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Prognostic Application of Psychological Techniques in
Convulsive Therapy
Robert L. Kahn Ph.D. and
From
Max
Pollack Ph.D.
the Department of Experimental Psychiatry, Hillside Hospital,
L.I., N.Y.
Aided, in part, by grants M-927 and MY-2092 of the National
Institute of Mental Health, National Institutes of Health, U.S.
Glen Oaks,
Public Health Service.
Read at the Eastern Psychiatric Research Association,
October 25, 1958.
IV: 10-2h-58
New
York,
�Prognostic Application of Psychological Techniques in
Convulsive Therapy
One
of the more important
clinical applications of
psychological testing techniques is the prediction of the
has
there
In
treatment.
in
particular,
results
psychiatric
been a considerable effort to determine valid psychological
The
to
results
somatic
the
for
therapies.
criteria
prognostic
date, however, have not found clinical acceptance.
Using the Rorschach, for example, Rabin (1) has stated
that ”single Rorschach factors cannot serve as indices or as
has
Piotrowski
In
contrast
of
improvement."
predictors
published a number of papers on the prognostic use of the
Rorschach in insulin coma and convulsive therapy (2, 3, h, S, 6).
Unfortunately, his criteria, as reported in successive papers,
are vague and contradictory. In l9h1 he reported six explicit
prognostic signs which were applied in predicting clinical
months
the
termination
of
several
after
a
over
period
response
of treatment. But Rees and Jones (7), in a study of schizophrenic
found
somatic
that
of
a
therapies,
receiving
variety
patients
Piotrowski's signs were related to the results on a chance basis
only.
The differences in the studns of various investigators
can be accounted for by methodological variables. These
variables include factors of population, number of patients
observed, the method of analyzing data, the kind of somatic
therapy utilized, and the criteria for evaluating improvement,
�-2made
in
evaluation
is
which
the
clinical
time
the
at
including
incon—
Another
for
basis
treatment.
of
relation to the course
sistent results may be the lack of an adequate theretical
framework.
in
been
have
we
engaged
several
years
past
These
were
studies
convulsive
of
therapy
the
process.
studies
mode
action
of
the
concerning
a
to
hypothesis
test
initiated
of convulsive therapy which was derived from observations on a
hypothesis
of
the
to
brain-damaged pepulation. According
Weinstein and Kahn (8, 9) the therapeutic effect of convulsive
function
brain
of
altered
the
induction
to
therapy was related
of
symbolic
a
new
type
for
conditions
the
creating
necessary
adaptation, mainly denial, in characterologically disposed
shown
altered
that
have
Our
already
studies
previous
persons.
change
behavioral
for
condition
a
function
is
brain
necessary
(10, 11) and that the manifestation of denial language patterns
with treatment is related to the evaluation of improvement (12).
The purpose of the present report is
l) to summarize the
the
and
demonstrate
2)
to
on
personality factors,
findings
application of these findings as prognostic criteria for
convulsive therapy.
For the
�Method:
studies were conducted at Hillside Hospital, a
non-profit, voluntary, mental hospital, admitting patients
who are considered as having early and curable illnesses.
Psychotherapy is the principal treatment employed, with
somatic therapies available when needed. The material presented was collected in a series of studies during a period of
three and a half years. While a total of 180 patients have been
investigated, varying numbers were tested with each of the
techniques of personality evaluation. The patients ranged in
age from 20 to 66, with a median of hS, and included twice as
These
many women as men.
All patients received convulsive therapy administered
three times a week, using either a Medcraft alternating current
instrument or a Reiter C-h? electrostimulator. A minimum of
12 treatments was given, with the total course determined by
the supervising psychiatrist in charge of the convulsive therapy
unit. All psychological procedures were adminstered in the
week prior to the start of treatment.
The determination of the patient's response to treatment
was based on the medical director's evaluation at the time of
discharge, usually within six to eight weeks following treatment.
�Procedures and Results:
1.
Family Interviews.
According to the original
theory, it was considered that persons showing characteristics
of the "explicit verbal denial" personality, as described by
Weinstein and Kahn (13) would be most likely to show a behavioral change rated as improvement following treatment. This
was tested in a standardized interview with members of the
patient's family, eliciting information on the patient's
attitudes, mode of communication and reactions to stress.
Fifteen areas of behavior considered to be related to denial
tendencies were scored from the interview material. A score
of O, 1 and 2 was given for each item, depending on whether
the designated behavior was minimally, moderately or markedly
shown. The sum of the scores thus obtained was used as the
denial score.
The relatives of h? patients were interviewed, and
denial personality scores ranged from O to 25, with a median
of 11. The patients were divided into two groups: those with
scores from 11 to 25 were classed as "high denial," and those
from 0 to 10 as the ”low denial" group.
results of this analysis were significant, showing
that of the patients with high denial scores, 58% were in the
much improved group and only one patient was unimproved. Of
the patients with low denial scores, on the other hand, only
The
30%
were much improved and an equal number were unimproved (1h).
�-5-
results based on family interviews
felt that our conceptions of prognostic
Although these
were promising,
we
personality factors could be extended and made more amenable
to practical application by the use of standardized psycholog-
ical procedures.
For this purpose the Rorschach test
2.
The
Rorschach Test:
We
used.
have obtained Rorschach
was
protocols in 87 patients receiving convulsive therapy. The
&
of
the
to
records were scored according
Klopfer
criteria
Kelley (15). Only those components were analyzed which were
considered related to the personality aspects under study.
It was found (16) that the much improved patients had
significantly fewer total number of responses, and a significantly
greater per cent of whole and form responses than did those
The
who
rated
as
unimproved.
were
stereotypy and
patients
limited imaginative capacity of the much improved patients
was also shown by their giving a greater percentage of popular
responses, with little diversification of content categories.
They were less likely to have any kind of shading response.
Those patients who had human movement (M) responses had the
poorest clinical responses, while those with no movement of
any kind had the best results. With respect to color, an F6
response was associated with a poor clinical result, while those
with no color at all did very well.
Combining some of these factors tended to sharpen the
differentiation in terms of outcome. Thus, of those who had
�.6.
In
much
improved.
as
rated
both
M
much
66%
improved
FC,
were
with
nor
neither
those
of
contrast,
and only one patient was unimproved.
We have converted these results into prognostic criteria,
M
and FC, only
as shown
in Table
I.
17%
In one column are
listed those
Rorschach
closely related to a favorable
In the other column are those factors which are
factors which have been
prognosis.
were
most
For
example,
outcome.
unfavorable
clinical
of
an
prognostic
67%
much
were
of those patients with ten or less responses
16
more
with
or
those
of
28%,
responses
however,
Only
improved.
had a good
result.
�TABLE
I
Prognostic Rorschach Indices of ImErovement
Favorable Prognosis
%
Unfavorable Prognosis
Much
%
Ingroved
Improved
of Responses
Number
Movement
Color
F
and
FC
less
(67%)
16 or more
(28%)
present
present
(28%)
None
(63%)
M
No FC
(60%)
FC
-
75
a:
Shading
M
10 or
~
100
None
Much
(21%)
(59%)
o - 59
(27%)
(58%)
Present
(33%)
Neither Present
(66%)
Both Present(17%)
�’8-
It
should also be noted that comparison of post treatment
Rorschach records with those obtained prior to treatment failed
to show any significant change. This confirms similar observa-
tions by others (6, 17, 18, 19) and indicates that the Rorschach
pattern is probably a reflection of the basic personality rather
than transient aspects of the disease process.
3. Social Attitudes: The F Scale. While these Rorschach
results amply confirm the concept of the relation of personality
factors and results of treatment, further data was obtained in
application of measures of social attitude such as the California
F Scale.
This scale, originally developed in studies of ethnOa
centrism and authoritarianism (20) has been increasingly used
in the study of more central psychological processes. In our
laboratory the F Scale has been regarded primarily as a reflection
of stereotyped thinking and communication. It has been observed
that patients who receive convulsive therapy at Hillside Hospital
P
scores than those given psychotherapy
higher
significantly
alone (21).
In these studfls a ten-item modification of the F Scale
(22) has been used. The test is rapidly administered, taking no
longer than 10 minutes in most cases. The subject reads 10
ambiguous statements and indicates whether he agrees or disagrees
with each statement, and to what extent. The score given for
each item ranges from one to seven and the range of total scores
is 10 to 70. The greater the agreement, the higher the score
have
�-9-
statements themselves are extreme, conventional
or stereotyped expressions. For example, one of the statements
is: "If people would talk less and work more, everybody would
obtained.
be
The
better off."
This
test
patients prior to
score of ho as a cut-off point,we
has been given to 96
convulsive therapy. Using a
found that of those patients with scores of ho or more 71% were
rated as recovered or much improved. In contrast, only 36% of
those with scores below ho were so rated. In general, the
higher the score, the better the clinical result.
We have also tested an additional 13 patients, referred
for convulsive therapy, but who either refused treatment or
terminated it of their own accord prior to completion. Of
these, eleven had F scores below ho, an observation consistent
with the general expectation that such persons haVB a poor
response to convulsive therapy.
�-10-
Discussion:
These observations have shown
that in the course of the
investigation of theoretical problems of convulsive therapy,
certain standard psychological procedures have provided data
which is significantly related to the therapeutic outcome. This
data can now be applied to the practical problem of clinical
prognosis.
that
favorable improvement rating is given
to those patients who develop euphoric, hypomanic or denial modes
of adaptation following treatment (23). Such behavioral change
is most likely to occur in persons whose premorbid personalities
may be characterized as non-empathic, non-introspective, nonverbally communicative and highly conventional and stereotyped
with little imaginative or creative capacity (1h). On the
Rorschach prior to treatment these patients give few reaponses,
fail to show human movement, shading or integrated color responses
(F0) and have little variety of content. 0n the F Scale, their
scores were apt to be over b0, showing a high degree of stereotypy in their communication.
In contrast to such patients, others are either unchanged
by convulsive therapy or develop such modes of reaction as panic,
paranoid behavior, or increased somatic concern, such as
We
have found
a
complaints about their memory. These patients are rated as
unimproved. While this latter group of patients showed diverse
patterns in their premorbid personality characteristics, they
were more apt to be imaginative, introspective and less stereotxnd
in their communications. On the Rorschach they gave human
�-11movement, integrated color and shading responses, and were more
On
good
than
the
prognosis patients.
diversified in their content
the F Scale their scores were most likely to be under ho.
finding that meaningful prognostic criteria can be
derived on the basis of personality constellation rather than in
terms of nosological entities has important implications. For
one thing, this conception leads to the use of further psychologSuch
application is
for
prognostic
ical techniques
purposes.
laboratory
Secondat
Hillside
under
in
Hospital.
our
way
currently
mental
of
increased
an
understanding
derive
to
is
possible
ly, it
disorders, their management and prevention. Thus, we have previously noted (1h) that the same personality factors which are
related to a good prognosis with convulsive therapy, are etiologof
of
psychiathe
certain
types
development
in
important
ically
tric disorder. Studies of patients with psychiatric depression,
for example, demonstrated a prominence of premorbid personality
patterns characterized by the inability to communicate verbally
(2b), and rigidity and lack of imagination (25). Such persons
and
verbal
conventional
to
techniques
are generally refractory
require non-verbal therapeutic techniques. It seems that the
same personality factors which make a person responsdve to nonverbal forms of therapy are involved in his susceptibility to a
depressive reaction. The same stereotypy and conventionality
which lead to a catastrophic response in the individual faced by
the sudden loss of a job or close relative, permit the develop-. t
ment of denial, minimization and displacement under the conditions
of altered brain function and are considered "improved" by the
family and the therapist.
The
�-12-
that in the course of investigation of
theoretical problems of convulsive therapy, certain standard
psychological procedures have provided data which is
significantly related to the therapeutic outcome. This data
can now be applied to the practical problem of clinical
We
have shown
prognosis.
On the Rorschach test, those patients without human
movement, shading or integrated color (FC) responses, few
total responses,
and with
little originality
or variety of
content have the best prognosis. On the F Scale, a score of
less than no is prognostic of a poor clinical reaponse.
The theoretical conception developed in these studies
leads to the application of additional psychological techniques
for prognostic purposes, and to an increasing understanding of
the etiology of psychiatric syndromes with its implications
for management and prevention of such disorders.
�-13-
W
REFERENCES
1.
Rabin, A.I.: Effects of Electric Shock Treatment Upon
Some Aspects of Personality and Intellect, Am. Psychol.
23 28,4,
19b7o
5'1
Rorschach
the
of
Possibilities
Z.:
Prognostic
Piotrowski,
Method in Insulin Treatment, Psychiat. Quart. $3:
679, 1938.
3.
Piotrowski, Z.: Rorschach Manifestations of Improvement
Med.
Psychosom.
in Insulin Treated Schizophrenics,
508’ 1939.
6.
l:
A
the
Device
for
Experimental
Z.:
Single
Piotrowski,
in
Prediction of Outcome of Insulin Treatment19h0
Schizophrenia, Psychiat. Quart. lg: 26?,
Aid
in
Method
a
Prognostic
Rorschach
as
2.:
Piotrowski,
the Insulin Shock Treatment of Schizophrenics,
19h1.
807,
Quart.
lg:
Psychiat.
Effects
N.D.C.:
Z.
and
Lewis,
Piotrowski,
B.L.,
Pacella,
of Electric Convulsive Therapy on Certain Personality
10h:
Am.J.
in
Psychiat.
Traits
Psychiatric Patients,
83, 19h7.
An
Rorschach
of
the
A.M.:
Evaluation
Jones,
Test as aPrognostic Aid in the Treatment of
Coma
Therapy, Electronarcosia
Insulin
by
Schizophrenics
&
Leucotomy, J. Ment. Sci.
Therapy
Electroconvulsive
Rees, W.L. and
21:681, 1951.
Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During
Electroshock Therapy: Its Relation to the Theory of
Shock Therapy, Am. J. Psychiat. 109: 22, 1952.
Weinstein, E.A. and Kahn, R.L.: Denual of Illness:
Symbolic and Physiological Aspects, Springfield, Ill.
C.C. Thomas, 1955.
10.
11.
12.
of
M.
E.A.:
Relation
and
Weinstein,
Fink,
R.L.,
Amobarbital Test to Clinical Improvement in Electro&
1956.
23,
Neurol.
Arch.
shock,
lg:
Psychiat.
EEG
M.
of
Delta Activity
and
Relation
R.L.:
Kahn,
Fink,
to Behavioral Responses in Electroshock: Quantitative
&
1957.
516,
Neurol.
Arch.
Psychiat.1§:
Serial Studies,
Kahn,
Kahn, R.L. and Fink, M.: Changes in Language During
Electro-
shock Therapy. In Psychopathology of Communication,
&
New
Grune
York,
Roch, P. and Zubin, J. Eds.,
Stratton, 1958.
�~1h—
13.
Factors in
Weinstein, E.A. and Kahn, R.L.: Personality
&
Neurol.
Arch.
Denial of Illness,
Psychiat. Q2:
355, 1953.
Personality Factors in Behavioral
Response to Electroshock Therapy, Conf. Neurol. (in
press).
Kahn, R.L. and Fink, M.;
New
The
Rorschach
D.:
Technique.
Kelley,
Klopfer,
York, World Book Co., 1§E§.
Kahn, R.L. and Fink, M.: Prognostic Value of Rorschach
Criteria in Clinical Response to Convulsive Therapy.
Paper read at Electroshock Research Association
meeting, San Francisco, 1958.
Beck, S.J.: Effects of Shock Therapy on Personality as
Shown by the Rorschach Test, Arch. Neurol. & Psychiat.
fig: h83, 19h3.
Kelley, D., Margolis, H. and Barrera, S.E.: Stability of
the Rorschach Method as Demonstrated in Electric
Convulsive Therapy Cases, Rorsch.Res.Exch. 5: 35, 19b1.
B. and
16.
17.
18.
19.
20.
21.
22.
23.
Kisker, G.W.:
A
Projective Approach to Personality Patterns
During InsulinéShock and Metrazol-Convulsive Therapy,
&
Soc. Psych. 21: 120, 19h2.
Abn.
J.
Adorno, T.W., Frenkel-Brunswick, E., Levinson, D.J. and
New
The
York,
Authoritarian
R.N.:
Personality,
Sanford,
Harper, 1950.
R.L., Pollack, M. and Fink, M.: Social Factors in
the Selection of Therapy in a Voluntary Mental
HOSpital, J. Hillside Hosp. g: 216, 1957.
Levinson, D.: Personal communication.
Fink, M. and Kahn, R.L.: Behavioral Patterns in Induced
States of Altered Brain Function. Paper read at
Divisional meeting, American Psychiatric Association,
Kahn,
New
York, 1957.
.
A
a
A.
N
a__.....
..-
Cohen, M.B., Baker, R.G., Cohen, R.A., Fromm-Reichmann, F.
and Weigart, E.V.: An Intensive Study of Twelve Cases
of Manic-Depressive Psychosis, Ps chiatr , 11: 103,
195h.
.A-aL.......;.—..M.u
~.~
,
i
Hamilton,
D.M. and Mann, W.A.:
Hospital Treatment of
In Depression, Hoch, P. and
&
Involutional Psychoses.
Zubin, J. Eds., New York, Grune
pp. 199-209-
Stratton, 1952,
j
5
E
t
i
2
1
s
�
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