with high It is more evident that, in our population, critical I scores are more and discriminating persons, undifferentiating and �.26.. and stereotyped in their reactions. is related to the process of selection This observation or patients for convulsive therapy. A high degree of atereotypy or thinking and communication is inconpatable with the establishment of a conventional psychotherapeutic relationship, preventing the psychoanalytically-oriented psychotherapy stressed at Hillside Hospital. It follows that the high sill be F score patients unsuccessful in psychotherapy and nest likely reterred for convulsive therapy. To answer the second end patients were given the treatnent period) and F third questions raised above, 69 scale before, during (at 10-12 after convulsive therapy. Ten of these and the control constituted random, group at selected 'patients, received subconvulsive electrostinulation. nean There was a increase of 05.7 during treatment in the convulsive group, a difrerence significant at the control group (+0.5). The showed an SS level. In contrast, the insignificant change during the cane pertd extent or increase in the convulsive patients was �-27- related to the degree of cerebral dysfunction as found to be determined by delta delta (h0% +8.6. activity on the EEG. Those F patients with high or more of the sanple record) had a nean increase of low with delta indices, however, showed a patients statistically insignificant increase of the The +3.h. Following treatnent scores were comparable to the pretreatnent levels. These findings support and elborate previous observations the effects of convulsive therapy. on the F Greater agreement with seere scale statements during treatment stereotypy and difficulty in discrimination. show conventional The change in I n . P score thus seen part of the same process shown by the z characteristic language changes of increased denial, evasion, qualification, I and use of cliches and stereotyped orpressions It is also comparable to the increased visual tactile perception ( and ( ) difficulty in and figure-ground ( ). complex discninination )- Details of these findings were presented at the Eastern Psychological Association in 1958 and will be elaborated at the �forthcoming Divisional nesting of the American Psychiatric Association in H. flew Zork. Aspects of the TherapistaPatient Relationship Affecting Choice of Therapz. As indicated previously the selection or therapy involves other aspects than the actual behavioral pattern or the patient. In the past year further efforts to been undertaken, emphasizing relationship. clarify this problem have factors in the therapist-patient he have hypotheSised increased tension, frustration and that such factors as hostility in the therapist~ patient relationship, as well as implicit and explicit pressures present in the environment have a significant influence in referral for sonatic therapy. In a and pilot study 76 structured interviews with residents supervisors were initiated following requests fir sonatotherapy. These interviews were designed to referral. It there was found a sudden change elicit the basis of the that in only relatively few cases was in the patient's clinical status which directly led to the referral. most In instances there had been �-29- or progression no change the presenting eynptons. in‘ Factors of impending included the to timing contributing the referral diccherge, avoiding administration discharge, and pressure tron the patient's family or ward personnel. It res also noted were'treatod that ptiients with ainilarhehcvior patterns given senatotherapy and others none. The 4‘ renged reasons for this raged from'"whin" to quantitative difference! differently, some . in synptonetelogy and individual preferences for type of treatment. initial The conclueien wen that in a significant 0; cases, factors other then clinical indication played number a role in the referral. These sane extraneous factors also influenced the timing or the referrals is e results of these findings Referral Sheet" to was completed by the From c ’Scnatic Treatment developed‘(see form at end or report) to therapist whenever somatic therapy is reqneeted. this questionnaire we hope to obtain further information regarding indications for somatic treatment, more specific data �-30. concerning the therapist-patient interaction, and a more definite idee of the therapist's expectations for such treatment. I. Individual Differences in Selection of, to Convnlsive.Theragz. and Response In the elucidation of individual differences related to sonstic therapy, a variety of peripheral-cognitive procedureshave been used. tachistoscopic perception of enbedded colored figures The has been given to 65 of 35 consecutive were 20 patients. experimental group consisted The convulsive referrals for therapy. The controls patients treated with phenothiazine medication (thorazine and pronasine) and ten patients receiving no somatic treatment. All subjects were tested prior to treatment, and after four weeks; the convulairee were tested s third tine two weeks following the cessation of treatment. It was found increase in that there mean number was a statistically significant of errors with convulsive therapy, while following treetnent there was e significant decrease from the pretreatment scores. at Controls made significantly fewer errors �.31- (practice effect). errors between patients classified (per cent time delta) were significant difference in There was a when compared as showing low with high high retest correlations for all groups. EEG changes changes. EEG Marked There individual ditferences in response patterns were noted prior to treatment. With brain changes there was a reduction in perseveration, conpletion patients, and contabulation in some and and increase in others, with no unique patterns attributed to cerebral dysfunction. Even in those patients with high his response pattern was showing completion type to make such EEG 'stjh' changes, the ntein naintained. Thus a errors prior to treatment ore patient would continue errors with convulsive therapy, although the threshold at which completion was shown might change. Details of this study were_presented at the Eastern Psychological Association in Atlantic city, April 1959. The Red and h? Irene Test (after Witkin) was administered to Harked somatic for referred therapy. consecutively patients individual dirierencee in performance were correlated with age, �w _‘“ .v .32-‘ education and score on the Calibrnia vertical Judgment of the frame (field dependent) F scale. Patients whose fies strongly influenced by the sunnunding were more frequently referred for convulsive therapy than drug therapy. No significant change ‘ was found with drug or.convulsive treatment. convulsive groups retest correlations drug For both/and were high (.86 and on differences in the individual considered that is It Frame test reflect personality factors that are in psychiatric treatment. .88). Rod and of importance �5 “J a , :1: 7/16/59 L, wig/r 1 _/ Function Brain Altered Following Electroehcck ‘ 24.927 Progress Report - Febmary 1. 1958 - September 1, 1959 m: L previous In our studies we have demonstrated that an understanfing of the convulsive therepy process required a nultifectoriel approach involving neurophysiologic, perceptual, personality, paychodynemic and eocielogic eepecte cf behavior. Thus is essential it wee ehcwn that: The convuleim to the therapeutic process (Fink, Green end Kuhn, 1958); murcmeielegic changes reflective of altered brain function ere e a Heinetein, 1956; Fink & Kenn. 1957) neceeeery prerequisite for behavioral change end ixproveemt‘ the (Kuhn, Fink biochemical beeie of the convulsive therapy preceee lay level of cholinergic activity of the central nervous is an mm increased (Fink, 1958); there are characteristic perceptual chengee with altered brain function induced by convulsive therapy (Fink, Kuhn and Korin, 1957; Kehn and Pink, 1957); retina cf improvement after convulsive therapy are related to personality characteristics defined by Rorschach and {mm (Kahn and Fink, 1958). interviews (Kuhn and Fink. 1957); end that evaluations of �mm (Kuhn 8.: -2. were related to changes in syntactic aspects of language Fink, 1958). In the pest eighteen (18) months these statics wen completed and extended, and an investigation of poychophamcologic agents begun. The {mark View we for these investigation: of convulsive therapy (Veimtedn Fink and Kahn, 1957) extended mandarin patients (Pink, The been the nmxrophyeiologic adoptive Kahn, 1955; Knhn 8c at all, 1956; to other physiodynenic treatmmta or 1957) . tho convulsive therapy process were relieving aspect- of studied: 1. Siflficence or the Commune Mologic, A cooperative study of neuro- paychologic and bohemian). effects of electrical and inhalant (Indoklnn) induced convuhicaa. 2. @2326 Basic of NeuroMiologg-c Chang: Further studies of the effects of acute wtmtric 3. “notation agents on both the Mgwogo AoEm of of marinentnl anticholinergic 'noml“ and and pout-convulsive EH}. Comm Thomas 3. Relation of the factors or age, education, nativity and �n3. mmotm (mound w the California max-aw, duration of 1:. Chang“ clung» to EEG hoapiuuuum, of F 1" scale) with selection of diagnosis and diochnrgo ratings. scale with treatmnt, and relation of those indiceo. h. Mother-Lg and Conwlsivo Tim-ram: In aupervioory sessions, alterations in psychotherapy with convulsive thorapy were studied. W: 5- Both patterns or change and individunl diffomnooo on tuohistoocopio figumfl ground flicker immoy domination tutu, critical and perception of the upright with induced ‘ emulsions were studied. 5093*ch are «tended to dmg therapies and the following studies undertakom 1. 1010 :1. c: Relation of EEG charge on acute and ohmnic administration of poychophamoouticals to clinical behavioral change. b. EEG as a screening device for psychomrnceuuc potency. �.. h .- c. Elation of 6. EEG EEG clause: to hallucinogenic activity. effects at neginide. 2. Omnicstion Patterns: Relation of induced neurophyeolcgie change to dyadic diversifi- cation and syntactic language maeuree. 3. Aspects of the Therapist .. Patient Relationship affecting choice of somatic therapy. metudiec View have supported and expanded the mumphyaiologxo-adapuu of convulsive therapy, and dancnetrated that. such a applicability to our understanding of the mode munch has of action of psycho- phamacologic agents. PROGRESS A. tar: l. REPORT: Gasman new?! PROCESS figniricance of the Convaleion: A cmmrable study of Indoklcn and electrically-induced convulsime in psychiatric therapy was control eubccmuleive completed. An mm demonstrated changes occurred almost exclusively electrocomruleive therapy. The earlier convulsive- that. uinIicant behavioral in patients receiving grand mal present report is an assessment at �-5the relative neurophysiologic, behavioral and clinical effects of hm different of. methods inciting convulsions - electrical cuxjreet) and inhalant (indoklon) . (eltemating 'consemtive patients referred for convulsive therapy Thaw-nave classified into were tendonly Won / 3Wt, / . ,:./ patients and by two groups the steward - «isms Model-oft mowed in alternating current in. in twelve by the inhalstion of heMlumdetlvl—ether findeklon). In both groups treatment was ochinistered three times a .5 {f} [f book for a total of IKE/o: x! I! if / 3' 10 to 21; applications, determined on the basis clinical criteris by the supervising psychiatrist. ,f‘. \ A All patients were tested one to two days prior to the treatment, following 10.12 treatments, and first m weeks renewing the lost tacatment. In addition to evaluations of behavioral. change, tests included nouns-es of intellectual function (five aubtests In the Kodachr-Bellme Intelligence Scale), perception (figure-groom! discrimination using wedded geamtric figures, the perception of pewdeochrcnstic color plates at high speeds of toohictoocopic exposure, and the Stmt moguls“ figure: test), and lucid �.- 6 1e etfltude (the Lennon revision of the California 1" Scale). An testing of each the periods, obtained during electroencephalogram was on! mom-ed for the per cent. time slow we (6 ope or slower) activity from a continuous 66 second sample. The to failed Insults show any significant inter-group teat differences between the electroshock and indoklon groupe at each of the three test periods. Inbregtoup groupe made onlyale, that during treatment both increased errors on the intellectual and perceptual taste, end had higher _ hmr, showed some on the F scale. By two weeks otter the terminal-g for tion of treatment both groupe returned to near pretreatment. levels ' moat mete. Both groupe were comparable for the degree of indeeeed wave activity after for the 10-12 treatments. indokloa group was 51% and The EEG slow per cent time slow activity for me electroshock group It? 5%. within each group individual differences in behavioral change were the with thoee change of neurophysiologic the degree to reload behavioral change. the greateet sharing delta cent tine highest per �-7mm: order correlations batman changes in test performance and degree of slow wave activity with treatment. were positive fer all proeedwes, except the eomehension subtest of the Wechalar-Bellevm, level of statistical significance for digit. span 1" scale (4* .33, 13 .05). .01), object Assembly (hub, and reached a (+ 1,61, p p .05), ucmnoacopac perception (+.67, p of embedded figures («13, p This study demonstrated .01) and perception .05). that up different eonvulsant. agents produce similar neurophysiologic and behavioral changes. eencluded that. the behavioral change It was is related in convulsive therapy/to the degree of altered brain function, and an non-specific for the type of agent. used to induce the eohvulsion. (mud, in part, at the Eastern Psychological Assecatien, Atlantic City, April, 1959). 2. modicum ”mate of the Convulsive The significance of high voltage There}?! l’fit‘eceae2 m delta activity in the convulsive therapy process (Ruth 213.1) 1951, 1957; Fink and Wm, 1957) and the report that this delta activity ministration (mate was blocked by the of the antteholinergic agents atropine and scepolamine and Johnson, 1957) provided the basis t‘or mane studies. As �- 8 a. there Here attendant unpleuent systemic etfeote with the comm-tre- tion of these agents, report: describing diethulne as an entioholmcrglc effects (Jenknor compound with potent neurologlc but mm manic and Loohner,19553 Lechner, 1956) 13+. us studies similar to those of Ulett and John-on using (Rink, 1956). These observations with diethacine this to mderteke compound lot to the investiga- tion of other experimental antichollnerglc agents. Clinical and electroencephalographic responses to the intravenou- adninistration of dicthaxine and atropine in plychntrlc patients at therapy were studied. Each The Win. 2299, is bemctyam, JD 318, dB 336 various: etegee of convulsion a potent antiohollnergic agent 121 um. eubjecte were ninety psychiatric patients referred for convulsive therapy, ranging in age from 18 to 67, with Wes. A total of 107 observations were rude, a. since variety of some subjects were studied with more than one compound. The observations were 8 channel made in the EEG laboratory ucing a standard instrument and needle electrodes. In each coupound under study was tual, the mastered intravenously at a set rate �-9 .. per minute until clinical behavioral oz- eleetrogrephic changes were observed. It was was observed that salinistrstion of these sntichonnergic agents associated with e) dosynchmmisstion of bloom of post-convulsive delta activity; EEG 1:) rhythms with s alerting, excitstory behavioral response with illusory, delusional end Mllucinatory mention, and c) systemic effects of muscular weakness, dryness of the south, dry skin and techycerdia. end systemic effects The electromfluc, behavioral were concurrent. These observations are regarded as consistent with the suggestion that the physiologic basis in central of, convulsive therapy nervous system cholmergic Observations that LSD, lies in an increase activity. substantive, nasceline sympathemnetic and antihistaminic agents - and diphenhydmmns also induced convulsive d‘ delta desynchronisation, blocking post EEG activity clinical oucitstory scfiviw support the suggestion that the and mvioral md electrogrsphio patterns of these compounds are also based on alteration in synoptic activity. Increased synaptic activity (cholinergic, synpethclytic effects) is sssocieted with - EEG Immora- synchreniseticn, and clinical sodation and euphoric; while decreased �.. 1o - synapmc activity (anticholimrgic, sympathmimtnc) is mandated with dosynchmniution and clinical excihtory and hallucinogmic EEG states, thus supporting the Wthesia mually described mama by Wilder (19514). algont, atropine, Deacrepant observations with the anticholinergic are considered to be related to significant differences in dosage. (Presumed, in put, San d‘ Biological Paymatry, the Society at first Francisco, 1958 and awarded tbs Award of that Society; and, in part, at City, 1959. Published, in part, 380-387, 19573 and accepted 3. Socio a. A. E. Bennett cal 01 A A 1. A American EEG PsycIfiItrio Research Somty, Atlantic Arch. Neural. & cMat. g9. for publiaation, ma Olin. Nemflmool.) shiatric Treatment ate of Duration at Hoggtaluation. Dawn and .' Madam Evaluation. In an earlier study of the Hillside Hospital populationmahn, Pollack birth :3: and Pink, 1957). it was noted social attitudes that age, causation, place of F California measured the by as were related to the aelecfim of therapy. Those pation‘ua older, had less education, scores on the F scale, who were were foreign-born am with high stereotype scales were more likely to waive convulsive therapy. �- 11 In oontmt, petiente I ‘ who were .. younger, better eduoehdmetiveobem end obtained it»: theeoree on the 1’" scale, received peyoheflmerepy ee their sole router treatment. nutty Another wee undertaken to determine the relations of theee eodepeyohologioal factore to 1) the duration of hospitalization, 2) the Meal evaluations at time of discharge, and 3) the final diegxoaia. The entire impatient edalt population studied. This oomieted on! maize in age from 16 to 171 68 patients, years, no: on March 7, 1957 was 57 men and 11]; mo, a median of 35 years. Patients hospitalized for the shortcut period (1 - 5 months) were noted to be the oldest, have the least education, were more likely to be foreign-hem, and have the highest scores on the “ scale. Younger, native-bum, more educated, loner months). (10 more the or longest each hoepitelieed ship of: F more patients The same these factors to length of hosmtelizetion was found eepehte Ienelyeee them F relation» when were made according to diagnosis and type of (eomleive thempy or peyohotherepy). �,' 12 u. Discharge evaluations of improvemnt were significantly related _ to age - the older patients having the most favorableratingm Miami! of the date by type of treetnent,hovever, demonstrated that among the oeuvulsive therapy patients rating: of recovered or much inproved were given to those patients with the highest F scores, least education and who were foreign-born. Diagnoses of schizophrenia or peyohomuroeie were undated with lower F eeoree, younger ages, more education and native birth. The older, less educated, femignnborn, high more F score patients were frequently classified as involutionel or mic—depressive psychosis. It was postulated that these relationships reflect the influence of nodal background and psychological proceeoee, such as the behavioral patterns of communication and modes of expression. These Thane not only oontflbute to the pattern of mental illness, but affect all aspects of the patientoflxerapiet interactim. (Pmeented at the Beaten: Psychological Association, Atlantic City g April, 1959, and the Acedm of Psychoanalysis, Philadelphia, April, 1959. Accepted for publication, Archives of General Psychiatg.) �.. 13 .. 13. Treatment. Convuleive with Social Attitude in Gwen: Following the earlier observations that the California is 1“ scale useful in understanding mien-a1 for ccnvuleive therapy and the evaluation of clinical reepcnee following such treatment, fizz-flier studies were undertaken with thieeeale in regard to the {alluring 1) iihet deal the F scale measure in a psychiatric question: a population? 2) Dc 1“ scores change with convulsive therapy? 3) Are these changes related to the degree of altered brain function? entire in-patient population of the heepital was given the The :16 one month scale, in later, was retested with a "reverse“ finch each statement wee changed The “reverse" scale as to the opposite or! F F scale, the original. scored in the same manner as the ccnventicnal scale, with high ecoree reflecting greater agreement. It was noted that than patient: who made low scores initially, showed an with the statements, disagreement indicating a wedcninant increase on the "reverse" scale, indicating a high degree of agreement. In contrast, patients the mde high scores little change on initially shaved same the to etatexunte the with agreeing reteeting, �.. m .. extent even thong: the nearing was reversed. let: P score patients are more critical and It is evident that diesflmimting persons , while those with high F scores are more undifferentietihg and stereotyped in their reactions. This aberration is related to the process or selection of patients for convulsive thmpy. thinking and commutation on! A high degree or sterotwpy of is incomtsble with the a conventional psychotherapeufic rehtionship, psychoanalyticslly—oriented psychotherapy stressed Hospital. It follows that the high F establishment meeting the at Hillside score patients will be unsuccessful in psychotherapy and most likely referred for con- vulsive therapy. In anotlmr study, sixtr-ndne patients were given the F scale berm, during therapy. Ten (st 10-12 treatmnt period) patients, selected at group and received subconvulsive mean increase in group a. F random, and after convulsive constituted a control electrostimlsuon. There was s. score of +5.7 during treatment in convulsive a difference significant at the 5% level. In contrast, the �- 15 In confines. the control group .. showed an insignificant change during the echo period (+0.5). The extent of increase in me convulsive petiefits was related to the degree of cerebral dysfunction es <1er by delta sctiflw on the m. The patients with my: d6“? (1:010: 3955 of the mp1” 1‘3“”) had a // l'hebe patientsvith mean ' increase e a ’8’6” f low delta indioes, however, off 43.14,. Following treatment the showed an increase 3 2/ 15’03&8tashv ,f 1/ / ”(7/ -/'4,7,3? ,. V ,2” / / ,. /"5 scores were comparable to the levels. ‘ , ‘ “these ,flndmgs support and eleborste previous observations on the [5%. ,2)" , 7752/ 1" cadets” e’f convulsive therapy. Greater agreement with the ,. scale ‘f std/Wes /} F during treatment show conventional stereotypy and 3" /r (35“:ow I _ 1n discrimineuon. Changes in F score thus parallel the fo’hehoteristio hnguege changes or increased denial, evasion, /// " , ,/,.L‘ ,r l7 //qdeiflicetlon, ' / / and use of cliches and stereotyped expressions (Kuhn ‘ j" & 2 Fink, i953) . It 1. .1“ ompmble to the increased difficulty in / / l / / cochlea: visual and tactile perception (Flak, fairs-groom discrimination j’(heseo1{;e§ at. Knhn (Karmic Fink, 1957). /flbyohletrlc Association, at the Divisions]. Meeting of the American 3' ‘81 I ‘- r {'1' 4" Karin, 1957) and the Eastern Psychological Association, 1958; and aeoepced for?" presentation ‘ 8: New York, November 1959.) �~16- h. Psychotherapy and thsicdzgamic Therapy: Previous studies indicated that patients referred for of electroshock in this hospital are/two types. The largest number are patients in the older education and are foreign born. age groups who have They tend to be limited non-introspective persons, stereotyped in their language and thinking and verbally unconnunicative. Their predominant symptoms are depression, agitation, withdrawal and somatisation. The second, and smaller, group of patients are younger, native-born, bettereducated, and verbally communicative with a capacity for introspection. They characteristically exhibit thinking disorders and overactive behavior, with lesser degrees of aonatisation and depression. Four patients, two for each group described above were studied to determine 1) reasons for referral, different attitudes management, and 2) whether were required in psychotherapeutic 3) the relation of the psychotherapeutic �-17. approach to the patient's clinical response to convulsive therapy. It was suggested that these patients were referred for convulsive therapy because of a failure of communication in the psychotherapeutic relationship. a In two cases this was reflection of the patient's limited verbal and introspective capacity related to educational and social factors. instances, however, the impaired communication by unmanageable was In two manifested acting out behavior. Following treatment, is older, less educated patients were able to maintain a behavioral change with a reassuring, supportive technique, amplifying tendencies to minimization and denial developed during electroshock. In the better educated patients, electroshock decreased acting out was associated with increased use of interpretive forms of psychotherapy. It uas concluded that the relationship of psychotherapy to convulsive therapy varies with the communication pattern �~18 - and adaptation shown by the individual patient. (Published in the Journal of Hillside S. Hos ital, 1: 17-25, 1958). Perception: A variety of perceptual-cognitive test procedures have been studied in l. patients receiving somatic therapies. Tachistoscopic Perception of Colored Figures: The Embedded This task was studied in an experimental group consisting of 35 consecutive referrals for convulsive therapy, and "control" groups of 20 patients treated with phenothiazine medication (thorazine and pronasine) and ten patients receiving no somatic treatment, matched for age. All subjects were tested prior to treatment, were and tested akhird time after four two weeks weeks the convulsive patients following the cessation of treatment. There was a number of there statistically significant increase in errors with convulsive therapy, was a significant decrease mean and following treatment, from the pretreatment scores. "Control” subjects made significantly fewer errors (practice �-19- effect). significant difference in errors between There was a patients classified as delta) when compared showing low with high EEG changes (per cent changes. EEG tine There were high retest correlations for all groups. There were marked individual differences in response patterns prior to treatment. With brain changes there was a reduction in perseveration, completion and confabulation in some patients, and an increase in others, with patterns attributed to cerebral dysfunction. patients with high pattern was EEG no unique 3V0“ in thOBO changes, the ”style" of his response maintained. Thus a patient showing completion type errors prior to treatment would continue to make such errors with convulsive therapy, although the threshold at which completion was shown might change. were Details of this study presented at the Eastern Psychological Association in Atlantic City, April 1959. 2. Rod and Frame Test gWitkinzs This task was administered to h? patients consecutively referred for somatic therapy. Marked �- 20 - with correlated age, were in performance individual differences education and score judgment of the frame (field on vertical was dependento were more frequently referred for No significant treatment. found with drug or convulsive convulsive groups It retest cerrelations change For both drug and were high (*.86 and +.88). is considered that individual differences Frame whose influenced by the surrounding strongly therapy. than drug convulsive therapy was Patients the California F.ecale. on the Rod and of importance are that factors test reflect personality in psychiatric treatment. B. PSYCHOPHARHAOOLOGIO STUDIES 1. Neuroghzsiologic Studies: view the of neurophysiologic~adaptive the to Acoprding convulsive therapy process, the clinical efficacy of repeated induced convulsions is dependent upon the induction of a providing function, nervous central in alteration persistent the with interaction the in subject's a milieu for changes examiner and the environment. In these studies the best been of those has aspects change of neurophysiologic index the electnoin by delta activity reflected function cerebral �enoephalogran (Fink and Kahp,1957). The efficacy of newer psychopharnaceuticals in altering psychotic behavior patterns has led to the suggestion of aI/fl ,1 1} similar hypothesis for the node of action of these agents{ and to studies of the relationship and specificity of altfired behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of an the psychophsrmaceuticals tested in acute experiments increase in syhchrony with or without an increase in slow wave and activity has been observed for chlorpromasine, pronasine triflupronasine. Behaviorally, these drugs were associated with a) increasing sedation,drowsiness, denial and euphoria; b) decreasing agitation, panic, excitement and delusional and hallucinatory activity; and c) minimisation and displacement or synptons. an Barbiturates regularly induced increase in fast activity with an increase in synchrony, with the associated behavorial changes of sedation, euphoria, denial and minimization. Amphetamine and methamphetamine increased fast activity without increased synchrony and behaviorally were associated with behavorial alerting, hyponania, �- - 22 excitement and increased motor activity. and per cent time of slow wave post-convulsive delta activity Decrease in voltage activity in subjects with was seen with LSD-2S, bcnactyzine, Win-2299, JB~318, JB~336 and diethasine. Of these drugs, benactyzine produced increased alerting, excitement, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional and paranoid ideation. The electrographic patterns were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, sedation and minimization of symptoms were concurrently associated with increased EEG synchronization and shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with desynchronisaticn of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorprcnazine and barbiturates, augmented the per cent tine delta activity and enhanced the clinical patterns; agents that desynchronized frequencies, as diethasine, LSD-25 �-23and benactyzine, minimized the clinical effects typically ascribed to repeated convulsions. Various experimental psychopharnaceutioala were tested. In addition to extensive studies or 3-3 methylethylgiutarimide (Heginide) and hexetluorodiethylether (Indoklon) the following nhsnyltoloxanine (PHD-Bristol), methenalide agents were studied: (BLH~lfll;lhristol), tropin-h-Ghlorhenzhydryl ether (WI-21h9, Wyeth), dinethylaninsethanel and verieties, Riker), JB-3;;, its oongeners (Deaner and 329 and 336 (various piperidyl- Geigy). and (Torrinil, Lakeside) inipranine bensilatss, significant behavioral Because or 31:31 changes, a was and electrogrephic intestigation of imipramine (Torrinil), nere intensive undertaken. In 28 acute experiflmenta, consecutive patients referred for physiodynnmie therapies were tested in the EEG TofrEnil solution of treatment. various stages at laboratory (10 ng/oc) was administered intravenously until electrographic or behavioral changes a total of h0-12S mg at a set rate (1 cc/ho sec) became prominent, (0.5-2.5 mg/kg). Behavioral observation for �«Zh- and In electrcgraphic recording continued for one to three hours. patients referred for pharmacotherapy because of manifest depressive, withdrawn or retarded behavior oral Torranil of 75-350 mg administered. was In the acute studies there was initial restlessness, associated with dissiness, dry mouth, “taintness,” nausea, and on tour occasions, voniting. These symptoms persisted for t 10-20 minutes, and were accompanied by lasdtude, heaviness of the extremities and eventual drowsiness. unchanged or slowed. Blood Heart rate was pressure dropped by in older (age>’ 60) patients. 20-ho% Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrcgraphic patterns accompanying these behavioral changes were initiated during the injection. had been halved. activity, such by a gradual By in decrease in voltages ten minutes, the per cent tine alpha In patients with moderate anounts of beta activity occasionally increased in voltage and �-25per cent time. twenty minutes, in association with By behavioral lassitude, low voltage (to theta frequencies (5—? 50 nicrovolts) random In records with post~ cps) appeared. convulsive delta activity, there was a marked decrease in voltage and per cent time of slow graphic patterns persisted for i wave to two There was considerable individual acute EEG of Torrinil, EEG who These electro- hours. variability in this received 100 mg or more all and behavioral changes were observed in In six patients, dosage of TorrEnil less than 50 but three. were In patients response. activity. associated neither with EEG mg nor with behavioral changes. In chronic Torranil studies, behavioral changes generally appeared during the second, and were maximal during the week of was treatnent. The most prominent euphoric denial. behavioral adaptation Patients complained less of somatic symptoms, and denied, minimized or displaced inquiry. It became lite relationships third, their illness on increasingly difficult to discuss significant with then. In six patients sonatisation and �restlessness increased and depressive affect persisted. In three, restlessness, agitation, excitement, insomnia and vomiting, led to the cessation of therapy. No change in sfgntons were noted in five patients after four weeks of therapy. Electrographio studies a decrease on chronic administration showed in voltages with poorer record modulation. voltage theta (S~7 cps) activity up to defined fast activity 10% r‘ became more p~ominent appeared. Low Well in a few. (presented at the Collegian Interantionale Neuro-Psychopharmacologicum, Rome, September, 1958) at the Conference on Depression and Allied States, Montreal, March, 1959] and American EEG Society, June, 1959; Published, in part, in the 3 Proceedings of C;I.N.P. Psychopharnaoology Frontiers, ed. 3. 9 Kline, 325-332, 19593 Canad. J. Neurologz, g} 682~685, 1958. Pe chiat., 1959 (in prose); �-272. Language Patterns as Resource of Behavioral and Nauroghzsielogic Change with Drugs. In previous studies of the convulsive therapy process, it was demonstrated that syntactic two language measures, a content analysis (Kahn and Fink, 1958) and dyadic diversification a scores or instructured interviews (Jaffe, Kahn and Pink, 1958) provided objective indices of behavioral change, and were related to the degree of altered brain function. "In a further test of these language measures as indices of behavioral and neurophysiologic change, they were applied to interview on ’ acute administration of various psychopharnacologic agents. Seventy-two interviews with patients at various stages of drug therapy have been analyzed, using the following agents: emobarbital, benactyzine, ohlorpronazine, diethazine, lysergie— acid diethylanide, and Win-2299. unFollowing a routine electrographic recording, an structured psychiatric interview, with short periods of {\‘\ structured inquiry, g was tape recorded. With EEG running, intravenouq injection was then given at a slow rate. When on �—28- specific electrogrsphic or clinical changes were induced, the interview was repeated. Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The shifts in (delta) The EEG was measured for changes in synchronization, dominant frequencies, and per cent time of slow waves and beta frequencies. tape recordings were transcribed and measured for the diversification of consecutive participants (dyadic) and for 25 word samples of speech of both syntactical changes. In the dyadic analysis, the pooled verbal behavior of both participants was transcribed, divided into 25 word samples, and for each sample the ratio of the number of different words to the words (a diversification score) was calculated. total The number of syntactic langw ge analyses were based on the response to standardized questions using a method previously described (Kahn and rink, 1958), scoring such changes as syntactical use of person, alteration in tense, evasion, qualification, displacement or verbal denial of symptoms, use of stereotyped expression or cliches, cryptic �-29withdrawal and or response, silence. the both dyadic observed in were changes Consistent diversification classified and syntactic language neasurss in subjects behavioral and according to the neurophysiologic effects of the drugs applied. neurophysiologic are and chlorpronasine Ancbarbital high inducing regularly imobarbital synchronising agents. at activity fast synchronised voltage well chlorpronasine administration synchronisation of the EEG was 20¢2h cps, while increased folloudd by record and a shift to slower occasional slow including frequencies wave burst activity. sedation and with associated Behaviorally these drugs are tranquilisation. in stereotpy and On increase was an there measures the language with increasing associated repetitiveness displacement in and-evasion. cliches, tense, alterations of use Diethasine, benactysine, LSD—25 and Wine2299 areheuro» compounds. desynchronizing physiologic These drugs are and decreased per voltage with associated characteristically �-30- cent tins of alpha activity and increased irregular low voltage fast activity. or Behaviorally hallucinatory, exoitatory illusory activity are observed. there was On the language measures decreasing repetitiveness, wide diversity of words, less variability of diversification scores, and decreased use of cliches and alterations in tense. Further explaation of language neasures are suggested as a rational basis for the understanding of the psychologic effects of the new therapies. (Presented at the Conference on Peychodynanio, Psychoanalytic and Sociologic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April, l958, and at the American Psychiatric Association, Philadelphia, April, 1959. 3; To be published). Aspects of the Therapist-Patient Relationship Affed ting ” Choice of Therapy. The selection of therapy involves aspects other than the manifest behavioral patterns of the patient. In the past year further efforts to clarify this problem have been undertaken, emphasising factors in the therapist-patient relationship. We �-31have hypothesized that frustration therapist-patient relationship and and hostility in the implicit or explicit environmental pressures have a significant influence in referral for somatic therapy. In a and pilot study 76 structured interviews with residents supervisors were initiated following requests for sonato~ therapy. these interviews were designed to elicit the basis of the referral. It was there a sudden change in the patient's clinical status which vas found that in only directly led to the referral. In relatively few cases most instances there had been no change or progression in the presenting symptoms. Factors contributing to the timing of the referral included impending discharge, avoiding administrative discharge, and pressure tron the patient's fanily or ward personnel. It was also noted that patients with similar behavior patterns were treated differently, sons given eonatctherapy and others none. The reasons for this ranged from ”thin" to quantitative differences in syntonatology and individual preferences for type of treatment. �-32- It was concluded that factors other than clinical indication played a role in the referral in a significant number of cases. These the timing of the As a extraneous factors also influenced referrals. result of these findings Referral Sheet" was developed be completed by the requested. same From a ”Sonatic Treeteent (see for: at end of report) to therapist ehenever somatic therapy is this questionnaire and continued and ward personnel interviews we hope to obtain therapist further infernation regarding indications for somatic treatment, more specific data concerning the therapist-patient interaction, and a more definite idea of the therapist's expectations for such treatment. �Soptonbor 1, 1959 A an»- « FINAL REPORT H~927* ’ Doportmont of Exporinontnl Psychiatry HILLSIDE HOSPITAL Glen Oaks, L. 1., N. I. Aoknowlodgnont Summury, Five Yours, 195k - 1959 Summary #h, Feb. 1, 1958 - Sept. 1, 1959 Publications, 195h - 1959 Prosontationl, Initial studios 19Sh ~ 1959 a. b. 2S 30 bogun 1:11 1953, supportod by tho Board of Diroctora' nooonroh Fund. Supported by Nationul Institute of Mental Honlth Fund, Soptombor l, 195k - August 31, 1959. Study continuing with support of grant MI-2715, United Statos Public Health Sorvico (Jan. 1, 1959) �Acknowledgment studies reported here would not have been possible without the faith and support or the Founder at Hillaide Hospital, Dr. Iorael Strauss, the Board of Directors and tho Administrator, Hr. Maurice Bachraoh, who auetained this program during its early vicissitudes. Financial Support was also given during this period by the Kaufman Foundation, the Foundatione' Fund for Research in Psychiatry, the Daaian Foundation of New fork; the following pharmaceutical firms: Smith, Kline and French Laboratoriea, Wyeth Laboratories, Geigy Pharmaceuticals, and Bristol Laboratories; and the Mental Health Board of Nassau County. The �SUMMARY 14-927 19Sh - 1959 laboratories of the Departnent of Experimental Psychiatry were established at hillside Hospital in September, 195k. During this five year period neurophysiologic, psychologic (personality and perceptual), lingustic, and socioloéic aspects of "somatic" psychiatric therapies have been the principal foci. The 1. Convulsive Therapy: The view of the convulsive therapy process as the induction or a non-specific state or altered brain functbn, similar to. craniocerebral trauma (10, ll, 21) was supported and amplified with this altered cerebral milieu, subjects were seen to respond in various ways (26) of which the most successful was explicitf verbal denial (7, 31). This latter was most prominent in characterologically disposed individuals (36). in alteration in brain function was pro-requisite to behavioral change (7, 8, 11, 26). Grand mal seizures were this to essential process (26) but electrical induction was not (Boh2). Such alteration in brain function was measured by various ways including electroencephalography (6, ll, 12, 2h, 39, language patterns (h, 7, 1h, 31, h}, B-Zh), perceptual tasks (2, 16, 17, 37, hé, 8-26, h1, h?) and tests of recall. A variety of behavioral changes were seen during convulsive therapy (26, 8—17). Such patterns were lbwed as adaptations to altered brain function,wand were believed dependentlupon Refcrbnce nunEers are to publications or presentations (5- I listed in the appendix. �characterologic and environmental factors (7, 25, 26, 36, ho). Clinical ratings of improvement were seen as value Judgments by the observer of the behavioral changes in the subject (26). Adaptations characterised by denial mechanisms, both in behavior (3—17) and in language a, 31) were assessed with the best rating of improvement. Such adaptations were noted to be related to habitual nodes of conduct (character, personality) (36, Bull, ‘ 32). durability of the altered behavioral nodes was seeh‘. to be dependent upon such factors as the degree and duration of altered brain function, the environnental expectations, and the type and degree of family and medical support. Different behavioral patterns were best supported by varyinc types of The psychotherapy (19). It also suggested that the neurophysiologicgbasis or convulsive therapy nay lie in an alteration in central synaptic cholinergic ~ adrenergic relationships, with a predominant shirt to increased cholinergic activity as the operationally significant pattern. Such interpretations were based on the relationship of high voltage EEG slow wave activity to behavior! change (6, ll, 26) and the blocking of the electrographic and behavioral changes in central anticholinergic agents (21, 3h, 35 hl, ht) and by central synpathonimetics (ha). Heasures of linguistic behavior in structured (7, 31) and unstructured (1h, 29, B-2h) interviews showed characteristic was �- 3 - alterations towards increased denial, minimisation, displacement, stereotypy and repetitiveness, related to the degree of altered brain function (B-Zh). These changes were blocked or reversed by anticholinergic hallucinogens (21, h3). Various perceptual tasks provided indices of behavioral change and were related to the degree of altered brain function. These included the perception of simultaneous tactile stimuli (17), snbedded (Gottschaldt) figures (37, 8-16), and tachistoscopically exposed words (37) and embedded color figures (hl). Sociopsychologic aspects of age, years or education, nativity and degree of stereotypy and sonventionality (measured by California F Scale) were also studied and were related to selection or therapy, duration of hospitalization, diagnosis and treatment response/ in hospitalized patients (15, 36, ho, hS). 2. Neurophysiolegic~Adaptive Hypothesis of Somatic Therapy. Based on these studies, a hypothesis of the node of action of other psychiatric therapies such as insulin coma, leucotony and psychotropic drugs, was expressed (10, 33, 38). This view holds that these therapies are also methods of inducing varying states or altered brain function, in which varying adaptive patterns may become prominent. The adaptive pattern is viewed as dependent upon the type, degree and duration of altered brain function, the personality of the subject, and tolerances and expectations of the environment. Examination of this hypothesis as applied to drug therapies is now in progress, supported by USPRS grants HI-2092 and HI-2715. �Insulin Coma Therapz. in initial case description (3) showed the significance of denial patterns and persistent altered brain function to the behavioral change in this form of therapy. In an insulin cons - chlorpronazine control study (27), no differences in hospital improvement ratings were observed in the two treatment groups. Chlorpronazine was safer, easier to administer, permitted continued adninistration and allowed for greater degrees of concurrent relationship therapy than insulin coma. These observations led to a replacement of insulin come 3. by psychotropic drugs in h. this institution. Pharmacotherapz. Also derived from these hypotheses is the ongoing program in evaluating various psychopharnaceuticals. Electrographic and linguistic analyses of effects of acute intravenous administration and chronic clinical administration of various are in progress. EEG patterns, along such continua as synchronisation~desynchronisstion, and frequency shift are being related to behavioral (21, 3h, bl, ha) and linguistic changes (21, h3); The neurophysiologic basis of experimentally induced hallucinogenic states have also been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (h2). Initial work on this hypothesis ( ) is now being expanded. new compounds �.32.. In addition to these phenomena, other patterns of language and non- verbal aspects of behavior have been observed which can also be understood as symbolic forms of adaptation to illness. These include the syntactical use of the second and third person, changes in mood, withdrawal and selective inatten- tion, and alterations in sexual behavior (6). in enduring fashion in patelectroencephalographic records indicated diffuse cere- These types of behavior have been observed ients whose lesions and bral dysfunction; In patients with brain damage who did not Show delusional denial and disorientation on ordinary clinical examination, the phenomena might be elicited in sodium. an interview following the intravenous administration of amytal This observation furnished the basis for the ”amytal test" for brain disease in which the persistence of certain patterns of denial and disorient- ation is considered an indication of cerebral dysfunction (h,5). In considering further the relationship between brain damage and the mechanism of denial it has been demonstrated that the premorbid personality important in determining what type of symbolic adaptation occurred. Thus, was pat- ients with the most striking and enduring manifestations of anosognosia were those who had habitually used verbal denial and rationalization as a means of coping with On their problems (10). the basis of these observations the hypothesis was developed that the of creation the convulsions in induced lay of action electrically therapeutic a milieu of brain function in which the patient might express his problems in symbolic fashion, particularly in the form of explicitly denying them. A case reported in which a patient received electroshock treatment in an attempt to relieve intractable pain associated with a Spinal cord tumor (11). After was a number of treatments, coincident with the appearance of disorientation for state, the patient dennot clinically apparent they a place and time, paraphasic misnaming and a euphoric ied pain. ‘dhen these associated.phenomena were � 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 Research Files and Unpublished Works 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 Relation Between Altered Brain Function and Denial in Electroshock Therapy (research), 1955-1959 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-2-002 Date A point or period of time associated with an event in the lifecycle of the resource 1955-1959 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 <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: research with Robert L. Kahn, and Edwin A. Weinstein 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 Research