65 100 6561 http://exhibits.library.stonybrook.edu/mfp/files/original/af740e98144d028e26e5fec2d40615a4.pdf afc1227c0db6f6fb5249948d79152e7a PDF Text Text September 11, 1993 Mr. Ivan Schick ElCoT 14 East 60th Street; Suite 1207 New York, NY. 10022 Dear Ivan, I had a very ﬁne lunch with Dick Glabers and Bob Ewing (we met at the Mirabelle, our **** restaurant near my home). Their questions were mainly about the present status of ECT as a practice; the impact of health care changes on ECT practice; the relative strengths [and weaknesses] of the present devices and their manufacturers, and the [my] experience with the ElCoT devices. I do not know whether I was of some help to them (or to you), but we did agree that if another device were to come to market, the manufacturer (or the manufacturers together) would probably need to develop an educational program for both psychiatrists, generalists, and the public on ECT in order to expand the market for ECT devices. In any case, we missed you. Call me when you return from Turkey and we can discuss their ideas. My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Schick, Ivan Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-3-059 Date A point or period of time associated with an event in the lifecycle of the resource 1992 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/964043eb5c74c880746dacee6aa2e41d.pdf 280f38fdab93d25ae0e7170ee5b995d3 PDF Text Text July 8, 1993 G. Northoff, M.D., Ph.D. Zentrum der Psychiatrie Klinikum der Johann Wolfgang Goethe-Universitat Heinrich-Hofmann—Str. 10 6000 Frankfurt am Main 71, Germany Dear Dr. Northoff, In response to your letter of June 17: We occasionally appoint Fellows for post-residency training and research. These appointments are usually made from our own graduates, but about half the positions are given to trainees from other programs. For those interested in clinical research, we require the satisfactory completion of the ECFMG examination, and a visa which will permit the candidate's stay in the US. This is usually the J-1 Visa which is issued on the request of the University. A letter of application, accompanied by a copy of your curriculum vitae, and a statement of your ECFMG status (Passed, date; or, scheduled examination date) will start the application process. The letter should indicate the date on which you anticipate a willingness to begin training, the duration of your willingness to take such training, and your social status (married or single) and dependents. We are actively involved in research in catatonia. These are under the supervision of my associate, Dr. Andrew Francis. Our prospective study of incidence and our rating scale developments are being written for submission for publication this summer. We are continuing these studies and are developing a prospective study of the biology of catatonia. We hope to have a protocol completed and submitted for funding by the early fall. Thank you again for your interest. Let me know how we can be of ﬁirther help. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Northoff, Georg Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-3-063 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/f4bfefb992926dc24c5f8bd09be5e9c4.pdf 78533c571fbfffc39d49f8153797e237 PDF Text Text June 16, 1993 Markus Gastpar, MD. Direktor der Klinik ﬁir Allgemeine Psychiatrie Hufelandstrasse 55 4300 Essen 1 Germany Dear Markus, It was good to see you again in San Francisco. As the enclosed preprint will show, I took your advice and asked my co-worker to complete her report which will now be published in the September number of Convulsive Therapy. I thought you would like to see a copy before it is printed. Our experience with maintenance ECT continues, and for the most part, we now believe that such continuation treatment is an important addition to our treatment program. My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Gastpar, Markus Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-3-064 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/48af4534c3a2bc3e83f79ce50305e8cf.pdf 191dfe5261fafd5409e7babc426b1215 PDF Text Text % m/ﬂ June 16, 1993 Robert T. McQueeney, MD. 1110 Tenth Avenue Menominee, Ml 49858 Dear Bob, Thank you for the copy of your letter to John Greden. The request is rather clear, but to whom do you wish his comments sent? Is it to you? Attached is another such note, addressed to you, which you may submit to the appropriate boards in Michigan. Good luck in your efforts. My regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: McQueeney, Robert T. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-3-065 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/3c2cd7e05377ae12e1e4211cc3d65041.pdf 6eb46b31eaf8c79a975795ecf12265bf PDF Text Text June 10, 1993 Dr. John Little H&CS Lakeside Hospital Gillies Street PO Box 63 Ballarat 3353 Victoria, Australia Dear Dr. little, It is not clear why you sent the proposed guidelines for ECT to me. The best U.S guidelines are those proposed by theAmerican Psychiatric Association Task Force in its 1990 report Electroconvulsive Therapy: Recommendationsfor Treatment, Training and Privileging (APA Press, Washington DC.) or the 1992 text written by Richard Abrams (Electroconvulsive Therapy, Oxford University Press, 1992). Both contain the present consensus in the US. regarding all the questions you summarize in your report. I attach some speciﬁc comments on your document, which may be idiosyncratic with me and my team. There is no experience to warrant or justify any speciﬁc decisions regarding pulse width or frequency in treatment efﬁcacy. Swartz makes claims about duration, arguing that some brief pulse trains at 4 to 8 seconds are more eﬁ‘icient (more effective?) than the short trains of the MECTA. There is evidence that total energy (mC) is a factor in efficacy when unilateral electrode placement is used. For my part, we are dedicated to the THYMATRON device which allows changes in energy and duration. When we use the MECTA device, we use the SR—2 as the more facile of the MECTA devices. In the US, it is no longer acceptable to undertake ECT without EEG monitoring; we would no more think of unmonitored ECT than we would think of unmodiﬁed (no anesthetic) ECT. �Page 2 I have not been to Australia, and would probably be pleased to come if the arrangements were suitable. Much of what I know about modern ECT comes from articles in Convulsive Therapy, the quarterly journal now in its ninth year of publication. I do not think you know it in Australia -perhaps you could subscribe and educate your peers. Sincerely yours, Max Fink, MD. Editor �Page 3 Electroconvulsive Therapy: A Medical Guide page 1: In discussing theories, why not cite the neurohumoral and the GABA-ergic hypotheses? These are detailed in Convulsive Therapy (vol 5, #3, September 1989). page 2: Why is catatonia cited among both psychiatric and non-psychiatric reasons for ECT? And what makes the non-psychiatric 'controversial'. For catatonia, if benzodiazepines are not effective in a few days, ECT is clearly justiﬁed even in catatonia secondary to systemic disorders (lupus, typhoid, NMS). The contraindiCations are not consistent with the APA discussion. We no longer accept any absolute contraindication. We now approach each case with a risk/beneﬁt analysis, and if ECT is commanded by the psychiatric conditon, no systemic condition is seen as a contraindication. page 3: ECT was not the ﬁrst effective treatment for mental illness; it was believed to be effective for dementia praecox and that was its novelty. Inanition and manic delirium are conditions that should be added to the list. We would not accept the statement that the anesthetist decides whether a patient is ﬁt for ECT. That is the psychiatrist's decision; the anesthetist is to do his best with what is given to him, much as he has to do with traumatic or non-elective surgery. (When ECT is compelled by a patient's illness, it is not elective.) page 4: It is too sanguine to say that permanent brain damage does not occur. At times, as a result of poor techinique, a prolonged seizure is not recognized, an airway is not maintained and a permanent dementia ensues. You can say that 'permanent structural brain damage does not occur under usual treatment schedules'. page 5: A common problem is post-seizure agitation or delirium. For consent for ECT, we usually insist that a 'signiﬁcant other' to the patient consent as well as the patient. �Page 4 page 7: I believe fractures occurred in T10, not T5. Pre—oxygenation does not reduce the seizure threshold unless you have evidence not in our literature. The eﬁicacy/ energy relationships are restricted to unilateral electrode placements. Brief pulse currents produce less cognitive impairment than alternating currents. page 9: I cannot believe you mean 2780 amperes -- perhaps milliamperes? Any reference to the electric chair in an ECT document is pejorative. Delete it. page 10. AT this late date, you cannot be serious in stating that the observer can tell when a seizure starts or ends in ECT when patients are effectively paralyzed and asleep. In our studies in 1980-81, we showed that cuff monitoring and EEG monitoring were essential. By 1987-90, we became convinced that EEG monitoring was essential, mainly as a protection against missing a prolonged seizure. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Little, John Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-3-067 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/38f7c751658fa3a5701ae50b2e4576c2.pdf 6b1690a89c0fc5db05f0b8aa5a979ac3 PDF Text Text May 8, 1993 Committee on Ethics American Psychological Association 1200 Seventeenth Street, NW; Room 406 Washington, DC. 20036 Gentlemen: am writing in response to the complaint of improper ethics charged by Ms. Linda Andre against Professor Harold Sackeim of Columbia University. I am acquainted with the professional activities of Dr. Sackeim for more than a decade. participated in the symposium on ECT which he organized at the New York Academy of Sciences in 1985; we worked together on the American Psychiatric Association Task Force on Electroconvulsive Therapy, 1988-1990; and he has been an invaluable member of the Editorial Board of the journal Convu/sive Therapy since its inauguration in 1985. I I date of the complaint, the ECT review course under the auspices of CME, Inc. chaired that course and was responsible for inviting Dr. Sackeim and for planning the course. With regard to the cited location and I am personally acquainted with Ms. Linda Andre. first became aware of her activities when was asked to be an expert witness for defendants in a malpractice suit in which she alleges that she received ECT without proper consent, that the diagnosis was erroneous, and that she has been left with permanent memory lacunae for events over her whole lifespan. In reviewing this case, have read the hospital record, including summaries of her prior psychiatric hospitalizations; her record of suicidality and psychosis; her deposition and that of her treating therapists; as well as supporting documentation. I I I I On the occasion of the course in which Dr. Sackeim is alleged to have lied, Ms. Andre took the microphone during the question period, harangued me for my failure to acquiesce to her statements that memory loss was permanent. During this time, she stood with a large covered object, and when failed to answer her queries, she marched up to the platform and placed a large black skillet with an animal’s brain in it; the brain was lying on a bed of dollar bills. I �American Psychopathological Association Page 2 When gave a public lecture before the SUNY History of Medicine the history of the anti-psychiatry movement, Ms. Andre attended and on group again argued with me about her rights as a patient, and my failure to credit her brain damage or to acknowledge that she had been assaulted by physicians. I She travelled to an international meeting on ECT in Graz, Austria. As chairman of the first session, called for questions after presentations on the practice of ECT in Europe. She took the floor and again challenged me for my lack of interest in her memory problems and those of other patients whom she alleges had been assaulted by psychiatrists. I On the specific allegations made in her complaint, I find these fabricated and the result of her pathological imagination and thoughts. In response to inquiries from the audience, Professor Sackeim described events in his practice which reflected the problems of the intrusiveness of the antipsychiatry advocates. He did not mention Ms. Andre by name, nor did he specify any individual. Her association that the description referred to her is a paranoid identification, and is consistent with her psychopathology. On the more general complaints, the present effort at harassment is part of her present life activity as the leader of the Committee for Truth in Psychiatry. Ms. Andre dedicates her life to challenging psychiatrists, and particularly those interested in convulsive therapy. Her legal suit has not been adjudicated, and she seeks adjudication in the public arena before that in the legal arena. urge the APA to hold Dr. Sackeim blameless and return the challenge to Ms. Andre with an appropriate admonition. I Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology Editor, Convulsive Therapy Member, APA Task Forces on ECT, 1975-1978; 1988-1990 � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: on Ethics Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-4-069 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/1b9547e66a975493c8ac10d28fcd9829.pdf c61c617f1327d6e809764016f0c600b7 PDF Text Text May 10, 1993 Kenneth R. Kaufman, MD. 8635 West Third Street, Suite 985W Los Angeles, CA 90048 Dear Dr. Kaufman, Thank you for the excellent case summary of your patient with seizure disorder and surgical lesion with suicidal ideation warranting ECT. look forward to the outcome. I am not sanguine about a position at this University but am willing to send your records for review in our Departments. Please send a copy of your c.v. and three or so reprints that may be useful. [The case report was incomplete-- only page 51 was enclosed] I trained in I Dr. Janowsky at UNC in Chappel Hill is advertising for ECT. You may wish to write to him. someone Good luck with your patient. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Kaufman, Kenneth R. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-4-071 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/3a223603e9b7cb103d77f8052ae5c2a2.pdf 07dff742552ec257bf1dd62cf97cdb89 PDF Text Text April 23, 1993 Captain Richard Pico, MC, USAF Wilford Hall USAF Medical Center Lackland Air Force Base, TX 78236-5300 Dear Rich, Thank you for your very nice letter of April 5. You should apply to NARSAD for a startup grant for your first-break psychosis study. would be glad to support your application and provide the needed letter as mentor/advisor. However, it would be better if your sponsor were someone in San Antonio or at a neighboring city in Texas. The reviewers are aware that distance is a deterrant to useful interaction. Ray Faber should be supportive; if not, A. John Rush at Dallas is a good friend and would get the two of you together if you are willing to get to Dallas. [If you have another sponsor, will gladly write a supporting letter.] I I I am not sure what is best for your third year time, since do not recall the constraints. The brain imaging laboratory at UT is at the forefront of a national brain imaging database collection program, and am impressed that if you came to master the techniques described at the ANA meeting, you would be doing yourself an excellent service -- both for your science and for any clinical future. I I I As for EEG, much good work has been done, but the neurologists and electrophysiologists have a less sanguine image of EEG brain imaging than do I. Newer methods, like MRI, PET, and SPECT are flashier. Newer methods get more industrial and academic support [there is more money in MRI, CAT than EEG]. Perhaps, the clinicians are correct, and we have reached the limit of what can be learned in an individual case from scalp recording. do not believe that we have reached the limit of EEG as a scientific brain imaging tool -- it is so I responsive to set and emotional change, so easily and safely recorded, so easily quantified, and so much has already been done to relate EEG change to behavior. can see no harm in getting to read EEG records by the usual page turning methods; at the least, it will provide a source of income should you wish to continue such work in practice. I Call me any late afternoon or evening at my home-office: 516 862 6651 and we can discuss this further. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Pico, Richard M. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-4-072 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/050f862d88da7566f71759ca325e43dd.pdf 13827b1f21e3deb002a206100a10405b PDF Text Text Ma April 3, 1993 Barbara Melisch, M.D. Universitatsklinik fiJr Psychiatrie Auenbruggerplatz 22 A-8036 GRAZ, Austria Dear Dr. Melisch, For reasons that are outside our control, regret to say that we are unable to accept a Fellow in ECT for the coming year. I Thank you for your interest, and my regards. My regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology �Post-It" brand fax transmittal memo 7671 lilo! pages T° Fm“ Mai): Fr 32' E). HEusui rt ' l mt Co. Co. Dept. Phone # szxv43~31¢-38§-55I6 Fax # 5M: KM. 8604 “Ca/oy— February 13, 1993 Barbara Melisch, M.D. Universitatsklinik fiJr Psychiatrie Auenbruggerplatz 22 A-8036 GRAZ, Austria Dear Dr. Melisch, This letter is in response to your inquiry regarding a fellowship at this University for 1993-1994. Ordinarily, our committees have their budgest assigned and have made their decision by this date. This year, however, the University budgets have not yet been assigned, and i am writing to tell you that a ﬁnal decision will not be made until the end of April. I difficult. recognize that such a delay is frustrating and makes any planning My regards. Sincerely yours, Max Fink, MD. Professor of Psuchiatry �August 26, 1992 Barbara Melisch, M.D. Universitatsklinik fUr Psychiatrie Auenbruggerplatz 22 A-8036 GRAZ, Austria Dear Dr. Melisch, We received your letter of application for a fellowship in psychiatry and the supporting material. Thank you. The file is as complete for the present as we need. The Fellowship committee will consider the application in the late winter and announcements of awards are made in early February for the next academic year which begins in July, 1993. Before the end of this year, you will receive additional inquiries and advice about your application for a suitable visa from our Training Office. understand that such an application will have to be made by yourself in Austria. I look forward to seeing you in Munich. Hopefully, will have more information at that time. I I . ' Have a good holiday. Sincerely yours, Max Fink, MD. Professor of Psuchiatry the f’/ l/ 5 ”4/ / a) ' I/ﬂ/[ �August 26, 1992 Barbara Melisch, M.D. Universitatsklinik ftir Psychiatrie Auenbruggerplatz 22 A-8036 GRAZ, Austria Dear Dr. Melisch, We received your letter of application for a fellowship in psychiatry and the supporting material. Thank you. The file is as complete for the present as we need. The Fellowship committee will consider the application in the late winter and announcements of awards are made in early February for the next academic year which begins in July, 1993. Before the end of this year, you will receive additional inquiries and advice about your application for a suitable visa from our Training Office. understand that such an application will have to be made by yourself in Austria. I look forward to seeing you in Munich. Hopefully, will have more information at that time. I I Have a good holiday. Sincerely yours, Max Fink, MD. Professor of Psuchiatry wW - ( 4% M // - _ % -— /r/ Llag‘e‘r’ ’z. (0?” FM” / �July 3, 1992 Barbara Melisch, M.D. Universitatsklinik fiJr Psychiatrie Auenbruggerplatz 22 A-8036 GRAZ, Austria Dear Dr. Melisch, Thank you for your inquiry about research opportunities in our Department. Each year we offer fellowships to qualified candidates in consultation & liaison, sleep disorders, ECT and psychopharmacology, and child psychiatry. If you specifically wish to work with my team, the fellowship ECT and psychopharmacology would be appropriate. in Please send me a new letter requesting consideration for a specific fellowship, effective July 1, 1993, describing what experience you seek. if possible (and know it is difficult), the note should specify why you seek U.S. training. [e.g., to undertake a specific research project; or for general research experience to allow you to return to Austria and an academic career; or for greater exposure to US. clinical experience; etc. If you have a specific project in mind, would you include a few paragraphs describing the project?] I We will also need the following information: - curriculum vitae copy of ECFMG and any other certificates of training in English copy of certificate of any post-M.D.training. Zapotocky (or other senior psychiatrist) would describe your education and experience. It would be particularly helpful if the letter would suggest what expectations are held for the additional training. It would be useful if Dr. This reads like a lot to do but application for a fellowship. My regards to Dr. it will be useful to support your Zapotocky. Sincerely yours, Max Fink, MD. PRofessor of Psuchiatry � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Melisch, Barbara Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-4-073 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/bbafc025e028e113bde1d26f33b7bfa6.pdf ea06902a644e0f8b54141ccd93b1c8dc PDF Text Text January 9, 1993 Dr. H. Folkerts Klinik und Poliklinik fiir Psychiatrie Albert-Schweitzer—Strasse 11 D-4400 Munster Germany Dear Dr. Folkerts, One week fellowship courses are available at Columbia University [Harold Sackeim, Ph.D., New York State Psychiatric Institute, 722 West 168 Street, NYC 10032] and at Duke University [Richard Weiner M.D., Ph.D., Department of Psychiatry, Duke University School of Medicine, Box 3309, Durham NC 27710]. These are formal courses, with a set syllabus. They charge a fee and provide a certificate of completion at the end of the course. At one time, we had such a course but the work was too onerous. We often have visitors who come for a day or a week or longer. We are accustomed to having visitors attend our rounds to see the patients on my service; attend the ECT sessions; and work with my ECT Fellows. The latter are directly responsible for the actual administration of the treatments and they supervise the ongoing research projects. We do not charge vistors, nor do we provide an ’official’ document of attendance. Our laboratory is equipped with the THYMATRON DG and MECTA SR-l and SR—2 ECT devices. These are brief pulse devices. Our treatments are fully monitored according to the best established standards. We also treat a number of high risk medically ill, as we are a tertiary care referral center for complicated cases. The best time to visit would be when I am ’on service’, responsible for the treatment of patients at University Hospital. I am ’on service’ in February/ March this spring, and again later this summer. If you decide to come to Stony Brook, it would be helpful to have a letter of referral or request for attendance from the director at the clinic. Thank you for your interest. Sincerely yours, Max Fink, MD. Professor of Psychiatry � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Folkerts, H. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-4-079 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/42c9000ced8d162af9eab7599ef7a320.pdf 2abf4558ee3dd51fa3504ea29b0a8e4f PDF Text Text December 20, 1994 William Graettinger, MD. University of Nevada - Reno VAMC 1000 Locust Street Reno NV 89520 Dear Dr. Graettinger, I am pleased to write this letter of recommendation on behalf of your consideration of Edward Coffey, MD. for the position of Professor and Chair of the Department of Psychiatry. I have known Ed for about 8 years, ﬁrst through his research studies at Duke University , then in our association as teachers of convulsive therapy at various teaching sessions throughout the country, as editors of Convulsive Therapy, and as members of neuropsychiatric societies. Ed and I have not worked directly in research, but our common interests in neuropsychiatry, seizures, and ECT have led to many discussions. Ed is well trained in psychiatry, neurology, and neuroradiology. His record as a researcher is outstanding. He is the nation’s leader in applications of MRI technology to problems of changes in brain ﬁmction with depression, aging, ECT, and drug therapies. He has recently edited a book on neuropsychiatry and a few years ago edited a volume on advances in ECT, both for the American Psychiatric Press. He is an excellent teacher and speaker; a man of high moral character and impeccable manners. Ed is a family man; he has three children and is happily married. [I have met him and his family on numerous occasions] He is well liked by his co-workers and by his peers. He is at the right age and with the right record to consider dedicating the next few In October, when the chairman of our Department resigned, I recommended chairman. years as a Ed among three clinician/scientists to the search committee. I would be delighted if he were to join our faculty. I appreciate his record, his personality, and his dedication, and recommendhim for the position of leadership with enthusiasm. I trust these comments are helpﬁil. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Graettinger, William Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-080 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/38866671a01a6a84874bc860af2d93eb.pdf f3b10a0f49d49f21096bdb021fae0899 PDF Text Text December 7, 1994 Edward Shorter, Ph.D. Faculty of Medicine University of Toronto 88 College Street Toronto, Canada MSG 1L4 Dear Dr. Shorter, In 1983, in preparation for the 50th anniversary of the ﬁrst induction of seizures for mental illness, I sought historical data from Meduna’s family [could not ﬁnd any member] and from his co-workers. One sent me a hand edited copy of an autobiography, seemingly written in response to a shorter version prepared for Marti-Ibanez, Sackler, Sackler & Sackler: The Great Physiodynamic Therapies, 1956, Hoeber-Harper, New York. The text needed much editing. As Editor of Convulsive Therapy, I published the text in the ﬁrst two numbers of Convulsive Therapy [1985; 1:43-57; 121-138]. I used this text and the shorter Marti-Ibanez et al text for my 1984 article. Another version of Meduna’s history was written by Walter Freeman, MD. in The Psychiatrist: Personalitiesand Patterns, Grune & Stratton, New York, 1968. Of the various versions, the edited autobiography rings truest. I met Meduna on a number of occasions, and was impressed by his modesty, sincerity, and appreciated him as a ‘ gentleman’ . The journal Convulsive Therapy is available at the Clarke Institute. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Shorter, Edward Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-081 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/376a2be3941caebb72c0f49c7048f7aa.pdf 0f9c40a5d58bade58ae853f52395ba92 PDF Text Text November 15, 1994 Dear Dr. Lasch, I recommended Norman Endler: Holiday of Darkness: A Psychologists ’s Journey Out of His Depression, originally issued in 1982 by John Wiley & Sons in hard cover, and re-issued in 1990 in soft cover by Wall & Thompson, Toronto [6 O’Connor Drive, Toronto Canada M4K 2K1]. I do not know any other testimonial that is as effective in portraying the tragedy of depression and the recovery process. It is kind of you to ask about my lecture schedule. I am scheduled to present an ‘Update’ on ECT at a professional meeting in New York at the New York Hilton Hotel on Saturday, December 3 from 11:45 to 12:30. The conference is a joint presentation of the Albert Einstein College of Medicine and the American Society of Clinical Psychopharmacology. Unfortunately, they are requesting hefty registration fees, and I am not sure that you will get your money’s worth. A more productive meeting on ECT will be held February 27-28 at the Ritz Carlton in Naples, Florida. Those sessions will be led by the nation’s leading therapists. A brochure describing the course is, as yet, not available but an inquiry can be directed to Dr. Charles Kellner at the Medical University of South Carolina [803 792-9072]. I am pleased that we were of service to your mother. I can claim little credit since her care was under the direction of my co-worker Dr. Laura Fochtmann. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Lasch, P. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-083 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b97abfddb045be487bc44fb70fa30d04.pdf b2af67b9c3398da391afadae6a2c0b46 PDF Text Text November 7, 1994 Fred H. Frankel, M.B.Ch.B., D.P.M. Department of Psychiatry Beth Israel Hospital 330 Brookline Avenue Boston MA 02215 Dear Fred, I regret your impression that Dick Abrams’ remarks honoring my work in ECT detracted from the work of the 1978 Task Force. Faced with the task of writing a note honoring my contributions, he cited a long list, including the experience with our 1975-7 8 committee. I know that he meant no disservice to others. This note reminds me of your earlier suggestion that the Task Force be memorialized in 1995, at the 20th anniversary of its inception. Somehow, I think that is premature, since our product was not available until 1978 -- would a recognition in May, 1998 be more appropriate? My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Frankel, Fred H. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-085 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ee233df981caea4b8fc36dee68d434ef.pdf afc5ed12d46f119c9257a072676c999f PDF Text Text Dr. Denise White July 29, 1994 Department of Psychiatry Groote Schuur Hospital Observatory 7925 Cape, South Africa Dear Dr. White, Thank you for the recommendationof Dr. Ian Lewis for the position as Fellow in our Department of Psychiatry. The application needs documented evidence of the completion of medical training; satisfactory completion of residencytraining in psychiatry; letters of recommendationfrom three sponsors [he should advise us to whom to write]; and satisfactory grades in the FMGEM or USMLE examinations. [The last is essential for all trainees in the US] It is my understanding that the examination schedule can be obtained from the US. Consular offices. Please ask him to write a letter of appliication addressed to me. I attach a copy of the letter I recently formulated for another applicant; it will give Dr. Lewis a better idea of the work that is ongoing and planned. It was a pleasure to work with you again in Philadelphia. It has taken me more time than it has taken you, but I am now convincedthat NMS is a variant of catatonia. In talking to Teri Rummans of the Mayo Clinic who recently described their experience with malignant catatonia, she added the modiﬁcation that NMS should be seen as a variant of ‘malignant catatonia’ -- a correction which I consider reasonable. Such associations lead logically to a different protocol for the treatment of NMS -- that of‘lorazepam and ECT rather than dantrolene, bromocriptine, amantadine, and l-dopa. I am rather pleased with the changes in DSM-IV regarding catatonia, and decided that since it is most likely that the APA Task Force will get brickbats and complaints, that perhaps someone should extend a friendly hand. I did so in an editorial for Biological Psychiatry; a copy of the accepted article is enclosed for your interest. from him. Thank you for the recommendationof Dr. Ian Lewis. I look forward to hearing My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: White, Denise Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-091 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/04c624b1dbb52e4866cf5abac5a78baf.pdf 383e92cec1646eeb388337a9459958b4 PDF Text Text A State University of New York at Stony Brook School of Medicine —— Department of Psychiatry Max Fink, M.D. Professor of Psychiatry PO. Box 457 St. James, New York 11780 / /4 jail”! 9? b ' Phone: 516 444-2929 516 862—6651 Fax: 516 862-8604 July 23, 1994 TO: Robert Hirschfeld, M.D. FROM: Max Fink, MD. Subject: Ted Hutchinson’s memorandum14 July 94 M Ted is a lay-person who was advised that his son needed ECT in California, and he came up against the community prejudice and legal devices to frustrate its use. He succeeded in getting treatment which was most helpﬁil. Since then, he has read widely in ECT, developed a unique knowledge of the legal issues, especially those affecting the FDA, and the role of the anti-psychiatry movement in the US. His ‘alerts’ to members of the ECT community are respected. He was instrumental in getting D. P. Devanand, Tom Bolwig, and Harold Sackeim to compile the data in the reecent review of the pathology of ECT, the review appeared in the recent number of the Am. J. Psychiatry. [He is a co-author]. I take his advice seriously and respect his knowledge. The APA Task Force on ECT, headed by Richard Weiner, was establsihed in response to requests for advice by the FDA in 1981 or 1982. It is still responding to the FDA, and you may wish to get his advice, to correlate your responses. [Te1: 919-681 8742} � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Hirschfield, Robert Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-092 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/0c4ecd13a32b541f24973905f278f261.pdf b55da0d142bca3c48135713618a7231f PDF Text Text State University of New York at Stony Brook School of Medicine ~— Department of Psychiatry Max Fink, M.D. Professor of Psychiatry PO. Box 457 St. James, New York 1780 Phone: 516 444-2929 516 862—6651 Fax: 516 862-8604 1 July 8, 1994 TO: FAX FROM FAX Dr. Sweeney Pillay 617 855-3754 Max Fink, MD. 516 444-7534 7 The citations you requested are: Fink, M. :EEG and behavior: Association or dissociation in man? Integrative Psychiatry [in press, 1994] Fink, M., Irwin P., Weinhold P.: EEG proﬁle studies of clozapine in volunteers and psychiatric patients. Neuro-Psychopharmakologie1979; 12: 184-90. My best regards to Jonathan. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Pillay, Sweeney Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-093 Date A point or period of time associated with an event in the lifecycle of the resource 1993 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/2f1c754dd8a39da53bcfa9cecb67b38f.pdf 9540841bb88506d1664767d0a7ffc976 PDF Text Text “State University of New York at Stony Brook School of Medicine — Department of Psychiatry Phone: 516 4442929 Max Fink, M.D. Professor of Psychiatry PO. Box 457 St. James, New York 1780 516 862-6651 Fax: 516 862-8604 1 April 29, 1994 TO: FAX: Greg Fricchione, MD. 617 738-1275 FROM: Max Fink, MD. 516 862-8604 FAX: There is no secure literature on ECT in patients with amyotrophic lateral sclerosis. The closest are the early reports of the successful use of ECT in patients with multiple sclerosis [Savitsky and Karliner, N YSla/e .1. Med. 1951; 512788] and Alexander [JNMD 1951; 1 14:283-306]. Others have written about the usefulness ofECT in Parkinson Disease, general paresis, progressive muscular dystrophy, and intractable epilepsy, in each case without negative effects on central nervous system ﬁmctions. While none of these experiences are directly relevant to a case with amyotrophic lateral sclerosis, I believe the consensus today is that if ECT is compelled, there are no systemic disorders that would prevent the administration of ECT. I would anticipate no speciﬁc difﬁculty other than that associated with swallowing and respiration -— if brainstem signs are present sufficient to compromise these functions, the anesthesiologist may well decide to intubate. patient, keep good records and have your junior write up. While cannot promise the response of my successor as Editor of Comm/Siva 'l'herapy, I expect that he would look upon such a report with favor. Ifyou decide to treat such it a I Good luck, and my best regards. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Fricchione, Greg Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-096 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/a82fb242e6d75e11ddca592c04c61280.pdf 5bc26828eff5ce6feb7c52a5f4f87be0 PDF Text Text April 29, 1994 Donald F. Klein, M.D. NY State Psychiatric Institute 722 West 168 Street New York City 10032 Dear Donald, After your letter about the hunt for the article on an evaluation of psychoanalysis, I thought of calling Abe Lurie [516 681-5004]. He recalled a similar story, stated that he had brought the tale to HH aﬁer sitting next to the author on a ﬂight. He recalled that there was another evaluation done at Hawthorne-Cedar Knolls in the 1960s The report was critical of psychotherapy, but could not give me any more data. Perhaps you can jog his memory a bit more. My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Klein, Donald F. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-097 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/9fb9667c00ec216b6a6a214a4dbf9a22.pdf a09b3e3f9b45f3a6ddd9321b7401b854 PDF Text Text December 27, 1993 Werner Herrmann, MD. Clinical Psychophysiology F reie Universitéit Berlin Eschenalle 3 D—lOOO Berlin 13 FRG Dear Werner, I received your Fax regarding your nephew and took it up with Fritz Henn. He will ask for approval from the Dean’s ofﬁce and should know within a few weeks. We have had such scholars previously. Our third-year students have a clinical course of 6 weeks which is both didactic (lectures) and clinical. It is preferable that he be assigned to work on 10-North at University Hospital and if possible, should be there when either I or Fritz Henn are ‘on service’. When approval comes, let me know what dates he has available and I will advise you how to maximize his experience. My best wishes for a happy and healthy 1994! Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Herrmann, Werner Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-102 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/9a9acf174a954215c97b7e506fc93a45.pdf e837c88db593120602ef932be8382bee PDF Text Text February 8, 1994 Walter Sannita, M.D. Institute for Neurophysiopathology University Hospital San Martino GENOA Italy Dear Walter, First, the good news that your good fairy deposited a check for $9,980 to your account on January 10, giving you a balance of $14,335. As for compiling a book from a meeting, it is a good idea and many publishers will welcome the opportunity to publish, provided that you can convince them that there is a market. That is usually done by showing that a society is behind the book, and that the society will ‘sell’ the book to the members by making it part of the annual dues; or by internal advertising; or by subvention. The latter method is the most secure, since the publisher asks that you assure him of a set amount [usually enough to cover his direct costs for 500, 1000, or 2000 copies], and he will then gamble on making some money from additional sales. It is not the list of speakers, nor their eminence, that will make the book -- but the eminence of the authors, that is, the actual submissions that you receive to publish. The usual procedure is to develop a ‘proposal’ for the book, which you can present to science editors of publishing houses. I have attached the topics for a proposal. Raven Press is a good bet, and when you have a proposal, send it to me, or bring it when next you are in New York. Other publishers are Elsevier, Academic, Plenum, Karger, Thieme, and others. Having a co-editor is a pain, unless you can ﬁnd one who is obsessive and wishes to do the work involved. Ciao! Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Sannita, Walter Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-5-105 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/c4b042dc1452c19aaeff3b9499221ac2.pdf 6414feb61423fcd0af8b46caf53b98f8 PDF Text Text December 5, 1995 Chittaranjan Andrade, MD. Department of Psychopharmacology NIMHANS Bangalore 560 029 India Dear Dr. Andrade, Thank you for sending me your most recent publication which outlines the research contributions of NIMHANS to our understanding of ECT. It is impressive. By happenstance, Dr. Sanjay Sandragiri was assigned to work on my service this month. He is a trainee in our residency training program. He appears to be talented, enthusiastic, and well trained already, so that it seems a shame for him to spend the next three years in pedestrian learning activities. I was considering encouraging him to undertake studies in ECT concurrent with his residency training. I understand that he spent some time at NIMHAN S. I would be grateful for any remarks that you would share with me regarding his potential for an academic career and his ability to assume the double burden of residency training and innovative research. My regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Andrade, Chittaranjan Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-6-109 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/2a29c9abb9ed91e516605dc2d35c3f6c.pdf ec086d920872deff90f10525b146ccb5 PDF Text Text Directions in Psychopharmacology Published by The Hatherleigh Company, Ltd. 420 East513t Street New York NY 10022-8095 EDITORIAL BOARD RESPONSE FORM Name Max Fink, MD IE I D In addition, I would like to write a lesson on: would like to serve on the Program Advisory Board of Directions in Psychopharmacology. h /2 ' W AIM! I] A deadline of El Thank you for the invitation to serve on the Board, but I must decline at this time. JW Signature is requested for my manuscript. (576 ) 4¢¢~2¢90 Telephone number //F/»\//¢ @ 579.5001. swysa. (5/4 ) £42— FAXnumber (604! EZML e-mail address Please indicate any address correction here: de 60X [IA/K, HUA- 70. 57. ‘70.”, 6/5? My xx/rowe/s? Please return this form, along with an updated curriculum vitae, and send to: Steven L. Pessagno Managing Editor The Hatherleigh Company 420 East 51 Street New York NY 10022-8095 Thank you for your time in completing this form. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Pessagno, Steven L. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-6-112 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ad0bc68ba5348033e0f356799407b978.pdf b7e403b1ec397f5c267b544150e64355 PDF Text Text November 26, 1995 Lizzie Sand Stromgren, MD. Department of Biological Psychiatry Psychiatric Hospital in aarhus Skovagervej 2 DK-8240 Risskov, Denmark Dear Lizzie, I read your essay on ECT in acute delirium with much interest. I marked up the text, and made suggestions which I believe will clarify the presentation. I also made marginal numbered notes which are discussed in the attached memorandum. There is little question about the efficacy of ECT in severe melancholia, stupor, or acute manic states. The argument which I believe you wish to present is that in acutely ill patients with histories of psychiatric or systemic disorders, the appearance of an acute delirium, with or without fever, with or without rigidity, with or without autonomic signs, is a possible indication for ECT; and if ECT, the use of en bloc [2-?3 ?4] treatments may be life-saving. The discussion of unilateral and bilateral ECT and cognitive features is beside the point. I believe we need a follow-up of the Kramp and Bolwig article as an invitation to others to entertain the possibility of using ECT in this special type of case. Thank you for the opportunity to read this report. My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Stromgren, Lizzie Sand Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-6-113 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/edcb31442fc15ba288bbf25f8e13e93a.pdf c6bd7111d8b56e812d810c39d4423768 PDF Text Text State University of New York at Stony Brook . \J ’ 9 a I School of Medicine — Department of Psychiatry , Max F ink, M.D. Professor of Psychiatry and Neurology PO. Box 457 St. James, New York 11780 Voice: (am) 516 444-2990 (pm) 516 862-665 Fax: 516 862-8604 E-mail: mﬁnk@epo.som.sunysb.edu 1 November 26, 1995 Dr. Daniel Flores Amargos Inst. de Psiquatria y Psicologia de Montevideo Ellauri 1221 Montevideo, Uruguay Dear Dr. Flores Amargos, I am indeed ﬂattered by your invitation to particpate in a medical specialty training program in Montevideo, and whicl I am inclined to accept the invitation, I am aware that there is no suggestion as to what is expected of me. Do you intend to develop courses over extended periods in Montevideo, or single day seminars? Or, do you wish a list of sites to which you can send trainees, much as you did Dr. Savi? I will reserve my answer until I am apprised of the details of your program. Meanwhile, I am interested in hearing of any programs developed since Dr. Savi’s visit here. My regards to Dr. Lyford-Pike and Dr. Savi. Si erely ours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Amargos, Daniel Flores Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-6-114 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/9f0981900307dec3783ffb664e977b13.pdf 2b0a91a1c60fa3b3b931936f9ef03f21 PDF Text Text July 17, 1995 Worrawat Chanpattana, MD. Department of Psychiatry Srinakarinwiroth University Vajira Hospital, Samsen, Dusit Bangkok, Thailand Dear Dr. Chanpattana, I have read the outline of your proposed study of continuation ECT in interest. There is a need for a prospective study of ECT contrasted with with schizophrenia neuroleptic drugs in schizophrenia. The basis for this belief is the review, now in press in Schizophrenia Bulletin, which I recently completed with Dr. Harold Sackeim; a copy is enclosed. The question which you seek to answer with the design of your study, however, is not central to our present concerns. Most patients are treated with neuroleptics ﬁrst, and only treatment failures are considered for ECT. In such a group, there would be little justiﬁcation to continue treatment with a failed compound [such as a neuroleptic]. If you wish to answer the question which intervention reduces relapse rate for longer periods, and at what cost, then patients who failed an adequate neuroleptic trial for schizophrenia could be assigned to receive either a continuation neuroleptic [although an atypical neuroleptic like clozapine would be preferred] contrasted with those treated with ECT [either alone or combined with the atypical neuroleptic]. Such a study would parallel ongoing US studies comparing the relative efﬁcacy and safety of continuation ECT, continuation lithium combined with a tricyclic compared, and lithium alone. It is probably inappropriate to use haloperidol combined with ECT since there are few studies of this combination. Considering the high risk of haloperidol for inducing dyskinesia, it is not favored by many psychiatrists. I am not directly involved in the support by our governmental or private agencies of mental health research, and so cannot answer your query about support. My regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Chanpattana, Worrawat Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-6-115 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/151991bf8aeefaf85bdfdf9fc4f609d2.pdf 587805ae95561f78500f1fd8114a710c PDF Text Text Self <PSYCH|ATRYIMFINK> taylorm@mis.finchcms.edu(Taylor Mickey) Re: congrats on MEDLINE From: To: Subject: Date sent: Wed, 2 Oct 1996 15:48:19 -0500 Dear Mickey, Monday morning visited the library and the librarian showed me the list of new journals accepted for indexing by NLM, and l was so delighted to see ourjournal listed! Then came home and the mail said the same thing. I I How reassuring! How wonderful! You are to be congratulated on getting the journal so far. have decided that the lay-world needs a verbal explanation of ECT, something akin to the videotape. So have been working on a 'popular' book for the trade market titled ELECROSHOCK! Two publishers are interested, but before signing a contract l decided to finish a good part of the book and then see if get a better deal. So far, 21 chapters are written -- in various stages. hope to have it done by the winter. I I I I Harold Sackeim is the chairman of the SBP meeting in May 1997. He visited us yeaterday and among topics, asked whether he was interested in a discussion [debate, symposium, whatever] on the difference in the US eclectic view of catatonia and the European classical view that catatonia IS schizophrenia. He seemed interested. suggested Beckmann and Stoeber of Germany, Taylor and Fink for the US. Any thoughts? Could you go to California in May if carry this through? I I I All my best. Max � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Taylor, Michael A. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-121 Date A point or period of time associated with an event in the lifecycle of the resource 1994 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/f633e8d930a3382ebc84a058310346ed.pdf 397ce2f11ec99a1feb4240988e2268dd PDF Text Text S 30 <0c 6001M~ _ >UO_.mmO 03:063. 26 000960 392063 306 6003? 030 3306 06c0 :20. 00606300 6:02P 33 06050019 0033 03 .3 0m 000_0m003m 0.n mc600. 38 mm! 30103203000 030 0< 6m003m0m. 00300_ _.00§3© 030 3 =360 330 86 6003 30 000030 $030300~ : <02 <<0m 38 30 30 000_0m003m 30003 0 0m<0300<3036 _.0c6:0 030 800 w 03 00306003 303030203 003030? 63003 566‘ 300003006. 0006603 006 .30: 006 30 9630:0069 003303. 03 38 03 3333529 $0.0m 2363 0c0=m300 $030300 00303036 01:.0 _3 mOa 63 ._ 6003,? 3c03 03 60:09, 306 >0 mnﬁ mm! 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E0: 8 03 ﬁ0<w0<< 0 3003030 002010;. 303300 050010300 _ 0: 0* 30 720 <30: _ 30<0 Z0c~00m<0294<n 2:: 0150.5 30 30:0. mﬂﬁ 0:030 0390. £00000 5.03, 32:90 mQMAwoS. 36204? 30a 3020 _ 0053 x00: 220: _ 05: +0 3 03:00: 3 >30: 00030? ©_00_< ©_00_< Or _ 30 <<=_ <<___ 002‘ 21:0: 00__m 0203003 30 003,0 30<0 000200 0% 30 <0_c30 +0 US 30<0 03:00:. ZIZK ﬁ0<m0<<3© 0m 2010 30 00: 0-30: <03c0w 00 <09~ mm! <0cﬁ 0100 3060K 0003 006010300 0< : .3020 :03 000300 3a 30 <30 :0<0 0., 003<c_m.<0 0 <0c~ _ 031003 cm 030 030 30:0 3 mazoﬁ 02029? 28 #0900 300 0.n 2:: +0 00033 � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Tennison, Michael B. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-127 Date A point or period of time associated with an event in the lifecycle of the resource 1995 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/d163f8b6823f518ad6587beaf6288182.pdf 24fdb48012a0deb8ea2648540dd879a9 PDF Text Text Robert M. Post, M.D. NIMH Building 10 Room 3N212 9000 Rockville Pike Bethesda, MD 20892 May 21, 1996 Dear Bob, I am pleased to nominate Harold Sackeim of Columbia University for the NARSAD Selo Prize. For the past decade, Harold has been the nation’s leading researcher into the practical issues in electroconvulsive therapy. He has deﬁned the importance of the seizure threshold, energy dosing, and electrode placement in the eﬂicacy of ECT for affective illness. In addition, he has clariﬁed the role of ‘pharmacotherapy-resistance’ in the efficacy of ECT in affective disorders. Leading from those experiences, he has organized and is now analyzing the data of the nation’s only study assessing the relative efﬁcacy of continuation TCA vs continuation lithium plus TCA vs placebo in the aftercare of patients who complete ECT. He has also made important suggestions as to the mechanism of action of ECT, and in the present brouhaha about TMS, he is carrying out the most organized and detailed studies of this possible alternative induction method. He has been an NIMH scholar, a NARSAD scholar, received an award of the ACNP, and is now a member of the APA Task Force on ECT. For the decades of the 19605 to the 19803, it could be said that I led the ECT research community. In the past decade, that role has surely been taken by Harold and his leadership should be acknowledged. I am pleased to nominate him for the honor. My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Post, Robert M. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-129 Date A point or period of time associated with an event in the lifecycle of the resource 1995 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/7f15af7a20a4ddaf50e613ab53746fe0.pdf d2f82701779052e80f3e0a5082ef6db2 PDF Text Text Health Sciences Center School of Medicine Department ol' Psychiatry and Behavioral Science April 16, 1996 TO: Charles Kellner From: Max Fink Subject: Letter of Mr. Herman W I am in receipt of a copy of a letter addressed to you by a Mr. David Herman regarding the use of CT pages for Szasz. DH is a chronic psychotic who has latched on to ECT and drugs as the cause of his difficulties; he is active in writing to everyone about his desire to save the world by stopping ECT and drugs. He likes Szasz and Breggin. He has written often; and as often, I have not answered. My lack of reply is no sign of agreement or acquiescence. See what being an editor gets you! State University of New York at Stony Brook Stony Brook, New York 1 17947810] 5i 6444—2990 Fax: 5 ()7444—7534 I � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Kellner, Charles Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-131 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/d2452c2f3626ab48ed944da8dec7ac88.pdf ec0c7866fee35738bc21d19d9655753a PDF Text Text March 19, 1996 Greg Fricchione, MD. Division of Psychiatry Brigham & Women’s Hospital 75 Francis Street Boston MA 02115 Dear Greg, What a terrible story about Anthony Bouckoms! I liked him very much; last November I invited him to join me and Charlie Welch in an ECT symposium at the Boston APA meeting. He did well, and he told us of the changes in progress at Hartford Hospital. Pity, such an untimely personal and professional loss; more than doubly sad for his wife and remaining children. I have read the article on catatonia with interest. My suggestions -- I cannot read any article without and editorial pen in hand -- are in the text and margins. Overall, I think the essay presents the experience well. But, if we are to be of service, we should be more deﬁnite about the conclusions which we wish to leave as the ‘messages’. The ﬁrst message is to recognize catatonia, and that is done well. Andy and George will probably wonder why you do not recommend the use of their handiwor -the catatonia rating scale. By the time you get this note, it will be published [it is in the March number of the Acta]. Instead of tables 4-6, should you not adopt the rating scale and test method? We will surely have no objection to such use. [There is one small point -both George and Andy saw the scale as their ‘special’ handiwork and in the text of the article labeled the scale as the ‘Bush-Francis Catatonia Rating scale’ or BFCRS —- a cumbersome title that will not sell well. I believe you can adopt the scale without the mnemonic label, as I have done elsewhere] Similarly, you may wish to amplify the paragraph discussing the Bush et al experimental ﬁndings in incidence of cases and treatment results, much as you do for the Ungvari and Rosebush data (pg 16). �The discussion of the theory of the mechanisms in NMS, catatonia, and malignant hyperthermia deserves a clearer message (pg 23). When NMS was discerned as an entity in the late 1970s, it was seen as similar to malignant hyperthermia, leading to the suggestion that dantrolene be tried. But no commonality between MH and NMS has been demonstrated except the superﬁcial appearance of the syndromes. Further, the evidence for the efﬁcacy of dantrolene alone in NMS is anecdotal at best. (I am not convinced that it does anything material in CNS disorders.) It does no good to continue to recommend its use in NMS. In the theoretic argument (pg 24), you argue for a speciﬁc site for pathophysiology. Perhaps you would include a statement that one should assess PET with xxxx as the ligand or SPECT for lesions in yyyy and/or zzzz. Such speciﬁcity may bring you more attention than the more general, non-speciﬁc loci recommended now. [I believe Mickey Taylor did himself a disservice by hsi trepidation in not seeking to argue for more speciﬁcity; as a result his work is usually seen as ‘something happens to the brain, more in the front than the back, I think . . .] Finally, the summary argumen -- which is usually the most read- should be clearer about what you recommend as a course of treatment. The journal is ‘critical care medicine’, read, I assume by clinicians. What I have learned since we treated our patient on 16N together is that that all neuroleptics need to be discontinued promptly; that supportive measures instituted; and that lorazepam needs to be ‘pushed’. My present dosage range for lorazepam is up to 16mg/day. I see no need to ever consider bromocn'ptine or dantrolene -- if lorazepam fails, ECT is the deﬁnitive treatment. If the diagnosis of catatonia is secure, such Rx will surely optimize the best for the patient. I have also pencilled in corrections for some of the citations. On a more personal level, I do not need to be a co-author of another paper. I am delighted to help in this effort -- and will gladly review a penultimate draﬁ -- and all I warrant is a note of thanks in the acknowledgements. Many thanks for the opportunity to read this review. My best regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Fricchione, Greg Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-137 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ed10f1701a537571c4caeef3644623f2.pdf 08f2635fd18f48d6334a3311a165a8b7 PDF Text Text DatezFebruary 22, 1996 TO: D.R. Milne FAX # 419 382-2378 Total Pages (including this sheet)-1- Dear Mr. Milne, I do not participate in public debates except for and with mypeers. The tragedy in public discussions of electroshock is the anger shown by many in the laity and some in my profession to the mentally ill. The same persons who would undergo coronary artery bypass surgery or hysterectomy or other surgery with alacrity are distressed out of all proportion at the idea of electricity coursing through their brains, not realizing that their brains are hotbeds of electrical circuits already. You would do better to ask the question: Why is it that E CT is available at the leading academic centers in the nation but not in almost all the state and veterans administrationpublic mental hospitals? Why do we have a two-tier treatment program? [It is notﬁnancial since mentally ill patients are equally likely to be admitted to the academic hospitals in your state as to the publicfacilities.] Try the professor ofpsychiatry in your [or any] state and its commissioner of mental health. Max Fink From: Max Fink, M.D. P.O. Box 457 St. James, New York 11780 FAX: 516 862-8604 TEL: 516 862-6651 �Date: Feb 21, 1996 TO: Mr. D. Milne L9 FAX # 419 382-23175 Total Pages (including this sheet)-lDear Mr. Milne, The essay by Gary Figiel is in the nature of ‘Chicken Little’s fears. The four articles to which he refers ﬁnd no justiﬁcation for the routine use of labetolol or esmolol other than the anxiety of the physicians. ECT is no more riskful to the heart than climbing a ﬂight of steps -- indeed, less so. More harm is probably done by routine use of anti-hypertensives than by unmodiﬁed seizures, since severe and persistent hypotension is a common accompaniment of such use. If you publish such anxious statements, perhaps at the least you would ask the author to specify what he means by ‘MAJOR’ and what he means by “MINOR’ effects. Also, a complication is an unexpected, and potentially damaging event. You may ask the author what the consequent ‘complications’ were in the unmedicated series. I will not consider a reply. You do no service by such publication. Max Fink From: Max Fink, M.D. P.O. Box 457 St. James, New York 11780 FAX: 516 862-8604 TEL: 516 862-6651 � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Milne, D.R. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-141 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/7c5681118ee118e010d81f3d7fcfe975.pdf 930ebd4ced5dd4a2a31514d87d0d3b86 PDF Text Text February 17, 1996 Ms. Sarah Lentz DMS Box 470 Hanover, NH 03755 Dear Ms. Lentz, Thank you for the opportunity to read you report on ECT and pregnancy. It is quite good, but as an Editor, I have some suggestions to improve the history and the practice. In the history, the introduction of electrical inductions by Cerletti and Bini was a modiﬁcation of an established treatment, that of Metrazole convulsive therapy. The induction of seizures with camphor and then pentylenetetrazol [Metrazole] was introduced by Ladislas Meduna in 193 4, highlighted in an international conference in Muensingen, Switzerland in 193 7, accepted throughout the world as a treatment [see the supplement to the Am J Psychiatry 193 8]. These events preceded and were surely the stimulus to the Italians [Bini attended the 1937 meeting]. It would be better to state that the introduction of convulsive therapy by Meduna was the innovation that altered psychiatric practice. He deserves the credit. The charge of overuse and inappropriate treatment of ECT is incorrect. All treatments that are perceived as successful and safe are ‘overused’ as practitioners seek to extend and deﬁne the indications. Think of the present enthusiasm for ﬂuoxetine or the newer alleged psychotropics; or the extensive overuse of coronary artery bypass surgery; or of caesarian deliveries. The canard should not be repeated and this section should be deleted. Further, ECT like other somatic treatments in use in the 19505, was replaced by medications, but its renewed interest [in contrast to psychosurgery and insulin coma] was occasioned by the failures of pharrnacotherapy. Despite the enthusiasm of the public and the blandishments of the pharmaceutical representatives, many patients fail modern drug therapies and are later successﬁil with ECT. �In your suggestions about ECT in pregnancy, there are a few that are more dangerous than you consider. Vaginal examination is not only not necessary but a dangerous procedure during pregnancy and should not only not be recommended, but enjoined unless compelled by signs or symptoms that warrant such an examination. There is nothing about the examination that would alter or affect ECT, if ECT is compelled by the patient’s mental state. Anticholinergic medication as part of the ECT procedure is acceptable and useful. External fetal monitoring during the procedure has been done, and remarkably, the fetal heart rate is unaffected by the procedure. There is no justiﬁcation for such monitoring as a routine procedure because the expense is excessive and the information yield nil. In patients in the second half of pregnancy, intubation is part of the standard of anesthetic care, and it is routine for all our cases. The use of antacids is optional and our anesthesiologists no longer ﬁnd it useﬁil. I am puzzled by the CME credit questions 2 and 3. ECT is indicated during because the patient is so psychotic as to require hospital care and is exhibiting pregnancy either suicidality, mania, inanition, or command delusions which threaten the life of the mother or the fetus. The emphasis on diagnosis does not reﬂect the compelling indication for ECT, that is behavior which puts patient or others at risk.It is not the diagnosis that is the indication; many mentally ill mothers cany to term without medication or treatment. Question 3 is ambiguous. Each of the modiﬁcations of procedure are relevant to the care of pregnant patients. Aside'from these quibbles, I commend you on your report. We are now a main center for treating pregnant psychotic patients and treat at least one a month. Two are in treatment now, one for severe depression and suicidality and one who was in manic delirium. The ﬁrst is continuing in ambulatory treatments and cares for her other child; the second has just had the delirium erased and is still being treated for mania and psychosis. Good luck in your career. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Lentz, Sarah Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-143 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b19c4e7f59ae6371b281a0cd90f36543.pdf 2ef2a4ec998748b63028de45cff8dda4 PDF Text Text February 8, 1996 Dr. Sydney Archer Rensselaer School of science Troy, NY 12180-3590 Dear Sydney, My recollections of the patients are hazy. But I called Dick Resnick and he seemed more au courant. I have sent him your letter and asked him to call you. If I can be of help, let me know. My regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology cc: Richard Resnick MD. 43 West 94 Street New York City 10025 � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Archer, Sydney Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-144 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b86c405cccc48c343810b5915496b4a0.pdf 889d9d49bf090acf9beea2c8bdf47ffe PDF Text Text Dr. Richard Horton February 3, 1996 42 Bedford Square London WC 1B 3 SL United Kingdom Dear Dr. Horton. I read the essay ‘Revising the research record’ with much interest and sympathy. As editor of Convulsive Therapy, no problems of scientiﬁc error have been brought to my attention. Our level of error has been at a more triﬂing level, and so we have not been faced with the difﬁcult decision as how to alert the readers to scientiﬁc error. I am impressed that the Table ‘Taxonomy of error’ in your essay reﬂects the best stande available today. Since a published report has gone through the journal’s peer review, when is found error or charged, it seems logical to go through the same procedures to establish error. Assuming the review concludes that error of fact or procedure occurred, such conclusions warrant publication. The suggested ‘withdrawal of aegis’ by the journal is a reasonable and innovative step in maintaining scientiﬁc integrity. The principal downside risk is the assurance that the material presented the readers in the ‘withdrawal of aegis ’ be complete and able to withstand procedural and legal scrutiny. The guidelines for authors should reﬂect the possibility of such review of published material and the possibility of such published revision. Should you wish a publisher’s point of View, Dr. Alan Edelson, the founder of Raven Press and the former President of Lippincott may be able to answer an inquiry more formally than I [amedelson@aol.com;or 16 Washington Avenue, Irvington NY 10533} Incidentally, I have stepped down as Editor of Convulsive Therapy, but am still interested in the problems of editing and editors. My regards. Sincerely yours, Max Fink, MD. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Horton, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-145 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/9327fbd0a02f7d209bae7f77d256037d.pdf eff8d749f7b7a5a67cb0b63ef8853f01 PDF Text Text Saturday, January 27, 1996 1300 EST Dear Alan, Martha and I have just returned ﬁom a delightful 5-days at the Spice Island Inn in Grenada. The weather was excellent, the food adequate, the accommodations among the best we have had in the various islands. The hotel was next door to the offshore medical school in Grenada. I was able to chat with many of the students who were relaxing and reading on the beach -- their cafeteria and dining tables are on the beach front. I was saddened by the thought that these -- what seemed to me to be ﬁne young Americans -- had to get their education in what seemed to be poor facilities [despite a glorious beach]. I could see little that would distinguish them from our students at Stony Brook. Among my mail on my return is the communication from Richard Horton, Editor of Lancet. I had been in touch with him when I edited CT. I am puzzled by his inquiry. First, I had to look up the word ‘aegis’ [see ‘egis’] and found that it is a protective inﬂuence, a shield. As I read [and re-read] the article, I come to the conclusion that the ‘withdrawal of aegis’ is a legitimate editor’s response to an unsatisfactory article which passed through the review net. What do you think? I am still pausing in getting to write about ECT on the Internet. I have an invitation from ‘www. mhsource.com ’, the home page of John Schwartz [CME, Inc., The Psychiatric Times], and another from Ben Green [Psychiatry On—Line-- www. cityscape.co. uk/users/ad88/psych.htm]. In addition, Stony Brook has decided to has invested in a server for the medical school ‘home-pages’ and has invited faculty members to set up their own. If my work-load decreases, I will think more about it. It is pouring this afternoon -- why am I here instead of in Grenada? ? ? My best to Carol. a. W � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Edelson, Alan Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-146 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/204de220add2e761ea045527a997cc4b.pdf 529c1931185d5aee13ad748dfb9521b4 PDF Text Text January 28, 1996 Dr. Lawrence C. Perlmutter Department of Psychology Finch University of the Health Sciences 3333 Green Bay Road North Chicago, IL 60064-3095 Dear Dr. Perlmutter, Dr. Avi Calev has been a neuropsychologist in our program since 1990, and has asked me to write a letter on his behalf. I have known Avi for about a decade, ﬁrst becoming acquainted with him through his work with Dr. Bernard Lerer at the Hebrew University in Jerusalem. At the time, Dr. Lerer was studying the electroshock process, and Avi provided most useful examinations focused on cognition. With Dr. Lerer’s encouragement, he applied and was appointed in our Department as a member of our electroshock evaluation program. He was well liked and when an opening appeared in the inpatient clinical services, he was appointed as the psychologist of my inpatient team. My relationship with Avi is therefore at multiple levels -- as a co-worker, supervisor, and friend. Avi is a talented neuropsychologist with an excellent grasp of psychometrics, projective testing, statistics, and experimental design. He has been an active co-worker and a leader for various projects, as attested to in his curriculum vitae, where he has a large range of coworkers. In addition to the reports of the cognitive effects of ECT, he has also assumed responsibility for studies to determine whether pre-treatment with caffeine will inﬂuence therapeutic results and cognitive effects of ECT. He has already published the preliminary results which argue that the effects are favorable and is now completing the data collection for a random assignment study. I have known him also as the team neuropsychologist on our inpatient service. As he has been most helpﬁil in assessing patient characteristics, elaborating the techniques for such, our residents and medical students, and assuming responsibility for psychotherapy in selected patients. In the latter instance, he both treated patients and supervised our residents. �Lately, he developed a relationship with Dr. Lynn DeLisi, an expert in the study of schizophrenia. Together, they are working on a number of projects with which I am not directly acquainted. Avi is a conscientious, interested, intelligent, and well trained psychologist. He is well liked by his co-workers and I have been delighted to work with him. He is knowledgable about the literature, is able to document his positions in argument, and is technically skilled. I am distressed that he has been asked to leave -- a situation which has been occasioned by the necessary down-sizing of our Department and not associated with any of his defects or actions. Sincerely yours, Max Fink, MD. Professor of Psychiatry & Neurology Attending Psychiatrist, University Hospital � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Perlmutter, Lawrence C. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-7-147 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/9d2c26ecab07442f2aac65a9c4386da3.pdf 94c9268427d9025a4d53c68cbb463619 PDF Text Text August 28 1997 Dr. Valdir Pricoli Rua Albilio Soares, 639-123 04005-002 Sao Paolo Brazil Dear Dr. Pricoli, Thank you for your letter. I am pleased to have been of help. I am moving my teachiong and research operations from SUNY at Stony Brook to the Long Island Jewish-Hillside Hospital complex in Glen Oaks, Long Island. It is closer to the city. The hospital has a long tradition of ECT research -— back to 1953 -and I have developed a research team there. We would be pleased to have you visit. Arrangements can be made to stay in Great Neck, about 10 minutes from the hospital, or in New York City —- about 30 minutes. You can reach me at my ofﬁce address as on this letterhead. My regards. Sincerely yours, Max Fink, M.D. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Pricoli, Valdir Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-153 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/095ba8fc2cfd167106c6568f53a07f6c.pdf 419fa279ac108e0411b62aa86ca9e868 PDF Text Text July 16, 1997 Harold S. Orchow, M.D. Montevista Hospital 5900 West Rochelle Avenue Las Vegas NV 89103 Dear Dr. Orchow, The relationships between number and frequency of seizures, reduction in mood disorder (efﬁcacy), increase in cognitive symptoms (safety), and electrode placement are described in an extensive series of reports. The details are well described by Abrams in his textbook Electroconvulsive Therapy (Oxford U. Press, 3rd Ed., 1997). The most recent reports are those from Jerusalem by Bernard Lerer and his co-workers. 1. 2. 3. 4. 5. Efﬁcacy in ECT for mood disorder improves with both frequency and number of treatments. Cognitive symptoms worsen as number and frequency of treatments increase. Efﬁcacy is greater for bilateral electrode placement, but such efﬁcacy is associated with greater cognitive symptoms. Efﬁcacy is less for unilateral electrode placement, and such lesser efﬁcacy is accompanied by lesser cognitive symptoms. Twice a week treatments achieve the same efﬁcacy and less cognitive effects than three times a week treatments; but two weeks after the end of the treatment series, when efﬁcacy is equivalent, cognitive effects are not distinguishable. As a consequence of these syllogisms, practitioners select the parameters of treatment according to the severity of the symptoms. For severely ill and debitated patients, where one seeks immediate improvement and is less concerned with cognitive effects, ECT is given 3x/week with bilateral placement. This assures the best results. [In severely manic or psychotic patients, this series may begin with two to four treatments daily.] For patients who are not too distressed, where cognitive effects are feared, with unilateral electrode placements, at 3x per week. treated patients are �In the elderly, where cognition is a principal risk, treatments are given with bilateral placements no more frequently than two times a week. Some practitioners deliver two seizures in a single setting. This is a relic of 'multiple monitoered ECT' developed by Blachly and Gowing in 1966. MMECT was tested and shown to increase risks with limited gains. The practice is no longer endorsed except in the very severely manic, psychotic, or stuporous patient where an immediate effect is required. The practice of giving 12 treatments in four to ﬁve days, even with unilateral electrode placement, sounds like MMECT — a practice which is not generally recommended. The APA Task Force of 1990 wafﬂed on these data and recommendations because the members of the panel were aware that many practitioners were still using the MMECT model. A better review of MMECT is to be found in Abrams' textbook. I trust these remarks are helpful. For other opinions, you may want to post a speciﬁc case example on the intemet site of 'convulsive-therapy@psycom.net' and see what others answer. Sincerely yours, Max Fink, M.D. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Orchow, Harold S. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-154 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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). 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Ecmﬂgcoozcm 22528:. v cm>m 2.228 50E; 20E; 595. .mchE m5 Sn m E258. :0 Emmw 2 >63 .mnEzc $3 93% _ 58 m .2 $2 >=Eﬂ >_m>o_ m5 �as: boom >9: mEEuEﬁ 2x225: bm> Emccoﬂézmamﬁx -- .95 m gm; mm 23% 53> ccmExomm .0 >9: 05 ucm m mg mEBEmo : cu om Sn ucm 568529 meEgoqum toaazm £58 mmm xmncmi me. .mEmanwEom 2 .96: new uoom :_ Emu 4222 mcmEEG Fo _ xm_>_ >__mco_mmooo Emu m5 £5, m5 5:? m8; mEmE >=E£ m_ 25 ucm .050 m_ 22% 3333 new m ma 2650 :0 uoom ._ ucm 2:0 85888 o>mc ucm 2 >2... 8:8... 5:0 $558 mg... .. 9.5235 mmEEuc>m .953 .Emnmu 39: � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Wyatt, Richard J. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-156 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/afbe8b229bbdc7d665a13a4b0dd99df3.pdf 48223f41e34dd5cb920fb4cf2717dffc PDF Text Text State University of New York at Stony Brook School of Medicine — Department of Psychiatry . ’oe| I Max Fink, M.D. Professor of Psychiatry and Neurology PO. Box 457 St. James, New York 11780 Voice: (am) 516 444-2990 (pm) 516 862-6651 Fax: 516 862-8604 E-mail: mfmk@sunysb.edu . March 11, 1997 Alan J. Gelenberg, MD. Department of Psychiatry University of Arizona HSC Tucson AZ 85724 Dear Alan, Your reminder of a failure to review manuscript 4406 “The use of ﬂumazenil in the anxious and benzodiazepine-dependent ECT patient” sent me to my desk and ﬁles. I have not received the manuscript. my custom. Please send it on and I will get a review within a few days of receipt, as is My regards. W Sincerely yours, Max Fink, M.D. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Gelenberg, Alan J. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-160 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ada4e3e3605613852b053ddf6011b854.pdf 1f4c8847787ea1d7dacfe0e07c4ea555 PDF Text Text State University of New York at Stony'Brook School of Medicine — Department of Psychiatry Max Fink, M.D. Professor of Psychiatry and Neurology PO. Box 457 St. James, New York 11780 Faculty Committee on Honorary Degrees Graduate School SUNY at Stony Brook Long Island, New York 11794 Voice: (am) 516 444-2990 (pm) 516 862-6651 Fax: 516 862-8604 E-mail: mﬁnk@epo.som.sunysb.edu April 25, 1997 Dear Committee Members, Dr. Dale Deutsch has nominated Dr. Raphael Mechoulam of the Faculty of Medicine of the Hebrew University of Jerusalem for an Honorary Degree at this year’s commencement. I endorse his nomination with enthusiasm. Recognition of Professor Mechoulam’s extraordinary achievements in medicinal chemistry, especially in the most difﬁcult chemistry of botanicals, is well deserved. I ﬁrst met Dr. Mechoulam in 1970 when I was the Principal Investigator in NIMH contract on the study of the chronic and acute effects of inhaled cannabinoids in an human subjects, both in Athens, Greece and New York. We were asked to examine the behavioral, psychologic, and electroencephalographic effects of different cannabinoids to assess which were the most active in altering behavior and their dependence liability. It was from Dr. Mechoulam that we received large sample amounts of various cannabinoids derived from special samples of hashish provided by Dr. Costas Miras of Athens and marijuana from US. government ofﬁces. Based on his cooperation, we were able to demontrate the activity of A9 and A8 cannabinoids, and contrast these with other complex compounds. His recent identiﬁcation of a natural cannabinoid-active compound in the brain has sustained a good part of the academic research into cannabis, at a time and under conditions of national and international confusion about its risks. Such an honor is well deserved and I am delighted to join Dale Deutsch in this nomination. Sincerely yours, Mug/Lac Max Fink, M.D. Professor of Psychiatry and Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Deutsch, Dale Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-161 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/8be8d6c037a0183a06654c37349a1194.pdf 8e11b4a3f4e89018c4150ad69bec20d0 PDF Text Text April 13, 1997 Mrs. Katherine Graham The Washington Post 1150 15th Street NW. Washington DC 20071 Dear Mrs. Graham, Reading the story of Mr. Philip Graham’s death in your Personal History is a sad reminder that even the best educated in America do not get the best medical care. The tragedy reﬂects the failure of the early recognition of manic depressive illness, the failure to use available medications, and what is most egregious, the failure to use electroshock. While much has been learned since, the beneﬁts of electroshock, including its use against suicide, were clearly well known in the profession at the time of the tragedy. Why write now? Because your tragedy is still repeated in America. It is one thing to have a fatal illness for which no remedy has been devised; it is another to have an available remedy and not use it because of professional bias and incompetence, encouraged by the bias of the press and the media. Electroshock, as you hint [pg 329], is different today than what was available a quarter century ago. But the negative attitudes to electroshock expressed by your husband’s physicians are as prevalent today. The legislature of the State of Texas is considering a bill to abolish the use of electroshock in the state; it already has regulations that proscribe its use in persons under the age of 16. A starting point could well be the enclosed memorandum from Texas. The bias against the use of ECT is largely engrained among mental health professionals and managed care companies where ECT is seen as a ‘last-resort’ therapy -— to be used only after all other possible treatments have been tried and failed. Dependence of oft-repeated ineffective trials encourage suicide and death. �Mrs. Katherine Graham Page 2 Perhaps you can turn the powerful searchlight of the Washington Post on national bias and hostility against the use of an effective and safe treatment for severe our depressive illnesses. Sadly, few of the active psychiatrists at NIMH have experience with electroshock. The only two names that come to mind are Dr. Richard Wyatt and Dr. Matthew Rudorfer; the ﬁrst has an academic knowledge but little clinical experience; the second a limited clinical experience. But they are knowledgeable. Thank you for writing such an interesting story and for expressing so clearly the tragic effects of professional bias against an effective intervention. Sincerely yours, Max Fink, M.D. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Graham, Katherine Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-162 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/6b1e558a4545a7860d53391fce32ac37.pdf 2d7ec677f8818f096f90091183d38871 PDF Text Text March 11, 1997 Mr. Philip A. Pardee, Membership Coordinator American Psychiatric Association 1400 K Street, NW. Washington DC 20005 Dear Mr. Pardee, I should like to endorse the application of Guillermo Jose Castrofor Quintela membership in the American Psychiatric Association. I met Dr. Castro during my visits to Montevideo as a consultant and speaker at national meetings over the past few years. He is an associate of Drs. Alexander Lyford-Pike and Gabriel Savi in their teaching program and clinical practice. He participated in clinical case conferences and expressed a good knowledge of clinical practice. Dr. Castro has attended meetings of the APA and has attended courses with his co-workers. In one ECT course when I was the instructor, Dr. Castro participated actively in the program. He is an excellent candidate for Corresponding Member and I recommend him without reservation. Sincerely yours, Max Fink, M.D., F.A.P.A. Professor of Psychiatry & Neurology � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Pardee, Philip A. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-163 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/2dfaddba8ed2b7f7af4fd7f5bb57a19d.pdf 0cf40cff6731a7b878957eec0d91afb1 PDF Text Text Date: March 11, 1997 T0: Dr. Athanasios P. Zis FAX # 604.822.7922 Total Pages (including this sheet) -5- Dear Athanasios, Sorry for the delay in answering your FAX but I have been on holiday. A search of the ECT Database ﬁnds only a few studies of parkinson’s disease and ECT. I attach the citations from the ﬁle. I know of no studies in progress on PD and ECT. A few years ago I was told that Dr. Melvin Yahr at the Mount Sinai Hospital in New York was managing such a study but I have yet to hear or read an abstract. Richard Abrams had such a study in progress in Chicago but the intake must have been slow because he retired and I have heard nothing more of it. Ray Faber at the VA in San Antonio, Texas told me of his program in ECT in PD and that he was doing maintenance treatment. Ray was the one who explained our cases of delirium and advised me to reduce the l-dopa doses. His review with Tn'mble is a good He would be the one to call for possible experience. I know of no PET studies published or in progress. Sounds like you have a good problem in hand. Go row Max From: Max Fink, M.D. FAX: TEL: 516 862-8604 516 862-6651 P.O. Box 457 St. James, New York 11780 Alternate FAX: 516 444-7534 Alternate TEL: 516 444-2990 � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Zis, Athanasios P. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-165 Date A point or period of time associated with an event in the lifecycle of the resource 1996 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/f3b4535cd8d18345eba5e6ce2381ad8f.pdf 673e3836611ae6e6892168734b53f624 PDF Text Text February 6, 1997 Lee C. Miller, MD. Northwood Ofﬁce Center, Suite 9 2201 Forest Hills Drive Harrisburg PA 17112 Dear Dr. Miller, You inquire about a 39-year old man with a ‘life-long’ depression who has been sensitive to the side-effects of medications and is considered a treatment failure to psychotherapy and medications. He began ECT on September 6, 1996, showing improvement after 6-8 treatments ‘and then curiously the gains seemed to recede.’ Treatments continued and then ‘switched over to maintenance treatments.’ Treatments have had to be given weekly, and any attempts at lengthening the interval between treatments is followed ‘by a drop in mood’ [and presumably a request to continue]. The beneﬁts of ECT usually persist alter the course has ended. But some patient’s beneﬁts are limited to a few days after each treatment and it was for such patients that continuation therapy, either medication or ECT, has been recommended. 1. How to explain it? The beneﬁts of ECT arise from our ability to stimulate the hypothalamic-pituitary axis to liberate, in greater quantities over a persistent period, of those hormones [labeled by me as ‘antidepressin’] which regulate mood. In some patients, ECT ‘j ump-starts’ the process and further stimulation is not required. In others, the change is transient and repeated stimulation is required. The best analogy is our experience with insulin -- in some patients, diabetes can be controlled by diet; in others, oral agents; and yet others, daily and mullti-daily dosing of insulin is necessary. To get around it -- treat more intensively and hope to get the system working again. At times, we have re-admitted patients to hospital and given a new course. 2. ‘Indeﬁnite’ courses of treatment are occasionally required. At UH we have records of patients with 40, 140, and 180 treatments over periods as long as 10 years. In some, the period between treatments was lengthened by concurrent treatments -lithium and then lorazepam in one case, clozapine in another. �Given these facts, I have no concern about continuation treatment. I would, however, do the following. a. Assess by careful inquiry to the family whether unprescribed medications are being taken out of your ken. Speciﬁcally, alcohol, benzodiazepines, or even barbiturates muck up a treatment series. I would surely enquire what is meant by ‘a small dose ofXanax at bedtime ’. Self-restraint is not a feature in benzodiazepine use. b. I would next entertain a series of treatment trials —- lithium at levels of 0.4-0.6 mEq/l; lorazepam at 0.5mg bid; and if well tolerated, lorazepam at 1mg tid. c. Perhaps, an independent consultation as to diagnosis is warranted. If the underlying pathology is that of a dysthymic disorder [a lifelong atypical depression] or an Axis 11 character pathology, perhaps the best course is to forego ECT before any damage is done. Prolonged courses of ECT are the basis for legal suits, the plaintiffs arguing that the treatments incapacited their ability to survive and work in society and their claims for damages achieve credibility with insurers and juries. Your question is interesting. I will be out of the country until February 26. If you want to discuss this ﬁn'ther, try me late afternoons at the numbers above. Sincerely yours, Max Fink, M.D. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Miller, Lee C. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-167 Date A point or period of time associated with an event in the lifecycle of the resource 1997 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/d09c6edd336dd64fdd9c870cb01b5ce1.pdf dfd8dae2a3557321796cb4382af9aca4 PDF Text Text February 5, 1997 Henry Pechstein, MD. 145 Cathedral avenue Hempstead, New York 11550-1125 Dear Henry, What a lovely surprise! It was a pleasure to look through that Newsletter of 1959 and to realize that it was almost 40 years ago. The names alone -- Lenzner, Nord, Shapiro, Zuger, Bauer, Whittier, and the speakers Nate Klein and Harvey Tompkins-brought back images. I remember almost all of them. It was a much freer time in psychiatry; our battles with the psychologists seem like the battles of Neanderthals today. archives. I am delighted that you are sending the old numbers to the Society I am still teaching at Stony Brook. I have maintained an active research interest, and seem to have made a name in keeping electroshock alive. My book in 1979 was useful; my student Richard Abrams took it over in 1988 and is now issuing his third edition. Not to compete with him, I decided that a ‘popular’ book on electroshock was needed and I have just signed a contract with Oxford University Press for a ‘trade’ [read= popular] book which I hope to have done by June. All in all, life has been good to me. I trust the same for you. My thanks for thinking of me. Sincerely yours, Max Fink, M.D. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Pechstein, Henry Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-168 Date A point or period of time associated with an event in the lifecycle of the resource 1997 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/61c33925791b5d54df352aaeb8e8f263.pdf 0409434e3bdb6db1fdf603492858b4f1 PDF Text Text Walter Sannita, M.D. Institute for Neurophysiopathology University Hospital San Martino 1 6 1 32 GENOA, ITALY February 4, 1997 Dear Walter, Thanks for your recent notes. I worked on the IPEG Artiles of Association and enclose my pencilled comments. I think that some members would be shocked to think that the residual money -- even if there will not be any -- was committed to the German EEG Society. Better to have the ofﬁcers decide what to do at the end. It is usual to give a party and spend all the money when a society dissolves. Good times and good memories should be had by all. As for Dr. Valducci, it is a tragedy. But, electroshock is a surgical procedure and even if someone has given more than one-million treatments, the same care must be given to the one— millionth-and-one. The patient’s death, as described, is the result of a doctor’s error. It happens, but that does not excuse the physician. The family deserves recompense. The reason is simple —if there is a question about eating before ECT, the treatment is either passed over; or if the treatment is compelled by the state of the patient, it can be given, provided that the patient is intubated. [Hence, our insistence in the US. on an anesthesiologist for every treatment] Tell Dr. Valducci we are sympathetic, but he seems to have erred. I am off to Astralia for two weeks. It seems that they want an American ‘course’ in ECT and Martha agreed to go with me. My best regards to Titty. Sincerely yours, Max Fink, M.D. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Sannita, Walter Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-169 Date A point or period of time associated with an event in the lifecycle of the resource 1997 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/1230f9c4f00d73be1d469b9abdd26496.pdf 8e349e2582d217a5d7b01049fe29f056 PDF Text Text January 12, 1997 Dear Jack, It was good to hear from you again; I also received a card from Sophie and her family on holiday. All is well here. Martha has just returned from a short visit to our two grandchildren in Phoenix. The are growing well and the reports were glowing. My son, as a Department chairman, is in that phase of his life that he is dealing with ‘movers and shakers’ -- deans, university presidents, and corporate executives. He likes the power. At the same time, he is at a pinnacle of his research career, with much research money and many students, and has to decide which effort -- the academic or the political -- to follow. Martha reminds me that I was in the same phase when I was in Missouri as the head of an institute. I am glad I chose the research. On the topic of research, a few years ago I urged some leaders in ECT to organize a study comparing the efﬁcacy of continuation ECT to that of continuation medications [lithium and a tricyclic]. After three years of bargaining, the Government has awarded grants to four hospitals in a collaborative effort. Unfortunately, the federal funds are inadequate to do the study properly. In the past, universities were willing to support the research effort, seeing such work as part of their academic responsibility. No longer. The issue now is wholly -— how much money do you bring in as a clinician; how much are we paying you; and if we cannot make a proﬁt, maybe it is time to go. So, I am in the process of returning the money to NIMH. The process has become ugly. The Dean has asked whether I am willing to retire now. After all, he says, he can hire two psychiatrists for my salary. When I noted that I have been accorded all sorts of honors as a teacher and as a leader in research, he smiled and said that the school had paid me for such efforts in the past, but for me to ‘get with it’ -- the times have changed. Martha and I have begun the necessary dialogue to retire later this year, after I have completed my present assignments. These end in June and after some months of terminal leave, I should be free. My book ELECTROSHOCK is coming along nicely. I have written a for the laity. I have a good publisher [Oxford University Press]. All the main description chapters are written; I am busy with the end-notes and appendices. While it will not lead many to this useful treatment, it will serve to answer some questions. �As with my university, a similar immediate return seems to have affected old your company. Earlier in the year, when mirtazepine [ORG 3770] was about to be marketed, I reached the research director at Organon USA and suggested that we undertake a clinical trial of mirtazepine in delusional depressed patients, with an eye to deﬁning its efﬁcacy in hospitalized patients. I noted that the ﬁling data in the US. [which he had sent me] was limited to out—patients. In return, he said that they were not at all interested in testing mirtazepine in in—patients. [I do miss the days when it was possible to talk directly to Organon’s leaders] I replied that I ran a clinic of depressed patients and I offered to examine mirtazepine in either our depressed patients after a course of ECT [was it as effective as a tricyclic in continuation treatrnent?] or in those who were not so ill, and for whom we could deﬁne the clinical efﬁcacy at the same time as its effects on adrenal functions. Again, he wrote to say that they were not interested. Too bad. The competition for attention in modern psychopharmacology is based wholly on hiring ‘names’ to give ‘talks’ about new drugs and to ‘testify’ as to their effects. Most of my peers are already on the do g-leash for other compounds [of which there are about eight]. I fear that mirtazepine will have no better fate than mianserin in this country. Martha continues her supervision of student teachers; our daughter Rachel in Massachusetts has adopted a lovely, bright, and intelligent Chinese girl whom we love. And Linda has convinced her husband to take a position in Virginia -- they are building their home on almost 200 acres of mountain-top nearby to her college. I continue to give courses in ECT and lecture on my new-found interest, the syndrome of catatonia. Martha and I are off to Melbourne in late February. That will be our ﬁrst trip to Australia. So, we move on from one phase to another. When I step down, it should be possible to travel more freely. We will see. Meanwhile, Martha joins me in thanking you for your kind note, and we wish you and your family continuing health in 1997. � 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 Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Jack Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-170 Date A point or period of time associated with an event in the lifecycle of the resource 1997 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 Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource 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 Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/4b34d77a93adfdf543aae63a1ead5831.pdf 9a3d77013a79d7057f02f224ed583aa6 PDF Text Text 42.5.3. gm Standin- of tho ‘ alteration in mum the focus or mufﬁns 1 laboratory for olmtmnmphllompm studying A or the Dona-“mm. of Manley during eh. ambuahod, and ”min manta]. oyndma m. introduced. grasp Band», dapreuivu m mm ammmud with unplug“ illmaua, men-u, man-hm. We: m method- for on, The tha change in pal-cerium in and following alactrocomulaivo therapy. “fact. at barbiturate”, ”mun um um intentiuly studied. “new of the Wan. put you. invents;pmimWe“ 51113393“ to alwltmm stimulation buts, hogan at tinted study gationa or the raspame of by Dr. w with changu in brain funeum wan and 1.780er acid (181345) on such The mammal latter part or the year, a corn-3.1M in brain function during data-woman“. thump: m In tho m psychologists. Dr. march assistants to the Imam Robert him and In; R. Karin worn uppointod «Mt, tad Dr. in: link a fellow of the ﬁatiml for Infmtiln Fanlyain mu appoinm to mum” the laboratory work. oi: Databa- 1, 1953 am charmmloganQ laboratory was cmbliahod with a Man. 8 clam}. instrumnt. In the mum. mm month. 65 mount. are taken. 01' than 19 um emulation muons m M in the ovum of th. integrated study an altered bran functian. [mung tn. year. 55 consultation mum matured. ﬁgure than half of mania mental am.» “mated with amt-"sin 111m“, were far or mhtod to duotmnhook thonw‘ 301m awn». neuritic types of pain, 1nd abnoml involunm menu and. up the bulk of mum. 81.: patients with «ism «11:0er um mum and controlled with anaemia to the neurologiml service of mi. Sinai amen. Thu. patient. are fie-pita?! m further ima’oiauogu for nmlogim conditions chums»! at tho m mum: We mm haapi talc �~2- m pmodural chm m introdum by an dmﬂunﬁ. u an Ad to evaluating thu uremic mum sum, tn. «ma “but” no introduood m Ivar round tbu 1m thin m1: «as worming an m put yaw, mum. ' folio-“mg the am of ehktrolhm mutant” and the In part of the in maid». mu m at mmimlmholim inugrltod study an olectrwhaoh in (month) A: In Want chlorich new“ mmmm mum; as mutated. and at «Iv m tho no! emu)“ m1- want. 1: mm «amnion: in indumn; roux-Man mum cum mining agent: 50mm. 121 Mates! m: or thetroﬂmck wanmu. 3.. at 4:1: The damn“ an at maharhiul ”dim in Mam” m. Jaw. Psych. zommm. (Jump) 1953. Eu- 31131108.» (1953) Mr. 11.8.! Kit.“ of link, I!" Harm, 9.3., Bath-awn, I. and on Perception, Trans. Amer. Hm. used... Jun- 1953. m, it" Green, )1- and Binder, Simultaneous 3.3.x Perception of & Malta, am. mm mu. m». mm» 5: A ma a. sum-um. study m: a ﬁnk. Tmhw, w mummy Jour. 31mm. Hosp. 236%71 (Ha-ch) 1953. 117th34¢9 m I thtu M11. um.) emu 1953. momma mamas, �October h , 195“ Interin Report Dear Dr. Miller, requested I wish to report that the following projects have been in progress this summer in this department. 1. Effect of electroshock on memory func» tion tests. Twenty-four patients are now fully studied; the data is beingA collected; and a report is planned for the 1955 A P meetings. 2. Effect of Lysergic Acid on perceptual functions, including Rorschach; and on blood chemistry. These experiments are now in progress and will be completed by the end of the year. ‘E3iy Under the terms of the U.S.P.H.S. grant a continuing study of perceptual changes in insuli n, and EST patients is now in planning. a. A psychiatric rating scale, modified after Malamud, is in use. As soon as it is standardized in this population, it will be presented to the Research Eonmittee. £5. The Funkenstein test (Hecholyl) in EST and insulin therapy is being checked in our pop— As you ulation. Sincerely, HF33RB �Obtober Projects in Progress as. 1954 / ,2-\ Relation of mental changes to behavior f‘ 1' (1) Effect of organic mental syndrOme on results of EST. (3) Changes in perception with I92. \ (3) Can ACTH. cortisone alter brain function and thereby (a) l ; i results of (b) EC! or ICT? \ \ Psychophysical measurements of Psychiatric terms - an operational approach to terms of diagnosis. (1) Denial: Relation to improvement in electroshock Relation of premorbid character to change in behavior in electroshock. (2) Ambivalence: Is it possible to measure ambivalence by psychophysicel menad and relate to the past history of the patient in choice of neurosis? Relation of chemical agents to psychoses. psychological. (o) biochemical and behavioral aspects. (d) 9 Rating Scale' �October 1?, 195b Dear Dr. Rachlin, requested I wish to report the following projects have been i n progress this summer. (1) Effect of electroshock on memory f unction, FRO, Amytal tests and nerceptual tests. Twenty four patients have been fully shielded. The first revert on the relation between the response to treatment and the occonotal test is being submitted to the A E A. The observat ion support As you the thesis that there is a relation between t development of an organ. he Mental syndrome and improvement. Effect of lysergiv acid on perce ptual functions. Rorschack and blood chemistry. The psychiatric and psychologic tests are being prepared for presentetnion at the American Psychopathological Association. (3) Under the terms of the U.S.P.H.S. gr ant a continuing study of perceptual changes in insulin and EST patient a is now i n planning. (3) A psychiatric re.ing scale, modified after Halemud, is i n use. As soon as it is standardized in this population, it will be presented to the (2) Research Committee. (5) The Punkenetein test (neohom) in EST and __ �nsulin the rapy population. 1 18 being checked Since rely, 1 n our � 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 Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-001 Date A point or period of time associated with an event in the lifecycle of the resource 1953-1954 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 Annual report - department of neurology; Interim report to Dr. Miller; Progress Report; Letter to Dr. Rachlin; 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 http://exhibits.library.stonybrook.edu/mfp/files/original/e5d103cbe3dc9cd93159ddec488b3ecc.pdf 022eaace568b7d0816980adc5ccaa74c PDF Text Text �nau- mmmmtmw.mumntwmsm Mmammmmawmatmmmummm mmmwmmawmmwmmmamuwum uwmmummmmmm. mammmmipwh umummonm. mwwumwamm vamwwmhym.mmm. mmuummmmmmmmww mmmmmmwmmuormmmm 1. Wanna-m mmmummwummwtw wommwmmmumzmmmmmm mamawaum. itmhmmummum wm.mmm1mmmwm.mm,mmmm Wm W W M as th- an M: to» Manama. at Bra. 13.311.313.31, a «mud mam-1. m mgm.mmmmmmmﬁam.mmmruuw u1wmmmamwmmmtmmmm. M mmwmmmgmmwummmuzmw. m W‘M‘MWMWmmwMWMMdm msMMMmMmm-cmaammm.m 1mm». smu‘mmmmuwmmmmmm umwmmmwmdmmwwnmmm mwumwmuwmwmamummuum. ' mmummmmmmmwuammmm ammmmam~mummdummum mwummnmmmm. �03¢ unmmmumswummmammau wthmquduWMuMdehu-W atmwmummthummmu-mum ﬂat “mm. ”mum, mum... 'm man-om. mm: mmmummmmmmpmnymm and a; W13M.Wﬂ a. WWW mimnmmtmmmatﬁmmm W(mm)maamum. Wmmmmm minituamtmﬂtmmlymmsum. mmmmmmmmmtmmanm M 1(th m.w.muammmmammuumm ﬂaw. maem,nnmmwgmnhmtmnmu Madmanhdtnmmmm. nmmmm,mm Mmtmm)mmlwwm.nm,mmmnum nu mm“ m madam ( mm mm. 31WCW319511}. in. thWWWMtWWthqu man up man. um), mum m by the (at... P. mm um), WMWWW‘WuM): Wmmmtzmm mﬁmleohtaM (mu. 3» a.» scam mum (in. A. mm) m: mm mm mm m afﬁrm! 1*» the mama about»: mlmumtomammumwmmmm mmmuwmmumdmm mommamm mwmmmmammmm �ah- m.nmmmmtm.amahmummm mammwmmwmmumarmmmwnmwmm ww-wwmmumzwmmmmdm- mummmmmmm Ammaomwmt . mumermmmmmmd. mammalian ”wind to: m :mm mm, W Wm m1 momma-g. Wammmmormmmw mmmmmmmuma,mmmm wuunmmu.m«smmormum. mummm monarwmm,wmm9r£mgmtmrormwa Wcmmummmuamumwm. nmmuumymawwwmm W..1tmwmtm‘uitr1nhmdmhm mmmammmm. Mmmmemdin mommmum. num-mmmummmu immiwﬂmmmmg nmwmmm.m.mmmwwm mmwmmmotmummmmmmmm PM!» mmmmimhﬁmotuMMiﬂthmhm wmmummmwmmmmnww wwwmmtawmummwmwm. Pu WW hammmwmamummmaaw WWhmamﬁSﬁmmmnu-ammnh «ma-W'mmmwmmhnmmmwmm hmuuaummumMmmwrm-um unmmmm,m.m,wmmummm ��.ﬁ‘ V mum mum. mm am-ammummmrmmmam ummmmmmmnmw hr mum iii. W mumt WM AM}. 1955. www.mmmmarumwanm mnmwmmmwmmumummuw mmmu‘mummm‘ WW. 8. mMMMMWWWhNWW‘ mu m in nan-mm m :15 7.» WW Mmemm 3» mm .mumwmummmwbmmmmwm «mmgmumﬂormwmwmmwu mummuuwotmmumm 9'9me”. mammmmdmuuatmummmmum murwmwmuwuwmmmnr ammmxmysa. ��Dr. Fink January 18, 1955 To: All Department Heads 'Re: Annual Report Please prepare Report all - l95h of your data for the 195h Annual at the earliest possible date. All tables and other information should be turned in to Mrs. Bailey, Office Manager, on or before February 10. uith your statistical data, Dr. Miller requests that in addition to any tables or general statistics which you will furnish, that you write a succinct out— line of the'work of your department for the calendar which comments in appeared the to similar l9Sh, year Along the last Annual Report for your department. Please submit all data in three copies. I think that will be Report in.March of this With everyone's cooperation, able to publish the Annual year. a report of I vities of the hospital similar to the would like you to Janua RY 19 meeting. make all research'acti— one given Maurice Bachrach Administrator. Mled at the �(33L Biochemical Research Material assistance was offered the laboratories during 1954 in the form of enlarged quarters, and by the award of a two-year grant from the National Institutes of Health. The program initiated the previous year by Dr. Harry Goldenberg, Director of Laboratories, was continued along the following lines: Clinical Methodoloww It has become abundantly clear that the clinical laboratory can no longer cope with the special problems of mental disease using ther standard chemical tests carried out in general hospitals. Consequently increased attention has been directed towards providing the clinical laboratory with procedures for testing adrenal and carbohydrate metabolic function as well as for determining the course of drug and shock therapy. Reference has previously been made to ketosteroid and corticoid analyses. A new direct colorimetric test for hormone conjugates is nearing completion. Rapid micromethods have alib been perfected for two standard analyses, viz. blood phosphorus and which have hitherto been subject to large experimental phosphatase, A simple technique is also being investigated for following errors. the course of chlorpromazine excretion in urine. Metabolism of Steroid Sulfate Conjugates Impetus to our earlier studies on the metabolism of sulfuric acid—bound steroid hormones has been furnished by an InStitute of Health Grant which makes provision for much needed equipment and simple personnel. At the outset of the grant period a remarkably method was discovered for the colorimetric assay of steroid sulfates, based on the use of basic dyes. Further inquiry shows that, aside from its use in enzyme research, the method offers great promise for the assay of bound steroids in blood and urine as an index of these lines. Studies along continuing are stress. physiological Mechanism of Action of Lysergic Acid Diethylamide and from drawn have been vitro conclusions inc preliminary ig which induces LSD mode 25, a of of drug action on the vivo studies in a—transient psychotic state: (l) LSD 25 is a powerful inhibitor of human serum cholinesterase. (2) Parallel with a definitive response by the individual receiving LSD 25 there is a rise 11),..38rum alpha keto acids. Hormone Assay with Enzyme Systems There appears to be little doubt but that hormones are implicated The in establishing deterrent prime mental aberrations. and emotional in of for of assay suitable procedures this relationship is the lack . �function. Were such procedures available it should be possible to catalog mental illness on a chemical basis and suggest corrective action as an adjunct to the psychiatric services. Since the effect of hormones on various organs is mediated via enzyme systems, an extended study has been undertaken into the The hormone for systems isolated enzyme of‘using assay. possibilitywould involve incubating the test fluid with the appropriate procedure enzyme system in a test tube, and then determining the degree to which the enzymes are altered by the hormone in question by measuring conditions the release of a colored product. To determine the choice of makuxx been necessary to for carrying out these measurements it has The on two mathematical studies. papers out detailed first carry in Several manuScripts are more been have published. this'subject of preparation. various stages hormone Bibliography Goldenberg, Harry "Rectification of Nonlinear Beer's 690 (1954). Goldenberg, Harry Law Plots”, Anal. Chem., gg, "Rectification of Nonlinear Enzyme Activity Curves. Arch. Ricchem. and Biophys., §§, 288 (1954). I. Preliminary" �.; and Research of the of Publications Department Psychology ;/ Research in the Department of Psychology was oriented around several themes including: Refinement of psychological tests, the persis— tent problem of schizophrenia, and the effect of maturation and agang as measured by objective criteria. Certain aspects of the Rorschach test were dealt with more objectively by a series of papers by Dr. Gurvitz and Mr. Eichler and Mr. Feinberg. These set up for the first time objective adult standards for evaluating many Rorschach criteria which were not available previously. Further data was made available to experimenters illustrating the normal process of aging and maturation to further extend the cancept that if people grow older there are decrements in intellectual functioning and personality ingegration. In two new papers to be presented at the Eastern Psychological Association meeting, further progress was made in diagnosing schizophrenia by teens of psychological tests. The past and current research in psychology at Hillside has continued to attract attention both in terms of the acceptability of papers in both scientific meetings and professional journals, and also in terms of the many hundreds of requests for reprints sent in by psychiatrists, psychologists and social workers. These papers and research projects have also served as a training medium for psychological internes in the Department of Psychology and the past year was noteworthy for the fact that each one of the psychological internes or staff members presented at least once at a psychological convention or participated in some published research.project. ��RESEARCH During the calendar year l9Sh two projects were in process. their families pay for hospitalization a) Study of rates which patients and as correlated with time Spent in the hospital. b) The adjustment of applicants referred by psychiatrists found unsuitable for admission to Hillside Hospital during period 1951/1953. This latter study is a series of studies which is being done to determine the adjustments in the community and the use of community resources for applicants who have applied for admission to Hillside HOSpital but were found unsuitable. It is planned to continue this series during the year 1955. In addition, the joint project with the Jewish Community Services of long Island concerning the placement of discharged patients in private residence continues. W3 research project is being set up at the Altro'work Shop to which patients discharged from Hillside Hespital go in order to learn work habits. A Publications: )/ <3'“>( '21” ,~ 63‘” 7 s====r ;) Vocational Adjustment for the Emotionally Disturbed Authors: Roland Baxt, Abraham.Lurie, and Joseph .A. Miller, . - M.D. Presentations at conferences: a) [pulse Pinsky presented a paper at the National Conference of Jewish Communal Service in May, 1951;, called, "The Impact of Medical Crisis on the Family". b) AL:hd ‘ Abraham Lurie Spoke at the National Conference of Social‘Wbrk in may, 195h, "The Implications for Psychiatric Social‘work of Team‘work Relationship Between Social'workers and Psychologists". �MEMORANDUM FROM THE CREATIVE THERAPY DEPARTMENT WWW 1955 Study on the constructive and/or destructive use of passive and active aggression as a differential test for determining schizophrenic responses. Data for this research project had been gathered for the past three years. Their sifting and clinical evaluation is planned in the near future. The test is carried out within the C.T. program and consists of 16 specific proand number of jects EZ/r #290 a sub-tests. “a 707 Ernest Zierer �Fsbmary 2, 1955 Memorandum from: Dr. To: Subject: Fink M. Bondsr, M. D. 24.1). Anmsl Report of Hillsids Hospitals and medical services with other Coordination md cooperation with the psydxiatrio staff past you. With in. slsotmoncsphalogmm, for the of laboratory sstsblishnsnt tho crossed use of this facility and of the consultation faoilitin m was incrsssed during the: ands by members of the resident and attsndim staff. the answered attending by 19 consultations ssrs the yes“: hiring neurology oer-vies, and 1:0 consultations in addition vsrs anmrsd by the rssidaxt neurologist. In the slootrosnoophahgramio laboratory 111:8 this nun":- 75 constituted consultstion taken rsoords wars the 0! records. maindsr, follow-up ”cords vars taken. rsqnssts and 01' in tho oourss of two invsstigations - one in tho effects of electro- shosk on brain function; and the second on the relationship between treatinsulin the of and the rssults can function brain in changes mt. Evaluation of the organic mental mamas provided the major with three Thurs were patients consultations. nourologio Icons for the clinic. followed in sud who controlled wars disordsrs leisurs Four logic nonrafurther for another institution to transfsrod sore pstiants work—up and troatmnt. when direction another in The neurologic service nto consultation prior for aimissions olinis nods tbs tron qussts ms was extended hospital admission. your and Sm such oomltstions were dons during the svnlustion butts:for s an upper-unity ssrvioo providsd this �of the patients problems before autumn“. introduced to you in 1953 to evaluate organic m natal The " mail test" which was mm richly used during the put year, syndmmlg . �Fobmary 15', 1955 modem Annual Report of Wt of Neurology, 11111:“. Hospital — moperation with the psychiatric star! and other mdical gen-ion by when of the neurology was increased during the year. 63th Fortyunino «nomination: by the attending neurologists, and «agitation: 1:0 additionﬂ were answered by the supervising neuropaychiatriut. the eiootroenmphalographie laboratory 111:8 ream-ch mm m. In this 01' lumber, 75 constim‘bod consultation requests and follow-up rewards. Evaluation of the organic mantel syndrome provided the major focus for ammlog‘io consultations. more were three patients with mime disorders who were controlled and followed in the patients mm tranatemd to work-up and treatment. Hillsido in 1953 was The «3111116. Four guard hospitals for further nonmlogie «um»; ﬁrst“ which to: introduced at mm widely used to evaluate organic mental and» must. {the mmlogic service uni also extended when rogue“; worn man from the admissions clinic for consultation prior to hospital admission. such consultations were answer-ad during the your and Sm this service provided boron admission. Under tom an opporhnity for a batter evaluation of patients of a U.S.P.H.S. grant, the electroencephalographic laboratory was swarmed for taohirboscopy, and a number of basic nouns. physiological problems were smdiod. f ’13:“ ��_ my}- 1955 Neurology hmommmwumammmwumh mes in the visiting a... was noon almond by mm. Wynn». tndmtharrﬁ m supervising mailman In th. metro-n mphdographic laboratory, 210 mom an am, of which 7!; war; consultaticn "quests. For the most put, the consultations in!" on)» momentum (6); pain syndma (3) and axiom cum tit-onion (7); men-1 wt: >nenrnlng1c mum (10). 'th wk). test for organic bran dim” Wmtinﬂpt’dnnu. activities mar-aura: ”sued mm... «momma-mt uﬂmofuorganicmtalayﬁmﬂﬂ ingpmmo. mmormmmmommsmemzm “Wmtmmmum var. mammotmmpaum fonmddnringthairtmmtﬂth aerial Wanndawmtem. numﬂtamsoam.tunmnn¢mdnmmm ammunmummmmmmmmamm mummiﬁufornm �"... u. p.-.. “N... . . N, ~ mm .mu—mww." wwmmw’mwm. ., W, .vnx— “‘Wn" .7 m as: u.- momma! Dr. H1110? TO: Dr. H. Fink RESEARCH SERVICE, smcrmmmya-pm-m. Dummmtharmmhthemmamanumwmume . in organizing an mom nhctmshook 2mm, the and the mam, the mm m Scrpuil project. Considerable mm electron-Museum laboratczy, and sum Public Health Bunion for adds! lamb Grant “97. penis“ w mm in project with Dr. spout in letting up WMar by the equipment mud thu no , Fonoving discussion with Dr. Embers and Dr. known, Dr. LnQuor Wimudtoviaitiﬂllgidumdmmmm..Dr.LIQm15mchup of the Luann unit at Grandma: State Hospital. a: March 9th, Dr's. numbers, mum and melt mum cm:- to as Dr. hQuor'I mam unit. m intended in his that. Vinita, the use or split mm mm: to induce com. mm. This '11]. be mm RobertluhnandnvaeuvisiudDr. hulﬂoehandnr. thhtric Imtituto chitin-$133M. Wﬂaittonr. WWW Dr. undue for the nut Following Med research emanate. at. Dr. Blmbarga suggestion din- mud a similar project ban, and the protocol was prumtod at the nut numb can-dun mating. nth» w. purponoracqmmuthmmaentnumh with Dr. Ismail m most helpful as m. second Our b. has had dmidunbla experience in psychoplvaicq. tachniquu. SW8 ut his ham and dime.“ withhmthemdforimmudmndsforthocmmm. Iupmssodtohiu (h March 17th I Visited Dr. Ismail thodllinbﬂityofhlvingmummeo that Dr. ﬁlmmldbo thoDuunPoundntionorthoPnaidcntamifm Public mppomw ‘19de that ��mm: Glon om, no: Ia-k KEPITAI. April 28, 1955 to, Dr. Josoph S.A.Hillor,llodioal Dix-sates M8 Dr. Kl! Pink 8i: subJoot: ' hospital, Honth Promos Ropu-t and Room-noun". Atthsondstthofirstsixnouthsasbirootorotnosoomhatth 1 should libs to dosoribo tho prosont stoto of our rosoaroh program, thhnsfathoﬂuturo,anitonkowonoouasndationsforsrosm asparagus. I: Prosoat m dotinitivo report of tho rosooroh aotivitioo of tho dspsrtnsnts of tho hospital was prooontod to tho nsdioal Board on April It, 1955. by tho chairman of tho Itososroh Omittoo. A tho prosont tins, tho staff assisting tho Dirootor inoludos two it psychologists and a part-tins sscrotary ( supportod by norm and Dausn Foundation grants); and o half-tins no toohnioian. Port-tins roooorch ootivitios aro cox-riot! out in tho various sorvicod sports-onto. In tho Doportuont at Ioborotorios, two toohnioians oro assisting Dr.Goldonborg, undo:- tho tons of a noon-oh grant of tho USPRS. Of tho psychiatric staff, two supss‘visim psyohiatrists and two rosidonts aro ootivoly oncogod in part-tins rosoaroh. Of tho ottonding staff, tour labors of tho Hodicol Board as in diroct collaboration with hospital psrsonnol in spocitio projects. is octivo in tho following projootst a. Following on tho sumoay of tho 1951; proJoot on thorolotion of altsrod brain mnotion to following olootroohook thorapy, a oooond projoot has boon undsrtoksn to asaosa tho chorootomlogioal and bioehonioal factors in impromnt. b. An snluotion of sorposil so a thoropoutio ogont hao boon undortakon as an intomopsrtaontal projsot, with tho sotivo oooporotion of tho .diool dopu-tmnt, onporvisim psychiatrist and a rosidont psychiatrist. has Dinotor imam. o. dosslopuont of moan-so of abivolonoo, both as a chorootonologiosl factor and a symptom of psychiatric choc-ponsation. “his study is in conjunction with a lambs: of tho Hodiool Board. d. and taoMstoooopio ”physiological of tho new, is now noaring oonplotian. Dnﬁont Tho 'l'ho laboratory, built with funds Tho hm m'ass stimlata's, nocosoary for tachis- mt. mublod. oscilloooops, and roloy and lons tosoopy havo boon dolivorsd, on?! are being boon outlinoo and will begin by slid-Mu. Projects hovs �4-2Bimltonoomly with thou motto, I havo boon participant in a nunbor of tho dopartnontol projocto at the hoopitalp oooporatod with tho ﬁbcultun Study Omittoo in tho dmlop-ont of its protocol; and havo mlnatod throo protocola which uoro oubnittod to tho Roaoaroh Conittoo from outoido loot-coo, and out. opooifio roommdationa on oooh. now mum problou of mohiatry involvo all aopooto of tho moo, oonroo, for thoo'pocitio tonic tron-int and provontion of tho Nor poyohoooo. an! innmatory poychoooo, nothing is known of tho otioloy of ochioophronia, involutional paycheck or antic-domain illnooo. Itch duoription of tho oouroo of thooo illnooooo io availablo, but thio haa boon of littlo bola": in troatnont or promotion moot in ioolatod inotonooo. mutant io omit-idol; and W at boot, poi-ital". ' " control roam for hospitalisation in loot pationto in tho dmlomontvo! owning tonsion and anxiow, and pmhotio thoughto. lutorporoonal rolaticnohipo havo boom diotortod, culmination blurrod, and otfootivo activity oo to throotod oolf-prooorvation. rho vat-1m porchiotric thorapioo oo availablo today attack difforont aopoota of thooo problouo. A prion-y goal io tho doovoaoo in tonoion and musty, and tho ovum-o of mohotio idoation. hob offal-t in «pound ot chaining intorporoonalxolatimohipo and oodoo of omnioation; and nontual ”education and oupport d tho pationt in dirootim his ootivitioo along «room ohannolo that lood to on! meiot- prooorvotim. Tho m1 alto 0'thMom. “ti-toot“: intho njority or ma‘ont nothoda portion.- in at loaot town-11y atomim tho poyohotio rollovine tonnion and indnoim a roturn to non offoctivo In this prooooo, tho following nothodo are pennant at tho hoopitoln Ont 1. W. By 2. By 3. By hoopitolilation, thoe pationt ' is ”poo-om pm, and ioolatod ' tron bio » .diootion, barbitnratoo, oorpooil, and chlorpronaoino, and by olootz-oohook and ubnlatory insulin trootnonto, ton-ion and anxioty are roduood. dmg W oo olootroohock, olootz-onaroooio and inmlin cola thorapy pontwtio idoation in omod by altoring brain function. It. By group and social aotivitioa, om group thong, in a poniooivo onvironoont, bottor communication io footorod. 5. individual poyohothorapy intorporoonal rolationahipo oro tootorod alom nan-tic line. 6. onvironnmtal “Isolation, sob ”causation, and oooial oorvioo bolp, offootivo mnotioning is By By Onrnaoaroh prom W. io dovotod to ltudyingthooo Miovnda-otamthomwmt moo. diooiplimo aro omtmotivoly appliod at tho hoopital, tho offootivonooo of aw hao not boen mftioiontly some»; nor hao tho undo While thooo ' �W. mwummmammm WﬂMWbW: mmmmmwm-mmammm mmmmmume-‘mmm “aluminum”. ”Wmmuth-ﬁmm ammuqumwn-mmmmwaw mun-nuns 1mm ”mama-um but...“ WWmWI-wb“ name: Amara naom: Wabﬁofmmmwmmmmgm ammphmaumammmmmugm B. nummhummmmwmmm. Wm”. ntmwnmwpmmwwwormm ammmnmotmwtmpmormm MMvoo-R'Wﬂmtbmofmmm Waited-mum. imam-Malawian“umumormmwwmwm. ammmwrmmmm: mmmmmtormm.mumonam wmmmmmuwmmtmmm MW. mamwmvwmmwumm www.mwmm-meummmrm «mwgmnkmmmmmm Sm: mgwmmm'm*wmw muwumwmmmmmmmu mammanmmmmumwm MW”. Was mum W but“ mmammwmwmuﬂc mmmmwmmmumsmmam 13. of (Iona-up): MmmthotmmuWW-wh .szthbmotMW,amwwm-amnmtu mmuwmwm nil-M. nmmnmormm-mmnmwmuuot : Aummmuammmtommmumm Immmmmusmmmmw coucﬂohgyuthomnc. mums-unmet» nu mmmmwamcmauwmmormw numb-u; �, m W WV '7, ,7. _ 7.- ‘av‘nnwf ”WIV , w 0.77 ——-r.,,~__. mm Mm 7,7 .. ,_,_.w. w. 4.-.. x» -vuJ. v a... » “.:.y. V um .t‘A—f»lw"‘.. 5;?u11VI/1‘IIKV pom). devoted $0 and: Mn. 1 mm Wthatmchuuuﬁcolnn'muoh‘uﬁammz manna.at the urvioo (lupus-taunts aft!» hospital; mam 1t abuzle hm would mien «are of mat mural-u of th- men 80m, fun-tine «mam fund» 2;. 50 3. with - Wmum d. Boom 1mm. a. m mm:" mm 1n Manning 5. ‘3 fur ﬂu Ina-mix Its-den ’ i , ‘ Wam ”W ' Why 6. WOW in ' in " ' 8.8mm 7. 9. ' 10.. ~ , 3mm Mot '1. Director '0 which at! «nan-1 ”um-1. Aux-ml 2. «mmw 1:: 7m It soon). ’m -m (1/2 a Comm-m. azppnu m1 Equip-ant: up) wannabe! mm 6.“ 8.W¢ 5.“ . 5.200 . 10,000. mono . 6.000. 3,760 - 3.300. It,“ 6'”. . 1,300 . 1,8001 .25 . 20:33:. 12.600 o. 8,000 a 10.000. “ 103W. .- 2.500. 1’”. Immune-anthem wumrollwimmtlumw: MWWNUSSvaUSé. mama-Manon 10m 2. hunch bout-m . Psychiatry by hog-kw 5: suppuu W1. mm 6. m1 u 13:. 70 335.000. 7.500. 3.200. W & ' hmm(mmngmn) 2%: 1,000. o 7m. @3600. ��, W, ‘ . . 7. 20 TM. “7 » ... , ‘ ~- ...~ ”v- .. -r “qt-u — rm.wnm,——«__..a.; v,r~w-w—;m—u~,‘.wg-W. “my“. m’mwz’wvu-vwww‘,..w;v-— ”Mim. mg} _ v. “VF _. . .‘m ,romummmrmmmmuatmmmm; 23* and to curry an moi: indupenduut‘ ruuponuthinty projuutu; um a um «can. um W to W W m meugm;w mummmm. amt-Assum- his at! umumuwwuwmamupmum in in woman-y mommy, nun-in thuussoeiutu dual-1w“ psychiatry. A. with lb both and uhenld luvu I: cap-rum, By uumu rayon-winter for that portion of the function: of ﬂu umicu "sigma ta him by ﬂu car-octet; in th- diruétor'u “111 um Whmw «tum mtmmuu, neetingu und um touching function: u moon-Mud than”; by ﬂu and». M1. mmmeym-mmmmum. ma~812.0mt920,m0. . . WWhmhnbh. Munoz-1um. “Minna-dc Tb is m Wuhan-vim m migudtohhhytbmm.v «nation mung "than, nun-tun «nudism units, withukluuutmyumuupurumu. Thu ﬂu uumding ofAusooiuiu uaoniuto in ”analogy m for than mantionuaf ﬂu An at control. of in we Mu ruuponuibinw. m dam to guidu ruuponuibmw 91' :u nupuctu of ﬂu mum at and u mucus-uh mmmnumuns n- Mussocuuinmcholmnybuohouunfmthu mun-uh azimuth runa-~36,ooo to 10.000. prod-uh uupmtuu mung-ad hthudupurhunu WWutthurouidummchnw Mfg uusm hundu u smut uid 1n cranium; such projuctu; «Mu ﬂu 61mm of m aunt-uh puma“; uttund comm, ms. uportu und on Inch pupuru, um! madman us ﬂu mutate:- (£th «mm our: my ”train. Mama" mmmummumummbymmm MﬁWWofthWWundthuDimtorofﬂuuu-oh. 3. thumb A3313 renumtthudmmmmwutmandwryon thuwrkofthudupumm.Mushtmti-bbumpoau1bhtomdm such tutu, reports, and pnunt thou mun manners madam, mu mududmtdbyﬂubimw.usmmtobumm1udbymmag undupu‘iumuforﬂnupudﬁud Johan—u. Mus-etc!» oniutudbythu mmmwnthu nuimﬁmdthnmofmch. l. Aututunt 1n Puyohiutxy: For Inch mohiutdutu who hm bud thruu thuoppu» ormnyuuruoIIMpuyohmmonMt mtmmm, for on. team on: and Ruuuurcthmypz-widuthuau~ Mt: ormuywu for maturation in renewal: uluo prom the dimtor with ﬂu mutton uuiutuneu at pcuomul 1n buwuunthu ruuidunt ma ﬂu Memo Mute Thu “shunt. 1n puyuluutry uuu uuawu mpommnty for tho auction ' "0001‘“. �{a &1.th 7- W torthovmm prom; mum chuguinb-hmvuh and of tho int—Ewan“ “as. in tutor. mom mm” «.111 the want Wear of th- p-thnt; Tho "spanninw um fa. than aspects “W ofﬂmbhummu‘auonumiuhmhu Hoﬂlluﬁhumhrm,~mmmuueh mmwwmam. mmttmummutwwm kmlnhmchm,hmm¢h mm'mummmdmnmmwmmuMufmhapimummduuw-ﬂ' aux-y nap-nuns nap mm. W. ’ neopo, ' ' 06.000 to 10,000. on twmpuyeholoyuﬂanm mammal. mmwamm,mummmpommwrortu nothoda and smut-hum at thbut Newt. smart. duign ' with tho soul- of thy . ‘ 'thryrumn-Sﬁﬁoommhwo «Wotan. ”mam Mat-311W W, build can. mmuw “Wham cm; with tho parallel-exist inc m maul-d) mat: MW ”Wham cup-rd..in ohmic“ magnum" mum m. b. mum: a); 1ft!» hbontcry u asp-aloe to m. manna-n whatnot-chain studio’s. Wlmmmmtdﬂummool con-urn. Salary to 30,900. mg. Mtg ",3‘ an an -, o :7 . sup-n13. abducts-Inna; Ia and: null-1 than“ 1‘0 and Wm a- 85,200 W 1mm wWad cum W We m, um ”hum 1M www.mmupmdmwmmw mum mm: rem um mm mm Wwamn‘tarofthu “hm; wtocmmmumumhmungmmm unioapnjocum toba-Iunhyﬂu ”Mummhmm; alum d. And-mt - Social WI 3.5. (Seaman-k) with yum work. on use-sing funny nhtiennhipu. Pinon-1 ambit: 11' pmiou mun-ch «pox-hm. with or mum-nu it should be Muﬂy might-d. Aid-tut. u to napouihdhty for on binary tad to obtain {tantalum ad to the only you. of durum] to with tho mm of f1” 1- in amusing mum, m1 new mammal Ihichhcwmoorgwuththnpm «mammal-am follow up contact. undo. For :11 fellow-up touting an! thc 1:111 like tin mos-cry contact- tad arrangunufor Hindu-actor. “0mm Tho wot-hr to th- aws-Itch amo- I111. 11‘ t1.- 13 mm]... cooperate with the Dix-actor 3350:3111 8mm. in ﬂint prawn 5% WtuWNIIMMWtMDMrMMIWO. aim-Monongooor WmomMmuwW-innm �hme-mlmm,aw0uommmwm anuslupus. alum; m “not. In. "can!”mum «a! £11m; “parts WM mmmegaMnmmp—m. ”00 I;thMtum-mhmmutbm. ‘9 ”‘mo “’m‘ 1 .“ ”m m1. PM W, 2. Gallop M00, WW1. m.mehw. huststthubmmm” uthmmmnngarmm mamwmmusimmmm.mmmmwnm «.memgmummmmmormgwmua mmmpamgmw,mnmmm1mm. mrmdwmmmmmuémm. ﬁmmmﬁmgmmmw 81 1'' m.ummumniymowu‘mumma bmmamtimingfumtimmdukolomm mum-norm. plmning haiblo, it is mud-d 0h“ W stummmormmmmmuwaecmmm of . nun-buds» of 060,000 870,000; and with . 3 luau-uh 1955-56 by Ommhﬂl] ﬂat 836.100. mmnwwmmmbmm-uﬂ, lab-1M. Wily We!” lam, 3.0. I955. �HILLSIDE HOSPITAL Glen Oaks, New York April 28, 1955 Tb: Dr. Joseph S.A. Miller, Medical Director From: Dr. Max Fink Six Month Progress Report and Recommendations. Subject: At the end of the first six months as Director of Research at the hospital, I should like to describe the present state of our research program, our plans for the future, and to make specific recommendations for a research department. I: Present 'A Proggam definitive report of the research activities of the departments of the hospital was presented to the Medical Board on April h, 1955, by the chairman of the Research Committee. At the present time, the staff assisting the Director includes two psychologists and a part-time secretary (supported by USPHS and Dazian Foundation grants); and a half~time EEG technician. Part-time research activities are carried out in the various service departments. In the Department of Laboratories, two technicians are assisting Dr. Goldenberg, under the terms of a research grant of the USPHS. Of the psychiatric staff, two supervising psychiatrists and two residents are actively engaged in part-time research. Of the attending staff, four members of the medical Board are in direct collaboration with hospital personnel in Specific projects. The Director is active in the following projects: a. Following on the summary of the l95h project on the relation of altered brain function to improvement following electroshock therapy, a second project has been undertaken to assess the characterological and biochemical factors in improvement. evaluation of serpasil as a therapeutic agent has been undertaken as an interdepartmental project, with the active cooperation of the medical department, supervising psychiatrist and a resident psychiatrist. b. An c. development of measures of ambivalence, both as a characterological factor and a symptom of psychiatric decompensation. This study is in conjunction with a member of the Medical Board. d. neurophysiological and-tachistoscopic laboratory, built with funds of the USPHS, is now nearing completion. The two Grass stimulators, DuMont oscilloscope, and relay and lens systems necessary for tachistoscopy have been delivered, and are being assembled. Projects have been outlined and will begin by mid-May. The The v' / �-2... Simultaneously with these efforts, I have been a participant in a number of the departmental projects at the hospital; cooperated with the Subculture Study Committee in the development of its protocol; and have evaluated three protocols which were submitted to the Research Committee from outside sources, and made specific recommendations on each. II. Future Programs Present problems of psychiatry involve all aspects of the cause, course, treatment and prevention of the major psychoses. Except for the specific toxic and inflammatory psychoses, nothing is known of the etiology of schizophrenia, involutional psychosis or manic-depressive illness. Much description of the course of these illnesses is available, but this has been of little help in treatment or prevention except in isolated instances. Treatment is empirical, and at best, primitive. central reason for hospitalization in most patients is the devel~ opment of overwhelming tension and anxiety, and psychotic thoughts. Interpersonal relationships have become distorted, communication blurred, and effective activity so minimal as to threaten self-preservation. The various psychiatric therapies available today attack different aspects of these problems. A primary goal is the decrease in tension and anxiety, and the erasure of psychotic ideation. Much effort is expended at clarifying interpersonal relationships and modes of communication; and eventual reeducation and support of the patient in directing his activities along effective channels that lead to self- and social- preservation. The present methods are apparently satisfactory in the majority of patients in at least temporarily stemming the psychotic process, relieving tension and inducing a return to more effective functioning. In this process, the following methods are prominent at the hospital: Our 1. By hospitalization, the patient is separated environment. and isolated from his 2. By drug medication, as barbiturates, serpasil, and chlorpromaline, and by electroshock and ambulatory insulin treatments, tension and anxiety symptoms are reduced. 3. By electroshock, electronarcosis and insulin coma therapy psychotic ideation is erased by altering brain function. b. By group and 5. By social activities, environment, better and group therapy communication is fostered. in a permissive individual psychotherapy interpersonal relationships are fostered along realistic lines. 6. By environmental manipulation, job reeducation, and help, effective functioning is strengthened. Our social service research program is devoted to studying these processes. A. To Understand the'ﬂay Therapy'Horks: disciplines are constructively applied at the hospital, the effectiveness of any has not been sufficiently assessed, nor has the mode While these �.3mode of of the lhe study evaluated.r present been adequately of operation has Electroshock of our interest. example an electroshock of is operation By assessing in many from patients. depression psychotic resulted in improvement be works will electroshock the various possibilities it understood. If this is accomplished, then some ideas about the mental and The understanding of become clear. may in depression physiological processes A plan for a of service. research the electroshock treatment is the first goal similar study of insulin coma therapy is now in preparation; and others at the environment as a therapeutic of the hospital a study planning hospital are is hoped that the way mechanism. B. Relationship of Character Structure to Diagnosis: child— of the the demonstrate importance to devoted been study has hood environment in the development of character, behaviour patterns under stress conditions and the neuroses. Other investigators are actively involved in assess— of adult in the variety result that childhood relationships the in the factors ing behaviour patterns. It is not possible to carry out such studies at Hillside, but the important relationship between character and the type of mental illness of behavioural to of the character patterns the relation the patient shows; change which we call 'improvement'; and the aspects of character that resist treatment methods can be assessed. A prototype of such studies is now in progresselectroshock in therapy. improvement to basic of character the in aspects much C. Biochemical and Physiological Factors in Mental Illness: ill for long periods, appear to take on a stereoPersons who have been and chemistry in their reflected which is ultimately typed behaviour pattern, by neurologic, 'non—reactor' and patterns such of 'reactor' Study physiology. the failures in assessing methods important and are drug biochemical physiologic, and physical illness between psychiatric the relations of present therapies; Such and a improvement. between therapies 'organic' and the relation illness; to drugs EST and reaction where second project, the in incorporated study is and of long short terms in be assessed will electroencephalogram changes in the term improvement rates. (Follow—up): Results Treatment of D. Continuing Evaluations suffer treatment of generally of present the results studies Follow-up of the evaluation done an without are only; one therapy because they assess control to standard and compared not are improvement; for subject‘s potentialities followcontinuing a be to organize possible With may active support, it groups. evaluated on admission; assessed are the in hospital which patients up program, in followed a and over then methods at discharge; and psychiatric by psychologic number of years with an evaluation as to sustained change and reasons for failure. much would have at discharge, the to predictions Such an evaluation, if compared base—line for and a provide of choice therapies, present merit in assessing the the evaluation of any future therapeutic methods. III. Recommendation of problems the methods in attacking of suggested In this outline the treatment best; as one made to specific specify no effort have I psychiatry, is that fragmentary so it knowledge is Present the specific. or one etiology as of psychoses. the major to the eticlogy make as only a to poor guess possible A multidisciplinary approach with full freedom to follow many leads is the best of a establishment recommend the would For I be this offered. reason, that can �- u - Research Service, with full-time personnel devoted to such studies. I would suggest that such a service have "research" as its function; that it be independent of the service departments of the hospital; and that it have a basic budget which would assure continuation regardless of the availability of outside research funds. A. The Research Service should have the following organization: 1. Director of Research -- Responsible to the Medical Director. 2. Research Associates in Psychiatry and Psychology. 3. Research Assistants: a. b. c. d. Psychology Neurophysiology Psychiatry Social Service h. Secretarial and clinical personnel. 5. Technicians. B. Annual Budget recommendations for the Research Service: 1. Director 2. Associate in Psychiatry " in Psychology b. Assistant in Psychiatry " 5. in Psychology “ 6. in Neurophysiology " 7. in Social Service 8. Secretary 9. Technician n 10. - Lab EEG (1/2 time) $20,000 12,000 8,000 6,000 5,200 5,200 h,000 2,760 h,000 1,300 Equipment: As warranted Consumable Supplies Travel Overhead: As decided by Administrator. - $25,000. - 20,000. - 10,000. - 10,000. — - - 8,h00. 10,000. 6,000. 3,300. 6,000. 1,800. 2,h00. 1,000. available as a continuing commitment to the Medical Director for long range planning of the Research Service. These funds should be made For the budget year 1955-1956. I should like to make the specific recommendation that the following are the minimum requirements: 1. 2. 3. h. 5. Director Research Assistant " " Secretary Consumable Supplies 6. Travel 7. Overhead 8. EEG - Psychiatry - Psychology & Equipment Technician (in Operating budget) $15,000. 7,500. 7,200. 3,000. 2,h00. 1,0000 - $36,100. 1,600. $37,700. �0. Space: Problems of space at the hospital are acute, and will provide an increasing measure of difficulty as the service is developed. It is suggested that in the next capital outlay by the hospital for construction, some allowances be made. for the Research Service ‘ D. Relation with Other Departments: activities of the Research Service are to be those designated by the Director. Interdepartmental projects will be carried out by the Research Service, or in those instances where approval of the Research Committee is obtained, by the departments involved. Supervision of such interdepartmental projects will lie with the Research Director. The Interdepartmental projects are to be fostered by the Director. Prior approval by the Research Committee and the Medical Director is required. Such projects as are consistent with the service functions of the departments involved W111 be fostered. Presentations and reports are to be approved by the Research Committee prior to publication. E. Job Description: 1. Director of Research: objectives of the Director of Research will be to: (l) Organize and maintain an active program of research and a Research Service; (2) Promote, supervise and integrate research activities at the Hospital; (3) Educate hospital personnel in research methods and progress; and (h) Administer research funds. The The director of research will: a. Organize a central project or series of projects appropriate to the unique character of the Hospital and integrate this into the activities (therapeutic) of the Hospital. Progress reports will be submitted to the Medical Director and to each meeting of the Research Committee of the Medical Board; and such data as is approved for presentation will be submitted by the Director or his delegate at the appropriate scientific society. all staff to plan and carry out individual research projects. Third year residents in psychiatry are to be specifically encouraged to undertake research projects under his direct supervision, or that of an attending psychiatrist. For these residents, and any other professional members of the staff, the director of research is to assist in the planning of b. Encourage members of the the project; in its integration into the hospital program; and in both technically and financially. its support 0. Carry on such educational activities as the supervision of third year residents in research; monthly seminars in research problems and progress; and periodical reports of important psychiatric meetings. The director will maintain a calendar of meetings and lectures; stimulate attendance thereto; and foster the He such of is also to invite such meetings. at Hospital activities presentation guest lecturers and seminar leaders as are available. d. Administer all research funds with the approval of the Medical Director. This includes the stimulation of fund sources; the application for funds; and their allocation to hospital projects. �2. Research Associate: Director in all projects at the hospital; to assume responsibility for specified projects; and to carry on such independent investigations as his training and experience dictate. Tb work with the Associate in Psychiatry is to be a qualified diplomats in psychiatry, with extensive experience both in psychoanalytic psychiatry and in descriptive psychiatry. By training or experience, the associate should have teaching qualifications; and some training in research methods. A. Such an assume responsibility for that portion of the functions of the service assigned to him by the director; assume responsibility in the director's absence; attend conferences, meetings and assume teaching functions as recommended by the director. He range — will Salary to be determined by qualification and experience. Probable $12,000 to 20,000. B. Such an Associate in Psychology is to be a qualified psychologist with at least 10 years experience. Psychoanalytic experience is preferable. The equivalent in academic standing of Associate Professor is the guide line. research associate in psychology is to assume responsibility for those functions of the Research Service assigned to him by the director. An evaluation of testing methods. statistical evaluation of results. and a of the research of of aspects contr0l the.functioning procedure in all rigorous service are his responsibility. The research associate in psychology may be chosen from the research assistants. Salary range - $8,000 to 10,000. The will: organize and supervise projects in the department; supervise projects of the resident psychiatric staff; assist such department heads as request aid in organizing departmental projects; advise the director of new research possibilities; attend conferences, write reports and papers, and carry on such administrative activities as the Director may require. Both Research Associates Board at Appointments to Research Associate are to be made by the Medical the recommendation of the Medical Director and the Director of Research. 3. Research Assistants: assist the director in his research activities and carry on the work of the department. Each assistant is to be responsible to the director, and will carry on such tests, procedures, write such reports, and present those To papers designated by the Director. Assistants are to be qualified by training and experience for the specified jobs named. They are to be appointed by the Medical Director at the nomination of the Director of Research. a. Assistant in Psychiatry: For such psychiatristswho have had three or more years of formal psychiatric training but not yet certified, the opportunity to work for one or more years on a Research Service may provide the stimulation for continuation in research and also provide the director with the assistance of personnel intermediate in experience between the resident and the associate. The assistant in psychiatry can assume responsibility for the selection �-7of the patients for the various projects; evaluate changes in behaviour with treatment; assess the importance of intrapsychic and environmental factors in the present behaviour of the patient. the assistant.vill assume responsibility for those aspects of the problems under investigation as are within his scope, and assigned by the director. He will write such reports, papers and make such presentations as the director may suggest. He will make such tests, learn such technics and work with those members of the research service or the service departments of the hospital as his projects permit. Salary is dependent on experience. Probable range $6,000 to 1C,000. b. Assistant in Psychology: Graduate in psychology with a minimum of doctorate. Preferable experience in research methods and publication experience with some specialization in laboratory methods. Equivalent academic status of assistant professor. The assistant in psychology is to carry on such psychologic and laboratory tests, and make such statistical and methodological evaluations as the projects of the service require; and to make such reports and presentations as the director may suggest. He is to direct the laboratory technicians, organize their work and assume responsibility for the maintenance of all testing equipment and materials. In the design of projects, he is to assume responsibility for the application of the best methods and design commensurate with the goals of the project. Salary range ~ $5,200 to 8,h00. c. Assistant in Neurophysiology: M.D. or Ph.D., with a minimum of three years experience in electroencephalography or neurophysiology. To supervise and coordinate all neurophysiological studies, now being organized; develop and build electrophysiological equipment; assume responsibility fer such animal studies as are organized; cooperate with the psychologist in coordinated neuropsychological investigations; and supervise technicians in electrical methods. This position can be filled only if the laboratory is expanded to include more basic studies. Personnel can then be recruited from medical school training centers. Salary range - $5,200 to 10,000. d. Assistant ~ Social Service: B.S. (Soc. Work) with minimum of five years experience in field or administrative work. Emphasis on interviewing technics and assessing family relationships. Personal analysis recommended. If previous research experience with psychiatrists or psychiatric clinics is noted, it should be heavily weighted. Assistant is to assume responsibility for interviewing relatives of patients and develop technics of assessing premorbid characteristics based on history and interview; to obtain histories from relatives and patient relevant to the early years of development; to cooperate with the psychologist in assessing the personality of the subjects; and to coordinate research testing in the various projects. Patients seen during their hospitalization in any of the research service projects are to be seen by the social worker prior to discharge, and eVery effort at follow up contact made. For all follOWbup testing and evaluation, the assistant will make the necessary contacts and arrangements for the director. The social worker assigned to the research service will, if time is available, cooperate with the Director of Social Service in those interdepartmental projects which he may have organized with the approval of the director of research. Assistant is to be selected by the Director of Social Service. Salary range proportionate to experience in research. Range - $h,000 to 6,000. �e. Technicians: EEG -~ High l. fundamentals school graduate, although two years college preferred. To learn the of electroencephalography; make the necessary measurements and place electrodes; obtain artefact free records; maintain card files; type reports; keep records in systematic way; and maintain equipment. Technician is to be responsible to the assistant in neurophysiology or the director. Salary -- if untrained, $52,600; if trained, $33,060 to 353,600. 2. Lab. Technicianp-Neurophysiology. College graduate, preferably with some engineering or physics experience. To assist the assistant in neurophysiology and/or the assistant in psychology, in the development and maintenance of electrical equipment; to assist in the handling of animals; to cooperate in the experimental procedures; to build, adjust and design special equipment. Salary range dependent on training-- Rangeﬁ .000 to 6,000. IV. Summary: Research Director is actively involved in a number of studies of the mechanism of treatment. To maintain a continuing function and make long term planning feasible, it is recommended that a Research Service be established; that be an integral part of hospital organization with a continuing annual budget. it A proposed organization is included in this report, with a projected annual budget of $60,000 ~ $70,000; and with a minimum budget 1955-56 of $36,100. The This report approved by the Research Committee April 27, 1955. Respectfully submitted, Max Fink, MoDo Director of Research �HILLSIDE HOSPITAL Glen Oaks, New York April 28, 1955 Th: Dr. Joseph S.A. Miller, Medical Director From: Dr. Max subject: Six Fink Month Progress Report and Recommendations. first six months as Director of Research at the hospital, I should like to describe the present state of our research program, our plans for the future, and to make specific recommendations for a research At the end of the department. I: Present A Program definitive report of the research activities of the departments of the hospital was presented to the Medical Board on April 5, 1955, by the chairman of the Research Committee. At the present time, the staff assisting the Director includes two psychologists and a part-time secretary (supported by USPHS and Dazian Foundation grants); and a half-time EEG technician. Part-time research activities are carried out in the various service departments. In the Department of Laboratories, two technicians are assisting Dr. Goldenberg, under the terms of a research grant of the USPHS. Of the psychiatric staff, two supervising psychiatrists and two residents are actively engaged in part—time research. Of the attending staff, four members of the l"ledical Board are in direct collaboration with hospital personnel in specific projects. The Director is active in the following projects: a. Following on the summary of the l9Sh project on the relation of altered brain function to improvement following electroshock therapy, a second project has been undertaken to assess the characterological and biochemical factors in improvement. b. evaluation of serpasil as a therapeutic agent has been undertaken as an interdepartmental project, with the active cooperation of the medical department, supervising psychiatrist and a resident psychiatrist. c. development of measures of ambivalence, both as a characterological factor and a symptom of psychiatric decompensation. This study is in Dmedical member of the with Board. a conjunction d. neurophysiological and tachistoscopic laboratory, built with funds of the USPHS, is now nearing completion. The two Grass stimulators, DuMont oscilloscope, and relay and lens systems necessary for tachistoscopy have been delivered, and are being assembled. Projects have been outlined and will begin by mid-May. An The The �-2... Simultaneously with these efforts, I have been a participant in a number of the departmental projects at the hospital; cooperated with the Subculture Study Committee in the development of its protocol; and have evaluated three protocols which were submitted to the Research Committee from outside sources, and made specific recommendations on each. II. Future Programs Present problems of psychiatry involve all aspects of the cause, course, treatment and prevention of the major psychoses. Except for the specific toxic and inflammatory psychoses, nothing is known of the etiology of schizophrenia, involutional psychosis or manic-depressive illness. Much description of the course of these illnesses is available, but this has been of little help in treatment or prevention except in isolated instances. Treatment is empirical, and at best, primitive. The central reason for hospitalization in most patients is the devel- opment of overwhelming tension and anxiety, and psychotic thoughts. Interpersonal relationships have become distorted, communication blurred, and effective activity so minimal as to threaten self-preservation. The various psychiatric therapies available today attack different aspects of these problems. A primary goal is the decrease in tension and anxiety, and the erasure of psychotic ideation. Much effort is expended at clarifying interpersonal relationships and modes of commun— ication; and eventual reeducation and support of the patient in directing his activities along effective channels that lead to self- and social- preservation. present methods are apparently satisfactory in the majority of patients in at least temporarily stemming the psychotic process, relieving tension and inducing a return to more effective functioning. In this process, the following methods are prominent at the hospital: Our 1. By hOSpitalization, the patient is separated and isolated from his environment. 2. By drug medication, as barbiturates, serpasil, and chlorpromaaine, and by electroshock and ambulatory insulin treatments, tension and anxiety symptoms are reduced. ' 3. By electroshock, electronarcosis and insulin coma therapy psychotic ideation is erased by altering brain function. ' b. By group and social activities, and group therapy in a permissive environment, better communication is fostered. 5. By individual psychotherapy interpersonal relationships are fostered along realistic lines. 6. By environmental manipulation, job reeducation, and social service help, effective functioning is strengthened. Our A. To research program is devoted to studying these processes. Understand the Hay Therapy Vorks: disciplines are constructively applied at the hospital, the effectiveness of any has not been sufficiently assessed; nor has the mode While these �.3mode of of The the study evaluated. present been adequately of operation has Electroshock of interest. our example an electroshock of is operation By assessing in many from patients. depression psychotic improvement resulted in be works will electroshock the way that hoped is the various possibilities and mental about the ideas some then accomplished, understood. If this is it The of become understanding clear. may in depression physiological processes A plan for a of service. the research electroshock treatment is the first goal similar study of insulin coma therapy is now in preparation; and others at the environment as a therapeutic of the hospital study a planning hospital are mechanism. B. Relationship of Character Structure to Diagnosis: study has been devoted to demonstrate the importance of the childhood environment in the development of character, behaviour patterns under stress involved in assessOther actively are and investigators the neuroses. conditions of adult the in variety result that childhood relationships the in factors the ing behaviour patterns. It is not pOSSible to carry out such studies at Hillside, mental of illness and the between type character the but important relationship of behavioural to of the patterns character the relation shows; the patient of character that resist and the aspects 'improvement‘; we which call change A be prototype of such studies is now in progressmethods assessed. can treatment electroshock therapy. in improvement to basic of character the in aspects Much C. Biochemical and Physiological Factors in Mental Illness: ill for long periods, appear to take on a stereoPersons who have been and chemistry in their reflected which is ultimately typed behaviour pattern, by 'non—reactor‘ neurologic, and patterns of such 'reactor' Study physiology. the failures in assessing methods important and are drug biochemical physiologic, and physical illness between psychiatric the relations of present therapies; Such a and improvement. between therapies 'organic' and the relation illness; and to drugs EST reaction where second project, study is incorporated in the and of long short terms in be assessed will electroencephalogram the changes in term improvement rates. D. Continuing Evaluations of Treatment Results (Follow~up): suffer treatment generally of of present the results studies Follow-up of the evaluation done an without because they assess one therapy only; are control standard to compared and not are improvement; subject's potentialities for followa continuing be to organize possible may With active support, it groups. evaluated on admission; assessed the are in which hospital patients up program, in followed a and over then methods at discharge; and psychiatric by psychologic number of years with an evaluation as to sustained change and reasons for failure. much would have at discharge, Such an evaluation, if compared to the predictions for base-line and a provide of therapies, choice present merit in assessing the the evaluation of any future therapeutic methods. III. Recommendation of problems the methods in attacking of suggested In this outline the treatment best; as one made to specific specify no effort have I psychiatry, is that fragmentary so it knowledge is Present the specific. or one etiology as of the psychoses. major to the etiology make as only a to guess poor possible A multidisciplinary approach with full freedom to follow many leads is the best of a establishment recommend the would For I this reason, that can be offered. �- h - Research Service, with full-time personnel devoted to such studies. I would be indesuggest that such a service have "research" as its function; that have a basic pendent of the service departments of the hospital; and that budget which would assure continuation regardless of the availability of outside it it research funds. A. The Research Service should have the following organization: 1. Director of Research -- Responsible to the Medical Director. 2. Research Associates in Psychiatry and Psychology. 3. Research Assistants: a. Psychology b. Neurophysiology c. Psychiatry d. Social Service h. Secretarial and clinical personnel. 5. Technicians. B. Annual Budget recommendations for the Research Service: 1. Director 2. Associate in Psychiatry " 3. in Psychology b. Assistant in Psychiatry " 5. in Psychology " 6. in Neurophysiology " 7. in Social Service 8. Secretary 9. Technician " 10. — Lab EEG $20,000 - $25,000. 12,000 - 20,000. 8,000 - 10,000. 6,000 - 10,000. 5,200 - 8,h00. 5,200 - 10,000. h,000 - 6,000. 2,760 - 3,300. h,000 - 6,000. 1,300 - 1,800. (1/2 time) warranted Consumable Supplies Travel Overhead: As decided by Administrator. Equipment: As 2,h00. 1,000. available as a continuing commitment to the Medical Director for long range planning of the Research Service. For the budget year 1955-1956. I should like to make the specific These funds should be made recommendation 1. 2. 3. h. 5. 6. that the following are the Director Research Assistant " " Secretary Consumable Supplies Travel minimum - Psychiatry Psychology ~ & Equipment 7. Overhead 8. EEG Technician (in Operating budget) requirements: $15,000. 7,500. 7,200. 3,000. 2,h00. 1,000. - $36,100. 1,600. $37,700. �C. Space: Problems of space at the hospital are acute, and will provide an increasing measure of difficulty as the service is developed. It is suggested that in the next capital outlay by the hospital for construction, some allowances be made. for the Research Service ' D. Relation with Other Departments: activities of the Research Service are to be those designated by the Director. Interdepartmental projects will be carried out by the Research Service, or in those instances where approval of the Research Committee is obtained, by the departments involved. Supervision of such interdepartmental projects will lie with the Research Director. The Interdepartmental projects are to be fostered by the Director. Prior approval by the Research Committee and the Medical Director is required. Such projects as are consistent with the service functions of the departments involved will be fostered. Presentations and reports are to be approved by the Research Committee prior to publication. E. Job Description: 1. Director of Research: objectives of the Director of Research will be to: (l) Organize and maintain an active program of research and a Research Service; (2) Promote, supervise and integrate research activities at the Hospital; (3) Educate hospital personnel in research methods and progress; and (h) Administer research funds. The The director of research will: a. Organize a central project or series of projects appropriate to the unique character of the Hospital and integrate this into the activities (therapeutic) of the Hospital. Progress reports will be submitted to the Medical Director and to each meeting of the Research Committee of the Medical Board; and such data as is approved for presentation will be submitted by the Director or his delegate at the appropriate scientific society. staff to plan and carry out individual research projects. Third year residents in psychiatry are to be specifically encouraged to undertake research projects under his direct supervision, or that of an attending psychiatrist. For these residents, and any other professional members of the staff, the director of research is to assist in the planning of b. Encourage all members of the the project; in its integration into the hospital program; and in both technically and financially. its support c. Carry on such educational activities as the supervision of third year residents in research; monthly seminars in research problems and progress; and The director will maintain of meetings. important psychiatric periodical reports a calendar of meetings and lectures; stimulate attendance thereto; and foster the He such of is also to invite such meetings. at Hospital activities presentation guest lecturers and seminar leaders as are available. d. Administer all research funds with the approval of the Medical Director. This includes the stimulation of fund sources; the application for funds; and their allocation to hospital projects. �2. Research Associate: Director in all projects at the hospital; to assume responsibility for specified projects; and to carry on such independent investigations as his training and experience dictate. Tb work with the Associate in Psychiatry is to be a qualified diplomats in psychiatry, with extensive experience both in psychoanalytic psychiatry and in descriptive psychiatry. By training or experience, the associate should have teaching qualifications; and some training in research methods. A. Such an assume responsibility for that portion of the functions of the service assigned to him by the director; assume responsibility in the director‘s absence; attend conferences, meetings and assume teaching functions as recommended by the director. will He Salary to be determined by qualification and experience. Probable range - $12,000 to 20,000. ‘ B. Such an Associate in Psychology is to be a qualified psychologist with at least 10 years experience. Psychoanalytic experience is preferable. The equivalent in academic standing of Associate Professor is the guide line. research associate in psychology is to assume responsibility for those functions of the Research Service assigned to him by the director. An evaluation of testing methods, statistical evaluation of results. and a rigorous control of procedure in all aspects of the functioning of the research service are his responsibility. The research associate in psychology may be chosen from the research assistants. Salary range - b8,000 to 10,000. The will: organize and supervise projects in the department; supervise projects of the resident psychiatric staff; assist such department heads as request aid in organizing departmental projects; advise the director of new research possibilities; attend conferences, write reports and papers, and carry on such administrative activities as the Director may require. Both Research Associates Board at Appointments to Research Associate are to be made by the Medical the recommendation of the Medical Director and the Director of Research. 3. Research Assistants: assist the director in his research activities and carry on the work of the department. Each assistant is to be responsible to the director, and will carry on such tests, procedures, write such reports, and present those To papers designated by the Director. Assistants are to be qualified by training and experience for the specified jobs named. They are to be appointed by the Medical Director at the nomination of the Director of Research. a. Assistant in Psychiatry: For such psychiatristswho have had three or more years of formal psychiatric training but not yet certified, the opportunity to work for one or more years on a Research Service may provide the stimulation for continuation in research and also provide the director with the assistance of personnel intermediate in experience between the resident and the associate. The assistant in psychiatry can assume responsibility for the selection �-7of the patients for the various projects; evaluate changes in behaviour with treatment; assess the importance of intrapsychic and environmental factors in the present behaviour of the patient. the assistant will assume responsibility for those aspects of the problems under investigation as are within his scope, and assigned by the director. He will write such reports, papers and make such presentations as the director may suggest. He will make such tests, learn such technics and work with those members of the research service or the service departments of the hospital as his projects permit. Salary is dependent on experience. Probable range $6,000 to 10,000. b. Assistant in Psychology: Graduate in psychology with a minimum of doctorate. Preferable experience in research methods and publication experience with some specialization in laboratory methods. Equivalent academic status of assistant professor. The assistant in psychology is to carry on such psychologic and laboratory tests, and make such statistical and methodological evaluations as the projects of the service require; and to make such reports and presentations as the director may suggest. He is to direct the laboratory technicians, organize their work and assume responsibility for the maintenance of all testing equipment and materials. In the design of projects, he is to assume responsibility for the application of the best methods and design commensurate with the goals of the project. Salary range - $5,200 to 8,hOO. minimum M.D. of with a Ph.D., or Assistant in Neurophvsiology: c. three years experience in electroencephalography or neurophysiology. To supervise and coordinate all neurophysiological studies, now being organized; develop and build electrophysiological equipment; assume responsibility for such animal studies as are organized; cooperate with the psychologist in coordinated neuropsychological investigations; and supervise technicians in electrical methods. This position can be filled only if the laboratory is expanded to include more basic studies. Personnel can then be recruited from medical school training centers. Salary range - $5,200 to 10,000. d. Assistant - Social Service: B.S. (Soc. Work) with minimum of five years experience in field or administrative work. Emphasis on interviewing technics and assessing family relationships. Personal analysis recommended. If previous research experience with psychiatrists or psychiatric clinics is noted, it should be heavily weighted. Assistant is to assume reaponsibility for interviewing relatives of patients and develop technics of assessing premorbid characteristics based on history and interview; to obtain histories from relatives and patient relevant to the early years of development; to cooparate with the psychologist in assessing the personality of the subjects; and to coordinate research testing in the various projects, Patients seen during their hospitalization in any of the research service projects are to be seen by the social worker prior to discharge, and every effort at follow up contact made. For all followbup testing and evaluation, the assistant will make the necessary contacts and arrangements for the director. The social worker assigned to the research service will, if time is available, cooperate with the Director of Social Service in those interdepartmental projects which he may have organized with the approval of the director of research. Assistant is to be selected by the Director of Social Service. Salary range proportionate to experience in research. Range - th,000 to 6,000. �e. Technicians: l. EEG -- High school graduate, although two years college preferred. learn the fundamentals of electroencephalography; make the necessary measure— ments and place electrodes; obtain artefact free records; maintain card files; type reports; keep records in systematic way; and maintain equipment. Technician is to be responsible to the assistant in neurophysiology or the director. To Salary -- if untrained, $2,600; if trained, $3,000 to $3,600. 2. Lab. Technician--Neurophysiology. College graduate, preferably with some engineering or physics experience. To assist the assistant in neurophysiology and/or the assistant in psychology, in the development and maintenance of electrical equipment; to assist in the handling of animals; to cooperate in the experimental procedures; to build, adjust and design special equipment. Salary range dependent on training-~ Range$h,000 to 6,000. IV. Summary: Research Director is actively involved in a number of studies of the mechanism of treatment. To maintain a continuing function and make long term planning feasible, it is recommended that a Research Service be established; that be an integral part of hospital organization with a continuing annual budget. it A proposed organization is included in this report, with a projected annual budget of 3,560,000 - $570,000; and with a minimum budget 1955—56 of $536,100. The This report approved by the Research Committee April 27, 1955. Respectfully submitted, Max Fink, M.D. Director of Research �Viva—v Wu'I-v-r “IV 11; 1955 mom DR. M. FINE SUBJECT: MOW REPORT, RESEARCH SERVICE «- APRIL 1. My louder ectiviw this month has been the planning and preeentim to the Director, the Research Committee end to the Medical Affairs a plan for a research department. This was discussed at length at the hoepdtel. and then presented to the Research Omittee, April 27th and approved. It was later presented on May 3rd to the Medical Affairs Oomittee. 2. Research pro cots underm: a. BM 2: theetndy ienowinmllewingendueam followingconoeoutive patients with all our indiciee of change. (30th " b. Ambivilence: Our equipment for techietoecopy hue been set up. Correlations between clinical evaluations between embivilunce made by Dr. Tmohow and tween, and the laboratory studies using the techietoecope and the TAT test, are new in pmgmee. \ electrouetimuletore and oscilloscope have been coordineted and preliminary measurements are being made in the alteration in tactile perception in electnoehock patients. (I. Serpaeil project continues despite some difficulties in the choice of patients. c. The ' e. Subculture: This comittee has continued ite work despite a number of hwering developments. This eppointment of Dr. Navarro to the adolescent pavilion hue limited the amount or time available for this project. Simlteneouely, Dr. Outwits announced that because of the pressure of other activities, he would be unable to devote the mountﬂ‘ time previously outin- eted to the project. For the meanwhile, the committee elucidating a protocol. is continuing and in Projects begun: Dr's Ledemn end Emberg have begun a study or the use of divided insulin doses and their effect on come levels. 3‘. attended: Dr. Knhn attended the Eastern Psychological Asediction nee e in Philedelphin, Ind participated in a panel and presented a paper based npm his work at the hunt Sinai Hoepital. I attended the April meeting of the New York Neurologic Society. 1;. ' p 3 " 5. Pipers published: In the Joumel or the Hillside Hospital, the ”th1 Test in Mental Petientc' by Dr. Kuhn, Weinetein and myself. . �MEMORANDUM Dr. Joseph so A. Miller, Mono FROM: Dr. Max Fink SUBJECT; Monthly report, Reaearoh Service T08 1. Activities of - Boy of the Research Service during the month have been attendance at various psychiatric matings; the presentation of papers; and tho continuation of ongoing projects. members 2. Papers Presented: (c) The paper entitled "RelatiOn of want in Eleotroshockﬂ was read, ~ Kwalwasser. To . and Learning to Improve» the Electroahcck Rosearoh Association Changes in Memory hy title, by Mr. Karin, Dr. Fink, and Dr. This paper received the Annual Prize Award of the association. (b) To the American Psychiatric Association, the paper entitled "Relationship Betucon Altered Brain Function and Denial in Electroshook Therapy“ was presented by Dr. Kahn and Dr. ?ink. ‘(c) the resident's meeting of tho New York Neurologic Socioty, Dr. Grnubert road the paper 'Daluaional Rodnplication of Parts of the Body After Insulin Coma Thorapygﬁ To final manuscripts of these three paperc Committee, at the end of the month. The 3. Meetings uttendod: were sent to the Resoarch or the Research Service attended the following meetings: Amorican Psychosomatic Society, American Psychiatric Association, Electroshock Ecuooroh Association - all at Atlantic City. Also the Nowhers York Neurologic Society and the American Psychopathological Association in New York City. ‘ How h. Notes regarding ongoing projects: a. Further data has been con llected for the two projects - EST # 2 and Ambivalence. b. Serposil: Some difficulties in the selection were cleared in conferences with Dr. Loderman and Dr; Blumberg. Later on in the month Dr. Laderman requcsted that he be relieved of working on this project except in the aupervisony role since he has to many other activities. The project will continue with Dr; chhspress assuming the major psychiatric role. 0. Subculture: Furthor work in preparing a protocol has continued during the month despite the hampering difficulty of the nooignaticn of Dr. Gurvito and the increased activities of Dr. Navarre. It is my anticipaticn that a satisfactony protocol may be available by the and of the month. up �S. New Projects: Following an initial meeting with Dr. Loon Helium: of the Sloan Kettering Institute on April 25th further dismsions were held at the hospital between Dr. Goldenberg and myself and a second visit to the institute was made on May 23rd. With the elucidation of their program, our own protocol is being prepared and will be submitted to the Research Committee and Medical Dimctor within the next few days. ‘ The Annual Prim Award of $100.00 was donated to the the Electmshock Research urea]. Strauss Research Fund, Association for also renewal mquest for tho grant. of the 0.3. Public Health Service were submitted on May 3rd. 6. Funds: 7. Papers Published: None. �DOW 0! 310011-131.” eeeeeeseeeeeeeeeeeeeeeeeeeeeeee Dr. 8. mm MW 1. PROGRESS mom, m Gold“ 19” WtionctchlorpromeineendSeryuilinSem,Urineend embroepdnel Fluid. Wire inthodhesbemdevelopedrorthe detemiutionor drugesnd rented elheloidel compounds in blood end urine. The procedure involves extinction orthe buiriedi‘luidwith heptsneendreextraetionottheecupoundfromthe heptsne leyer with hydrochloric acid. an mixing the acid solution with methyl orange e complex is formed which dissolved in ethyl.” dichloride to give I: soln. whose color in directly proportionel to the amount of chlorpromssine, eerpcsil, or other elkeloid origindqureeent intheteettluid. Adeteiled etudyhes eleo bean nude or the specificity of the melytiecl method. Prelim-:7 results obtained with serum of petiente indicate an «trench rapid rate of dieeppesrsnee or the mister-ed meterinl. Studies are being mderteken to determine whether this 1e due to repid elimination, detonticetion, or both, and whether the degree or retention of the drugs can be correlated in em we: with their clinical effectiveneee. 2. Inhibition of Sena Cholinestereee by Hallucinogen» stub wee reemd or en intereeting observation that had been made in our lobe. lest Sept... 195:. but not subsequmtly followed up became of leek of personnel. it that time it was noted that LSD 25 is e potmt inhibitor of mm 11;. The cholinesterese. question eroee as to whether thie phenomenon correlates in may we; with the echisogenic ection of LSD 25, end whether hallucinogenic in general have 1 eimer effect on cholineetereee from serum, cells, end brain. serum Prelilinery results with serum cholineetereee indicate a perelleliem between hallucinogenic eetivity of the 3 druge teeted, listed in the order or decreasing activity, '13., lysergic acid diethylenide > lyeergie seid monoethylamide > mecsline, end their ability to inhibit the anyone. 3. Steroid 3mm. Conjugate Studies. einple method hec been found for eliminating the protein and alkaloid interference with steroid sulfate cnelyeis or biological fluids. Procedure involves eddition of alkali to diesoeiete steroid sulfate bound to protein, followed by extraction with lipid oolvente end treatment with e eulronie eeid resin to remove excess bees as well a: tree alkaloid. Progreee along theee lines has been extremely rapid and fruitful. It hes also been discovered that the home sulfates ere synthesized by the liver. Chromtomphic end paper electrophoretio methods are being adopted ee companion tools to our dye teehnie in order to establish the identity or the component hormone conjugates. A �mm .1..qu MW “mm.o 1. Papa of biological fluids to Maniac tho 1nd alkaloidol drugo, prosciu- in mm... Italics “mid on 2. Preparation for following out. to ho conduct-d on blood and urino or tor urinary “mid studios hy Slow-Kauai.“ mend opp-oval): steroid sum». uhloido, phosphorus, plating ' fum- W151" chemo-two, ma poooihly total War; of 1W Wm. W, 2.xuuam1cmmmmmmummnmidmum; 1. K. Board with! ham Education “pm to orients." July lot, 1955. mmwﬂmﬁal 3mm}: Mo. Hmoido sponsorship by tho �mm mm: 199N955 Themuumhmﬁuﬂoaatthohoammm for-1mm uiththeappdnhamtofﬂr.mnnkuninctorefﬁomm0¢tomg mdmop‘muwuybytheostamahnntdnnmhurumbym Humans-a. what. mmmmmmmamm mud sum mm m the grunts Health Service and wmmmmmmrerhmmwmmmud mmmmmrormumubymmunmm. mummcemmamwlymmdmamr otwwmgmlmwotfulds.whhstyeuamw«fthe dehwkmmdam.meﬁmtstwmmd mmntyotWMhWnMMmtanmmtefarm Wtfommtmﬁmnt. Thamsultaofthiaam mummmmttmmwmmﬁmmwmpm mumedtotmmamhockhmhsmmmdmu wmmrmmmmmmhdem. Mummtha um of am toineludofurﬂmr thanpym cumming; and lave becnhroadamd upcﬂnftheWsinﬁwedbyinsMasmuu 0W.mammal studio! m the effects at 11:11am: Wymlﬁudhsmmrpdmmdchlmmmgmd anwamw «mm museum“! � 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 Progress and annual reports; research activities (folder title 1/2). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-002 Date A point or period of time associated with an event in the lifecycle of the resource 1955 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 Annual report - research; Biochemical research; Research and pUblications of the Department of Psychology; Annual Report of Department of Neurology, Hillside Hospital; Letters to Dr. Miller (Budget); Research Progress Report 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 http://exhibits.library.stonybrook.edu/mfp/files/original/6d5d109f552158de5a99360da32ba4a2.pdf cbe6f09f352080376a08471f0e47212a PDF Text Text HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263RD GLEN OAKS. N. Y. STREET FIELDSTONE 3-7300 JOSEPH S. A. MILLER. M. D. MAURICE BACHRACH MEDICAL DIRECTOR ADMINISTRATOR SIMON KWALWASSER. M. D. Assoc. June 27’ 1955 MEDICAL DIR. Dear Dr. Fink: This is to I sure that there acknowledge, with thanks, the receipt of $100 for the Research Fund, from yourself and your Associates, Hyman Karin and Simon Kwalwasser. no need am for us to tell you is of the importance of our research program. The Directors are appreciative of the sentiment underlying your gift of this $100. to Hillside Hospital. Very sincerely yours Maurice Bachrach MBzhm cc: Dr. Kwalwasser Dr. Miller Mr. Korin AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �June 30, 1955 Somatic Therapy'fbsearch Program 1955-57 From the Research Service of the Hillside Hospital mode of action the to investigate A. AIMS: It is the purpose of this study We do by this to plan mental illness. of somatic therapies in and personality behavioral of physiological, the systematic investigation factors which B. may be involved. mechanism conc‘eming the therapeutic Although many theories BACKGROUND: been have they advanced, been have of the somatic therapies cannot validity their that either empirically disproved, or, are so vague be and hypothesis, meaningful more of a development the More recently, tested. new methods of study have provided the opportunity ion. In l952,'ﬂeinstein and Kahn (Amer. for a fruitful investigat- Journal Psychiatry l923 22-26) sug- of milieu a creating by improvement to gested that the somatic therapies lead Some could of denial operate. anisms mec in.which function brain altered support for this hypothesis has been found in the literature. Carter (Am. earlier work of Janis, unpleasant life memories after the of some confirmed 1953) has §5 330, Psychologist of selective forgetting there is showing that electroshock. non—emotional and emotional of Using tachistoscopic presentation demonstrated 1953) hhS, §5 (Am. Psychologist words, Teicher that of repression" to emotional stimuli occur in the post-shock state. For the past year and a half preliminary studies "mechanisms investigating this done been have hypothesis at these laboratories at Hillside Hospital. results to date striking. have been patients were followed.with serial taneous tactile Twenty—four The consecutive electroshock electroencephalograms and amytal, simul- perceptual and memory tests. A marked correlation between �.02. improvement and early, persistent alogram, and in the amytal tests was observed. appear, improvement did not occur. sistent and severe changes on the electroenceph- It is If such changes did not our conclusion that early and per- sufficient, prepossible to predict changes in these indices are a necessary, though not make These observations improvement. for it requisite the short term response to therapy during the second and third week of treat- ment. A report on the amytal test results was presented at the recent meet- ing of the American Psychiatric Association (May 1955) and submitted fer public- Electroshock the At of of meeting American Journal a Psychiatry. the to ation Research Association on May 8th, a report of the changes in memory and learn- This was treatment presented. electroshock of the course ing occurring during he Award citation Association. the of Annual Prize awarded the was report noted the methodology as exemplary, and offering a fruitful method of study- ing electroshock. Concomitant with these studies,t7e have followed patients on insulin therapy. Recent reports onthe value of prolonged coma as the basis for improvement (Kwalwasser and Caplan: J. Hillside Hospital l; 1&5, 1952; Revitch, coma E. : Neurol. Arch A.M.A. Rowsell: and 195h; shagass 72, Quart. ﬁg; Psychiat. and Psychiat. 225 705, l95h; and Yeager 195h) In one gt 3;; J. Nerv. & Ment. Dis. llgg h35, 2 the over studies past in years. in our patients unusual case report the direct relationship between altered brain fun- have been confirmed (Delusional demonstrated Reduplication been has and improvement denial ction, of Parts of the Body After Insulin Coma Therapy, J. Hillside Hospital, 1955, in press). C. METHOD: 1. we plan to verify and amplify our preliminary observations on the relation of changes in behavior to altered brain function after somatic treatment. �-3” E.A. and Kahn, sease, Am. electroshock will be given amytal tests (heinstein, DiBrain Sodium In Organic Use Amobarbital of Diagnostic Patients (a) 3.: on J. Psychiatlggf Test" for Brain Disease: 889—89h, 1953; Its Serial Administration of the "Amytal Arch A.M.A. Value, and Prognostic Diagnostic and before and electroencephalograms l95h) Neurol. and Psychiat. 1;; 217-226, treatment. make be a used to This will data preat stated intervals during diction of the short term response to treatment. (b) Double simultaneous tactile perceptual tests will using threshold electrical stimulation. be carried out Using two Grass Sh-B stimulators, to be his for tested ability the will patient monitored by an oscillograph, of his body. different parts to simultaneously two stimuli applied perceive shown to been previously has stimulation simultaneous double of technique hé-SB, g} Neurology, (Fink function 3}, be a good index of altered brain at The January, 1952). By applying this highly refined technique it is hoped that elicited. be will patients tests, changes in brain function which are not otherwise apparent will be and amytal of electroencephalognmn the case in tested before and at stated intervals during treatment. As 2. Other Physiological procedures will be carried out in con- junction with the tests above. (a) Each patient will be given the mecholyl-epinephrine cribed by Funkenstein and associates The results will (J. Nerv. (b) sulin coma as des- Ment. Dis. Egg: h09, Nov. 19h8). be compared with the work of previous as with the results of our other physiological test investigators as well tests. and electroshock of undergoing Biochemical testing patients treatment have been in progress for some time in- in these laboratories. In this series of patients, estimates of urinary ketosteroid excretionxates Simultaneously esexcretion rate. be post-treatment to compared their will timates of steroid sulphates; phosphatase; and blood levels of steroid sulphate, �«hphosphorus, phosphatase and total alkaloid will be done. of many that investigation 3. It has been evident in our preliminary months. within six treatment somatic relapse the patients tm.t improve after imp of duration the to involved in regard The critical problem of the factors provement is also to be studied. One hypothesis now under investigation is related to the premorbid personality. denial" verbal of the "explicit characteristics the with patients Specifically, Denial Factors in Personality R.L.: and Kahn, personality (Mainstein, E.A. that sustained improvement may be 1953) March, 1-13, ﬁg: Psychiat. Illness, A.H.A. Arch. Neurol. more likely to maintain improvement, than patients & of who do will be not have this pre- morbid personality makeup. (a) two with interviews by personality of premorbid the Evaluation close relatives will airre will be used to be made elicit dictive value such as need to for each patient. A standardized question- characterological factors, which be at least may have pre- right, prestige-consciousness, sensitivity toczﬁticismand compulsive drive. words: and of pictures (b) Tachistoscopic presentation The threshold material be compared.with will illness to related levels of subject matter characterological for be evaluated data This will of more indifferent nature. assessed be as quantwill in response alterations In addition, indications. itative indices of denial. (c) and be Rorschach given will and the Test The Thematic Appereeption evaluated for the same factors as the personality interviews. to of response predictions material, the of personality (d) the basis of treatment the to start Prior made at different periods.. treatment will be 1) those unthree to possibilities: according be classified patients will On and temporarily; moderately or to improve 2) those likely to improve; likely 3) those improvement and sustained marked maintain to likely (for at least 6 �.5. Prediction will also be months). made during the course of treatment (the third weekfbr the electroshock patients) taking into account the physiological At the of factors. the premorbid personality well analysis indices as as conclusion of treatment patients will be evaluated for actual immediate response to the treatment. Those who showed some improvement ified again according to whether or not improvement will will then be be class- sustained. h. Evaluation of the change in behavior of patients undergoing treatment will Such ratings will be be made on the basis of a modification of the made independently of all Malamud the other rating scales. test results by a supervising psychiatrist. D. FACILITIES AVAILABLE: l. Hillside Hospital is a 200 bed voluntary hospital for psychiatric care. All patients subjected to phy— siological therapies are available for study. Periods of hospitalization.are 2-8 months; and a h-6 week observation period is generally available prior to the institution A of physical therapy. Research Service has been established, with a full time professional staff of a Director (neuropsychiatrist); assistant in psychiatry; biochemist EEG and technician (Ph.D.) research and assistant chemist; neurophysiologist and secretary. A full time psychologist and two chemists are associated on a project basis. Laboratory a Medcraft D-8, two S—hB 8 facilities include: (a) Electroencephalographic unit with channel instrument; (b) Neurophysiological laboratory with Grass stimulators, Du Mont # 3&0 R oscillograph; two synchronized tach- Biochemical (0) laband equipment; electronic auxiliary projectors istoscopic the followwith and of equipped 1000 with feet laboratory space square oratory ing major items: Beckman spectrophotometer,'Warburg respirator, Coleman Spect- rophotometer, and radioisotope unit following the basic specifications of the A.E.C. �2. Personnel: (a) Dr. Max Fink, M.D., Director of Research: After undergrad- uate studies at the University College of his D-A. New York University where he received cunllaude with Honors in Biology in l9h2, he attended the New York University College of Medicine, graduating in 19h5. After a rotating interneship he served in the U.SL Army, where he attended the School of Military Neuropsychiatry. training Formal neurologic York (19h8-l9h9) and was received at Montefiore Hospital in at Bellevue Hospital ( l9h9-1951). Formal psychiatric training received at Bellevue Psychiatric HOSpital (6 Hillside Hospital (1952). and During 1951, again in 1953, New at months 1950) and then he was a research fellow of the Nat- ional Foundation for Infantile Paralysis, first at of Medicine and then at Mount Sinai Hospital in New New York University College York. Both periods of study were under the supervision of Dr. Iorris B. Bender. In 1952 he was certified in Neurology by the Amer. Board of Psychiatry and Neurology, and was granted complementary May certification in Psychiatry in l95h. Simultaneously he attended and.gsunnﬁndfrom the William Alanson Institute of Psychoanalysis, Psychiatry Certificate for Physicians in January 1953. White and Psychology, receiving (b) Dr. Jeseph Jeffe, M.D., Assistant in Psychiatry: undergraduate studies at their Following Columbia College (B.A., l9hh), Dr. Jaffe attended the New York University College of Medicine, and was granted was elected to Alpha Omega Alpha. He was an interne his M.D. in 19h7. He at the Morrisania City Hospital, and then began three years intensive study at the Bellevue Psychiatric Hospital. First as a resident in psychiatry, theniizneurology, and he com» pleted his studies as a U.S.P.H.3. post-doctoral research fellow under the supervision of Dr. Morris B. Bender. �~7— From 1951 to 1953 he was in the United States Air Force. He graduated from the School of Aviation Medicine and was Chief Psychiatrist at the Mitchell Air Force Base Hospital. Since discharge from the military service he has been in the private practice of psychiatry. He was certified in psychiatry by the American Board of Psychiatry and Neurology in 1953. Since 19h? he has been a candidate in White Psyof Psychoanalysis, Alanson Institute William the at psychoanalysis in Research Assistant two and the and for past years Peychology; chiatry Neurology at the Mount Sinai Hospital of (0) New York. Dr. Robert L. Kahn, Fh.D.: Assistant in Neurophysiology: After graduation from Brooklyn College Columbia University which was United States Army. in l9h0, he started graduate interrupted by work at four years of service in the In the army he went to Clinical Psychology School and served as psychologist in various hOSpitals within this country and overseas. On leaving the army he became a Research Psychologist in the Department of Neurology of the Mount Sinai Hospital in the supervision of Dr. time. To date, M. B. New York, where he has worked under Bender and Dr. E. A. Weinstein up to the present he has been an author of more than twenty co-author of the monograph. "Denial of Illness: ASpects" which was published in Symbolic and Physiological May, 1955. received his Ph. D. from the He publications, and is New York University School of Graduate Arts and Sciences in 1953, and was an instructor of psychology and Hunter Colleges sultant to the New for York at Brooklyn For the past two years he has been a con- years. State Department of Mental Hygiene and has conducted two training programs in several of thé mental hospitals. (d) Chemist: A Dr. Harry Goldenberg, Ph.D.: Director of Laboratories and Chief Trethe of he where was a C.C.N.Y. l9hh, of recipient in graduate maine Scholarship and graduated cum laude, Dr. Goldenberg received his Ph.D. in �~8l9h9 from the Polytechnic Institute of Brooklyn. (who-ll?) Institute the Polytechnic at biochemistry He (1951 to date).' In l9h7-h9 National Institute U.S.P.H.S. project he was a Research Fellow an been has and in instructor in at Brooklyn College enzymology of the of Health, and from 1950 to 1952 he was a chemist to a at Jewish Hospital of Broeklyn studying enzyme methods in clinical chemistry. (e) Mr. Hyman Korin, Research Assistant (Psychology): Following four College of the City of military service, he matriculated at and received his B.S. in 19h? and his M.S. in 1950. During years of New York 1951-52 he was Ph.D. his for and matriculated Sinai Hospital psychology interns at the in Research Assistant been 1953 has he June Since New York University. at thesis doctoral his completed and has recently Psychology at Hillside Hospital Mount on "The Effects of Electroshock on Retroactive Inhibaticn." 3. Publications: Recent publications of the Research Service include: The Amytal Test in Patients with Mental Illness, 1955. 3-13, ii: Hospital, Hillside J. Electroshock, in Improvement and to Memory Learning of in Changes Relation press). Conf. Neurologica, 1955 (In Delusional reduplication of Parts of the Body After Insulin J. Hillside Hospital, 1955 ( Therapy, In press). Relation Between Altered Brain Function and Denial Amer. Coma in Electroshock Therapy, J. Psychiatry (submitted). Rectification of Nonlinear Beer's Law Plots, Anal. Chem. gé: 690, l9Sh. Bioand Biochem. Arch Curves, Enzyme Non-Linear Activity Rectification on phys., ﬁg; 288, l95h. �July 1, 1955 BUDGET l. -. RESEARCH SERVICE, PERSOM'EL 1955-56 EFF—ES. Director of Research 15,000 - BD OF DIRECTORS 15,000 in Psychiatry 7,200 Research Assistant in Neurophys. 7,500 Chief Chemist 8,200 Assistant Chemist 2,800 Research Assistant in Psychology h,000 h,000 - Assistant Chemist h,000 h,000 ~ Assistant Chemist 1,800 1,800 - 2,520 960 150 150 3,810 2,1uo 1,670 1,000 200 800 $ 57,980 $20,750 $37,230 Research Assistant Secretary - EEG Technician 2. EQUIPMENT 3. CONSUMABLE )4. TMWBL-CONFERENCES TOTAL SUPPLIES 7,200 7,500 - 8,200 2,800 1,560 ��your grant for the biochemm and neuroplvsiologiul approved. A mpplamuzy grunt request fer $7992.00 apprum! by the Public Health Serum for the 24—927 pmaeem This may will amt thsalary or Dr. R. him. 6. grants were A. , 3 The ascend In sdditionk protoccla were submitted thmgh Hr. medatim. m Calm ta the Hofheimr �Department of Biochemistry ................................. RESEARCH PROGRESS REPORT, JULY-AUGUST A. Major work Dr. H. Goldenberg 1955 in Progress 1. Determination of Chlorpromazine in Blood and Urine procedure for the colorimetric estimation of chlorpromazine and related alkaloids, described in the June 1955 progress report, has been further refined to permit detection of the extremely small amounts of drug circulating in blood. The method is based on two new features: (1) The finding that drugs can be quantitatively extracted from biological fluids with a single portion of an ethylene dichloride-ether solvent mixture, and (2) The use of a three—phase solvent dye partition system of analysis. The Clinical data are also being obtained on bound as well as free circulating promazine, based on the use of hot acid to liberate the conjugated drug. 2. Inhibition of Cholinesterase by Hallucinogens These studies are being continued as indicated in the prior report. 3. Steroid Sulfate Conjugates All but one of the major problems involved in the assay of steroid sulfate metabolism.in mental disease have now been solved. A novel device has been introduced for eliminating the interference with our test due to phenol sulfates in blood and urine. A two-phase system incorporating dicyclohexylamine (DCHA) as a complexing agent effectively separates the steroid from the phenol sulfates, permitting their unequivocal determination. The procedure for serum is now as follows: is treated with alkali to release the hormone conjugates. b. A lipid solvent is added to precipitate the proteins and simultaneously extract the hormones. DCHA The and between to brought is dryness supernate partitioned c. lipid a. Serum and chloroform. free steroid sulfates are released by shaking the chloroform extracts with acidic resin. e. Final assay of the sulfate conjugates is effected by adding dye and reading the color. d. The considerable amount of clinical data have already been obtained on normal people and on patients selected for independent studies by the Sloan-Kettering Institute. An immediate correlation has been established in our laboratory between urinary conjugate levels and sex, males excreting about twice as much conjugate as females. This ties in well with what is known of steroid metabolism A �and tends to confirm the validity of the method. Attention is now being devoted to fractionation of the steroid hormones in conjugate form. Paper electrophoresis has proven inadequate for the purpose. Paper chromatography is more successful and is under continuing study. B. Papers, Lectures and Conferences following papers are in preparation: (1) "Colorimetric Determination of Alkaloids, with Particular Reference to Chlorpromazine", and (2) "Steroid Sulfate Conjugates. II. Colorimetric Microestimation". The C. Funds and Personnel Changes 1. Research Grant #A-675 from the National Institutes of Health the fiscal period Sept. 1955 - Aug. 1956. 2. Messrs. Michael Miller and Spencer Parness terminated in the laboratory at the end of August. cc. to: Dr. Fink Dr. Miller their was renewed for summer employment �Department of Biochemistry ................................. RESEARCH PROGRESS REPORTI SEPTEMBER - A. Major werk Dr. H. Goldenberg 12§§ in Progress 1. Determination of Chlorpromazine in Biological Fluids As a result of repeated analyses of blood drawn from patients receiving chlorpromazine, the circulating blood level has been established as less than 1 microgram per ml. serum. The three-phase solvent dye partition scheme of analysis mentioned in the previous report has therefore been adopted as the only method capable of detecting the extremely minute amounts of drug in peripheral blood. A new shaking machine has just been obtained from the A.H. Thomas 60., Philadelphia, to permit application of the method on a broad scale. question naturally arises as to the metabolic fate of chlorpromazine in humans. We have recently detected in patients! urine an ether-soluble carboxylic acid which reacts with ferric chloride and appears to be an oxidative byhproduct of chlorpromazine metabolism. The 2. Inhibition of Cholinesterase by Hallucinogens three-phase system mentioned above has been found applicable to the analysis of LSD 25 as well as chlorpromazine and serpasil. By combining this observation with the earlier discovery of the inhibitory effect of LSD 25 on human serum cholinesterase, it is now possible to relate the enzyme inhibitory action to the alkaloid concentration in "unknown" samples of fluid and so deter— mine the specific molar inhibitory action at the 0.1 microgram level. This amounts, in effectI to the first sensitive chemical test ever reported for the detection of LSD 25 and related hallucinogens. The 3. Steroid Sulfate Conjugates work progressing cc. to: Dr. essentially as described in JulyhAugust report. Fink Dr. Joe. S.A. Miller M. �TJ'M‘ W10,” kW!“ mmMume mmﬁmmmam.mu¢wmtbmmmm dﬁltﬂdmﬁord’pﬁiﬁﬁd‘ﬂ. 7 mauummm �WW Wmmtmmmunmmngmpm. 3.) nmmmm Wamwmm‘m M.anummt.mk mmmwmmummmm.w. mmrpmhmmmmdmdt “Wumm Mnuwhmwmmmmmmmunm �.3. «W. wammnwunm-Wmum. 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Dr. mmnuuudatwrmnummmmmhmmm �mum-mu. n.) nun-rum WWII-luminous mummmnmummmwmm. mum Wummmmomumsnnamw-m www.mum.mmummmma: ’mmuem‘mwmrvwgm W m&% 11.:an . �\ﬂ October 20, 1955 MEMORAEDUM TO: Dr. Joseph S. A. Miller mom: Max Fink, 14.1). SUBJECT: Six Months Report of Research Activities at Hillside Hospital At the request of the Chairman of the Medical Affairs Committee, I am submitting this six month report of the activities of the Research Service and associated research activities at the hospital. During this period, numerous projects have been under investigation, our staff has expanded, and our space requirements were met. Two projects are being completed, and one project has just been instituted. A. PROGRESS l. hmw2: In ONGOIﬁG PROJECTS: ELECT§9§§QQK # Our second electroshock project was undertaken in March project had clearly demon- in September. Our first strated that cerebral changes were essential to improvement and that these 1955, and completed could be measured by the electroencephalogram and by amytal tests. 'Ue also concluded that memory tests were a poor index of improvement and believed that there were specific psychological patterns indicative of denial which were more prominent in the improved group than in the unimproved. Following this study, the second project was undertaken and was designed to demonstrate the reliability of the electroencephalogram and the amytal tests for prognostic purposes; and to ascertain the characterological as‘ﬂe term be term the short which and in results. long factors might pects have studied.twenty-seven patients to date. The data of this project is now being processed, and will be available following our six month follow up period, (which is from November to January). data from the first study was pres nted at various meetings, including the American Psychiatric Association, the Electroshock Research Association, and the Eastern Association of Electroencephalographers. The memory data, presented by Mr. Korin at the Electroshocx Research Association The in May, was awarded The their annual prize. electroshock project # 3 is below), and will be instituted November 15. now in the planning stage (see This project, which has been undertaken with Dr. Sidney Tarachow of the Medical Board, has accomplished a considerable amount of its basic work. Three approaches to the problem of measuring ambivalence have been accepted. These include an interview evaluation; the thematic apperception test, and tachistoscopic presentation of pictures. During this period of evaluating methods, twenty-three patients have been studied. Dr. Tarachow has been attending to this work, and the testing has been undertaken by dr. Korin. 2. AMBIVALcNCE: ‘ �~2- Serpasil evaluation study, undertaken at the end of last year, is com~ double blind a by been have studied intensively Seventeen patients pleted. Blumberg Drs. andeachspress. evaluated by The now data being is technique. To date, the clinical results are disappointing. Patients who were depressed, who were over-active Patients symptom. of this manifested an eﬁag ration disturbed/EnogIIeviation of this activity but the psychotic ideation genand of secondary induced a The variety intramuscular dosages erally persisted. complaints. In the evaluation of'the mecholyl responses following serpasil, The blood in pressure response all subjects. effect consistent was a there of this presentation considering Dr. and Blumberg is lower was significantly data at the next meeting of the American Psychosomatic Society. 3. SQRPASLL: The } Preliminary studies by Dr. Laderman in 20 patients in a series of clinical not was but significant this alterations and behavioral showed symptom studies of Shaw evaluation undertook an Dr. In mid-September, in the doses used. A protocol coma therapy. Thorazine as a possible substitute for insulin French and Kline submitted Smith, to was The Research Committee, approved by and approved, assuring us of adequate supplies for the duration of our proof 8,to a medication for period receive will In this study, patients ject. 12 weeks, comparable to the insulin coma period. During this time, very have been To be used. patients eight date, will thorazine of doses large The obser3600 1500 initial from to The daily. mg. dosages range studied. three had clinical response; a show significant three the patients vations h. THORAZINE: and one symptoms, toxic developed one minimal had patient changes; patients medthe of Cohen and Blumberg Drs. medication. the patient has just begun our using to permit controls the have contributed necessary ical department such large doses of this potent drug. Since June, Drs. Goldenberg and Royce have been coopof a in study Sloan—Kettering Institute the chemists the at with erating the possible alteration in the keto-steroid excretion patterns in our patSince June. Committee Research in by our This was approved study ients. then five patients have been under investigation. The initial data is not in Dr. Goldenberg by studied Each of being the is patients available. yet his laboratory as well as by the chemists at the Institute. 5. SLOAN KETTERIDG STUDY: Dr. Goldenberg has been occupied in studies measurand acid of devising the effects lysergic estimating ing chlorpromazine, methods to measure steroid sulphate conjugates. This basic research is to which to we apply measurement plan of methods the to provide necessary our patients. (a) Chlorpromazine: An ultra~sensitive technics has been of amounts this drug. microgram) minute (0.1 which measure can developed Golden— Dr. Thorazine, of number By applying this to a patients receiving bloodstream. the amounts in small appear demonstrated only that has very berg LSD has been by cholinesterase The LSD: of serum (b) inhibition A compounds. demonstrated, and this test applied to other hallucinogenic correlation between hallucinogenic activity and cholestestcrase inhibition was found. 6. BIOCHEMICAL RESEARCH: �*3“ a (c) Steroid Sulphate Conjugates: ‘Nith the grant support from the USIHS, methods to estimate these compounds have been devised. By studying hormone demonstrated sulphates are synthat Dr. Goldenberg liver slices, of the level in difference and a there sex is that the thesized by liver, steroid excretion. Both these observations are of fundamental significance, and will be presented to various societies this winter. In the Department of Medicine, hrs. Cohen and Blumberg have continued Durand the electroshock of the patients. serpasil studies their Mocholyl and than more been have studied to additional an patients this period ing half have had more than one such evaluation. The serpasil group demonstrated a significant alteration in their blood pressure patterns following this done be and been will has The correlated not data electroshock yet drug. as soon .8 our electroshock # 2 data is available. 7. MECHOLYL: Following the approval of this project by the Research Committee last spring, Drs. Navarre and Graubert had a number of meetings with members of the Medical Board. Following these discussions, they have begun a pilot study of one patient, and intend to evaluate those factors in the hospital environment which may be contributory to the patient's improvement. This satisfactory pilot study was udertaken in an effort to clarify a protocol to the Ibsearch Conmittee and of sufficient quality to be submitted for 8. SUBCULTURE: To some extent, this project outside to organizations. financial support was hampered by the multiple duties of members of the committee and by the resignation of Dr. Gurvitz. Since September, however, the committee has been working very actively and it is anticipated that a satisfactory protocol will be available by the end of the year. In June, following some discussions concerning the Laderman and Drs. coma of insulin doses for insulin treatment, correct doses between the multiple relation into undertook an Blumberg investigation 05 insulin and the blood glucose level. lt was anticipated that multiple small doses of insulin might reduce blood sugar significantly earlier and large dose. It was quickly determined, for longer periods than a single .) however, that multiple small doses, even if the sum total was equal to a This and of depth. coma degree a not did satisfactory produce dose, single project is now being prepared for publication. 9. B. DIVERE' I SULIN D SE8: PROJECTS PLANI‘IED: November # the third Electroshock 3: Beginning let, l. electroshock project will be undertaken. This study is designed to extend our experience with the factors which may be relevant in both the long and short term clinical reSponses following electroshock. Also, in this study specific emphasis is placed on the psychiatric and language changes which follow electroshock treatment and which we have been accustomed to calling "improvement." Dr. Joseph Jaffe has prepared a number of specific studies, including detailed interviews with patients prior to and during treatment, in which specific aspects of behavior and language will be assessed. �a... In this study, also, a basic problem in the perception of multiple simultaneous tacti e stimuli will be undertaken. Under our original grant from the United States Public Health Service, we were given funds to study the problem of Satisfactorily delivering single and multiple independent and The completed was designed equipment wave impulses. electrical square in Septemler and for the past few weeks has been undergoing rigorous clindur« be and will applied found been has satisfactory highly ical tests. It between changes the of relation the with question specific ing this project the in and in behavior, changes stimulation tests simultaneous double in electroencephalogram and in amytal tests following electroshock. 2. EIOC ‘thAL APPLICATION OF HEM TESTS: ’ Dr. Golden— berg has completed.the pilot studies necessary to devise measures of Specific compounds. He believes these should be applied to our clinical population over the next year. A specific protocol for this application is being prepared. 3. For more than a year, has been interested in form- EEQQNOSTIC IdDIGATQE§ﬂIﬂ ELECTROSHOCK: ' ‘ Dr. Karliner of the attending psychiatric staff electroshock. would be in which helpful factors some prognostic ulating Discussions were held in June and at the suggestion of Dr. Miller, Dr. Karlbe This scale will evaluate scale to prognosis. iner prepared a special months. next the six and Committee assessed over Research the to presented C. STAFF CHANGES: Dr. Joseph daffe, a practicing peychoanalyst, was and in research psychiatry, assistant Service Research as appointed to the behavioral the in is Dr. interest Jaffe's work on September began lst. induced altered brain function and the by and language changes which are relation between such changes and premorbid personality. were resolved effectively Lowenstein of the floor the on the of first extension the laboratory by The reduced. been tachistoscopic have also Our problems equipment building. be able now to works and well. are into alignment was brought equipment During this period our space problem simultaneously. two or individually pictures tachistoscopically present The electric stimulatorsale functioning satisfactoraly so that we are now able to produce isolated simultaneous square wave stimuli with the ability to vary any of the essential parameters. D. FUNDS: In May, we submitted an application to the United Sept— In of Dr. Jaffe's Service Health program. for support Public States an in the and staff interviewed the Frank Jerome came to hospital Dr. ember, USPHS the from in we anticipate a response evaluation of our program. mid—December. In June, we also submitted the necessary forms for second renewals and both and Dr. Goldenberg myself, both renewal for grants year the these both renewals, note for that to were approved. It is important overhead allowances were increased to 15%. At the suggestion of Mr. Coleman, specific protocols of our re» search program were submitted to the Kaufman, hoffheimer, and lttleson Foundations during this period. �-5the been for has Service writing Research the which The protocol of Committee Research the submitted to was Ford Foundation grant pr gram was the protocol that the consensus was the Medical Board in September. It suggestions, their Following be submitted. not and that it unsatisfactory of Drs. the with cooperation Service Research made the by changes are being Lenzer and Luttrell. another submit application to am planning I present time, re— March for meetings their to the USth in January for consideration at to an application am contemplating also I newal of our present program. ambivalence study, the for for Fund support for Psychiatry Foundation the as soon as the basic work is completed. At the E. Q?HER.ACTIJITIES: l. ISRAEL 5T3§p?§nF9§E§Ei9F THE JOURNLL QEWEELEEERE HOSPITAL: Following diScussion with Dr. Tarachow, the Research Service has undertaken the Tarachow issuin Dr. work in and ssisting editorial necessary secretarial Journal. Volume of Hillside the Commemorative the special ing 2. ISRAEL STRAUSS LECTURE: Consideration is being given by members of the at Discussion is next the lecture. Committee for Lecture Strauss Israel should decision and a final candidates of number present centered about a be available by the end of November. Respectfully submitted, . i "’ -," ’- 4 H7 ”.51 ‘ ‘) {I 1 «I g.“ ,--‘or ,. ‘ j . If ‘f‘ \ Fink, M.D. Director of Research Max . . �Department of Biochemistry ................................. Research Pro ress Re Major werk l. rt, Dr. H. Goldenberg November l9§§ in Pregress Chlorpromazine Studies previous work has been summarized in the report for the 6 month period ending Oct. 1955. We have subsequently learned from two representatives of the Smith, Kline and French Laboratories that Drs. Salzman and Brodie, working at the National Institutes_of Health, have identified chlorpromazine sulfoxide in the urine of dogs and men after treatment with chlorpromazine. A sample of the sulfoxide was requested from Smith, Kline and French and arrived the end of Nov. Our ultraviolet absorption spectrum of the sulfoxide was determined in aqueous solution and compared to the Spectrum obtained with extracts from patients! urine. A remarkable similarity was noted. On the basis of this and other data accumulated in our lab., there can be no doubt but that urine from mental patients receiving chlorpromazine contains: (1) chlorpromazine, (2) the sulfoxide, (3) one or two other alkaloids of related structure, and (A) at least one break-down product which yields a violet color with sulfuric acid, as contrasted to the pink colors typical of chlorpromazine and its sulfoxide. The Using our dye—partition scheme, the sulfoxide yields a color which is roughly 1/5 the value given by chlorpromazine in equimolar concentrations. Hence our dye scheme is not applicable as such to the analysis of fluids con~ taining both derivatives, unless some additional information is available on the relative amounts present.‘ Fortunately the relative proportions can be estimated from the extent to which the color is depressed by the addition of ether. Nonetheless, we are withholding a manuscript dealing with chlorpromazine analysis until this question is completely resolved. Ultraviolet and chromatographic studies are to be undertaken soon to establish the various chlorpromazine derivatives in urine and their clinical significance. 2. Role of Toxic Agents in Mental Diseas : An Enzyme Test for LSD first draft of a manuscript entitled "Inhibition of Serum Cholinesterase by Lysergic Acid Derivatives. Submicro Detection of LSD 25" has been completed. Copies are to be forwarded to the Research Committee on Dec. 8th. The 3. Steroid Hormone Conjugates Little progress has been made in this area in the last 6 weeks because of a delay in construction of our chromatography cabinet and unavailability of electrical parts needed for the circuit. This situation should be remedied by the middle of December. cc. to: Dr. M. Fink Dr. Jos. S.A. Miller �ELECTROSHOCK THERAPY EVALUATION PROGRAM from the Research Service of the Hillside Hospital Glen Oaks, New York December 20, 1955 Alvin E. Coleman, President Joseph S.A. Miller, M. D. Iiedical Director �Electroshock Therapy Evaluation Program em I. Aim II. Background III. Previous Studies Development and Progress in Studies IV. Tests of Altered Brain Function Premorbid Personality of Adaptation Patterns NonAVerbal Verbal, Evaluation of Improvement Steroid Excretion Studies Autonomic Studies V. Program Summary Method Significance VI. Facilities Available Laboratories Personnel VII. Budget Present Budget Requested Support VIII. Appendix References Bibliography of Personnel Page �I. E: During the past few decades there has been an of various new somatic intensified development therapies for mental illness. Jhile some have even- been an has established as electroshock therapy into fallen disrepute, tually important and successful method for both immediate and long term results (1). Despite its empirical usefulness, the many theories concerning the mechanism of this therapy have been either disproven or are so vague that their validity tested. In a comprehensive review, Kalinowsky and Koch (2) emphasize the lack of information in this regard stating: ".......the theoretical cannot be aspects of the various somatic treatments in the case of the shock treatments, still ..... are poorly understood, or, as entirely obscure in their mode of action." The aim of this program is to study the therapeutic mechanisms in electro- convulsive therapy by the systematic investigation of behavioral, personality, physiological and biochemical factors. Thile the program has electroconvulsive therapy as its focus, considerable theoretical and experimental information can be derived to relate the phenomena observed in this therapy to other somatic treatments such as lobotomy, electronarcosis and insulin coma. �II. BACKGROUND: of abundance has stimulated an electroconvulsive therapy of use and the Both kind theories of the much and research. exper(3) hypotheses The of interest the reflect however, particular undertaken, imental investigations the origin frame reference of regarding and theoretical his the investigator of mental disorders. Thus, each has been usually limited to one aspect of the problem. In general, these theories may be differentiated between those that emphasize physiological, biochemical, or psychological constructs. A who classical physiological construct is exemplified suggests that the various by Gellhorn (h) forms of shock therapy "act on the centers of the autonomic system, produce intensive and prolonged sympathetico-adrenal mental activity, hypothalamic-cortical augmented and alter, through discharges processes and behavior." psychogalvanic reflex, The varying responses of blood pressure, heart rate, and other physiological indices to chemical stresses are obtained been has data huch of sympathetic reactivity. interpreted as indices to and Show autonomic reactivity, in this induces change a electroshock therapy that (5) coaworkers and support this his Funkenstein by studies recent conclusion. Much illness and biochemical study has been devoted to the relation between mental steroid metabolism. between ketosteroid excretion Numerous rates instances (6) in which a relation and change in mental state following electroshock therapy are reported, but the clinical difficulties in the measurement of steroids have left this issue unresolved. Kore recent studies excretion to the total steroids between individual the relationship exploring rate (7) utilize elaborate chromatographic separation technics. �In a good review of the biochemical and neurophysiological hypotheses, mode the view the that evidence to justify Ashby (8) presents experimental of action of electroconvulsive therapy is through effects on the adrenal cortex mediated by direct stimulation of the hypothysis. Psychologic constructs generally fall into three designs - studies of the psychic significance of the loss of consciousness; the relative importance of ities memory loss; and an estimate of the subject's re-integrating abil- the Numerous unemphasize studies of confusion. following a period conscious significance of the treatment as a “rebirth which eliminates reand exneed punishment for of a satisfaction narcissism" a (9); or gressed piation for committed sins (10). Amnesic effects are a common concomitant of treatment but most studies of these The significance of impairment. the nature emphasize the temporary defects for therapeutic results is emphasized by numerous authors. Data is the on emotional charge patreduces the treatment that presented to emotionallyfor of induces familiarity loss a associations (ll), ient's show toned associations (12), or a selective forgetting of unpleasant life memories (13). These constructs are further elaborated by authors who believe that the as behavioral responses confusionalemate including of an organic induction im» electroshock the for basis is over-reacting euphoria, impulsiveness or provement (1h). A more umerated by Weinstein & recent elaboration of this explanation is that enKahn (15), described subsequently. �-h- adaptive in changes proregard explanations of psychologic Another group describe (16) and Frosch Impastato mechanism. cesses as the basic therapeutic on a which then re-integrates the of ego electroshock as causing a dissolution suggestopinion similar has a Alexander of adaptation. previous or higher level ing that defensive operations. enhances active and electroshock arouses For this in'whii1 conditions those in effective such is therapy that he asserts reason conp in ineffective but are low ebb, as in depressions, such operations are at a (17). alerted highly already ditions in which defensive operations are most two in.which Kahn (15) and Another hypothesis was developed by weinstein were the process of therapeutic aspects related. They asserted that the thera- of altered milieu of a creation the in convulsions lay induced of action peutic is of problems his expression symbolic brain function in which the patient's Their them. studies, denying of form the explicitly altered, particularly in cerebral with with patients documented by an extensive neurologic experience behavior. in adaptive of changes a function, amply demonstrate great variety dys— attention (l9), orientation (18), They describe altered patterns in language manifestations (21) as defect of and awareness (15b) (20), sexual behavior the patient's constitute mechanisms these conclude that and of adaptive behavior attempt to deny his illness or striking and enduring in those its meanings. patients Such who had most were denial at attempts habitually used the defenses with their of coping means a as and rationalization of verbal denial of indicative these patterns that problems (22). They also demonstrated administraintravenous the following interview "denial" could be elicited in an interview the clinical manifest in not when were they tion of sodium amytal (23)-* followdenial and explicit disorientation of * This appearance of patterns with associated so clearly sodium is amytal ing the administration of authors these by described been has diffuse cerebral dysfunction, that it test." named "amytal the been has This (23). as a test for such dysfunction �-5of denial between a patient's noted direct relationship a they cere— of the of and signs the electroshock appearance therapy pain following test) of mechanism the that suggested they amytal bral dysfunction (positive Thus, when electroshock therapy may be the facilitation of patterns of denial by altered brain function (15). and psychophysiological at integrating This hypothesis is an attempt which terms in View it of the and As operational in such, factors. logical have which studies base our theoretical upon a has provided is stated, it been elaborated. �III PREVIOUS STUDIES: of altered manifestations studies investigating For the past three years, cerebral function in psychiatric patients, have been in progress at Hillside Hospital. In 1952, the application of the amytal was asseSSed (2h). test to psychiatric subjects Positive responses were found only in patients who had had electroshock therapy or had other indications of organic brain disease. in order to test the relationship between altered brain referred consecutive patients electroshock to therapy, and the function response electroencephalograms, with serial intervals weekly at tested treatment were for During 1953-195h% amytal tests, simultaneous tactile perception%% tests, and tests of recall function. A marked correlation was found between improvement therapy and early, persistent the electroencephalograms. following electroshock and severe changes in both the amytal If no such tests such changes did not appear, improvement and failed correlations were manifest between improvement to occur. In contrast, and tests of recall function or changes in simultaneous tactile tests. WM TWenty—four subjects were tested in this first study, and were classified improved markedly as psychiatrist the supervising by independently ately improved (6) and unimproved (7) at the (ll), moder- end of one month post-treatment. Paralysis Infantile for Foundation National from the Aided Fellowship a by * (Dr. Fink, 1953) and Grant K—927, National Institute of Fental Health, National Institutes of Health lQSh-Sé. stimuli two simultaneous tactile of the of perception as Previous studies one localize to or of perceive failure demonstrated characteristic patterns of the stimuli in patients with diffuse cerebral dysfunction (25). �-7Of the markedly improved patients, every one had at least one positive amytal reaction during treatment. Of the 50 tests given to this group, 38 (765) were positive. In contrast, of the unimproved patients, five of the seven never showed a positive result, positive. 6 (13%) were and of the The LS tests administered to this group, only moderately improved group showed more positive re- sponses than the unimproved patients, but fell far short of the much improved group. In addition, there were consistent changes in language and non-verbal as- pects of behavior indicating alterations in adaptive mechanisms in the in interviews not employing amytal. These alterations improved group, even were much either minimally or only transiently manifest in the unimproved group and then only under the influence of sodium amytal.* Concomitant studies of the electroencephalograms taken on a day pre- ceding the amytal first measured test indicate for per~cent time a similar 31 w wave relationship. The 160 records were (delta) activity, the extent of burst activity and the amplitude and frequency of the slowest waves present. They were then placed in a rank serial order. Those falling in the upper third were labelled "high abnormality" abnormality." ality after Of the and those in the lower much improved patients, one week of treatment; 80% after 25% showed third as "low a high degree abnormp two weeks and over 90% after three In the unimproved patients, however, none had a high degree abnormality record during the first three weeks and only one had such a record by the fourth weeks. week of treatment. The records of the moderately improved patients fell between these two groups.*% * Presented at the Annual Meeting of the American Psychiatric Association, Kay 10, 1955. ** Presented at the joint meeting of the Eastern and Southern Electroencephalographic Societies, Bethesda, September 30, 1955. �Changes in memory and learning were tested in these subjects by using the principle of retroactive inhibition. 3-letter originally learned By the serial testing of recall of words following the interpolated learning of nonsense syllables, patterns of decrement in learning and recall were elicited. As a week of treatthe showed to third impairment the increasing up patients group, ment, and a rapid improvement after the cessation of treatment. No relation- ship, however, could be established between impairment and reSponse to treatment.* The responses of these subjects to simultaneous tactile tests using touch stimuli were also assessed. While an increasing impairment in the ability to be two demonstrated with increasing could and stimuli the localize identify treatment, no relation to improvement was noted. however, and in anticipation that more meaningful The tests were extremely gross, correlation for this index of altered brain function could be obtained, a study using threshold electrical stimuli has been undertaken (pg. 10). As ent and result of these studies, it was our conclusion that early, persistsevere changes in both the electroencephalogram and in the amytal tests a are a necessary, though not sufficient pre—requisite for improvement following electroshock therapy. These observations make it possible to predict the short term response to electroshock, and such a study was undertaken earlier this year (pg.ll). Concomitant with these studies, we have made some preliminary observations in patients undergoing insulin coma therapy. Recent reports of the value of prolonged coma as the basis for improvement (26) have been confirmed in our patients. In one unusual case report we noted a direct relationship between * Presented before the Electroshock Research Association,1;ay 8, 1955 and awarded their Annual Prize award for excellence in research design. �altered brain function, altered patterns of adaptation in language and behavior, clinical and improvement (27). Concurrent with these psychologic investigations, basic studies have been done in in biochemistry. 1950* with an The initial biochemical research laboratory was established program of study of the relationship between steroid excretion patterns and states of mental illness. studies, utilizing alumina column chromatography, demonstrated atypical The number excretion of a levels in psychotic ketosteroid patients. urinary The of B—steroids (particularly dehydroisoandrosterone) was found to be elevated, and the etiocholanolone was depressed (7a). The ll-ketoetiocholanolone values appeared to be sex-dependent: male patients excreted the steroid metabolite in normal amounts, while the several female patients studied had markedly elevated values. During the past year, a collaborative study was chemical department of the Sloan-Lettering initiated with the Institute of new York. bio~ Similar steroid excretion pattern studies were undertaken utilizing paper chromatographic technics. In the first phase of the study recently completed, the elevated excretion of ll-ketoetiocholanolone was confirmed, with a severe reduction in the excretion of this when compound prior to discharge, at a time the patient had shown considerable improvement from her * Supported by grants from the Dazian Foundation illness. for Hedical Research. �.10... IV. §EUDIES IN PROGRESS 1. Relation 2f AND Tests IN DEVEILEEENT: Improvement: Function Brain 33 Altered 3; altered between relationship direct Our earlier studies this that however, apparent, is treatment. It to and function response brain and not only function brain altered of indices certain holds for relationship and elabconfirm to undertaken been has for others. Further study, therefore, have shown a methods of measuring orate these findings, as well as to investigate improvement. clinical to related function which are more reliably a. cerebral Amytal Test and Electroencephalogram: Amytal tests and electroencephalograms are done and second the and during subjects before, third in all weeks of electroshock treat— make a used predicto data is the findings ment. On the basis of our earlier those that predicted is treatment. It to term short response the of tion and with positive abnormality electroencephalographic patients with a high degree amytal test findings will be most likely to show improvement; while those with amytal and with negative abnormality a low degree electroencephalographic results are considered unlikely to improve. b. Tactile Perceptual Tests: perceptual tactile simultaneous the As described before, was planned inconclusive. It were of test results in our first series patients conditions under stimulation, electrical to repeat this study using threshold terms Under controlled. be could rigidly wherein the various stimulus parameters two of consisting assembly instrument (M—927) an USPHS grant of an existing dewhich can devised was oscillograph monitored by an Grass Sh-B stimulators the assembly, this Using stimuli. electrical wave independent square liver stimuli applied simul- to perceive their ability for tested patients are technique refined this By applying body. taneously to different parts of the two �.11be may otherwise not apparent function brain in it is anticipated that changes and of improvement the be to degree compared will observations These elicited. to our other test~results. As in the case of the electroencephalogram and the and intervals during stated before at tested are amytal tests, patients course of treatment. c. Hemory Tests: imp and loss of memory of relation the Numerous theories provement have been described. Our own data to date shows no significant re- and words and simple nonsense syllables for lationship forselective a there is evidence that considerable But there is improvement. For memories. and situations of life significant getting, during treatment, between the memory loss a record this purpose, may be is made of events during the preceding six months which of emotional significance to the patient. During treatment, inquiries records verbatim of these events, recollection patient's are and these compared to the pre-treatment reports. made of the 2. Relation gf’Premorbid Personality to Duration 3; made, Response: has also been apparent that the relationship between altered It brain function and clinical response is valid only for the short term response When six followed a for treatment. weeks several after to treatment, ite., return a had showing relapsed, the of improved several patients period, of their former symptoms, and in some instances requiring further hospital- month ization. thesis To account for the varying duration of was advanced that the difference personality patterns. Specifically, it was clinical response, the hypo- related to differences in premorbid was suggested that patients who showed would (22) denial verbal personality" the of "explicit the characteristics likely to maintain improvement. premorbid personality of each patient is assessed be those more The an interview with family members, psychologic and psychiatric interviews. by four procedures tests, tachistoscopic tests - �a. Family Interviews: At least two close relatives are seen in independent interviews. A standardized questionnaire has been devised to elicit characterological factors indicative of the "explicit verbal denial" personality. For this study fifteen characteristics defined as typically present or absent in conscious— Such include items prestige selected. were of this type personality and and to sex attitudes temper to imagination, criticism, ness, sensitivity illness. Each patient is rated on a scale of 0 to 2 for each item - the higher score signifying a greater tendency to denial. b. Psychologic Tests: Each patient is tested on a standard psychologic eval- uation battery including the Rorschach and Thematic Apperception TEStS. These adap— defense of and usual or types structure character assessed for tests are tation. Such tests are repeated at the termination of the treatment program and again prior to discharge, to obtain additional information as to changes in behavior in the course of treatment. - c. Tachistoscopic Tests: tachistoscopic study has been devised; in which pairs of emotional and non-emotional words are flashed on a screen at 10, 20, 50, 100, and 250 millisecond periods. The patient's ability to identify the words, A the reaction time, and the distortions are ascertained. This pre-treatment data is now being explored as to defense patterns. The its ability to clarify the patient's usual tests are repeated at the end of greatment and again prior to discharge for the possibility that characteristic changes in perception develop with altered modes of adaptation.. �-13.. d. Psychiatric Interviews: In the course of estimating changes in behavior, patients are seen prior to treatment, and at intervals during treatment. In a clinical interview setting, an assessment is made of the patient's symptoms, and usual of adaptation. Changes in symptoms, behavior, language and modes of adap- modes tation are noted. By interviews with the patient's therapist, judgment as to the significance of such changes and bral states can ment their relation to treatment, or altered cere- be made. On the basis of the data in a-d above a prediction of response to is made. treat- Prior to the start of treatment the patients are classified as: 1) those unlikely to improve; 2) those likely to improve moderately or temporarily; 3) those likely to maintain marked and sustained improvement (for at least six months). During the third week of treatment, (after the patients have had ments), a second prediction of the short term response change is made 7—9 treat- according to the in the physiological indices. 3. Altered Patterns g£.Adaptation Kanifested in‘Verbal and NonéVerbal Behavior: In the earlier study on the amytal test it had been noted that specific changes in language and behavior indicative of altered adaptive responses occurred in the improved patients to a significantly greater degree than in the unimproved patients. Further experimental procedures were necessary to clarify the nature and significance of these changes. deemed �alb- a. The is a highly structured interview of the patterns of language. made ients who show language will in émytgl Tests: amytal test procedure is recorded. This Language Changes Induced situation, The and systematic observations are hypothesis tested is that those pat- consistent, increasing use of the following types of adaptive be more likely improve: 1) The use of the second or to third person. In such instances the patient reports his main trouble as "the Doctors say I'm depressed", or state the wish that "my family should be well." 2) The selective response to questions, as answering readily questions about date and location but failing to answer, illness. tive mumbling or using neologisms when asked about 3) The use of conditional or qualifying expressions, or the subjunc- mood which has the effect of vitiating the patientis committment to the is I feel kind of dBpressed", in w hich "sometimes" qualifies the temporal degree of illness, and "feel" and "kind of" statement. An example "sometimes ‘qualify the intensity of the illness. Committment would be indicated by the direct, unconditional statement of "I am depressed". h) or stereotyped expressions in discussing illness, as "to or "well, in a manner of speaking..." or "I didn't keep wheel". 5) Language antic statements. 6) problems. tell my The use of cliches you the shoulder to the filled with nonpsequiturs, circumlocution, ornate The use or pedp of humor when talking about their illness or other 7) The use of metonymy or paraphasia, as Dr. as a "recorder". 8 )The various forms of ulation about the main problem truth..." referring to the examining explicit denial including confab- and temporal displacement. 9) changing the sym- bolic frame of reference in response to questions, as replying to the question, feel?", by stating, "with my hands." 10) The use of hyperbole, as "you're the best Dr. in the whole eastern Atlantic seaboard area." "how do you �.15- State: Confusional the PostaShock b. Language Changes in Each orientation for tested is patient and awareness of treatment. a following immediately awakening of the period in his main problem such At intervals. weekly and then at treatment the initial done after @his is most severe, and a defects are cerebral neurologic the times, These of language appear. tive changes in the pattern variety of may be comparable adap— to the records are and the situations, interview other the in noted changes language and changes language the later to both as indications assessed for prognostic the degree of improvement. Study: Sentence Completion 0. in language in and changes A way of studying the patterns technique. completion sentence a devised using been has fashion a quantitative accordstructured been have which complete, to sentences to given The patient is the in first been have put sentences the of Ten different patterns. ing to four when....", criticized am "I Wish that......", such "I as unconditional, person, the in expressed are they that except meaning in identical Ten others are etc. sometimes "people as aspect, qualifying or conditional third person and with a the In reetc. When.....," criticized wish that.....", "people are usually these of senten In indicated. maining twenty items no person is specifically or occurrence exact an to refers or direct is sentence the tences, however, event as "every time....", ”when the doctor comes in.....", etc. The remainp "at times....", as aspect, indefinite or qualifying conditional, have a ten ing etc. when.....", better "things usually seem a little for analyzed not in sentences The response of patients to the incomplete rated is each response Instead, manner. psychologic content in the traditional �16 the whether include ratings for its grammatical or syntactical structure. or conditional, direct or is second third person, or response is in the first, The 1h). (page above described of language manifests aspects 1) assumptions: following the on This study is based begins in the to most obviously applicable a manner A sentence which patient (e.g., first person, adaptive reto elicit likely unconditional) creates conditional is or the third in person A sentence which is expressed 2) sponses. and least minimal is stress creates is less applicable to the patient. It complete used to The 3) person syntactical likely to elicit adaptive responses. maximum stress and is most of indicative is to person in regard indeterminate is whose beginning sentence a shows less of the person first the use the degree of stress experienced (e.g., third second or the of the use defensiveness, person shows greater defensive— ness). d. Attitude Interviews: In this part of the study an attempt the of mechanisms ego. adaptive the tionally Two is made to define opera— structured interviews followed. The attitude of the questionnaire is interone In next. the to interview from one examiner, however, is reversed and the in concerned, view the examiner is empathetic, pessimistic, minimize to and tends insensitive non-empathetic, he brusque, is other interview are held, in which the the patient's same difficulties. In general, the first attitude produces good a in grossly results latter the while rapport with these disturbed patients, each asked in are non-communicative situation. Although the same questions to be appropriate to the examiner‘s attitude. interview, the wording is altered "YOu must today?", poorly "feeling as such he questions asks In one interview worse?.“ been getting "has and it consider your condition pretty serious?", don't "you today?", well While in another interview he asks, "feeling pretty consider your condition serious, do you?" and "have you been improving?". �.11.: The two structured.interviews are performed just prior to electroshock interviews All are treatment. of treatment and repeated following the course of the patient's 1) alteration the study: in recorded. There are two variables The four attitude. examiner's the in behavior by treatment, and 2) alteration recordings are studied for and changes. language vocal changes, content, The it defensive mechanisms of the patient both out be carried can that transactions of the of terms range in ationally, and any changes in can be defined, oper- be commmay patient depressed For a example, very treatment. and after before he whereas interview, empathetic concerned, the in treatment before unicative jovial, mood is the when latter examiner's the in will be unable to participate of one is treatment to his response However, if and minimizing. bantering becomes he sustreatment Following reversed. be euphoria, the situation may and empathetic, concerned examiner is when the anxious or hostile, picious, Thus the interview. the optimistic in stressful less communication is whereas terms, objective in be stated the defensive system of the patient can change i.e., in of interpersonal standardized range to a in terms of his reactions uations. in sit- M h. Clinical Ratings 2: "Improvement": changes evaluating of methods and test These various experimental ratthe psychiatric in significance further have may and behavior language considerable experienced we studies revious In our : rovement." "im of P ing Or, be guide? the to relief symptomatic Is our patients. difficulty in rating to recovery Is be the goal?. to improvement" "social recovery" or is a "social relief? Agreement by symptomatic well as as of insight be judged by the degree "unimproved" and improved" "much "recovered", of definition the in psychiatrists is not available, investigations, to further crucial is issue and yet, this We �they terms as these of assessing task further the undertaken have therefore apply to the electroshock population. of incapacity and type the degree are Central to this problem of evaluation and the the of therapist, the goal personality, of the patient, his premorbid capacity events, intercurrent as Other aspects, therapy. to attitudes patient's environmental the patient's of therapy, suitability of the therapist, temporal present. at encompassed not but are assessment, to important also assets are To are studies evaluation following the "improvement", of meaning clarify the in progress. Evaluation: Pre-treatment a. the by therapy electroshock Patients are referred for and resident therapist. supervising psychiatrist evaluation is made by the research psychiatrist. An Two independent psychiatric aspects are specifically decompensation of signs clinical encompassed in this study: of sympdegree for and rated mental status descriptive a recorded in which are of the patient‘s estimate 2) an (28); scale tomatology on a Kalamrd rating 1) the symptoms and operations. defensive usual his of with description a develOpment of ego level Relationship: Therapist—Patient the in Changes b. to held prior therapist resident the with interviews In and the therapist between relationship the therapy, electroshock of the onset recomp the for the reason on emphasis with specific explored the patient are and the patient's treatment, the of the goals mendation for this form of therapy, mental of treatment of method Since the primary attitude to the treatment. electroshock for recommendation the disorders at this hospital is psychotherapy, the between patient communication that assumption the with carries it generally deis the exploration For this reason, meaningful. no longer was and therapist and recommendation, the led to that relationship the in voted to those changes �19 and symptoms that it is behavior of of those aspects statement a definitive We the in interested also therapist's affect. treatment are may the anticipated attitude to this may form of treatment, and attempt to assess the role this attitude play in the eventual results. of the the results theories relating numerous there are Furthermore, made being are attempts and in our inquiries, therapy to its punitive aspects, to assess the significance of this factor in the outcome. During the interviews with the resident therapist and with the patient, the patient's attitude behavior) and against (both language defensive operations to the treatment, his his in and alterations the electroshock represents, the reality threat that attitude during the weeks of treatment are studied. Further information regard— of our the in course be ascertained will of factor this ing the significance control study (page 21). c. Follow—up Study: Crucial to the evaluation of "improvement" is the oppor— treatment of the period following various periods tunity to repeat evaluations at from hosthis discharged of the patients follow—up report Recently, a four-year between customary the disparity indicated and (1) this pital was made available of inthis the In course illness. discharge ratings at out carried being observers is same the vestigation, repeat evaluations by As check a treatment. months after and six various times during hospitalization and eventual course of the and the physiological of the personality basis the on the predictions two—week the for recorded factors studied, specific follow—up evaluations are (long-term months period and the result) six post-treatment period (short-term made on ther— the resident of the to ratings result). These evaluations are compared each In instance, medical director. and the apist, supervising psychiatrist and the of terms projected formulated in the ratings made in this study are and interpersonal language of behavior, those noted aspects in actual changes �Excretion 23 Improvement: 5. Relation of Steroid and their reof steroids excretion patterns of The studies of the More recently continuing. is 9, on described page mental to states, lation of measurement the for of techniques development the on been has emphasis colorimetric and * new separative steroid conjugates. During the past year sulfate steroid measure to (29) devised techniques have been these for patterns excretion blood and urine. Daily urinary compounds in compounds are and prior again electroshock of the course assayed prior to treatment, during resolve to is of this program The object selected patients. in to discharge individual total the with values these and compare bound steroids, the sulfate excretion hormone between relationship the elucidating Besides hormone levels. which to extent the indicate of mental illness, such studies and rates states hormones. steroid of metabolism the the liver (30) participates in Electroshock Therapy: Results Functions of on 6. Effect of Autonomic behas studies, it electroencephalographic of our In the course alterations the typical fail of number patients that a apparent come to also fail These patients treatment. extensive in cerebral rhythms despite and frequently tactile tests, in the amytal tests, simultaneous to show show changes reactivity the studies, these with Simultaneous periods. confusional evince no mecholyl of administration the to rate and the pulse blood of the pressure to done was prior too, This, out. carried been have "Funkenstein—test") (the Marked ended. had treatment of the course after immediately treatment and two test these found in were medication this to variations in the responses the of earlier the reports way general a in followed observations These periods. between relationship the of exploration the undertaking workers, but we are now tests. physiological and these function brain altered of tests in the alteration * Aided by a grant (A-6YSC) Public Health Service. States United Health, of from the National Institutes �v. THE PROJECTED PROGRAM: SUMMARY 1. 3 21 - Method: the along and development continuation The projected program is a Our ultimate of this two report. sections lines indicated in the preceding the systematic by therapy electroshock of mechanism goal is to clarify the of behavioral, inter-relationship the of and integrated investigation biochemical factors. and physiological sonality, This program is per— rev interdisciplinary full-time a by undertaken being neurophysiolpgist, psychoanalyst, of psychiatrists, search staff consisting help. technical and allied biochemist physiologist, experimental psychologist, Some in scope clear already are the in program of the specific studies and new continues the program as become apparent Others will and outline. Two new basic develop. leads promising further or problems appear critical decided been upon. already have methodological aspects date work to our in 1. Control group:0ne of the major deficiencies starting Accordingly, control group. has been the absence of an adequate two into divided be will electroshock for referred January 1, 1956, patients of conusual course the receive will One group fashion. random a in groups treatments. sub-convulsive be given vulsive therapy; the other group will Ulett of study instructive recommendation follows the recently reported This et a1. (31). In other respects the two groups will be treated in the same will each group in are patients who will The only person fashion. of The purpose treatments. the administering be the supervising psychiatrist in— of the effects physiological the differentiate to is such a control group know which outcome. therapeutic the affecting Some duced convulsions from other factors disease process, the of particular 1) nature the of these factors might include 2) the attitude and symbolic etc.; depression, involutional or as schizophrenia of a large attention 3) the special the patient; to treatment of the meaning �~22: numbers of observers h) the incident to being placed on the treatment program; attitude of the patient's therapist toward the patient and toward electroshock therapy, including the expected goals in each case; and S) the relative effectiveness of other forms of therapy provided for these patients in the hospital milieu. The use of a control group will also clarify the nature of "Spontaneous recovery" and may aid in the understanding of "atypical" results in the patients actually receiving convulsive therapy. 2. Insulin Coma: It is planned to extend the present methods of study to an investigation of those patients receiving insulin coma therapy. �~23.- 2. Significance This program of study has both applied and theoretical significance. there since electroshock of therapy use clinical It can lead to the improved be mechanism. will It the of therapeutic will be a greater understanding to who better improve, will those patients more skillfully select to possible and to predict the involved therapeutic in process, factors other manipulate more accurately future management problems. of the psychounderstanding to a greater however, also This study leads, pathology of mental picture which illness. Through the various methods of study a clearer will be obtained meaningful criteria for of the mechanism of defense and modes of communication may contribute more operationally accurate and "improvement". of determination the for diagnostic classification techtherapeutic other on throw light may Finally, the investigation and and obserthe function cerebral in niques. The studies of the alteration have signifi— damage and cerebral behavior between vations on the relationship also is It electrocoagulation. and cerebral cance for the studies in Ibbotomy modes of and in language the changes into here gained the insights that likely of psychotherapy. study eventual significant make an possible adaptation may �VI. FACILITIES AVAILABLE: 1. Hillside Hespital is a 200 bed non-profit psychiatric hospital. All admissions are voluntary, with periods of hospitalization varying from h-lZ months. All patients are available for study. The hospital was established in 1927, for the purpose of treating ulatory psychiatric patients. A amb- residency training program.was instituted earxy, under the supervision of an active staff of psychoanalytic psychiatrists. In 1950 the research biochemical laboratory was established, to be followed in 1953 by the neurophysiological research laboratory. In 19Sh these laboratories were combined and expanded, and a Research Service established as a:full-time operation of the hospital. Research Director was appointed to integrate program. At this time, the staff consists all A full-time the studies into a basic of the Director, research assis— tants in psychiatry and psychology, biochemist and assistant biochemist, siologist, and EEG technician. In addition, a psychologist and phyb two chemists are associated on a project basis. Laboratory Medcraft D-8, two S-hB Grass 8 facilities include: (a) Electroencephalographic unit with a channel instrument; (b) Neurophysiological laboratory with stimulators, tachistoscopic projectors ical laboratory with Du Mont # 3&0 R and feet of laboratory space Beckman Coleman Spectrophotometer, and ifications of the A.E.C. two synchronized auxiliary electronic equipment; (c) 1000 square the following major items: oscillograph; Biochemp and equipped with Spectrophotometer,'Warburg respirator, radioisotope unit following the basic spec- �£2 5.. ﬂ 2. Personnel:* studies Undergraduate Research: of (a) Dr. Max Fink, H.D., Director the and degree New Yorn College University, of Universitv were undertaken at the {e the attended l9h2. in was granted of B.A. cum laude with Honors in Biology New l9h5. in graduating of Hedicine, York University College interneship he served in School of the from he where graduated U.S. Army, the Military Heuropsychiatry in Knox After a rotating 19h7, and was Chief of the Psychiatric Section, Fort Station Hospital during 1947. Formal neurologic training was received at hontefiore Hospital in York New Formal psychiatric (l9h9«1951). Hosoital Bellevue Dsychiatric and at (l9h8-l9h9) and than (1950) at Hospital Bellevue ?svchiatric undertaken at training was Hillside Hoscital (1952). During 1951, and again in 1953, he and then at Mount In 1952, he was American Board of first at Sinai Hospital in a research fellow of the Hational Both periods of study were under the Foundation for Infantile Paralysis. ection of Ur. horris 3. Bender, Was ﬂew York dir- University College of ﬂedicine ﬂew York. the by in l95h, and Psychiatry, in Feurology, in certified ‘sychiatry and Neurology. Simultaneously he attended and gradof Psychoanalysis, Psychiatry and Institute 1953. In January, in Physicians for Psychology, receiving their Certificate Mental of Institute National the of June, l9Sh, he was granted a research grant uated from the ”illiam Alanson Fhite Health for a 2-vear study of electroshock processes. In September, l95h, he was Fink Dr. Hillside Hospital. Service at Research appointed Director of the is 33, married and has one son. _____._.__.___.___________.___.____________.._._____._______._____________.______. 38. apaended, page of is personnel * Bibliography �7-20Collowing Psvcuiatry: in Assistant (b) Dr. Joseph Jaffe, h.D., the attended Jaffe Dr. l9hh), (B.A., Columbia College at studies undergraduate Then 19b7. M.D. in his and.was granted of hedicine, College New vorlr. University he began interneship, rotating a he was elected to Alpha Omega Alpha. Followinr resident a as First Hospital. DelleVue Psychiatric the at of study three years U.S.P.H.S. posta as studies his he completed in psychiatry, then in neurology, lender. 3. Morris Dr. of doctoral research fellow under the supervision from graduating Air Force, States United the in he was 1953, From 1951, to Air Eitchell the at Psychiatrist Chief He was ﬁedicine. Aviation the School of Force Base Hospital. prac— the private been in has he service Since discharge from the military of Board American the by psychiatry in He certified was tice of psychiatry. psychoin candidate been he a has Since l9h9, 1953. in and Neurology Psychiatry Psychiatry Psychoanalysis, of Institute 'hite Alanson analysis at the William the at Assistant Research been has a two years the and past for and Psychology in position present to his He was appointed Mount Sinai Hospital of New York. September, 1955. Chemist: Chief Ph.D., Goldenberg, (0) Dr. Harry A graduate of the Tremaine of a recipient York New in of the City of College D. in ”h. his received Goldenberg Dr. Scholarship and graduated cum laude. in instructor He been has an Brooklyn. of Institute from ‘olytechnic the l9h9 l9hh, he was the College Brooklyn and at (l9h6-h7) biochemistry at the Dolytechnic Institute Natthe of enzymology Fellow in Research he l9h7~h9 was a In (1951 to date). ional Institute of Health, and from 1950 the to chemist he was a 1952, to methods enzyme studying of Brooklyn Hospital Jewish the at U.S.D.H.S. project in clinical chemistry. �...27.. Dr. Robert L. Iahn, Ph.D., Assistant in Psychology: (d) After graduation from Brooklyn College in l9h0, he undertook graduate studies at Columbia University. These studies were interrupted by four years of service and School Dsyc‘hology went he Clinical to where United Army, States in the On and overseas. country in this various hospitals served as psychologist in of Neurology the Department in Research T’syc‘iologist became he the army leaving of the Mount of Dr. horris Sinai Hospital in New York, where he wormed under the supervision B. Bender and Dr. E. A. "einstein until January, 1955. is He of monograph, the and co-author is studies, experimental of numerous the author "Denial of Illness: He Symbolic and Physiological Aspects" published received his Ph.D. from the New in May, 1955. York University School of Graduate Arts instructor of psychology at Brooklyn and Huntto been he a.consultant has two two For the past fbr years years. er Colleges conducted and has training proMental of Hygiene New York Department State the and Sciences in 1953, and was an he been has 1955, a Since January, mental the of several hospitals. in grams member of this staff. (e) Dr. Hyman years of military service, received his 3.8. in ogy interns at York four Following Psychology: in Assistant Ph.D., Korin, he matriculated l9h9, and at College of the City of his H.S. in 1950. During 1951-52 he the Hount Sinai Hospital and University. New was York and psychol- matriculated for his Ph.D. at New Since June, 1953, he has been Research Assistant in Psychology at Hillside Hospital. He recently completed his doctoral thesis on "The Effects of ﬁlectroshock on Retroactive Inhibition," and received his Ph.D. in October, 1955. his'L. F. (f) Dr. Arnold Blumberg, H.D., Internist: Dr. Blumberg received from the University of Pennsylvania in l9h2, for studies in physiology, and in l9h5, received his E.D. from the Mew York University College of Medicine. continued he two of and service, military years interneship Following a rotating 1952. l9h8 First from to Memorial Goldwater Hospital at his residency training �-28he completed Fellow Medicine, in then a as as a resident in neuropsychiatry, He has 1950-1952. Division Research the his studies as a Research Fellow in been a Fellow in Medicine at the New York University College of Medicine, 1951-Sh. He was is an certified Internal Medicine in l95h and of Physicians. He is the associate by the American Board of associate of the American Attending Internist at Hillside Academy Hospital and has'been directly responsible fa' of coordinator well as as Research Service, the physiological studies of the the biochemical programs. 3. Function of Research Service: the Research Service, the of research programs In addition to the with actively They cooperate functions. staff is active in two additional research who on part-time carrying are those members of the hospital staff In such instances, aid nature. of clinical a chiefly projects, the planning of goals, project clarification the is given in and design of programs, and is needed. and during in is progress, program Secondly, an active resident training independon an to opportunity carry an given is the third year, each resident been have two service projects of this ent project. Since the development such technical assistance as the include projects completed, and three are testosterone of and the use states anxiety in of reserpine clinical evaluation include resident At projects present, coma therapy. insulin to adjuvant an as now active. The completed a factor, therapeutic milieu a as the of hospital a study clinical evaluation and clinical, coma therapy insulin for substitute a of chlorpromazine as aMbivalence. of measures and tachistoscopic psychologic �-29In May, 1955, the Research Service established a. liason with the Sloan- York of steroid New out study to cooperative a of Institute carry Kettering excretion rates in psychotic patients, with emphasis on the patterns altered during and following electroshock thefapy. �-30.. VII, M PRESENT BUDGET AND REQUESTED SUPYOR : Budget and Present Support: 1. Present anus—“u The following is the full budget of the Research Service for the fiscal year l9SSmS6. The major Share of the program is supported by the Board of Directors, supplemented by grants of the United States Public Health Service. Under Grant M—927 of the National Institute of Mental Health, $1h,807 of direct costs and $2221 of overhead costs was granted for the year September 1, 1955 to August 31, 1956. This grant is the second year of a 2-year grant for neurophysiological studies including the present Electroshock Evaluation Study. awarded $6500 The National Institute of Arthritis has for the second year of a twoayear grant for biochemical studies. �~31- 1. w.- ' Board of Directors U.S.P.H.S. 15,000‘ 15,000 -——- Psychiatry* 7,200 7,200 --— Research Assistant in Psychology 8,000 -——-— 8,000 Research Assistant in Psychology 5,000 -—-—- 5,000 2,520 2,520 -———— Chief Chemist 8,600 8,600 -—-—- Assistant Chemist h,000 __—- h,000 Assistant Chemist 2,800 2,800 -——- Assistant in Chemistry 1,800 -——- 1,800 h50 -—-— h50 3,810 2,253 1,557 1,200 1,000 200 Personnel Director of Research Psychiatgz: Research Assistant in 7E0 Technician - Secretary Biochemistgz: 2. Equipment 3. Consumable supplies h. Travel - Conferences Total Overhead TOTAL * 3/5 time to September 1956. 60,380 39,373 21,007 2,521 ______ 2,521 62,901 39,373 23,528 �.32.. 2. Requestegjg‘udgetagr Support: A. include requirements of the Electroshock Therapy Evaluation Project The two two of other modification the to professional staff, additions specific allocations of equipment funds. (1) Psychiatrist: The cooperation of an additional full time psycoma insulin include of to the study the needed to enlarge scope chiatrist is positions, and of evaluations the in to assist control the study; therapy; to supervise diange in patients and carry out follow-up studies. For this position, an- alytic experience is essential. (2) Physiologist or Heurophysiologist: Present physiological studies of Further physiostudy and the Internist. Director the out by carried are by full-time a of studies these coordination the changes requires logical physiologist, (3) M.D. or Ph.D. Equipment: and physiology. For Present needs are focused in two areas - biochemistry further refined studies of the steroid sulfate patterns mechanical and a Beckman.Spectrophotometer the attachment for a recording carry out the anticipated physiological studies modifications and attachments to the electroencephalograph are shaker (Dubnoff) are requested. To suggested. following budget is one suggested to continue the present proneeded completo the of 1956 personnel addition the with July 1, gnmn after ment the present staff. The budget is divided into three categories, followB. The Research Serthe coordinated in which divisions are the three laboratory ing and five period, a for the for year Estimates listed first year, are vice. including projected salary increments. �M First 1. Psvchiatqz: a. Director Secretary Conferences 13 Year Five Year Total (20,-25,000) 20,000 112,500 (2,6-3,100) 2,600 1,200 11,220 (15,-18,000) (15,-18,000) 15,000 15,000 9,000 5,500 82,500 82,500 52,500 35,000 1,200 3,600 . Personnel 1. Psychiatrist 2. Psychiatrist 3. Eeychologist 13.. Psychologist c. Supplies Subtotal - & ( 9"12:OOO) (5’5' 8,500) Equipment 388,820 69,500 Psychiatry 2. Neurophysiologx: a. Personnel 9,000 3,600 52,500 12,000 b. Equipment 1,000 1,000 c. Supplies 1,200 6,000 1. Physiologist 2. Technician (9,-12,000) (3 : 641-31400) 71,500 10,800 Subtotal - Neurophysiology 3. Biochemistry: a. Personnel Chief Chemist (9,-11,000) 9,000 6,000 0,000 1,800 36,000 25,000 11,200 b . Equipment 7,000 7,000 0. Supplies 1,500 7,500 1. 2. 3. h. Chemist Chemist issistant Subtotal - Biochemistry (6,-8,h00) (bu-6,000) (1,8—2,600) 29,300 137,700 �Total First - All Programs .. All Programs 113,600 598,020 17,0h0 89,700 130,6h0 687,720 Overhead Allowance\(15%) TOTAL Five Year Total Year C. Budget Reconciliation: 1. Salaries: The salary range for each item is consistent with pre- sent positions established at the hospital, or for new positions, with neighbor- for supervising psychiatrists is $12,-15,000, with a projected revision to the stated scale in 1956. ing institutions. Present salary 2. Equipment: ment expenditure ance range For psychiatry, the initial year includes the equip- for tape recording system (#600) and an annual for expenses. The $600 allow— physiological equipment expense (51000) is to allow modification of present electroencephalographic equipment to record other physiological indices. The expenditure for supplies includes allowances for consumable items and the provision for the building of specialIized equipment. In biochemistry, the a recording attachment for the Beckman intiial expenditure includes $7,200 for spectrophotometer and 9800 for a Dubnoff shaker. 3. Conferences: Present budgetary items include this of the Director or members of the sum for the use staff to attend appropriate scientific meet- ings. h. Overhead: Consistent with hospital policy and recent administrative changes in other grants, a 15% allowance is requested. This amount includes hospital allocations for Social Security coverage; and for such contingencies in the expenses of the program as not reg iring a significant alteration in the budget. 5. Subtotals and Total: The budget is presented in three sections, representing natural subdivisions of the program, thereby allowing for modifications in support. �VII. APPENDIX A. REFERENCES: from Discharged 317 Patients of Study Follow-up H.L. RACHLIN, 2E.§i: 1. in Hosp., Hillside press. l?50, J. in Hillside Hospital and other Psychosurgery Shock Treatment, 2. KALINOWSKY, L.B. and HOCH, P.H.: New York, Grune Stratton, (2nd a ed.), Somatic Treatment in Psychiatry 1952. 19h8. 397, Mil. Surg. $92: Theories, Shock Therapy Fifth GORDON, H.L.: 3. and Dsvchiatry, Neurology of Foundations h. GELLHORN, E.' Physiological 1953. Minneopblis, Hinnesota Press, University of Nervous Autonomic H.C.: S.a FNNKENSTEIN, D.H., Ment. 3 Nerv. J. Shock Treatment, System Changes Following Electric GREENBLATT, M. Dis. 329%.: 2109, and SOLOMON, 19,480 Which PreA Test H.C.: 5.b FUNKENSTEIN, D.H., GREENBLATT, M., Schizophrenic on Treatment Shock Electric of dicts the Clinical Effects 1950. 889, Am. 199: Psychiat. J. Patients, AND SOLOMON, 5.0. Autonomic Changes H.C.: SOLOMON, and M., FUNKENSTEIN, D.H., & Nerv. J. Patients, in Mentally Changes Psychologic Paralleling GREENBLATT, Ment. Dis. 6.a. 11;: 1, 1951. Ill Exthe and in HOAGLAND, H. et al: Changes in the Electroencephalogram of AgitTherapy Electro-shock Accompanying cretion of T7-Ketosteroids 19h6. Med. §32h6, Psychosom. ated Depression, Excretion on Treatment of Effect B.H.: 6.b. ALTSCHULE, N.D. and & Neurol. Arch. Mental Disease, with Patients in of l7-Ketosteroids 1950. 516, éﬁ: Psychiat. Cortins of Excretion the on Convulsive Therapy 6.c. ASHBY,‘W. 1.: Effects of 19h9. 275, Ment. Sci. 23: and Ketosteroids, J. PARKHURST, Excretl7-Ketosteroid the of Studies Chromatographic H. WERBIN, 7.a. gt El: Hosp., Hillside Normal J. Individuals, and ion Datterns of Psychotic 195,40 2011, 2: l7~ Neutral of Urinary The Fractionation S. R.: M. STITCH, and REISS, 7.b. Ment. $99: Sci., J. Male Schizophrenics, Chronic from Ketosteroids 7011, 195,40 8. ASHBY, W. R.: Mode 22: 202, 1952. of Action of Electro-Convulsive Therapy, J. Ment. Sci. �.36... 9. Shock Therapy, Hypoglycemic and JELLIFFE, S. E.: Discussion on Insulin 1937. 200, & 2Q: Psychiat. Arch. Neurol. of Aspects Psychologic Certain 0n E. MOSSE, 9.: and J.A.B. 10. MILLETT, l9hh. 226, Med. 6: Electroshock Therapy, Psychosom. Shock Electric with Treated Patients in Functioning Memory ZUBIN, J.: lla. l9h8. 33, Dersonality Therapy, J. ll: on Therapy Convulsive Electric of Effect S.E.: BARRERA, and ZUBIN, 11b. J., 596, l9hl. ﬁg: Biol. Soc. Exper. Hemory, Proc. Assoword the on Performance on Shock Therapy of : Effects ZEAEAN, J. 12, 19h7. Association, Psychological Eastern the at Presented ciation Test. J. Treatments, Convulsive Electric Following Loss Memory JANIS, I.L.: 13. 191.18. Personality 1.1: 29, der mit Erfabrungen Psychopathologische GROBE,’W.: and W. BAEYER, von, lha. l9h7. 163, Psychiat. $12: Elektrokrampfmethode, Arch. f. after Patients Mental on Observations E. STAINBROOK, J.: H. and LOWENBACH, lhbg l9h2. 828, Am. 2g: Psychiat. J. Electroshock, Post—Convulsive of Immediate Description Rorschach STAINBROOK, E.J.: Ibo. 19AM. 302, & Personality'lg: Mental Function, Char. Electroshock During Psychosis KAHN, and R.L.: LIEN, L., WEIWSTFIN, E.A., 15a. Am. Psychiat. J. Shock Therapy, of the Theory to Relation Its Therapy: 1952. 22, $92: and PhysioSymbolic of Illness: Denial KAI-1H, R.L.: 15b. mnrsmm, F..A and 1955. Illinois, C. Springfield, Thomas, Charles Aspects, logical Ego, the on Treatment Shock of Effects D.: IMPASTATO, and FROSCH, J. 16. Psychoan. Quart. I]; 226, l9h8. l7. 18. 19. 20. Recent Under "Normal" Person of Electroshock on a L.: Effect 1953. 696, Am. J. Psychiat. $92: Stress, in (Paraphasia) Misnaming Non—aphasic UEINSTEIN, E.A. and KAHN, R.L.: 1959. 72, 61: a Psychiat. Neurol. Arch. A.M.A. Brain Disease, Organic Organic in Disorientation of Patterns KAHN, R.L.: WEINSTEIN, E. A. and 1951. 21h, & Neurol. I: Brain Disease, J. Neuropath. Clin. "47.1%.: 7-iithdrawal, Inattention, 310133, and mms'mm, E.A., ram-I, R.L., 1955. 235, & IA: Psychiat. and Pain Asymbolia, A.M.A. Arch. Neurol. ALEXANDER, �-3721. T‘JEII‘YST‘EIN, & E. nsychiat. A. _6_L_l: and mm, 772, 1950. D. Neurol. Arch. Anosognosia, of L.: Syndrome " of Denial Illness, in Factors Personality R.L.: MEN, and 22. IEINSTEIN, E.A. 1953. §_9_: 355, & T.‘Ieurol. Psychiat. 11.14.11. Arch. 23. L.A. and LINN, R.L., SUGABI'JIAN, Brain Disease, Sodium Organic in Amobarbital of “IEINS'I'Em, 33.11., MEN, Am. Use Diagnostic 1.: J. Psychiat. 112: 889, 1953. 21;. Test" "Amytal E.A.: H. and vmmsmm, KAI-1N, R.L., PINK, 1955. 3, Hosp. 3: Hillside Mental Illness, J. in Patients with Differential the in Tests Perceptual NJ: Tactile 25a. DEF-HER, MB. and 1952. 21, Hosp., Hillside 1: J. Disorders, Psvchiatric of Diagnosis Sign 8. Diagnostic Test as Face-Hand 1.1.3.: 25b. PINK, M. GREEN, M. and BINDER, 1952. h6, 2: Neurology, of Organic Mental Syndrome, ImproveClinical and Damage Brain 26a. REVITCE-I, 13.: Observations on Organic 195h. §_8_: 72, Quart. ment Following Protracted Insulin Coma, Psychiat. Coma: TreatInsulin A Prolonged Case of M.: 26b. IC-“IALEJASSER, S. and CAPLAN, 1952. 1115, Hosp. 1: ment, J. Hillside and ClinicElectroencephalographic 26c. SHAGASS, C. and ROFSML, P."T.: Serial & Neurol. A.Z"T.A. Arch. Coma, Insulin Prolonged of Case al Studies in a 195b,. 705, Psychiat. 12.: Posthypoglycemic in Studies 26d. TRACER, C.L. at £1: Electroencephalographic 19530 1135, 1.32%: Dis. l‘ient. Coma, Jo NerV. Parts of 1-5.: Reduplication Delusional and N. FINE, 27. KAHN, R. L., GRAUBTE’ET, D. 1955. 13h, Hosp. g: Hillside Coma Therapy, J. Insulin After 1Jody the of Scale, Rating the A Psychiatric of Revision 28. MALAI‘EUD, 'T. and SANDS, S.L.: Am. J. Psychiat. _l_9_l_l: 231, ram. Colorimetric Quantitative the for Dyes Basic Use of 29. GOLDENBERG, H.: Chemical Society American Conjugates, Sulfate Estimation of Steroid 1955. 'Iarch 31, 200, Abstract, Highspeed by Synthesis Sulfate Steriod : T4.. REIL’IANN, J. and 30. GOLDEHBERG, Chem. Soc. in Am. press. J. , Liver Supernates, Convulof Evaluation the in Matched Groups Use The of G. A. 313 31.: 31. ULE'IT, 195h. 128.: 138, July, Menn. Clin. Bull. Photoshock, Subconvulsive and sive F11 K, (31‘. �B. Publications of Personnel: Dr. N l. x Fink: Subdural Hematoma Developing during Hospitalization, Amer. J. Psychiat., 191: 381-383, 1950 (with Dr. M. Green). 2. Patterns in Perception of Simultaneous Tests of Face and Hand, Trans. Amer. Neurol. Assoc., 22; 250, 1950 (with Drs. M.B. Bender and M. ..., Green). ibid, Arch. Neurol. & Psychiat., éé: 355-362, 1951. Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology, 2: hé-58, 1952 (with Drs. M. B. Bender and M. Green). The Face-Hand Tactile Perceptual Tests in the Differential IJiagnosis of Psychiatric Disorders, J. Hillside Hosp., 1; 21—31, 1952 (with Dr. M. B. Bender). A Clinical Evaluation of Carotid Angiography, Conf. Neurol., 13: Exosomesthesia, or Displacement of Cutaneous Sensation into Extrapersonal Space, Trans. Amer. Neurol. Assoc., lg; 1952 (with Drs. M. F. Shapiro and M. B. Bender). .... ibid, Arch. Neurol. & Psychiat., éﬁ: h8l-h90 1952. 9. Order of Dominance in Cutaneous Perception, Trans. Amer. Neurol. Assoc. 2E3 238~h0, 1952 (with Drs. M.B. Bender and M. Green). 10. Development of Perception of Simultaneous Tactile Stimuli in Normal Uhildren, Neurology, 2; 27-3h, 1953 (with Dr. M. B. Bender). 11. Perception of Simultaneous Tactile Stimuli by Mentally Retarded Adults, J. Nerv. Ment. Dis. 111; h3-h9, 1953 (with Drs. M. B. Bender and M. Green). l2. Spinal Fluid Findings 2: 137, 1953 (I-rit‘n Dr. 13. Following Cerebral Angiography, Neurology, M. Stein). Statistical Study of a Psychoanalytic Hypothesis; Absence of a Parent as a Specific Factor Determining Choice of Neurosis, J. Hillside Hospital, a; 67-71, 1953 (with Dr. S. Tarachow). A Effects of Barbiturates 15: 1953 (with Drs. on Perception, Trans. Amer. M. B. Bender, P. Bergman and M. Neurol. Assoc., Nathanson). Homosexuality with Panic and Paranoid States (Case Report) Hillside Hosp., _2_: 16h-9o, 1953. J. 16. Standardization of the Face-Hand Test, Neurology a; 211-217, 195h (with Dr. M. Green). �.3917. Patterns of Perceptual Organization with Simultaneous Stimuli, Arch. Neurol. & Psychiat., 12: 233-255, 195A (with Drs. M. B. Bender and H. Green). 18. The Amytal Test in Patients with Mental Illness, J. Hillside Hospital, g; 3-13, 1955 (with R. L. Kahn and E. A. Heinstein). l9. Delusional Reduplication of Parts of Body After Insulin Coma Therapy, Dr. Joseeh Jaﬁig: 1. Perceptual Patterns During Recovery From General Anesthesia, Jour. of Neurol. Neurosurg. & Psychiat., 1%; 316-321, 195l (with M. B. Bender). 2. Factor of Symmetry in Tests of Double Simultaneous Stimulation, Brain, 15: 167-176, 1952 (with M.B. Bender). Dr. Rdbert Kahn: 1. Toxicity of Quinacrine (atabrine) for Central Nervous System: Experimental & Human Neurol. Arch. on Psychiat., 5g: 28h—299, l9h6 Study Subjects, (with Dr. T. Lidz). 2. After-Imagery in Defective Fields of Vision, J. Neurol., Neurosurg. and Psychiat., lg: 196-20h, l9h9 (with Dr. M. B. Bender). 3. A Hereditary Syndrome Characterized by Mirror Movements, Left Handedness and Organic Mental Defect, Trans. Am. Neurol. A., ZS? 22h—226, 1919 (with Drs. I. Freiman and L. Michaels). Tumors and Vascular 15: 277-278, 1950 (with h. Correlation of Clinical and EEG-Abnormalities in Disease of the Brain, Trans. Am. Neurol. A., Drs. E. A. ieinstein and H. Strauss). 5. Syndrome of Anosognosia, Arch. Neurol. (with Dr. E. A. Heinstein). & Psychiat., ég: 772-791, 1950 6. Patterns of Disorientation in Organic Brain Bisease, J. Neuropath. Clin. Neurol. 1; 21h-226, 1951 (with Dr. E. A. heinstein) & 7. Nonaphasic Misnaming (Paraphasia) in Organic Brain Disease, A.M.A. Arch. Neurol. & Psychiat., él: 72-79, 1952 (with Dr. E. A. Neinstein). 8. Preoperative and Postoperative Personality Changes Accompanying Frontal Lobe Heningioma, B. Schlesinger). 9. J. Nerv. & Hent. Bis., llh; h92-510, 1952 (with Dr. Phenomena of Reduplication, A.M.A. Arch. Neurol. & Psychiat., 81h, 1952 (with Drs. E. A.'Heinstein and L. A. Sugarman). él: 808- �uhO- Shock Therapy, Am. J. Psychiat., heinstein and L. Linn). Its Relation to the Theory of 222; 22-26, 1952 (with Drs. E. A. 10. IBychosis During Electroshock Therhpy: ' Brain Sodium") Sodium ("Amytal Organic in Amobarbital of Diagnostic Disease, Am. J. Psychiat., 109: 12, 889-89h, 1953 (with Drs. E. A. Ueinstein, L. A. Sugarman and L. Linn). Use Neurol. Arch. of Denial Factors in Illness, Personality Q2: 355—367, 1953 (with E. A. Heinstein, M.D.). & Psychiat., Behavior Disturbances Following Cataract Extraction, Am. J. Psychiat., and L. Linn). E. 1953 A.‘ einstein (with Drs. 281—289, 219} Delusional Reduplication of Parts of the Body, Brain, 7?: h5-60, l95h (with Drs. s. A. deinstein, s. Halitz, and J. hozanshiT: Serial Administration of the "Amytal Test" for Brain Disease: Its Diag195h & 217-226, Neurol. Arch. and Psychiat., Value, Prognostic nostic ll: (with Drs. E. A. Heinstein and S. Malitz). 16. Ludic Behavior in Patients with :rain Disease, J. Hillside Hospital, A. Sugarman). and L. B. A.'Heinstein l95h (with Drs. 98-106, 2: 17. Test in Mental Illness, J. Hillsiﬁe Hospital., (with Drs. M. Fink and E. A. ﬂeinstein). The Amytal Q; 3-13, 1955 Amer. "Irritative" Lesions, in of Functioning Intellectual Patterns 18. PSychologist, 25 h02, l95h (with Dr. E. A. Meinstein). 19. "Spatial inattention" in Patients with Localized Lesions of the CereN. S. l95h (with 327-328, Drs. Psychologist, 2: Pollack and M. B. Bender). brum, Amer. M. Batteery, 20. The Adaptive Role of Behavior Accompanying Brain Disease as Exemplified by the Phenomena of Reduplication, Amer. Peychologist, 2; h90, l95h (with Dr. E. A. ieinstein). 21. Denial of Illness: Symbolic and Physiological ASpects, Springfield, I11., Charles C. Thomas, 1955 (with Dr. E. A. ;einstein). 22. Coma Therapy, Insulin Body After of of Parts the Jelusional [@dnplication M. and Fink). D. Graubert 1955 (with lBh—lh7, Drs. J. Hillside Hosp., g: and Pain Asymbolia, A.M.A. Arch. Neurol. 23. ’kithdrawal, Inattention, Psychiat., 1h: 235—2h8, 1955 (with Drs. s. A. neinstein ana'h. H. & Slote). Spatial Inattention in Focal Cerebral Lesions, Brain, in press (with Drs. C. S. Battersby, M. B. Bender and.M. Pollack). �25. Autokinetic Movement in Patients with Sensory and.Motor Disturbances, J. M. M. and B. Pollack S. (with Drs. H. Battersby, Exp. Psychol., in press Bender). 26. Relation Between Altered Brain thction and Denial in Electroshock Ther& Peychiat., in press (with Drs. M. Fink and A.M.A. Meurol. Arch. apy, E. A. heinstein). 27. Mount Sinai of J. With Picture Schizophrenia, Clinical a Encephalitis Hosp., a1; 1955 (with Drs. E. A. Heinstein and L. Linn). Korin: Dr. .1. The New Effects of Electroshock York University, 1955. on Retroactive Inhibition, Ph.D. Thesis, Dr. Hargz Goldenberg: and of Amino Acid Esterase Trypsin Activities of the 1. Chymotrypsin, Arch. Biochem., 22; 15h, 1950 (with V. Goldenberg). pH Depenﬁence 2. Several Derivatives of Acetyl-dl-phenylalanine, J. 5317, 1950 (with V. Goldenberg and A. McLaren). Am. Chem. Soc., lg: 3. Effect of Ultraviolet Light on the Specific Activity of Chymotrypsin and Trypsin, J. Am. Chem. Soc., 72: 1131, 1951 (with A. D. McLaren). h. An Ester Leucine of Ethyl Hydrolysis the Enzyme-Catalyzed Into Inquiry Gold1951 V. (with Biochem. 110, Acta, Biophys. 1; et Chymotrypsin, by enberg and A. D. McLaren). 5. Report D-12, April 1, l9h6; cf. pp. 117-119, concerning 8-Hydroxyquinoline Method (Alcohol Extraction), in C.J. Rodden's "Analytical Chemistry of the Manhattan Project", (with J. Greenspan, M. J. Sohuler, D. Taub, and A. S. Carlson). 6. Calcification. V. Influence of Fluoride and Cyanide Ions in the Presence and Absence of Magnesium, Proc. Soc. Exp. A. L. Sobel). Biol., 19: 719, 1951 (with kaline Earths on Survival of the Calcify1952 (with A. E. Sobel). 695, Exp. Soc. Proc. g1: Mechanism, Biol., ing 7. Calcification. IX.Inf1uence of A 8. Calcification. IV. Influence of Strontium and Magnesium Ions on Calcification in vitro, Proc. Soc. Exp. Biol., IQ: 716, 1951 (with A. E. Sobel and A. Hanok5. 9. Calcification. XI. Studies of the Incorporation of Citrate in Calcification in vitro J. Dent. Res., 3;: L97, 19Sh (with A. E. Sobel and E. Schmeriler). �~h2§ Ions and Cyanide Fluride by Inhibition 10. Calcification. XII. Cation-Linked & Hed., éé: 27S, Biol. Soc. Exp. Proc. in B-GlycerophOSphate Medium, l9Sh (with A. E. Sobel). 19Sh. 26: 690, Chem., Anal. Plots, ll. Rectification of Nonlinear Beer's 12. Curves. Nonlinear Activity of Rectification Biochem. & Biophys., ég; 288, 195h. Enzyme Law I. Preliminary, Arch. �Studs.“ '1 tho room. L 01‘ 91‘ the “mum Width. 01‘ tn: 1:: Win A man}: Wm Wtm «mum, 01’ khanm tar claatraoncophﬂampw W! «mum “W studying 01-min manta]. with WW in brain during tin mmmd. m and Wm M wt yaw. W method. for YMMMW mmmmno at Madam ta stimulation mm W m,mmmmuhhmmmmmmmmpumm thew. m Wu. Mitmun. mental W «mum int-mm: um M m huts, ham gatima or tho hymn dam-uni" affect: of inn-ms, and human um cum-a. tannin; haloahraaanmkin acid (mp-was) an anal: and In tho mm- 5: yaw, a my at tho was in brain function during mmmuw mm «I Mpmholamu. Dre WWW”. Kmmlwomm and the Pink to Dr. fellow of tha a «mm. m mum «mm. Mutilation tar Inna“): Win an imam to sup-mu that kbonhary work. “W. Ha rm on with a Main: 1. W 1953 In a alumni ultimatum immut- In tbs Ané’t‘tmwmu aluminum tantalum tho integrator! “My an laboratory was «unnamed mam than math! Wamhéin 11W brain mum. the 1mm ammo: 65 m W of {w with maul mania 111mm, dwmatu ”mum 3W m mm mum to mmm mime. Mam dim, mun WI ef pain; mwnwmmmmumwmmotmmmmm» mtkm; with «13m (litmus-I m tuna-Id ma amtralkd with anal-put: drugs. may ammu- m ta m mammal mm a: am: 1m1uuoha During tho yaw, $5 mutton tum-Ind. More than half. aw 85.1: mm}. hospi'alk m- mmr M m mammal «mum at... am an. an. �4-» mmmaohmmmmwmwmmmm ”mutate ermg than thﬂu Ina 1mm yum, ”we“. macaw «:1th at mum. mmmwmnmmsunmmmmumm :Mz‘mmwmmmmnwdwumﬂoftb W. «ammuﬁmmnsmmmmmmmuuumma mm m In addition. tan on m at mammalian!!- mmmmm McMithmmmmmmngnmm_ mmammmomrmmmammmmmammm uttkﬂhoapim. . wmmm, s. A. at .1: The mm, M. am PM o: mama: mm in m damn IWtSMﬂs (Jam) Bibltoﬂ (1953) 1953:» m. mm. m. tau-m, 9.5.. Ramon. n. m mm on Pmopum, Mm... Jam 1953. il'ink. K... m m, M; m. u. and Bond», 11.3.: remap-um a: w man-11y mm: m mm at mm.“- 51mm mm. Stimuli Now. a m. nu. mam-w (Jar-u) 1953. am. mm, 3. m: m, m A sumac-1 away ’or a mummm mom-m, am. swam no». 2167*?! (March) 1953. rm, � 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 Progress and annual reports; research activities (folder title 2/2). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-003 Date A point or period of time associated with an event in the lifecycle of the resource 1955 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 Letter to Fink; Somatic Therapy Research Program; Monthly report; Research Progress reports - Department of Biochemistry; Letters to Dr. Miller; Electroshock Therapy Evaluation Program; Annual Report - Department of Neurology; 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 http://exhibits.library.stonybrook.edu/mfp/files/original/5fddf7ec4456da255de4e0d4b1d4c29a.pdf e18d9957071a91ab8e65015c0fde8e69 PDF Text Text January 15, 1956 Perceptual Changes Induced M Prorress Report Maximilian Fink, Director of Research M. D. 927 By Drugs and Electroshock (c) September 1, 1954—January 1, 1956 ' Hillside Hospital Glen Oaks, New York aHEMRY: Beginning with a study of perceptual changes induced by electroshock, emphasis has shifted to a study of the mechanism of electroshock therapy. A marked relationship was demonstrated between clinical improve- ment and certain indices of altered cerebral function. Early, persistent and severe changes in amytal tests and the electroencephalograms were ob- served; but no correlation was demonstrated for memory double simultaneous stimulation. tests or tests of clinical improvement did not alvays persist, further studies to elucidate the relationship of premorbid personality to both short and long term improvement were devised. Preliminary data demonstrate a relationship between persistent improvement and a specific character pattern. Since suprathreshold simultaneous tactile stimulation techniques failed to discriminate in terms of clinical response, threshold studies utilizing square—wave electrical stimuli were undertaken. This technique elicits patterns of altered function not clinically apiarent, and the relation of these patterns to clinical improvement is under study. As �PROGREeS REPORT The inception of M~927 in September 1954 permitted an expansion of studies previously undertaken as a Fellow of the National Fbundation for Infantile Paralysis. Three studies were in progress: (a) evaluation of the amytal test(l) in psychiatric subjects; (b) relation between al~ tered cerebral function and tests of simultaneous tactile stimulation; (c) effect of lysergic acid diethylamide, pervitin, and amytal on visual perception. and In the amytal test, the patient is asked questions concerning his illness, orientation, and recall before and immediately after the intravenous administration of amytal to the point of nystagmus and slurred speech. In the original studies at the Nount Sinai Hospital, the development of disorientation and explicit denial of illness was clearly associated with diffuse cerebral dysfunction(1). As a admissions to Hillside Hospital were tested. patients control study, consecutive Of 68 interviews essayed a- not had recent electroshock therapy, 56 were adequately completed. Of these, 51 were "negative" for brain dysfunction; and of the five " positive" results, hree showed other evidence of brain mong damage. who had In addition to further defining the scope of this test as an in- dex of cerebral dysfunction, the study demonstrated other differences from a group of patients with physical disabilities but without brain disease. There was more transient disorientation and denial, more withdrawal and ludic behavior and more changes in the syntactical aspects of language in the psychiatric population.‘ ._____.________________________..____.______________________________________ *Kahn, R.L., Fink, M., & Heinstein, E.A.: The "Amytal Test" in Patients with mental Illness, J. Hillside Hospital ﬂzﬁ-lj, January 1955. �2. When such tests were applied in patients who had recently under- gone electroshock therapy, "positive" amytal reSponses were elicited. This aberration had previously been reported by Weinstein, Linn, and Kahn(2), and formed the basis for their explanation of the mode of action of electroshock therapy. In a second study, patients undergoing electroshock therapy tested by simultaneous tactile stimulation methods(5). With were increasing amounts of electroshock therapy, patients demonstrated consistent alterations in the perception of the two stimuli. Failure to report one stimulus and mislocalization of one or both stimuli in predictable patterns were demonstrated. These patterns were transient, however. Electroence- phalographic records were also obtained in these subjects at weekly vals. progressive appearance of delta activity, The first inter- as random, low voltage activity, and later as symmetric, high voltage bursts, previously described by numerous authors(4) was confirmed. Attempts at this time to correlate changes in the electroencephalogram tests and the simultaneous tactile unsuccessful. were third group of studies, of the effects of d~lysergic acid die— thylamide and pervitin on visual perception were inconclusive. A variety of ill~defined subjective perceptual alterations which failed of objec— tive verification were observed and the study was discontinued. A The experiences with amytal tests and simultaneous tactile tests formed the background for the studies undertaken since September 1954 un- der H—927. To determine the relationship between various indices of a1- tered brain function (the amytal test, the electroencephalogram, and �5. tactile tests) simultaneous a correlated study was undertaken. Conse— cutive patients referred for electroshock therapy were studied. Treatment was administered three times a week. Electroencephalograms were done weekly on a day following a treatment. tests Simultaneous tactile stimulation tests were done once a week immediately preceding a treatment and 48 hours after a previous treatment. In addition, special tests of memory and recall utilizing the technique of retroactive inhibition were carried out at weekly intervals. and amytal In addition to intercorrelations between these indices, we were anxious to determine the relation between such changes and clinical alteration in behavior. For this purpose a clinical evaluation of improvement at weekly intervals during treatment was made ing therapy. and the These patients and unimproved. showed by the ratings were The symptoms their therapists; and up to one month follow~ were made independently classified as markedly of the other indices, improved, moderately improved, markedly improved patients were those that brought and the who no longer to the hospital; were rated improved them nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. showed no change The unimproved or only transient changes. were those who had some imtrovement in The patients were those who moderately improved patients symptoms, but in whom severe dis- turbances as obsessional thinking, paranoid ideas or somatic preoccupation persisted. A marked correlation was found between clinical improvement and early, persistent and severe changes in both the amytal tests and the �4. electroencephalogramx to occur. No If such changes did not appear, improvement failed such correlations were manifest between improvement and the tests of recall function or changes in simultaneous tactile tests. Thirty patients were essayed in this study, but 24 were success- fully concluded. At one month post-treatment, eleven were classified by the supervising psychiatrist as markedly improved; six as moderately improved; and seven as unimproved. the markedly improved patients, every one had at least one positive amytal test during treatment. Of the 50 tests given to this group, 58 (76%) were positive. In contrast, of the unimproved of the 45 Of patients, five of the seven never showed a positive result, and tests administered to this group, only 6 (15%) were positive. The moderately improved group showed more positive responses than the unimproved patients, but fell far short of the much improved group. In addition, there were consistent'changes in language and non- verbal aspects of behavior indicating alterations in adaptive mechanisms in the much improved group, even in interviews not employing amytal. These alterations were either minimally or only transiently manifest in the unimproved group and then only under the influence of sodium amytal.* Concomitant studies of the electroencephalograms taken on a day preceding the amytal cords were first test indicate M a similar relationship. measured for per-cent time slow wave The 160 re- (delta) activity, frequency of the the duration of burst activity and the amplitude and slowest waves present. The records were then placed in a rank serial order. Presented at the annual meeting of the American Psychiatric Association, May 10, 1955; and submitted to the Archives of Neurology & Psychiatry for * publication. �5. falling in the upoer third were labelled "high abnormality" and those in the lower third as " low abnormality". Of the much improved Those patients, 25% showed a ment; 80% after two weeks and 90% patients, iowever, first after three weeks. The treat- In the unimproved none had a high degree abnormality record during the three weeks and only one had such a record by the fourth treatment. these high degree abnormality after one week of records of the moderately improved patients week fell of between two groupsc* Changes in memory and learning were tested in these subjects by using the principle of retroactive inhibition. recall of three-letter originally learned By the serial testing of words following the interpola- ted learning of nonsense syllables, patterns of decrement in learning and recall ment up elicited. As a group, the patients showed increasing impairto the third week of treatment, and a rapid inorovement after the were cessation of treatment. No relationship, however, could be established between impairment and resnonse to treatment.** The responses of these subjects to simultaneous touch stimuli were also assessed. ability to identify and While an localize the two tactile tests using increasing impairment in the stimuli could be demonstrated with increasing treatment, no relation to improvement was noted. By tent the spring of 1955, and severe changes tal tests it was our conclusion that early, persis- in both the electroencephalogram and in the amy- are a necessary, though not sufficient, pre~requisite for ..___....-—_. m---_—. » Presented at the joint meeting of the Eastern and Southern E1ectroence~ phalographic Societies, Bethesda, September 50, 1955. * Presented before the Electroshock Research Association, May 8, 1955, and awarded their Annual Prize Award and cited for excellence in research design. ** �6. improvement following electroshock therapy. initial part of the This obserVation confirmed the hypothesis of weinstein, Linn and Kahn(2) ascribing the therapeutic results of electroshock to the facilitation of patterns of denial by altered brain function. But was it true that the patient's improvement resulted from denial of illness or denial of other a- More symptoms? daptive mechanisms manifest? Also, within a few months a number of the markedly improved patients had relapsed. At this time, a second Why? electroshock population was studied. First, to confirm our previous observations on the relation between improvement and changes in the amytal tests and the electroencephalogram. if exnlicit denial is a mechanism in improvement, it post—treatment and directly related to improvement. advanced that those patients who showed cit verbal denial" personality Secondly, should be manifest The hypothesis the characteristics of the would be those more was “eXpli— likely to maintain im— provement. Between April and August, were studied. Satisfactory data electroencephalograms and amytal and again d ring the second and thirty consecutive electroshock patients was obtained in twenty-five subjects. The tests were carried out before treatment, third week of treatment. The patients were again independently rated for improvement by a supervising psychiatrist du- ring treatment, and one month following treatment. These patients are also now being seen in six month follow-up visits to assess the " long-term" changes. In addition to these of subjects was tests, the premorbid personality of this group assessed by an interview with family members, psychologic �7. tests and a tachistoscopic study. in independent interviews. to A At least two close relatives were seen standardized questionnaire has been devised den verbal "explicit the of indicative factors characterological elicit this study fifteen characteristics defined as typiSuch in selected. were of absent in this personality tyne or cally present tons include prestige consciousness, sensitivity to criticism, imagination, temper and attitudes to sex and illness. Each patient is rated on a scale nial" personality. of 0 to denial 2 For for each item - the higher score signifying a greater tendency to o l Each patient vas also tested by a standard psychologic evaluation These Thematic and Tests. Rorschach the Apperception including battery tests were assessed for character structure and the usual tynes of defense or adaptation. tional A tachistoscopic study was devised, in which pairs of emo- and non-emotional words were flashed on a screen at 10, 20, 50, 100 patient's ability to identify the words, the reaction time, and the distortions were ascertained. This pre-treat~ nent data is now being studied as to its ability to clarify the patient's and 250 millisecond periods. The usual defense patterns. Only the short term group nine uatients were results of this study are available. Of this rated as showing marked improvement; twelve as mo- derate inprovement; and four as unimproved. Of the physiological indices assessed in these patients, a signi- ficant difference was again noted in the anytal tests and the electroence— phalograms between the markedly improved and unimproved groups. no There was difference between the markedly and moderately improved groups. �8. relation of personality ratings and improvement, an indefinite correlation was manifest in this small group. Lcores expressive of tendency to "oxalicit verbal denial" ranged from O to 25 in a scale of O Asgarding the to 50. The following table describes the natterns of each grouw when "high" and "low" scores are compared. (10 and Below) Low ﬁarked Improvement (9) Hoderate " " Uninproved High (Above 10) 2 7 (12) 7 5 (4) e 0 Because the scores were unusually low in this group, a sample of consecutive private electroshock estients were studied. lity ratings and clinical evaluations were made. To Similar persona- date, ten patients have this study is continuing. This study is still in progress. The six month follouaup is now being undertaken and further correlations will be done. Kcanwhile, certain conclusions can be entertained. The relationship between alteration in the been studied and physiological tests and improvement It became apvarent that the patients manifesting clinical exolicit denial of illness post-electro— was confirmed. shock did not have the best long—term response. Lesser degrees of adaptive better prognostic value. This observation led to an analysis of the only verbatim recorded data for this series - the language changes changes may have in the amytal interviews. The data is now being analyzed for a variety of adaptive language changes and correlations with clinical assessment are to be made. �9. Chile these studies of the ohenbmena underlying improvement in electroshock therapy have been under investigation, the tual studies have run concurrently. group studied, the lack of In the first (1954) electroshock correlation between simultaneous tactile sti- mulation tests and improvement was nuzsling. The tactile tests tremely gross, hovever, and this might be a factor. a more meaningful was developed. anticipation that be obtained from Previous exteriences with von Frey hairs for such threshold stimulation had convinced mulus In were ex- this index if threshused, equisnent for threshold electrical correlation could old stimulation techniques were stimulation tactile percen- me that the variation in the sti- often exceeded the fluctuations in hreshold, and the studies were inconclusive. Reports by Segal(5) on the perception of square-wave elec- trical stinuli led to our development of similar equipment. 84~B stimulators and isolation units monitored by a deliver independent stimuli. A Dnnont Two Grass oscillograph switch box and l centimeter steel disc e- Difficulties in isolating the stimuli precluded this testing being carried out satisfactorily until septenber. A continuation of the second electroshock group has been in prolectrodes corolete the assembly. gress since September. The same nhysiological tests and personality assess~ patient's responses to simultaneous hreshold electrical stimuli is tested before treatrent and at weekly intervals. To date, 18 patients have been studied. The same phenomena of exments are undertaken. In addition, the tinction, displacenent, nerseveration, and confabulrtion described in patients with organic mental syndrome with suprathreshold stimuli by Fink, 4. �10. Green, and Bender(6) are apparent technique elicits these patterns in these natients during treatment. This clinically manifest. while extinction is also manifest in yrs-treatment testing, displacement and perseveration are related to the extent of treatment. This study is now though they are not in progress. Concomitant with these studies, preliminary observations of a milar nature have been made in patients undergoing insulin coma si— therapy. Recent reports of the value of prolonged come as the basis for improvement by Revitch, Kwalvasse? and Caplan, Sharass and Rowsell, and Yeager gt al<7> have been confirmed in our patients. In reported a direct relationship between altered brain function, altered patand imnrovement.* and behavior terns of adantation in lan mace clinical t: . ' - one unusual case we r R.L., Graubert, D.H. and Fink, N.: Delusional Reduplication of Parts of the Body After Insulin Coma Therapy, J. Hillside Hbsnital ﬂ;154v147, 1955. * Kahn, �11‘ Summary of Our Work to Date and Plans for the Future: studies of perceptual changes induced by electroshock are pro- is in elucidating the factors underlying improvement following electroshock therapy: changes in shysiologiccl indices; adaptive changes in language and behavior in resnonse ceeding in two concurrent and related courses. One to altered brain function; and the factor of personality. study of the watterns of threshold tactile perception The second is a under conditions of altered cerebral function; their relation to "inprovenent" following elec— troshock; and the relation to other indices of altered cerebral function. The problems before this study are conylex. The rating of "improve- is primitive and further vork alcnf this line is mandat ry. The delineution of the explicit verbal denial character is a gross anprOfination of this problem. FUrther study of the role of personality and a descrip- went" tion of defensive operations other than denial which may significance is in progress. To clarify in our data the have therapeutic 203 beneficial be which ascribed to "general interest", electroshock can of therany result "spontaneous cure" or "placebo" effect, a control study is being instituted on February 1. Titb the concurrence of the Sedical Board of Hillside Yos- be will electroshock referred for therauy treated, by ranpital, pitients dom selection, by either pentotbal-convulsive electroshock or jentothal— subconvulsive stimulation. The cerebral chmnjcs induced by pentothal- subcenvulsive stimulation are miniwal and result in a minimal inprovenent rate(8) o �M References l. einstein, E.A., Lahn, R.L., Sugarman, L.A., & Linn, L.: Diagnostic Use of Amobarbital sodium in Organic Brain Disease, Am. J. Tsychiat. 112: 889—894, 1955. 2. Heinstein, E.A., Linn, L. & Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to a Theory of Shock Therapy, Am. J. Psychiat. 102:22-26, 1952. 5. Bender, H.B., Fink, H., & Green, N.: Patterns in Perception of Simultaneous Tests of Face and Hand, Arch. Neurol. & Psychiat. §§3555-362, 1951- , ~ 4. Pacella, B.L., Barrera, o.”., a Kalinowsky, L.: Variations in the Electroencephalogram Associated with Electric Shock Therapy of Patients with Mental Disorders, Arch. Neurol. & Psychiat., ﬂl:567~58#, 1942. f‘! 5. Segal, Harry: Prick Threshold stimulation with Square ‘ave Current: A New Heasure of Skin Sensibility, Yale Jour. Biol. & Med., g§:145-154 1955. A 6. Fink, 3., Green, D. & Bender, U.B.: Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Eeurology.g:46-58, 1952. , 7. (a) Revitch, E.: Observations on Organic Brain Damage and Clinical Improvement Folloring rotracted Insulin Coma, Psychiat. auart. gé: 72, 1954. (b) Kualwasser, S. and Caplan, M.: A Case_of Prolonged Insulin Treatment, J. Hillside Hospital 35145, 1952. Coma: (c) Shagass, C. and Rowsell, P.W.: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma, .M.A. Arch. Neurol. & Psychiat. 13:7059 1954. (d) Yeager, C.L. 33 El: glycemic Coma, 8. Ulett, Electroencephalogranhic studies in PosthypoJ. Harv. & Ment. Dis. 118:455, 1955. of Matched Grougs in the Evaluation of Convulsive and Subconvulsive Photoshock, Bull, Kenn. Olin. l§:158, G. A. gt_al: The Use �m 30, 1956 mama Ammm m mm m - 3.955 FollwingthsamﬂmdﬁnﬁamtheMamm,msmstyw mrked by integratim at um. 38mm with ongoing 15h. mdnpamimotthsntaff. Maddiﬁmlgrantsm wise rewind its first prize award. Wk left Ht. 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(a) Research Service: With the two additions to the expand staff, Dr. Fink was able to continue and his studies of the changes in behavior'widch fallowed electroshock therapy. These studies were directed to understanding the effects of the treatment on the brain, as well as trying to understand the changes in the patients behavior, language,and memory which might result from such changes in brain function. There were three different tests that were used. The changes that occured in the brain patterns (electroencephalogram) were studied and it was shown that it was necessary to have some changes in the brain wave patterns before patients be- wave came better from electroshock. Secondly, by giving the patients injections of who have that patients it changes in brain function show certain specific changes in language after the drug. Thirdly, by special tests of the ability of the patients to perceive two touches simultaneously applied to different body parts, it is possible to get a seditive drug (sodium amytal) is possible to show another index of brain function. These three indices, together, form the best way available today to demonstrate changes in brain function. One way of showing changes in a patient is to study his language. We have continued our studies of language following the administration of sodium amytal. In addition, Dr. Jaffe has begun a study of the changes in language which follow changes in the doctors attitude to the patient. For this purpose interviews between himself and the patient during which he changes is recording his own attitude he to the patient and then measures and examines the type of responses the patient has to this change. �-3- interest has Much been aroused in the newer drugs in psychiatry. A pre- vious study at Iﬂllside Hospital had shown that small doses of reserpine had very little effect on our controlled study and the patients. When purified reserpine was undertaken by one of internist, Dr. was made available, a the resident physicians, Dr. Wachspress Blumberg, to determine whether high doses of reserpine eleviate anxiety in our patients. It was the impression of the observers that the reserpine failed to relieve anxiety symptoms regardless of dosage and, would that it increased the depressive symptoms. These observations will reported in a forthcoming issue of the Journal of the Hillside Heepital. moreover, be In the biochemical program, under the direction of Dr. Harry Goldenberg, three projects were undertaken. In one study of the effects of chlorpromazine, Dr. Goldenberé carried out fundamental studies azine to under-Stand where and how this on drug might the metabolism of chlorprcm- act. In this study he was us- ing special techniques that he had developed. In a study of the effect of some new drugs in inducing disturbed behavior like schizophrenia, Dr. Goldenberg had studied a variety of alkaloids for their ability to affect a special enzyme system (serum cholinesterase) he reported that the most powerful of the new compounds (hallucinogens) known as which looks to be a very potent enzyme inhibitor as well. the development of a very refined technique so that he can lysergic acid diethylamide Most remarkable was measure very minute was quantities of drugs in the body. Thirdly, fundamental studies on the function of the liver in the he made some metabolism of hormones. (b) Psychiatric Staff : (1) Ambivalence Study: This study was continued by Dr. 3. Tarachow, H. Karin and 5. Freidman. In this study, an effort is patients develop the kind of neurosis that they do. psychologic measured. tests as well as made to understnad Emphasis is made by why some special clinical interview, the degree of ambivalence is This study attempts to prove a hypothesis that there is a relation bea �tween the loss of a parent early in life and the type or neurosis that developes in adulthood. (2) Subculture 5tugy: Under the directian of Dr. R. Navarre, supervising Graubert D. Dr. of (resident therapist), psychiatrist, an interdisciplinary staff Dr. H. Korin (psychology), Mr; A. Lurie (social service) and.Miss Z. Putter (group activities) have studied the hospital environment as a therapeutic agent. They are emphasizing the fact that just coming to a hospital has therapeutic value. Also, that there are many agencies at the hospital which affect a patients change, besides the specific psychiatric treatment that they are receiving from the phy- sicians. In a pilot study, they demonstrated the value of a diary of patients activities in clarifying the communications between patient and therapist, and also to explain unusual changes in patients behavior. The staff has devoted a good part of its time to understanding some of the aspects in thenhospital which motivate changes in the patient. In September, following our preliminary exper- (3) Chlogprcmazine Study: iences with chlorpromazine, one of the newer psychiatric drugs, two of the res- ident psychiatrists Drs. a potential substitute for insulin coma coma undertook a study of are divided into two groups in a randem fashion insulin It is this drug as therapy. Patients referred for insulin R. Shaw and G. Gross, coma hoped - one receiving routine therapy; and the other receiving chlorpromazine for three months. that this study will make a little bit clearer the usefulness of this new drug. (h) Prognostic creteria in Electroshock Therapy: PARAGRAPH REMAINS UNCHANGED �-5(0) Departmental Research Programs: In addition to the cooperation between various hospital services, the following projects were in progress or jndere taken during 1955. (1) Medical Demrtment: In addition to the medical and physiologic observations of the patients undergoing treatment with the newer drugs, reserb pine and chlorpromazine, Dr. A. Blumberg has investigated a new test-the test has Funkenstein Test. This been described as being able to a patient will improve following electroshock or insulin coma tell whether treatment. There- fore, to find out whether this is true at Hillside Hospital, Dr. Blumberg has been seeing all the patients prior to physical treatments. The test is harms less and so far, the results are not available. Dr. Blumberg also studied the possibility that insulin a number of hours. He dosage could be made smaller showed, both by clinical if it were and laboratory divided over studies, that divided doses were not as good as single large dosages of insulin. (2) Social Service: Student affiliates in Social Service have been studying the inter-relations of various factors in patient care. For the most part these studies relate the length of hospital stay, discharge evaluation, fee paying, and.a follow-up of patients who were unsuitable for Hillside HOSpital. These studies show great promise because they help us understand the social factors in mental illness. �Department of Biochemistry .............................. April 30, 1956 Progress Report, MarchpApril 1256 A. Active Projects 1. Steroid Sulfate Conjugates It that high speed liver supernates catalyze sulfate conjugation with the following sterols: deso corticosterone, androsterone, and cholesterol, as well as dehydroisoandrosterone, estrone, and testosterone. The underlined sterols conjugate most readily. Considering the various positions in which the hydroxyl functions are located in these molecules, it may be concluded that the conjugase(s) is nonspecific and can act at C 17, 21, 3a, 38, has been established and on phenolic compounds. least four steroid sulfates have been separated from urine using paper chromatography. The major conjugate has been identified as dehydroisoandroster— one sulfate. The other conjugates are under investigation. At 2. Chlogpromazine Study of a hitherto unidentified metabolite of chlorpromazine have been isolated from 9 liters of a pooled urine collected on the wards. The compound crystallizes in beautiful colorless needles, m.p. 190°C. It has been sent out for an element analysis. We suspect it is chlorpromazine mercapturic acid; the analysis will reveal whether our hunch is correct. Another metabolite has been separated electrophoretically and is believed to be an hydroxy derivative. 270 mg. B. Projects Planned to study the metabolism of mescaline this Summer, provided funds are forthcoming from the Dazian Foundation (see below). The investigation would throw light on the mode of detoxication of hallucinogens in the body and facilitate follow~up work dealing with trace endogenous alkaloid excretion in mental disease. We C hope . Funds grant application was submitted to the Dazian Foundation fer personnel support and for the purchase of a spectrofluorometer. We were infonned that funds are not available for instrumentation, but that personnel coverage may be forthcoming. Further information is not available at this time. A — cc. to: Dr. Fink Dr. Jos. S.A. Miller Max H. Goldenberg, Ph.D. �HILLSIDE HOSPITAL GLEN OAKS, N.Y. geptember h, 1956. Mr. George W. Galinger 170 East 79 Street New York, New York Dear ﬁr. Galinger: is Facilities". a copy of the "Recommendations for Expansion of Research Space and This data has been compiled by Dr. Max Fink, who prepared an original outline on the basis of the needs of the Department of Neurophysiology and Neuropsychiatry, and on the basis also of a discussion with myself and with the heads of the Departments of medicine and Biochemistry. The present draft also was discussed in some detail at a special meeting of the Research Committee held on Tuesday, August 28th. Enclosed I understand that will refer these outlines, which include the main functional uses to which thisnnew building will be put, to the architect. The current plans are based on three floors of space (a basement and two floors) with an approximate area of hO' x 100‘ for each floar. The data includes the expected expansion during the next few years of the current projects of the Department of Neurophysiology, the set-up and inclusion of a clinical laboratory, projected space for dynamic and psychological research. The building plan should include the possibility of establishing 12-20 interviewing or psychotherapy rooms which would be housed on the first floor, either at the beginning of construction or sometime later. Such space would be valuable in offering a replacement for the present psychotherapy rooms used for in-patient psychotherapy and housed currently on you the second floor of the Elizabeth Sloman Lowenstein Clinic Building. where Our it present plans are to leave the research and biochemistry department presently is located, but to move the clinical laboratory into the new research facilities. If there is any other data or clarification that you would 11g; from.n§; the Research Committee or Dr. Fink, please feel free to communicate With me.~ Yours JSAl-‘I:1b encl. sincerely, Joseph S.A.Miller, M.D. Medical Director �TO: DR. 1v .. 8-31-56 J.S.A.Miller gear-1: Max Fink, q§UBJECT: RECOMMENDﬁTIONS F R EXPANSIOT OF RESEARCB;§?ACE. M.D. “u.- following recommendations for the development of facilities for research summarize the consensus of meetings held by me with my staff; Dr. Miller, Dr. ReCohen and the to Blumberg; Dr. Mr. as presented Dr. Bachrach, Goldenberg, search Committee of the Medical Board, at its meeting August 28, 1956, and apBoard of Directors. the committees of the them to for appropriate referral by proved The I, INTRODUCTION: A.) Eggatiggi - The major share of the work in the recommended facilities who and are in the acute be with patients the chiefly population, will in-patient services. For this reason, the research building should be in close proximity, recommended Lowenstein for consideraBuilding. Sites Morris the to attached or a3 LowenThe Morris between the include order area the in ofusefulness, tion, stein Building and 76th Avenue;.b) The smaller area lying between the Morris Loqenstein and Elizabeth Sloman Lowenstein Buildings, the connecting tunnel and 76th Avenue; and c) The field east of the Morris Lowenstein Building, and north of the Israel Strauss Pavilion. W 3.) Facilities: 1.) In the development of the Research Service, during the past two Anamet have been various by measures. temporary the space.requirements years, needs the for reasonable well work expansion as the as of present program, lysis next five years, has resulted in the following recommendations. The character of the research program, at present, is along the lines of experimental psychiatry and neurophysiology. Such a program requires neurophysiology laboratory space, sound recording rooms, and special laboratory equipment as the first objective. logical expansion of the research program.as outlined by the Research Committee, by the development of a section in Clinical Psychodynamic Psychiatry, the next need is for facilities for interviewing patients and relatives; offices for staff members; and space for the observation of the psychoﬂierapeutic interview. The latter should be capable both for the observation of single patients and, also, groups. 3.) For the cooperation of staff members, conference rooms are needed. These should be so placed and equipped that much of the interaction between staff members will occur in that area. b.) Another need lies in facilities for the 2h-hour physiologic observation of patients. A four-bed unit, next to the thSiOlogy laboratories, will serve both as a recovery room for physiologic studies, as well as an observation unit for physiologic and biochemical studies. 2.) Keeping in mind the 5.) Another recommendation is with regard to the potential growth and utilization of the medical library. During the past few months, in which we have had a librarian on a full-time basis, space in the library has beCome �-2 '9 overtaxed. A major portion of the librarian's time is devoted to work in conjunction with the Research Service. It would be advisable that pro— vision be made in the same area of research expansion for the medical library. Facilities for an adequate reprint file, and facilities for microfilm reading are recommended. 6.) For time, the present separation of the Medical Clinic (in.Morris Lowenstein Building), the X—ray laboratories (in the Littauer Building), and the @linical Chemistry Laboratories (in the Sloman Lowenstein Building), has made adequate service cumbersome. It is recommended that the Clinical Chemistry Laboratory be relocated in the Research Building, in close proximity to the physiologic observation ward. some With the moving of the present neurophysiology offices from their present position, on the first floor of the Morris Lowenstein Building to the Research Building, three rooms adjacent to the present Medical Clinic will be vacated. It is recommended that these rooms be converted to the x-ray, fluoroscopy and radio~isotope laboratories of the Department of Medicine. With the Research Building attached or in proximity to the Morris Lonenstein Building, the present separated facilities will be in close proximity. Relocation of the Clinical Chemistry Laboratory, from the Sloman Lowenstein to the Research Building, will free an additional 300 ft. of laboratory space for the expansion of the Research Biochemistry Laboratories. 7.) In the history of the growth of this hospital, it is ap— parent that the growth rapidly outstrips the projected allowances. In the development of this building, it is recommended that provisions for expansion be provided in the initial designs, by ind.uding a foundation strong enough for the addition of 100% of the Space; space for elevators; and utility resources adequate for this type of expansion. Also storage space rapidly outstrips the needs of the laboratories. For this reason, a recommendation is made that a basement storage, equal to 15% of the initial floor area, be provided. 0.) Name: is inadvisable 'It"Laboratories" to apply to this building or wing the name or "Experimental". To follow the traditions "Research", of the hospital, the name of a benefactor may he applied, or other non- specific designation. D.) Research Beds: item of research need is not recommended. That item is a To ward. research provide facilities for the continual observaspecial tion of a large number of patients, separated, even in name only, from the rest of the hospital group, would dilute to potentialities for the utilization of all other patients, as well as provide a psychologic barrier to the experimental program. For the present, it is inadvisable to admit One patients for "research.". �.3. II. . GENERAL OUTIINE 0F SPACE RELOCATIQE: Taking into account the available fUnds and the potentiality of additional Public Health Service support, a three-story building, approximately of the size 100 ft. x no ft. is projected. A.) Basement: To include space for the following: 1.; 2. 3.) h.) Library stacks. Storage Space. Clinical Chemistry laboratory and offices. Space for expansion of Chemistry Research laboratories. include utilities, enlarged to 5,000 sq. ft.). (To it may be advisable to have the basement area B.) Egret Floor: l.) waiting room - receptionist. 2. Medical library. 3. Large conference room. Small conference room. h.) 5. Offices and interviewing rooms - 12. 6.) Secretaryfs office and filing room. C.) Second Floor: 1.) 2.) 3.) h.) 5.) 6.) III. Neurophysiology laboratories - 2 - and central recording room. Physiology observation ward. Psychophysical laboratory. Psychotherapy experimental laboratories - 2 - and central sound recording room. Four offices. Small conference room. SPECIFICATIOIB: A.)‘.Taboratories: l.) Physiologic and Neurophysiologic Laboratory: Two rooms for the simultaneous observation of two subjects should be placed about a central third room, which will contain the physiologic recording equipment. In such a system, single pieces of recording equipment can serve dual functions. Such rooms should have independent facilities for temperature and humidity control. Initially, the central equipment room will contain a single EEG unit; but space for a second unit and a frequency analyzer should be allowed. The equipment room should contain recording equipment capable of continuous, simultaneous observation of a number of physiologic variables, such as blood pressure, pulse rate, respiratory rate, and galvanic skin reflex. The position of these three rooms should be in close proximity to the physiologic observation ward. a.) Location - Second floor. b.) Approximate size: each experimental sq. ft., the equipment room of 180 sq. ft., with an adjoining smaller repair laboratory of 120 sq. ft. room of 150 �.h. c.) Relationship access to and access: Each experimental room to have the phySiology ward; and to the equipment room. Equipment room to have large glass port into experimental room. Port to slide into wall to allow direct communication between equipment and experimental rooms. d.) Special construction: (1) Individual temperature and humidity control for experimental rooms. (2) Sliding port. (3) Double walls and ceiling for sound-proofing. (h) water piping and sink in each experimental room. 2.) - Physiological Observation War ‘ Attached to the physiological laboratory, there should be a four-bed observation unit. Such a unit should be equipped for the 2b hour study of patients for biochemical and hormonal studies. A nursing unit should be provided, as well as storage space for the medical equipment needed to protect patients who are under investigation. a.) Location: second floor. 800 sq. ft. Size: b.) c. Relationship and access: access from the main hall and offices; as well as the two physiology laboratories. d.) Special construction: (1) Two two-bed units. (2) Two lavatcries and one shower. (3) opace for storage of clothes of patients; and nursing equipment. (h) Nurses station of desk, storage space, reirigerator and 3 1m 0 (5) Doors wide enough for stretchers or bed. 3.) - Esychophysical Laboratory: This laboratory should be equipped for visual and tactile studies. he room should have windows with built-in light- proof shutters, and the doors should be such that complete darkness can be achieved. For a visual laboratory, the length should be at least 2h to 26 feet. This room should have individual temperature and humidity control. a.) Location: second floor. 250 Size: Length sq. ft. b.) and c. Relationship should be 2h access: access to the logy equipment room and an office. d.) Special construction: El) Light-proof shutters ft. hall, the and doors. 2) Individual temperature and humidity control. physio— �-5h. Psychotherapy Experimental Laboratory: Sound Recording Unit. For the proper observation of patient and therapist, two experimental rooms about a central observation equipment room, should be provided. These rooms should be sound-proof and isolated, preferably at the end of a hall, away from traffic . Lighting should be provided in experimental rooms so that filming of the procedure can be done without additional lights. The central equipment room should contain sound recording equipment which can be controlled either remotely from inside the observation room or from the equipment room itself. A port should be provided from the equipment room into each of the experimental rooms for filming. It would be advisable that at least one of the two experimental rooms be of sufficient size to permit a group of six or eight patients to be under continuous observation. Observation will go on from the central equipment room through one-way vision.windows. should be possible to accommodate a large By adjustable, one-nay vision mirrors, group of observers in the large experimental room, to study the procedures in the smaller experimental room, while recording is accomplished for the separate recording it room. a.) Location‘ second floor (this facility may be placed the first floor in exchange for officeS.) b.) Size: three rooms: (1) Experimental room, large - ZhO sq. ft. on (é) Experimental room, small - 100 sq. ft. (3) Recording-observation room 150 sq. ft. 0.) Relationship and Access: (1) Both experimental rooms are to have one-way ports from the recording room. (2) The large experimental room should have a one-way port into the small experimental room. (3) Access to hall from each experimental room and recording ' room. (h) Access from recording room into large experimental room. d.) Special Construction: (1) Double walls, ceiling for soundproofing. (2) One-way mirrors as in (c) each into filming Special room. experimental port (3; (A Cable connections from each experimental room to recording room. (5) Loudspeaker connections from small experimental room to large. (6) Microphone location and outlets placed in original wall brackets and fixtures. 5, Clinical Laboratory: Relocation of the Laboratories for Clinical Chemistry in close proximity to the physiology ward is advisable. The Clinical Laboratories should heprovided with adequate benches for routine and special test procedures. In View of the space recommendation for Research Biochemical Laboratories, it is advisable to locate the Chemical Laboratories in the basement, with access bv open stairway to the first floor reception room. a.) Location: basement near stairwell. b.) Size: 750 sq. ft. c.) Access: from hallway in basement; to first floor reception room and second floor laboratories through stairwell and elevator. �u6u d.) Special construction: (1) High ceiling to allow for hanging pipes and "false" ceiling. (2)'work benches, sinks, electrical, compressed air, hot and cold water, gas outlets according to detailed specifications of biochemist. 6. Allowance for Expansion of Research Biochemistry: 1500-2000 recommended that is allowances of the this In building, it expansion. biochemistry future be for basement incomplete, of left area sq. ft. Such area should have higher than average ceiling to allow for the installation of necessary piping. B. foice Space: Individual work space for each of the members of the research service inpsychiatry in experimental The requirement staff be present should provided. and two provision psychologists, clﬁles two psychiatrists, a neurophysiologist, and additional psychologist. an of a physiologist addition the by for expansion into would requirements I space picture Clinical Psychiatry, In the section for (anthropologist scientist social two a psychologists, clude three psychiatrists, of staff makes This professional a total worker. and a social or sociologist), One three persons. 1h. In addition, the secretarial services will require in she act also receptionist as a can such that be in a position secretary should secretarial Additional of offices. section the of entrance the a waiting room at adv In be where records will kept. section and filing help should be in an office pre-docresearch fellows, for be aside set two additional officesashould dition, research the with who become associated medical students may toral psychologists or nrqgram. be the on to first floor, largely is office Location: space a.) with some on the second. b.) Size: 1.) Offices of 2.) 3.) c.) Access 1.) 2.) 3.) ft. are recommended. Sixteen are required for the fourteen provisional personnel and two additions. A waiting roomplSO sq. ft. A large secretarial office for two secretaries and filing space - 150 sq. ft. and Relationship: Twelve offices on the first floor, each with access to. two of sets leave advisable be to may a hallway. It offices with an inter-connecting door for the administration heads of the two psychiatric sections. The reception room should be at the entrance to the and staircommand the hallway through and access unit case with the basement, second floor and all offices. The 10x12 or 120 sq. secretarial office should be located close to the reception room. d.) §pggial construction: Double walls and ceiling to establish privacy for the patients under observation. �C.) - Conference Room: important element in any research unit is a place where various A conference room so and discuss activities. their workers can get together This would be workers most the of be would for ideal. central placed that it would prevent the use of one office, the lihary or a laboratory for group disand slides films; blackThere be for should projecting provisions cussions. boards for discussions; and space for exhibits of projects under study. An A second small conference room should be provided for similar purpose on the second floor. a.) Location: first floor for large small. room; second floor for 180 sq. ft. and 120 sq. ft. Access and Relationship} (1) The large room should have access from the b.)Size: c.) library. (2) The small room needs access only from the hall and hall. centrally located on floor. d.) Special construction: facilities for slide-projection, blackboards, and exhibition space allocated on two walls Both should be of the room. D.) - Medical Library! present Medical Library contains one thousand volumes. In Committee has been aware that the library the the Library assessing collection, be obtained during volumes thousand will that one approximately by deficient is the next two years. In addition, considering the number of journals now in subadded and texts are that number neurologic of and the psychiatric scription, hundred hundred four to of three the rate at of a the expansion library annually, volumes per year is anticipated. In addition, the Library Committee anticipates For and these micro-cards. micro-film both the use recommending that library removed of the is location library the the that present well fact as reasons, as from the main activities of both the resident and research staffs, it is recommended that space for the library be provided; the Space to be divided into a main reading room; small librarian’s work room; and library stacks. The a.) Location: 1.) The main reading room to be on the first floor, The preferably near the entrance to the building. librarian's work room to be off the main reading room. 2.) Library stacks to be in the basement, preferably under the main library. b.) Size: c.) Main reading room Librarian work room Basement stacks: 900 sq. 100 sq. 750 sq. ft. ft. ft. Access and Relationship: The main reading room to have access from the hall and from the large conference room. The work room is to come off the main.reading room. The stacks to have access from the basement hallway. �.8d.) Special construction: In the main reading room, bookcases for current books, journal racks for current journals; special equipment for microfilm reading. Also a mechanical dumb-waiter to connect library and the stacks. E.) -;§nimal Laboratories: Present studies on steroid metabolism, the role of cholinesterase and acetylcholine, and the need for some experimental work on the threshholds of convulsions,hsve made me feel that facilities for animal studies diould be provided. The space presently allocated in the Sloman Lowenstein Building is satisfactory; and part of the funds allocated for this expansion should be utilized to equip that space. F.) ~ Storage Space: Storage space for patient records, laboratory data and equipment, should be provided. Such space should be considered in the basement. Minimal allocation of 500 sq. ft. for the laboratories is suggested. G.) - Egpansion: ._ Allowance should be made in the planning of this building, for the addition of a third and fourth floors. For this reason, an elevator well should be included in the original designs, as well as boiler and other facilities with expansion possibilities to accommodate doubling the original ﬂoor space. an Furthermore, to accommodate laboratories on the basement floor, extra-high ceiling is recommended. Also, construction of the foundation and supporting structures should be such as to accommodate the increase in floor space. �ham”. nus-an 1. \ um. um. ”a. “it. W 1.. Ida. nun. mu m u: hm, mm. may M. 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Miller Subject: Report of Research Service, Second Year - To September 1, 1956 At the request of the Medical Affairs Committee Chairman, I am sub. mitting this report of the Research Service, describing its activity during its second year. During this year, the staff has increased; we renewed our grants with the U.5.J.H.S. and through the efforts of members of the Board of Directors, received grants from the Kaufmann and Dazian Fbundations; and we were encouraged by the results in our electroshock evaluation, reserpine and chlorpromazineinsulin, and anbivalence studies. distressing feature of the year was the denigratration of the Research Service to separate services without a Director. As of September 1, 1956, the Research Service is divided into a Section of Experimental Peychiatry (under my direction); a Section of Clinical (Psychodynamic) Psychiatry, to be created; a section of Biochemistry headed by Dr. H. Geldenberg; and a section of Internal Medicine unfer Dr. Cohen's direction. 'Uhile there is some theoretical justification for such a development in a large institution, the development here has led to a diapersicn of activities and a lack of adequate supervision of ongoing One activities. high note at the end of this year has been the recommendation by the Board of Directors that the Ford Foundation funds be allocated to relieving the space problems of the Research tervice. Following this recommendation, and after discussion with interested members of the hospital staff, I drew up a basic program for the Research Building. This program was approved by the Research Committee of the Medical Board at its meeting on August 28, 1956, and is now in the hands of the hospital architect. A A. PROGREjs l§*9HGOING PROJECTS l. Electroshock.Evaluation.Proaec : We have completed Electroshock Project # 3 which demonstrated the dependence of the rating of improvement following electroshock on the patient‘s personality; as well as elicited definite measures of language changes which were correlated with improvement. result of these studies, we instituted a "control" study, designed to validate our hypotheses. we are new in the midst of this study, which will continue until spring, 1957. As a believe that we now understand the neurophysiologic, personality and psychologic factors in electroshock therapy. Our data has both prognostic and theoretical significance; and I plan to present a definitive report before the American Psychiatric Association in may,.1957. We presented the language changes in electroshock to the American Psychopathological Association; the EEG changes to the Eastern LEG Society; and will present a report entitled "Relation of Tests of Altered Brain Function we have �92- to Behavioral Change lolloning Electroshock" to the Divisional A.P.A. meeting in November, 1956. Reports of the memory changes, amobarbital test and EEG changes in electroshock have already appeared in press. T? Meanwhile, as part of the resident training program, we have encouraged a senior resident, Dr. Harold Esecover, to undertake a study of the type of psychotherapy which is best suited to different types of electroshock patients. Furthermore, as a consequence of data presented at the American ELG Society in June, I have devoted considerable time to an elucidation of the biochemical changes underlying electroshock. Such reading has led me to elaborate a theory of the relationship of acetylcholine and cholinesterase in blood and spinal fluid to electroshock results. nith the cooperation of Dr. Goldenberg, this study will be added to the ongoing control electroshock study. (a) Thorazine - Insulin: The control study instituted a year ago has continued with dramatic results. To date hS patients have been studied, 22 on Thorazine and 23 on insulin. All were insulin coma condidates. The thorazine group has demonstrated a higher improvement rate, and a lower refusal and complication rate than the insulin patients. we are impressed by this data and plan to complete the study by the end of the year, for presentation to the staff. 2. Drug Evaluation ﬁfudies: (b) Reserpine: See "com. pleted projects." (c) Anectine- Electroshock: Continuing our studies of paralytic agents in electroshock, we utilized a technic for administration of anectine devised by ur. William Karliner of the Attend. ing staff. ’Ue found it most useful and safe and the results prompted us to recommend the adoption of this technic for our unit.‘ This study, undertaken by Dr. Tarachow, has been successful in defining enmivalence in operational terms, i.e., by the tests used to measure A summary of the two years work is being presented to the staff on Octit. ober 7th. 3. émhiyalence Study: In addition to Dr. Tarachow, Dr. H. Korin has beenzactive in this project; and recently, under the resident training program, a senior resident, Dr. Stanley Friedman, has been assigned to the project. h. Commlication Studies: Aided by the grant from the Foundation, Dr. J. Jaffe has devoted this year to developing ways of measuring the verbal interaction between doctor and patient. To do this, he records his interviews with patient before and after periods in which he modifies his attitude to the patient. At one time he says little, later he may re-enforce the patient's positive (or negative) comments. By noting changes in language, rate of speech and in mood, Dr. Jaffe has developed an index of communication change. Kaufmann �-3... present, he is testing the validity of his scoring methods, and plans to apply them to doctor-patient interviews in the near future. At In addition, with Dr. Kahn, 3r; Jaffe has explored the possibility of other technics, as sentence completion tests and the reading of'a standard parab graph under conditions of immediate feed-back as measures of changes in commun- ication patterns. 5. Autonomic Reactivity: In his initial studies, Dr. Blum» berg demonstrated that the class; ification of patients according to their blood pressure response to mecholyl was meaningful for our population. He then applied the test to the patients on the reserpine study, and noted a consistent and persistent lowering of blood pressure 11th an a-.. increase in the mecholyl response Iuring the period of reserpine action. w“. Host significant, however, has been his studies of the electroshock He has studied 100 patients, and established celrelations of their mechgroup. olyl reactivity with age, diagnosis, and therapeutic result. He concluded that the mecholyl responsivity is directly related to age - and that this is the determining factor, more than the primary illness. He is describing his observations in the forthcoming Israel Strauss Volume of the Journals a consequence of these studies, he has recommended, and the Research Committee has approved, a study of better ways of measuring blood pressure; and a collaborative biochemical venture (with Goldenberg) inDC the chanes As . r. in adrenalinenoradrenalin in the blood. 6. Biochemistgy: (a) Steroid Sulfate Coniugates: As indicated earlier, the steroid studies were undertaken because these hormones are known to be implicated both in the physiological response to stress as well as in the sexual processes. Three impartand observations have been made in the Hillside Hospital Laboratory. First, has been noted that the steroids, which are manufactured by the adrenal and it sex glands, are converted in the liver to water-soluble steroid sulfate conjugu ates. Since this is one of the major forms whereby the sex hormones are elim» inated from the body (via urine), the liver evidently plays an important role in maintaining hormonal balance. A second discovery in this area was made by comparin“ male and female rat liver activity. Female rat liver was found to be remarkably active in conjugating the steroids, particularly the male hormnnes. This means that the female animal possess- a regulatory device whereby she maintains her ielaleness by preierentic.lly excreting the male hormone which, incidentally, are present in both senes. s Finally, in the first group of 18 normal human observed that urinary steroid sulfate output is a) so::-linked, being tnice as high in males as b) appears to be low in value for calm people, whoare innately tense, excitable, prone to controls it has been in females, and but rises in subjects anxiety. (b) Psvchotomimetic and szchotherapeutic Dru;s“ : Thesecond preject in the laboratory involves a study of the possible role of hallucinogens in the development of mental disease. It has been hypothesized that indole-like compounds, comparable to LSD, acrenochrome, or a.crenolutine may be formed in vivo as a result of faulty metabolism and give rise to the $3.rmptoms commonly.associated with the psychoses. Initial studies in Our laboratory have failed to detect these alkalw , �.u. oidal products in patient's urine. Ebssibly this is due to a poor choice of patients, since none were actively hallucinating. it of the the most proportion that greater likely appears suSpected alkaloids would be excreted in changed form, and very likely via the feces. r‘his is suggested by metabolic studies which we have carried out to is administered in known quantity. determine shat happens to mescaline when unaccounted The 5% the rest is urine. in unchanged comes about through Only carbon diobe A as of expired course carbon residues might of the portion for. LSD the isotope the drug. in would account not nitrogen for xide, but this hence excretion the of in drug accumulation gut, this indicate studios in Jurope studies For subsequent these reasons our here. seems also feces the likely in However, it will involve isotopically—labelled hallucinogens to determine their ultimate decould more then we intelligently these at our facts disposal, Having fate. termine the excretion of related compounds by psychotics. (c) 92lorpromazine project; Studies on the metabolism of chlorpromazine by psychotics were reported earlier, at which time chlorpromazine, chlorpromazine were derivative alkaloidal and unidentified an chromogen, the purple sulf Xide, demonstrated in urine. A sufficient quantity of the last compound could not be and the project conventional methods, by identification from for urine isolated was held up in April pending receipt of a continuous flow electrophoresis unit. This item has been on order for h months but has not yet come in. 7. Tactile Perception: Following the technics devised by Dr, Bender, Dr. Green and myself, we have, with U.S.P.H.S. support, set up studies of tactile perception using simultaneous threshold electrical stimuli. Patients have been studied before and during electroshock. To date, the data amply demonstrates that the phenom! ena of extinction, displacement and confabulation, noted clinically in childin all elicited readily are cerebral with dysfunction, and organic ren patients induced the organ— with electroshock, Furthermore, threshold levels. at subjects ic cerebral changes exaggerate the perceptual errors in identifiable patterns. This study is continuing and it is planned to present the data before the appropriate neurologic societies. ' 8. Prognostic EngiCatorg g: glectrgshgggg This study, designed by Dr. Karliner to elucidate the relation between presenting symptoms and the results of electroshock therapy, is continuing. Forty-five patients have been studied, and it is anticipated that the results will be determined in the coming weeks. �.5. B. COMPLETED PROJECTS: collaborative study of the urinary steroid pattern changes with electroshock has been discontinued. The initial findings demonstrated a significant alteration in the steroid patterns after electroshock in improved patients. After studying these results, Dr. Hellman of the SKI and I prepared a protocol of experimental drug administration designed to clarify these findings. 1. Sloan Ketterinr Study: The presentation of this protocol to the Research Committee, it was their recommendation that, despite the merits of the research design, it not be approved for this hospital. The chief criticism was one of the risk to the pat. Upon ient of the procedure. these studies could not be meaningfully carried out at the hospital, the program.has been transferred to Creedmcor State Hospital, where the cooperation of the Medical Director and the Commissioner of Mental Hygiene of New York has been assured. As 2. subculture: project has been discontinued following the initial reports of the study group. hour observation of a patient, islaeing prepared The primary study, that of a 2h for the Research Committee by Dr. R. Navarre. The 3. Reserpine Egalyation: The high-dose reserpine evaluation study was completed in harsh. The results demonstrated a limited usefulness of this drug in our population. Hhile it occasionally controlled overactivity, it did not reduce the symptom of anxiety; and did increase existing feelings and states of depression. The results were reported in the April issue of the Journal and summarized for the administrator and staff in memoranda and meetings in April. As a result, reserpine was made part of the hospital formulary, with specific recommendations for its limited use. C . PROJECTS Fulﬁl-ED: 0*.“ 1. Cerebral Reactivity: In the course of our studies cf electroshock, we have been imp pressed by the differences in brain responsivity to electroshock. Some patients show a quick and intense change in behavior and on our tests; while others require more frequent treatments, higher voltages, etc. to induce any change. u developed a series of hypotheses which ascribe the differences in reactivity to (a) biochemical differences in acetylcholine-cholinesterase metabolism; (b) personality differences; and (c) generalized hypo-responsivity to all stresses. For this purpose, we are now elaborating protocols to test these hypotheses. As developed, they will be submitted to appropriate granting agencies for support. we have 2. Autonomic Reactivity: See "Ongoing ProjectS." �3. Digghemistrv: Following the present studies it is planned to continue the studies of bio- chemical changes in mental steroifs sulfate excretion illness along the following lines. end a) Comprehensive survey of urinary its relation to anxiety. b) Circulating steroid sulfate levels in blood and spinal fluid. c) Enzymic and fluorometric evaluation of alkaloids excreted in feces, with particular reference to patients who are hallucinating. Cholinesterase and acetylcholine levels in spinal fluid of patients undergoing electroshock therapy (as part of the electroshock evaluation study). d) D. STAFF CHANGES essential change during this period has been the reorganization of the hospital‘s research activities. As of SepteMber, 1956, the Section of Experimental Psychiatry, which is one of the surviving sections of the Research Service, consists of the following: The Dr. N. Fink D?, - J, Jaffe Dr. R. Kahn Dr. H. Karin Dr. H. Green Research Associate Research Assistant~Psychiatry Sr. Research Assistant-Psychology Research Assistantufsychology Research Assistant-Neurophysiology and a full (Mrs. H. Hosquera). time secretary (Miss Gayle Iankel) and 2/5 - time EEG technician chief addition has been the addition of the EEG technician and the part time appointment of Dr. M. Green. For the present, and until December 1957 As of January somatic the 1, Green ﬁlerapies. Dr. 1956, supervising is 31, he will devote all his time at Hillside to experimental work. The E. FUNDS: for 1956-57 have been received from the U.S.P.H.S. From the National Institute of Mental Health, support for Dre. Kahn and Karin, in the electroshock evaluation study, and for biochemical studies in the relation of alkaloids to mental disease. Also, from the National Institute of Arthritis, funds for the study of steroid sulphates, now used to support one research Grants chemist (Hrs. Ruth Foley). Also, a small grant from the Dazian Foundation supported the summer employment of a chemist; while the Kaufmann Foundation has been supporting the studies of Dr. J. Jaffe. �I are planning to submit an application for support of the studies in cerebral reactivity; while Hrs. Blumberg and Miller are submitting one for their studies in autonomic reactivity. Both reAt present, Dr. H. Green and quests are to go to the U.S.P.H.S. before F. OTHER November 1, 1956. ACTIVITIES l. hedical Library: In mic-1955, the hospital obtaineo the services of a part-time 1110(l0a1 librarian. By the year's end, it was apparent that the acecuate utilization of our library required a full time librarian, anc as of March 1956, miss Rosalind Lazarus was apppointed. I was appointed chairman of the Library Committee, and through our joint efiorts, the medical library was activated. A definitive budget was prepareC and approved; rules for library use established; and more recently, a 2000 volume addition to the library was recommended to bring this library up to the standard as the most complete psychiatric library in the North Shore area. of the Journal of the Hillsidee“ 2. Israel gtreuﬁg_folune S ervice Research* m<.1d3ers o;t of the the By active aith Dr. cooperation HosEital: S. Tarachov 3 the volume was orranized and editec. It is new in the hence of the printer and fill appear in November, 1956. 3 3. Isreal Strauss hemorial Lecture: The appointment of the second lecturer, Dr. Hilliam Halamud, an” the detailed arrangements for the lecture were made by the Committee headed by Dr. Bender, with the active cooperation of members of the Research Service. Research Builcing: Following the recommendation of the Board of Directors, the members of the Research Service were most active in planninf the new structure; describA. The and the for architect. relationships descriptive ing its uses; establishing first blueprints were submitted and after considerable discussion, were returned with corrections. Continued liason with the architect is planned. 5. Resident Training: During the past year, members of the Research Service gave bimonthly seminars on recent advances in psychiatric research. Two special lectures were arranged; and the local Research Conference of the Nassau Heuropsychiatric Society'nas held at Hillside Hospital. Respectfully submitted, Mfﬁgw Fink, M.D. Research Associate (bxperimental Psychiatry) Max �ﬁ— - Methods New Reports .For Evaluating Electroshock Hosﬁpifali W . . thropies, is engaged in a number of investigations into the basic causes and treatment of mental ailments. Dr. Maximilian Fink, research associate at Hillside, said that electroshock actual1y Fan change the way the braln functions, and that these Changes can be observed and measured by electroencePhalography. The change' in the brain also, shows itself in the response to dru es, M s cholo gical testin e and the weakening of unpleasant memories. The Hillside researchers report new and definite methods for measuring the extent of these changes. In the successfully treated electroshock patient, these brain changes enable the person to maintain better control over his emotions and behave more like a normal person. An' important clue to how'to identify patients less likely electric shock therapy affects to benefit from electroshock the human brain has been un- so that they can be treated covered by researchers at Hill- earlier by other methods. side Hospital, Glen Oaks, it The electrOShock developwas announced today. ment was described in the Hillisannual report side Hospital is It expected that this discovery will increase the ability sued todayvto select patients most likely Hillside, a non-profit mental to benefit from electroshock. hospital affiliated with the This development also will help Federation of Jewish Philan‘ ll llIlllllllllllllllllllllllllllllllllllllllllllllllllllll . For Free. 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SP'“*" 8" Pr°°£ ‘ i V ‘ 3 QUARTS—‘l 1.75 0 CASE or 12—4650 . r nolh§§§£§§ZXt°£atlt°2§§§i§ 31;: HEAR-OLD "MITCHELL" MARYLAND RYE patient to benefit more readily from psychotherapy administered during and after the . tcourse of electroshock. .tElectroshock therapy will continue to be used in the treatment of depressions occurring in patients in the 30 -to 60-year age groups, and also in younger schezophrenics showing mainly excitement or stupor as symptoms. In issuing the report, Dr. Joseph s. A. Miller, medical director, also presented the following data about the year’s activities at the hospital. Among 575 patients treated during the year, the average length of hospitalization was 176 days. Of_ these, 32 patients were admittﬂd t0 the Israel Strauss Adolescent Pavilion, a facility for adolescent girls; which was founded in October, 1954. The out-patient service treated 224 patients. ‘ ——~— �. following day- BERNETHY—Elnia 1... on October 30, 1956. wife of the late Richard 3.. beloved mother at Gertrude Tobias and 1Estelie Abcrnethy. ervices Thursday, November lst. 8:30 P. M. at the Clarence F. Simonson Funeral gall-[EL 1119-04 Hillside avenue. Richmond ntermeni‘ Friday. 1]. A. M. Maple Grove Cemetery.lALICCHlO—Raifaele, on October 30. 1956. of 101-28 99 stret, Ozone Park, beloved husband of Marianna, dear father of .Vincent and Florence. dear brother of Carmine. also survived by eight grand— l children. Leposmg at the Cassese .Funeral‘ Home, Inc.. 101-07 101 avenue, Ozone Park. Funeral Saturday, 9:15 A. M. Solemn requiem high mass St. Mary Gate of Heaven aterment St. John’s Cemetery. IHRISTENSEN—Chauncy J., on October 30, 1956, after a long illness, belov‘ed husband of Amelia.‘ devoted father of the late Dorothea C. Herold. loving grandfather of Barbara and Richard Herold. ‘uneral from the Walter B. Cooke Funeral Home. 158-14‘ Northern boulevard. Flushing L. 1. Friday, 3 P. M. nterment Cedar Grove Cemetery. URClo—Lena. on October 28. 1956, of 73-11 Metropolitan avenue. Middle Village. devoted wile of Carl. loving mother oi Salvatore and Joseph. Leposing at the Phillips Funeral Home. 79-02 Metropolitan avenue. Middle Village. Funeral Friday at 10 A. M. Solemu mass of requiem at st. Margaret's R. C. Church at 10:30 A. M. nterment st. John's Cemetery. “NAN—Elizabeth. on October 29. 1956. beloved wife of William. mother oi Lulu Harrington and Mary Mattoe; also survived by two great-grandchildren. teposing at the Walsh Funerar Home. 94-08 118th street. Richmond Hill. Services Friday. 1 P. M. nterment Mount Olivet Cemetery. HEDGE—Catherine V.. of 585 Seneca avenue. Ridgewood. on October 30. 1956.-age 66 years, beloved mother of Walter. Joseph, Madeline, Frances Connell, Mary Jo. (Dolly) Connell. devoted sister of Ellen O'Loughlin, also survived by four grandchildren. ’uneral Saturday. 9 A. M. from Charles Morton Funeral Home. 578 Onderdonk avenue, Ridgewood. Solemn requiem mass St. Brigid’s R. C. Church. 9:30 A. M. e nterment St. John’s Cemetery. lAY—Laurance X, Staff Sgt. U.S.A.F.. suddenly at Carlisle. Mass. on Saturday. October 27, 1956. beloved husband of Patricia A. (nee Joerger). devoted father of Donna Patricia. Laurance and Kevin Gay, dear son of Lorraine and Margaret ,Gay. loving brother of James. Jere. Patricia Papscun. Marguerite Clay. Jeanne-Marie Dalessandro. and the late Lorraine Edwina Gay. uneral from the Gleason Funeral Home. 10-25 150th street. Whitestone. N. Y. on Friday. November 2nd. at 10:30 A. M. Solemn requiem mass st. Luke’s R. C. Church at 11 A. M. utennent United States National Cemetery, Pinelawn. L. I. lATCH—Helen Frances. on October 29. 1956. beloved wife of the late Lewis. devoted mother of Ruth E. ervices at Walter B. Cooke Mineral Home. goaOSrgdena avenue. Brooklyn, Wednesday, ' , . ' , :iterment Walkill Valley Cemetery. Walden. New York. lAVERLY—Joseph. of 60-27 78 avenue. Ridgewood. on October 28. 1956. age 76 years. beloved father of Joseph. Jr.. Henry and Robert Haverly. Catherine Anastasia. Lucy Corrado. Lillian Caverler. Marie Roethel: also survived by 28 grandchildren and nine great-grandchildren. uneral Friday. 9:30 A. M. from Charles Morton Funeral Home. 578 Onderddnk avenue. Ridgewood. Solemn requiem mass. 10 A. M at st. Matthias R. C: Church. nterment St. Charles Cemetery. Pinelawn. Long Island. sum": non Until 5:39 in «m... or I. IL Satori-y llliib‘S—Mai‘ie (nee Gademann). on Octoher 30, 1956. beloved wife of Edward Heiss. devoted mother of Carol Elizabeth. Nancy Edwina and Bruce Edward G. Heiss..deai sister of Frances. of Regen— burg, Germany, loving daughter of Reinhold and Francisca Koob of Munich. Reposing at the Leo F. Kearns Funeral Home. 61-40 Woodhaven boulevard at Dry Harbor road, Rego Park. Funeral Friday, 9:30 A. M. Solemn requiem mass at our Lady of Perpetual Help R. C. Church. Richmond Hill, 10 A. M. Interment St. Charles Cemetery. Please omit ﬂowers. ., .. , HOFFMAN—Augusta E., on October 29, 1956. beloved mother of Fhillip Pflug, dear grandmother of William Pflug, sister of Anna Uphoff and William Warnke. Services. at the Stutzmann Funeral'Home, 224-39 Jamaica avenue. Queens Village, L. I., on Thursday. 8 P. M. Funeral Friday, 1:30 P. M. Interment Lutheran Cemetery. Jun—Wilhelmina M.. on October 30. 1956. Beloved wife of Ernest. dear mother of Jr.. and grandmother of Leona Ergest u . SerVices at the Stutzmann Funeral Home. 224-39 Jamaica avenue. Queens Village. L.‘ 1.. on Thursday. 8:30 PM. Funeral a,_ ~ Friday. 10 AM. BAECH’I‘OLD—Emil Albert.‘on October 30. 1956. beloved husband of Anna '1‘. (nee Pfei er). dear father of Mrs. Ruth H. Will and Elmer A. Baechtold. brother 01 Christian A. and Walter 0. Baechotld. also survived by two grandchildren. Reposing ,at the Floral Park Chapel of Thomas F. Dalton. 29 Atlantic avenue. Religious serVices Thursday. 8 P. M. followed by Masonic services, Eureka Lodge No. 243, F. a. A. M.. Machinists Lodge, F. 8: A. M'., Interment Friday, 2 P. M._ Lutheran Cemetery. . BURNS—Samuel J., of 84 New York avenue. Baldwin. formerly of Brooklyn, on October 29, 1956, son of the late George J: Alice O’Keefe Burns; dear brother of. Belle Burns. Reposing at the Fullerton Funeral Home, 131 Merrick road. Baldwm. Solemn R. C. Eeguiegl Firiiiaiss €5.00C1Arilatopher'l urc r ay : . . 2312 Third Street. KOLLlNS—John S., of East Meadow, L. I.. suddenly, on Monday, October 29 1956 in his 45th Year. beloved husband of Angela. devoted ratherr of Adrienne. dear brother of Mrs. Bertha Bowers, Stanley and Tony Kollins. R'posing at‘ the Catholic Chapel. 2100 3e11more avenue, Bellmore. L. I. Notice of funeral later. Under direction of John J. Mlchalek. ' Interment Maple Grove Memorial Park. KENNEDY—Thomas F.. 116-30 221 street, FUNERAL HOME. BELMORE Cambria Heights, L. .I. Beloved husband of Ethel (nee Huxley), father of Eileen CAROW—Edward, of Malverne. suddenly Devlin. Kathleen Wilson.» Ethel Albert. October 30. 1956. beloved brother of Loretta McGivney. Adeline on Tuesday. of Rayhusband of Jennie. dear father Doyle.. Ethel Casey. Seven grandchildren. ' of Dorothy Koenig and Reposing at the Funeral Home of Lawrence mond. brother survived by four grand" Eldred. also D. Rouse Inc. 191.02 Linden boulevard, children, St. Albans. L. I. Solemn requiem mass. Reposing at the Flinch a. Bruns Funeral .Friday. 10 A.M.. Sacred Heart R.C. Home. 34 Hempstead avenue. Lynbrook. Church. Cambria Heights. L. I. Interment st. John's Cemetery. Middle The family will receive friends between the hours of 3 to 5 P. M. 8: 7:30 to Village. L. I. 10 P. ,M. Masonic services on Thursday. [ALLY—Philip E., on October 27. 156. 8:30 P. M. Religious services on Friday. dea; uncle of William F. Lawkins. 10 A. M. Funeral from the Queens Village Chapel Interment Knolls Memorial Park. Nassau at Thomas M. Quinn a Sons, 214-65 Port Washington. Jamaica. avenue. Queens Village. L. I..‘ on Friday, 9:30 A. M. Solemn requiem FLORENCE—John W.. on October 30. 1956. ﬁes: Olﬁ Lady of Lourdes R. C. Church, of 315 Locust avenue. Unlondale. Beloved husband of Frances. and loving father Interment St. John’s Cemetery. of John W. Jr.. Jeanne and Diane. SurLOMBARDO—Teresa vived by one brother and two sisters. (Rommanelli) , on October 29, 1956, beloved wife of Angelo Reposing at the Martin Funeral Home. 412 Willis avenue. ,Williston Park. Solemn Lombardo, devoted mother of Mary requiem mass at St. Martha R.C. Church Strollo, Anne Carro, Sue Cremona, John Frank and Edmund Lombardo, dear sis- on Friday. 10 A.M. ter of Rafiaela Genovese and Carmela Interment Holy.,Rood Cemetery. Impci'ato, also survived by seven grand~ children. KOLLINS—John S.. of 2312 {rm (1 street. Reposing at the Leo F. Kearns Funeral East Meadow, L.I.. suddenly n MonHome, 103-33 Lefierts boulevard near day, October 29, 1956. in his 45th year. Liberty avenue. Richmond Hil Funeral Beloved husband of Angela. devoted Thursday. 10 A. M. Seryice at the father of Mrs. Sophie Kincinski AdriChristian Pentacostal Church 'of God, enne, dear brother of Mrs. Bertha Bowers. Mrs. Ann Mankowskl. Stanley and Tony 10:30 A. M. Also surviving are two Interment “The Evergreensz” Kalirdohlisllgi en. ran c ._ Regiaosing 1956. 29 BellOctober 2100 BeMAYER—Bertha. on Catholic Chapel. the at loved wrfe of Otto Mayer, active member Bellmore. L. 1. Salem avenue. more ‘ of Ridgewood Heights Maenner Cbor. high requiem mass on Friday Noyember Memorial services at Buss-Avenius Funeral 2 at 11:15 A.M. at St. Rap leis R.C. Home. 63-32 Forest avenue. gewood. Newbrldge road. East Meadow. Church. L. 1.. Wednesday. 8:30 P. Funeral L. I. Thursday, 11 AM. Mt. Calvary Cemetery, Linden. Inger-merit Cremation Fresh Pond. ew ersey. Under direction of John J. Michalek MEYER—George F., on Tuesday. October l BELLMORE FUNERAL HOME 30. 1956. of 111~21 198 street. st. Albana. L. I. Beloved husband of Florence Meyer. 149 w. Stanton of E. and devoted father of Mrs. Florence McCRAI Victoria Combes. grandfather of Dorothy Combes. ,avenueltulaaldwin, on Monday. October 29. SerVices at the Fairchild Chapel, 220-05 1956. beloved wife of Morton C. McHillside avenue. Queens Village on FriGraime; devoted mother of Douglaomnd Kenneth: dear daughter of Eugenie and _day at 8 PM. Victor Fernandez. NIGRl—Lucia. beloved mother of Edmund Reposlng Funeral Brother: Weigand at oi” the ngl‘l Nigrl Furniture House. Home. 24 South Grand avenue, Baldwin. Orstehnydia Mancino: in Italy. Gaetano. Services Wednesday. 8:30 P.M. Elena. Dorotea, Teresna and Nicoletta. Interment Thursday. Milford Cemetery. Reposmg at Robert Giordano Funeral Milford Connecticut. Home. 2346 Pacific street. Brooklyn un-. til Friday, 9:30 A. M. solemn requiem QUAGLIATo—Anita Hill). on October (nee Our of Lady Loretta Church. 29. 1956. of 678 Franklin avenue. Massaf0“: alt/I pequa. L. I. beloved wife of Ferdinando: Interment St. John's Cemetery. devoted mother of Mrs. Lucille Rubusto. oasrﬁtLE—Aiwma. on-October 28, 1956. Mrs. Blanche Burns, Richard, Joseph. Services Wednesday. October Slst. at and Ferdinand Quagliato; dear sister of 8 P. M. at the Clarence F. Simonson Mrs. Rose Brandt. Mrs. Isabelle Snediker Funeral Iﬂome, 119-04 Hillside and William Hill; also: survived h- “-1-“ ‘ ___.__,_______———. - - _ . . . ‘ �Wham”. ”mi”: mashing”. mm”; ' WW W W W wmummwmmmw,w WWatt-bMMuﬁ-mtdw ww.nmmmumwm¢t:wum mammwmm (W)M murmugmmmdmmam wwummawmmm mamam'mmmwmnmu Whuumumwmmu mam “anmmmmthWu-m «mama-ammuuwmmuworbw WW‘OM . manuumnbuwm. ramming-ma. mamammaum.mmmm~p mmmwummww m mummmcmpmwum. 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Wu..m.h¢~mx.mmsu.mmmm H. m) I mum mumamnmumm.m. 396. 3.956. 15) (um mummy. m a. . «Whammwm‘mmnmma.mmm Wpiiﬂ'ﬂgm �,v .7. vie .._.,.._..,-,_ "W ’3"“W". m. .. a":r-x—z var Aﬁv DCK TERA?! or one administered third in electroshock therapy we in previous years the adult patients. For the meet pert, it was prescribed for peuente in the As forties and fifties who electroshock was used manifested depressive symptoms. (21: To a lesser extent, patients) in schisophrenic patients to modify ms- active, essenltin er delusional behavior. the studies the of earlier results of that was in this group pstients It Psychietry were applied and extended. Patients of the Departmnt or W received series a the electroshock psychiatrist by supervising for mmmded encberbital test These included electroencepmlogren, of neurophysiologic tests. for organic brain disease, and pemeptusl tests, tactile. During per week, the tests were both visual and the course of treatmentﬁhieh ms adminstered three times periodically repeated. with clinical Based upon changes "alustiens in these mumplwsiologic tests ceabined psMiatx-ist, the extent «amines; In these instances in which the neuro- by the resident and supervising of electroshock tmmpy was treatment bed been not behavior obtrdned, in alteration for basis physiologie intensively. week and acre occasionally times modified five to per regimes were Ch this basis, the usual com-es of tmmnt m the patients meshing between 6 me lo batsmen 11 and 19 with m percent of the patients received more than 20 of mtients rescind less an incomplete series. Twenty-five treehnen’os .. The number of tmtnnnts tmtmsnts. than 5 treatments, which in each instmee 10% Four and to reference with diswosie therapy results at in chart is condition at time at discharge is seen in chart #9. The original studies relating the alteration in brain function indueed by electroshock to the short term clinical results, were confirmed in this series amounts-sud of and his Fink staff Dr. where study. of patients in a predictive shown #10 and the I that only these patients in when alteration in the electroencephalogram and �#2 mbarbikl taste had bean to warrant the rating of a umber 031‘ reports have mud, had mm D. clung. in behavior sufficient uprated or momma. A: a Insult. of these studies, been presented before nation]. psychiatric societies. much �#3 During 1953 there had been considerable experience at the hospital with of the newer chemotherapeutic agents, chlorprousine and reserpine. It decided to evaluate ohlorpronasim as a potential substitute for insulin tVo was em therapy. The use of chlorpronnzine we suggested by the many reports thst mlcrpronasinc had been successful in schisophrenio psychoses. Also, the specie; report of the Medical Board noting the course of patients disohnrged roam dmonstnted that the poorest long tom results were found in the insulin cone population. For this reason, a control study was instituted. Beginning Septenber, 1955, and continuing until Deomber 31, 1956, :11 patients in 1950 had referred for insulin coma therapy by the supervising psychintriste were divided into tee groups: one group received insulin coma therapy in the established doses received in and second therapy the urge chlorprmsine group newer; over a four month period. Insulin coma therapy was given for a course of 50 comes in most instances. treatedlcsees. The results Chart #llxoﬂects the number of cones in insulin of insulin some therapy is noted in Chart #12 and it is seen that of the 15 much of inproved or recovered. were a four rating given patients ,. In the patients who were given chlorpronesine, dosage ranged betueen daily with a 800 600 of milligrams. to mge Treatment was oontimed for a period or shut four months. In this group 200 and 3600 tailligrsms of patients, who were median unselected except for having been candidates for insulin of the insulin to that were of improvement equivalent the ratings moment, cone population. 01' 21: patients discharged during 1956, one was discharged as riftem miinprored. and much as improved, as em recovered, three as inpmd, some Guptring the complication rates of both treatments, it was noted that prolonged of nine tones and in were insulin resis cmplications reactions ledondary ems, the insulin some patients. Wtansion airfioient to cause fainting and severe demtitis were complications in five of the chlorpronasine group. Agitation �#h and penis, seizures and numbers It refusal of further therapy were seen in muivalent of patients in both groups. was the opinion of the numbers of the Deparhuent of peydtiatry ami Manual the resident physicians, Doétora Robert Shaw, George Gross Mean for this study, that in to insulin coma therapy, chlorpromasine was safer, easier to ldminater, more controllable in its effects, and had fewer aid: effects. It was their recommendation that chlorpmmine therapy would be warranted as the initial and Fred Coleman, who had hem responsible treatment for patients in the younger age group who were suffering with schizophrenic disorders. In such cmditions, they anticipated that chlorpromuino would be most behavior. effective in modifying overactive, as saultive and delusional �#5 cogg sagx rmmr 01' the ﬁfteen patients treated by insulin com therapy, the modification of behavior was inadequate in ﬁve, loading to a be combined with insulin come. nemudntion that. electroshock of these, four patients were suffering fm a schizophrenic disorder and one from a manic-depressive not one of the patients were mach improved illness. In each instance, or recovered after combined mutant. Similarly, there were four patients or the insulin com group who had had metroshock therapy either prior to the insulin com or subsequent to the insulin con moment. Here too, the mtinga or immemnt were in the lower 4 two categories. � 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 Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-004 Date A point or period of time associated with an event in the lifecycle of the resource 1956 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, 1954-1965 Relation A related resource The Max Fink Collection Description An account of the resource Perceptual Changes Induced by Drugs and Electroshock - Progress Report; Research Activities - Annual report; Letters; Annual Reports - Department of Experimental Psychiatry; Newspaper clipping, Hospital reports new methods for evaluating electroshock, Long Island Daily Press, 1956-11-31; 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 http://exhibits.library.stonybrook.edu/mfp/files/original/c825cf38265f35eaf923d1fdede27f5a.pdf 8e37b7104043290b0428aed652df73e2 PDF Text Text Manhasseit Medical Center Hospital 4CZ54@/¢/;ﬁé€rn.2%éui%§C}¢%;lﬂéd536/ c<lgeyi N ]E W Y O R K PEARL A.KLICK ADMINISTRATOR 35K TELEPHONE MANHASSET 7-4000 1: "VINE February 25, 1957 Dear Doctor: Quarterly Medical Staff Meeting of the Manhasset Medical Center Hospital will be held on Thursday, March 7, 1957, at 8:h5 P.M., promptly at THE ALLISON, 1583 Northern Boulevard, almost directly opposite the hospital. The PART faRT 1. Review and analysis of Clinical werk in the Surgical and Medical Sections for the month of December 1956, and the months of January, February 1957 inclusive. 2. A. Surgical Section - Ralph S. Emerson, M.D., Chairman B. Medical Section - 3 ‘§~ “ Lawrence S. Kryle, M.D., Chairman Tissue Committee Report - Howard L. walker, M.D., Chairman SCIENTIFIC PROGRAM - Arnold G. Blumberg, M.D., Chairman "THE TRANQUILIZERS IN PSYCHIATRIC PRACTICE AND THEIR APPLICATION TO GENERAL PRACTICE." Dr. Maximilian Fink Director of Research in Experimental Psychiatry Hillside Hospital, Glen Oaks, N. Y. COLLNTION. Respectfully yours, John G. Connell, M.D. President - Medical Board Telephone number The MA 0 Allison is 7"558’4v at Harry H. Abrahams, M.D. Secretary - Medical Board ~ﬁg ��mmmwm,wmpmmmmmmmm at then obs-mum, w an both» that m. WW WMMwnwmmoma-pmiwhcwnmmw Mx «811.1% unit-(unmask mmmumtmwumatmimummmmm ”demhmlm,wmm mummmmmmmaMaummmmwm m Intact. WWWuloatmthm. and Minimum new '4» obmﬂw, We!» afresh. mmm»mwmmmt¢mhumo£mpmuyotmwb mm and than mm). mm. m: max-minim at than m mt: dWarinwclm,thntwhu-Wtomuswwmﬂd~ mwhmmmpemﬂmwhopawnmmwhmmml behavior me:- that special mum d um brain {motion (we Seats.“ 6). WWanhnwhduwmamtatolmkawm mmwammmmmmmmmtdmzmmntmt. shock a a manic mutant. Salaam” mug" in mm Maﬁa which metro-v mm two than than of lengthlarva-yang many him, mm. persist than Mending in way: his to almond! wfamt patent mums mmaponomiw. M13, am whammpomnmummmmwm his therapist, an! to other mum“. mthrMha when M oﬁurmple,musammutMnforhintoMo-nm,mmw in tutu mum. it mam, mum tulinaorwnhomisut by an mth bother muty to Man with othon. ma £106th thaw “Mammummtfortwmtmotwmma ' _ studio: at Mama. m not“ mt «that :Inth-ooumurthau 32:”:me had am that mmwnwumummnmmmnmmrm,w ��«In WW‘ AathtMpnviam momm W338 in the mm at inﬂiﬂéml MW in «mm. Mﬂty Ml . ummmwmummekam. wmamuamum mammnmammlma. nmlamamwuu W dummiom W whom. manummuumuhmormmmmuméapmrmwm mt: or or induced by mammm: Wmhhymmlﬁuut marmmmw,wuw Wmuhtiam the, response to tin «mm mama to 3551mm m boa umwwmmummmm(mmm Win In, itumuipum thutmlmntarywmmmmsumhm mmmuutnnmmmMmpmummum,mmtm ”munm'mummmw. Gum the the alumna-hip mm «Mmmad anmmmmamlmmummmnmwmw mat of 01 tramway. we may in mum." concurrently, Dr. ~ -- has - w na- 3. am, hu mm and ten W 3.“ 4 aw, under as: 013an have a: Dr. 31am mmbut: museum hero-m tho In Mmmmmmmmm manmummmmmu ammmchunamammmma‘nmsmwmawmm chum. ' 4* m: mmwmxmmmmmmmmmuor . , magma... mmnwmmuwummmmamwm maxim/:31“. hmm,‘§9‘pﬁmunhmdtwmmmm 1957. ﬂammmmnmwmmmmwmmw «Mammal!» It cmluim ”was M. «human ”mom” ﬂammable Warpatumulmmmtham. mm that. as �.5. mm m be the for diseharge to better for the claim-pren— ratings team uino group than for tho um group. H. emclmd that, in to 111M131: new therapy, ehloxpmine m mar, easier to aura contmlhbla in its effects. and had fmr $5.60 attach. We 3190 amended tint n9 evidame had appear“ in the fiftm math: a! the study that. either than” had altered thy basic. schiaaphmie process, nor did my real that either tom of therapy had a greater speciﬁcity far schizophnnie illnesses. At the concluaim of the stndy, the ladies). Biroctur placed in tin for» ulary and a um 13¢th a. its use 13m IV smut: mm”, the maidont staff. W: @10me During this” period Dr. Green has evaluﬂd magma, for its ability to bring out debuts in brain mum. The "port. at his findings mm meant-ad at. the aid-winter muting of the Eutem lasaeiation of Bleetroancephalographam. dials :6. Pro «aka 8: It. is anticipated that tha mark now in prams: in we will continue for the remainder of the year. The aleetmshock evaluation study will be cmletod this spring and the next few months will ha spent in a new agent in ulcetrooncepmlographg, M ' «muting biannual: chained and writing the reports. As indicated in the ongoing pmgraaa not”, a. War of development: have grown out. at these studies and it. is anticipated that than will he immoramd in the mum n— the W aeamh pmgrlm 1. been «aloud by Diffomma 3.3; Wen}. Romam pmtocol has Dr. “a: Franck, which incorporates than pmblem or panama 11 dictating individual rosponsivity to abattoshoek. By entertaining than subject‘ 8 patterns of perception in awfully devolopod arianhatim and visual 1uy tasks, in hope to demonstrate O. “hump batman: those pater-nu and the bov- both havioral under the. special conditim of altered brain funcuun. and the general condition of hospitalisation and plywothompy. 8min a study ream, has bearing on tha problems of the personality upset: of resume to change �«6. in behavior wider stressful maniacs (us in forceful indactrimum, isolatim. atarmtim); a3 well as an «imam at mimic madame fer various W“ chntric therapies. ma mamwwwm me mums“ W w: 2. with elootmahock have led us to Em- theua mute personality factors in the patient and which ing the chain of treatment. a workabla hypothasia. We He of a. hypo— the tharapi‘at affect» am in the process of developing our ideas into antiéipate mdertnking such Mt I stuck by the and of the last report this section has been mdeaigna‘bed an the of Men-1mm thiatry. In addition to the panama]. listed 31am the Department the timofﬂwwtmport,mhmappointad, maparttimbasis, mm at. mm assistant in psychalngy. Dr. Pomek, who has his 111.11. from Kw York: University in 1955, has bean a mum-oh psychologist at tho Haunt Sinai Hospital and the 145mm rmdaum for emu Research for the past six Ha is experienced in both pamanauty and perceptual ”pants in march. years. It. in anticipatod that he will be appoint“ an 2. m1 tin basis on My 131:. A the individual differences in bahavior with specific ambush to study pram Pamela, as on tho perceptual and ation has been made pemmnty sweats has teen «“10de by his and applic- to various foundations for support. mauve April 131:, than will be appeintod to the Duparfanent, a Assistant for linguistic analyses. Under the hem of the E) funds warn and: mm“ x. devised ‘by m: 21:: «:1th Firm.” far a technical assistant he carry Dr. Jane. manna»! 1mm Grant (see out. Senna the language for Renaud: in Psyuhutry has gxmtad Dr. Jute sun or [26,919 plml $5,700 overhud far continuum Fund support for two years in than of the study “Language of the Dyna“ which has been dmlopod during hm past year. �ﬂan MMMMmWVWWrmum. mama-mm «mumspm 1st. 3957 unmmmt. 1959. mmmmmummmmuwudmmwm mararmmawmmmwmam £100»,me mumwmmmxmm-mwmmwmzwnmm ammwmnmmummmsumw,wmmmm InWr,;mawrthammkqu atmmwmammmmmtmummm mummuuwnhumamunumsmmumwwm nmr,nr.ammmmnm mmmmw. inmwmmmmmwhgmwnwnmemum mm‘dWomx-l. kWawﬂmWﬁs dWWWWMMmmmmmammm in m Widv mom 153mm my. autism “MW tho Em MWMWtWamrdmmawvmmmuMmr ﬂammmrmmu»hpoumha1umtorpnmumu an Week mum}: mama. th- smosy or Mom-1 WW, tho Inumhiml Wan of RM and the Imam-Mom}. 0mm! fer WW.‘ hmumnmmmmwwwumwunmmm ma for humﬁml Puma? ”W4. Mm: WM: mum mummnnmmmmmammwnam thrmthMme,uthw-omcmmmmm summeodmga. Womanhmmmmmwupummmma mmwwm.hﬂo,umupmmungmormm mum»“momwmdummotmmrdmwmmmm Chum; �vammamwmmmmmmamw fowlmm. unnaommmwanmnmmum or J. Mt. 1: in Manny mm}. m 3mm mm: Dr. anti-u”. main mum” at. an mum Alma: mu mum means with an W Wthmmuthortmmmmho- W, matmwmmmmumum. of Dr. a mmmamnmsmvm‘mmmm Morn a: thin-Baum: an «an in an «Mama and m... other 19%. numtatmthm; WW: mwmmwmm. DnlgmmbmnmngtMpmbhmof smwwmmmmuhmm 0 Wm wmwammmw‘mﬂammwhmmm. mm puma pm: mm mm is um We Wm mmuwappmuwmmumm. hummmpmaaar with acumen ”mm. Elam during typu of no bu been mpcmm ﬂu «mm-hock maniacal... 69min supports.“ an! that. and In thin new: be mmmwumum. Dr. 3. Fri-mm contributed mun-My to mmamm mm. mmmmmmwwmw. In WWmnodWMme,mmofmmmtmm mm m a may mm“ mm: m- m on at .m u» mam mm: mmmmmmmuw. Manama, WM” W 1913!! a: tum-3mm Mammary: Wm Max Pink. 11.13. �March 1957 Personality Factors in Behavioral Beeponse to Electroshock Therapy Robert L. Kahn, Ph. D. andMax Pink, From New 14. D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, York. Aided by grant 14-927 of the National Institute of Mental Health, l“aﬁcional Institutes of Health, APublic Health Service. Presented a the Electroshock Research Association, Chicago, May 1957. �INTRODUCTION The behavioral response of patients receiving electroshock therapy is variable. In previous studies of the factors related to this variability we that patients who showed early, persistent and relatively marked degrees of altered brain function, as measured by the e1ectroencephalogram.and the amobarbital test for brain disease (10), were most likely to show a clinical The (h) (6) which (7). improved rated was present study is an as response investigation of the role of personality in the behavioral reSponse. An explicit hypothesis concerning this relationship has been derived noted from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), that patients who we reported develop such language patterns as explicit denial of ill- and of and symptoms; displacement qualifitemporal Spatial personal, ness; cation, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) in their studies of neurological patients with cerebral dysfunction. They characteru ized this behavior as the "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "ex€M)On the of these the denial" basis verbal observations, personalit plicit hypothesis was advanced that those patients who most closely approximated this "explicit verbal denial" personality type would be more likely to havioral changes after The purpose EST show the be- which are rated as improved. of the present study, therefore, was to determine: 1) whether personality characteristics related to the behavioral reaponse to electroshock therapy show proved. differentiated; and patients with greater "denial" tendencies are more likely behavioral changes after electroshock therapy which are rated as imp 2) whether to can be �.2POPULATION Sixty-three consecutive patients referred for electroshock therapy were studied. staff, The selection of patients for treatment was made by the psychiatric independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of I47, and included 21 men and 142 women. METHOD Prior to treatment each patient was evaluated according to the following methods : l. Structured EM Interviews: Personality was evaluated in inter- patient' 3 family. At the opening of the interview, the relative was asked to describe, in his own words, the patient's usual interests and attitudes. The relatives were encouraged to talk about any aspect they wished, and the interviewer followed the trend of their talk, rather thm proceeding in a serial fashion. The interviewer asked questions, however, to been 15 obtain information in m described as charspecific areas which have views with members of the acteristic of the "explicit verbal denial" personality,“. The number and withgibrelative varied according to the degree of type of questions required spontaneous production and the infomant' 3 capacity to comprehend and 00mm:- icate. The informant was encouraged to give concrete examples of all state- ments. basic items included the presence and extent of each of the following features: 1) stress verbal symbols such as resolutions, homilies, cliches and The rationalization; 2) are prestige and security conscious, and do not enjoy the intrinsic benefits of health, work, leisure, money and property; 3) regard illness as an imperfection or disgrace, keeping neighbors, and are it a secret from the family and reluctant to seek medical care; troubles and are considered practical persons who )4) "shake off" their advise others; 5) have drive and compulsive energr, and are guilty or uneasy if own much not occupied; 6) are conscientious with a high sense of duty and responsibility; 7) are sensitive . �.3to criticism, regarding it as an attack on their integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly affectionate or emotional; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; 1h) do not have temper outbursts; 15) and are not After the interview, each item if score of 0 was given 1 2 was rated on a 13) do not discuss sex openly; ludic (25). scale of 0, 1 or 2. A the aSpect was noted to a minimal degree; a score of indicated that the characteristic was moderately present; while a score of indicated the definite and marked presence of the pattern. The scores for each item were added and the resultant score is termed the "denial personality score". 2. Clinical Evaluation: Each patient weekly intervals during and evaluation prior to and at following the course of treatment. The clinical was determined by was interviewed the patient's behavior in the few weeks following the end of the course of treatment and was based on the evaluation of the pat- ient's therapist, the therapist's supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: much improved, moderately improved, or unimproved, criteria outlined previously (6). 3. Language gtggy: In addition to the clinical interviews, following the each patient standardized series of questions determining his attitude was examined with a toward his illness. trouble?" and "If you Two of the questions asked were, “What is youi'mein had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim responses were analyzed for changes in language according to the method previously described (7). RESULTS The relatives of scores ranged from O h? patients were interviewed. The<ienia1 personality to 25, with a median of 11. For statistical comparison �.14- the patients were divided into two groups. Patients with scores ranging from 11 0 to to 25 were 10 were frm considered the "high denial" group, while those with scores classed as low in denial tendencies. 1. Personality score and clinical response: Patients with high denial personality scores in these family interviews were most likely to be rated as much improved, and patients with low scores, however, the basis, with chance only one case was considered unimproved (Table 30% I). In clinical response rating occurred on a of the patients being regarded as mimproved. I TABLE Relation of Denial Personality Scores to Clinical Response to Electroshock Much Improved Moderately Improved Total Unimproved Personality Score 11 0 - 25 1h 9 1 2h 10 7 9 7 23 21 18 8 it? Total The proved difference in the denial scores between the patients, when compared sigzificant.* Although the much and moderately im- to the unimproved patients is statistically much improved patients have a higher mean score is not significant. 2. Qualitative observations: Although there is a relationship between high denial personality scores and the clinical rating, 30% of patients with than the moderately improved group, this difference low denial scores were also evaluated as showing a marked improvement. While trig/1:119 group of seven patients is a small one , certain common characteristics can be described. Although these subjects lack the competitive security needs of the high denial subjects, they or imaginative capacity or ability to think Si ~K- vb; { {ran-M at 1% level of confidence by show drive, prestige and a similar lack of creative critically of their Mann-Whitney U Test. own or other's �.5relate to the environment primarily by non-verbal forms of commmication. They are described by their families as laughing or crying feelings. They excessively; and as showing anger by muteness, ”go into a shell," ”walk out of the room in a huff,” or by violent tempers with table-pounding, throwing objects or direct physical assault. These patients are "ludic," by Weinstein and Kahn (12) to denote comic, language analysis described in a in clinical interviews term used tragic, or melodramatic behavior.* 1m: previous study (7), the 3. Personality score and Meg -a Applying the technic of i__n_ changes in language were compared with the denial personality scores. Nine patterns of language change, such as explicit denial of illness or symptoms, displacement, qualification, £33. have been described as characteristically occurring after electroshock. ified according to the plicit language As in the previous study, each patient was class- dichotomy of whether or not he showed three or more ex- changes. Patients with high denial personality scores showed a greater number of language changes, than those with low denial personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes the 1% is .71, significant + at better than level of confidence. TABLE II Relation of Denial Personality Scores to Clinical Language Changes During Treatment Number Langggge Changes 0 - 2 3 or more Personality Scores 11 .- 25 (20) 8 12 - (20) 17 3 25 15 o 10 Total This term was taken from Piaget who applied behavior of young children (8). *- it to the play and imitative �h. Illustrative Cases: Case 1. High Denial Personality Score: A 61-yearbold housewife was admitted to the hospital with a 15 history of insomnia, abdominal pain and fear of cancer. On admission she was depressed, retarded, and seclusive, evincing little interest in her month surroundings, and wandering aimlessly about the ward. The patient reaponsible person with and was unable home. her husband as a conscientious, dependable, integrity. She had no hobbies, outside interests, was described by much to relax. She was ”mortally As a consequence, she busied herself with chores at afraid" of doctors, minimized her illnesses and con- cealed ailments, even from her husband. Very restrained, she openly showed no affection or emotion, never discussed sex and rarely lost her temper. She had "a long memory for little things if she felt that she was wronged," a ”streak of stubborness," and would "just as soon hold another person responsible for her mistakes." She was proud and would ”rather go without food" than borrow or take money from others. According to the denial criteria, her score After 20 electroshock treatments, she was 20. became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doc"model" ”while her who, a reluctant to discuss her personal patient toi/called feelings, asserted that she had no difficulties at hue-'had home, a wonderful band.uho was very good to her, considered herself lucky and eagerly anticipated her discharge.” Case She was discharged with a 2. A Low rating of "much improved." Denial Personality Score: hl-year-old housewife was admitted to the hospital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission the patient �was' noted to pay little attention showed psychomotor The whom He it patient retardation and was was described by was not easy to her personal appearance, cried readily, circumstantial in speech. her husband as a "negative personality” with to get along because she was opinionated and argumentative. regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. An excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, however, she would become either completely mute, or "very nasty, just don't know any better.” Although considered a “cold" person, able to talk freely about sex. She frequently complained of physical implying you she was ailments and went to physicians readily. She was ”naive" and "unrealistic," believing, for example, that she had a flair for writing although others con- sidered her amateurish. Her personality score was rated as h. patient received eighteen electroshock treatments, which were terminated at her own insistence because she was too frightened to take any more. At the time of her discharge her doctor noted her as "quite depressed,” but The felt that hospital. it was doubtful that she could benefit from further treatment She was discharged with at the the recommendation for continued psychother- apy. DISCUSSION The structured family interview was designed to test the specific hypo- thesis derived from earlier observations that patients with the "explicit verbal denial” personality are most likely to Show both the language and behavioral changes to electroshock therapy which are rated as the examiner. The much improved by data supports this hypothesis and is also consistent with �the theory of the mode of action of electroshock therapy advanced by Weinstein, that “....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain function in which the mechanism of denial is facilitated in characterologically Linn and Kahn in 1952 (9). They suggest diaposed individuals." The degree of explicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. 0n the basis of the present data and methods of analysis a broader view of personality patterns in relation to improvement with as clinically EST is now possible. improved are characterized by such Those patients who are rated features as: l) non-empathic - unable to think critically or sensitively about the needs,feelings, or - commun- ications of others; 2) non-introspective - - unable to think critically about their own feelings or needs; unable to achieve insight even with the collaboration of others in a psychotherapeutic relationship; 3) rely heavily on nonverbal communication - - even tial when they are talkative there is little referenp communication, the words being cliched, stereotyped, or representative of feelings and emotions rather than transmitters of information and h) highly conventional - - without imaginative or creative capacity, and with few resources to deal with stressful or With re8pond new this pattern as the situations. common background, two classes of patients who to treatment can be defined: a) the driving, conscientious, independent, successful, emotionally-controlled person who can be characterized as the ”explicit verbal denial” personality type; b) the chronically inadequate, affectd::;;;&rfrom and ively labile ludic, dependent person, an impoverished socio- cultural background. While both types are rated as improved in their short tenm response to electroshock, preliminary folloWhup observations indicate that the "explicit verbal denial" personality type clinical response, while the Indie group is more likely to sustain the is likely to relapse quickly. �Consistent with our previous studies we have found that altered brain fun- ction is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change shown with altered brain function, however, vary markedly in different patients. ment of symptoms and are states, become withdrawn, Some Show mood rated as improved. Others develop paranoid agitated or show additional somatic or are rated as unimproved. In this study in those cases we who were memory complaints, and here stressed the personality factors whose behavioral reSponse was considered the patients changes and denial or diSplace- rated as improved. we have not rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information in this regard is minimal, as this problem has not'been approached with a specific hypothesis. raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support These observations the concept of a characteristic predepressed personality. Abraham (I) noted that states of depression occurred in obsessional persons. Arnot ‘2) describes depressions as being overly conscientious and perfectionistic. Hamilton and (5), reporting various aspects of the personality in involutional depression, include such features as "followed a rigid pattern of behavior....displayed a lack of imagination....narrow range of interests....thorough, cone Mann scientious, meticulous devotion to duty....lack of feeling for point of view of others....hard, uncompromising drivers....oversensitive....reserved.“ Cohen, et a1 (3) in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige-conscious; little concerned with prdblems of interpersonal relatedness; stereotyped; conventional; having for communicative interchange; and unaware of little capacity other persons' feelings toward �.10himself or of his feelings toward others. They emphasized the patients' inability to communicate verbally and suggested that the therapeutic relationship should be in nandverbal terms rather than emphasizing the intellectual contents of the exchange. These studies of the personality background of depression show a that is pattern similar to those personality asPects which have been described as the "explicit verbal denial" personality. The factor of personality could thus most explain the fact that depression is the condition which responds best to electroshock treatment. The same personality factors which to a depressive reaction are those which forms of therapy. These factors enable make him him make a person susceptible responsive to noneverbal to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism, and prestige-consciousness, which produce a catastrophic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed ”improved” by the family and the therapist. �SUMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for electro- shock therapy were studied by means of a structured family interview. 2. The 3. The which results that aSpects of personality can be differentiated are significantly related to the response to treatment. show basic personality pattern of the patients who reSpond best can be characterized as a) non-empathic, b) non-introspective, c) communicate non- verbally, and d) highly conventional and stereotyped, with or creative capacity. h. 'Within the context of this of improved patients. One group is common little imaginative core, there are two main subdivisions comparable to the ”explicit verbal denial" personality, showingiﬁzch features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to be chron- ically inadequate and dependent, coming from deprived socio-cultural back- grounds, who are affectively 5. labile and ludic. relationship between these personality patterns and descriptions of the personality of depressed persons is noted. The same personality factors The which contribute to a depressive reaction, contribute to a behavioral change under the conditions of altered brain function following electroshock therapy which is evaluated as improvement. �~12REFEEENCES 1. Abraham, K.: Selected Papers Press Ltd., 1919. Amot, on Psychoanalysis. London: The Hogarth Predepressed Personality, A.M.A. Arch. Neural. Chiato, L6: 617-618, 1956. The 12.: & Psy- 3., Baker, G., Cohen, R. A., From—Reichmam, F. and Weigert, E. V.: In Intensive Study of Twelve Cases of Manic-Depressive Psychosis, Psychiat., 1.1: 103-137, 1951. Cohen, M. Pink, and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock, EEG Clin. Neurophysiol., Q: 158, 1956. M. Hamilton, D. M. and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression (Hock, P. and Zubin, J. , eds.) , New York: Grune & Stratton, 199-209, 1952. L., Fink, M. and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, 11.14.11. Arch. Neurol. & Psydliato, 16-: 23-29, 1956. Kahn, R. 7. Kahn, R. L. and Fink, 14.: Changes in Language During Electroshock Therapy, in Psychopatholog of Commication (Hock, P. and Zubin, J. , Eds.) in press. ‘ 8. Piaget, J.: Play, Dreams and Imitation in Childhood. New York: W. W. 9. Weimtein, E. 1., Linn, L. and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. PSYChiato’ 3:99.: 22.26, 1952. 10. Weinstein, E. A., Kahn, R. L., Sugaman, L. A. and Linn, 1a.: Diagnostic Use of Amobarbital Sodium ("Anwtal Sodium") in Organic Brain Dis- ease, ll. Weinstein, Am. J. Psychiat., 113: 889-891;, 1953. E. A. and Kahn, R. L.: Personality Factors in Denial of & A.M.A. Arch. Neural. Psychiat., 92: 355-367, 1953. ness, Ill- Weinstein, E. A., Kahn, R. L. and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp. , 2: 98-106, 1951;. 13. Weinstein, E. A. and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. Springfield, 111.: Charles C. Thomas, 1955. �April 1, 1957. MEMORANDUM TO: Medical Affairs Committee FOR: Dr. Joseph S. A. Miller FROM: Department of Experimental Psychiatry SUBJECT: 1957. 1956 to April 1, September of Departmental Activities, Report Experimental of the Department of the of activities following report since the period covering of’Dr. Miller, the submitted request at Psychiatry is The September 1956. A. Progress in Ongoing Projects: the evaluate The signifito control study Evaluation: 1. Electroshock be com1956, will on April 1, instituted electroshock therapy, cant elements in been has been have studied. It 1957. Seventy patients pleted by the end of’May the electrointo insights have we and gained significant successful a most group, made 1955-56, in observation, the we original verified shock process. First, dethe is electroshock therapy behavior in in change that the prerequisite for function. brain in and sustained alteration degree velopment of a significant Under the conditions of altered brain function, however, patients respond in electroshock is follows that the improvement In some patients, various ways. the that was opinion our It disappears. rapidly while in others, it sustained, observations. these determinant in instrumental the was patient's personality in the of patients the personality studied have intensively we For this reason standard interview developed tests, this last group. By applying specially have we number of questionnaire tests, and a modifying psychological tests, and of type between personality the number of relationships determined a behavioral the we At predicting are time, the present behavioral response. and during our predictions electroshock to therapy, the of patients response As a result chance. than better been have months significantly the past few include to personality extend study our to we planning are of these observations, G). Section (see results psychotherapy in factors changes the been has perceptual of patients Our second interest in this group to deable have been we control of a By group, virtue induced by electroshock. and those treatment the to related which are changes termine those perceptual im— been have we In these observations, which are related to practice effects. and their the of the patients personality close interrelation.bf the pressed by two so behavior of is The these of aspects interrelation perceptual processes. in differences individual of undertake study a decided have to we close, that under the behavior eventual to such differences and to relate hope perception 0). Section (see function brain of altered special conditions Our which electroshock therapy of concept a to have led develop us studies Electrotreatment unit. of this management the in has been of significant help which function brain in induces changes treatment. It shock is a non-specific Under these two months. than less of usually time, persist for varying lengths depending environment different in ways to his the responds patient conditions, his he to better 'With relates certain a personality, upon his personality. �-2The and better that he relates to to other his patients. family, therapist, other people the less reason is there-for him to become tense, anxious or 6nce the feeling of well-being is set into motion, it is sustained depressed. by the patient's better ability to function with others. Electroshock therapy is not a specific treatment for a specific fbrm of mental illness. 2. Biochemical Changes in Electroshock: In the course of these studies of electroshock, we noted that other investigators had reported that there were and the one report fluid after in trauma, in Spinal changes enzymes specific noted similar changes after electroshock. Dr. Goldenberg and I undertook a study of these enzymes in order to verify the previous reports and to clarify our own picture of the electroshock process. To date, we have collected 30 spinal fluids. I anticipate that this phase of the work will continue until the end of 1957. 3. Communication Studies: Our interest in communication problems has led to two types of studies. In one, Dr. J. Jaffe has developed a technique for the analysis of recorded interviews which provides us with an objective index of change in behavior. Support for this phase of the work has been obtained from the Foundations' Fund for Research in Psychiatry. At present, he is analyzing the recordings of interviews with electroshock patients made earlier in the year, and his findings are correlating very well with the clinical results. we antiand the in of language changes to an technique analysis this applying cipate behavior that occur in ps;chotherapeutic interviews. analysis of the structured amytal test intero views according to changes in syntax and content. The original findings of this study were presented to the AmeriCan Psychopathological Association in June. Since then, all our amytal test interviews are being analyzed in like fashion and the original findings have been verified and amplified. ”e have come to understand that the language of our patients tells us readily whether or not changes have occurred in brain function and in behavior. Furthermore, correlations between the personality evaluations and the language changes have shown a direct relationship between high degree language changes and certain personwith other personality types. and changes minimal-to-no language types; ality Language is thus a recordable facet of behavior and we are ODtlmiStiC that a combination of the language analyses developed by Drs. Jaffe and Kahn would be a meaningful index of changes in behavior applicable to any form of psychiatric therapy, including psychotherapy. h. Egrebral Reactivity: As described in the previous report, our interest in the question of individual variability in cerebral reactivity has been stimulated by our electroshock studies. One part of this study is the A second is the study of the biochemical in changes fluid. of spinal study rate of development of electroencephalographic change induced by electroshock. Dr. Green has begun this phase of the work and since September has surveyed all EEG basic of their by records, and their an electroshock analysis our patients been has Mcgimide to the cerebral to Also, response hyperventilation. reSponse A second study is a language assessed and this phase of the work completed (see Section B). Beginning in May, the admissions new hOSpital the to that will screen is laboratory anticipated it and that various activation procedures will be tested, so that the definitive study can be undertaken in the Fall. Concurrently, Dr. Green has assessed the relationship between the electroshock seizure threshhold and cranial resistance as factors influencing the development of electroencephalographic abnormality. This study is in progress. �.3This study, under the direction of Dr. Sidney TaraNew York have and been before the the observations continued has presented chow, Neurological Society in January. The observations have been summarized in a reand A.M.A. Archives of which Neurology the in Psychiatry. will shortly appear port S. B. Ambivalence: Completed Projects: 1. Chlorpromazine-Insulin Coma: Control Study: An interim report on the results of this control study was submitted to the Research Committee of the Medical Board on January 31, 1957. In this study, 59 patients referred for insulin coma were divided into two groups - one-half receiving insulin coma and the other half receiving chlorpromazine therapy. It was our conclusion that chlorpromazine is as effective in modifying psychotic behavior patterns as insulin coma therapy. There was a tendency for the discharge ratings to be better for the chlorpromazine ,we to concluded insulin in comparison coma the than for insulin that, group. group coma therapy, chlorpromazine was safer, easier to administer, more controllable in had Tb evidence concluded had no also and that fewer side effects. apits effects, peared in the fifteen months of the study that either therapy had altered the basic schizophrenic process, nor did we feel that either form of therapy had a greater specificity for schizophrenic illnesses. At the conclusion of the study, the Medical Director placed chlorpromazine in the formulary and permitted its use by the Resident staff. Insulin Coma 2. Megimide Evaluation: During this period, Dr. Green has evaluated a new agent in electroencephalography, megimide, for its ability to bring out defects in brain function. The report of his findings Twere presented at the midwinter meeting of the Eastern Association of Electroencephalographers. 0. Projected Studies It is . 1957-58: in progress in the Department will The electroshock evaluation study will be completed this Spring and the next few months will be spent in correlating the information obtained and writing the reports. As indicated in the ongoing and have of studies these out number of developments grown it a progress notes, is anticipated that these will be incorporated in the_active research program. anticipated that the work continue for the remainder of the year. now A Behavioral Reapgggg: protocol has been 1. £ndividual_Differences in developed by Dr. Max Pollack, which incorporates the problem of personality affecting individual responsivity to electroshock. By determining the subject's patterns of perception in specially developed orientation and visual tasks, we hope to demonstrate a relationship between these patterns and the behavioral response, both under the special condition of altered brain function, and the general condition of hospitalization and psychotherapy. Such a study has bearing on the problems of the personality aspects of resistance to change in behavior under stressful conditions (as in forceful indoctrination, isolation, starvation); as well as the definition of suitable candidates for various psychiatric therapies. 2. Personality Factors in Doctor and Patient Affecting Choice of Thera : Our experiences with electroshock have led us to a unmber of hypotheses which relate personality factors in the patient and the therapist affecting the choice of treatment. We are in the process of developing our ideas into a workable hypothesis. We anticipate undertaking such a study by the end of the year. �D. Changes in rersonnelz- Since the last re\ort, this section has been redesignated as the Department the of time the at the to personnel In addition listed of Experimental Psychiatry. Max Research Dr. as Pollack, a have on we part-time basis, appointed, last report, New York from who University has his_Ph.D. Dr. Pollack, Assistant in Psychology. and mount the Sinai Hospital the at research been has psychologist a in 1955, He is experienced the six for Research Child past years. Ittleson Foundation for he that is anticipated research. in and It perceptual aspects in both personality A the indito study July on program basis a full-time be on lst. appointed will and the on perceptual personemphasis with behavior specific vidual differences in made various been has to and him been application by developed ality aspects has foundations for support. Technical a the be to Department, appointed will there Effective April let, FFRP (see Section Grant Under the of terms the analyses. Assistant for linguistic E) funds were made available for a technical assistant to carry out the language measurements devised by Dr. Jaffe. E. Funds: Foundations' Fund for Research in Psychiatry has granted Dr. Jaffe continuation overhead for h5,700 a26,000 of sum plus two the in years support for the been has developed during which past year. Dyad" the of "Languahe the of study FFRP The Kaufmann Foundation. grant will exthe This work had been supported by tend from April 1, 1957 to March 31, 1959. Health Mental fbr of National made Institute the been to have Applications subthe Green. Dr. protocol Also, work by undertaken of support for the program of Division and Development Research the to been has sent Pollack mitted by Dr. FoundaMalina and the to Army, States United the of the Surgeon-General's Office The tion. F. Publications and rresentations: In November, a summary of our studies on electroshock was presented at the Montreal a in Association in report American the Psychiatric of Meeting Divisional FollowChange Behavioral to Function Brain Altered entitled "Relation of Tests of "Electroencephalothe Green Dr. report December, presented Electroshock". In ing Electroenceh of Association Eastern the Negimide" at of Lffects and Clinical graphic studies during the of electroencephalographic In a summary February phalographers. Differences in "Individual entitled a two in was report presented the past years EEG Besponsivity" before the Metropolitan EEG Society. The Department has submitted a number of reports to various societies for the the at for been have presentation accepted Summer Papers and meetings. Spring the Psychiatry, of Biological Society the Research Association, Electroshock International Congress of Psychology and the International Congress for Psychiatry. American the Psysymposia at in to been have invited participate In addition, we These meetings. for Psychiatry International Congress and chiatric Association Department of this the experiences considerable detail summarize in reports will and to electroshock to with regard and two one-half specific the years, past over methods of the language anato have we present an opportunity also will drugs. to as some of our speculations well as presenting Dr. as devised by Jaffe, lysis the role and mode of action of the newer drug therapies in psychiatry. �G. Educationi_ Various members of this Department are continuing their education by formal courses. Dr. H. Korin has been enrolled in courses at the Graduate School of New York University with specific emphasis on statistics. Dr. J. Jaffe is completing the formal training requirements at the William Alanson White Institute of Psychoanalysis. Dr. Robert L. Kahn has been accepted for training in psychoanalysis at the William Alanson White Institute. H. Other Activities: 1. Israel Strauss November 1953. and Members Volume: The Israel Strauss Volume appeared in of this Department were active in the development fulfillment of that volume. 2. Resident Training: Since September 1956, two Residents have worked H. Esecover has been studying the problem of Dr. the in Department. actively psychotherapy with electroshock patients. In this study he has been supervised He made. has have been number conclusions and of a members the Deiartment of by demonstrated that patients differ considerably during the electroshock process and that no single type of psychotherapy is meaningful. Certain supportive and He is now in the process of have value. definite may approaches interpretive describing his observations. Dr. S. Friedman has contributed considerably to the ambivalence study. this work he was supervised by Dr. Tarachow. In During the period September to February, members of the Department participated in a weekly lecture series for the Resident staff on the subjects of research methodology and newer trends in psychiatry. Respectfully submitted, Max MFzgw Department of Experimental l’sychiatry _ ﬂillside Hospital Glen Oaks, New York Fink, M.D . �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH JOSEPH S. A. MILLER, 75-59 263m: M. D. STREET. GLEN OAKS. NEw YORK FIELD STONE Medical Director LEON $7500 Lowwsrm Honorary Chairman Board of Directors SIMON KWALWASSER, M. D. ROY FOSTER Assoc. Medical Director Chairman Board Of Directors MAURICE BACHRACE Administrator E. COLEMAN President ALVIN Dear Sir : basis for the discussion of the research activities at the meeting of the Medical Affairs Committee on Monday, April 8th, I am herewith enclosing the following memoranda= As a 1. Report of Dr. Fink for the Department of Experimental Psychiatry. 2. Research activities in the Department of Biochemistry, by Dr. Harry Goldenberg. 3. Research in the Department of Medicine, by Dr. Arnold G. Blumberg Aside from the regular Medical Board members of the Medical Affairs Coxmnittee, there will also be present Dr. H. L. Rachlin, Chairman of the Research Comittee of the Medical Board and Dr. Max Fink, Director of the Department of Experimental t’sychia’cry. Yours sincerely, f4,WIM, Joseph S.A.Miller, M.D. JSJALI: 11b Medical Director encl. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �April 1, 1957. MEMORANDUM TO: Medical Affairs Committee FOR: Dr. Joseph S. A. Miller FROM: Department of Experimental Psychiatry SUBJECT: Report of Departmental Activities, September 1956 to April 1, 1957. Experimental of the Department of the activities of following report since the period ofHDr. covering Miller, the request Psychiatry is submitted at The September 1956. A. Proggess in Ongoing Projects: the evaluate The signifito control study Evaluation: 1. Electroshock be com1956, will on April 1, instituted electroshock therapy, cant elements in been has studied. been have It pleted by the end ofTMay 1957. Seventy patients the electrointo insights have we and significant gained a most successful group, made 1955-56, in observation, the we original verified shock process. First, the deis electroshock therapy behavior in in change that the prerequisite for function. brain in and sustained alteration velopment of a significant degree Under the conditions of altered brain function, however, patients respond in electroshock is follows that improvement the In some patients, various ways. that the was opinion our It disappears. rapidly while in others, it sustained, observations. these in determinant instrumental the was patient's personality in the of patients the personality For this reason we have studied intensively standard interview developed tests, this last group. By applying specially have we number of questionnaire tests, a and modifying psychological tests, and of type between personality the number of relationships determined a behavioral the we predicting are At the present time, behavioral response. and during our predictions electroshock therapy, to reSponse of the patients As a result chance. than better been have significantly the past few months include to personality extend study our to we planning are of these Observations, G). Section (see results factors in psychotherapy changes the been perceptual has of patients Our second interest in this group deto able been have we control a group, induced by electroshock. By virtue of and those treatment the to which related are termine those perceptual changes imbeen have we In these observations, which are related to practice effects. and their the of patients the personality interrelation.of close the pressed by so behavior two is of The of these aspects interrelation perceptual processes. in differences individual of undertake study a decided to close, that we have under the behavior eventual to such differences and to relate hope perception G). Section (see function brain special conditions of altered which electroshock therapy of a concept to develop have led us Our studies Electrotreatment unit. this of management the in has been of significant help which function brain in changes induces shock is a non-specific treatment. It Under these two months. than less of usually time, persist for varying lengths depending environment different ways in his to responds the patient conditions, his to he better relates With certain a personality, upon his personality. �-2— family, his therapist, and to other patients. The better that he relates to other people, the less reason is there for him to become tense, anxious or depressed. Once the feeling of well-being is set into motion, it is sustained by the patient's better ability to function with others. Electroshock therapy is not a specific treatment for a specific form of mental illness. 2. Biochemical Changes in Electroshock: In the course of these studies of electroshock, we noted that other investigators had reported that there were Specific changes in enzymes in the spinal fluid after trauma, and one report noted similar changes after electroshock. Dr. Goldenberg and I undertook a study of these enzymes in order to verify the previous reports and to clarify our own picture of the electroshock process. To date, we have collected 30 spinal fluids. I anticipate that this phase of the work will continue until the end of 1957. Communication Studies: interest in communication problems has led to two types of studies. Tn one, Dr. J. Jaffe has developed a technique for the analysis of recorded interviews which provides us with an objective index of change in behavior. Support for this phase of the work has been obtained from the Foundations' Fund for Research in Psychiatry. At present, he is analyzing 3. Our the recordings of interviews with electroshock patients made earlier in the year, and his findings are correlating very well with the clinical results. we antiand the in of language changes to an technique analysis this applying cipate behavior that occur in pa chotherapeutic interviews. analysis of the structured amytal test interviews according to changes in syntax and content. The original findings of this study were presented to the American Psychopathological Association in June. Since then, all our amytal test interviews are being analyzed in like fashion and the original findings have been verified and amplified. We have come to understand that the language of our patients tells us readily whether or not changes have occurred in brain function and in behavior. Furthermore, correlations between the personality evaluations and the language changes have shown a direct relationship between high degree language changes and certain personality types; and minimalvto-no language changes with other personality types. Language is thus a recordable facet of behavior and we are optimistic that a combination of the language analyses developed by Drs. Jaffe and Iahn would be a meaningful index of changes in behavior applicable to any form of psychiatric therapy, including psychotherapy. h. Egrebral Reactivity: As described in the previous report, our interest in the question of individual variability in cerebral reactivity has been stimulated by our electroshock studies. One part of this study is the A second is the study of the biochemical in of changes spinal fluid. study rate of development of electroencephalographic change induced by electroshock. Dr. Green has begun this phase of the work and since September has surveyed all our electroshock patients by an analysis of their basic EEG records, and their reSponse to hyperventilation. Also, the cerebral response to Mcgimide has been assessed and this phase of the work completed (see Section B). Beginning in May, is anticipated that the laboratory will screen new admissions to the hospital it and that various activation procedures will be tested, so that the definitive study can be undertaken in the Fall. A second study is a language Concurrently, Dr. Green has assessed the relationship between the electroshock seizure threshhold and cranial resistance as factors influencing the development of electroencephalographic abnormality. This study is in progress. �.3’ 5. Ambivalence: This study, under the direction of Dr. Sidney TaraNew York have before been and the the observations presented chow, has continued Neurological Society in January. The observations have been summarized in a report which will appear shortly in the A.M.A. Archives of Neurology and Psychiatry. B. Completed Progects: 1. Chlorpromazine-Insulin Coma: Control Study: An interim report on the results of this control study was submitted to the Research Committee of the Medical Board on January 31, 1957. In this study, 59 patients referred for insulin coma were divided into two groups - one-half receiving insulin coma and the other half receiving chlorpromazine therapy. It was our conclusion that chlorpromazine is as effective in modifying psychotic behavior patterns as insulin coma therapy. There was a tendency for the discharge ratings to be better fer the chlorprcmazine we concluded that, in comparison to insulin coma the than for insulin group. group coma therapy, chlorpromazine was safer, easier to administer, more controllable in had evidence concluded had no ‘b that also fewer and side apeffects. its effects, peared in the fifteen months of the study that either therapy had altered the basic schizophrenic process, nor did we feel that either form of therapy had a greater specificity for schizophrenic illnesses. At the conclusion of the study, the Medical Director placed chlorpromazine in the formulary and permitted its use by the Resident staff. Insulin Coma 2. Megimide Evaluation: During this period, Dr. Green has evaluated a new agent in electroencephalography, megimide, for its ability to bring out demidTJere the The of his findinas at presented function. brain in report fects winter meeting of the Eastern.Association of Electroencephalographers. C. Projected Studies 7 l9§7~§8: the work now in the in Department will that progress anticipated is It continue for the remainder of the year. The electroshock evaluation study will be completed this Spring and the next few months will be spent in correlating the information obtained and writing the reports. As indicated in the ongoing and have of studies these out number of developments grown it a progress notes, is anticipated that these will be incorporated in the active research program. A i“Response: Behavioral protocol has been 1. lgdividual Differences in IVia}: Dr. Pollack, which incorporates the problem of personality affectdeveloped by ing individual responsivity to electroshock. By determining the subject's patterns of perception in specially developed orientation and visual tasks, we hOpe to demonstrate a relationship between these patterns and the behavioral response, both under the special condition of altered brain function, and the general condition of hospitalization and psychotherapy. Such a study has bearing on the problems of the personality aspects of resistance to change in behavior under stressful conditions (as in forceful indoctrination, isolation, starvation); as well as the definition of suitable candidates for various psychiatric therapies. 2. Personality Factors in Doctor and Patient Affecting Choice of Therapy: Our experiences with electroshock have led us to a number of hypotheses which relate personality factors in the patient and the therapist affecting the choice of treatment. We are in the process of developing our ideas into a workable hypothesis. We anticipate undertaking such a study by the end of the year. 17 , 914.4 f 3 f 1 b Va. 1,5 _. �D. Changes in Fersonnel: the Department been as has redesignated section this Since the last re ort, the time of the at listed the personnel to In addition of Experimental Psychiatry. Max Research as Dr. Pollack, a basis, last report, we have appointed, on part-time New York University from Ph.D. who has Dr. Pollack, his Assistant in Psychologr. and the mount Sinai Hospital the at in 1955, has been a research psychologist He is experienced six the Research for past years. Ittleson Foundation for Child he that anticipated is It in both personality and perceptual aspects in research. A program to study the indiJuly on basis lst. on the perceptual and personwill be appointed on a full-time vidual differences in behavior with Specific emphasis made various been to has and him by application been developed ality aspects has foundations for support. Technical a the Department, to be appointed will there Effective April lst, FFRP Section (see Grant of the Under terms the Assistant for linguistic analyses. the language out to assistant technical a carry made for available E) fUnds were measurements devised by Dr. Jaffe. 3- £211.42: Dr. Jaffe has granted Fund Research Psychiatry Foundations' in for The continuation overhead for $5,700 u26,000 of plus sum the two years in support for the been during past developed has which year. Dyad" the of "Languace the of study FFRP The will Fbundation. exKaufmann grant the by been had work supported This tend from April 1, 1957 to March 31, 1959. Health Mental for of National made Institute the to been Applications have subthe Green. protocol Dr. Also, by work undertaken support for the program of of Division and Development Research the to been sent mitted by Dr. Pollack has FoundaMalino and the to Army, States United the Surgeon-General's Office of the tion. F. Publications and Presentations: the at was presented electroshock on studies of our In November, a summary Montreal a in Association report in American Psychiatric the of Meeting Divisional FollowChange Behavioral to Function Brain entitled "Relation of Tests of Altered "Electroencephalothe Green report Dr. presented December, Electroshock". In ing Electroenceb of Association Eastern the Megimide" of at graphic and Clinical Lffects during studies electroencephalographic the of In a February summary phalographers. Differences in "Individual entitled a in report two was presented the past years EEG Besponsivity" before the Metropolitan EEG Society. the for societies various to number of submitted a reports The Department has the at for been have presentation accepted Summer meetings. Papers Spring and the Psychiatry, Biological of Society the Research Association, Electroshock for Congress Psychiatry. International and the Psychology of Congress International Psy— American the symposia at in In addition, we have been invited to participate These meetings. for Psychiatry International Congress and chiatric Association Department of this the experiences detail considerable summarize in reports will and to electroshock to regard with and one-half specific two years, over the past methods of anathe language to present have we an opportunity also will drugs. to as some of our speculations well as presenting lysis devised by Dr. Jaffe, as in psychiatry. therapies the newer drug of mode and of action the role �-5G. Education: Various members of this Department are continuing their education by formal courses. Dr. H. Korin has been enrolled in courses at the Graduate School of New York University with specific emphasis on statistics. Dr. J. Jaffe is completing the formal training requirements at the William Alanson White Institute of Psychoanalysis. Dr. Robert L. Kahn has been accepted for training in psychoanalysis at the William Alanson White Institute. H. Other Activities: 1. Israel Strauss Volume: November 1955. and Members The Israel Strauss Volume appeared in of this Department were active in the development fulfillment of that volume. 2. Resident Training: Since September 1956, two Residents have worked H. Dr. Esecover has been studying the problem of the in Departnent. actively psychotherapy with electroshock patients. In this study he has been supervised He has made. have been number and conclusions of a members of the Department by demonstrated that patients differ considerably during the electroshock process and that no single type of psychotherapy is meaningful. Certain supportive and He of the now have in value. is definite process may approaches interpretive describing his observations. Dr. S. Friedman has contributed considerably to the ambivalence study. this yprk he was supervised by Dr. Tarachow. In During the period September to February, members of the Department participated in a weekly lecture series for the Resident staff on the subjects of research methodology and newer trends in psychiatry. Respectfully submitted, Max MFzgw Department of Experimental i"sychiatry > hillside Hospital Glen Oaks, New York Fink, M.D. �April 1, 1957 Medical Affairs Cummittee TO: For: Dr. Joseph S.A.Miller From: Department of Biochemistry Subject: Report of Departmental Activities, July 1956 to March 31, 1957. Steroid Studies Studies were continued on the steroid hormones because of their importance in the physiological response to stress. Experiments with rats showed that the liver converts neutral and sex hormones to their sulfate conjugates which are subsequently voided in the urine. Female rat~ liver was far more active than male preparations in conjugating the steroids, particularly the male hormones. These findings indicate that the liver plays a major role in the maintaining hormonal balance, femalssbeing endowed with a regulatory device to dispose of excess male hormones produced in their bodies. Urinary steroid sulfate excretion studies on human subjects were carried out The and total chromatographic techniques. complexation with our newly developed sulfate output was found to be related to both sex and age. Interesting results were obtained with urine from schizophrenics, the level of one fraction (dehydronumber of cases. elevated sulfate) in a being epiandrosterone Drugs and Alkaloids New colorimetric, chromatographic electrophoretic techniques were establipsychothenpeutic drugs. These were recently and for both the psychotomimetic and presented at the American Chemical Society shed Meeting (Brooklyn, February 15, 1957). findings are now being applied to determining the role of trace urinary alkaloids in schizophrenia. our earlier chlorpromazine studies, which were dropped for lack of suitable instrumentation, are again under way with financial help from the National Institutes much throws because The of interest it light on Health. is ver great of subject from the be which cannot gained (microsome action gross liver function liver function tests in currentuse. we find the chlorpromazine molecule is in many ways The from information gleaned to some in isotopes. ways ideal superior an tracer, this study would also throw light on the Akerfeldt "six~minute blood test for from whether suffer a decide schizophrenics should to and us help schizophrenia" defect in oxidative metabolism leading to the in vivo production of hailucinogens. The Electroshock Lavels Therapy. in gholinesterase Earlier investi ations by Tower and others have indicated demonstrable changes in acetylcholine, acetylcholinesterase, and pseudocholinesterase in spinal fluid following electroshock therapy as well as other forms of head trauma. AccordingEEG of have to correlate undertaken Fink patients and Ur. patterns associates ly, EST values cholinesterase in concurrent and with alterations after during before, of spinal fluid. Simultaneous serum cholinesterase determinations on these patients blood red to extend these studies and cell we to carried plan also being out, are (true)cholinesterase. The specific enzyme methods in use were developed at Hillside Hospital and have recently been presented at the American Chemical Society Meeting in Brooklyn. Further reference is made to Dr. Fink's progress report for findings to date. Future plans: More of the same. Harry Goldenberg, Ph.D. �April 1, 1957. Medical Affairs Committee TO For: Dr. Joseph S.A.Miller From: Department of'Medicine subject: Report of Departmental Activities, July 1956 to March 31, 1957. to of An the patients of psychiatric Test: response l. Mecholylof mecholyl analysis between correlation a revealed has striking subcutaneously injections electroshock to and therapy. and diagnosis response age, response have machine blood recording automatic of an studies pressure 2. Preliminary machine for and of this the evaluate practicability to out accuracy been carried now seems As these of result a studies, the work mecholyl it test. on further of the evaluate to used be reproducibility machine usefully can likely that this the mecholyl test. 3. Drug evaluation studies on meprobamate are being carried out. h. Chemical studies with the laboratory department are being conducted on possible hepato-toxic effects of chlorpromazine in our patients. Proposed Research for the coming year: 1. Evaluation of meprobamate in psychiatric patients. three months). 2. (to be completed within Evaluation of reproducibility of mecholyl test employing a recording sphygmo- mamometer. by chromatographic with therapy chlorpromazine alterations of Evaluation 3. protein techniques. h. Evaluation of or Trilafon. a substitute fbr chlorpromazine. This will be either Spaﬁine Arnold Blumberg, M.D. �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH JOSEPH S. A. MILLER, 75-59 263RD M. D. STREET. GLEN OAKS. NEw YORK FIELDSTONE Medical Director LEON LOWENSTEIN 3-7800 Honorary Chairman Board of Directors M. D. Assoc. Medical Director SIMON KWALWASSER, ROY FOSTER Chairman Board of Directors MAURICE BACHRACH E. COLEMAN President Administrator ALVIN A Proposed Study for the Behavioral Max From Assay of New Drugs Fink M.D. the Department of Experimental PBychiatny October 30, 1957. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �AProposed Study for theBehavi9ralwg§§ay of New Dm mgs MaxFi‘nk M.D. * 1 . Problem: is little disagreement that the newer psychopharmamode of these drugs of action the behavior, alter cological agents and factors in the marked individual variability in response are unresolved problems. Difficulty in resolving these problems lies, While there in part, in the lack of a theoretic framework subject to operational the is assay perplexing and Particularly experimentation. analysis of new, i;g., clinically untested agents capable of altering behavior. Many the because reports are to assess studies difficult are present and classifications nosologic defined; the poorly population subjective; are unsatisfactory. Based on our previous studies, we have expressed the hypothesis that the efficacy of psychopharmacological agents in psychotic states measurable changes induce to persistent to their related ability is in cerebral function (1). Such alteration in cerebral function provides the milieu for changes in adaptation of the patient in his environmento In this view, alterations in cerebral function following drug administration are not "complications," or "untoward but the sing SEE 293 of the mode effects," of action of these therapies. Changes condition not sufficient but a a cerebral are physiology in necessary, for improvement. * Director, Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. �,2This hypothesis is a direct outgrowth of four years of experimental investigations of electrcconvulsive, insulin coma and various drug therapies in use at Hillside Hospital. These studies are summarized in the appended report (1). we have used a wide t variety of measures of brain function (2, 3, h, 10, 12). Most successful have been changes in the frequency spectrum of the EEG, patterns of language and perceptual tasks. In our experiences with electroshock, slowing of most EEG frequencies has been helpful (2). In drug studies, however, this is less prominent, although fundamental; Language and perceptual tests, however, have given us clues as to ways of measuring brain changes, more subtle than present electroencephalographic techniques. It is this study to logic agents according to their effects the purpose of patterns and on perceptual tasks. to test the following: The compare various psychopharmacoon the study EEG, on language is specifically designed I (a) Can the extent of behavioral change in psychopharmacologic agents be related to the degree of (b) To EEG spectrum changes? what extent can visual discrimination measures of changes in language be tests, and refined to provide reliable, predictablezueasures of changes in clinical behavior? (c) To what extent can such measures predict the clinical usefulness of psychopharmacologic agents? �II. Method: 1. Subjects: All subjects are drawn from the adult impatient service of the Hillside Hospital. In general, these patients are erative, well educated good physical health. intelligent. All are and alert, coopT ambulatory and in 2. Procedure: Two methods of drug assay are in progress. (a) Acutg_Experiments: In the laboratory setting, with simultaneous EEG and language recording in process, single intravenous or oral doses of drugs are administered. the period of drug Patients are under constant observation for activity. (b) Clinical Experiments: Patients are referred by their therapist to the super- vising psychiatrist for treatment with psychopharmacologic agents. Prior to drug administration, EEG and language recording interviews are held. Perceptual tasks are completed. Drug administration then until toxicity is manifest, and drug reduced to a maintenance dose. Testing is repeated, and be- proceeds dosage at a rapid increment havioral observations made, at frequent, defined intervals. in previousstudies, subjects are randomly divided into As groups - an experimental and a control. The experimental group receives the medication, the control group placebo medication. two �3. measurements: (a) 33.29. is Recording with an 8 channel Medcraft instrument in progress. Records have been visually analyzed for changes in frequency, voltage, symmetry and rhythmicity (2). Activation by hyperventilation is routine. validity of other activating and photic hypoglycemia megimide (6), intravenous as procedures The stimulation is being assessed. (b) Perceptual. Within the past decade certain perceptual procedures have been shown to be (11, 12, 13). sensitive measures of cerebral dysfunction Such techniques as critical flicker fusion (OFF), and "embedded" of figures polychromatic the tachistoscopic recognition in a These visual background are being assessed (10, 12, 13). measures have the adVantage of giving a reliable quantitative complex measure of pretreatment functioning in terms of a continuous variable, rather than the qualitative dichotomy of "normal" versus "abnormal;" imposing no undue stress on the patient; and the apparatus and pro- relatively inexpensive. 1) Critical flicker fusion SCFFZ: As the rate of the that the illusion there develops of increased, flicker light is point this at of The the light flickering frequency steady. is light cedure are simple, convenient and is the CFF. The CFF threshold is measured using a Sylvania glow ratio is brightness is varied to robtain thresholds at different tube pulsed by an electronic power supply. The light—dark fixed, and �-5- levels. The psychophysical method of is descending steps limits using ascending and employed. 2) Tachistoscopic recognition of pseudoisochromatic gigures: The H—R-R pseudoisochromatic plates (American Optical Company) con~ sisting of a series of cards with numerous small circles of various sizesare used. The circles vary in color, and form outlines of various geometric patterns, as ring, cross and triangle. These patterns form a "figure" on a constant background. The "neutral" plates are recognized by all subjects - blind." These plates have been photographed and projection slides. initial normal and "color- mounted as 2" x 2" of exposure which permits accurate The speed identification of the figure is the index used. (0) Eggggggg. Interviews with patients are recorded. Both unstructare The records analyzed included. and ured structured periods are for diversity (7) of the dyadic speech. been found useful in analysis of changes in for changes in syntax (9), These methods have and behavior with other therapies. (d) Evaluation of clinical changes. Psychiatric evaluations are made at fixed intervals as to type and degree of changes in behavior, and a rating of "improvement" and is made. in "improvement" are The methods now of rating both change in behavior under study. Present ratings have been based on the Malamud-Sands Rating Scales and have been of limited usefulness. The present descriptive statements of the evaluator, �-6following an outline of specific areas of behavior combined with a review of the nurses' and resident therapist's notes is being continued. h. Pharmacologic Agents: Previous experience with amobarbital (8), megimide (6), reserpine (IA) and chlorpromazine (5) provides the background for the selection of new agents. At present, acute study of diethazine (SKF 1026-A) is in progress. Clinical studies of meprobamate, perphenazine and chlorpromazine are under investigation. have been formulated reaponse. to test other agents, with different spectral Available: The Department of Experimental Psychiatry was established at the Hillside Hospital in l95h. clinical duties. EEG . - III. Facilities Plans of the department have no Members They devote their full at the institution to time the research prognmns. Eight rooms of laboratories and offices in the principle medical building of the hospital are provided. These include: a) EEG Laboratory - equipped with Medcraft encephalograph and Grass photic-stimulator. on a A 8 channel Electro- technician is employed full-time research basis. b) Psychophysical Laboratory - Two Grass stimulators, Dumont oscilloscope and step-up transformer power supply in a rack-mounted assembly. This equipment has been used for the past three years to study threshold and after for simultaneous tactile stimuli of patients before induced states of altered cerebral function. �.37.- A tachistoscopic assembly consisting of two projectors, solenoidaactivated shutters, and opal glass screen is in use. c) Psxcholinggistic Laboratogz: A third laboratory has been established for the recording of interviews. a Magnecord tape recorder, two It is equipped with and mixer. microphones, Electrovoice auxilliary recorders for transcription are available. The available for study. All patients in the hospital are research programs have been well integrated into the hospital Two milieu so that manipulation of experimental variables are readily accomplished. �and Reggrts: Iv. Publications l. 2. of Physiodynamic Action of the Unified Theory Fink, Therapies, J. Hillside Hosp. (in press). M. : A and Kahn, R.L.:' Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. and Pachiat. (in press). 3. h. m: Diffuse of Effects and H.: Korin, , Altered Brain Function in Perception. Read at XV Int'l Congress of Paychology, Brussels, 1957. , : , Relation of Tests of Altered Brain Function to Behavioral Change Following mectroshock. Read at the A.P.A. Divisional Meeting, Montreal, November, 1956. 5. and Coleman, F.S.: Coma and Insulin of Chlorpromazine Comparative Study in the Therapy of Psychosis, J. Amer. Med. Assoc. , Shaw, R., Cross, 6., (in press). 6. Green, Fink, M.: Megimide, EEG. 7. Jaffe, J.: Clinical Effects of W M.A. and An EEG and Clin. Neuromvsiolu g: 180-181, 1957. Objective Study of Communication in Psychiatric Interviews, J. Hillside Hosp. (in press). 8. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electro8c Psvchiat. 1956. 23-29, Meurol. A.M.A. Arch. lé: shock, 9. 10. ll. Durinf-j Ele ctroLanguage Changes in , of Cormnunication, shock Therapy, in P cho tholo Ein press). Crune and Stratton : Em‘oedded Figures After of Perception , Induced Altered Brain Function, Am. Psychol” 1.3: 361 (Abst.) 1957. : Effects of Visual, Vestibular and Somatosensorimotor Deficit on Autokinetic Perception, J. @332. §_2_: 398~LLlO, 1956 (with Battersby, 11.3., Pszchol., Pollack, Mr: Kahn, R.L. and Bender, 15.8.) �0-9- 12. Pollack, M.: Tachistoscopic Identification of Contour in Patients with Brain Damage, J, Cam . Ph 101. szchol., 50: 220-227, 1957, {with Battersby,‘W.S. and Bender, M.B.) 13. Visual Deficit After Brain Damage in Man as Measured with Rapidly Exposed Chematic Stimuli, Amer. Peyphol., 12: h68,(Abst.) (with Battersby,‘w.s. : and Bender, M.B{7: 1h. WachSpress, M., Blumberg, A.G., Fink, M. and Miller,J.S.A.: Evaluation of High Dose Reserpine Therapy for Relief of Anxiety, J. Hillside HOSE. 5: 67-77, 1956. �.10V. Financial Support: Support for the ongoing programsof the Department of Experimental ' Psychiatry is provided by U.S, Public Health M-927, (Altered Brain Function Following Electroshock), the Foundations' Fund for Research in Psychiatry grant 56-151 (Language of the Dyed), and the Board of Directors' Research Fund. The proper development of the specific aspects of this protocol require support for the following, for a two year period. 19 8 Dr. M. P01130k, PhoD. Senior Research Asst. Psychology EEG $ _ Technician - Hrs. Hannah Hosquera 12§9 8,250 $ ‘ 8,750 3,720 3,8u0 2,000 2,000 50 th 50 th 200 300 Equipment: (Over 2 year period). Analyzer (Edin) Flicker Fusion Apparatus EEG Projector, Slides Calculator (h,000) (800) (100) (880) hDO hOO Travel: ) (Amer. Psychol. Assoc. (Amer. Psychiatric ASSOC.) $ 15,060 Overhead (15%) TOTAL $ d 15,h80 2,26h 2,327 17,32h n 17,807 ' �\ KILLSIIE mSPITAL Glen Oaks, NOYO January 27, 1958. MORAN!!! '10: Medical Affairs Committee FOR: Joseph FRCM: Merimental Psychiatry 1958. January 1957 1, to 1, Report of Activities, April Miller, M.D. Deparhxent of SUBJECT: I. 30 A. -~.—-- INTROIIJCTION: achieved has professional work Department the of the nine months, In the past various of understanding We our reflecting have presented reports recognition. and these and international societies, national before physiodynamic therapies October the in work were presented of Five our aspects have been well received. psychiatric by been leading have accepted and other Journal reports the of issue Journals and will appear in 1958-59. convulmode of of action the of Our studies have given us a clear picture confidence to has us given information ibis coma and therapies. insulin sive to these in therapies which were fruitful and techniques extend the hypotheses behavioral concerning a ideas in protocols have expressed our drug therapy. We Psychothe both by received been well These having new ideas, of drugs. assay comand various pharmaceutical U.S.P.H.S. the of Center Research pharmacology 1958. for studies new the in been implemented have panies, . , . therapy, we were , . . number a. of ancillary led to electroshock In evaluating The value for psychiatry. have which basic significance broad, investigations found and assessed were change behavioral of indices of language measures as While a studied. "improvement" was The of defining problem satisfactory. been has approach operational an accomplished, not was satisfactory resolution which the criteria Also, studies. recent defined which was successful in our has an to led Hillside at various the therapies for determine patient referral of choice therapy. factors and affecting psychologic the sociologic evaluation of In addition, the ability of this department personnel to work together has been have the in hospital and Our relationships roles been amply demonstrated. hosthe from at staffs all cooperation excellent defined and we have received pital. II. PROGRESS IN (A) ONGOING PROJECTS: Therapy Evaluations: l. Flectroshock. We electroshock therapy. Our studies have defined the process of physiology; brain in induced changes the to behavioral the have related response behavioral of the type affect that and factors sociologic described personality and clinical behavioral between response the and defined relationship response; of various the types to relate us These studies permit ratings of improvement. PM 1090), electroshock and its varieties, (metrazol 3, convulsive therapy as drug "convulsive there. of concept (Indoklon) meaningful into a and lately, inhalant , pies '. �-2Based on these studies, reasonable criteria for the type of patient "do well" with convulsive therapy can be defined. Continuing studies will behavioral the in of role the personality amplify designed.to in this area are non-electroshock referbetween'out-patient differences the define to response; convulsive inhalant of and evaluation an (IIIc) rals and in~patient populations ' who therapy (111a). 2. . £235 Therapy. control coma-chlorpromazine insulin of conclusion our the Following 1958. and .A.M.A. in early will appear study, our report was accepted by he J the experimental program.for have developed a we months, six the During past which begun was (see IIIb), agents psychopharmacological new of evaluation 3. Selection of therapies: of the based on type generally is of therapy While the selection the Such as aspects decisions. such affect factors mental disorder, other and cultural education his communicate verbally, to facility of the patient have we and been have studied, "authoritarianism” background, and the degree of rebear significant a and aspects psychologic such historical reported that These services. for ancillary lationship to the choice of therapy or referral of the in factors these of results studies have led to an interest in the role socioof role the evaluate further to therapy, and we have designed a study (see IIIc). and therapy outpatient of inpatient psychologic factors in results (B) Language as measurable behavior: one. complex "in is a 'improvement psychiatry of definition and change behavioral of In evaluation of various therapies, the definition have sought we adequate, are While descriptions clinical improvement is crucial. Two methods of our behavior patients. the language in guides more objective for interviews of structured analysis of analyses have been developed - a syntactic and a dyadic of unstructured. The non-convulsive and convulsive induced by changes have described the do clinical reflect patterns these language therapy, and find that changes in to these techniques of the have application to led Our experiences evaluation. We the drug evaluation studies. effort in an in are of progress language other analyses In addition, methods. the of present the broaden applicability to (C) Neurophysiology of Behavior: the between relationship the noted we In the electroshock studies We concluded behavioral response. the and change neurophysiologic of degree and behavior in change to a essential was physiology cerebral in change that a coma therapy. insulin for conclusion We same the come had to to "improvement". chlorpromazine in treatment the response between Since we had observed a similarity was mode action of same the that seemed plausible therapy and insulin coma, it drugs. newer tranquilizing the for operative �-3review of the literature and some preliminary experiments supported the to potent are agents psychopharmacologic newer the that this hypothesis We have function. brain and affect predictably extent that they measurably and in of Psychiatry Congress International the at hypothesis this expressed new undertaken have we As a a Hillside the Hospital. result, the Journal of (see IIIb). various drugs therapies evaluating project .A Concomitantly, our interest has continued in the biochemistry of convulsive therapy. we have observed that diethazine, a potent anticholinergic demonstrated has a Further analysis electroshock effect. the drug, reverses These observadiethazine. LSDHZS to and mescaline between marked similarity as system cholinesterase-acetylcholine the of confirm the significance tions which behavior of psychotic the type a basic mechanism for psychotic behavior may be affected by convulsive therapy. Percgption: (D) have change behavioral of index an as studies of perceptual tests continued. We have defined the relationship between the degree of perceptual demonstrated Our have studies function. alteration and the degree of altered brain Our but the response, in perceptual only not type of personality the significance also in the physiologic response, to convulsive therapy. Our studies of tactile perception clarified the role of strength of stimulus and of the type of instructions (set) in the reported reponses. Individual Differences in Behavioral Responses: The program of study of the ways in which individual differences in various to of subjects and affect response physiology the perception, personality of neurophysiologic Green's Dr. studies under well way. is psychiatric therapies Dr. emphasis and Pollack's EEG electroshock, to the response differences affecting of the both phase in are drug to therapies on perceptual aspects as they relate collecting data in consecutive groups of subjects. (E) III. (A) New Pro ects - Pro am.l 8 Inhalant Convulsive Therapz: In the studies of electroshock, we have been puzzled by the significance of the electric current in the treatment response. In the convulsive-subconvulsive was aftreatment the for response seizure the of the control study, significance compound, inhalant an Recently, clear. not was current of the role but firmed, conﬂescribed simple was as a safe, of ether anesthesia, the to ethyl similar vulsant. We visited the laboratory at Spring Grove State Hospital, Maryland, We and observed the treatment. It was reliable, quick and easy for the patient. have obtained a supply of this compound and are undertaking a study on February of biochemical and effects psychologic of neurophysiologic, the clinical, lst, convulsive therapy using this compound. (B) Mbde of Action of Psychophammaoologic agents: experiences with other forms of therapy have led us to formulate a the In agents. essence, psychopharmacologic (see IIc) regarding hypothesis and kind of effect the degree to related behavior which is affect drugs to degree EEG. Fbr this the purpose,we by measurable in part, brain have on function, they and personnel equipment for special obtained and support have written a protocol from.the U.S.P.H.S. and various pharmaceutical concerns. Our �-l+- In these studies, patients referred for drug therapies, as chlorpromazine, promazine, reserpine, meprobamate, etc. , undergo special tests before and during treatment, which may predict and reflect the treatment response. (0) Psychologic and Sociologic Factors in Out Patient Therapy; result of our studies in inpatients defining certain psychologic sociologic factors as they affect treatment choice and treatment response, As a and we have made predictions regarding the outpatient population. to undertake a sociologic study of outpatients, and extend our studies this Spring. IV. (A) W318 We are planning inpatient AND. I’UBLICATIONS: Eigerimental Psychiatry Issue, Journal of Hillside Hospital: of this Department wrote five articles reflecting various aspects of our study program for the October 1957 issue of the Journal. This encompassed the whole issue. Such an effort is unique in the Journal‘s history. At Dr. Tarachow's (B) invitation, members Publications: In addition to these five articles, our report on the relation between EEG changes and treatment response in electroshock appeared in the Archives of Neurology and Psychiatry. Seven other reports have been accepted for publi cation and two others are in the hands of editors as of January let. (G) Presentations: Reports of our studies have been presented to psyc iatric, neurologic and psychologic societies. Twelve reports were made before National societies in the U.S. and three before International Congresses in Brussels and Zurich during the summer. These reports have been generally well received. V. PERSONNEL: changes in personnel have been made. We have requested, and the Research Committee and Medical Director have approved, a restatement of the titles for staff members from "Research Assistant" and "Senior Research Assistant" to "Research Associate". The present staff consists of nine members including: No Martin A. Green, M. D. Joseph Jaffe, M. D. Robert L. Kahn, Ph.D. Hyman Korin, Ph.D. Max Pollack, Ph.D. Associate (Neurophysiology) - Research " " (Psychiatry) -" " " (Experimental Psychology; " " (Experimental Psychology " " (Ehcperimental Psychology) - and four technical assistants: Mrs. Hannah Mosque'ra (EEG) , Mrs. Jean Kolodw and Mrs. Ann Horowitz(~?sycholinguistics) and Mrs. Janet Bowie (Secretary). �-5VI. (A) TENTﬁIIVE BUDGEE PROJECTION: 1228-52. Personnel: In addition to the personnel listed above, we will request the addition of a Research.Associate in Social Psychology; and a redesignation of the halftime neurophysiologist to a full-time status. These items will increase the budget by $9500 above authorized annual increments for ongoing personnel. (B) Supplies. Em ment and Travel: There will be an increase of $l000 in supplies and travel and a specific equipment expense of $5200 for an EEG Analyzer. This instrument will provide greater flexibility in EEG analysis. A supplementary request for this amount has been asked of the U.S.P.H.S. L Total Egpensesz (C) av" . total expenses for 1958-59 1957-58, an increase of $16,98h. The (D) will be $95,796. as against $78,812 k" "u. Income: In the past six months, this Department has been more successful than anticipated in attracting research funds from private and governmental sources. Fbr the current year, we anticipated $33,595 and so far have been advised that we can expect $h3,h31 for 1957-58, an increase of $9,836 over expectations. Fbr 1958-59; we have already been assured of $50,66h which is $7,233 more than 1957-58. It may be of interest that we already have funds for 1959-60 in the amount of $15,297. These grants totalling $115,235 have been made available to the Department for the period April 1, 1957 to December 1960. Max Mszb/b Fink, M. D. A}\ fork¢3”4 We Respectfully submitted, V‘ � 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 Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-005 Date A point or period of time associated with an event in the lifecycle of the resource 1957 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 Letters; Personality factors in behavioral response to electroshock therapy (draft) by Robert L. Kahn and Max Fink; Progress reports of departmental activities; A proposed study for the behavioral assay of new drugs by Fink; Report of activities 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 http://exhibits.library.stonybrook.edu/mfp/files/original/e160cd659a1c0564650ed815c2ffda05.pdf 287e408e3d76bfef4519f4c1ea5b9ae6 PDF Text Text ( g , a n I E . ! r l , E i P me: plated the 70110113; Wt. it. own» 1957. tho ﬁrst wu- of of W mun-y oa- of tho clan-pu- of natal 1.1an“. WW with. W, mun-mm-m m mum of th- buio and We” pm dandy!” wmmuﬁow WW $81957. m: CW Mtnmwwmmtmunuhanmmmw has. at an a: 0. mm}. 6103111 ”My W; N's-pm“ m “ﬁrm" mmuhm-M muum m may. for in and tho «01015310 at! rum-Mu, mmmacnzwm mmtarmmmmmummmmm can control study. an. anon-mud in 6110me Wanna Maturation, nWtdﬁzomuuﬂmd Geno a» m In. 3mm mm, W nun mum. mm. m magma“, manur- m mum (Imp and 0! o. with the Ward am of nut 11.“.qu of we: Into applying an Into pitta-n- of cannula-ﬂan comma. obs-euro mined: at «unique! of and h mmmWWu-W-mmmwm when; mud. aunnmummmmpum. mn- We Wc wimp-MW" mm,mummwsnmmnud and m induced mum bu» for continua. mm which“! 1n mp”. �.g......__‘-_, <. . r._wr..v,... a.“ .. . an“... ~. My; ’1‘...” w V “rpm—c. v..-.~7.vv....v ”my—W..- m- 7 ~-‘ _ V- w..." ,___ w'J—ln'n .. ,_ —.-‘ \ ,u.,, .N nu . vvvwmr ,. » w..,.._.v..... d. mummdthonmm, unmask-Wt. that ad {in Was: manna. What“ umm Journal tho of thfor 'hponmnul um unk). we)... Why" m of tho é : mnm- Hospital. ﬂu sun and“: m “aA. m, W am. um lab-n 11.9. Edi. 11.». m, Ill: mm, m. “lemma. I» Bub. " - -.. _, “mt mu (Wong) W " " * .u " I (me) (Noun-um Why) _ “ - a wzutmpmmwmmayuM7 E i ‘ amurmwmmunnahrmummm,m hum). mum at rum mu. an Wanna cm» at munmmmanummmmumm. mm, mm . w m. E “n.— ﬁ__.__4w-~m_——__V O ”in. n ,. — �Richard Weiner FROM: FOR RELEASE FINN INCORPORATED 13u.East 59 Street RUDER & MAX York 22, New York PLaza 9-1800 New FOR: 7, 1958 HILLSIDE HOSPITAL A Island psychiatrist whose research points to the underlying Long changes necessary to reverse the depressive type of mental honored this Dr. week by Max be Fink, Director of the Department of Experimental Psychiatry at Hillside Hospital, A. E. illness will a major national psychiatric association. Glen Oaks (Queens), New York, will receive the first Bennett Neuropsychiatric Research Foundation Award. The Society of fé Biological Psychiatry will present the award at the group's 13th Annual Meeting in San Francisco, California, on May 11. The meeting is part of : '1‘ the American Psychiatric Association Annual Meeting. Dr. Fink will present a paper on his work Cholinergic Agent, Diethazine, on EEG titled, "Effect of Anti- and Behavior: Significance for Theory of Convulsive Therapy." The report describes experimental studies of the neurophysiologic for "shock" therapies. Dr. Fink and his associates at Hillside Hospital have observed that changes inla specific enzyme and biochemical bases system of the brain, acetylcholine-cholinesterase, are intimately to improvement in electroshock. However, changes related in the opposite direction are accompanied by hallucinations, delusions, and psychotic behavior. that decrease the activity of the acetylcholine normally present, in the brain excite psychotic activity. They also reverse the electroshock Drugs effect. Some of the newer hallucinogens, such as lysergic acid (LSD) and , �-2mescaline, are most potent in this regard. halts the hallucinogenic action of these shock effect. The On the other hand, chlorpromazine compounds and enhances Hillside research extends the understanding of the the electro- mode of action of convulsive therapies by defining the biochemical bases for the observed neurophysiologic effects. The studies have been supported by the National Institute of Mental Health and the Board of Directors' Research Fund of Hillside Hospital. Dr. Fink is Secretary of the Section of Convulsive Disorders and Brain Function of the American Psychiatric Association and President- Elect of the Nassau Neuropsychiatric Society. Hillside Hospital, an affiliate of the Federation of Jewish is a non—profit, non-sectarian hospital for psychiatric treatment, training and research. Philanthropies of New York, #### �_ »‘.>\7"» >v.— '— ~v- 16 Peace Missionary May ;’Have to Pacify “Family ' i i . ' i Mrs. Lola Stone, pretty young Long Island. housewife who’s on an interna— tional peace mission to ban nuclear tests, may have some pacifying to do when she gets home. The husband and two children of the globe-trotting proud of her campaign, but they miss her and Wish she’d 'peace missionary are hurry home to Kanes Lane, Huntington Bay. , .TA Reiecis 1 "‘We think she’s wonderful, we’re quite proud of her, but it urts some time,” her husband, Robert, said with a smile. ‘We’re counting the days.” Mrs. Stone is one of a group of five pacifists on a 4,000- Protest mile tour of European capitals ‘ By MBA ‘ They have been stalled in Helsinki for a week because of the reluctance cf the Soviet Union to grant them entry The Transit Authority today visas. brushed aside a Motorman’s “We are hoping the visas Benevolent Association protest will come through,” Mrs. Stone that it would be “dangerous” told her husband by phone for‘ motormen to leave their from Helsinki. “The most imcontrols on the EMT Myrtle, portant part of our mission Avenue line to help operate the lies ahead. We hope this is doors. just a routine delay.” “The MBA is making a DR. MAXIMILLIAN FINK The group flew from Idlemountain out of a molehill,” a wild April 14, and stopped at TA spokesman said. London, Paris, Bonn and West Theodore Loos of Jamaica, Berlin to interview national the association’s president, proleaders and “just plain people.” tested yesterday that a train’s Despite a brush-off "at 10 brakes might slip -— and the Downing St., official residence train start rolling—while the of British Brime Minister Harmotorman was out of his cab. old Macmillan, the overall re“Under our order,” the Tranaction was “favorable and opsit Authority spokesman said, timistic,” Mrs. Stone reported. “the motormen will have to l.The scheduled last lap of the leave his cab only under cerjourney was to be Russia, tain conditions . . . and those A Long Island psychiatrist where the group hoped to perconditions Only crop up once will receive the first A. E. Ben- suade Kremlin officials to in a blue moon. Even if the motorman leaves nett Neuropsychiatric Re- agree to an unconditional ban on nuclear testing as “a demhis controls, he’ll never be search Foundation Award. more than four feet from the He is Dr. Ma'ximillian Fink onstration of their sincerity.” Expenses of the trip are brake.” of 13- Bayview Ave., Great being borne by “Non Violent The TA said its order applied only to a few stations on Neck, director of experimental Action Against Nuclear Weapthe Myrtle Avenue line. At psychiatry at Hillside Hospital, ons,” the same group that sponsored the voyage of the those stations, there’s no Glen Oaks. “Golden Rule,” stopped change collector at night, so Dr. Fink ‘will receive the ketch, the conductor on the train col- award. Sunday from the Soci- by the Coast Guard off Hawaii. lects fares. The motorman will ety of Biological Psychiatry at be asked to help the conductor its annual convention in San Fishermen Angry out when a “big crowd” boards Francisco. the train. Over Empty Pond He is being honored for re“We only pick up an aver- search- into the effect of HARTFORD, Conn. (UP)— age of four persons per trip at “shock” Red-faced officials of the State all those stations put together,” “we’vetherapy. been able to discover Fish and Game Department the TA spokesman said. “We the mentally ill respond admitted somebody goofed . . almost never get a crowd how to shock therapy,” Dr. Fink when angry fishermen pomt') \ ' there." explained. “And, just as im- ed out in a department-proportant, we’ve learned why vided pamphlet that Day Pond some persons do not respond in Colchester was stocked with ”at trout and open for fishing. to such treatments.” j t'Dr.’ Fink has livedtin Long The anglers had risen before I Island since 1950, and was ap- daWn! ion:- opening day and made thetrip to the Mind, ' r 3 _ ' ‘ ' Psychiai‘risfs Will Honor L. Docfor _ _ giteconsider '11:, , Q . . ’ . U �1/15/59 Department of Egperimental Psychiatry and the of presentations a chronologic Following is list of members Experimental the of Department of the publications Psychiatry during 1958. M Publications: A. 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps cho atholo 3. eds., Grune E Stratton, (Kaﬁn, R.L. and Fink, M.) 2. Lateral 3. h. 5. 6. Gaze Nystagmus as an Index of Sedation Threshold, Clin. Neurophysiol. l9: 162-163 (Fink, M.). Effect of Diethazine on EEG and Significance h for Theory 8101. 19: of Convulsive Therapy, EEG. Clin. Neuro 207-208 (abst.) (Fink, H.5. Experimental Studies of the E1ectroshock Process, Dis. Nerv. Syst. l2: 113-118 (Fink, M. and Kahn, R.L.). Comparative Study of Chlorpromazine and Insulin Coma 18h6-1850 166: J.A.M.A. of Psychosis, Therapy (Fink, M., Shaw, R., Gross, G. and Coleman, F.C.). Eleotroencephalographic Correlates of the ElectroshockM. 227 (Abst.) (Fink, Nerv. Dis. Syst. 12: Process, EEG. and Green, 7. 8. 9. 10. l1. R.,. Language of the Dyad, Psychiatry El: 2h9-258 (Jaffe, J.). Clinical and EEG. Effects of Megimide in Patients without M. 682-685 (Green, Cerebral Disease, Neurology g: and Pink, M.) Effect of Anticholinergic Agent, Diethazine, & on EEG and Psych. ﬁg: 380-388, Behavior, A.M.A. Arch. Neurol. (Fink, M.). Experimental Studies of Convulsive and Drug Therapies on A.M.A. Arch. Theoretical Implications, Psychiatry: Neurol. & Ps ch. 80: 733-73h (Abst.) (FinE, R., Kahn, R.E. and Green, M77. Brain Damage, Mental Retardation and Childhood Schizophrenia, 12. Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat.‘12: 720-726 (Pollack, M. and Krieger, H.P.5. 13. A.M.A. Arch. of Denial in Factors Illness, Interpersonal& Ps chiat. ﬁg: 653-656 (Jaffe, J. and Neurol. SiBtEj'W.H.). �1h. B. Predictions of Outcome, in Youthful Offenders at Hi hfields, Weeks, H. Ashley, e3. U. of Michigan P ress, Ann Arbor (N. Siegel). Presentations: EEG Correlates of the Electroshock Process, at the 1. Eastern Psychiatric Research Association, February, M. N.Y. (Fink, 3. and Green, M.A.). EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). and Drug Therapies Convulsive of Studies Experimental in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal in and Attention Visual Perception ’Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, (Jaffe, Philadelphia J., and F Behavioral Physiological Score to of Relation Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication The (Kahn, R.L. and Fink, M.) 7. Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Perception Stimulation Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychological Association, April, Philadelphia (Korin, H.). �-3- 10. Socio-Psychological Aspects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) Drugs in Psychiatry, April, Montreal (Fink, M. and All. 12. 16. 17. 18. 19. Psychological Factors Affecting Individual Differences in Behavioral ResPonse to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). Effects of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of Drugs, at Section on Neurol. & Psychiat. Queens. County Medical Society, June, N.Y. (Fink, M.). Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Jaffe, J.). ' Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at IEastern Association of Electroencephalographers, December, New York (M.Green). �uuucav twain; by»: anuunsu .lmost as well as if he :ould see. Here he climbs the schdol steps with his ypewriter to attend ‘ a class. \\\\\\ &\\\\\\\\\\\\\\\\ \\\\\\\\\\\“ \\\\\\\ t J} \ MD Records Brain Waves Of Patients , A history written in brain waves is telling the story today 01' how successfully the mentally ill are responding to electro-shock and drug treatments. Dr. Max. Fink, a Great Neck psychiatrist who gave up a proﬁtable private practice to “prospect for Iacts”,»~ has developed a method of evaluating the brain waves of patients at Hillside Hospital, Glen Oaks,_ where he’s been leading an eight--man research team for four years. The brain wave "history”, recorded on graph paper and transmitted by an. electroencephalogram, enables the hospital's staff to “treat patients with more direction” Fink says. It works this way: The encephalogram picks up brain waves of a new patient and records a “base line” on the graph. As the patient is treatedand repeatedly tested the variations are recorded on the graph. Comparisions show whether a patient is . or isn’t . . . responding to a drug or shock treatment. , l f , 1 ; I 1 1 l K 1 ‘ . - - 3|! 1|: 1‘ “THE STUDY gives a new and keener sense of direction in treating the patients,” Fink said. For example: If a patient’s brain wave “history” shows that his response to is suddenly ' ' �“1191110 Jemeqm 01 31110 Buons KlaA 8 S1,, 1112833 301s Amman: amooaq 01 1113111 £11231 S1 911 -aonpu1 119011119110 9111 queued . 12 s1s1sax PWWI‘IXa 9H 'ppas 151111210st 1 ' ha] um 112112, 51901u19110 01121190 puno; aA'eq 9AA” 3511; 'BO‘BId mnsu! me 01111 111 11011 mm 1nd 219111 3111 lent 1elr SSJBABJ KHJBIOG 9113, g 3111 111911311 10 1110 [swam K1219 1; eu1uua1ap d19q 11mm (111 Fsoq am #4,!» '.1c'[ 5111110111 Emma 9111 3,5121 sanp seq wee], 91110:) unease; s‘xum ma; 1111111 19111311111 3,2111 ’Ielld sgqgepuno; [no panoddns A11u1o§ p112 ”3.190111 -‘Kq‘ s; 109(0ch 9111. was Hum ‘l‘summeu p003 KJIBA” paonp v; '-o.1d seq 21031on Jeeﬁ-e-ooo‘oow ép1s111H 112 pomém man ‘ 'sKes a: $11.11 1101129591 9111 $1110 9111 i “‘mou 919111“ pasn s1 as avg ii 13d 08 11190 AIa1'eu11x01dde”, o1 padumg ' .seq eBe1uaJJad 3111, 1911qu 3111 mm; paseapx aq 01 K11ua1o111ns pI—JJBAOOGJ smemman 110qu .10 8111p smeared 0111 10 “3,1130 13d 09 moqe” K1uo ‘1211dsoq 91.13, 12 pasn_ pue paldope sem pomaux aAem pa.11nb‘ax 011m ' KING. .‘mo ‘ ”0198 “'Janeq smamman 51311113. 'JCI sn smone 0), az1111n Apn1s emem 1112.1q PIPS RUM VICI «1-1qu 9111,, qu 01 mammal; man 11 'UOIS -SB.IBB.I 3111, 1199110 p118 An A13131d -1noa 'e 2193 52111 ‘wJo; [eu1 $1.10 511 o; xoeq ssa.1831 o1 su133q uo1z11puoo asoqm .10 ‘luauxaAmduu JO nonessao 'e uaaq $911 91311), sa;eo1pu1 uo111p1100 asoqm waned V 911'), -3AOJliﬁlt _ Kauanbaa; umoqs qde s1 3113111 mun aﬁesop 111 .10 peseaxou1 aq — ! B 33’ 000i u1ens pue’ ssans 10 p1.10m 9113, 01111 peseeﬁu uaqm 1121111 -soq b1 11:10 aAeq em ssa.1 spun 1111M -30.1d 4113; ho inmo- atn “‘1uaned XOGN e or 01 39.1391) 1101112» 9111’ 19111 ZS .r‘»_(’ ’ �February 25, 1959. Department of Experimental Paychiatry Annual Report - 1958 During 1958, the major emphasis of the staff of the Department of Experimental Paychiatry shifted from evaluation of convulsive therapy to systematic investigations of newer psychopharmacologic agents. These investigations, derived from the successful evaluations of the mode of action of convulsive therapy (l95h-l958), reserpine (1955), and chlorpromazine and insulin coma (1956-1957), are based on the neurophysiologic-adaptive hypothesis of physiodynamic therapies developed in the Department in 1957 ﬂggg. é? 197-206). the The many new compounds (J. Hillside interrelationship of the neurophysiologic effects of with the psychodynamic, perceptual, personality and sociologic aSpects of patients' behavior provide the framework for these investigations. In addition, linguistic indices developed in the Department during the past two years by Drs. Kahn and Jaffe are being studied as measures both of behavioral change and of neurophysiologic effect. During the year, the evaluation of convulsive therapies was continued effects of indoklon, an inhalant convulsant, with electroconvulsive therapy. 'This study was undertaken by two senior resident by comparing the psychiatrists, B. Alan and H. Lefkowits, and Drs. Green and Fink. While indoklon therapy was a successful treatment, technicallimitations made poor substitute for the established electrical methods. The it a study was of theoretic value in indicating that the significant element of convulsive therapy was the induction of the grand mal convulsion, with its attendant neurophysiologic effects, independent of the type of agent employed. �V , .2Investigations into the relations of sociologic factors to the selection of therapies at Hillside Hospital were extended by Drs. Kahn and Pollack. Not only were the factors of age, education, birthplace, and score on the California F Scale significantly related to the choice of therapy but these factors were also related to the results of therapy, the diagnosis and the duration of hOSpitalization. These observations were presented in the Sunday Conference of October 16, 1958. and On October 7 the study was repeated; similar studies of the population of other primarily psychotherapeutic hospitals, and the Hillside Hospital Out-Fatient Department were undertaken. To augment these studies, Dr. Nathaniel Siegel was appointed as Research Associate in Sociology, with the support of a grant from the Mental Health Board of Nassau County. In an extension of the communication studies, both the syntactic content analysis and dyadic diversification measures of formal aSpects of speech were applied to an evaluation of the changes in language patterns following the acute administration of various new psychotropic compounds. These measures demonstrated and the neurophysiologic The consistent changes both with the induced behavioral effects of the drugs. acute drug interviews were but one asPect of the continuing evaluation of the biochemistry of convulsive therapy. Previous studies had indicated that repeated induced convulsions resulted in an increased level of central nervous system acetylcholine activity. €g¥:;;;;:;;;;:§ of various anticholinergic stages of convulsive therapy we compounds By the acute administration to patients at various elucidated the synaptic chemical events which are the basis of the convulsive therapy process. �-3In addition, Mr. Karp and Drs. Kahn and Pbllack continued their perceptual studies in patients receiving psychodynamic therapies. The interrelation of psychotherapy with physiodynamic therapy was studied by Drs. Esecover, Jaffe and Kahn; and in the and H. Lefkowits began an latter part of the year, Drs. A. Kaplan investigation into the interpersonal factors in therapists, as well as patients, leading to the referral for physiodynannc therapies. During the year, Dr. H. Korin resigned, and was replaced by Mr. Eric Karp. TWO new staff appointments include Dr. Nathaniel Siegel, Assistant Professor of Sociology at Columbia University, as Research Associate in Sociology; and Dr. Donald Klein, research candidate at the New York Psychoanalytic scientist at Institute, as Creedmoor Institute Research Associate in Psychiatry. Support for this extensive program was provided by the Board of Directors, and continuing grants of the Foundations' Fund for Research in Psychiatry and the National Institute of Mental Health. At year end, this program received considerable Support from the Psychopharmacology Service Center of the National Institute of Mental Health, which augmented extensive commitment by a grant of $268,000. These its already further sums were increased during the year by support from the Mental Health Board of Nassau County which provided funds Smith, Kline & for sociologic studies; and from Bristol, Geigy, French, and wyeth Laboratories ~ who aided the drug evaluation program by grants as well as extensive supplies of the agents During the year, fourteen reports of the work of staff to be studied. members appeared; and twenty reports were presented to major professional societies. �-hIn addition to national societies, work of the Department was presented at the Conference on Psychodynamic, Psychoanalytic and Sociologic Aspects of Neuroleptic Drugs in Montreal, and the International Congress of Neuropsychopharmcology in Rome. Staff first members were awarded two prizes. Dr. M. Fink received the annual A.E. Bennett Peychiatric Essearch Award of the Society of Biologic Psychiatry for his report on the effects of anticholinergic agents on EEG and behavior. Dr. J. Jaffe received the Gralnick Foundation annual award for his report on the application of analysis of changes in fonnal aSpects of Speech in psychotherapy. �-5The staff of the Department of Experimental Psychiatry included, at year end: MEX Fink, M.D. Direeees Joseph Jeffe, M.D. Research Associate (Peychiatry) Donald F. Klein, Research Associate (Peychiatry) MQD. Robert L. Kahn, Fh.D. Max Pollack, Pth. Research Associate (Experimental Psychology) Research Associate (Experimental Paychology) Nathaniel Siegel, Ph.D. Research Associate (Sociology) Eric Karp, B.A. Research Assistant (Experimental Peychology) Martin A. Green, M.D. Associate in Research Abraham A. Kaplan, M.D. Associate in Research (Paychiatry) Barre Alan, M.D. Fellow (1957-58) Henry Lefkewits, M.D. Fellow (1958-59) The (Neurophysiology) technical staff included Mrs. Janet Bowie, Jean Kolodny, Mbsquera and Blanche Hannah Zaitz. addendum: In February Dr. George Krauthamer, Ph.D. was appointed as Research Assistant (Experimental Psychology). electroencephalography. He is a trainee in �nan-{u £55, 1959. lupurtuoat at ngcriunutal rayshxttvr ‘lunaal Icpcrt ~ 1955 ﬁtting 1953, it: 3.3.9 atyhnstg I! it. i‘l!‘ at tho ﬁapartunat it xxptriuaninl firth$¢%ry Ihlf‘ll tron utilisatog at convulsivt thurupr to tru‘unsttc tavnu‘acatinua a: utuar paynhnpitamnnoiauin attain. tunic tsvultxgntaill. inrtth Iron in. littl8if§1 evaluaiiOII or ﬁt. and: of 30‘s.: it nonralltvv thirty: (19$h~1956). IlllrpllO (1958). in: ohlcrv prunastnn uni 13.31%: can. (1!5‘~1!S?). are biaad on th. ultrtplftiﬂltilinlltpit?! lyptihovti at piyctudynugac shoIUplon ilviaupul in it. ﬁdpnriutnt in 1’37 (3. lilgggdﬁ aggg.‘gi 191~!06). {it zutirrtxitiluuhiv a: it. noarophyltqlocso uttccts at st; unnr'nou taupe-nan with ﬁt. ysywhodraunic. pavuuyttnl. parlouulttr can 100301.110 Itpoc£a a: paﬁtunts’ ﬁchavtor pruvt‘o it. tranauurk (or that. tatto$1gtttona. In I‘¢1$&Qn. linguistic indict: Ctvtltptd In it. burnrtanat during tho y‘at iii 3“?! h: ﬁra. its: an: anxta £33 icing aﬁnlacd a: ltnntrns butt-o: snttvaornl gluugc and a: unuroatylaslal11_c££¢st§ Birlll ‘ 30:», ‘hn nviltnssal ¢r cunvllutv. ihariaaao It! «outlnnwd hr aiuparins tic ntIUuic a! xndokxou, ll intalint Giuvnlnult. wait cioctitcinv‘lctvu ‘hirlpr. this Itu¢r'uua Iatcrﬁnhtu i7 is. nonior routdnnt purittotrtgtc, I. 51:. an: £33 I. 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Ira. tarp. it. saw tint: appalltntata tlilﬁdﬂ Dr. lithnnatl $13.1, ttoisttnt frotoccor c: sacialtur l‘ Guarani. Unawaraity, at Itnnutah ltuuctntc in IOISOIII13 Ind Br. Basalt Izctn, rootarct auiuuttit n! erauilsor Inniiﬁutc and canlslato at $8: low lurk rqrcho:xllyﬁie Inltttlto. at am! and“. a puma-y. �4,. mt t m ﬂu an I! autism: fmﬂ‘mv 3mm, all“ m tu- .1, nu main m 9min“ is Inn-“ah vacuum m "an": at a m mm at m tu- mm mu. an» m. an 9mm unit“ «a» tun m Myth-awn.” 8min «mm. mm of a. bum tutu“. .2 mm m1», nut W «mm “68mm. its alum M om“ annual-nit 37 MM! in” m a» grant a: m mm m; m wnwmummm mama-Inn‘smu um mm: M. in mama Isms»; M 3m tram, «m. mu, na- Mat. ml in“ 3.5mm”. -m a. nu walnut. "an: by an” a an u «may. mm» at the am“ a In this“. tho may my", tum mu 0! a. an! a «at: and mun mama; m» mm: an yum-mm to “an ”wanna mun». 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M, ‘O ”#3; mm 0m. 30‘. . 3",; 3"“; AW 3.; It!!! ”all, I’D; lint: Luthuui‘s, lpﬂ. ltﬂiﬁrti Aasuoiuﬁn (firthtttry) Iliilfﬂh Atlliilii_ (lupotinuuttl rtvuhaztux) Intonrnh snln¢tutn (invtrilnttll P-vthnlacy) inaalvuh Asaaitnﬁc (80:103.:71 Icaiirdh Aaltcﬁaut .(lagnrlnnntul rurnlnlocy) £::o¢tnto in nasatvcl (lvuruphyntilugy) guspntsia in Ittoarol (rsywhaatry) villuu (19£?~$ﬁ) Ibllov (1955-59) ‘15:: Juan Janet tuulllod urn. tastu1¢i1 loioinr, Inuit. It. luntni aboqutti an: lxanaht 3a1$n. �1/15/59 Department of Experimental Psychiatrz list and the of presentations a chronologic Following is of Experimental members of the Department of the publications Psychiatry during 1958. A.“ Publications: 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps cho atholo 3. e38., Urune E Stratton, (Kaﬁn, R.L. and Pink, M.) of Sedation Threshold, 2. Lateral Gaze Nystagmus as an Index162-163 (Fink, M.). EEG. Clin. Neurophysiol. lg: EEG and Significance for Theory on of Diethazine 3. Effect of Convulsive Therapy, EEG. Clin. Neurophzsiol. l9: 207‘208 (abate) (Fink, Process, his. h. Experimental Studies of the Electroshock M. and Kahn, R.L.). 113-118 (Fink, Nerv. l2: Coma and Insulin of Chlorpromazine 5. Comparative Study 18h6-1850 166: J.A.M.A. of Psychosis, Therapy G. and Coleman, F.C.). Shaw, Gross, M., R., (Fink, 6. Electroencephalographic Correlates of the ElectroshockM. S Nerv. Dis. st. $2: 227 (Abst.) (Fink, Process, o o stt. and Green, H.$. 7. 8. 9. 10. (Jaffe, J.). Pszchiatrz 3;: Effects of Megimide in Patients without M. Language of the Dyed, Clinical and EEG. 2h9-258 Cerebral Disease, Neurologz Q: 682-685 (Green, and Fink, M.) EEG and on Diethazine, Agent, of Anticholinergic Effect & Pszch. ﬁg: 380-388, Arch. Neurol. L.M.A. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental Arch. A.M.A. Theoretical Implications, Psychiatry: Neurol. & Ps ch. 80: 733-73h (Abst.) (FInE, 3.. Kahn, F.I. and Green, M77. ll. Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Pszchiat. 115: h22-h28 (Pollack, M.). 12. Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat..12: 720-726 (Pollack, M. and Krieger, H.P.5. 13. Arch. A.M.A. of Denial in Factors Illness, Interpersonal& Ps chiat. ﬁg; 653-656 (Jaffe, . and Neurol. Slate, W.H.$. �1’40 B. Predictions of Outcome, in Youthful Offenders at Hi hfields, Weeks, H. Ashley, e3. U. of Michigan P ress, Ann Arbor (N. Siegel . Presentations: 1. EEG Correlates of the Electroshock Process, at the Eastern Psychiatric Research Association, February, N.Y. (Fink, M. and Green, M.A.). 2. EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). 3. and Drug Therapies Convulsive of Studies Experimental in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal and in Attention Visual Perception Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, Philadelphia (Jaffe, J., Relation of F Score to Behavioral and Physiological Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication 6. The (Kahn, R.L. and Fink, M.) 7. Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and Stimulation Perception of Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychological Association, April, Philadelphia (Korin, H.). �-3- 10; Socio-Psychological Aspects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic ASpects of the Neuroleptic (tranquilizing) M. Montreal (Fink, Drugs in Psychiatry, April, and 11. 12. 13. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Reaponse to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on Diethazine, of Agent, Anticholinergic Effects and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & Neurol. on Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). on Post Convulsive Effect of Anticholinergic Compounds EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �law HILLSIDE HOSPITAL Glen Oaks, New York March 16, 1959 MEMO TO RESEARCH FROM: RE: ' COWITI'EE JOSEPH S.A. MILLER, M.D., MEDICAL DIRECTOR ATTACHED RESEARCH REPORT I herewith enclosing copy of Dr. sending it a few days in advance of the meeting, familiarize yourself with some of the main facts position to discuss this when it is presented at meeting on March 25th. am Fink's report, so that you might and be in a better the forthcoming �FebmaIy 25, 19590 Department of Experimental Peychiatry Annual Report - 1958 During 1958, the major emphasis of the staff of the Department of Experimental Paychiatry shifted from evaluation of convulsive therapy to systematic investigations of newer psychopharmacologic agents. These investigations, derived from the successful evaluations of the mode of action of convulsive therapy (l9Sh-l958), reserpine (1955), and chlorpromazine and insulin coma (1956-1957), are based on the neurophysiologic-adaptive hypothesis of physiodynamic therapies developed in the Department in 1957 Eggg. the ﬁg 197-206). The many new compounds (J. Hillside interrelationship of the neurophysiologic effects of with the psychodynamic, perceptual, personality and sociologic aspects of patients' behavior provide the framework for these investigations. In addition, linguistic indices developed in the Department during the past two years by Drs. Kahn and Jaffe are being studied as measures both of behavioral change and of neurophysiologic effect. During the year, the evaluation of convulsive therapies was continued by comparing the effects of indoklon, an inhalant convulsant, with electro- convulsive therapy. This study was undertaken by two senior resident psychiatrists, B. Alan and H. Lefkowits, and Dre. Green and Fink. 'While indoklon therapy was a successful treatment, technicallimitations made it a poor substitute for the established electrical methods. The study was of theoretic value in indicating that the significant element of convulsive therapy was the induction of the grand mal convulsion, with its attendant neurophysiologic effects, independent of the type of agent employed. �.2the to factors of the sociologic relations into Investigations Kahn and Drs. extended by were Hillside Hospital of at selection therapies Pollack. Not only were the factors of age, education, birthplace, and score on the California F Scale significantly related to the choice of therapy but and the of diagnosis the to results therapy, related also these factors were the duration of heapitalization. These observations were presented in the Sunday Conference of October 16, 1958. and On October 7 the study was repeated; similar studies of the population of other primarily psychotherapeutic undertaken. were Out-Patient Department and HOSpital Hillside the hoSpitals, To augment these studies, Dr. Nathaniel Siegel was appointed as Research Associate in Sociology, with the support of a grant from the mental Health Board of Nassau County. In an extension of the communication studies, both the syntactic content analysis and dyadic diversification measures of formal aspects of epeech were applied to an evaluation of the changes in language patterns following the acute administration of various new psychotropic compounds. These measures demonstrated consistent changes both with the induced behavioral and the neurophysiologic The effects of the drugs. acute drug interviews were but one aspect of the continuing evaluation of the biochemistry of convulsive therapy. Previous studies had indicated that repeated induced convulsions resulted in an increased level of central nervous system acetylcholine activity. By the acute administration of various tertiary-amine anticholinergic compounds to patients at various stages of convulsive therapy we elucidated the synaptic chemical events which are the basis of the convulsive therapy process. �-3In addition, Mr. Karp and Drs. Kahn and Pbllack continued their perceptual studies in patients receiving psychodynamic therapies. inter- The relation of psychotherapy with physiodynamic therapy was studied by Drs. Esecover, Jaffe and Kahn; and in the latter part of the year, Drs. A. Kaplan and H. Lefkowits began an investigation into the interpersonal factors in therapists, as well as patients, leading to the referral for physicdynamic therapies. During the year, Dr. H. Korin resigned, and was replaced by Mr. Eric Karp. TWO new staff appointments include Dr. Nathaniel Siegel, Assistant Professor of Sociology at Columbia University, as Research Associate in Sociology; and Dr. Donald Klein, research candidate at the New York Psychoanalytic scientist at Institute, as Creedmoor Institute Research Associate in Psychiatry. Support for this extensive program was provided by the Board of Directors, and continuing grants of the Foundations' Fund for Research in Psychiatry and the National Institute of Mental Health. At year end, this program received considerable support from the Psychopharmacclogy Service Center of the National Institute of Mental Health, which augmented extensive commitment by a grant of $268,000. These its already further sums were increased during the year by support from the Mental Health Board of Nassau County which provided funds Smith, Kline & for sociologic studies; French, and wyeth Laboratories - who and from Bristol, Geigy, aided the drug evaluation program by grants as well as extensive supplies of the agents During the year, fourteen reports of the work of staff to be studied. members appeared; and twenty reports were presented to major professional societies. �.1... In addition to national societies, work of the Department was presented at the Conference on Psychodynamic, Psychoanalytic and Sociologic Aspects of Neuroleptic Drugs in Montreal, and the International Congress of Neuropsyohophamacology in Rome. Staff first members were awarded two prizes. Dr. M. Fink received the annual A.E. Bennett Paychiatzic Research Award of the Society of Biologic Psychiatry for his report on the effects of anticholinergic agents on Em and behavior. Dr. J. Jaffe received the Gralnick Foundation annual award for his report on the application of analysis of changes in formal aspects of Speech in psychotherapy. �-5The staff of the Department of Experimental Psychiatry included, year end: Max Fink, M.D. M Joseph Jaffe, MlD. Research Associate (Peychiatry) Donald F. Klein, Research Associate (Psychiatry) MgD. Robert L. Kahn, Ph.D. Research Associate (Experimental Peychology) Pollack, Ph.D. Research Associate (Experimental Psychology) Max Nathaniel Siegel, Ph.D. Research Associate (Sociology) Eric Karp, B.A. Research Assistant (Experimental Psychology) Martin A. Green, M.D. Associate in Research Abraham.A. Kaplan, M.D. Associate in Research (Paychiatry) Barre Alan, M.D. Fellow (1957-58) Henry Lefkowits, M.D. Fellow (1958-59) The (Neurophysiology) technical staff included Mrs. Janet Bowie, Jean Kolodny, Mosquera and Blanche Addendum: Hannah Zaitz. In February Dr. George Krauthamer, Ph.D. was appointed as Research Assistant (Experimental Psychology). electroencephalography. at He is a trainee in �1/15/59 Department of Experimental Psychiatry and the of presentations a chronologic list Following is of members Experimental the of Department of the publications Psychiatry during 1958. Publications: A. 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps chopatholo 3. eds., Grune & Stratton, (Kahn, R.L. and Fink, M.) 2. Lateral 3. h. 5. 6. Gaze Nystagmus as an Index of Sedation Threshold, Clin. Neurophysiol. 19: 162-163 (Fink, M.). EEG and Significance for Theory on of Diethazine Effect of Convulsive Therapy, EEG. Clin. Neurophysiol. 19: EEG. Experimental Studies of the Electroshock Process, Dis. M. and Kahn, R.L.). 113-118 (Fink, Nerv. Syst. 12: Coma and Insulin of Chlorpromazine Study Comparative Therapy of Psychosis, J.A.M.A. 166: 18h6-1850 G. and Coleman, F.C.). Shaw, Gross, R., (Fink, M., Electroencephalographic Correlates of the ElectroshockM. Process, Dis. Nerv. Syst. 12: 227 (Abst.) (Fink, and GreenTWMTfT—___-—*— (Jaffe, J.). 7. Language of the Dyad, Psychiatry 31: 2h9-258 8. without Patients in of Megimide Effects Clinical M. 682-685 (Green, Q: Cerebral Disease, Neurology and EEG. and Fink, M.) 9. 10. on EEG and Effect of Anticholinergic Agent, Diethazine, & Psych. g9: 380-388, Neurol. A.M.A. Arch. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental A.M.A. Arch. Theoretical Implications, Psychiatry: Kahn, M., & (FinE, 80: 733-73h (Abst.) Neurol. Psych. R.E. and Green, M77. 11. Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Psychiat. 115: h22-h28 (Pollack, M.). 12. Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat. 12: 720-726 (Pollack, M. and Krieger, H.P.5. 13. A.M.A. Arch. of Denial in Factors Illness, Interpersonal& and 653-656 J. Ps (Jaffe, ﬁg: Neurol. chiat. Slote, W.H.§. �1h. B. Predictions of Outcome, in Youthful Offenders at H. Ashley, ed. 5. of Highfields, Weeks, Michigan Press, Ann Arbor (N. Siegel). Presentations: the EEG at Electroshock of the Process, Correlates l. Eastern Psychiatric Research Association, February, M. N.Y. (Fink, and Green, M.A.). EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). Experimental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Visual Perception and Attention in Normal and Abnormal Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Communication Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, (Jaffe, Philadelphia J., Relation of F Score to Behavioral and Physiological Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Fink, M.) Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Stimulation Perception Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychol~ ogical Association, April, Philadelphia (Korin, H.). The �-3- 10. Socio-Psychological Aspects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) M. Montreal (Fink, Drugs in Psychiatry, April, _ and 11. 12. 13. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on of Agent, Diethazine, Effects Anticholinergic and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & Neurol. on Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). on Post Convulsive Effect of Anticholinergic Compounds EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �1/15/59 Department of Experimental Psychiatry and the of presentations Following is a chronologic list of Experimental the members Department of the of publications Psychiatry during 1958. A. Publications: in Therapy, Electroshock During Language Changes in 1. and Zubin, P. Hoch, Communication, of cho Ps atholo 3. eds., Grune & Stratton, (Kaﬁn, R.L. and Fink, M.) of Sedation Threshold, 2. Lateral Gaze Nystagmus as an Index162-163 (Fink, M.). EEG. Clin. Neurophysiol. 19: EEG and Significance for Theory on of Diethazine 3. Effect of Convulsive Therapy, EEG. Clin. Neurophysiol. 19: h. 5. 6. 7. 8. 9. 10. 11. 12. 13. Process, Dis. Experimental Studies of the Electroshock M. and Kahn, R.L.). 113-118 (Fink, Nerv. Syst. 12: Coma and Insulin Comparative Study of Chlorpromazine 18h6-1850 166: J.A.M.A. of Psychosis, Therapy and G. Coleman, F.C.). Shaw, Gross, R., (Fink, M., Electroencephalographic Correlates of the ElectroshockM. 227 (Fink, (Abst.) Nerv. Dis. Syst. 12: Process, and Green, M.,. 2h9~258 21: (Jaffe, J.). the Dyad, Psychiatry Language of without in Patients of EEG. Megimide and Effects Clinical M. 682-685 (Green, Cerebral Disease, Neurology g: and Fink, M.) EEG and on Diethazine, Agent, Effect of Anticholinergic & Psych. ﬁg: 380-388, Neurol. Arch. A.M.A. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental Arch. A.M.A. Implications, Theoretical Psychiatry: (FEEET'MTT’Kahn, 733—73h & 80: (Abst.) Ps ch. Neurol. ﬁ.f. and Green, M77. Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Psychiat. 115: h22—h28 (Pollack, M.). W..— Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat..12: 720-726 ,fPollack, M. and Krieger, H.P.5. Arch. A.M.A. of Denial in Illness, Interpersonal& Factors Ps chiat. ﬁg: 653-656 (Jaffe, J. and Neurol. Slote, W.H.$. �1h. B. Predictions of Outcome, in Youthful Offenders at Hi hfields, Weeks, H. Ashley, ed. U. of Michigan Press, Ann Arbor (N. Siegel). Presentations: EEG Correlates of the Electroshock Process, at the 1. Eastern Psychiatric Research Association, February, M. N.Y. (Fink, and Green, M.A.). EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). and Drug Therapies of Convulsive Studies Experimental in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal and in Attention Visual Perception Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, (Jaffe, Philadelphia J., Relation of F Score to Behavioral and Physiological Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication The (Kahn, R.L. and Fink, M.) Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Stimulation Perception Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychological Association, April, Philadelphia (Korin, H.). �-3Socio—Psychological ASpects of Diagnosis and Treatment: 10. Drug Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic ASpects of the Neuroleptic (tranquilizing) M. Montreal (Fink, Drugs in Psychiatry, April, ‘ and 11. 12. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Reaponse to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on of Agent, Diethazine, Effects Anticholinergic and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & Neurol. on Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Relationship between Seizure Threshold and Duration of Seizures to ERG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �1/15/59 Department of Experimental Psychiatry and the of presentations Following is a chronologic list of EXperimental members the of Department of the publications Psychiatry during 1958. Publications: A. 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps cho atholo M.) and E R.L. (Kahn, Fink, Grune Stratton, J. eds., 2. Gaze Nystagmus as an Index of Sedation Threshold, 3. h. 5. 6. 7. 8. 9. 10. 11. 12. 13. Lateral M.). 162-163 (Fink, Clin. Neurophysiol. 19: EEG Theory for and on Significance of Diethazine Effect of Convulsive Therapy, EEG. Clin. Neurophysiol. lg: EEG. Process, Dis. Experimental Studies of the Electroshock Nerv. Syst. 12: 113-118 (Fink, M. and Kahn, R.L.). Coma and Insulin of Chlorpromazine Comparative Study 18b6-1850 166: J.A.M.A. of Psychosis, Therapy and G. Coleman, F.C.). Shaw, R., Gross, (Fink, M., Electroencephalographic Correlates of the ElectroshockM. 227 (Fink, (Abst.) Nerv. Dis. Syst. 12: Process, and Green, ﬁ.$. 2h9-258 (Jaffe, J.). the of g1: Dyed, Psychiatry Language without in Patients EEG. Megimide of and Effects Clinical M. 682~685 (Green, Cerebral Disease, Neurology g: and Fink, M.) EEG and on Diethazine, Effect of Anticholinergic Agent, & 380-388, Q9: Neurol. Arch. A.M.A. Psych. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental Arch. A.M.A. Implications, Theoretical Psychiatry: Kahn, (Fink, & ﬁ., 80: 733-73h (Abst.) Ps ch. Neurol. R.I. and Green, M77. Childhood and Schizophrenia, Mental Retardation Damage, Brain Am. J. Psychiat. 115: h22-h28 (Pollack, M.). Oculomotor and Postural Patterns in Schizophrenic Children, & Ps chiat._12: 720-726 Neurol. Arch. A.M.A. (Pollack, M. and Krieger, H.P.5. Arch. A.M.A. of Denial in Illness, Factors Interpersonal& and 653-656 J. Ps (Jaffe, chiat. g9: Neurol. Slote, W.H.$. �1h. B. at Predictions of Outcome, in Youthful Offenders U. H. of Ashley, ed. Weeks, Highfields, ichigan Press, Ann Arbor (N. Siegel). Presentations: the at EEG Electroshock of Process, the Correlates 1. Eastern Psychiatric Research Association, February, M. N.Y. 2. (Fink, and Green, M.A.). EEG Changes in Significance of Individual Variability During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). and Drug Therapies Convulsive of Studies Experimental in Psychiatry: TheoreticalNewImplications, at York Society of Neurological Society and Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal and in Attention Visual Perception Children, at American OrthOpsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, Philadelphia (Jaffe, J., and F Behavioral Physiological to Score of Relation Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication The (Kahn, R.L. and Fink, M.) 7. with Space Occupying Intellectual Deficits in Patients Eastern Psychological Lesions of the Cerebrum, at Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Stimulation Perception Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychol— ogical Association, April, Philadelphia (Korin, H.). �-3- 10. Socio-Psychological ASpects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) Drugs in Psychiatry, April, Montreal (Fink, M. _ and 11. 12. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on of Agent, Diethazine, Effects Anticholinergic and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & on Neural. Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, MI). 20. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �\\.\" ‘\ Soptubor 1, 1959 rm m2 mm H.927 Dumb-at of mparimntal Psychiatry HWPM WEE Glen H. L. m, 1. thmm 3. 3mm 8mm, h. Publications, 1951: - 1959 5. Presentations, 1951; 6. Smnmry #1, September 1. - 1959 1951:: - 7. Sunny #2, Mary 1. 8. Smmry #3, April 1, 1957 2. #1:, February 1, 1959 Five Years, 199; - - Sophombor 1956 ~ January 1, 1956 Am; 1, - February March Asaoomboa EEG 1957 1, 1958 Ha: (kparmanul 1, 1959 1959 Principal Investigator Research Associates I. I.) Psychology) (Neurophysiology) Technician Secretuy m,n.n. Robert L. Kahn.Ph.Do Hymn Karin, £11.13. Eda M,M¢A. Martin A. momma. mummﬁub. 19%4953 1958 ’ 1956 .1951; 1959 ‘- 1957 1956 Joseph Jaffe,M.D. Donald F. K1o1n,24..n. 1959 Nathaniel 319301,Ph.D. 1958 «- Georgo Hanna Mosquera Janet Baltic Associates, supported throng: other grants: Research Associate Mouth Associate amorob Associate Research Associate (kperimntal Paydnol.) ( Psychiatry) (Psychiatry) (Sociolm) Max Pollackﬁhon. . «- - �he mm: Amwhmr reporwd here would nab have has: possible without the interact and support of the Ecuador of Hillside 808mm, Dr. 18ml Sinus, ﬂu Hard of Directors and the Hr. Maurice when faith sustain“! an. pmm aux-mg its only uwnmau. W, mutter, Wemﬂsoindcbtodtothexmmnnandmm Ina-k, the Pomdntiona' Fund for Board of Nassau County and the um and Rosearoh I Waumdﬂu in Psychiatry, the 1mm Health mm sum. My Wane-la, tonamg pharmoouticll and Ranch Laboratories, Wyeth Laboratories, Bristol Laboratories, thou support in amt-fully achnﬂadgod. �3m. m Dam“ me labor-mm- of on of Exparimntsl Psychiatry oatsblishad so musics Homul in Smtmber, 1951:. During this fivc your period mumpbyuoloéio, psychologc (personality and pamptm), linguistic, and sociolcgio upsets of 'soutic" psychiatric have been tho pmipu [£001. mums 1. WC The Thong: =, visit or the convulsive mnpy process as the induction of a nonnspeciftc state of altered brain function, similar to omnioosrsbnl trams was supportcd and upliﬂed (10, 11. 21). Within this altered osrobn}. milieu, subjects were seen to respond in variom ways (26) , ”lino: m9}: post "successful" no explicit verbal dsnial (7. 31). This lotto)? adsptation was most prominent in chamooerclogioﬂly disposed indvidmls (36). J? in altshﬂon bran function was pro-requisite to boluvionl orange Grand m1 scams were column]. to this 26). 11, 8, (7* The alterations but (26) induction was (34:2). not electrical pm: in mmfunction were measured in various ways including doom(6.n,12,2h,39), language patterns (h.7.3h.31.h3; Mb). pen-mm mu (2,16,17,37,h63 magma) and tests of real]. (8). 1n Wham "v I". 316mb numbers tho appsndix. on to publications or pneumatic” (B- ) listed in �variety of beluvieml changes lure eeen during convulsive therapy (26; 8-17). Such patterns were viewed as edepteticne to altered brain A Motion, and were believed dependant upon chencterologic end environ- mental tactore (7, 25, 26, 36, ho). Clinical retina: of improvement cbeemr or the behavioral change. in the subject (26). Adaptations chmcterieed by denied www.mm 1n behavim' (13.17) and in language (7. WM— Such adaptations! were related to habitual node. were new as value Judgments by the W or conduct (character, The ML (inability per-MW) BMW (36; 3-11, 32). of the altered behavioral nodes wee noted ee dependant upon the degree and duration of mm alterec breln function. the expectatlone, an! the type and degree of family and medical support. Different behavioral patterns were beet supported by WIt m eke typee or psychothonpy (19).. that the ’nemphwelolcglcel beele of lie in on duration in central emptic suggeeted M? commune therepy any cholinerglc - cannot-31c relationship, with a predominant to incremd cholinergic activity as the operationally significant wt :3th. illumination: were based on the nutimdllp of man voltage EEG Olav wave activity to behavioral change (6, 11, 26) and the blocking at Such poet-mun ; electmgrephic and behavioral changee by central entichonnergic agents (21; 3h: 35; bl. 1&2) and by centre]. unpethwmtic agents (ha). ”664%? ;;;m u— 00'“ ? 4, @3. M‘,£~§. W m 4/: “3/93,”?1 will, ’?.L<»Jv%ué~éiy.i �-3.‘ Become of linguistic behavior in structured (7, 31) and unstructured (1h, 29 ; 13-21.) creaeed denial, interviews shoved characteristic alterations towards in- minutiae, displacement, stereotypy and repetitivemes, related to the degree of altered brain function (8.214). These changes were blocked or reversed by enticholinsrgic mlucinogm (21. ha) . Various perceptual tasks provided indices of behavioral, change and were related to the degree of altered brain function. These included the perception of cinulteneoue tactile figures (37; 3-16), color tigorcs (1:1). and stimli (17), embedded (Gottschsbdt) techistoaoopioelly exposed words (37) and embedded upsets or age, years of education, nativity and degree of stereotypy and conventionslity (measured by Column F Scale) were related to selection of therapy, duration or hospitalisation, e diegmeie and treetsent response in hospitalised patients (15, 36,. to, 1:5). Sooiopsyohologic 2. Nsmmmlogio—Adspuve mom-1e of Sonauc' Theron. Based on these studies, a hypothesis of the node of action of other psydxistx'ic therapies such as insulin coho, leucotoav and psychotropic drugs, was expressed (10, 33, 38). This View holds that the efficacy of these therapies depends upon the indiction of states of altered brain The become which prominent. in adoptive varying mttems my much, adaptive pettem is releted to the type, degree end duration of altered brain function, the personality of the subject, and tolersnoes end expectaﬂons of the environmnt. Elicitation of this Wthesis as applied to drug therapies is our in progmss, supported by uspm greats 111.2092 and 111-2715. ' ' �3. Eula Gena Thong. in iniﬂal case yettem e'mdy showed the significance both or denial and peraieten’e in insulin coma altered brain function for the behavioral change (3)} thenpy In an insulin chlorpruesim control stuck, no differences in hospital. immanent ratings were observed in the eve treatmnt gronpl (27). Chlorpruuine was eater, easier to administer, pernitted continued coma «- administration and allowed for greater degrees or concurrent relatimehip therapy then insulin insulin In. eon-a. These observations cm by psychotropic drugs led to a mlaoenent d in thin institution. Phameabherapz. in evelmting various peyohophamoeutieele is derived from then methane and linguistic analyses of intmenone of effects acute azhinietretien and chronic clinical emu-tration of variom nu compound: are in progress. EEG patterns, along such The ongoing program Mamie continue as eynehmiaatien-deeynahroniuﬂun and tmqnency units are being related to behavioral (21, 3h, The neuromyeiologic 141, 1:2) and linguistic changes (21, 1:3). basis of experimentally induced hallucinogenic etetee have also been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (ha). Initial work on this hypotheail (21. ha) in now being �WERE 195, 'mmWnumucm-mmw Mann WIWQWMWW. mwnmmmmmmmum mmuaummmmamrm; Mahatma! W mmummmmmmmm,m W, wmmmuarmmmm. mama“: “Wt. Mad. W3; and Mummmuwmeuvﬂ. awning” mmmuammwmwmmmmu WMoututmdm. �“Wm mmuwdmdmw. ammawmm mmnmummummmmmw wmmbﬂtwmm.ndatm,$m mmmummmm mmummumamm mwam-uwummmrw,ummm m.m,mmmmwmammsm WQMWQIWWWMSwtu-umw wwmmwammpammmmvs? “1959; nmumwwmmummm ammwmmmm,mmawmm ”www.mwmnuumm Wumnmwm.mmmuw mammwmaasgmmm nmnm,mmmtnmmmnm mamamwmtmmmmwmu:m -muramn.t.mnummungnrmmmww vmwmmmmmmma am QWWM.WWMW”M¢:M,10§ wmumu. mammmuamsmaumu Wuwmumdthynm. WWWuﬁMWq anti-Hum mmmmuumxmnmnmmmumm �Wﬁmmum, unlimpmmting Watfmofiu tho It»?! also participated in tho Intomtiml New W. Allied sum held in Mansion in m mm. and on cm: in out: during the your mama tin £111:an or George Knuth-gr,- am. :and Dmld P. mm, 11.1). "as to the Bowman Dr. mutt L. m. “hr the ﬂares-Mao, htttommammumd'ma‘ mmucnof WW, waist of Dr. Hospital. mum POM, 11me Jam MW wanna. manning ammuummummpmh «ma tho patina: of Faculty Huber and Wu Director of the White Hanson at mums. mun mm conﬁrming mmttorthommm obhinndfmamﬁoudot of mm Hum: of Dix-om, mm m the mm ham). mum at prom the mud sum mus mu: serum, and mu supper: from the Health Board of 13mm county. �Why Wm M aunt-m « .. 199 In I‘m. 11.». Ian-u 1. Dan. 11.8. mran-u. 3.3. L. in: am m. M. I. m1, W(up.W. I'd. M. m m. m 15.3. 3.9. mum”. unh- Mn. A. 3.». um. mun-emu, Maul am m (Wily) mu m (ham m) m m Mb (Win W) m m (mm) m um um (W) Wh‘ 'W) (W m Ann-cw. W ma:unm(W) Must. a um :- mm (mm) m(m~ml an. ' * ' (may) M M. m mm Jun mum �Hillside Hospital Department of Experimental Psychiatry Following is a chronologic list of the presentations and publications of the members of the Department of Emperimental Psychiatry during 1959. A. Publications: 1. Effect of an Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Biological & Grune N. Y. pp. 18h-19h ed. Masserman, chiat P, Stratton, J., , (Fink; Egg. 2. Alteration of Brain Fpnction in Therapy. Psychopharmacology Frontiers, 6d. Kline, No, Little, Brown & COO, Boston, pp. 3 Fink, Mo .3. Significance of EEG Pattern Changes in Psychopharmacology. g(Fink, ) M. ). 2 : 398 (abst. Neurophysiol._ EEG Clin. h. Effect of Electroconvulsive Therapy on Intractabie Pain. A.M.A. Arch. Neurol. and Ps chiat. ﬁl: 37-b2 (weinstein, E. A., Kahn, R. L., and Eargman, P.5. 5. Electroencephalographic and Behavioral Effects of Tofranil. Psych. Assoc. J. g; 1665-1718 (Fink, M.). 6. Canad. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy, J. N.M. D. 128: 2h3-2h8 (Fink, M., Kahn, R. L., and Pollack, M.). 7. Effects of Diffuse Altered Brain Function on Perception, Phat Int. Con . Ps chol., Publ. North-Holland, Amsterdam, pp. 23 8- 239 (Fink, M., Kahn, R. L., and Korin, H. ). 8. Complex Visual Perception in Patients with Brain Tumor. Proc. XV Int. Con . Ps chol., Pub1.North-Holland, Amsterdam, pp. 2 33-237 (gander, M. B., Battersby, w. 3., and Pollack, M. ). 1/5/60 �9. Therapy of Schizophrenia: Role of Alteration of Brain Function on h92Behavior, Con ess Re orts II Int. Con . Ps chiat II: h93 (Abst. nk, M., Kahn, R. L., and Karin, H.5. 10. EEG of Seizures of and Duration to Degree Threshold Relationship of Delta Activity Induced During Electroshock, EEG. Clin. Neurophysiol. g: 399 (Abst.) (Green, M.). ll. Prognostic Application of Psychological Techniques in Convulsive Therapy, Dis. Nerv. Sys. g9: 180-184 (Kahn, R. L. and Pollack, M.). 12. Communication Networks in Freud's Interview Technique, Psych. Quat. 33: h56-h73 (Jeffe, J.). 13. Sociopsychologic ASpects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discha e Ratings and Diagnosis, A.M.A. Arch. Gen. Ps chiat. l5 565-S7h Kahn, R. L., Pollack, M., and Fink, M.5. Set in the Perception of Simultaneous Tactile Stimuli, Jour. Psychol. 12.: 38h-392 (Korin, H. and Fink, M.). The Role of Am. Perception Across Sensory Modalities, (Abst.) (Krauthamer, G.). Form Am. Psychol. lg; 396 16. Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions, The First International Congress of Neurolo ical Sciences (III: §EG Clinical Neurosﬁgsiology and Epilepsy5, PBrgamon, London, pp. 513—519 (Fink, M., Kahn, R.L., and Karin, H.). 17. Personality Factors in Behavioral Response to Electroshcnk Therapy, J. Neuropsychiatgy l; h5-h9 (Kahn, R. L. and fink, M=). 18. Symbolic Reorganization in Brain Injuries, in Handbook of Paychiatgy, ed. Arieti, 3., Basic BOOkS, No Yo, V01. I, pp. 9 "9 l (Weinstein, E. A. and Kahn, R. L.). �B. Presentations: l. EEG and Ebhavioral Effects of Tofranil, International Conference on Depression and Allied States, Montreal (Fink, M.). 2. Sociopsychologic Factors Affecting Therapist-Patient Relationships, American Academy of Psychoanalysis, Philadelphia (Kahn, R.L.). 3. Effect of Induced Cerebral Dysfunction in Man on Tachistoscopic Perception of Embedded Color Figures, Eastern Psychologic Association, Atlantic City (Pollack, M.). h. Behavioral Changes with Different Methods of Induced Cerebral Dysfunction, Eastern Psychological Association, Atlantic City (Karp, E.). 5. Sociopsychologic Aspects of Peychiatric Treatment, Eastern R. (Kahn, L.). City Atlantic Association, Psychological 6. Language Patterns as Measures of Behavioral and Neurophysiologic Change, American Psychiatric Association, Philadelphia (Fink, M.). 7. Personality Correlates of (Krauthamer, G.). EEG, Metropolitan EEG Society, 8. Relation of Social Attitude to Psychiatric Treatment, Meeting, A.P.A., New York (Kahn, R.L.). 9. Comparison of New York N. Y. Divisional Intellectual Functioning in Childhood, Adolescent and Adult Schizophrenics, N. Y. Divisional Meeting, A.P A., (Pollack, M.). New York 10. Symposium on "Paycholinguistic Analysis of the Psychiai‘ic Interview", N. Y. Divisional Meeting, A.P.A., New York (Jaffe, :.). 11. Social Background and the Doctor-Patient Relationship, Acad. Psychoanalysis, New York (Jaffe, J.). �Hillside Hospital Department of Experimental Psychiatry Following is a chronologic list of the presentations and publications of the members of the Department of Experimental Psychiatry during 1959. A. Publications: 1. Effect of an Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Biological Ps chiat , ed. Masserman, J., Grune & Stratton, N. Y. pp. 18h-19h (F%:E, M.;. Alteration of Brain Function in Therapy. Psychopharmacology Frontiers, ed. Kline, N., Little, Brown & 00., Boston, pp. -3 , . . 3. Significance of EEG Pattern Changes in FBychopharmacology. g(Fink, ) M. ). 398 (abet. Neurophysiol._2: EEG Clin. . Effect of Electroconvulsive Theraﬁg on Intr:1ctabm Pai A.M.A. Arch. Neurol. and ngchiat. Ql: 37- (weinstein, E. A., hahn, R. L., and rgman, P. . Electroencephalographic and Behavioral Effects of Tofrénil. Canad. 14.3 1663“].715 (Fink, Mo). ASSOC. J. szch. Psychological Factors Affecting Individual Differences in Behavioral Reaponse to Convulsive Therapy, J.N.M.D. lag; 2h3-2h8 (Fink, M., Kahn, R. L., and Pollack, M.). 7. Effects of Diffuse Altered Brain Function on PercWptio Prsc. XV Int. Con . P chol., Publ. North-Holland, Amsterdam, pp. 53 3- 239 (335E, M., Kahn, R. L., and Korin, H. ). Complex Visual Perception in Patients with Brain Tumor. Proc. XV Cong. Psychol., Publ. North-Holland, Amsterdam, pp. 2 33-?37 n er, M. B., Battersby, w. 3., and Pollack, M. ). 1/5/60 Int. �“beam, 9. Therapy of Schizophrenia: Behavior, h93 C as Re 14., Alteration of Brain Function on 1:92Con . Ps chia rts II Int. II: , H321 '£.""‘EER"', orinL", ‘. an hn, Role of 10. Relationship of Threshold and Duration of Seizures to Degree of EEG Delta Activity Induced During Electroshoclc, EEG. Olin. Neurophzsiol. _2_: 399 (Abst.) (Green, M.). 11. Progncs tic Application of Psychological Techniques in Convulsive Therapy, Dis. Nerv. Sys. g9: 180-184 (Kahn, R. L. and Pollack, M.). 12. Communication Networks in Freud’s Interview Technique, Psych. Bust. 23: 156-1473 (Jaﬁ‘e, J.). 13. Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discha e Ratings and Diag10818, AeMeAe Arch. Gene P3 Chiate ;: 565-571; Kahn, Re Lo, Pollack, M. '. 14., and—Tink"—‘T, 1h. The Role of Set in the Perception of Simultaneous Tactile Stimuli, Am. Jour. Psychol. 1g: 38h-392 (Korin, H. and Fink, M.). tion Across Sensory Modalities, Psychol. 3;: 396 15. Form Perce 16. Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions, The First Internatior; 3.1 Congress of Neurolo ica3_Sciences (LII: EEG, Clinical Neurop._,jsiolog and Epilepsy), ﬁrgamon, London, pp. 13- 19 ink, M. , v-iahn, R.L., and Karin, H.) . (Abst. (Krauthamer, G.). Am. 1?. Personality Factors in Behavioral Response to Electroshntrk Therapy, J. Neuropgychiatg l: h5-h9 (Kahn, R. L. and :nk, ). 18. Symbolic Reorganization in Brain Injuries, in Handbook of Pa hia ed. Arieti, 3., Basic Books, N. Y., Vol. I, pp. '935-931 (Weinstein, E. A. and Kahn, Re Le). ; �B. Presentations: 1. EEG and Behavioral Effects of Tofranil, International Conference on Depression and Allied States, Montreal (Fink, M.). 2. Sociopsychologic Factors Affecting Therapist-Patient Relationships, American Academy of Psychoanalysis, Fhiladelphia (Kahn, R.L.). Man on Tachistoscopic Cerebral Induced in Dysfunction of 3. Effect Perception of Embedded Color Figures, Eastern Paychologic Association, Atlantic City (Pollack, M.). h. Behavioral Changes with Different Methods of Induced Cerebral Dysfunction, Eastern Psychological Association, Atlantic City (Karp, E0). 5. Sociopsychologic Aspects of Paychiatric Treatment, Eastern R. (Kahn, L.). City Atlantic Association, Psycholqgical 6. Language Patterns as Measures of Behavioral and Neurophysiologic M.). (Fink, American Fhiladelphia Association, Paychiatric Change, 7. Personality Correlates of (Krauthamer, G.). EEG, Metropolitan LEG Society, 8. Relation of Social Attitude to Psychiatric Treatment, Meeting, A.P.A., New York (Kahn, R.L.). 9. Comparison of New York N. Y. Divisional Intellectual Functioning in Childhood, Adolescent and Adult Schizophrenics, N. Y. Divisional Meeting, A.P,A., (Pollack, M.). New York 10. Symposium on "Pbycholinguistic Analysis of the Piychiai-ic Interview", N. Y. Divisional Meeting, A.P.A., New York (Jaffe, q.). 11. Social Background and the Doctor-Patient Relationship, Acad. Psychoanalysis, New York (Jaffe, J.). � 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 Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-006 Date A point or period of time associated with an event in the lifecycle of the resource 1958-1959 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 Department of experimental psychiatry annual reports; Letter acknowledging that Fink will receive the first A. E. Bennett Neuropsychiatric Research Foundation award; Newspaper clipping, Long Island Daily Press, Psychiatrists will honor L.I. Doctor; Lists of publications of the members of the department of experimental psychiatry; Newspaper clipping, MD Records Brain Waves of Patients; Summary 1954-1959; 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). 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K �2 9th Annual Report JANUARY 1, 1956—DECEMBER 31, 1956 Glen Oaks, Queens FOUNDED 1927 Joseph S. A. Miller, M. D., Medical Director AN AFFILIATE OF THE FEDERATION OF NEW YORK 0F JEWISH PHILANTHROPIES �Hillside Hospital is a non-profit, non-sectarian mental hospital for the treatment of voluntary patients suffering from early and curable mental symptoms. Patients are admitted regardless of their ability to pay. Hillside provides training for physicians in post-graduate psychiatry and psychotherapy and puts major emphasis on research in all phases of treatment. The hospital considers itself a pilot institution, pioneering in the human and efficacious application of psychiatry to the mentally ill. The hospital is licensed in the New York State Department of Mental Hygiene. It is approved for a two-year residency in psychiatry by the Council on Medical Education of the American Medical Association, the American Board of Psychiatry and Neurology and the American College of Surgeons. The Dental Department is certified by the American Dental Association as an approved hospital department. Hillside Hospital is an affiliate of the Federation of Jewish Philanthropies and a participant of the United Hospital Fund and the Greater New York Fund. HIGHLIGHTS Page 3 Hillside gets Ford grants Israel Strauss Adolescent Pavilion in its second year . . . . Page 6 . . . . Page 10 Hillside affiliating institution for student nurses at Queens college . Page 11 Social Service strengthens rehabilitation program . Page 14 . Chlorpromazine added to regular hospital drug formulary Research program strengthened . . . . . Page 18 �1956 has been a year of “Shakedown" for Hillside during which its Board and Executive Officers have experienced the first full year of operation without the supporting advice of its founder, Dr. Israel Strauss, who died during 1955. In view of the change throughout the organization of the hospital, it has been a year of consolidation and improvement. We are indebted to Dr. Dudley D. Shoenfeld, our Vice President, for his invaluable counsel in helping to reorganize the staff planning in the hospital. He was greatly assisted in this work by Dr. Joseph S. A. Miller, Dr. Simon Kwalwasser REPORT OF THE PRESIDENT OF THE BOARD OF DIRECTORS and Maurice Bachrach. has frequently been necessary for the Governing Board to ask advice and guidance from the Medical Board. We have had splendid cooperation from them. The two presidents of the Medical Board serving through the calendar year, Dr. Samuel Atkin and Dr. David Epstein, have been particularly helpful. It During 1956, the hospital has been able to expand its services in the OutPatient Department through the use of funds made available by the State Mental Health Authority through the N. Y. State Department of Mental Hygiene, and funds from the City of New York through the New York City Community Mental Health Board. Further funds from the City of New York for indigent mentally ill persons have enabled the hospital to maintain its services at a high level and to serve that segment of the community which most needs the services of a philan- thropic hospital. The research program, conducted at Hillside under the guidance of Dr. Maximilian Fink, has made excellent progress. The directors continue their deep interest in all areas of psychiatric research and anticipate further broadening of these activities. Psychiatry as a science still is in a rather fluid state and many new avenues of exploration offer hope and ideas. The compelling need is to look intensely for new information. At long last, throughout the United States, substantial organizations have become cognizant of these needs. Among these, the great Ford Foundation has allocated many millions specifically for research in psychiatry. In addition, large sums have been allocated to the country’s hospitals. In 1956, Hillside received a grant of $104,000. At Hillside we bring a sympathetic attitude to our patients, solace and encouragement to their families and decided improvement to a large proportion of the persons we treat. We make judicious use of all modern therapies available in the field and our record of improvement is excellent. We can be proud of it. But we aspire to find new and better techniques that will send more patients out of the hospital completely “recovered” rather than “improved”; new methods that will permit release of patients in a far shorter time than is now required. to these goals that we at Hillside are dedicated and we firmly believe that, as elsewhere in medicine, these aims can only be achieved by means of widespread and continued research. It is Alvin E. Coleman �REPORT OF THE MEDICAL DIRECTOR During 1956, Hillside Hospital completed almost thirty years of continuous operation, rendering high-level psychiatric services to the community. During these three decades, the Hospital increased its bed capacity for inpatients fivefold, established a ranking place as a therapeutic center for both inpatients and outpatients, became a notable hospital for resident training in the field of psychiatry and, in the past few years, developed an important research department. For over eight years, it has been a proud member of the family of the Federation of Jewish Philanthropies and, in conjunction with other agencies in Federation, it has developed and rendered meaningful aftercare and rehabilitative services. During the past year, there was an improvement in the coordination of professional services rendered in both the adult and adolescent inpatient departments. There was considerable expansion in our outpatient service with improvement of procedures and treatment in the aftercare clinic. Our practical experience with the Adolescent Pavilion and our attempts to augment our research programs have pointed up the need for expansion, both in personnel and in space. Every few years the advent of some special form of physical treatment—shock, surgery, and now new drugs—has reopened the debate concerning so-called specific versus non-specific treatments, short-term versus long-term hospitalization and therapy, treatment of many patients or clients rather than a few. All of these can really be related to the general question of the importance of quality versus quantity. One of the distinguishing features of American medicine is its goal and also, think, its practice of rendering qualitatively better medical services, as opposed to mere quantification. I Hillside Hospital has developed a distinctive philosophy which has led to the creation of a unique structure to implement its philosophy. Since the field of psychiatry is still in its developmental stages, it is characterized by frequent and rapid changes in all phases of its thinking and practice. Each change is a challenge to the Hospital’s established structures and points of view and we must continually decide whether a psychotherapy-centered, multi-disciplined treatment program such as ours delivers the best service that can be devised for the relatively long-term curable patient. How is a mental patient best served by a psychiatric hospital? This, of course, will depend on the type of mental patient. Some patients are easily treated by a consultation or two, by a course of shock treatment, or with tranquilizing drugs, or with a rest or vacation. Some need only a course of physical treatment with return within a month or two to their homes, to continue whatever treatment they may need in a clinic or with a private psychiatrist. Others, and these are the ones that Hillside has more experience with, require hospitalization of at least six to twelve months. These are patients who cannot or should not remain at home or in the community, and cannot therefore benefit from either a single psychiatrist's or clinic’s ministrations but rather need the hospital milieu or therapeutic environment of a team of professionals working with the patient, with �a psychiatrist at the center to emotionally re-educate the patient. Such emotional re-education through the process of properly understood and related inliving experiences lead to a patient becoming aware of emotional aspects that he did not suspect he had before and to recognize that there are more people who care rather than so many who are hostile to him. If at the same time, as at Hillside, important relatives, especially the nearest of kin are worked with by a professional trained in that field, the psychiatric social worker, the family's attitudes concerning the patient and his illness are changed for the better; and if this happens, the patient now has not only regained much of his lest esteem and self-confidence, but the very family environment has been improved and guarantees that the patient may continue and even enlarge upon gains initially made in the hospital. Thus, not only a single patient has been treated, but there has been complete reorientation of an entire family. Authorities in dynamic psychiatry, in child welfare and development, in community welfare, in the field of geriatrics, all agree that the most important ingredient in the total treatment of emotional problems at any age, is the psychological understanding and the meaning of the symptoms, even the physical ones, as various ways of attempting to meet the problems of anxiety and emotional crises. Of the various psychological and dynamic approaches to the problems of behavior, none have contributed as much as psychoanalysis. Hence the practice of hospital psychoanalytic psychiatry at Hillside. This is by no means to lessen the importance of the adjunctive services and especially of the medical and physical agents. The physical symptoms are often parallel or concomitant expressions of 'certain types of emotional distress and emotional disorder; and physical agents like drugs, are often very effective in shortening periods of acute panic or distress and thus allowing for earlier or more meaningful participation in psychotherapy. Since the problems of emotional disorder are mainly interpersonal ones, problems of getting along properly or happily with other people, psychotherapy whether in or out of a hospital is in our opinion the basis of all therapy of persons with severe emotional disturbances. The past year has been characterized by a rapid growth of psychiatric services in general hospitals. These, by their very nature, deal with more acute physical and mental disorders, while special psychiatric hospitals treat those psychiatric problems which specifically require more extensive hospitalization, removal from home and community for a long enough period to afford an opportunity for reeducation and resocialization of the patient. It is therefore clear that the two types of hospitals deal with different problems and have different basic principles, precisely because they deal with different types of patients. The growth of the general hospital practice of psychiatry is therefore not a factor toward the displacement of the special hospital but rather for the widening and enrichment of the total constellation of treatment services available to psychiatry, so that the general and special hospitals enhance and reinforce each other for the benefit of all patients. Joseph S. A. Miller, MD. �ADOLESCENT PAVILION Age range of patients The Israel Strauss Adolescent Pavilion is now in its second year. It is a dramatic example of the kind of pioneering Hillside Hospital does. The Pavilion provides a treatment program for emotionally disturbed girls between the ages of 12 and 16. It is an unusual experiment in tackling a major problem of our society . . . the rehabilitation of girls who are unable to live and function successfully in the community. Practical aspects of treatment Grave concern with the number of severely disturbed young people in our country has not resulted in enough practical work. The Adolescent Pavilion is a brave in all and facilities with the deal this experience to problem, using attempt psychiatric therapy of the Hillside Hospital in a treatment program oriented to the special needs of these patients. The number of girls who can be treated is very small compared to the need. But the knowledge to be gained from experience with them should prove immensely valuable. Flexibility of program The Adolescent Pavilion has its own, specially-designed living quarters and treatment facilities, and a separate staff. Its program is necessarily fluid and flexible enough to allow the constant adjustments necessary in a new and untried field. Some changes from original plans became necessary as work progressed this year. Twenty patients were admitted in 1956 and 25 discharged. Capacity of the Pavilion was reduced to 16 since it proved impossible to work successfully with the 20 originally planned. Basic treatment philosophy The basic treatment philosophy remains the same. The aim is to provide a wholesome living experience within the Pavilion with as intensive psychotherapy as seems advisable for the individual patient. But the concept of such a wholesome experience has gradually, step by step, taken in more areas, personnel and facilities beyond the Pavilion’s confines. As soon as girls are able, they are encouraged to use recreational and planned activities at the main hospital, to make contacts with the other staff there and to socialize with adult patients. As they are able, the girls are permitted to go to the nearby public high school and out into the community. A basic concern is to try to help with those aspects of the personality that are ill while never forgetting to encourage arid develop those that remain healthy. Family or family-type Work with parents or parent substitutes is intensive and a very important part of the treatment. When they are able, the girls are permitted and encouraged to spend time with family or friends. Some girls, unfortunately, have no family to go to. The use of volunteer help to fill this vacuum is being further explored. After-care and follow-up Another important need is the provision of after-care and follow-up. Unlike the mature patient, the Pavilion deals with personalities not yet fully formed. Their potential is unknown. It takes time to find out how fruitful the work will be. It had been hoped that close follow-up would be possible by providing after-care relationships �for all the girls in the Hillside Out-Patient Clinic. This proved impractical because it interfered too much with the ordinary pursuits of young people who, in most cases, lived at great distances from the hospital. For those girls who cannot conveniently use the Clinic, a variety of good treatment facilities elsewhere are recommended. encouraging to report that referrals to the Pavilion have come this year from more widespread sources, including a variety of family and social agencies, schools, treatment centers, private physicians and girls' residence clubs. It is also encouraging to report that, while it is too soon to reach any conclusions from the work in progress, the hospital does feel the work of the Adolescent Pavilion is becoming increasingly helpful. It is Prognosis for the future �I 7‘" . «F ‘ HillSIde In 1956 treated 561 ts, of ”709189 hospital days. The e-‘ﬁ Q‘ﬁt‘rhte were patients. Of theﬁital treated», 365 ﬁne Evaluatipnﬁg discharged :- . ’ ' I I; eme '. I Is . 5 ', I I 2 __ way f. ou come In a ~ I. ’ gcomparison. - f ‘quOﬁ rials». " ndon nt ' ‘ to denote mental condition at the time of Idischarg ient’ 5 condition gmbebaviqr he en left This is g 'uII a}; I: ‘ 1"7.” : ' o’ I ‘ _ I I . I I no chan-e I "”3 '_ .' .- or ’ f I : I I ﬁle-5V; "j ' m“ iable Rent; m that symptoms have disapﬁbare nd the patient conseemeﬁn good ‘e'ans Ion at the hospital, but there is no certainty of how he will function when he Eats back into I own an ial and working community; recovered means that, in “i has bee ef‘mucharrlﬁrmd reas c ad . tioma‘t ' I. atient will be or better" I; he did befor ‘ 1 -I r 3“ .92 *I f _ "1"" . _ I ’ . mandfuw;¥ tmhﬁ tateat I Mu ,, . lmpr. 4O 36 39 . �m O S PIT �PSYCHOTHERAPY AND MEDICAL SERVICES Major process of Psychotherapy continues to be the major emphasis and the core of treatment at Hillside Hospital. Other forms of therapy, each in its own way very important to the patient’s progress, are all part of the treatment program and are prescribed according to the patient’s particular needs. However, one of the main criteria for accepting patients at the hospital is their ability to participate profitably in psychotherapy. Analysis of hospital Patients are seen individually by well-qualified psychiatrists for psychoanalytically oriented treatment three or four times a week. Each patient is assigned to a specific psychiatrist who remains ”his doctor” for the length of his stay. The psychiatrist is the leader of the hospital “team” that plans and supervises the patient’s day-to-day treatment. The other members of the team are a psychiatric social worker, a psychologist, professional representatives of the adjunctive services — Occupational Therapy, Group Activities and Creative Therapy — and the Nursing Department. Types of therapy in use, including new drug therapies . . . facilities for treating the “whole" patient: physically and psychotherapeutically Group therapy continues to be used for selected patients. The hospital continues the use of electroshock therapy for about one-third of patients, especially those suffering from more severe emotional disorders. The extent to which it is used has, in many cases, been modified in accordance with the results of research conducted by the Department of Experimental Psychiatry. During 1956, as a result of a controlled research study, Chlorpromazine was substituted for insulin coma in certain patients. It had been found safer, easier to administer, and to have fewer side effects. For certain other patients at the hospital, insulin coma is still the treatment of choice. Chlorpromazine has now been added to the drug formulary of the hospital and made part of the regular therapeutic procedures. There is continuing work and interest at Hillside in Reserpine and the other newly developed drug therapies. Growth of non-psychiatric The Intra-mural Clinic and allied medical services of the hospital are concerned with the non-psychiatric, physical problems of the patient. Close cooperation between the medical staff and the psychiatric staff has brought the hospital nearer its goal of “treating the whole patient.” hospital treatment treatment “team" medical services The lntra-mural Clinic The continued cooperation of a large visiting staff in all the various branches of medicine, made it possible for the clinic to see 411 patients for a total of 11,844 visits this year. The Dental Department 10 The Dental Department, newly certified by the American Dental Association as a qualified hospital dental department, anticipates adding a dental intern to the staff. New equipment and a newly decorated interior have done much to facilitate and improve treatment. The dental clinic treated 736 patients this year, an increase of almost 25% over 1955. �f . The Psychology Department, in response to increased demand for psychological examinations, added one full-time psychologist this year and provided for the addition of two more early in 1957. Almost twice as many tests were admin- The Psychology Department istered this year as last. The department has been accepted and used as an integral member of the hospital team. Its services have been called for in pre-testing hospital personnel, and in connection with vocational counselling and rehabilitation plans worked out by the Social Service Department. The Nursing Department continues to pioneer in training nurses and aides in the special skills required for proper care of the mentally ill. The nurse fulfills a unique position in being in direct contact with the patient for long period of time. And yet the only training she generally receives in psychiatry is a brief threemonth period during student training. This department has organized two special training programs, one for psychiatric aides and one for nurses, which enable them to perform more effectively and with more understanding as working members of the hospital team. addition, members of the professional nurse staff participated in trips to various private and state psychiatric hospitals to observe new methods and techniques. In During the past year, students from Central lslip continued visits to Hillside as part of their psychiatric training. This year, Hillside became the affiliating institution for basic psychiatric experience for student nurses at Queens College. The hospital was fortunate in acquiring for its own staff 10% of the college’s first graduating class. The Nursing Department �Three departments of the hospital, make an essential contribution to each patient’s therapy. Each has a specific function and each is prescribed as a regular part of treatment planned in cooperation with the psychiatric staff. Group Activities Department The Group Activities Department organizes meaningful social, educational and work activities that draw patients into groups where they will have opportunities to form relationships with other patients and deal with situations that mirror community life. Each member of the department’s staff of professional social group workers is assigned as a member of a psychiatric team which plans a program designed to meet a patient’s specific problems. The group worker reports on the patient’s performance and reactions to group ‘and social situations. .Under the guidance of the staff, patients participate in self-government groups, special interest classes, a choral group, athletic activities, and current events discussions; they publish a newspaper, operate a patients’ library and engage in club activities suited to various age levels. In addition, they plan and take part in social functions, attend religious services and enjoy a varied program of evening entertainments which frequently include appearances by outstanding celebrities who generously give their time and talent. This year has seen the development of an adult education program, in conjunction with Adelphi College, which, in a ten-week course, offers popular subjects similar to those offered by the extension programs of universities and the New York City Board of Higher Education. Occupational Therapy Department Occupational Therapy the patient works in various crafts such as ceramics, wood, metal, leather, jewelry making, weaving and needlework. They offer him a creative outlet that increases his self-confidence, helps him to discover new skills and has therapeutic value in relieving tensions. By observing the way a patient reacts to tools and materials, how he copes with success or failure and how he carries out instructions and responds to authority, the staff is able to gauge his problems and his progress. In 1956 two registered therapists were added to the staff, bringing the total to six. Each therapist is part of the hospital team that plans the occupational program for each patient according to the patient's needs. In This year, for the first time, craft classes were scheduled which offer patients interested in particular crafts an opportunity for more intensive and specialized instruction. Another innovation was that the Commissary, a patient-run store, was brought under the direction of this department and patients were assigned there by doctor's prescription as a form of vocational training. 12 �distinguished visitor this year was Miss Ruth Shamah, Israeli delegate to the World Federation of Occupational Therapists, who spent three months at Hillside working and observing the methods used in the department. A Creative Therapy is a very special psychodiagnostic and therapeutic tool de~ vised by Dr. Ernest Zierer and his associate, Mrs. Edith Zierer. It consists of a series of controlled painting tests designed to reveal the patient's unconscious conflicts. The results are tabulated and interpreted in diagrams which present a “personality profile” considered to be a reflection of the patient’s ability to solve his life problems. Creative Therapy Department The department administered 1,423 tests during the year. In addition to regular consultations with the hospital team, progress reports were discussed at special conferences with treating psychiatrists and the supervisors. I3 �THE PATIENT Work of the Social Service Department The Social Service Department is the patient’s most direct and constant link with his family and the community outside the hospital. Its activities before admission, during the patient’s stay at the hospital and after he leaves, make easier both for the patient and for his family the many adjustments necessary to meet the economic and emotional problems that complicate successful treatment. 14 Number of yearly interviews and contacts the course of its work this year, the Social Service Department conducted 5,137 interviews with patients, 5,095 interviews with relatives, 7,555 telephone contacts with social agencies and 6,701 telephone contacts with relatives of patients. The department processes all admissions, functions actively throughout the patient’s stay and is intimately concerned with the patient’s welfare on discharge and for several months thereafter. Rehabilitation aspects of the social service program the past year the department has made a concentrated effort to strengthen the rehabilitation aspects of the social service program of the hospital. Experience has shown that the best results are achieved when maximum support is extended immediately on discharge and continued through the first six months to a year. Future plans are particularly concerned with opening up new avenues of cooperation with community agencies whose services can do so much to help the patient again become a useful and happy member of his community. In 1956 the following agencies have made marked and increased contributions in this connection. Contributing agencies to rehabilitation programs The Foster Home Program, which exists jointly with the Jewish Community Service of Long Island, was used to place newly discharged patients in a supervised family environment. This year the program also was used for patients awaiting admission to the hospital, with the result that hospitalization was averted in at least one case. In In ' �AND THE COMMUNITY The Altro Workshop which provides discharged patients with transitional gainful employment was used by thirteen patients during 1956. Through a grant by Mrs. Israel Strauss and the Federation of Jewish Philanthropies, a joint program with the Jewish Family Service of New York was initiated. This service permits discharged patients who need further counseling to get immediate help. Expansion of this service is expected to show the value of continued and prompt counseling in averting rehospitalization. Together with the Jewish Family Service of Long Island, the department developed a special program that helps keep the home intact when a mother has to be hospitalized. Homemakers are assigned to fill the gap during the mother’s absence and sometimes even after the mother returns, if this seems necessary. The program with the Division of Vocational Rehabilitation has been expanded. A vocational counselor is available to patients one day a week. Vocational guidance begins while the patient is still in the hospital and may continue after discharge. Training facilities are provided for those whose adjustment to the community might be made easier by learning new skills. The department is especially appreciative of the cooperation of the New York City Department of Education. The Home Instruction Program provides two teachers who come to the hospital several days a week to give instruction to patients under 21 who have not completed high school. The results have been very successful; 40 patients received instruction this year and six were graduated. During the coming year the program will be expanded to include patients over 21, who, on completing the work, will be able to take High School Equivalency examinations. Follow-up reports indicate that many patients develop an interest in carrying their education further after leaving the hospital. The Casework Program started last year in the After-Care Clinic, for the purpose of coordinating rehabilitative planning, has proven its effectiveness and is now an established service offered to patients and their families. The Social Service Department has continued to work very closely with the Federation Employment and Guidance Service. Their excellent facilities make it possible for many patients to receive job placement and vocational guidance soon after leaving the hospital. 15 �HILLSIDE LEAGUE The Hillside League and the work of “The Bridge" The Hillside League is an organization of former patients of Hillside Hospital. After facing almost certain extinction in 1954 and having an encouraging revival in 1955, it has made astonishing strides in the past year. That many of its planned goals have been achieved is due, in large measure, to the untiring and selfless efforts of “The Bridge, Inc.", a group of women and their husbands who conducted a successful fund raising drive and who continue in their wholehearted devotion to the League. Activities at Bridge headquarters 1956, the Hillside League moved to new quarters (supplied by “The Bridge”) at 231 West 83rd Street, in Manhattan. Here, in an area many times the size of its original rooms, members enjoy a comfortable, newly furnished lounge, equipped with a phonograph, television, table games and cards. The area is flexible enough to provide for large groups as well as intimate gatherings. The League is open every evening from Monday through Friday and one week-end a month for large social functions. Help with personal Hillside psychiatric social worker has been assigned as a full-time director of the League and is available for individual consultation and for referral service with regard to housing, employment, further treatment and other personal welfare problems. Thanks again to the efforts of “The Bridge,” the volunteer staff of the League has grown to meet the needs of a much larger membership. Membership From a low of 38 in 1954, the active membership has grown to almost 200, and in addition the League draws upon an active mailing list of almost 500. A club program, with membership arranged according to age group and interest has been an important development made possible by the increased membership welfare problems In A and staff. The Hillside League looks forward to the next year as one in which it will be well equipped to fulfill a vital function in helping patients continue the progress made at the hospital. QUEENS OUT-PATIENT CLINIC Hillside Hospital believes that in the Queens Out-Patient Clinic it has developed a pilot unit that demonstrates the highest level of clinical functioning and serves as a center for stimulating interest and training in psychiatry. Work of the clinic 16 The Clinic offers psychotherapy on a twice-a-week basis, up to a year’s duration, to residents of Queens, Nassau and Suffolk Counties, who require treatment but �are unable to pay for private care. For a family with an average income psychiatric service can become a severe economic burden. The Clinic meets an urgent need in a community rapidly growing in population but relatively lacking in out-patient psychiatric facilities. The Clinic setting, in addition, offers the advantage of psychiatric social work consultation for members of the patient’s family. ’ Intensive screening, by means of psychological tests and pre-admission consultation, make it easier for the treating psychiatrist to make early plans for the patient's treatment program. In contrast to the usual lengthy course of psychiatric treatment, the Clinic has developed a philosophy of attempting to accomplish limited goals. Often, by relieving his symptoms, the Clinic frees a patient to continue on with his life, with the strengths he utilized before he became ill. The Clinic treated 271 patients in 1956, the average length of treatment being eight months. Thirty psychiatrists, accepted after very careful selection, work on a part-time basis to make this extensive program possible. Permanent staff Goal of the clinic's treatment program Number of patients and staff members members of the Hospital are always available for consultation. 1956, the Clinic initiated a separate service for administering electroshock therapy on an out-patient basis. Recovery, on the whole, was dramatic, rapid and tremendously appreciated by the patient and family since it meant avoiding hospitalization. In MANHATI‘AN AFTER-CARE CLINIC The Manhattan After-Care Clinic serves Hillside patients as a link between their hospital stay and the resumption of community life. This is often a very trying time because the patient may suddenly be subjected again to old family stresses, job strains and social difficulties. The Clinic, conveniently located at Mt. Sinai Hospital, is open five nights a week and the average course of treatment is twice-a-week for a period of three months. Function of the clinic Successful accomplishment of the Clinic’s goals depends in good measure on cooperation between Clinical Assistants and Social Service Caseworkers. The Clinic takes this opportunity to acknowledge the extent to which that cooperation exists and functions. Accomplishment of goals l7 �THE HOSPITAL treatment of the mentally ill depends on intensive research . . . on a better understanding of why people become mentally ill and a surer knowledge of how treatment effects improvement. Hope for this rests with a wide variety of professional research workers in the many disciplines concerned with human behavior. As in any other field of medicine, progress in the Research and progress Research in mental illness is spurred on by the grave and immediate need for new insights and is complicated by the fact that the field of exploration is limited, almost entirely, to human beings, rather than lower animals. Hillside's hope is to include every possible approach. Work continues along those lines that seem to offer the most promise. Areas of basic study Psychotherapy remains the area of basic study and treatment. But because past experience has amply demonstrated that electroshock therapy is, for certain conditions, the most valuable of the known physical therapies, the hospital has devoted a major effort this year to study and further elaboration of its use and effects. Three other studies whose purpose was to devise more clearly objective methods of evaluating progress in therapy were developed, and a control study of Chlorpromazine-insulin coma was completed. Department of Experimental Psychiatry This year, the Research Service Was redesignated as the Department of Experimental Psychiatry, indicating its continued growth and anticipating the addition of a Department of Clinical (Psychodynamic) Research. Two new members were added to the staff in 1956. Support for the program came from contributions of the Board of Directors, from the renewal, for three years, of the Electroshock Study Program of the National Institute of Mental Health of the U. 8. Department of Health, Education and Welfare, and from the Kaufman Foundation of New York. Departmental research in Medicine and Biochemistry Research in the Department of Medicine concentrated chiefly on a study of new drug therapies. The Department of Biochemistry continued work on studies of hormonal balance and undertook a study of the relationship between certain physiological defects and schizophrenia. Funds for the latter were provided by the National Institutes of Health. �AND THE COMMUNITY During the year, increased recognition of the staff and work of the hospital came from a large number of lay and professional publications. The hospital is keenly aware of the value of this public interest because greater attention by the general public to the field of mental health will lead to greater support by govern- Publications and Presentations ment and private agencies, foundations and institutions. Berkowitz, Anne: A Study of the Caseworker’s Function at Hillside Hospital, J. Hillside Hospital, 5: 56-60, 1956. Fink, M: Denial of Blindness Following Cerebral Angiography, J. Hillside Hospital, 5: 238-245, 1956. Fink, M., Kahn, R. L. and Korin, H.: Relation of Tests of Altered Brain Function to Behavioral Change Following Electroshock; Presented at the Divisional Meeting, American Psychiatric Association, Montreal, November 8, 1956. Fink, M. and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock, EEG Clin. Neurophysiol., 8: 158, 1956. Goldenberg, H., and Goldenberg, V.: Inhibition of Serum Cholinesterase by Lysergic Acid Derivatives. Sumicro Detection of LSD, J. Hillside Hospital, 5: 246-257, 1956. Goldenberg, H.: Decantation as a Precision Step in Colorimetric Analysis, Anal. Chem., 28: 1003, 1956. Goldenberg, H.: Recent Advances in Enzyme Methodology; Presented at a Symposium sponsored by the American Association of Clinical Chemists at the 123rd Meeting of the American Association for the Advancement of Science, New York, December 1956. Goldenberg, H.: Concerning the Inhibition of Pseudocholinesterase by Hallucinogens; Presented at the New York Academy of Sciences, April 1956. Green, M. A. and Fink, M.: Electroencephalographic and Clinical Effects of Megimide; Presented at the Eastern Association of Electroencephalographers, New York, December 5, 1956. Green, M. A.: The Use of Electroencephalography in Differentiating Psychogenic Disorders and Organic Brain Diseases, Amer. J. Psychiat., 113: 27-31, 1956, (with P. Bergman). Green, M. A.: Neurological Manifestations of Conversion Hysteria, Trans. A.N.A., 80: 196-198, 1956. Jaffe, J.: Experimental Alteration of Communication in Doctor-Patient Relationship; Presented at the Nassau Neuropsychiatric Society, April 15, 1956. Kahn, R. L. and Fink, M.: Changes in Language During Electroshock Therapy; Presented at the American Psychopathological Association, New York, June 1, 1956. Kahn, R. L., Fink, M. and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Arch. Neurol. & Psychiat., 76: 23-29, 1956. Kahn, R. L., Fink, M. and Korin, H.: Studies of Mode of Action of Electroshock; Presented at the Nassau Neuropsychiatric Society, April 15, 1956. Kahn, R. L., Linn, L. and Weinstein, E. A.: Personality Factors Influencing the Rorschach Responses in Organic Brain Disease; Presented at the New York 19 �Neurological Society, February 14, 1956. Also, Arch. Neurol. & Psychiat., 76: 226-267, 1956. Kahn, R. L., and Pollack, M.: Effects of visual, vestibular and somatosensorimotor deficit on autokinetic perception, J. Exp. Psychol., 52: 398-410, 1956, (with Battersby, W. S. and Bender, M. B.). Kahn, R. L.: Patterns of Social Interaction in Brain Disease, Amer. J. Psychiat., 113: 138-142, 1956, (with E. A. Weinstein). Kahn, R. L.: Confabulation as a Social Process, Psychiatry, 19: 383-396, 1956, (with Weinstein, E. A. and Malitz, S.). Kahn, R. L.: Delusions About Children Following Brain Injury, J. Hillside Hosp., 5: 290-301, 1956, (with Weinstein, E. A. and Morris, G. 0.). Korin, H., Fink, M. and Kwalwasser, 8.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conf. Neurol. 16: 88-96, 1956. Lurie, Abraham, Miller, Joseph S. A., Bellak, L., Black, B. F.: Rehabilitation of the Mentally Ill Through Controlled Transitional Employment, Amer. Orthopsychiatric Assoc., 1955 Annual Meeting. Also, Digest of Neurology and Psychiatry, July 1956, Institute of Living. Lurie, Abraham: Book review—Delinquent Boys by Dr. Albert K. Cohen, J. Jewish Communal Services, Summer 1956. Lurie, Abraham: Integrating Services for Improved Patient Care; Discussant at 50th Anniversary of Social Service Dept. of Mt. Sinai Hospital, October 18, 1956. Lurie, Abraham: Identifying Casework Responsibility in a Multi-Discipline Health Setting; Workshop Chairman, National Conference of Jewish Communal Service, 1956. Pinsky, Louise: The Impact of Mental Illness on a Patient’s Family, Jewish Communal Service, Spring 1956. Pollack, M. and Kahn, R. L.: Unilateral “Spatial Agnosia” (“lnattention”), Brain, 79: 68-93, 1956, (with Battersby, W. S. and Bender, M. B.). Wachspress, M., Blumberg, A. G., Fink, M. and Miller, Joseph S. A.: Evaluation of High-Dose Reserpine Therapy for the Relief of Anxiety, J. Hillside Hospital, 5: 67-77, 1956. Zierer, Ernest and Zierer, Edith: Dynamics of Creative Therapy; Presented at the University Clinic in Tubingen, Neckar, Germany. Zierer, Ernest and Zierer, Edith: Structure and Utilization of Creative Therapy; Presented at the Institute of Psychotherapy and Depth Psychology in Stuttgart, Germany. Zierer, Ernest and Zierer, Edith: Non Artistic Creative Activity; Presented at the Art Academy of Stuttgart, Germany. Zierer, Ernest and Zierer, Edith: Seminar on Creative Therapy as applied at Hillside Hospital and Extramurally; Presented at the meetings of the Zierer Study Group in Stuttgart, Germany. Zierer, Ernest and Zierer, Edith: What is Creative Therapw Presented at the broadcast over the Suddeutscher Rundflunk “Millelwelle.” Zierer, Ernest: Dynamics of Creative Therapy; Presented at the National Psychological Institute for Psychoanalysis, New York. Zierer, Ernest and Zierer, Edith: Structure and Therapeutic Utilization of Creative Activity, Amer. J. Psychotherapy, 10: 481-520, July 1956. ' ‘ 20 �TEACHING AND TRAINING The Resident Training Program at Hillside continues to emphasize the interrelation between the training program and the treatment program. Each resident carries a case load of about 15 patients under the supervision of staff and visiting instructors, and attends lecture conferences conducted by the medical directors. Lecture seminars in the fields of psychopathology and psychotherapy, and reading seminars, are conducted by special instructors chosen from the hospital staff. Qualified residents are assigned to the department of Experimental Psychiatry for clinical and other psychiatrical research projects. During the year there were 18 residents in training. The Resident Training Program The hospital training program extends also to Clinical Assistants in the Outpatient and After-care clinics and on-the-job training of personnel. Regular lec- Training for other staff members The Sunday Clinical Conferences, open to and attended by psychiatrists and other professional personnel and by outstanding visiting physicians, are part of the resident training program and are based on cases prepared by the residents. They continue to make a significant contribution to the training picture on the New York Psychiatric scene. Sunday Clinical Conferences The Annual Israel Strauss Lecture, established in 1955 in honor of Hillside’s founder and late president, was delivered this year on April 8th. The speaker was William Malamud, MD, Professor and Chairman of the Department of Psychiatry and Neurology of the Boston University of School of Medicine. His Israel Strauss Lecture Hillside's Committee on Community Education continues active and its program of lectures to the laity promote interest and understanding of mental hygiene problems in the community. Community Education The Medical Library, considerably enlarged by the acquisition of the entire medical library of the late Dr. Israel Strauss, was able this year to increase its services and usefulness to the staff by the employment of a full-time librarian. Medical Library The Journal of the Hillside Hospital again showed an increase in the number of its subscribers, an indication of the prestige and general acceptance it enjoys. A 504 page Israel Strauss Memorial Volume containing articles by psychiatrists and other friends of Dr. Strauss, was published in 1956. Journal of the tures and conferences are scheduled for nurses and attendants, social workers, members of the various adjunctive services and for affiliating students from other educational institutions. subject was “Current trends in basic psychiatric research.” Hillside Hospital 21 �REPORT OF THE ADMINISTRATOR Deficits While the cost of running the Hospital increased again, from $1,175,635 to $1,326,454, the deficit this year has been substantially reduced because the City of New York increased its contribution toward the care of the indigent mentally ill from $14 to $16 a day. The average number of patients per day. 192, remained the same as last year —97% of capacity. However the length of stay increased somewhat and the total number of patients treated was 561 this year compared to 575 in 1955. Comparison of costs: 1955-1956 . . . Salaries Food . . . . Maintenance and Grounds Administrative EXpenses Medical Supplies . Repairs and Replacements Clinics . . . . . Total Total No. Patients Total Patient Days . . . . Average income per patient day Average cost per patient day Average loss per patient per day . . . . . . 1955 1956 $732,977 106,397 50,551 67,017 28,130 25,279 165,284 $797,805 113,428 59,436 82,608 23,950 35,105 214,122 $1,175,635 $1,326,454 575 69,903 561 70,189 $14.45 $15.34 $15.44 $15.84 $ .89 $ .40 Costs of expanded out-patient services should be noted that the largest portion of the $150,819 increase was used for expansion of the Out-patient service. This increase was entirely offset by grants from the New York City Community Mental Health Board, the State Mental Health Authority, and increased subvensions from the Federation of Jewish Philanthropies. Increases in salaries reflect a rise in salaries and salary rates rather than an increase in personnel. Other increases reflect the general pattern of rising costs for goods and services. Costs of the Israel Strauss Adolescent Pavilion 1956 it was decided to compute the costs of running the Israel Strauss Adolescent Pavilion separately from those of the main hospital. While the pavilion operates as an integral part of the hospital, it is a new and costly experiment, which, if included, somewhat distorts the general operating picture. It In The operation of the Adolescent Pavilion showed a deficitof $37,752, an increase of 13% over 1955. The difference is entirely accounted for by salaries for additional personnel found necessary for successful operation. Maurice Bachrach 22 �SOCIETY OF THE HILLSIDE HOSPITAL ‘President . . . Alvin E. Coleman *Chairman of the Board Roy Foster *Honorary Chairman of the Board Leon Lowenstein *Vice-President Dudley D. Shoenfeld, M.D. *Vice-President D. Herbert Beskind ‘Vice-President George W. Galinger Manuel Lee Robbins +Treasurer Alfred Levinger ‘Ass’t Treasurer Arnold S. Askin Ass’t Secretary Hilda Strauss Assistant Secretary Alfred Appel 'Secretary Board of Directors A. Leon Lowenstein“ Roy Foster" Jacob Abrams George W. Galinger‘ Arthur Garson Maurice Glinertt Mrs. Henry Goldman, Jr. Meyer Goldstein Louis A. Green M. Victor Leventritt Alfred Levinger? Morris L. Levinsonrl: Milton B. Loeb Sandor Lorand, M.D. Alfred Appel Arnold S. Askin“ John M. Bendheim D. Herbert Beskind‘ Saul Blickman Alvin E. Coleman Morris David Edwin Elson1~ Thomas Epstein Arthur C. Fatt‘ David Finkle David Finn: Charles H. Meyer“ Arthur Murray Manuel Lee Robbins” lrving Rosenbaum S. H. Scheuer“ Walter Scheuer Dudley D. Shoenfeld, M.D.‘ Harry Silverson Hilda Strauss Nathan Wigod Morton 8. Wolf Walter D. Yankauer Chairmen of Standing Committees Medical Affairs Committee D. Herbert Beskind Executive Committee Roy Foster House and Grounds Committee George W. Galinger Co-Chairmen Nathan Wigod Jewish Hospital Coleman Liaison Committee—L. Alvin E. I. Legal Committee Charles H. Meyer Publicity Committee Arthur C. Fatt Finance Committee Arnold S. Askin Social Service Committee Hilda Strauss Personnel Committee Meyer Goldstein ‘Executive Committee Members tDeceased in 1956 *Elected in 1956 23 �PROFESSIONAL AND ADMINISTRATIVE STAFF Medical Director Joseph S. A. Miller, MD. Associate Medical Director Simon Kwalwasser, M.D. Administrator, Maurice Bachrach, B.S. George Yessin, M.D. Jack H. Tabor, M.D. Supervising Psychiatrists Gerhard Schauer, M.D. Martin A. Green, M.D. Robert Navarre, M.D. Eugene Glynn, M.D. Supervising Psychiatrist Israel Strauss Adolescent Pavilion Alice Slater Stahl, MD. Director of Out-Patient Services Robert R. Luttrell, MD. Director of Research in Experimental Psychiatry Maximilian Fink, M.D. Internist, Arnold Blumberg, MD. Director of Laboratories, Harry Goldenberg, Ph.D. Resident Staff Ruth Adams, M.D.* Stanley Brodsky, M.D. Frederick Coleman, M.D. Warren Cox, M.D. Ilhan Ermutlu, M.D. Harold Esecover, M.D. Stefano Fajrajzen, M.D. Marie Friedman, MD. Stanley M. Friedman, MD. Ruth Fuchs, M.D. Harold Galef, MD. Robert S. Gilbert, M.D. Eugene D. Glynn, M.D.“ Victor Goldin, MD. Michael Gould, MD. David N. Graubert, M.D.* George E. Gross, M.D.* Peter Guggenheim, M.D.+ A. Russell Lee, MD. Joel Markowitz, M.D.* Robert Nodine, MD. Paul Pressman, M.D. Arthur Root, M.D. Jack R. Royce, M.D.* Robert Shaw, M.D.* Charles G. Silverman, M.D.* Myron Stein, M.D. Morton Wachspress, M.D. Leon Lefer, M.D. Other Professional St aff Heads Nathalie Burbach, R.N., M.A. Director of Nursing Abraham Lurie, M.S.S.W. Director of Social Service Abraham Levine, Ph.D. Director of Psychology Ernest Zierer, Ph.D. Director of Creative Therapy Eileen P. Fisher, B.S. Director of Occupational Therapy Zetta Putter, M.S. Director of Group Activities Angelina Canavan, B.A. Dietician Department Heads Dorothy Croghan Accounting Supervisor Lillian Dailey Office Manager Thomas R. Lumley Superintendent of Buildings & Grounds Sarah Travers Executive Housekeeper ‘Completed residency in 1956 fin military service 24 �MEDICAL BOARD *President *Vice-President ‘Secretary . . . M. David Sidney Tarachow, M.D. Sidney L. Green, M.D. Epstein, M.D. *Treasurer * Ex-President David Warshaw, M.D. Samuel Atkin, M.D. Psychiatrists Samuel Atkin, M.D.‘ Arnold Eisendorfer, MD. M. David Epstein, M.D.“ Margaret E. Fries, M.D.* I. Peter Glauber, M.D. George S. Goldman, M.D. Sidney L. Green, M.D.‘ William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, MD. Emanuel Klein, M.D. Sidney Klein, M.D.“ Samuel 2. Orgel, M.D. H. L. Rachlin, M.D.“ Lawrence J. Roose, M.D. Irving J. Sands, MD. Robert A. Savitt, M.D.* Martin Schreiber, M.D. l’sidor Silbermann, M.D.* Otto Sperling, M.D. Sidney Tarachow, M.D.‘ Non-Psychiatrists Director of Department of Medicine Lester Cohen, MD. 'Director of Department of Surgery Director of Department of Neurology Morris B. Bender, M.D. Director of Department of Gynecology Julius Jarcho, MD. ‘Department of Dentistry David Warshaw, MD. Paul Scheman, D.D.S. Chairmen of Standing Committees Adolescent Pavilion Sidney L. Green, M.D. Education of Resident Staff Arnold Eisendorfer, M.D. Community Education and Public Relations Robert A. Savitt, M.D. Group Psychotherapy Samuel 2. Orgel, M.D. Credentials Committee for Psychiatric Staff and Promotions Martin Schreiber, M.D. Manhattan After-Care Clinic Sarah R. Kelman, M.D. Credentials Committee for Non-Psychiatric Staff and Promotions David Warshaw, M.D. Credentials Committee for Resident Staff Sidney Klein, M.D. Queens Out-Patient Clinic William Karliner, M.D. Research Committee Hyman L. Rachlin, M.D. Publications Committee I. Peter Glauber, M.D. Journal Sub-Committee Sidney Tarachow, MD. 'Ex-officio 25 �CONSULTING, ATTENDING AND VISITING STAFFS: AND CLINICAL ASSISTANTS Consultants Psychiatry Leonard Blumgart, M.D. Sandor Lorand, M.D. Nathaniel S. Selby, M.D. Dudley D. Shoenfeld, M.D. A. M. Rabiner, M.D. Medicine Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, MD. I. Jesse Levy, MD. Neurology Hans Strauss, M.D. I. S. Wechsler, M.D. Dentistry Morris Fierstein, D.D.S. Attending Psychiatrists Samuel Atkin, M.D. Arnold Eisendorfer, MD. M. David Epstein, M.D. Margaret E. Fries, MD. I. Peter Glauber, M.D. George S. Goldman, M.D. Sidney L. Green, MD. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D. Samuel 2. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, MD. Robert A. Savitt, M.D. Martin Schreiber, M.D. lsidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D. Associate Attending Psychiatrists Frank Berchenko, M.D. Cornelius Beukenkamp, M.D. Mark L. Gerstle, Jr.+ Soll Goodman, M.D. Attilio Laguardia, M.D. Samuel R. Lehrman, M.D. Abraham S. Lenzner, M.D. Martin H. Orens, M.D. Abraham Kaplan, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. George P. Krupp, M.D. Peter Laderman, M.D. Nathaniel S. Lehrman, M.D. Harold S. Leopold, MD. William W. Pike, M.D. Adjunct Attending Psychiatrists Edward R. Adelson, M.D. Renato J. Almansi, M.D. Herman S. Alpert, M.D. Irving L. Bauer, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Isadore H. Cohn, M.D. Alexander J. Friedman, MD. Albert E. Goldbert, M.D. Albert Harrison, MD. Thomas Hora, M.D. tResigned in 1956 26 David Milrod, M.D. Hugh Mullan, M.D. Helene Papanek, MD. Benjamin B. Rubenstein, M.D.+ Irvin Salan, M.D. Frederick F. Shevin, M.D. Jay Stanton, M.D. Aaron Stein, M.D. Samuel Tabbat, M.D. Fred U. Tate, M.D. Leonard Weinroth, M.D. Herbert Wieder, M.D. Arthur Zitrin, M.D.1- �Visiting Director Lester Cohen, MD. Visiting Physician George Sabrin, M.D. Visiting Physician L. Rosenblum, M.D. Visiting Physician A. Blumberg, MD. Associate Physician M. Kalkstein, M.D. Associate Physician J. Weinstein, M.D. Visiting Neurologist Medicine Adjunct Physician A. L. Berger, M.D. Adjunct Physician W. B. Brett, M.D. Visiting Dermatologist C. Stritzler, M.D. Associate Dermatologist Joel Schweig, MD. Adjunct Dermatologist N. Goldfarb, MD. Neurology Morris B. Bender, MD. Associate Neurologist Adjunct Neurologist Harry Harter, M.D. Director David Warshaw, MD. Visiting Surgeon Sidney Hirsch, M.D. Visiting Neurosurgeon Joseph Siris, M.D. Visiting Urologist L. G. Goldberg, MD. Adjunct Urologist Albert Sutton, M.D. Visiting Orthopedist A. H. Lewert, M.D. Director Julius Jarcho, MD. Visiting Gynecologist M. Warner, MD. Visiting Gynecologist H. Dubrow, M.D. Surgery Kurt Adler, M.D. Associate Orthopedist J. Schneiderman, M.D. Visiting Proctologist B. Warner, M.D. Visiting Ophthalmologist E. Seretan, M.D. Associate Ophthalmologist A. Minsky, M.D. Visiting Otolaryngologist S. Clayton, M.D. Visiting Anesthesiologist Georges Bean, M.D. Gynecology Associate Gynecologist Jack Cohen, MD. Associate Gynecologist B. Greenblat, M.D. Adjunct Gynecologist Eugene Streim, M.D. Radiology Visiting Radiologist Bernard Epstein, M.D. Director Paul Scheman, D.D.S. Associate Director J. G. Rubin, D.D.S. Associate Stanley Spiro, D.D.S. Associate Dentist B. Schwaid, D.D.S. Adjunct Dentist B. Lebow, D.D.S. Adjunct Dentist H. Lewis, D.D.S. Dentistry Adjunct Adjunct Adjunct Adjunct Adjunct Adjunct Dentist Dentist Dentist Dentist Dentist Dentist H. Adler, D.D.S. J. Goldberg, D.D.S. S. Platt, D.D.S. S. Plotnick, D.D.S. E. Friedman, D.D.S. M. Protell, D.D.S. Optometry Staff Optometrist Edward L. Steinberg, O'.D. Podiatry Staff Podiatrist Sam Sokolov, Pod. D. 27 �Clinical Assistants in Manhattan and Queens Clinics _ Lester I. Abend, ‘M.D. Ruth Adams, M.D. Romano Antonelli, M.D. Howard Boskey, MD. Paul Bradlow, M.D. Arline Caldwell, M.D. Mischa Caplan, M.D. Dominick J. Carlisi, M.D. Lionel Chertoff, M.D. Rita M. Chalef, M.D. Gloria Chung, MD. Julius Colantuond, M.D. Fred Dalton, M.D. Edward Einhorn, M.D.1- Joseph Feldman, M.D.+ Philip Friedland, M.D.t Hans Freymuth, M.D.1Arthur Gillman, M.D.t Harry Gonda, MD. David Graubert, M.D. Martin Hurvitz, M.D. Howard Hess, M.D. Gunthar Jacob, M.D. Wilbur Jarvis, M.D. Buck Luria, M.D. Meyer Monchek, M.D. Mathias Nachumi, M.D.1- Beatrice Nachtigal, M.D. Iris Orens, M.D. Edward Pinney, Jr., MD. Joshua Ramot, M.D. Willem W. Roosen, M.D. Henry Rosberger, M.D. Joseph D. Rosen, M.D. Gabriel Rubin, MD. Herman Tannor, M.D. Leon Tec, M.D. Clara Torda, M.D. Morton Wachspress, M.D. Irving Waitzel, M.D.l‘ tResigned 1956 STSANDL . are necessary to a v TO THE HOSPITAL he Society. The following form, however, se of the Hillside Hospital, the sum of - rty, such as bonds, stocks, etcetera, is serted instead of the words “the sum of 28 �l .,v . I ' I ., ‘ ,- . . �Glen Oaks, Queens, New York, �Hillside Hospital is a non-proﬁt, non-sectarian mental hospital for the treatment of from Patients mental curable and are early symptoms. voluntary patients suffering admitted regardless of their ability to pay. I Hillside provides training for physi- cians in post-graduate psychiatry and psychotherapy and puts major emphasis on research in all phases of treatment. The hospital considers itself a pilot institution, ill. the to the and human mentally in efﬁcacious application of psychiatry pioneering I The hospital is licensed in the New York State Department It is approved of Mental Hygiene. Medical Council the in on by psychiatry for a two-year residency Education of the American Medical Association, The American Board of Psychiatry and Neurology and the American College of Surgeons. The Dental Department is Association Dental American the as an approved hospital department. by certiﬁed I Hillside Hospital is an afﬁliate of the Federation of Jewish Philanthropies and a York Fund. New Greater the and Fund United the Hospital participant of M. DAVID EPSTEIN, M.D. �I The responsibilities and functions of the Medical Board fall roughly into two broad categories: 1. It is a consultative and advisory body to the Medical Director and the Board of Directors in all matters pertaining to medical functioning of the Hospital. In this capacity, it assists materially in the formulation of basic policy, and in the establishment of both short-range and long2. In addition, it range plans, directions and goals performs duties relative to the implementation of these plans and policies and plays an active role in the practical day-to-day operations and needs of the hospital, whether this be in terms of active supervision of the junior members of the staff, supervision of the Out Patient Clinic or the After-Care Clinic, careful and methodical screening of all candidates for positions on the professional staff, either House or Visiting, or working with other departments within the hospital, such as Psychology or Social Work It is not possible to report on all the activities of the Medical Board since the last report was rendered. However, some of the more important areas of Board activity are worthy of individual mention During the past year, the Liaison Committee of the Medical Board, working with the Medical Director and Lay Board, has been able, after long and delicate negotiations, to bring to a successful culmination the question of the establishment of a Psychiatric Service at our neighbor institution, the Long Island Jewish Hospital. One of Hillside’s Attending Psychiatrists will organize a staff at Long Island Jewish Hospital and will maintain liaison with Hillside Hospital. We will be glad to continue to render whatever assistance we can, and we look forward to a productive, progressive collaboration between the two institutions The Journal of the Hillside Hospital, under its able editor, has continued to grow and is achieving ever wider recognition in the professional world. The caliber and standards of the publication have remained consistently high. In the ﬁeld of publication a new project has been recommended and will shortly be carried out, viz. a series of monographs I I I I on important psychiatric subjects to be issued under the The Adolescent imprimatur of Hillside Hospital I Pavilion, a pilot project established several years ago, and a rather unique undertaking, has taken a great deal of time and work. It has gone through a variety of growing pains in its early exploratory and experimental period, but it is now an established and important aspect of the Board’s interest and efforts. Although it continues to present problems, or better, because it does, much is being learned about problems of adolescent psychopathology and their treatment and a sizable body of knowledge is being accumulated which will no doubt lead to advances in understanding and to important research results. In addition, the Pavilion continues to After much serve as an important training facility careful study and planning, the Medical Board has set the machinery in motion to establish a new project. This is to be a Child Therapy Unit, for the intensive treatment of a selected group of children and their parents where necessary, to be operated as part of the Out Patient Department. Such a unit would be a most valuable adjunct to our training program and will also help in ﬁlling an urgent need in the community. The basic set-up is ready to start functioning as soon as one or two remaining obstacles are overcome, and it is ardently hoped that this plan will be brought to fruition in the very near future Possibly two of the most important functions of the Medical Board are the organization and supervision of the Educational and Research Divisions of the Hospital. Under the guiding hand of the Educational Committee, our Resident Training Program continues to operate most successfully and the program of formal and didactic training and supervision is more than adequate. The Committee is constantly studying and re-evaluating the educational program, always seeking ways and means of reﬁning and improving teaching methods at the Resident level, a universal problem with which every training hospital has to cope. Currently, the Committee is exploring ways of expanding and rounding out the train- I I ing program, with a View to having Hillside accredited for a three-year residency, possibly with the aid of affiliations with other institutions. Such a development would be eminently desirable In the area of Research, much has been accomplished and the Committee or the Board charged with this responsibility has functioned most actively. In collaboration with the Directors of the various research divisions, a large number of projects have been studied and evaluated. In addition, several members of the Board and Attending staff are engaged in individual research projects of great interest and promise. The Board is still seeking ways of expanding the Research Program, broadening it to make it more inclusive and comprehensive by adding a Research Division devoted to the more purely psychological aspects of mental disorders. Unfortunately, our efforts thus far have not been successful, but the search for a suitable and available person to head such a program goes on actively. It is with profound regret that we are compelled to note the loss through retirement of two of our oldest and most respected Board members— Doctors Julius Jarcho and David Warshaw, both of whom have become Consultant Physicians, from which lofty eminence we trust their invaluable advice and experience will continue to be available to us A closing word now about our view of the future. We have no doubt that Hillside Hospital now stands at a critical point in its historical development and evolution.Great and important changes can be expected and far-reaching decisions will have to be made. These changes are made necessary by the need to expand and to be prepared to meet the exigencies of a rapidly expanding science of Psychiatry and even more rapidly growing community needs for service and for trained personnel. We must gear ourselves and plan with foresight for these changes. Hillside can and should become a vital element in the psychiatric world and an important training and research center. To make it such will require Vision, courage, perhaps even daring, and cooperation on the part of all who are associated with it. I I �//2 I TQM/r/M' e/0 poéra/ In 1957, Hillside saw many changes, some obvious, some not yet evaluated, in attitude and treatment, in ﬁnancial status, in acceptance in the eyes of the comI of am constructive these For signs progress, munity happy to commend our staff, the professional and nonprofesslonal personnel, the Medical Board and the everready help and unselﬁsh interests of the Board of DirecAs a non-proﬁt, non-sectarian hospital for the tors treatment of voluntary patients suffering from early and curable mental symptoms, the function of Hillside as a teaching and research center has enabled it to pioneer in many forms of therapy. To help in this area, an unusual number of grants were awarded to Hillside in 1957. Some $256,400 were allocated for research and nonthe contributions Of the making up operating purposes. grants, the largest was $104,800 from The Ford Foundation. Other sums were: Max Einhorn Estate, $50,000, Hillside Hospital Board of Directors, $50,000, and the US. Public Health, Institute of Mental Health, $35,000 Increasing attention from the nation’s press is being focused on the research, training and therapy programs of leading mental hospitals. We believe this is of great help to everyone in the ﬁeld of mental health. No small share of this publicity was directed at Hillside Hospital during 1957 However successful this side of Hillside’s remained still the in on 1957, emphasis was program the patient. At Hillside, the ﬁrst person a patient sees I I I I is his doctor. The large medical staff is concerned with various aspects of his recovery, but the doctor assigned to each patient is the most important person to look to for treatment, consultation, advice and help. The social worker assigned to help with the problems of the patient outside the hospital, as well as within its walls, stays with him as long as needed. The nurses and attendants offer to the patient the understanding of A new special training and constant association booklet dealing with these aspects of a patient’s relationship with the staff, and endeavoring to answer his questions and allay his doubts, has been written and made available to patients and their doctors, as well In 1957, as consultants and interested researchers the three alternate ways of dealing with Hillside’s patients and their varied needs evolved more strongly. A patient is helped to rejoin his family and the community not only by Hillside but by the various private and state employment groups, interested voluntary organizations, as well as the family which ideally gained new insight and understanding under the guidance of the social service worker He may need the continued attention of a social service worker, sometimes for as long as eight months. A continuous relationship such as this gives anchorage and stability to the patient. Should further psychotherapy be needed, he is referred to the After-Care Clinic, the Jewish Family Service, or other I I I I When the discharged patient cannot be sent back home, because the original environment is not suitable to maintaining recovery he is placed in private residence care through our liaison with the Jewish COmmunity Services of Long Island. Happily settled in newer, more sympathetic surrounding, the patient then can be seen in therapy for six to eight months. This time limit is arbitrarily set in the belief that the patient can be moved to a dynamic effort to With the entire emphasis of recover more quickly Hillside on an “open hospital,” the tendency more and more is to treat and hold the patient so far as possible in his normal environment. Carrying this a step further, Hillside now believes that its future lies not in enlarging the hospital’s facilities, but in expanding the pré-hospital The main orienguidance, and Out Patient Service tation, therefore, of the patients and staff at Hillside is to the inevitable return to the community and useful citizenship. The goal of the hospital’s treatment services. organizations I I both at the in patient and out patient levels, is to provide the best qualitative treatment for our patients, so that the result, ideally, is not merely an improved or recovered individual, but an improved or reclaimed family unit or small segment of the present and future community. Joseph S. A. Miller, M.D. �I 1957 was a good year for Hillside Hospital, and no apparent recession set in, with regard to the work of the hospital, or the demands made upon it were concerned. During the year, new ideas were presented and developed, such as the training of registered nurses in psychiatry at Hillside, in collaboration with the Queens Medical College. This plan inured to the beneﬁt of the hospital in that some of the nurses remained to practice with us. Additional funds secured from the New York City Community Mental Health Board and the Nassau County Mental Health Board permitted the further expansion of services in the Out Patient Clinic where, at the end of 1957, we were treating 205 patients each week We suffered a great loss through the death of our long time Treasurer, Alfred Levinger, who had been one of the original founders of the institution. During 1957, the Board of Directors created the new position of Honorary Director, and the first Director so honored was Mrs. Israel Strauss, the wife of the founder of our institution. Saul Blickman, one of our directors ‘of long One of the most standing, was similarly honored important events of the year was the appointment of Dr. Lewis L. Robbins as Director of Professional Siervices. Dr. Robbins, a nationally known psychiatrist, who has been with the Menninger Foundation for 18 years, will join the Hillside staff in July 1958 Our research work has continued and expanded through the ﬁnancial aid of several government organizations and private I I I ﬂﬂﬂﬂﬂ/ﬂ ' foundations, as well as donations of the Hillside Board of Directors. During 1957, the staff of the Department of Experimental Psychiatry extended our knowledge of the way various treatments affect our patients and have clariﬁed our understanding of electroshock, insulin coma, and the newer tranquilizers. Their studies have been presented before national and local psychiatric and psychologic societies, and eight reports have been published during the year. Three reports were presented at the International Congress of Psychiatry in Zurich and of Psychology in Brussels during the summer The need for greater research efforts is apparent to all who are even casually interested in this ﬁeld of health, and it does seem incumbent upon the governments of the United States and of each state, as well as private funds, to offer more generous support for these efforts. But surely, within the foreseeable future, progress will be made and we, at Hillside, are not alone in believing this. At the 1957 convention of the American Hospital Association, Dr. Julian P. Price, Chairman of the Joint Commission on Accreditation of Hospitals of the American Medical Association said: “The chemical nature of certain mental diseases will be discovered and their control brought about through the giving of drugs.” RecognizingIthe tremendous human values this will have, not to mention the enormous dollar savings, let us try our best to hasten this day with our own efforts and money. I ALVIN E. COLEMAN �of 545 total treated patients. Hillside a 1957, Admissions and Discharges—1n with an average daily census of 192. New admissions totalled 81 and readmissions after been an had discharged 351 of the end patients the 32. totalled By year, of summaries statistical the is similar to data This average stay of 182 days. recent years. %/tm/ / MARRIED F No. of patients treated Males Sex Females Admission (13-19 (20-29 Age (30-39 (40-49 (50-59 (60 plus No. of patients admitted Average no. days hospitalized (adults) WIDOWED M F DIVORCED & SEPARATED M F �I In any evaluation of discharges, it is important to realize that the terms used to denote mental condition at the time of discharge only signify a comparison between the patient’s condition and behavior when he came to the hospital and when he left, a relatively short period The following comparisons use terms which are deﬁned as follows. Unimproved means there has been I no change; improved means that symptoms or problems have been somewhat helped but still persist to an appre- ciable extent; much improved means that symptoms have disappeared and the patient seemed in good condition at the hospital, but there is no certainty Of how he will function when he gets back into his own social and working community; recovered means that in addition to what has been said for much improved, there is reasonable expectation that the patient will be able to return tO his community and function as well, or better than he did before he became ill. %/ , DIAGNOSIS ADULTS ADOLESCENTS /lﬂﬂ// a) a TOTAL NO. OF PATIENTS WHOLE SHOCK THERAPY 5'2 0F INSULIN COMA THERAPY % % RECOVERED MUCH IMPROVED IMPROVED UNIMPROVED Psychoneurosis 63 3 66 19% 12% 10% 46% 40% 4% Manic depressive psychosis 84 1 85 24‘} 34% 27% 43% 27% 3% Involutional psychosis 63 63 18% 39% 22% 49% 20% 9% 1 8% 26% 50% 16% 40% 20% 40% 39% 36% 12% 118 9 127 36‘)? Others 8 2 10 3% Totals 336 15 351 100% Schizophrenia % 76% 14% 18% 13% �%y¢%/%¢Q/% m/ giwzéw %%éa/ I One of the main criteria for accepting. patients at Hillside is their ability to participate proﬁtably in psychotherapy. Patients are seen individually three times a week for psychoanalytically oriented treatment by their assigned psychiatrists. The psychiatrist is the leader of the hospital “team” that plans and supervises the patient’s day-to-day treatment. The other members of the team are a psychiatric social worker, a psychologist, professional representatives of the adjunctive services—Occupational Therapy, Group Activities and At Hillside, the staff is Creative Therapy—and the Nursing Department much larger in proportion to the number of patients than in other mental hospitals. Thus, Hillside’s emphasis is entirely on the patient as an individual. Although all the latest physical and pharmaceutical techniques are used as needed, such as electroshock, insulin, Serpasil, treatment does not revolve the to since these supplementary around only they techniques are primarily psychotherapeutic approach. All departments bring into play the tools of treatment, prescribed according to the patient’s particular needs, and all aimed not only at relieving him of symptoms, but getting at the causes as well, so that he may be returned to full usefulness as a human being. The Psychology Department. under the direction of Dr. Abraham Levine, continued to expand both in staff and services. In addition to six new staff Uma Dr. for Hillside training a diagnostic year’s provided appointments, The Vocational CounselChowdhury, a cultural anthropologist from India ling Program was expanded through the addition of staff members. The Department conducted 222 new adult patient examinations, 21 examinations for the adolescent patients and 248 Out Patient examinations. 117 psychological I I discharge examinations were administered for In Patient adults, 8 for adolescents, and 19 for Out Patients. The Nursing Department. under the direction of Mrs. Nathalie Burbach, participated in all initial presentations, discharge conferences and team meetings, enabling them to offer more understanding and knowledgeable nursing care. 36 Psychiatric Aides were trained, and 57 student nurses from Queens College received psychiatric nursing experience. Central Islip School of Nursing continued to send student nurses for semi-weekly visits to compare opera‘ tion of state and private hospitals, and student nurses and nursing personnel from St. Vincent’s Psychiatric Unit in Manhattan Visited to obtain information generally helpful in the preparation of patients transferring from St. Vincent’s The Intramural Clinic has continued to handle all major to Hillside An of hospitalization. patients’ the during course arising physical problems overall supervision of the effect of the drugs used in psychotherapy was conducted with special emphasis on Chlorpromazine and Meprobamate. 1756 examinations were conducted for treatment in such specialized ﬁelds as Dermatology, Gynecology, Medicine, Neurology, Ophthalmology, Orthopedics, Otolaryngology, Podiatry, Proctology, Radiology, Surgery and The Dental Department made Urology 1123 examinations including restorations, I I �extractions, prosthetic treatments, and X-rays. Under the direction of Dr. Paul Scheman, a staff of 12 Visiting dentists continued to adapt consultation and treatment procedures to the special needs of the mental patient. The department, certiﬁed by the American Dental Association, presented a series of lectures for dentists who treat “problem patients”. tMa/QMM/féze gar/12w The Occupational Therapy Department. under the direction of Eileen P. Fisher, in order to give more intense individual treatment, registered no more than 45 patients at a session. No therapist has more than twelve patients to work with at a time. Though the Department treated fewer patients per month, the average daily attendance remained the same, since there was closer followa up on all patients and a closer relationship with individual doctors. The Department works closely with all members of the psychiatric team, particularly the social workers. A special class program was organized on a selective basis, offering individual instruction in ceramics, jewelry and sewing. A student training program is being planned as a result of approval as an alﬁliating center for students from New York University Lectures on the principles and uses of Occupational Therapy in a psychiatric hospital were given to student nurses, new personnel and visitors. I The Creative Therapy Department. under the direction of Dr. Ernest Zierer and his associate, Mrs. Edith Zierer, continued experiments with con- trolled painting tests, designed as a psychodiagnostic tool to stimulate the patient into projecting his unconscious conﬂicts by painting. An average of 42 patients were treated daily. A total of 4,509 paintings were analyzed and a total of 1,593 tests administered A new questionnaire form of tests was added to help the patient gain insight into his actions and reactions. The patients are encouraged in regularly scheduled individual sessions to give verbal interpretations of their paintings within the framework of the situation, also tied in with the test results Lectures were given to visiting psychiatrists, social workers and students. I I �@ﬁéﬂ/ [lﬂﬂ/ ﬂ @ammmw/ / �I Hillside Hospital believes in treating the mental patient within the community, rather than in isolation, away from family and familiar surroundings. Directly responsible for improving communications between the patient, his family and his community is Hillside’s Department of Social Services. Under the direction of Abraham Lurie, the Department works to help the patient keep his place in society, and return to it In 1957, the Dea better, more useful citizen partment was reorganized to include the Group Work Division. The Department, therefore, now consists of two divisions: The Casework Division, directed by Louise Pinsky, an assistant director of the Department, and the Group Work Division, directed by Arnold Eisen, also an assistant director of the Department As a result of this merger of staffs, there have been several improvements and developments in the program offered patients, and it is believed that the goal of integrating the patient with his family and the community is closer through these changes. The Casework Division. with the knowing cooperation of the patients and their families, works to maintain and strengthen family ties, and to I I solve, with the patients, their individual problems of rehabilitation. Through the Division, the hospi- tal reaches out from the patient to the family to the community. This link is established and maintained before the patient enters Hillside and continues for as long after the patient has left the hospital as seems necessary. In dealing with the realities of the home and the community situations that have contributed to the problems of the patient, the Division is concerned with such speciﬁcs as working opportunities, living arrangements, care of children, care of aged and interim ﬁnancial support Last year, a total of 1,566 applications for admission to the hospital were received. The majority of referrals (89%) came from the New York City area, but applications were received from every geographic section in this country and also as far away as Brazil As in previous years, twice as many female applicants as male applicants sought admission. Patients were referred by psychiatrists, social agencies, hospitals, churches, synagogues, courts, schools, trade unions, as well as by communities, expatients, and through publicity. Of particular signiﬁcance was the fact that the percentage of I I patients not found suitable for admittance was 19.2%, as compared with 25% the previous year and 26% in 1955. Thus, the trend, started two years ago, after the establishment of an Intake Service, continues to demonstrate the effectiveThe activity ness of pre-screening applications of the casework division is reﬂected in the following statistics: I Interviews with patients, including Out Patient Dept. and Adolescent Unit .................... 5,110 Interviews with relatives, including Out Patient Dept. and Adolescent Unit .................... 5,860 Collateral Interviews ............................ 186 Interviews with discharged patients ............ 253 Interviews with relatives of discharged patients ...................... 256 Telephone contacts with social agencies ...................................... 5,425 Telephone contacts with relatives of patients .................................... 10,077 The Group Work Division is concerned with �providing a milieu in which patients can form social relationships, assume responsibilities, develop new interests and learn new skills and so begin to ﬁnd places, ﬁrst in the hospital community, and then in the outside community Among important developments this year was an orientation and intake program designed so that the new patient, helped by the social group worker, quickly learns the social structure of the hospital, and examines some of the groups available to him. With help, he makes preliminary choices based on previous experience as well as current social interest and need As part of the trip program, another new development, patients go to bowling alleys, ice and roller skating rinks, and restaurants. Some patients undertake longer trips to museums, the United Nations, or other places. Since this requires planning, it is a measure of the group’s ability to unite in a common goal and These new to sustain interest in the activity developments supplement the program which is the patient’s most direct link with the community I I I he has voluntarily left behind. With a group worker assigned as advisor, all patients meet regularly in democratic self-government. They work to solve their problems in living together, assume some responsibility for group discipline, and plan their social life. Many activities are carried out by delegated members who serve on planning committees to choose books and records, plan parties and dances, and other social activities An important aspect of life at Hillside is the chronological grouping based on age and similarity of interest. There are currently clubs serving all ages and giving each patient a chance to be a member of a social unit of his choice. The Library Group, for example, selects new books and magazines for patients from a practically unlimited list. The Newspaper Group is responsible for the writing and production of a monthly literary magazine, “Inside Hillside” and other publications In addition to these self-chosen activities, all patients participate in a series of current events discussion groups, in order to keep informed about daily events in the community they hope to rejoin. Patients are encouraged to assume leadership in all matters—and share their skills with each other. As a result, at varying intervals during the year, there have been patient-conducted groups in such varied activities as tennis, I I �bridge, play reading, and theatrical production The Group Work Division operates with a director, supervisor, four social group workers, two graduate social work trainees, eleven undergraduate ﬁeld work students, two part-time musical teachers, and 25 part-time volunteer workers Last year, ten graduate social workers were placed at Hillside for specialized training. The Division works closely with two outside organizations, The Bridge, a group of women who help recently discharged patients to re-establish themselves socially, to find jobs, and to maintain themselves ﬁnancially while doing so, and The Hillside League, a club for ex-patients of Hillside. Located in quarters maintained by The Bridge, at 231 West 83 Street in Manhattan, the League offers social club privileges to members, including games, TV and meeting space, and, in addition, provides special help in ﬁnding housing, employment, further treatment, and solving other personal problems in readjustment The QueEns OII‘I‘ Paﬁen‘l‘ Clinic. located at the Hospital, provides psychotherapy for residents of Queens, Nassau and Suffolk Counties who are unable to afford a private psychiatrist. Directed by Dr. Robert R. I I I Luttrell, the Out Patient Clinic insures the availability of qualiﬁed specialists who focus on early treatment and prevention of emotional illness. The geographical location of the hospital’s clinic, in a corner of Queens, bordering on Nassau County, makes a resource for psychiatric care available to one of the country’s fastest growing population In 1957, the clinic treated 316 patients areas in individual psychotherapy. Of these, 134 cases were carried over from 1956 and 182 were started in treatment. 163 were discharged during the year from individual psychotherapy. Group therapy, a new development in 1957, has resulted in six discharged of the 23 patients in the group. Eight patients received electroshock therapy and 67 patients were seen in continuous casework. 267 psychological tests were performed and 285 patients were evaluated by the “intake” team. I Diagnoses of discharged patients were: Psychoneurosis ..............................................53 Schizophrenia and manic depressive ............ 46 Involutional melancholia .............................. 9 Character disorder ........................................55 Conditions at discharge were: Improved ...................................................... 1 14 Much improved ............................................ 20 Not improved .............................................. 29 I Average length of treatment at the clinic was about nine months. Because the clinic is an out patient facility, families remained intact and there was little or no loss of jobs. As with in patient care, fees are based on ability to pay, with the average fee about $6 per week. (The cost to provide this service is approximately $30 per week.) Another out patient service provided by the Hospital is the After Care Clinic which operates ﬁve evenings a week at Mt. Sinai Hospital, a convenient location for most patients. The Clinic assists the discharged Hillside patient to resume his community status, and deals with the immediate problems of job replacement, living and resumption of old environmental contacts that may have originally contributed to the patient’s illness Group psychotherapy was instituted on a trial basis in this clinic during 1957 in an effort to meet some of the continuing needs of these patients. I I �17% mm/ %ﬁ”2ﬂ7ﬂﬂlgy Research. When one out of ten adults is hospitalized for mental illness every year, it is obvious that much is still to be learned about why people become mentally ill. As much as has been learned about the care of the mentally ill in the past 20 years, there are still new areas to be studied, such as blood chemistry and the delayed effects of the electroshock treatment Hillside believes that in addition to treating mental patients, it is obligated to undertake research. So advanced is the hospital’s outlook that it is one of the few mental hospitals with a biochemistry laboratory. Although the amount of current research on the subject of mental illness is inﬁnitesimally small, Hillside employs a staﬂ of scientists and trained researchers seeking the answer to why people become mentally ill and a surer knowledge of how treatment effects the improvement of mental patients The Department- of Experimental Psychiatry. during 1957, under the direction of Dr. Max Fink, completed the ﬁrst phase of its studies on the mechanism and effects of therapeutic techniques presently employed. Following the elucidation of the neurophysiologic and psychologic bases of the process of convulsive therapy, a control convulsive-subconvulsive study was undertaken in 1956 and completed in 1957. This study clearly demonstrated the changes in brain function which are the necessary prerequisites for change in behavior; and the psychologic, sociologic and language aspects which are fundamental In concurrent to “improvement” after convulsive therapy studies, the equivalence of chlorpromazine therapy for insulin coma, and the advantages of newer drug therapies were demonstrated in a chlorpromazine-insulin coma control study. Consequent upon these observations, an hypothesis of the mode of action of tranquilizers was described and a program of be- I I I I havioral assay of new drugs undertaken Basic studies into patterns of communication continued. By applying new techniques of psycholinguistics, objective methods of evaluating behavioral change and “improvement” were described and are now being tested. Studies in tactile and visual perception, neurophysiologic and psychologic bases for individual differences in response to drugs and convulsive therapy, and biochemical changes in spinal fluid after induced convusions continued Support for this program increased through grants from the Foundation’s Fund for Research in Psychiatry, the National I �Institute of Mental Health, and the Psychopharmacology Center of the National Institute of Health. A research grant of $31,700 was awarded to Hillside by the Foundation’s Fund for Research in Psychiatry. The grant was given to Dr. Joseph Jaffe of the hospital’s Department of Experimental Psychiatry for research in the nature of the psychiatric interview. The Biochemistry Department was concerned principally with blood enzyme levels in the hospital patients and with their urinary alkaloid excretion patterns. Results of a third study ﬂatly contradicted European reports of a blood test for schizophrenia. Under the direction of Dr. Harry Goldenberg, laboratory co-workers determined that serum cholinesterase levels in patients receiving electroshock therapy vary according to sex, with female patients generally higher. Work with rats suggests that these ﬁndings may be related to an abnormal adrenal metabolism Preliminary studies on the more acutely ill mental patients revealed an excessive excretion of aromatic metabolites in the urine, in agreement with the reports of other workers. It is not yet known whether this phenomenon has a causal relationship to schizophrenia European claims of a blood test for schizophrenia which is based on serum oxidase (ceruloplasmin) assay were unsubstantiated. Positive tests were obtained in various conditions other than mental disease (pregnancy, upper respiratory infections, cancer), while many well-fed patients gave negative tests. It was concluded that the I I European patients who were studied probably were suﬂering from a Vitamin C deﬁciency. M ~”‘waﬁrm/WNWwWa/WM‘ WM l/lMWn/WWVWVWW vv 4 MUM/WWWW4“:WM WW “WA/WWW Mil/wk} WWW «WWW-mekmrmwwvymmm AWWx W'WWVWWWWWMrMWW/VW MANN“ �I During 1957, members of Hillside’s staff were much in demand as guest lecturers and convention speakers. As the hospital continues to prove its value as a pioneer in the “open hospital” philosophy, more and more demands are made on the staff for intensive training courses, lectures and publications. Staff members spoke at meetings of national organizations including the American Psychiatric Association, and the National Conference of Jewish Communal Service, state groups including the New York State Society for Mental Health, and local groups including the North Queens Mental Hygiene Association and the Queens County Mental Health Society I Staff members reported on therapy and research and other results in a large number of professional publications, The Journal of the Hillside Hospital, edited by Dr. Sidney Tarachow, included articles by staff members and also outside contributors. �Publications 1957: R. L. I Esecover. H.. Juffe. J. and Kuhn. R. L.: Psychotherapeutic Techniques with Electroshock Patients, J. Hillside Hosp. (in press) and Green. M. A.: Experimental studies of the Electroshock Process Dis. Nerv. Syst. ( in press) I I I Fink. M.. Kuhn. Fink. M.. Shuw. R.. Gross. G. and Colemun. F. 5.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis, J. Amer. Med. Assoc. (in press) Threshold, EEG Clin. Neurophysiol. (in press) I I Fink. M.: Lateral Gaze Nystagmus as an Index of the Sedation Fink. M.: Individual Differences in EEG Responsivity. Read at Metropolitan EEG Society, New York, February 1957 Fink. M.: Criteria in Evaluation of Clinical Behavioral Change: Neurophysiologic Aspects. Presented at A.P.A., Round Table, Chicago, May 1957 I and Green. M. A.: Experimental Studies of the Electroshock Process. Read at the Society of Biological Psychiatry, Atlantic City, June 1957 Therapy of Schizophrenia: Role of Alteration in Brain Function in Behavior. Presented at Int. Congress of Psychiatry, Zurich, Sept. 1957 Korin. H.: Effects of Diffuse Altered Brain Function on Perception. Presented at the XV Int. Congress of Psychology, Brussels, August 1957 Behavioral Patterns in Induced States of Altered Brain Function. Read at the New York Divisional Meeting, A.P.A., Nov. 1957 Shift for Psychiatry. Read at Metropolitan EEG Society, N. Y., Nov. 1957 81 I Fink. M.. Kuhn. R. L. Fink. M. and Kuhn. R. I..: Fink. M.. Kuhn. R. L. and Fink. M. and Kuhn. R. L.: Fink. M.: Signiﬁcance of EEG Frequency I Fink. M.: Effects of Diethazine on EEG and Signiﬁcance for Theory of Process of Convulsive Therapy. Read at Eastern Association of Electroencephalographers, New York, Dec. 1957 Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. I I I I Fink. M. and Kuhn. R. L.: Relation of EEG Delta Activity to Behavioral Response in Psychiat. 78: 516-525, 1957 I Fink. M.: A Unified Theory of the Action of Physiodynamic Therapies, �J. Hillside Hosp. 6: 197-206, 1957 I Goldenberg. H.. and White. D. L.: Chromatographic, Electrophoretic and Colorimetric Procedures for the Psychotomimetic and Psycho- therapeutic Drugs; Presented at the Meeting-in-Miniature of the Metropolitan-Long Island Sub-section, New York Section, American Chemical Society, Brooklyn, New York, February 15, 1957 I Goldenberg. H.. and Goldenberg. V.: Speciﬁc Colorimetric Determination of Cholinesterase Activity in Blood and Spinal Fluid; Presented at the Meeting-in-Miniature of the Metropolitan-Long Island Sub-section, New York Section, American Chemical Society, Brooklyn, New York, February 15, 1957 Inhibition of Serum Cholinesterase by Mental Drugs, Ann. N. Y. Acad. Sci., 66: 466-467, 1957 Electroshock, J. Hillside Hosp. 6: 229-240, 1957 Juffe. J.: Criteria in Evaluation I Juffe. J.: I Green. M. A.: Signiﬁcance of Individual Variability Study of Communication in Psychiatric Interviews. Read at the New York Divisional Meeting, A.P.A. Nov. 1957 Response to Electroshock Therapy. Presented at Electroshock Research Association, Chicago, May 1957 Induced Altered Brain Function. Read at Amer. Psychol. Assoc., New York, August 1957 Hosp. 6: 216-228, 1957 I I I I in EEG Response to Juffe. J.: I An Objective Kuhn. R. L. and Fink. M.: Personality Factors in Behavorial Kuhn. R. L. and Fink. M.: Perception of Embedded F igurm After Kuhn. R. L. and Fink. M.: Perception of Embedded Figures After Induced Altered Kuhn. R. L.. Pollack. M. and Fink. M.: Social Factors in Selection of Therapy in 3 Voluntary Mental Hospital, J. Hillside Tarachaw. S. and Friedman. S.): Perception Experiments in 241-250, 1957 I I I I I Kuhn. R. L. and Fink. M.: Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol. (in press) N. Y. Neurol. Society, N. U., Jan. 1957 Goldenberg. H.: An Objective Study of Communication in Psychiatric Interviews, J. Hillside Hosp. 6: 207-215, 1957 of Clinical Behavorial Change: Psycholinguistic Aspects. Presented at A.P.A., Round Table, Chicago, May 1957 Brain Function, Amer. Psychol. 12: 361, 1957 I a Study of Ambivalence. Read at Section on Neurology & Korin. H. (with Psychiatry of N. Y. Academy of Medicine and Karin. H. and Fink. M.: Role of Stimulus Intensity in Perception of Simultaneous Cutaneous Electrical Stimuli, J. Hillside Hosp. 6: Korin. H. (with Tarachow. S. and Friedman. S.): Perception Experiments in a Study of Ambivalence, Arch. Neurol. & Psychiat. 78: 167-176, 1957 I Karin. H. (with Tarachow. S. and Friedman. S.): The Relation of Ambivalence to Aggression and Authority in Psychoneurotic Patients. Read at Amer. Psychol. Assoc., New York, Sept. 1957 I Karin. H. (with Tarachow. S. and Friendman. 5.): Studies in Ambivalence. Presented before Schilder Society, New York, Oct. 1957 I Pollack. M. (with Goldfurb. W. and Dorsen. M.): Pain Reactions in Schizophrenic Children. Presented at Amer. Orthopsychiatric Assoc., Chicago, March 1957 I Polluck. M. (with Krieger. H. P.): Oculmotor and Postural Patterns in Schizophrenic Children. Presented at Amer. Academy of Neurology, Boston, April 1957 I Pollack. M. (with Buttersby. W. S. and Bender. M. 3.): Figure-ground Perception in Patients with Cerebral Tumor. Read at Eastern Psychol. Assoc., N. Y., April 1957 I Pollack. M. (with �Battersby. W. S. and Bender. M. B.): Defects in Visual Perception in Brain Tumor Patients. Presented before Int. Congress of Psychol., Brussels, July 1957 M. I Pollack (with Battersby. W. S. and Bender. M. B.): Visual Deﬁcit After Brain Damage in Man as Measured with Rapidly-Exposed Chromatic Stimuli. Presented at Amer. Psycho]. Assoc., New York, Sept. 1957 l Pollack. M. (with Goldfurb. A.): Cultural and En- Vironmental Factors Affecting Complex Perception in the Institutionalized Aged. Presented at the Gerontological Society, Cleveland, Oct. 1957 l Pollack. M.: Brain Damage, Mental Retardation and Childhood Schizophrenia. Presented at New York Divisional Meeting, A.P.A. Nov. 1957 and“; a. I Pollack. M. (with Goldfarb. W.): Face-Hand Test in Schizophrenic Chil- dren, AMA. Arch. Neurol. & Psychiat. 77: 635-642, 1957 farb. W.): Patterns of Orientation I Pollack. M. (with Gold- in Children in Residential Treatment for Severe Behavior Disorders, Amer. J. Orthopsychiat. 27: 3, 538-552, 1957 Battersby. W. S. and Bender. M. I Pollack. M. (with BJ: Tachistoscopic Identiﬁcation of Contour in Patients with Brain Damage, J. Comp. Physiol. Psychei. 50: 3, 220-227, 1957 (with Battersby. W. S. I Pollack. M. and Bender. M. 3.): Visual Deﬁcit After Brain Damage in Man as Measured with Rapidly-Exposed Chromatic Stimuli, Amer. Psychol. 12: 7, 468, 1957 I Pollack. M. (with Goldfarb. W.): Cultural and Environmental Factors Affecting Complex Perception in the Institutionalized Aged, J. Gerontol., 12: 4, 437-438, 1957 I Zierer. E. (with Zierer. Edith): Leonardo Da Vinci’s Artistic Proclivity and Creative Sterility, The American Imago, Vol. 14, No. 4«, 1957. Each publication is a tribute to the vision of the hospital’s founder, the late Dr. Israel Strauss. �gar ZM/ *w U 473/ c Jywwﬂky The Residenf Training Program at Hillside continues to emphasize the interrelation between the training program and the treatment program. Each Resident carries a case load of about 15 patients under the supervision of staff and visiting instructors. and attends lecture conferences conducted by the medical director. Lecture seminars in the ﬁelds of psychopathology and psychotherapy, and reading seminars, are conducted by special instructors chosen from the hospital staff. Qualiﬁed Residents are assigned to the Department of Experimental Psychiatry for clinical and other psychiatric research projects. During the year there were 18 Residents in training, 15 in the adult in patient service and three in the Israel Strauss Adolescent Pavilion The hospital training program extends also to Clinical Assistants in the Out Patient and After-Care Clinics and on-the-job training of personnel. Regular lectures and conferences are scheduled for nurses and attendants, social workers, members of the various adjunctive services and for afﬁliating students from other educational institutions. Included in the latter was the establishment of a very important afﬁliated training program for student The Sunday Clinical Connurses from Queens College ferences. open to and attended by psychiatrists and other professional personnel and by outstanding visiting physicians, are part of the Resident training program and are based on cases prepared by the Residents. They continue to make a signiﬁcant contribution to the training picture on the New York The third annual Israel Strauss Lecture, psychiatric scene established in 1955 in honor of Hillside’s founder and late president, was delivered this year on May 5th. The speaker was Norman Reider, M.D., Chairman, Education Committee of the San Francisco Psychoanalytic Institute. The topic of his lecture As anticipated, the Medical was “Transference Psychosis" Library has become a very important feature of the teaching and research activities of the hospital The Journal of the Hillside Hospi‘l‘al again showed an increase in the number of its subscribers and an indication of its greater inﬂuence and wider acceptance in the ﬁeld. Thus the Journal has met the expectations with which it was launched in 1952. I I I I I ��The Israel Strauss Adolescen'l' Pavilion. in its third year, continues as a resident treatment center for a selected group of emotionally ill girls between the ages of 13 and 17. Due to the experimental nature of work with adolescents, only a limited number of applicants are accepted. Because of the intensiveness of the program, adolescent girls are kept at the Pavilion under treatment for a much longer period of time than the adult patients. In 1957, the average period of hospitalization for the adolescents was 300 days, as compared to 192 days for the adults I Although there have been recurring problems with shortages of trained personnel, the pilot program of the Adolescent Pavilion has proceeded as planned, and many new discoveries have been made The seventeen girls who Were admitted in 1957 were afforded the opportunity for intensive psychotherapy and a well- I structured living experience. In an atmosphere reminiscent of a girls’ boarding school, a professional team has worked to make this unique program succeed. The team, under the direction of Dr. Alice Slater Stahl, includes three psychiatrists, a psychologist, nurses, teachers, an occupational therapist, a group activity worker, plus the non-professional help of nurses’ aides, members of the housekeeping and kitchen departments and volunteers. A two story building includes all therapy facilities as well as dining and lounging areas. The semi-private rooms are furnished to allow for the fact that disturbed adolescents are often more destructive than adult patients I It is �believed that if Hillside can work out techniques for treating emotionally ill adolescent girls, much can be learned about the problems of child guidance and juvenile delinquency. Certainly much of what has been learned in the past year can be applied to adult treatment. During the year, it was discovered that the original plan for isolating the girls did not work out as Well as integrating certain aspects of the program with adult activities. It has also been found that certain adolescents made more rapid recovery when transferred to adult cottages. The plan to let the girls attend school in the outside community was abandoned in favor of school inside the Hospital, though sep- arate from the Pavilion since the experience of “going to school” is important to the youngsters The girls became in- I terested in sewing and put on two fashion shows of their handiwork. One of these fashion shows was the highlight of the 10th Annual Hillside Hospital Field Day. They also made the drapes for the dining and recreation rooms in the Pavilion. In addition, unusual work has been done in ceramics, painting and metals I Of the 120 applications received during the year, 26 patients were screened and 17 were admitted. An attempt was made to evaluate each applicant to determine suitability of $52,400 from The Ford Foundation was used to expand the research, training and patient facilities, including extensions and improvements of the Adolescent Girls Pavilion During the year, the Out Patient Clinic of the Adolescent Unit provided I treatment for 22 girls. Four doctors worked to provide a total of almost 450 psychotherapeutic sessions. Two social workers continued their casework and counselling services with the families, and helped with vocational planning, schooling, job hunting and social problems The After Care program has I provided short term aid in the transition period between the hospital and community life, as well as longer term psychotherapy. Work With Other Organizations. No organization dealing with patients can operate in a completely isolated manner. Hillside’s emphasis on treatment of the patient as a whole, with particular regard to the family, pre-admission care, and post discharge care and follow-up, has resulted in working relationship with the following agencies whose invaluable cooperation has made these programs possible: ALTRO WORKSHOP FEDERATION EMPLOYMENT AND GUIDANCE SERVICE based not only on the criteria of illness, but upon the patient’s ability to beneﬁt from the hospital’s facilities, as well as the DEPARTMENT OF PSYCHOLOGY OF COLUMBIA UNIVERSITY existing group composition at the time. There was an average waiting period of three months after acceptance A grant JEWISH FAMILY SERVICE OF NEW YORK I JEWISH COMMUNITY SERVICES OF LONG ISLAND NEW YORK ASSOCIATION FOR NEW AMERICANS �/% ﬁﬁwl/ 7/ [Ma/whzm'éW/Mt This Annual Report has given a great deal of data regarding service to patients, treatment facilities and research. It has summed up a large complex organization’s work on behalf of the mentally ill, their families and the community which surrounds them. A most signiﬁcant aspect of our work is the extent to which we have been able to mobilize ﬁnancial support from many sources. Perhaps the most concrete and rigorous index of the adequacy of a philanthropic organization’s performance can be gleaned from the way in which it is supported in the realistic world of ﬁnance. It is therefore signiﬁcant that we passed this rigorous test quite successfully during 1957. Our work received excellent support from the City of New York, through its contributions toward the care of the medically-indigent, mentally-ill patient. The Federation of Jewish Philanthropies of New York gave substantial help in deﬁcit ﬁnancing. Without Federation’s tremendous interest, its constant readiness to give advice and assistance, and its careful and generous consideration of our ﬁnancial requirements, Hillside could not have developed the excellent and challenging programs described in this report. Our research programs, started only a few years ago, have begun to command increasing attention in the psychiatric world and signiﬁcant attention—support-wise—in the community at large. More than ﬁfty percent of our research expenditures were met by outside sources, such as the United States Public Health Service and various foundations. The total research deﬁcit was met by contributions from our Board of Directors and their friends Our chief items of expense are for treatment and training programs. The table below gives the comparative total cost of these programs for 1956 and 1957. I The In Patient Service continued to operate at 97% of capacity, while— at the same time—the average income per patient day followed the trend established several years ago of rising each year, in this case by 130 per day. The average cost per patient day, however, rose by $1.53. Therefore, the average loss per patient day in the In Patient Service rose from 40c to $1.80. These changes rise out of the whole complex of increasing cost of operation. In 1956, total expenses of $1,326,454. represented a rise of 12.82% over the previous year; in 1957, with expenditures rising by $169,238, the percentage increase was virtually the same—13%. It is interesting to note the extent to which this year’s increase is related to inﬂationary forces in the community, or to actual improvement or changes in services rendered. It is therefore signiﬁcant that those aspects of expense which are most stable and most clearly related to the price index—Salaries, Food, and Maintenance and Grounds—rose by 7%, 5% and 5% respectively, while the following items more clearly related to quality and quantity of service rendered rose as follows: Administrative Expense 20% Medical Supplies Repairs and Replacements Clinics (Out Patient Service) 24% 39% 30% Again, as in the past several years, the Out Patient Clinic Services accounted for the largest item of increase, reflecting the continued expansion of our preventative programs. This expansion was made possible entirely by grants from the New York City Community Mental Health Board, the State Mental Health Authority, the Federation of Jewish Philanthropies of New York and, during 1957 — for the ﬁrst time — by the participation of the Nassau County Mental Health Board. Included in the increased cost of Out Patient Services was the expansion of the Foster Home Care Program for discharged patients, carried jointly with the Jewish Community Services of Long Island and made possible by the Federation ofJewish Philanthropies. MAURICE BACHRACH COMPARISON OF COSTS 1956-1957 1956 Salaries ................................................................ $ Food .................................................................... Maintenance and Grounds ................................ Administrative Expenses .................................... Medical Supplies .................................................. Repairs and Replacements .................................. Clinics .................................................................. 1957 797,805. 113,428. 59,436. 82,608. 23,950. 35,105. 214,122. 3 855,848. Tofal ............ 1.326.454. 1.495.692. Total No. Patients ................................................ Total Patient Days ................................................ Average Income per patient day ........................ $ Average cost per patient day .............................. Average loss per patient per day ........................ $5 119,350. 62,654. 98,952. 29,811. 49,021. 280,056. 561 545 70,189 15.44 15.84 $ .40 $ 69,987 15.57 17.37 1.80 �PRESIDENT—Alvin E. Coleman* CHAIRMAN OF THE BOARD—Roy Foster* HONoRARY CHAIRMAN OF THE BOARD—Leon Lowenstein‘ VICE-PRESIDENT—Dudley D. Shoenfeld, M.D.* Herbert Beskind” VICE-PRESIDENT—George W. Galinger* SECRETARY—Manuel Lee Robbins* TREASURER—~Arn01d S. Askin“ VICE-PRESIDENT—D. ASSISTANT SECRETARY—Alfred ASSISTANT SECRETARY—~M. Appel Victor Leventritt ASSISTANT TREASURER—Arthur Carson ASSISTANT TREASURER—Harry Silverson HONORARY DIRECTORS—Hilda Strauss and Saul Blickman Board of Directors A. Jacob Abrams Alfred Appel Arnold S. Askin“ John M. Bendheim D. Herbert Beskind“ Saul Blickman Alvin E. Coleman" Morris David Thomas Epstein Arthur C. Fatt" David Finkle David Finn Roy Foster“ George W. Galinger“ Arthur Carson Maurice Glinert Meyer Goldstein Jacob Epstein KatzT M. Victor Leventritt Budd LevinsonT Morris L. Levinson Milton B. Loeb Sandor Lorand, M.D. Leon Lowenstein* Charles H. Meyer* ' Walter Scheuer Dudley D. Shoenfeld, M.D.* Harry Silverson Hilda Strauss Irving Weissglassi Nathan Wigod Morton S. Wolf * Walter D. Yankauer“ Arthur Murray Manuel Lee Robbins* Irving Rosenbaum S. H. Seheuer‘ Chairmen of Standing Committees Foster MEDICAL AFFAIRS COMMITTEE—D. Herbert Beskind FINANCE COMMITTEE—Arnold S. Askin EXECUTIVE COMMITTEE—Roy HOUSE AND GROUNDS COMMITTEE— George W. Galinger, Nathan Wigod—Co-Chairmen LEGAL COMMITTEE—Charles H. Meyer SOCIAL SERVICE coMMITTEE—Hilda Strauss LIAISON coMMITTEE—L. 1. Jewish Hospital—Alvin E. Coleman PUBLICITY COMMITTEE—Arthur C. F att PERSONNEL COMMITTEE—Meyer Goldstein PLANNING coMMITTEE—Meyer Goldstein GIFTS AND LEGACIES COMMITTEE—Walter D. * Executive Committee Members T Elected in I957 Yankauer �Miller, M.D. ASSOCIATE MEDICAL DIRECTOR—~Simon Kwalwasser, M.D. ADMINISTRATOR—Maurice Bachrach, B.S. SUPERVISING PSYCHIATRISTS—George Yessin, M.D. Gerhard Schauer, M.D. Robert Navarre, M.D. Zenos M. Linnell, M.D. Harold Esecover, M.D.* MEDICAL DIRECTOR—Joseph S. A. DIRECTOR, ISRAEL STRAUSS ADOLESCENT PAVILION— Alice Slater Stahl, M.D. SUPERVISING PSYCHIATRIST, ISRAEL STRAUSS ADOLESCENT PAVILION, OUT PATIENT DEP’T.—Eugene Glynn, DIRECTOR OF OUT PATIENT SERVICES—Robert M.D. R. Luttrell, M.D. DIRECTOR OF RESEARCH IN EXPERIMENTAL PSYCHIATRY— Maxirriilian Fink, M.D. INTERNIST—Arnold Blumberg, M.D. DIRECTOR OF LABORATORIES—Harry Resident Staff Norman Ackerman, M.D. Barre Alan, M.D. Stanley Brodsky, M.D.* Bernard Cohen, M.D. Frederick Coleman, M.D.* Warren Cox, M.D. Alan Dobrow, M.D. Necdet Ecder, M.D. Ilhan Ermutlu, M.D. Stefano Faj rajzen, M.D. Marie Friedman, M.D. Stanley M. Friedman, M.D.* Ruth Fuchs, M.D.” Harold Galef, M.D.* Robert S. Gilbert, M.D.T Victor Coldin, M.D.* Michael Gould, M.D. Sherwin Harris, M.D. Edwin Kleinman, M.D. A. Russell Lee, M.D.” Leon .Lefer, M.D.* Henry Lefkowits, M.D. Sidney Lytton, M.D. Robert Nodine, M.D. Goldenberg, Ph.D. Paul Pressman, M.D. Arthur Root, M.D.* Alvaro Rozo, MD. Herbert Schulman, M.D. Myron Stein, M.D.* Carl Towbin, M.D. Margery Wile, M.D. Other Professional Staff Heads Goldie Krupa, R.N.—DIRECTOR OF NURSING Abraham Lurie, M.S.S.W.—DIRECTOR OF SOCIAL SERVICES Abraham Levine, Ph.D.—DIRECTOR 0F PSYCHOLOGY Ernest Zierer, Ph.D.—DIRECTOR 0F CREATIVE THERAPY Eileen P. Fisher, B.S.—DIRECTOR OF OCCUPATIONAL THERAPY Arnold Eisen, M.S.S.W.——DIRECTOR OF GROUP WORK DIVISION Angelina Canavan, B.A.——DIETITIAN n Department Heads * Completed residency in 1957 1’ Deceased 1957 Dorothy Croghan—ACCOUNTING SUPERVISOR Lillian Bailey—OFFICE MANAGER Thomas R. Lumley—SUPERINTENDENT 0F BUILDINGS & GROUNDS Sarah Travers—EXECUTIVE HOUSEKEEPER snag—hr, g .. f �PRESIDENT—M. David Epstein, M.D.* VICE-PRESIDENT—Robert A. Savitt, M.D.* SECRETARY—Sidney L. Green, M.D.* TREASURER—Paul Scheman, D.D.S.* Ex-PRESIDENT—Samuel Atkin, M.D.* Samuel Atkin, M.D.* Arnold Eisendorfer, M.D.* M. David Epstein, M.D.* Margaret E. Fries, M.D. I. Peter Glauber, M.D.* Emanuel Klein, M.D. Sidney Klein, M.D. Samuel Z. Orgel, M.D. H. L. Rachlin, M.D.* Lawrence J. Roose, M.D. George S. Goldman, M.D. Sidney L. Green, M.D.* William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Robert A. Savitt, M.D.* Martin Schreiber, M_D_ Isidor Silbermann, M.D.* Otto Sperling, M.D Sidney Tarachow, M.D.* Cohen, M.D.* DEPARTMENT OF NEUROLOGY—Morris B. Bender, M.D. DEPARTMENT OF DENTISTRY—Paul Scheman, D.D.S. DIRECTOR OF DEPARTMENT OF MEDICINE—Lester DIRECTOR OF DIRECTOR OF ADOLESCENT PAVILION—Sidney L. Green, M.D. COMMUNITY EDUCATION AND PUBLIC RELATIONS—Robert A, Savitt, M.D. C‘REDENTIALS; COMMITTEE FOR PSYCHIATRIC STAFF & PROMOTIONS—— Martin Schreiber, M.D. CREDENTIALS COMMITTEE FOR NON-PSYCHIATRIC STAFF & PROMOTIONS:— Paul Scheman, D.D.S. STAFF—Arnold Eisendorfer, M.D. GROUP PSYCHOTHERAPY—Samuel Z. Orgel, M.D. MANHATTAN AFTER-CARE- CLINIC—Sarah R. Kelman, M.D. EDUCATION OF RESIDENT PATIENTCLINIC—William,Karliner, M.D. RESEARCH COMMITTEE—Hyman L. Rachlin, M.D. QUEENS OUT Peter Glauber,M.D. JOURNAL .SUB-COMMITTEE—Sidney Tarachow, M.D. ‘iTDQM;MIT-'I‘EE‘FOR ADIUNCTIVE‘ SERVICES—4'1. 'Peter Glauber, M.D. PUBLICATIONS COMMITTEE—e41. :CREDENTIALSCOMMI‘TTEE TORSUPERVISING- PSYCHIATRIC AND RESIDENT STAFF—— Sidney Klein, M.D.. COMMITTEE FOR LIAISON WITH LONG ,ISLANDRJEWYSH HOSPITAL..— Arnold/Eisendorfe‘r, M.D. , ‘*E’ixéé tsive :Coimmitte'e» M ember; \ i" 'V I ' > v , ‘ ' : " �%[7ZMW% WWM/ W Consultants Psychiatry up OZ Medicine Neurology Leonard Blumgart, M.D. Sandor Lorand, M.D. Irving J. Sands, M.D. Nathaniel E. Selby, M.D. Dudley D. Shoenfeld, M.D. Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, M.D. .1. Jesse Levy, M.D. A. M. Rabiner, M.D. Surgery Gynecology Dentistry Hans Strauss, M.D. I. S. Wechsler, M.D. David Warshaw, M.D. Julius Jarcho, M.D. Morris Fierstein, D.D.S. George S. Goldman, M.D. Sidney L. Green, M.D. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D. Attilio Laguardia, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, M.D. Robert A. Savitt, M.D. Martin Schreiber, M.D. 5011 Goodman, M.D. Samuel R. Lehrman, M.D. Abraham S. Lenzner, M.D. Martin H. Orens, M.D. William W. Pike, M.D. Aaron Stein, M.D. Isadore H. Cohn, M.D. Irving J. Crain, M.D. Albert E. Goldberg, M.D. Albert Harrison, M.D. Thomas Hora, M.D. Abraham Kaplan, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. George P. Krupp, M.D. Peter Laderman, M.D. Harold S. Leopold, M.D. David Milrod, M.D. Irving Salan, M.D. Frederick F. Shevin, M.D. Jay Stanton, M.D. Samuel Tabbat, M.D. Fred U. Tate, M.D. Leonard Weinroth, M.D. Herbert Wieder, M.D. Attending Psychiatrists ' Samuel Atkin, M.D. Frank Berchenko, M.D. Arnold Eisendorfer, M.D. M. David Epstein, M.D. Margaret E. Fries, M.D. I. Peter Glauber, M.D. Isidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D. Associate Attending Psychiatrists Cornelius Beukenkamp, M.D. Alexander J. Friedman, M.D. Mark L. Gerstle, J r., M.D. Adiunct Attending Phychiatrists Edward R. Adelson, M.D. Renato J. Almansi, M.D. Herman S. Alpert, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Belinkoﬁ, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Hugh Mullan, M.D. Helene Papanek, M.D. �MD. VISITING PHYSICIAN—George Sabrin, M.D. DIRECTOR—Lester Cohen, Rosenblum, M.D. VISITING PHYSICIAN—A. Blumberg, M.D. ASSOCIATE PHYSICIAN—M. Kalkstein, M.D. ASSOCIATE PHYSICIAN—J. Weinstein, M.D. ADJUNCT PHYSICIAN—A. L. Berger, M.D. ADJUNCT PHYSICIAN—W. B. Brett, M.D. VISITING DERMATOLOGIST—C. Stritzler, M.D. ASSOCIATE DERMATOLOGIST—Joel Schweig, M.D. ADJUNCT DERMATOLOGIST—N. Goldfarb, M.D. VISITING PHYSICIAN—L. VISITING NEUROLOGIST—Morris B. Bender, M.D.T ASSOCIATE NEUROLOGIST—Kurt Adler, M.D. ADJUNCT NEUROLOGIST—Harry Harter, M.D.I Hirsch, M.D. VISITING NEUROSURGEON—Joseph Siris, M.D. VISITING UROLOGIST—L. G. Goldberg, M.D.’r VISITING UROLOGIST—Daniel Kaufman, M.D. ADJUNCT UROLOGIST—Albert Sutton, M.D. VISITING SURGEON—~Sidney VISITING ORTHOPEDIST—A. H. Lewert, M.D. Schneiderman, M.D. VISITING PROCLTOLOGIST—B. Warner, M.D. VISITING-OPHTHALMOLOGIST——E. Seretan, M.D. VISITING GYNECOLOGIST—M. VISITING GYNECOLOGIST—H. Warner, M.D. Dubrow, M.D. Cohen, MD. ASSOCIATE GYNECOLOGIST—Bernard Greenblat, M.D. ADJUNCT GYNECOLOGIST—Eugene Streim, M.D. ASSOCIATE GYNECOLOGIST—Jack VISITING RADIOLOGIST—Bernard Epstein, M.D. DIRECTOR—Paul Scheman, D.D.S. ASSOCIATE DIRECTOR—J. G. Rubin, D.D.S. ASSOCIATE DENTIST—B. Schwaid, D.D.S. ASSOCIATE DENTIST—B. Lebow, D.D.S. ADJUNCT DENTIST—H. Lewis, D.D.S. ADJUNCT DENTIST—H. Adler, D.D.S.’r ADJUNCT DENTIST—S. Plotnick, D.D.S. ADJ-UNCT DENTIST—E. Friedman, D.D.S. ADJUNCT DENTIST—M. Protell, D.D.S. ADJUNCT DENTIST—L. Basson, D.D.S. STAFF OPTOMETRIST—-Edward L. STA-FF Steinberg, O.D_. OPTOMETRIST—Bernard Attinson, O.D. ASSOCIATE ORTHOPEDIST—J. Minsky, M.D. OTOLARYNGOLOGIST—S. Clayton, M."D. ANE-S'THESIOLOGIST—Ceorges Bean, M.D. ASSOCIATE OPHiTHALMOLOGIST——A. VISITING VISITING STAFF 'PODIATRIST—Sam Resigned 195;? I Deceased 1795-7 T Sokolov, Pod.0. �Lester I. Abend, M.D. Ruth Adams, M.D.* Romano Antonelli, M.D. Howard Boskey, M.D. Paul Bradlow, M.D. Stanley Brodsky, M.D. Arline Caldwell, M.D. Mischa Caplan, M.D. Daniel Chansky, M.D. Lionel Chertoﬁ, M.D. Rita M. Chalef, M.D. Gloria Chung, M.D.“ * Resigned I 957 Ralph W. Clemments, M.D. Julius Colantuono, M.D.* Frances Colonna, M.D. Fred Dalton, M.D.* Irving J. Farber, M.D. Robert D. Ferrell, M.D. Philip Friedland, M.D. Harvey Coldey, M.D. Victor Goldin, M.D. Sumner I. Goldstein, M.D. Clara Gonda, M.D. Harry Gonda, M.D. David Graubert, M.D. Howard Hess, M.D.* Martin Hurvitz, M. D. Gunthar Jacob, M.D. Wilbur Jarvis, M.D. Peritz Levinson, M.D. Buck Luria, M.D. Daniel Miller, M.D. Meyer Monchek, M.D. Beatrice Nachtigal, M.D. Iris Orens, M.D.* Edward Pinney, J r., M.D. Joshua Ramot, M.D.* William Roosen, M.D. Phoebe Rosen, M.D. Joseph D. Rosen, M.D. Henry Rosberger, M.D. J ehuda Rozanski, M.D. Gabriel Rubin, M.D. Charles Silberman, M.D. Herman Tannor, M.D.“ Leon Tec, M.D. David M. Tillim, M.D. Clara Torda, M.D. Aimee Wiggers, M.D. �Hillside Hospital is a member of: AMERICAN HOSPITAL ASSOCIATION AMERICAN PSYCHIATRIC ASSOCIATION FEDERATION OF JEWISH PHILANTHROPIES GREATER NEW YORK HOSPITAL ASSOCIATION HOSPITAL ASSOCIATION OF NEW YORK STATE NATIONAL CONFERENCE OF JEWISH COMMUNAL SERVICE NEW YORK STATE DEPARTMENT OF MENTAL HYGIENE NEW YORK STATE DEPARTMENT OF SOCIAL WELFARE NEW YORK STATE WELFARE CONFERENCE QUEENSBORO COUNCIL FOR SOCIAL WELFARE UNITED HOSPITAL FUND WELFARE AND HEALTH COUNCIL OF NEW YORK CITY We are fully accredited by: JOINT COMMISSION ON ACCREDITATION OF HOSPITALS 1%gzlled/ZJ ”42/ QWMJ . OF THE UNITED STATES AND CANADA (NO p recise words are necessar y to a valid le g ac y to the We are approved for re51dent tralnlng by: . . é % WM . . Society. The following form, however, may be suggested.) AMERICAN MEDICAL ASSOCIATION AMERICAN DENTAL ASSOCIATION ' We .C arr y Jom t progr am S i n which 5 p eciﬁc s e rvice~b to p atients are ad, , , mlnlstered by the hospltal and pald for by tax-supported publlc agenCIes: I give to the Society of the Hillside Hospital, for the use 0/ the Hillside ' _ _ Hospital, the sum of _ $_—__—_(if land or any speciﬁc property, NASSAU COUNTY MENTAL HEALTH BOARD such as bonds ’ stocks ’ ece t ‘e r a, iS g i”e n ’ a b r'“3f NEW YORK CITY COMMUNITY MENTAL HEALTH BOARD should be inserted instead of the words “the sum of NEW YORK STATE MENTAL HEALTH AUTHORITY NEW YORK CITY DEPARTMENT OF HOSPITALS DIVISION OF VOCATIONAL REHABILITATION, NEW YORK STATE DEPARTMENT OF EDUCATION NEW YORK CITY, BOARD OF EDUCATION UNITED STATES PUBLIC HEALTH SERVICE, INSTITUTES OF MENTAL HEALTH We have established programs of community education and community mental hygiene with: QUEENS COUNTY MENTAL HEALTH SOCIETY NASSAU COUNTY MENTAL HEALTH SOCIETY ' descnp tio " 0/5 h 5 P r 0P3 r‘9’ $_____”). �An aﬂiliate 0f the Federation of Jewish P/zilant/Lropies of New York �31:! ANNUAL REPORT V~ A FOR THE YEAR 1958 HILLSIDE HOSPITAL GLEN OAKS, QUEENS, N. Y. ��Federatwn f 0 a partzczpant 0f- the Fund and the Créat‘erg ��TABLE OF CONTENTS report of the director of professional services report of the medical director report of the President of the Medical Board report of the President of the Board of Trustees treatment psychotherapy and medical services psychology department intramural clinic nursing department department of dentistry occupational and creative therapy adolescent pavilion organization chart insert social service department casework division group work division Manhattan after-care clinic Israel and Hilda Strauss League Queens out-patient service Training programs Sunday clinical conferences Israel Strauss lectures medical library research experimental psychiatry department of biochemistry medical department Hillside publications Hillside journal grants and awards received 1958 report of the administrator society of the Hillside Hospital 3 4 6 7 10-13 ‘10 10 11 11 11 12 12 16-17 14-19 14 15 18 18 18 19 19 19 19 22-23 22 22 23 24- 25 25 27 30-32 �report of the director of professional services LEWIS L. ROBBINS, M.D. As a very new member of the staff of Hillside Hospital, I should like to look ahead rather than participate in a review of the past year. A forward-looking plan for the future development of Hillside Hospital is essential if it is to serve best the needs of the community today and tomorrow. The three main areas of activity at Hillside today are clinical service, education and research. We will never lose sight of our primary day-to-day service, which is the treatment of the mentally ill. Yet to consider enlarging the capacity of Hillside—to help more of the people who are psychiatrically ill—is not the answer for the future. Experience of larger institutions indicates the weakness of this approach. When the capacity of a psychiatric hospital is expanded beyond a certain point, individualized treatment of patients gives way to regimentation. The result is that the quality of clinical service falls. It is more probable that Hillside can best serve the community by striving to advance our knowledge of psychiatry for the greater good of everyone, whether or not he is ever a patient at Hillside Hospital; and by training professional personnel who will later make use of what they have learned here in other institutions throughout the country. The main shortage in psychiatry today is knowledge. Although there have been tremendous advances in the past 50 years, much remains to be learned. And while much has been spent in the development of all types of psychiatric facilities, relatively little ﬁnancial support has been given to psychiatric research. It is therefore recommended that the excellent facilities of Hillside Hospital and its present and potential relationships with other institutions in the area be utilized primarily for the advancement of psychiatric knowledge. A unique and productive approach would be the long-range goal of an Institute for Advanced Psychiatric Studies established at Hillside. Although there exists today an excellent research program at Hillside, it represents but a small fraction of the many types of AHEAD research that could be successfully conducted here. The clinical program of the hospital provides a great variety of clinical problems, as well as opportunity for thorough observation. The forward-looking philosophy of Hillside Hospital, along with its utilization of personnel from many different disciplines, constitute an excellent foundation for the development of a broad research program. Such a research program would develop spontaneously if personnel were adequate—both qualitatively and quantitatively—to take care of our clinical responsibilities. A staff must be developed who are not only good clinicians but who also possess an interest in and capacity for both teaching and research. The need for trained personnel in psychiatry is urgent. Hillside already has accepted education as one of its principal functions; and this function could very well be expanded without detracting from the research objectives which may be established. Hillside Hospital thus will continue to be a pilot institution providing the best psychiatric treatment currently available, constantly striving to develop newer and better methods, and sharing its experience with others for the welfare of the general community. Its future is limited only by the imagination of its staff, the leadership of its Board, and the support of its community. 3 �the of report medical director JOSEPH S. A. MILLER, MD. This will be my last Annual Report as Medical Director of Hillside Hospital. When I came to Hillside in 1947, there was a one-half time Assistant Medical Director, six Residents, one and a half social workers, no psychologists, and only a fair complement of nurses and attendants. There were eighty-eight patients. There was no out-patient department, and only the beginnings of an after-care program. There was no organized research. The teaching was carried on by the Medical Director and by members of the Medical Board. From about 1948 on, the services and facilities of the hospital began to grow. The new Lowenstein Pavilion was opened in 1949 and practically doubled the bed capacity. The number of Residents was increased to twelve and, in addition to a full-time Associate Medical Director, Staff or Supervising Psychiatrists were added. More attention was now paid to the discharge and rehabilitation plans and, with the interest and support of the Federation of Jewish Philanthropies, with whom we had just become affiliated, we enlarged our Social Service Department. In 1951, we began a small out-patient clinic and also improved the services of our aftercare clinic. With the construction of the Elizabeth Sloman Lowenstein Building in 1954, the small out-patient clinic was developed into a service able to treat some two hundred patients twice weekly. That year, also, the Israel Strauss Pavilion for Adolescent Girls was established. Supervised clinical training and teaching of the Residents was enhanced; teaching in basic clinical psychiatry, clinical diagnosis and psychotherapy was extended; regular stated clinical, diagnostic and discharge conferences were instituted; and we appointed special instructors to give didactic instruction in psychopathology and psychotherapy. 1951 saw the beginning of organized research at Hillside with a biochemistry research laboratory set up under Dr. Werbin. He was succeeded in 1954 by Dr. Harry Goldenberg, who now heads our Bio-chemical Research Department and who has made some original contributions which have been recognized and supported by grants from the United States Public Health Service and by funds from our own Board of Trustees. The largest contributions in the ﬁeld of organized research were made in the area of experimental psychiatry, especially electroshock therapy and tranquilizers, headed since 1954 by Dr. Maximilian Fink. There have been other signiﬁcant changes and trends. First of all there has been a change in the type of mental patient coming to the hospital. Our patients now are of the borderline-psychotic type, although they still fall generally within the qualiﬁcations for voluntary admission. There has been a deﬁnite drop in the average age of the patients from the mid-thirties to the midtwenties. Signiﬁcant, this year was the replacement of the insulin coma treat- ment by the tranquilizer, chlorpromazine. We also improved and enlarged our occupational therapy and group activity services, and, under the able direction of Dr. Aaron Stein, our group psychotherapy programs. Our out-patient services, ably directed by Dr. Robert Luttrell, and our community mental health clinics, with support from the New York City and Nassau County Mental Health Boards, have been regarded as models of clinic operation. Our attending psychiatrists, notably Drs. Martin Orens and Abraham Lenzner, have contributed greatly to the teaching and clinic conferences. At the close of the year a well-deﬁned program for the out-patient treatment of school age children was completed. The Israel Strauss Adolescent Pavilion completed 4 years of operation. The experiences gained there will mean not only an improved teaching and treatment program, but also, in the not too distant future, a worth-while research program. Our Resident Training Program has maintained its high standards, but has pointed up the need for more in-hospital or on-the-premises teaching and clinical supervision. This in turn has called for a larger number of better qualiﬁed supervising or staff psychiatrists, a call we have begun to meet. We have been aided to a generous extent by National Institutes of Mental Health in receiving a number of training grants for our Residents and teaching grants for our special instructors. There is a need for a more comprehensive research program involving projects which will deal, in a more integrated fashion, with the physical, mental and ecological factors in development and treatment of emotional disorders. The Journal of Hillside Hospital has, under the able direction of its editor-inchief, Dr. Sidney Tarachow, achieved a national reputation in scientiﬁc circles. �In the decade since Hillside joined the family of Federation, we have beneﬁted not only from their planning and other special committees, but even more from the association with Federation’s hospitals and agencies in common purposes. Mt. Sinai Hospital provided us with space for processing and interviewing patients in our after-care clinic for discharged patients. Since 1950, we have had a rich and fruitful liaison with the Jewish Community Services of Long Island, through which we have been able to establish supervised psychiatric services as well as a very worth-while family care or foster home program for our discharged mental patients. This program resulted in our winning the Milton Weil Award from Federation in 1955. As soon as the Long Island Jewish Hospital had begun its operations, we helped establish their psychiatric service. We are indebted to them for their outstanding help. Mention ought to be made here too of our help from the Federation Employment Service, and our dual participation in a vocational rehabilitation program with the Altro workshops. I want to mention also, our ever-friendly relations with the Jewish Family Service, who have not only provided ofﬁce space for our Social Services Department in Manhattan, but have also been cooperating with us in a long-range case work guidance program for our discharged patients. In these days of the “open hospital” and the establishment of psychiatric services and out-patient clinics in general hospitals, the question arises about the future of the separate or special mental hospital. The answer is that there will always be patients who will require in-resident therapy in a controlled therapeutic environment. The small psychiatric hospital need not be separated— indeed it should work in close relationship with the community and its hospitals, institutions and agencies. Hillside will become more and more of an open hospital in the modern sense, depending largely upon the education of, and acceptance by, the community. However, within the framework of its special treatment, teaching, and research services, it ought to remain as far as possible, autonomous. The mental hospital provides the essentials for the emotional re-educative process in which the patient is able to re-live and review his earlier and unsuccessful relationships. He learns to become a better functioning part of the new and smaller society of the hospital, and this in turn ﬁts him for better or improved adjustment in the larger society outside. The small mental hospital employs facilities for more individualized treatment—where he may be observed in his behavior toward others and taught how to live with them, and how to exploit his own personality assets. Fortunately for Hillside, my successor, Dr. Lewis L. Robbins, has a rich background of professional experience in teaching, treatment, research and administrative ability. His views and attitudes in regard to the special mental hospital—the types of psychiatric and other professional personnel needed, the hospital environment and the various adjunctive needs of the patients— are salutory and knowing. I close my ﬁnal report on Hillside with the utmost conﬁdence in the future that awaits this great institution. I am proud of the many achievements made during my stewardship. It is needless to state that this could not have been done except with the help of a marvelous staff as well as the cooperation of the Medical Board and the Board of Trustees. My thanks to all the professional staffs and employees of the hospital, and especially the heads of departments. And I want especially to thank my two “Chief Lieutenants” who worked with me for the good of the hospital and contributed so much to its success during the past decade: Dr. Simon Kwalwasser, Associate Medical Director and Mr. Maurice Bachrach, able and talented Administrator. I greet Dr. Lewis L. Robbins, with whom it is a pleasure to have been thus brieﬂy associated in the common venture at Hillside, and who, I am sure, will raise the hospital standards and services to even greater heights. Although this is my last Report on the Hospital as Medical Director it is not really a “bill of divorcement”. I am happy and proud to have been asked to continue as a general consultant to the Hospital, and as a special instructor to the Residents. I cannot close on a better note than by greeting the more than a hundred Residents who trained under me during these past'12 years. Hillside can well be proud of them, scattered as they are over the United States, and contributing, wherever they are, to the treatment, teaching and research aspects in the ﬁeld of psychiatry based on their early training and treatment experiences of their Alma Mater—Hillside. �the of report President of the Medical Board ROBERT A. SAVITT, M.D. 6 During the past year the Medical Board has continued to function actively in its role as an advisory and consultative the and Director Medical the to group Board of Directors. Through its standof which comprised committees are ing the various echelons of the attending staff, the Board is directly involved in all of the medical activities of the hospital. The Credentials Committee for the Supervising and Resident Staif under the chairmanship of Dr. Roose, has spent countless hours interviewing and processing applicants for psychiatric residency training. Over a period of collected is on information being years the method of choosing residents. It is expected that when this is collated and correlated, it will yield valuable guide the for criteria in determining posts choice of psychiatric personnel. As in previous years the residency training program continues to be a major interest of the Medical Board. In this connection Dr. Arnold Eisendorfer’s committee has held periodic conferences with Dr. Miller, the Medical Director, in order to further advance the means whereby Hillside will become accredited for a three year residency. One of the important recent advances in resident education and training has come by way of the revised group psychotherapy program. This is expertly directed by Dr. Aaron Stein and coordi- nated by Dr. Samuel Orgel.’s committee. Better liaison has been established between the psychiatric attending staff and the hospital’s adjunctive services. Dr. I. Peter Glauber and his colleagues are formulating a series of conferences and lectures which will increase the mutual exchange of educational and scientiﬁc information with the Psychology and Social Service Departments. Under the superb guidance of its editor, Dr. Sidney Tarachow, the Journal of the Hillside Hospital has expanded its circulation and widened its scientiﬁc achievement in this country and abroad. Currently, several manuscripts are being carefully considered by the Publications Committee for selection in the projected Hillside Hospital Monograph Series. On the basis of liaison agreements entered into during the past year with our neighbor, Long Island Jewish Hospital, a Psychiatric Service has been established at that hospital. It is being administered by Dr. Samuel Lehrman of our Board in collaboration with a number of additional psychiatrists from our attending staff. The Adolescent Pavilion has raised many provocative questions and problems which are gradually approaching resolution. It is expected that our experiences will serve as points of orientation and enlightenment for other psychiatric facilities dealing with the treatment of adolescents. Dr. Margaret Fries and her co-workers are elaborating a method of organizing clinical data which will be of great value in the study of adolescents, is expected to ﬁnd a place in the total resident educational program throughout the hospital. The Medical Board activities also reach out into the community of which Hillside is an integral part. Many of its attending psychiatrists render valuable service to the Queens Out-Patient Clinic and the Manhattan After-Care Clinic in terms of training and supervision of the in and colleagues, presenyounger tation of periodic clinical conferences. The Israel Strauss Memorial Lecture has become a notable yearly medical event which attracts a large audience from the psychiatric and related scientiﬁc professions. The annual Hilda Strauss Mental Health Lecture has also reached deeply into the local community’s stream of mental hygiene activities. It is with deep regret that the Board reports the loss of its beloved member, Dr. Sidney Klein. He died in August 1958, and left behind a legacy which exempliﬁed his love and loyalty to Hillside. Under the terms of his will this is to be devoted to special studies in child and adolescent psychiatry. A suitable memorial in his honor is being planned. I wish to express my deepest appreciation to my many colleagues on the attending staff, to the Medical Director, the Director of Professional Services, to the Board of Directors and those too numerous to mention, for their cooperation and devotion to Hillside Hospital. �report of the President of the Board of Trustees ALVIN E. COLEMAN A milestone in the 31 year history of Hillside Hospital was the appointment of the internationally known psychiatrist, Dr. Lewis L. Robbins, as Director of Professional Services. At the same time that Dr. Robbins is helping us to look ahead, he has helped to put the current program of the hospital in a signiﬁcant perspective. Our prime object is the continued improvement of the quality of the treatment available to our patients, and the scope and value of the knowledge that we are able to impart under our teaching and research programs. Each year it seems more evident that the future of the treatment of mental disease rests in the ability to conduct extensive research in order to learn entirely new methods. We are fortunate to have on our staff capable and farseeing men who are leading us along challenging pathways to the future. During 1958, a Department of Medicine, headed by Dr. Arnold Blumberg, was added to the research program. The Department of Experimental Psychiatry, headed by Dr. Maximilian Fink, did some outstanding work in the ﬁeld of electroshock and tranquilizer drug effects upon the patients’ personality and behavior. The U. S. Public Health Service allocated a 5 year grant of $268,000 for this department and appointed Dr. Fink to serve as a consultant to the Council of the National Institute of Mental Health, which itself passes upon applications for grants from those working in this ﬁeld. Four pharmaceutical houses, Bristol Laboratories, Wyeth Laboratories, Smith, Kline 81 French, and Geigy Chemical Company, provide ﬁnancial grants for further detailed study of how the new psychotropic drugs affect human behavior. The general use of insulin as a mode of treatment was discontinued because it has proven to be too hazardous for results obtained and that the same or similar results are now apparently available through the use of new drugs. The Department of Biochemistry, headed by Dr. Harry Goldenberg, made substantial progress in further studies based upon the premise that mental illness is accompanied by metabolic and other biochemical defects which can be detected. Dr. Goldenberg’s work, too, has received considerable recognition by the U. S. Public Health Service in the form of substantial public grants. Further plans for the modiﬁcation of the building and the treatment program are now being studied. Six new ofﬁces were added to the pavilion for adolescent girls at a cost of $35,000. A joint psychiatric service with Long Island Jewish Hospital, our neighbor, was established through the appointment as Chief of this service of Dr. Samuel Lehrman, Attending Psychiatrist of Hillside and a member of our Medical Board. Through the aid and encouragement of the Nassau County Mental Health Board, it was decided to open a Child Therapy Unit in April, 1959. This will be 50% supported by funds from Nassau County. During 1958, Hillside received a number of important bequests including the balance of the funds left to it under the will of the late Edwin Elson, our former Trustee; the total of this bequest was $52,000. We also received $20,000 from the estate of Dr. S. Klein, who had for many years been a valued member of our Medical Board; and $37,950 from the estate of Wilhelm Levinger, brother of our beloved former Trustee, Alfred Levinger, who had been one of the founders of this hospital. We were awarded a grant by the U. S. Public Health Service of $150,000 toward the minimum required sum of $300,000 for the construction of a building to be used solely for research in mental health. One of our ever-loyal and generous trustees, Mr. Si Scheuer, made it possible for us to promptly qualify and accept this muniﬁcent grant by himself giving us $50,000 towards the construction of this building, which will be knOWn as the Scheuer Building for Research. A 75th birthday was celebrated by one of our most distinguished trustees who has done so much for the Hospital by making possible the magniﬁcent facilities it now enjoys, namely our Honorary Chairman, Leon Lowenstein. We all wish him many more happy birthday anniversaries. 7 ��N 1958, there 342 patients who had this Hillside themselves treatment. admitted to numHospital Of for voluntarily ber, 211 were new admissions, and 131 were readmitted patients of whom 27 I were had previously received treatment at Hillside. the Included in males, 236 106 the 342 female females. were patients, 0f total are the 23 girls admitted to and treated in the Adolescent Pavilion. The average daily census of patients was 195; and the average stay of each ‘ i .‘ ‘ 9.. ’v;'r‘{1 'v: .2» ‘ . - “Amway-713w v ,, . patient was for 196 days. Upon discharge front the hospital, a patient’s condition is evaluated on a he when behavior mental his and basis: enthe status in diﬂerence comparative tered the hospital, and when he left. The ﬁve categories are listed below, (ﬁgures in parentheses indicate the number of patients who left Hillside in 1958) Unimproved (41): no change in condition. have still but been alleviated persist problems or Improved (137): symptoms to an appreciable extent. Much improved (134): symptoms have disappeared and the patient seemed in good condition while hospitalized; however there is no certainty as to his behavior when he returns to his normal environment at home and at work outside of the hospital. Recovered (24). the prognosis is that the patient will be able to return to his social and working community and function as well, or better than he did before he became ill. Without Mental disorder (5) Qied (1 ) OSPITAL ‘ �STAFF EXECUTIVES Abraham Levine, Ph.D. Sylvia Markham, M.A. Leonette Vanderhost, M.A. Director, Psychology Dept. Associate Psychologist Senior Psychologist treatment psychotherapy and medical services The center and core of the treatment program at Hillside is psychotherapy. The ability of the patient to beneﬁt considerably from psychotherapeutic treatment in this area is one of the main criteria for admission. The patient must voluntarily admit himself and be in an early and incipient stage of mental illness. (The long-term, chronic case, requiring custodial care, is referred to other institutions.) The Hillside patient has thus been selectively admitted, receives psychotherapy a minimum of three times a week. In addition, patients participate in group therapy, and all of the other accepted modern therapies, activity therapy, occupational, creative and recreational, drug therapy, and milieu therapy. é 10 _ / s .. .4 . Each team of psychiatric, nursing, social service and other professional personnel of Hillside Hospital meets regularly to pool its knowledge to help its patient along the road to mental health. psychology department The department continued to make its contribution to the understanding of a In the concept of milieu therapy, the whole life of the patient in the hospital, including associations and activities are designed to facilitate his treatment. The therapeutic program thus changes as the patient changes. To conduct this extensive program, Hillside utilizes a “team” approach integrating the skills of the specialists on its staff, under the general supervision of the medical director. Leader of the team is the psychiatrist who is assigned to a patient upon admission, and who remains in charge of the patient for the duration of his stay. Working closely with the psychiatrist, and coordinating the efforts toward the mental health and welfare of the patient are consulting psychiatrists, psychologists, psychiatric nurses, occupational and creative therapists, psychiatric social workers and psychiatric attendants. The team concept is a broad one, and under it conferences are held at which are presented initial diagnosis of newly admitted patient; periodic reports on status of patient and his response to treatment; pre-discharge consultation and rehabilitation, or after-care plans. patient’s strengths, weaknesses, and highly complex psychic states by means of psycho-diagnostic examinations. Objective results obtained through these tests have been helpful to the hospital staff in delineating a history of conﬂicts, defenses, personality. The tests help to reconstruct and chart the patient’s life to show what forces were at work to bring him to the hospital. They provide much informative material needed to plan treatment. Psychological tests are administered upon admission and before separation from the hospital. Last year 541 tests were administered to hospitalized patients and out-patients. Expansion of the department has made possible the inclusion of a vocational counseling program. This program has been especially helpful in developing a placement program within the hospital where a patient may acquire work experience that helps prepare him for the future when he leaves the hospital and returns to his community. In 1958, a doctoral candidate from the Department of Psychological Foundations and Services at Teachers College, Columbia University participated in the psychological counseling program. �STAFF EXECUTIVES Mrs. Goldie Krupa Miss Nancy Jeffries Miss Jean Hendry Miss Helen Schippincase Miss Eleanor MacPhillips Miss Flora McCartney Mrs. Alice McDonough Mrs. Edna Telesca Director of Nurses Assistant Director 0 f Nurses Nursing Instructress Day Supervisor Afternoon Supervisor Night Supervisor I ntra-M and Clinic Nurse Departmental Secretary nursing department intramural clinic This department maintains the patient’s physical health and cares for his non- psychiatric medical needs. Frequent consultations are held between Hillside’s staff and the Intramural Clinic’s specialists to integrate the mental and physical treatment programs. Under the direction of Hillside internist, Dr. Arnold C. Blumberg, the Intramural Clinic handled 2184 patient visits in 1958. The greatest number of patient referrals to Clinic specialists, were in the ﬁelds of Internal Medicine, closely followed by Opthamology, Dermatology and Gynecology. Important services also were rendered in Orthopedics, Otolaryngology, Proctology, Surgery, Urology, Neurology, Podiatry and Radiology. Plans have been made for the Intramural Clinic specialists to take an active part in a psychiatric training program for non-psychiatric physicians. Last year an In-Service Training Program for registered nurses was instituted. The program, which consists of lectures by psychiatric supervisors and doctors, has been of tremendous value to the nursing staff. Knowledge gained and shared has enabled the nurses to perform more effectively to the beneﬁt of the patients and the hospital. The policy of conducting ﬁeld trips through the hospital for students from Central Islip and St. Vincent’s Schools of Nursing was continued. In addition, during 1958, for the third consecutive year student nurses from Queens College received their psychiatric nursing experience at Hillside. F orty-four students participated in the teaching-working program. The training program for psychiatric aides was recognized by the Queens County Mental Health Society, which presented awards and certiﬁcates of honorable mention to four aides trained by the Nursing Department. The awards were made to focus public attention on the important role played by the indispensable psychiatric aides, who contribute so much to the patient through their interest, kindness, attention and skill. department of dentistry Approved by the American Dental Association, it is the oldest intramural department in the hospital. Its staff of 10 dentists, directed by Dr. Paul Scheman, last year received 1112 visits and rendered professional services in orthodontia, periodontia, restorative dentistry and oral surgery and X-ray. New dental equipment acquired in 1958 made it possible to vastly improve the dental care to patients. Members of the department frequently appeared before dental organizations to read papers and give lectures on methods of treating dental patients with emotional problems. ‘ ; I 11 �O. T. STAFF EXECUTIVES Director Eileen P. Fisher Joseph C. Chase Senior Occupational Therapist Adult-Section Esther Burack Senior Occupational Therapist Adolescent Pavilion occupational and creative therapy 12 Two adjunctive services at Hillside, which make an important contribution to the patient and staff are the Occupational and the Creative Therapy departments. Each of these departments has a speciﬁc function, and each is prescribed as a regular part of treatment in cooperation with the psychiatric staff. The OCCUPATIONAL THERAPY department, which is a member of the treatment team, performs a dual function. It provides a program under which a patient can work in various handicrafts, which offer a creative outlet that increases his self-conﬁdence. It also helps the psychiatric staff by reporting on the patient’s attitudes and reactions while he is so engaged. From these reports, which detail responses to success or failure with a project such as weaving, jewelry making, ceramics, the psychotherapist gains further insight to his patient not only at work, but also in his relationship with others in the group. In 1958, the department had maintained a close association with the hospital team. Occupational therapists attended meetings three times a week to contribute their knowledge of a patient, and also submitted regular progress reports to the psychiatric staff. The addition of one therapist to the staff during the year made possible the initiation of an occupational therapy program right in the patient’s room. This enables the therapist to reach a more disturbed patient more quickly and to give him more individual attention. At year’s end, a new prescription form was devised to effect an even closer working relationship between the C. T. STAFF EXECUTIVES Director Dr. Ernest Zierer Creative Therapy Associate Edith Zierer Director doctor and the occupational therapist. The form contains pertinent information which provides a direct guidance line and a higher degree of integration between the psychiatrist and the occupational therapist, indicating areas of concentration that will be most helpful to the patient. CREATIVE THERAPY at Hillside is a specialized form of art therapy devised and developed by Dr. Ernest Zierer. Department Director and his associate, Mrs. Edith Zierer. This therapeutic and psychodiagnostic tool involves the administration of a series of painting tests that reveal a visual expression of the patient’s attitudes toward recurrent life situations. This unique program furnishes a “personality profile” of the patient. This proﬁle supplies the psychiatric staff with documented ﬁndings delineating the patient’s stress and frustration tolerances, strength of motiﬁcation, actual and potential functional capacity and his ability to “integrate” into the societal structure. During the year, an average of 49 patients took part in the program daily and a total of 1640 tests were administered. adolescent pavilion STAFF EXECUTIVES Dr. Alice Stahl, Director Dr. Zenos M. Linnell, Supervisor Dr. Eugene Glynn, Director of After-Care Clinic Dr. Sidney L. Green, Consultant Mrs. Kathleen Cliggett, Head of Nursing Mrs. Sylvia Riback, Senior Social Worker The Israel Strauss Adolescent Pavilion, now in its ﬁfth year, was a pioneering venture of Hillside Hospital. It was 1. 2; �set up to treat and rehabilitate adolescent girls who need hospitalization for emotional problems during a most crucial transistory period of their lives. Hillside Hospital, in venturing into this hitherto neglected ﬁeld, recognized that adolescence is an ideal time to employ the knowledge and skill of modern psychiatric care to help young people when help can be decisive. The Pavilion provides individual psychotherapy, milieu therapy, a school program, a group activities program and nursing care for girls between the ages of .13 and 17. It also conducts an intensive social work program with the families of all patients to create a healthier climate and better understanding at home, of the girls’ problems. The 23 patients admitted to the Pavilion in 1958 remained in the hospital for an average of 315 days, as compared to the 182 days for adults. The conditions range from transient behavior problems to the major psychoses. The staff includes a supervisor, three resident physicians, three registered nurses, two social workers, two school teachers, a group activity worker, an occupational therapist and 16 psychiatric aides. The patients live in a two-story building that includes all therapy facilities, studio-type bedrooms for two girls, dining rooms, lounge and recreation areas. The girls, however, attend school classes in another building to simulate as much as possible the atmosphere of “going to school”. As soon as they are able to, girls are encouraged to join in recreational activities outside their own group in the Pavilion. There have been two notable advances during the year. The ﬁrst is a more structured and individualized program. Under this program the group work department offers a . variety of activities and each patient is required to sign up for two of those activities. The structured program helps the patient to do what she cannot do for herself. The second advance has been to use the concept of individual and group responsibility to foster growth. Housekeeping duties have been assigned to girls and the relationship between various privileges and the patients’ readiness to exercise self control has been stressed. As the Pavilion gains wider recognition among members of the 4" psychiatric profession, greater numbers of referrals continue to come in from distant parts of the country. However, to maintain its high standard of individual attention,the Pavilion restricts its patients to 16 at any given time. The operation of the Adolescent Pavilion is in conformance with the basic thesis of Hillside Hospital; early treatment for those mentally ill patients who can beneﬁt in a relatively short period of time. Even though the adolescent years are directly related to the Hillside orientation, it was obvious at the time the Pavilion was set up, that the adolescent years are the “difﬁcult years.” This period of greatest individual change also is the period about which relatively little is known to the psychiatrist. Five years of treatment of adolescent girls have resulted not only in the improvement of the patients involved but also have led to insights and approaches to modiﬁed and new treatment concepts. These results already have been applied to adolescents, as well as young adults. Follow-up studies of discharged adolescent patients presently are being conducted. In summary, the operation of the Adolescent Pavilion has provided an exciting area for a combined treatment and research project. i 13 �CASEWORK DIVISION EXECUTIVES Abraham Lurie Director, Dept. of Louise Pinsky Sylvia Solovey Sylvia Riback Seymour Silverberg Social Service Department casework division 14 The Social Service Department is the hospital’s most direct link between the patient and his family. The department’s function is to help the patient and his family cope with the personal, social and economic problems caused by the illness. It helps a patient come into the hospital, to stay in the hospital by working with the family members in an effort to relieve pressures on the patient, and ﬁnally, to leave the hospital, and return to a good home climate. This is accomplished by participating directly and actively in the planning that concerns the patient. To accomplish this, in the course of 1958, the Casework Division of the Social Service Department conducted 11,593 interviews with patients, (including those in the Adolescent Pavilion and the Out-Patient Department) and their families. There were, in addition, 10,517 telephone contacts with relatives of patients. This represents an increase over last year’s ﬁgures because a drop in median age of patients, to include many more teenagers, made it necessary for social workers to spend more time with patients and their families. About 35% of the adult patients admitted in 1958 to the hospital are between the ages of 17 and 25. This is due to two principal factors: the policy of selecting patients in the early stages of mental illness, and also the fact that young people are more Social Services Assistant Director, in charge of Casework Supervisor Supervisor Executive Director of the “Bridge” likely to seek hospital help when they are mentally ill. (Older people frequently reﬂect social taboos concerning this type of hospitalization.) The preponderance of young people has changed the social structure of the hospital in many ways including such things as the types of group activities. In 1958, a more intensive effort was also made to screen the 790 male and 1220 female applicants to determine those who could best beneﬁt from the treatment of the hospital, prior to their screening at the clinic. Collaborative relationships with social agencies were continued. One of the most active joint programs was with the Jewish Family Service, which permits discharged patients who need further counseling to get immediate help. At the close of the year, 18 patients (and their families) were receiving aid. Though still a pilot project, this two year old program offers considerable promise for further expansion. Nineteen patients were placed during the year through the F oster Home Program, conducted jointly with the Jewish Community Services of Long Island. This extremely active and important program beneﬁts those patients who, which home have to discharge no upon to return, or who should not, for their well-being return to the same environment in which they lived before admission to the hospital. An invaluable service, which, on occasion, makes possible the hospitalization of a mother, is the Homemaker Service, conducted with the cooperation of the two aforementioned Jewish agencies. This service, supplied to temporarily motherless children, enables the mother-patient to derive maximum beneﬁt from therapy by freeing her from worry about the care of her children. In 1958, 10 families were helped over this particularly difﬁcult time through this program. The Altro Workshop, in the East Bronx provides transitional employment to discharged patients and was used by 13 patients during 1958. The work gainful providing by program, in a protective shop where each employee works at a rate of speed that does not tax him, makes it easier for the �ex-patient to eventually resume normal employement in the community. The Federation Employment and Guidance Service, the New York State Employment Service and the Division of Vocational Rehabilitation have continued to cooperate to the fullest in helping patients secure job placement soon after leaving the hospital. The school program provided by the New York City Board of Education was particularly signiﬁcant in 1958 because of the large number of young patients. Sixty-two patients under the age of 21, who had not yet completed their high school educations were enrolled; 17 were graduated, and six patients passed their high school equivalency examina- tions. The mental patient, unlike the general hospital patient, usually requires longer care and long-time follow-up after discharge. These social service programs indicate Hillside’s recognition of this fact, and the hospital’s community responsibility to provide leadership and coordination of other agencies who could help in the continued care of mental patients during, and after hospitalization. Thus, dozens of private agencies (particularly those afﬁliated with the Federation of Jewish Philanthropies) and public agencies are able to pool their resources. work division group The Group Work Division, under the direction of Arnold Eisen, focuses on the re-socialization of the patient, re-orienting him to group living. The patient is helped to function in an improved manner with his family, friends, employer, fellow-employees and the community in general. A major change in 1958 has been the increased development of community links and a closer coordination with the Casework Division. During the year this division developed a number of new services, programs, ideas and approaches: The New Patients Orientation Group, formed to soften the impact of hospitalization on a new arrival and to supply factual, comforting information to help alleviate fears. Development of Community Program Resources, under which community agencies open their doors to patients on speciﬁed occasions. Trips have been made to YMHA, YWHA, YWCA and YMCA branches in Manhattan, Jamaica and North Hills. Special Cooperative Services with Community Agencies: In cooperation with the Federation Employment and Guidance Service, Group Vocational Guidance sessions were held to discuss the job market, stimulating patient interest in the post-discharge period. Under the Discharge Plan expatients returned to the hospital to tell patients of their experiences at the postdischarge social rehabilitation center, the Hillside League. This has been most effective in relieving separation anxiety. Joint Patient-Family Programming is an outgrowth of Field Days, at which both visitors and patients participate in recreational activities. As an experiment, patients were permitted to invite members of their families to a dance at the hospital. The success of this social event has resulted in planning of other joint events in the future. Internal Programming in 1958 was responsible for establishing several additional lounges, dance therapy, English lessons for foreign-language speaking patients, and other similar programs. A weekly newspaper, edited and published by the patients is now available in addition to their quarterly literary magazine. 15 ��., ~ g _ f TAk 7., . a u, 1 .«f ~ . . I ‘ 1.. . . e. . at. 5,. w ., , >11. .K .,, . . m 7 . ,i . .m.«:, ¢ , . .. L . .w . . . m k . v . . ¢iyu§$ta$ﬂw€u1qﬁm . . \ _.. sub A w ~ m . . v- 4% .. . A. f, . . is» n , N . , ‘ g . ‘ ‘ . / , _ «JD, . . . m a a h ., . . 1: , .. 2 I 1:“ K, ﬂ - w a _ ,. x . . . V . . \ g _ . ., . . _ . . W I K I . . u ‘ . . < l V m . q v I . . _ . ~ v. .. o . . . :8 , ; ‘ V . ‘ . .P A ‘ v �L , Bid-"“1 ' . Gﬁ'emiggry R5e'sea-rqh: Fé‘llby’ﬁ Adjupptjve" ' ’ I , ', Therapies v V ' "' VCI'mlc'al ' ‘ V SoCi’al swipes �‘ ” BOARD ' ;‘ COMMITIEES: Medical Advisory Board . 7, Outside/Affiliations f ‘ Dietary AVDM-IvNiS-TR'ATI'VE‘ SERV‘IQE ' As'sT. ADMINISTRATOR ‘ ADMINISTRATOR Buildings Grounds _ Department . Auditing Secreta rial 0“. Pool» Finance Budgets Diets Menus Dayshift Night Shift ., rchasing Inventory Cleaning 1 P_u 1? Linen Decorating Sto res .- 7 ChefsStaff " . Water Gas Heat Buildings ~ Kitchen Dining Rooms ”Po rters Storekeeping ’ Payrblls Reports Construction .Ma'i nte n anee Craftsmen Porters Attendants ’La'bo‘re'rs Gardeners. Linen Room Engineers Laundry ‘ ' ‘ . Typing. Personnel Supplies Purchases ~' '7 . Medical Budgetary Control ‘ Reports 0 _ ' . Mail Room _ Communications -' , '1 . Medical" _ Statistics 'Grougnds Maids .. gitceou»nts._ : ' i=Bookkee‘pers‘iv~ . ‘ ,Audito rs 'QI e rks Secre'ta ries ' Q, .' Typists - Receptionist Telephone Operators ‘ Typing Pom Trucks“ Cars Gatem’en security A. .4..._. n a em. Hillside Hospital a nd. its Patients . _ ' ��STAFF EXECUTIVES Director of Out-Patient Services Robert R. Luttrell. MD. Assistant Director of Robert Navarre, M.D. Out-Patient Services Miss Sylvia Solovey Mrs. Joan Weisman Mrs. Anne Wexler Mrs. Ida Baumstein Mrs. Estelle Pitts Manhattan after-care clinic The Manhattan After-Care Clinic, located is at week, ﬁve a nights open Mt. Sinai Hospital, a convenient location for most discharged patients. It assists the Hillside discharged patient to resume his role in the community and to deal with the immediate problems of job adjustment and resumption of old environmental contacts. Approximately 30 patients are seen twice Weekly in an effort to bridge their adjustment from the hospital setting to the community setting. The treatment is intense but brief. The importance of this Clinic cannot be underestimated because this helps people who come to the clinic to avoid readmission to the hospital. If they can be helped during the ﬁrst few months, their chances of adjustment in the community are greatly improved. Group or individual therapy is provided, depending on the needs of the patient. Israel and Hilda Strauss League The Israel and Hilda Strauss League is an organization maintained for the social rehabilitation of former patients of Hillside Hospital. Situated in quarters at 231 West 83rd Street, Manhattan, the League furnishes a meeting place for social and recreational purposes. A lounge is equipped Supervising Social Worker Sta]? Psychologist Caseworker Caseworker Caseworker Queens out-patient service with a record player, radio, television, magazines and table games. Its existence is made possible through the devotion and unﬂagging efforts of a group of women volunteers from the community who sponsor the League by raising funds and by offering personal services. The group name “The Bridge”, is symbolic of the purpose of this volunteer organization; $30,000 was raised last year by “The Bridge” for the League. A former Hillside psychiatric social worker, Seymour Silverberg, is assigned as a full-time director of the League. He is available for individual consultation and referral service relating to housing, employment, further treatment and other personal welfare problems. Active membership in the League is now 366, an impressive growth compared to its start in 1954 with 38 members. Devoted volunteer participation has kept pace with the membership. The Queens Out-Patient Service was established to help the emotionally disturbed person before his mental health problems grow and require hospitalization. Psychotherapy is offered to residents of Queens, Nassau and Suffolk Counties who require treatment but cannot assume the economic burden of private care. Selection is made on the same basis as that for in-patients: patients suffering from acute emotional illness are selected after careful screening to determine their likelihood of responding to intensive treatment of a year or less, based on twice-a-week visits. In 1958, 33 psychotherapists worked on a part-time basis to treat 306 patients in individual psychotherapy and 30 patients in group therapy sessions. Usual length of treatment consisted of eleven months. Of the 306 patients treated, 156 were patients admitted to the Clinic in the previous year, and 150 were new patients. To select the 150, 222 patients were fully screened by social workers, through psychological tests and interviews with psychiatrists. Statistics, however, do little to reveal the amount of anguish and tension successfully resolved. They must be translated into the numbers of families kept together, the jobs saved, the fears allayed. �Training programs Hillside’s Resident Training Program continues to emphasize the interrelation between the training program and the treatment program. In 1958, there were 20 Residents in training. Each Resident carried a case load of about 15 patients under the supervision of staff and visiting instructors. In addition, he atttended lecture conferences conducted by the medical director. Instructors from the Medical Board conducted lecture and reading seminars in the ﬁelds of psychopathology and psychotherapy. Qualiﬁed Residents were assigned to the Department of Experimental Psychiatry for clinical and other psychiatric research projects. Seven student case workers from three schools of Social Work were assigned to the Casework Division of the Social Services Department; and six graduate students received training in the Group Work Division of the Department. The training programs extend to Clinical Assistants in the Out-Patient and After-Care Clinics and on-the-job training of personnel. Regular lectures and conferences are scheduled for psychologists, nurses and attendants, social workers and members of the variOUS adj unctive services. Israel Strauss lecture The Annual Israel Strauss Lecture, established in 1955 in honor of the founder and late President of Hillside, was delivered in 1958 on April 20. The speaker was Dr. Paul H. Hoch, Commissioner of New York State Department of Mental Hygiene. His subject was The Open Hospital. Sunday clinical conferences The Sunday Clinical Conferences, open to and attended by psychiatrists and other professional personnel and by outstanding visiting physicians are part of the Resident Training Program and are based on cases prepared by the Residents. They make a signiﬁcant contribution to the training programs in the ﬁeld of psychiatry in the metropolitan area. Medical library The Arany Lorand Memorial Library with Miss Rosalind Lazarus as Librarian continued its rapid expansion program. During the year, 470 books and monographs were added, and 110 periodicals subscribed to. The personal library of the late Dr. Sidney Klein was incorporated. A generous bequest of Joseph Meyer was applied to the psychiatric collection. A gift in the name of Dr. Attlio Laguardia was used to augment the teaching collection. l 19‘ ��- ‘ , ». V , ESEAR CH at Hillside Hospital is a multi-disczplined combined approach of biochemists, chemists, physicists, psychologists, psychiatrists, sociologists and statisticians. Even though the treatment program at Hillside is psychoanalytically oriented, the hospital recognizes that every approach must be explored and utilized in order to increase knowledge and improve the therapy of mental patients. Serious mental illness, with all its disruptive influences, today touches one family in three, since one person in 10 requires hospital treatment for a psychiatric disorder at some time during his life. Hillside believes that the mental health problem requires a total approach, and that progress in the treatment of the mentally ill depends vitally on a program of intensive, never-ending research. A staﬁr of scientists and trained researchers is constantly engaged in the laboratories, in a program of test-tube probing into the mental health program. Research goes on at Hillside on three fronts: in the Department of Experimental Psychiatry, in the Department of Biochemistry and in the Department of Medicine. ESEAR0 �STAFF EXECUTIVES Director Max Fink, M.D. Research Associate (Psychiatry) Joseph .laf’fe, M.D. Research Associate (Psychiatry) Donald F. Klein, MD. Sr. Research Associate (Experimental Psychology) Robert L. Kahn, Ph.D. Research Associate (Experimental Psychology) Max Pollack, Ph.D. Research Associate (Sociology) Nathaniel Siegel, Ph.D. Research Assistant (Experimental Psychology) Eric Karp, B.A. Associate in Research (Neurophysiology) Martin A. Green, MD. Associate in Research (Psychiatry) Abraham A. Kaplan, MD. Barre Alan, M.D. Henry Lefkowitz, M.D. TECHNICAL STAFF Fellow (1 957-58) Fellow (1958-59) Mrs. Janet Bowie .lean Kolodny Hannah Mosquera Blanche Zaitz experimental psychiatry 22 During 1958, the major emphasis of the staff of the Department of Experimental Psychiatry shifted from the evaluation of convulsive therapy to systematic investigations of newer drug therapies. These investigations were based on the theories developed in the Department in 1957, which derived from the successful evaluation of the mode of action of convulsive therapy. Studies were conducted on measures of speech behavior developed in the Department during 1956 and 1957. In an extension of the communication studies, the language indices were applied to drug therapy. The evaluation of convulsive therapies was continued in 1958, by comparing the effects of indoklon, an inhalant convulsant, with electroconvulsive therapy. Results indicated that while the indoklon worked, it was a poor substitute for ECT. The study was important because it illustrated graphically that the convulsion was the important factor, not the electrical stimulus. Investigations into the relations of sociologic factors to the selection of therapies at the hospital showed that not only were the factors of age, education and birthplace signiﬁcantly related to the choice of therapy, but these factors were also related to the results of therapy, the diagnosis and the duration of hospitalization. Similar studies of the population of other primarily psychotherapeutic hos- pitals, and the Hillside Out-Patient Clinic were also undertaken. A grant from the Mental Health Board of Nas- sau County helped support and augment these studies. The acute drug interviews were but One aspect of the continuing evaluation of the biochemistry of convulsive therapy. Other research projects during the year consisted of perceptual studies in patients receiving psychodynamic therapies; the inter-relation of psychotherapy with physiodynamic therapy; and the inter-personal factors in therapists, as well as patients, leading to the referral for physiodynamic therapies. Three members were added to the staff during the year, and the department received support through continuing grants of the Foundations’ Fund for Research in Psychiatry, the National Institute of Mental Health, the Psychopharmacology Service Center of the National Institutes of Mental Health, the Mental Health Board of Nassau County; and from Bristol; Geigy; Smith, Kline 81 French; and Wyeth Laboratories. Staff members were honored with two awards: Dr. Maximilian Fink received the ﬁrst annual A. E. Bennett Psychiatric Research Award of the Society of Biologic Psychiatry for his report on the effects of anticholinergic agents on EEG and behavior; Dr. Joseph Jaffe received the Cralnick annual award for his report on the application of analysis of changes in formal aspects of speech in psychotherapy. department of biochemistry The Department of Biochemistry, headed by Dr. Harry Goldenberg as Director and Dr. Vivian Fishman as Senior Biochemist showed a major growth during 1958, with the assistance of three research grant awards from the National Institutes of Mental Health. The laboratory staff was increased to seven members to make possible more intensive fundamental biochemical studies as well as the initiation of several collaborative clinical projects. The change in the hospital treatment program from shock therapy to chemotherapy introduced new problems which required laboratory assistance. As an aid to the drug therapy program, toxicological tests were set up to detect various pharmaceutical preparations in body ﬂuids. The laboratory was called upon periodically during the year to conﬁrm suspected drug intoxication. A chemical study was carried out with Dr. Arnold Blumberg, of the Department of Medicine to assess the prognostic signiﬁcance of the physiological response to mecholyl. While this study was in progress, it was noted that mecholyl triggers the release of adrenaline in the urine, as well as smaller amounts of related substances. In connection with adrenaline studies it was observed that preferential excretion of adrenaline occurred in normal subjects in the laboratory following the induction of a stress reaction with the drug LSD. Maj or emphasis in the laboratory continued on the premise that mental disease is accompanied by detectable chemical changes in the body. Blood and urine studies were undertaken to determine whether there is any correlation between body chemistry and the various psychiatric disorders. Studies were also continued on enzyme systems concerned with the elimination of toxic substances from the body. �Intensive studies were also made to demonstrate metabolic defect in the liver whereby toxic substances are formed but not eliminated at a sufﬁcient rate to maintain sanity. At Hillside, it is felt that a balanced biochemical program, involving both chemical and other fundamental studies will best serve the present and future welfare of the hospital. Inter-departmental clinical studies help to bind the various hospital activities into one fabric; and the theoretical studies provide more lasting insight into the physical aspects of mental disease, whose corrective treatment offers a more lasting support to psychotherapy. medical department As new drugs are introduced into the treatment of emotional disorders, studies of the basic physiology open new vistas in the understanding of the pathology of mental disease. During 1958, the Medical Department under the direction of Dr. Arnold C. Blumberg collaborated with the Department of Biochemistry on studies of the inter-relation of the adrenaline system and emotional disease. All patients on drug therapies were screened and medically controlled by the Medical Department. Toxic reactions to the drugs were carefully scrutinized and a report on the hypotensive response to toxic doses of meprobamate were submitted for publication. Alterations in liver function with the phenothiazine derivatives were also observed in cooperative studies with the Department of Biochemistry. �Hillside publications During 1958, the Hillside Hospital Staff made numerous appearances as guest lecturers and speakers at conventions in this country and abroad. They appeared before major national professional societies, as well as before lay groups. In addition to national and local societies, reports on hospital programs were presented at conferences in Rome and Montreal. Staff members reported on therapy and research in a large number of professional publications, and in the Journal of the Hillside Hospital. FINK, M.: Lateral Gaze Nystagmus as an Index of Sedation Threshold, EEG. Clin. Neurophysiol. 10: 162-163. FINK, M.: Effect of Diethazine on EEG and Signiﬁcance for Theory of Convulsive Therapy, EEG. Clin. Neurophysiol. 10: 207-208 (Abst.). FINK, M.: Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior, A.M.A. Arch. Neurol. & Psych. 80: 380-388. FINK, M.: Effects of Anticholinergic Agent, Diethazine, on EEG and Behavior: Signiﬁ- cance for Theory of Convulsive Therapy. Presented at the Society of Biological Psychiatry, May, 1958 in San Francisco. 24 FINK, M.: Role of EEG Frequency Shift in Behavioral Effects of Drugs. Presented at Section on Neurol. & Psychiat., Queens County Medical Society, June, 1958 in New York. FINK, M.: Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior. Presented at the American EEG Society, June, 1958 in Atlantic City. FINK, M., SHAW, R., GROSS, G., COLEMAN, F.C.: FINK, M.: EEG and Behavioral Effects of Collegium Internationale Neuro-Psycho M.: Clinical and EEG. Effects of Megimide in Patients without Cerebral Disease, Neurology 8: 682-685. FINK, M., GREEN, M. A.: EEG Correlates of Signiﬁcance of Individual Variability in EEG Changes During Electroshock Therapy. Presented at the Eastern Association of Electroencephalographers, March, 1958 in Montreal. Psychopharmacologic Agents. Presented at Pharmacologicum, September, 1958 in Rome; and also at the Eastern Association of Electroencephalographers, December, 1958 in New York. the Electroshock Process. Presented at the Eastern Psychiatric Research Association, February, 1958 in New York. FINK, M., GREEN, M. A.: Electroencephalo- graphic Correlates of the Electroshock Process, Dis. Nerv. Syst. 19: 227 (Abst.). FINK, M., JAFFE, J.: Drug Induced Changes in Interview Patterns. Presented at the Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) Drugs in Psychiatry, April, 1958 in Montreal. Comparative Study of Chlorpromazine and Insulin Coma Therapy of Psychosis, J .A.M.A. 166: 1846-1850. GREEN, M., FINK, GREEN, M. A.: A.: Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock. Presented at the Eastern Association of Electroencephalographers, December, 1958 in New York. GREEN, M. H.: Chairman of Symposium on Catechol Amines. Held at the New York Academy of Sciences, October, 1958. GOLDENBERG, H.: Biochemical Aspects of Mental Disease. Presented at the Jewish GOLDENBERG, Chronic Diseases Hospital, Brooklyn, New York in February, 1958. FINK, M., KAHN, R. L., GREEN, M. A.: Experi- GOLDENBERG, FINK, M., KAHN, R. L., POLLACK, M.: Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive H., BLUMBERG, A. G., GOLDENBERG, V.: Inﬂuence of LSD and Vasotonic Drugs on Urinary Excretion Patterns. Presented at the 125th Meeting of the American Association for the Advancement of Science, Washington, D.C., December, 1958. FINK, M., KAHN, R. L.: Experimental Studies of the Electroshock Process, Dis. Nerv. Syst. 19: 113-118. H., GOLDENBERc, V.: Urinary Excretion of Aromatic Metabolites in Mental Disease. Presented at the 125th Meeting of the American Association for the Advancement of Science, Washington, D.C., Decem- mental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretical Implications. Presented at the Neurological Society and New York Society of Clinical Psychiatry, March, 1958 in New York. Therapy. Presented at the American Psychiatric Association, May, 1958 in San Francisco. FINK, M., KAHN, R. L., GREEN, M.: Experi- mental Studies of Convulsive and Drug Therapies on Psychiatry: Theoretical Implications, A.M.A. Arch. Neurol. & Psych. 80: 733-734 (Abst.) H.: New Analytical Procedures Based on Dye Partition Analysis. Presented at the Long Island Jewish Hospital, New Hyde Park, New York in March, 1958. GOLDENBERG, GOLDENBERG, ber, 1958. H., WHITE, D. L.: Standardized Method for the Assay of Serum Oxidase Activity (Ceruloplasmin) , Clin. Chem. 4: 551, 1958. GOLDENBERG, �Presented at the 10th Annual Meeting of the American Association of Clinical Chemists, Iowa City, September 1958. V.: Colorimetric Determination of Carboxylic Acid Derivatives as Hydroxamic Acids, Anal. Chem., 30: 1327, 1958. GOLDENBERG, GOLDENBERG, V., GOLDENBERG, H.: An Im- proved Method for the Estimation of Serum Copper, Clin. Chem. 4: 551, 1958. Presented at the 10th Annual Meeting of the American Association of Clinical Chemists, Iowa City, September 1958. J., KAHN, R. L., FINK, M.: Communication Patterns with Altered Brain Function. Presented at the Eastern Psychological Association, April, 1958 in Philadelphia. JAEEE, J., SLorE, W. H.: Interpersonal F actors in Denial of Illness, A.M.A. Arch. Neurol. 81 Psychiat. 80: 653-656. JAFFE, .IAFFE, J.: Language of the Dyad, Psychiatry 21: 249-258. F INK, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Hoch, P. and Zubin, J., Eds., Grune 81 Stratton. KAHN, R. L., M.: The Relation of F Score to Behavioral and Physiological Response with Altered Brain Function. Pre-' sented at the Eastern Psychological Association, April, 1958 in Philadelphia. KAHN, R. L. FINK, KAHN, R. L., FINK, M.: Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. Presented at the Electroshock Research Association, May, 1958 in San Francisco. KAHN, R. L., POLLACK, M.: Socio-Psycholog— ical Aspects of Diagnosis and Treatment: Theoretical Implications. Presented at the Symposium—Eastern Psychological Association, April, 1958 in Philadelphia. KAHN, R. L., POLLACK, M.: Social Factors in Selection of Therapy in a Voluntary Mental Hospital. Presented at the American Psychiatric Association, May, 1958 in San Francisco. KAHN, R. L., POLLACK, M.: Prognostic Application of Psychological Techniques in Convulsive Therapy. Presented at the Eastern Psychiatric Research Association, October, 1958 in New York. H.: Intensity of Stimulation and Perception of Simultaneous Stimuli in Cerebral Dysfunction. Presented at the Eastern Psychological Association, April, Philadelphia. KORIN, LEVINE, A.: A Comparative Evalution of Latent Schizophrenic and Overt Schizophrenic Patients with Respect to Certain Personality Variables, J. Hillside Hosp. 7: 131-152. P.: Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. 81 Psychiat. 79: POLLACK, M., KRIEGER, H. 720-726. Predictions of Outcome, in Youthful Offenders at Highﬁelds, Weeks, H. Ashley, Ed. U. of Michigan Press, Ann Arbor. SIECEL, N.: L.: Juvenile Delinquency. Presented to the Sociology Department at Hofstra College on November 26th, 1958. VANDERHOST, Hillside Journal POLLACK, The Journal of the Hillside Hospital showed once again an increase in the number of its subscribers as an indication of its greater inﬂuence and wider acceptance in the psy— chiatric and related ﬁelds. In this country and throughout the world about 1200 copies are subscribed for by medical schools, training hospitals, social service agencies and many institutions in other countries, particularly Israel. In 1958, 15 major articles by members of the Hillside staff and by other professional contributors, were published in four issues. Contributions come from various parts of the US. and especially the West Coast. The Journal offers an unusual feature by reporting clinical conferences in full including the entire discussions. Now in its 7th year the Journal is still under the able leadership of Dr. Sidney Tarachow. The Editorial Advisory Board consists of Morris B. Bender, M.D., Dudley D. Schoenfeld, M.D., and Sandor Lorand, MD. The Associate Editors are Renato Almansi, M.D., Abraham S. Lenzner, M.D., Samuel R. Lehrman, M.D., Joseph S. A. Miller, M.D., Aaron Stein, M.D. POLLACK, M., BATTERSBY, W. S., KAI-IN, R. L., BENDER, M. B.: Intellectual Deficits in Pa- Grants and Awards Received 1958 LEVINE, A., HARRIS, J., CAMINSKY, I., LURIE, A., BACHRACH, M., MILLER, J.: An Explora- tory Vocational Counseling Program in a Mental Hospital, J. Hillside Hosp. 7: 153-161. 5.: Pathological Reactions in Women After Parturition. Presented to the Department of Obstetrics at St. Albans Naval MARKHAM, Hospital on December 13th, 1958 in New York. S.: The Dynamics of Post-Partum Pathological Reactions as Revealed in Psychological Tests, J. Hillside Hosp. 7: 178-189. MARKHAM, POLLACK, M.: Visual Perception and Attention in Normal and Abnormal Children. Presented at American Orthopsychiatric Association, March, 1958 in New York. M.: A Critique of “Pre-Conscious” Perception and the “Poetzl Phenomenon”. Presented at the American Psychiatric Association, May, 1958 in San Francisco. POLLACK, M.: Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Psychiat. 115: 442-428. tients with Space Occupying Lesions of the Cerebrum. Presented at the Eastern Psychological Association, April, 1958 in Philadelphia. ........ Foundations Fund for Research U. 5. Public Health Service in Psychiatry .................. $74,460 16,250 25 �«saw». �report of the administrator “Kim. MAURHIIBACHRACH The 1958 Annual Report strikes a new note which reﬂects the tremendous strides that are being made in the ﬁeld of mental health. The hospital’s operations during 1958 were effected by the profound changes which came with the introduction of the psychotropic drugs. Chemotherapy has enabled us to entirely discontinue Insulin Shock Therapy and is reducing the use of Electro Shock Treatment to a point where it may soon be eliminated. These changes produced certain changes in our expense picture, in that the cost of giving the physical therapies, which are being abandoned, is reduced. But, there are attendant increases in costs for drugs and, more importantly, a need for expansion of personnel in the adjunctive and activities therapies. Another profound inﬂuence is introduced by the Professional Department program which our Director of Professional Services, Dr. Lewis L. Robbins, had recommended at the end of 1958. It is almost certain that the implementation of these recommendations including, as they do, a considerable increase in the number of full time Staff Psychiatrists, as well as expansion of the Social Service, Occupational Therapy, Psychological and Group Activities Staffs, will change our expense picture considerably, although they may have no impact on the 1958 experience as such. Comparison of Costs 1957-1958 1957 Salaries .......................................... $855,848 Food .............................................. 119,350 Maintenance and Grounds ............ 62,654 Administrative Expenses .............. 98,952 Medical Supplies .......................... 29,811 Repairs and Replacements .......... 49,021 Clinics ............................................ 280,056 Total ................ $1,495,692 1958 $936,330 127,142 72,049 108,693 31,997 48,101 337,712 $1,662,024 The above table shows that the total cost for the entire Hillside Hospital complex increased by 11% during 1958. One-half of this total increase occurred in salaries which increased by 9%. This is in keeping with our experience for the past ten years, where salaries have been increasing steadily at the rate of seven to ten percent per annum due largely to the need of the Hospital to keep pace with the increasing cost of living. Very little, if any, of this increase during 1958 can be ascribed to additional staff. The largest percentage increase, 21%, was in the cost of Out-Patient Services. This reﬂected a combination of increased costs and continued expansion of clinical work from Out-Patient Services, but this should be contrasted with the 307(increase in the cost of Out-Patient Services during 1957. This indicates that although our Out-Patient Services are still expanding, the rate of expansion is slowing down. The other items, food, maintenance and grounds, administrative, medical supplies and repairs and replacements, increased by varying amounts, but they are all in keeping with the general picture of roughly 1071 increase for all expenses. Service Statistics 1957 Total Number of Patients ........................ 545 Total Patient Days .................................. 69,987 Average Income per Patient Day ............ $15.57 Average cost per Patient Day .................. $17.37 Average loss per Patient Day .................. $ 1.80 1958 536 70,691 $16.58 $18.73 $ 2.15 The data given in the above table refer to ln-Patients only. The total number of patients treated and the number of patient days show no signiﬁcant change over 1957. The average income per patient day as well as average cost per patient day increased with costs rising faster than income, so that the average loss per patient day rose from $1.80 to $2.15, an increase of 16%. The reason for this increase in the average loss per patient was that, although there was a slight increase in average income per patient day, all of this increase coming from fees paid by patients or the patient’s family, the per diem rate paid by the City of New York remained the same during 1958, in spite of increased costs. Our research programs continued to expand with a concurrent increase in cost; but these increases were almost entirely absorbed by increased support by the National Institutes of Mental Health, so that deficits arising out of research operations were held to a relatively modest ﬁgure, $35,000, which was made up by the Board of Trustees of Hillside Hospital. 27 �Financial Support Picture Hillside Hospital has been fortunate over the years in the support it has received from the Federation of Jewish Philanthropies. Year after year, since 1948, the Federation has carefully reviewed the Hospital’s fees and supplied a grant which was always consonant with the Hospital’s deﬁcit requirements. Our gratitude to the Federation of Jewish Philanthropies is profound and we hope that we will continue to deserve the support of the Jewish Community, as it is expressed through the Federation. We have received legacies from time to time, and as our reputation and tradition grows, these are becoming .increasingly more. The following is a list of legacies received by the Society of the Hillside Hospital from 1948 to 1958. It is interesting to see that each year the number and amounts of these legacies is growing. We hope that a larger and larger number of persons who desire to beneﬁt humanity and especially to bring about some amelioration of the suffering of the mentally ill, will ﬁnd it possible to name Hillside Hospital as a beneﬁciary in their Wills. Amount Simon Lefcort ................................ $ 2,000 Leonora Solinger Baum ................ 23,317 (A) Florence Tim .................................. 1,000 Rose Simon .................................... 456 Max Richter .................................... 5,000 Solomon Rothfeld .......................... 10,000 Harry T. Epstein ............................ 8,835 250 Year 1948 1949-1958 1949 1949 1950 1950 1952 1953 Beatrice S. Bowman ...................... 1953 Aaron C. Horn ................................ 3,000 Flora Haas ...................................... 60,000 (B) 1954 250 Dora Monness Shapiro .................. 1955 Robert L. Leeds .............................. 2,500 Charles Benoff ................................ 1956 380 28 Max Einhorn .................................. 77,155 897 Julius Grossman ............................ 1956 Hermenia Goodman ...................... 2,000 Christine King ................................ 1,058 Wilhelm Levinger .......................... 37,950 Joseph Meyers ................................ 2,500 (C) 1957 Notes: (A) Approximately $2,300 per year in perpetuity (B) Restricted for care of Adolescent Girls (C) Restricted for Medical Library 1957 1958 1958 1958 During 1958, the following persons other than Trustees made gifts to the Hospital as noted below: Amount Bernard M. Baruch, Jr ......................................... 3 500.00 Bristol Laboratories .............................................. 2,500.00 Grand Street Boys Foundation ............................ 675.00 Jack Bleibtreu ........................................................ 185.00 Wyeth Laboratories .............................................. 1,500.00 Lightolier .............................................................. 1,000.00 Susan Greenwall Foundation ................................ 200.00 Smith, Kline 81 French Laboratories .................... 2,500.00 Gustave Levy .......................................................... Edward Goldberger ................................................ Alfred Hazan .......................................................... J. A. Samuels .......................................................... Gaisman Foundation .............................................. Laurence Alexander .............................................. 100.00 500.00 100.00 100.00 100.00 150.00 William J. Hammerslaugh .................................... 500.00 Henry Homes ........................................................ 1,000.00 l.M.M. Charities .................................................... 500.00 Carol B. Loeb Foundation ...................................... 1,000.00 Blanche Ittleson .................................................... Blanche Freeman .................................................. 100.00 Sylvia 100.00 Krohn ............................. 100.00 Arabel Foundation ................................................ 1,000.00 Eugene Blum .......................................................... 4,000.00 Edward L. Fabian .................................................. 5,000.00 Geigy Chemical Corp ............................................. 5,000.00 Lawrence Mark ...................................................... 100.00 Louis Neiweg .......................................................... 1,049.00 Samuel Silverman .................................................. 200.00 Our gratitude to these benefactors is of course profound. It is our hope that as our work becomes known to a larger and larger circle of interested individuals, they will send us gifts for the support of our work. ��Director, Israel Strauss Adolescent Pavilion Alice Slater Stahl, M.D. Supervising Psychiatrist, Israel Strauss Adolescent Pavilion Zenos M. Linnell, MD. Director, half—time, Adolescent After Care Clinic Eugene Glynn, MD. Society of the Hillside Hospital Officers President Alvin E. Coleman * Chairman of the Board Roy Foster* Honorary Chairman of the Board Leon Lowenstein* Vice-President Dudley D. Shoenfeld, M.D.* Vice-President D. Herbert Beskind * Vice-President George W. Galinger* Secretary Manuel Lee Robbins* Treasurer Arnold S. Askin * Assistant Secretary A. Jacob Abrams Assistant Secretary M. Victor Leventritt Assistant Treasurer Arthur Garson Assistant Treasurer Harry Silverson Honorary Directors Hilda Strauss and Saul Blickman Board of Trustees A. Jacob Abrams Jonas AdlerT Alfred Appel Arnold S. Askin* John M. Bendheim D. Herbert Beskind* Saul Blickman 30 David BunimT Alvin E. Coleman* Martin ColemanT Morris David Thomas Epstein Arthur C. Fatt* David Finkle David Finn Director of Out-Patient Services Robert R. Luttrell, MD. Assistant Director of Out-Patient Services Robert Navarre, MD. Director of Research in Experimental Psychiatry Maximilian Fink, M.D. Roy Foster* George W. Galinger* Arthur Garson Maurice Glinert Meyer Goldstein Jacob Epstein Katz Carl L. Kempner‘l' Harold P. KurzmanT M. Victor Leventritt Budd Levinson Morris L. Levinson Milton B. Loeb Sandor Lorand, M.D. Leon Lowenstein* Charles H. Meyer* Arthur Murray Manuel Lee Robbins* Irving Rosenbaum S. H. Scheuer* Walter Scheuer Dudley D. Shoenfeld, M.D.* Harry Silverson Hilda Strauss Irving Weisglass Nathan Wigod Morton 5. Wolf* Walter D. Yankauer* Chairman of Standing Committees Executive Committee Roy Foster Medical Affairs Committee D. Herbert Beskind Finance Committee Arnold S. Askin House and Grounds Committee George W. Galinger Nathan Wigod, Co-Chairman Legal Committee Charles H. Meyer Social Service Committee Hilda Strauss, Honorary Chairman M. Victor Leventritt, Chairman Personnel Committee Meyer Goldstein Internist Arnold G. Blumberg, MD. Director of Laboratories Harry Goldenberg, Ph.D. Resident Staff Nominating Committee Walter Yankauer Gifts and Legacies Committee Walter Yankauer Committee on Administrative Savings Arnold S. Askin Building Committee D. Herbert Beskind 81 George W. Galinger, Co-Chairmen *—-Executive Committee Members f—Elected in I958 Professional and Administrative Staﬁ' Medical Director Joseph S. A. Miller, MD. Director of Professional Services Lewis L. Robbins, MD. Associate Medical Director Simon Kwalwassr, M.D. Administrator Maurice Bachrach, B.S. Supervising Psychiatrists George Yessin, M.D. Gerhard Schauer, M.D. Harold Esecover, M.D.* William Benjamin, M.D. Morton Wachspress, MD. Norman Ackerman, M.D.** Barre Alan, M.D. Reva Berstock, M.D. Bernard Cohen, M.D.** Warren Cox, M.D.** Alan Dobrow, M.D. Necdet Ecder, M.D. Elhan Ermutlu, M.D.** Marie Friedman, M.D.** Michael Gould, M.D.** Sherwin Harris, M.D. Raymond Hollander, M.D. Doris Kells, M.D. Edwin Kleinman, M.D. Henry Lefkowits, M.D. Sidney Lytton, M.D. Stanley Machlin, M.D. Harvey Mandel, MD. Robert Nodine, M.D.** Paul Pressman, M.D.** Henry Rosett, M.D. Alvaro Rozo, M.D. Mollie Schildkrout, M.D. Jack Schnee, M.D. Herbert Schulman, MD. David Steinman, M.D. Carl Towbin, M.D. Margery Wile, M.D. Other Prof esional Staff Heads Director of Nursing Goldie Krupa, R.N. Director of Social Services Abraham Lurie, M.S.S.W. Director of Psychology Abraham Levine, Ph.D. �. .W. <| ', Psychiatrists afﬁx] .4; Director of Creative Therapy Ernest Zierer, Ph.D. Director of Occupational Therapy Eileen P. Fisher, B.S. Director of Group Work Division Arnold Eisen, M.S.S.W. Dietitian Angelina Canavan, B.A. Supervisor Clinical Laboratory and X-Ray John Croghan, R.T., M.T. Department Heads Accounting Supervisor Dorothy Croghan Manager Lillian Dailey Superintendent of Buildings & Grounds Thomas R. Lumley Executive Housekeeper Sarah Travers Oﬂ‘ice *—Resigned in 1958 **—Completed residency in 1958 Medical Board President Robert A. Savitt, M.D.* Vice President Sidney Tarachow, M.D.* Secretary Sidney L. Green, M.D.* Treasurer Paul Scheman, D.D.S.* Est-President M. David Epstein, M.D.* Manhattan After-Care Clinic Sarah R. Kelman, M.D. Samuel Atkin, M.D. Arnold Eisendorfer, M.D.* M. David Epstein, M.D.* Margaret E. Fries, MD. I. Peter Glauber, M.D.* George S. Goldman, M.D. Sidney L. Green, M.D.* William Karliner, M.D.* Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D.iL Samuel R. Lehrman, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D.* Lawrence J. Roose, MD. Robert A. Savitt, M.D.* Martin Schreiber, M.D.* Isidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D.* Consulting, Attending and Visiting Staffs Non-Psychiatrists Psychiatry Director of Department of Medicine Lester Cohen, M.D.* Leonard Blumgart, M.D. Sandor Lorand, M.D. Irving J. Sands, M.D.l~ Nathaniel E. Selby, M.D. Dudley D. Shoenfeld, M.D. Director of Department of Surgery Sidney Hirsch, M.D.* Director of Department of Dentistry Paul Scheman, D.D.S.* Chairman of Standing Committees Adolescent Pavilion Sidney L. Green, M.D. Credentials Committee for Psychiatric Attending Staﬂ & Promotions Martin Schreiber, M.D. Credentials Committee for Non-Psychiatric Visiting Staff & Promotions Paul Scheman, D.D.S. Education of Resident Staﬂ Arnold Eisendorfer, M.D. Group Psychotherapy Samuel Z. Orgel, M.D. Queens Out-Patient Clinic Martin H. Orens, M.D. Sub-Committee for Child Guidance Clinic Isidor Bernstein, MD. Research Committee Sidney Tarachow, M.D. Publications Committee I. Peter Glauber, M.D. Committee for Adjunctive Services I. Peter Glauber, M.D. Credentials Committee for Supervising Psychiatric and Resident Staﬂ Lawrence J. Roose, M.D. *—Executiue Committee Members i—Deceased in 1958 Medicine Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, MD. I. Jesse Levy, MD. Neurology A. M. Rabiner, M.D. Hans Strauss, MD. I. S. Wechsler, M.D. Surgery David Warshaw, M.D. Gynecology Julius Jarcho, M.D. Dentistry Morris Fierstein, D.D.S. Attending Psychiatrists Samuel Atkin, M.D. Frank Berchenko, M.D. Isidor Bernstein, MD. Arnold Eisendorfer, MD. M. David Epstein, M.D. Margaret E. Fries, MD. I. Peter Glauber, M.D. George S. Goldman, MD. Paul Goolker, M.D. Sidney L. Green, M.D. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D.T Attilio LaGuardia, M.D.TT Samuel R. Lehrman, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, MD. Robert A. Savitt, M.D. Martin Schreiber, M.D. Isidor Silbermann, M.D. Otto Sperling, M.D. Aaron Stein, M.D. Sidney Tarachow, MD. Associate Attending Psychiatrists Renato J. Almansi, M.D. Alexander J. Friedman, MD. 5011 Goodman, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. Abraham S. Lenzner, M. D. Martin H. Orens, M.D. William W. Pike, M.D. Geraldine Pederson-Krag, M.D. i—Deceased in 1958 H—deceased I959 31 �Visitings Optometry Medicine Staff Optometrist Edward L. Steinberg, OD. Director Lester Cohen, M.D. Staff Optometrist Bernard Attinson, OD. Visiting Physician George Sabrin, M.D. Visiting Physician Louis Rosenblum, M.D. Podiatry Staff Podiatrist Sam Sokolov. Pod.O. Visiting Physician Arnold G. Blumberg, M.D. *—Resigned in 1958 Associate Physician Jerome Weinstein, M.D. Clinical Assistants in Manhattan and Queens Clinics Adjunct Physician Arnold L. Berger, M.D. Adjunct Physician Wilbur B. Brett, M.D. Visiting Dermatologists Conrad Stritzler, M.D.* Associate Dermatologist .loel Schweig, M.D. Adjunct Dermatologist Norman Goldfarb, M.D. Neurology Adjunct Attending Psychiatrists 32 Edward R. Adelson, M.D. Herman S. Alpert, M.D. Alvin B. Balaban, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Belinkofi, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Isadore H. Cohn, M.D. Irving J. Crain, M.D. Joseph H. Feldman, M.D. Jules Glenn, M.D. Albert E. Goldberg, M.D. Albert Harrison, M.D. Thomas Hora, M.D. Abraham Kaplan, M.D. Eugene Kaplan, M.D. George P. Krupp, M.D. Peter Laderman, M.D. Harold S. Leopold, M.D. (on leave) David Milrod, M.D. Helene Papanek, M.D. Irving Salan, M.D. Frederick F. Shevin, M.D. Jay Stanton, M.D. Samuel Tabbat, M.D. Fred U. Tate, M.D. Leonard Weinroth, M.D. Herbert Wieder, M.D. Associate Neuroligist Kurt Adler, M.D. Surgery Director Sidney Hirsch, M.D. Visiting Neurosurgeon Joseph Siris, M.D. Visiting Urologist Daniel Kaufman, M.D. Adjunct Urologist Albert Sutton, M.D. Visiting Orthopedist A. H. Lewert, M.D. Associate Orthopedist Julius Schneiderman, M.D. Visiting Proctologist Benjamin Warner, M.D. Visiting Ophthalmologist Edward Seretan, M.D. Associate Ophthalmologist Arthur Minsky, M.D. Visiting 0tolaryngologist Sam Clayton, M.D. Visiting Anesthesiologist Georges Bean, M.D. *—Resigned in 1958 Gynecology Visiting Gynecologist Marie P. Warner, M.D. Visiting Gynecologist Hilliard Dubrow, M.D. (on leave) Associate Gynecologist Jack Cohen, M.D. Associate Gynecologist Bernard Greenblat, M.D. Adjunct Gynecologist Eugene Streim, M.D.* Radiology Visiting Radiologist Bernard Epstein, M.D. Associate Radiologist Paul Steinhorn, M.D. Dentistry Director Paul Scheman, D.D.S. Associate Director J. Gordon Rubin, D.D.S. Associate Dentist Benjamin Schwaid, D.D.S. Associate Dentist Bernard Lebow, D.D.S. Adjunct Dentist Henry Lewis, D.D.S. Adjunct Dentist Samuel Plotnick, D.D.S. Adjunct Dentist Elsa Friedman, D.D.S. Adjunct Dentist Martin Protell, D.D.S. Adjunct Dentist Leon Basson, D.D.S. Lester I. Abend, M.D. Edward R. Adelson, M.D. Romano Antonelli, M.D. Howard Boskey, M.D. Paul Bradlow, M.D.* Stanley Brodsky, M.D. Arline Caldwell, M.D.* Daniel Chansky, M.D. Lionel Chertoﬂ, M.D. Ralph W. Clemments, M.D. Frances Colonna, M.D. Stefano Fajrajzen, M.D. Irving J. Farber, M.D. Philip Friedland, M.D. Ruth Fuchs, M.D. Harvey Goldey, M.D. Sumner I. Goldstein, M.D. Clara Gonda, M.D. Harry Gonda, M.D. Martin Hurvitz, M.D. Gunthar Jacob, M.D. Wilbur Jarvis, M.D. Norman Levy, M.D. Peritz Levinson, M.D.* Zenos Linnell, M.D. Buck Luria, M.D. Howard Mele, M.D. Daniel Miller, M.D. Meyer Monchek, M.D. Beatrice Nachtigal, M.D. Iris Orens, M.D. Edward Pinney, Jr., M.D.* Phoebe Rosen, M.D.* Joseph D. Rosen, M.D.* Jehuda Rozanski, M.D. Gabriel Rubin, M.D.* Leon Tec, M.D. David M. Tillim, M.D. Clara Torda, M.D. Aimee Wiggers, M.D.* *—Resigned in 1958 ��HIL LSIDE HOSPITAL ‘3 ��JANUARY 1, 1960—JUNE 30, 1961 Society of the Hillside Hospital Board of Trustees GLEN OAKS, NEW YORK OFFICERS PresidentD. Herbert Beskind Vice Presidents George W. Galinger Charles H. Meyer ' S. H. Chairman, of the Board Alvin [3. Coleman Scheuer Walter Honorary Chairmen of the Board Roy Ecstie'r Leon towenste‘in Dudley‘D.-Shoenfeld, MD. D. Yankauer Treasurer Arnold .s. Askin Assistant Treasurers Arthur Garson MauriCe Glinert Secretary Jacob Epstein Katz Assistant Secretaries A. Jacob Abrams M. Victor Leventritt M EM B EIR‘S' A. Jaco‘b‘Abram's; George W. G'alinger Arthur Garson Maurice Glinert Meyer Goldstein" Jacob Epstein Katz’r Carl L. Kempner Harold P. Kurzman Robert L. Leeds, Jr. M. Victor Leventritt Budd Levinson Milton B. Loeb Sandor Lorand, M.D. Jonas Adler Alfred Ap'per Arnold S. Askin* John M. Bendheirn D. Herbert Beskind" ' David Bunim Alvin E. C'Ol'eman' Martin Coleman Thomas Epstein Arthur C. Fatt Roy Foster“ Leon Lowenstein* Charles H. Meyer Charles Revrson Manue‘lLee Robbins S. H. Seheuer Dudley D. Schoenfeld, John W. Straus Irving Weisglass Nathan Wigod M-.D.* Morton 8,. Wolf Adolph Woolner Walter D. Yankauer CHAIRME-N of STANDING COMMITTEES of THE BOARD of TRUSTEES Executive committee Alvin E; Coleman Finance. Committees Maurice Glin'ert Sub-Committee on Investments Adolph Woolner Gifts & Legacies Committee Jacob E-.; Katz - *Executiv.e Cémmittge‘ ' ”Deceased House & Grounds Committee George W. Galinger Nathan Wigod Legal Committee Charles H. Meyer Medical Affairs Committee M. Victor Leventritt New Building Committee David Bunim Nominating Committee Walter D. Yankauer Personnel Committee Harold P. Kurzman Public Relations Committee Arthur C. Fatt Social SerVice- Committee Maurice fGIin‘ert �ever—changing approach to the treat- President’s Report Hillside Hospital was founded in 1927 by Dr. Israel Strauss and his colleagues of the Committee of Jews for Mental Health, whose objective was to provide good psychiatric care to those who could not afford to pay for the service. Today’s Hillside Hos— pital is one of the few voluntary, nonprofit psychiatric hospitals in the United States. In 1958, the Board of Trustees determined to establish new goals for their hospital. Our physical size and personnel resources anticipated recent recom— mendations of the Joint Commission on Mental Illness. We endorse these recommendations and wish to participate in the solution of this major health problem by continuing our treatment program, by seeking an improved quality of patient care, and by providing outstanding professional training for doctors, nurses, social workers and other professionals. To accomplish these goals and to broaden the treatment program as a basis for fundamental research in mental illness, Dr. Lewis L. Robbins assumed the responsibilities of Medical Director. Dedicated lay members of the Board of Trustees together with the staff and the distinguished physicians who served on the Medical Board, have been continually reviewing the ment of mental illness and evaluating new concepts of care. The character of Hillside Hospital as a pilot institution seeking to broaden the frontiers of understanding mental illness is now well integrated. The years 1960 and 1961 saw the planning of a new building program designed to provide the physical facilities for current concepts of treatment, professional development and research. An activities therapy build— ing is needed to house the manifold creative, occupational, athletic and social activities which we know are so vital in the treatment of our patients. Equally important, offices, conference rooms and working areas must be created for the broader research program which will include, in addition to biochemical research and experimental psychiatry, a comprehensive effort in dynamic psychiatry. Adequate residence facilities are necessary to house our staff members. Funds toward the cost of these physical improvements are substantially in prospect and it is entirely possible to contemplate that construction can begin during 1962. In this progress report of today’s Hillside, I take great pleasure in the accomplishment of the ﬁrst and major phase of progress toward the long range goals we have set. The efforts, wisdom and material support of the trustees of the Society and the Federation of Jewish Philanthropies, and the informed and dynamic leadership which Dr. Robbins provides, instills great conﬁdence that the image of tomorrow’s Hillside will shine even brighter than today’s. D. HERBERT BESKIND President, Society of the Hillside Hospital �Professional and Administrative Staff Samuel Davis Assistant Administrator ADMINISTRATION Lewis L. Robbins, M.D. Medical Director STAFF PSYCHIATRISTS William Benjamin, M.D. Muriel Benton, M.D. Max Fink, M.D. Maurice Bachrach Administrator David Graubert, M.D. Irwin Greenberg, M.D. B. Bernie Herron, M.D. Elsa Katz, M.D. Donald Klein, M.D. John c. Kramer, M.D. Henry Lefkowits. M.D. Robert R. Luttrell, M.D. Robert Navarre, M.D. Paul Salkin, M.D. Alice S. Stahl, M.D. Barbara Ure, M.D. Morton Wachspress, M.D. George Yessin, M.D. PROFESSIONAL DEPARTMENT HEADS ACTIVITIES THERAPIES Morton Wachspress, M.D. NURSING EXPERIMENTAL Jean Axten, R.N. Director Frances Anderson, R.N. Associate Director PSYCHIATRY Director Max Fink, M.D. Eli Levy Director Assistant Director Joseph Chase Director, Occupational Therapy PSYCHOLOGY LABORATORY HarryrGoldenberg, Ph.D. Director Phyllis Hurteau, R.N. Associate Director lnservice Education John Croghan OUT-PATIENT DEPARTMENT Supervisor ADOLESCENT PAVILION Alice S. Stahl, M.D. MEDICAL LIBRARY Director James Montgomery MEDICAL SERVICES BIOCHEMISTRY Arnold Harry Goldenberg, Ph.D. G. Blumberg, M.D. Director Director RODSrt R. Luttrell, M.D. DII'CCTDI' Harvey Goldey, M.D. Assistant Director Hershey Marcus, M.D. Director Child Therapy Unlt Abraham Levine, Ph.D. Director CREATIVE THERAPY Mrs. Edith Zierer Director SOCIAL SERVICES Abraham Lurie Director Louise Pinsky Assistant Director, Casework Sidney Pinsky Supervisor, Group Work SOCIOLOGY Nathaniel Siegel, Ph.D. ADMINISTRATIVE DEPARTMENT HEADS FOOD ACCOUNTING SERVICE SERVICES Sol Fuchs Dorothy Croghan HOUSEKEEPING OFFICE BUILDINGS and SERVICES GROUNDS Robert Jones May K. Bottomley Thomas Lumley CLINICAL ASSISTANTS ADULT UNIT Nobel Endicott, M.D.. Sumner Goldstein, M.D. Curtis. Kendrick, M.D. Lionel Chertoff, M.D. Ralph Colp, Jr., M.D. Alan Dobrow, M.D. Raymond Edelman, M.D. Dahiel Miller, M.D. iris Orens, M,D. Esther Robbins, M.D. Jack Schnee, M.D. Maurice Shilling, M.D. JamesWatson, M.D. CHILDREN’S UNIT Sidney Finkel, M.D. John Price, Jr., M.D. Esther Robbins, M.D. Mollie Schildkrout, M.D. PSYCHIATRIC RESIDENTS Lucie Arato, M.D. Paul Ar'onow, M.D. Peter Ferber, M.D. Edward Gelardin, M.D. Seymour Gers, M.D. WarrenH. Goodman, M.D. Joseph Gross,'M.D. ' ‘ Edward‘s. Hartmann, M.D. Jerome L, Jacobs, M.D; Abraham Jankowitz, M.D. Henry K‘aminer, M.D. Herbert J. Levo’witz; M.D. Arnold Lieber, M.D. Julia Mehlman, M.D. Herman Oliver, M.D. Raymond W. Rakow, M.D. Rita S. Reuben, M.D. Ger-aid D. Roberts, M.D. Judy M. Roheim, M.D. Bertram H. Rosen, M.D. Ronald'Sa‘german, M.D. DECEMBER George Satran, M.D. Martin Shepard, M.D. Herbert J. Steinberg, M.D. Dan'ield Weitzner, M.D. Charlotte M. Zitrin. M.D. 31,1960-JUNE 30,1961 �Medical Director’s Report When one considers that there are hundreds of thousands of patients in public and private hospitals in the United States, one is forced to the conclusion that this represents a tremendous waste of human lives and community resources. The majority of these patients are in large public hospitals which have been viewed by the Joint Commission on Mental Illness as too large to provide the necessary individualiza— tion of treatment and the therapeutic relationships which are so important. Hillside Hospital with its 375 admissions and discharges per year does provide the type of treatment needed, but the service we can give is but a mere drop of water in the vast ocean of human misery. It would take us forty—ﬁve years to treat as many patients as are currently in just one of the nearby public institutions. The solution to the problem of mental ill— ness does not lie in the expanding of treatment facilities as much as it does in ﬁnding better answers to the causes and treatment of emotional dis— orders, and in passing on our knowledge to all those who are needed to treat the mentally ill. In accordance with these principles, Hillside Hospital has chosen to make research and training its primary goals. As always, it continues to be a pilot institution providing the best psychiatric treatment that is currently available, and is constantly trying to develop new knowledge and to share what we learn with others. The development of research and education are never any better than the clinical programs on which they are based. Conversely clinical pro— grams which do not include educational and research activities become sterile. During these past three years, our emphasis has been on further im— proving our clinical services and concomitantly expanding the psychiatric residency training program. Although there has been much progress in the several on—going research programs, the improvements in our clinical and educational activities should provide opportunities for considerable new effort in this important area. This report treats of our progress in connection with the restated goals of our hospital. The problems in ﬁnding solutions to the questions of mental illness are enormous, but we are taking steps towards assisting in the ﬁnding of needed answers. The work, the effort, support and dedication of our trustees and staff augur well for the future. LEWIS L. ROBBINS, M.D. Medical Director �Progress Toward Our Stated Goals move from closed to open units as was previously the practice. An open hospital has been estab— lished. Doors are rarely locked. I The therapeutic activities now I constitute the major of the part I Goals are quoted from the survey and report made by Dr. Robbins in late 1958. TREATMENT and TRAINING “The psychiatric hospital should be thought of primarily in terms of its staff and of the facilities for occupational therapy, recreational therapy, educational therapy, group living experiences and the like; as a total community in which the bed is used only to sleep in at night. A psychiatric hospital should be a thera— peutic community in which every aspect of the patient’s stay is designed to meet his therapeutic needs. To insure the best possible results includes not only the prescription of the speciﬁc treatment procedures mentioned . . .and the type of therapy best suited to meet the needs . . . but also the ‘emotional atmosphere’ in which they are to be carried out.” Patient care has been much more I individualized. staff has been reor— I Our treatment and treatment teams esganized tablished. Led by a full time senior staff psychiatrist the team is composed of staff psychiatrists, psychiatric residents, social caseworkers, I group workers, psychologists, nurses, and activities therapists. In order to stabilize patients in re— lation to stall, patients now remain on the same living unit, rather than I patients’ program. The treatment program has been approved by the Joint Commission on Hospital Accreditation. A children’s outpatient clinic has been opened. “The patients admitted to Hillside Hospital fall into the groups of those patients with severe psychoneuroses, early or incipient psychoses, and rather severe character disorders. Such patients require the optimum of psychiatric talent for help and one should be able to bring to bear in their treatment the best skills that are available. Even the most experienced psychiatrists need to have the participating skill of an adequate staff both qualitatively and quantitatively in all the areas of psychology, psychiatric social work, psychiatric nursing and the adjunctive therapies.” An Activities Therapy department has been established. The Occupational Therapy staff has been increased. I I Recreational Therapy staff I The has been increased. has been A work patient program I initiated. activities therapy Occupational are I related to work and to treatment I I rather than just to arts and crafts training. A pilot vocational rehabilitation program has been established with Altro Workshops. A program in which volunteers plan and lead patient activities has been established. �“One fact which seems to work against the success of the admission policy is the accumulation of a waiting list for admission.” The patient waiting list has been eliminated. The admission screening process has been improved. I I “The main shortage in psychiatry today is knowledge. . . One of the major responsibilities of every psychiatric facility is not only to provide the best possible service to patients, but also to train personnel. Psychiatry like all other branches of medicine, is best learned by intimate contact with patients and with one’s teachers, rather than in the classroom. Thus, the clinical staﬁ is simultaneously a faculty working in close day to day personal contact with the students The resident. . .can only meet the clinical needs of the patients in his care if he is given adequate supervision by more experienced teachers. The resident psychiatrist is a very busy person having on an average twelve patients at a time and admitting a new patient approximately every ten days. It is not possible to add some very necessary experiences (such as outpatient psychotherapy) to the residency program because of their already very heavy schedules. It would be desirable to increase the number of residents, not only to provide training for more doctors, but also to decrease the case— load for each resident. There has long been a desire to develop a full three year residency training program at Hillside Hospital. Experi- ence again has demonstrated that it is better for residents to obtain all of their psychiatric training in one place rather than to move from place to �place. This provides them with a more integrated three year educational experience. Specialized experience in certain areas, such as psycho- somatic medicine, geriatrics and neurology can be developed through liaison with other nearby institutions. It is, therefore, recommended that the excellent facilites of Hillside Hospital and its actual as well as potential relationships with other institutions be used primarily for the advancement of psychiatric knowledge. I I I I I The full time psychiatric staff has been greatly enlarged. The number of psychiatric resi— dents has been increased. The number of patients per doctor, and the number of residents per supervisor has been reduced. The quality of supervision has improved. Residency training in psychiatry has been approved by the American, Medical Association for three years. I dency training has increased qualiApplicants for psychiatric resi- I I tatively and quantitatively. The number of grants from the United States Public Health Service for training has been increased. Clinical training has been extend— ed into the Adult and Children’s Out-Patient clinics. I been improved and increased. of function Educational voluntary I non-paid attending staff increased. afﬁliations for psychiatTraining I ric residents established with Formal classroom training has I Creedmoor, Long Island Jewish Hospital, Monteﬁore Hospital and Meadowbrook Hospital. Graduate and undergraduate training in psychiatric nursing in I I afﬁliation with Queens College and Adelphi College. Inservice training program for nursing personnel established. Graduate training in Psychiatric Social Work and Group Work in afﬁliation with Adelphi College, Columbia University, Yeshiva and New York University. RESEARCH “A lthough millions and millions of dollars have been spent in development of all kinds of psychiatric facilities, only a small amount of money has been spent in the important area of psychiatric research . . . Far greater sums of money are being spent for research and other illnesses which have a much smaller incidence than do psychiatric disorders . . . Re— search is developed in most hopitals, as a derivative of the clinical and educational activities in the institution . . . investigations which must go forward on many fronts simultaneously; physiological, psychological and social. Because man is a biological, psychological and social being, the ultimate.answers in respect to psychiatric illness will not be found in any one area alone even though from time to time one may seem more promising than the others. Therefore, it is also encumbent upon every psychiatric institution not only to treat patients as well as our present knowledge permits and to educate psychiatric personnel, but also to continue to investigate the nature of psychiatric illnesses in order to eliminate many gaps in our knowledge.” I The research programs in experimental psychiatry, biochemistry and medicine have been in existence for many years under the re- �spective leadership of Dr. Max Fink, Dr. Harry Goldenberg and Dr. Arnold Blumberg. These programs have continued to produce valuable achievements, some of which are reported below. It is’ hoped that the next few years will see even greater emphasis on the research aspects of the goals for Hillside Hospital. I I Eight percent of the total Hillside Hospital budget is currently devoted to research. National recognition of the research work done at Hillside Hospital. Dr. Donald Klein was appointed as a United States Public Health Service career investigator. Dr. Max Fink was appointed to the committee on Clinical Psychopharmacology of the National Institutes of Mental Health, who sponsor a national program for the screening of new drugs in the treatment of mental illness, joining Dr. Lewis L. Robbins, who has continued as Consultant to the Review Committee in Mental Health Research; and the sponsorship of the ﬁrst International Conference on the EEG and Human Psychopharmocology, at the World Congress of Psychiatry, Montreal, June 1961 by the Department of Experimental Psychiatry. Dr. Harry Goldenberg, was hon— ored by appointment as Chairman of the Van Slyke Awards Committee, Chairman of the divisional meeting of the American Association for the Advancement of Science, and panel member of the Eastern Analytical Symposium. Dr. Vivian Fishman’s drug research studies were recognized by the National Institutes of Health with an invitation to present her ﬁndings before the Psychopharmacology Round Table in Atlantic City. EXPERIMENTAL PSYCHIATRY Dr. Fink and his staff completed their survey of forty psychotropic compounds and showed the electroencephalogram (EEG) to be the best available measure of psychotropic drug activity. Typologies of patient response to I I two major psychotropic com— pounds—chlorpromazine and imipramine were deﬁned. This work enables psychiatrists to determine the best drug for each patient. BIOCHEMISTRY Dr. Goldenberg and his staff investigated the chemical changes which occur in chlorpromazine due to glandular activity. Animal trials led to the discovery that two products (“metabolites”) derived from chlorpromazine may be equivalent or superior to the parent drug. Other animal studies were carried out in the laboratory dealing with the stress phenomenon; these experiments have led to observations that may be signiﬁcant to the solution of the problems of senile psychosis and atherosclerosis. I I MEDICAL RESEARCH Dr. Blumberg in his program of medical research has developed a ﬁrm basis for the mecholyl test. He has demonstrated the stability and the reliability of this test in chemical use. It is now used as an effective medical screening device to determine the patients receptivity to somatic psychiatric treatment. I �Publications A FINK, 'M_.: .EEG Techniques in Study of Psychotropic Drugs. Discussion.Actaiof Int.'I Meeting‘oh Techniques for Study of Psychotropic Drugs, Modena, Soc. Tip'o'grafic‘a Mo'de'nse, 1961. FINK, M. and KAHN, R. L.: Behavioral Reproducibility of the Mecholyi Test, Psychosomatic Med. 22: 1,1960. Convulsive Therapy. A.M.A. Arch. Gen. Psychiat. 5: 30-36, BLUMBERG A. 'G., LADERMAN- P. and FINK, M. Efficacy of Divided and FINK, M., KAHN, R. L. KARP, E.. POLLACK, M., GREEN, M., ALAN, B. and LEFKOWITS, H. 1.: Inhalant Induced Convulsions: Significance of the Theory. of theConvulsive Therapy Precess. A.M.A‘. Arch. Gen. Psychiat. BLUMB_,ER,G G.: 'Single Dose Schedules in Insulin' Coma Therapy, Am. 1. Psychiatry 116: 839-40, March, 1960.; and KLEIN, D F.: Severe PapiIIedema Associated With BLUMBERG, A. G. Drug Therapy, Am. J. Psychiat. 116:: 168- 170, 1961. BLUMBERG, A, G. and GOLDENBERG. H. Relation of the Mec‘hoiyl Test to Catechoiamine Excretion, Proc. Soc. Exp. Biol. 6: Med 106: 867-869, 1961. H. Union and Management Trainees: A Comparative Study of BOGARD, Personality and Occupational Choice, 1. of Applied Psychology 44: 56-63, 1-960. Nursing Staff Functions in a Treatment Setting, 1. Hillside Hosp. 9: 88-93,1960-. CLIGGETT, K.: Occupational Therapy at the Adolescent PaVIIion, 1. Hillside Hosp. 9: 80-87, 1960. ENGEL, R.: a Case of Depersonalization, 1. Hillside Hosp. 9: 106-127 1960. FAJRAJZEN, 8.: _On Effect of Anticholinergic Compounds on Post-Convulsive EEG and Behavior of Psychiatric Patients, EEG Clin. Neurophysiol. 12: 359-369, FINK, M.: 1960.- FINK, M.: EEG and BehaviOraI Effects of Psychopharmacologic Agents. In. Neuro-PsychopharmacoiQE-Yy ed. P, Bradley. Amsterdam, Elsevier, pp. 441-446, 1960. FINK, M., 1AFFE, 1. and KAHN, R. |:.: Drug IndUCed Changes in Interview Patterns: Linguistic an‘d Neurophysiologic lndices. In Dynamics of Psychiatric Drug Therapy. red. G. J. Sarwer-Foner, Springfield, "L, C. C. Thomas, 1960, pp. 29-44. FINK, M.: EEG and Behavioral fects of Tofranii, Ef- EEG C-IiII. Neuro- physiol. 12: 243-44 (abst.) 1960. FINK, M.: Differential Treatment and Prognosis in schizophrenia, by R. D. Wirt and W. Simon. Book Review, A..M.A Arch. Gen. Psychiat. 2: 121- 122,1960. Problems of Antagonists to Psychotropic Drugs. Discussion. Neuro—Psychophar‘macology 2: 30-32, ed. E. Rothlin. Amsterdam, Eisevier, 1961. FINK, M.:- Patterns In 11961. 4: 259-266, 1961. V. and‘GOLDENBERG, FISHMAN, H.: MetaboIi-sm of Chiorpromazine: 0rganIc-Extractable Fraction from Human Urine. Proc. Soc. Exp. Biol. 6: Med.104: 99,1960. 3.: Helping the Disturbed Adolescent Acéept Hospitalizatibn. Social Work 6.69 75.1951 FREEMAN, M.‘E. and FRIEDMAN, M. R.: .AfMethod-of Organizing Clinical Data: A Teaching Aid for Training ResiFRIES." dents apy. Psychoanalytic PsychotherHillside Hosp. ‘9: 25-47, 1960. in 1. GALE, M. .and SHATZKY, B.: P.S. 611 y—Queens Annex: ASchool in .a Psychiatric Hospital. 1. Hillside Hosp. 9: 94-99, 1960. Aftercare Program for Adolescents. 1. Hillside Hosp. 9,: 61'65, 1960. GOLDENBER-G, H., FISHMAN, V., WH'ITTIER, 1. and BRINITZER, W.: Urinary Aromatic Excretion Patterns schizophrenia, A.M.A. Arch. Gen. Psychiat. 2: 221.1960. in GOLDENBERG, H. and FISHMA-N, V.: Species Dependence of Chiorpromazine Metabolism, Proc. Soc. Exp. Biol. 8: Med. 106. #26884 1961. GREEN, S. L., KWALWASSER, S., and STAHL,.A. S.: The Role of the Psychiatrist in a Residential Treatment Unit. for AdoleSCen'ts. PSychi‘at. Quart. 34: 662-691, 1960. Relation Between Threshold and Duration of Seizures a'nd Electrbgraphic Change During Convulsive Therapy. 1. Nerv. Ment. Dis. 130: 235-239, 1960. M. A.: Approaches to Psychiatric Consultation in a Research Hospital Setting. A.M.A. Arch. Gen. Psychiat. 3: 691-697, 1960. GREENBERG, I.: I.: Acute lnterc-urrent Psychosis During the Course -of Familial Periodic Paralysis. Am. 1. GREENBERG, Psychiat. 116: 260-263, 1961. I.: Comparison; of the Cross-Cultural Adaptive. Process with Adolescence. compr. Psychiat. 2: GREENBERG, 44-50, 1961. 1.: ESECQVER, H., KAHN, R: L. and FINK, M.: Modification of 1AFFE, 1.. Psychotherapeutic Transactions by Altered Brain Function. Am. 1. Psychother. 15: 46-55, 1961. 1AFFE,1., FINK, M., and KAHN, R. L: Changes in Verbal Transactions with Induced Altered Brain Function. J. Nerv. Ment. Dis. 130: 235-239, 1960: Language Patterns as Character Defenses: Implications for Psychoanalytic Technique. Psychological' and, Psychiatric Aspect of Speech and Hearing, Disorders, ed. D. A. Barbara. Springfield, III., C. C. Thomas, 1960. pp. 138-151. 1AFFE, Formal 1.: and FINK, M;: Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. J. Neuropsychiat. 1: 242245, 1960. KAHN, R. L. and FINK, M.: Figure-Ground Discrimination after Induced Altered Brain Function. A.M.A. Arch. Neurol. 2: 547-551, 1960. KAHN, R. L., POLLACK, M. and FINK, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Ment. Dis. 130: 187-192, 1960. KAHN, R. L., POLLACK, M. LGLYNN, E.: An GREEN, Social Factors in the Doctor-Patient Relationship. In PsyChoanaly'sis and Social Process, ed. 1. Masserman. New York, Grune 8: Stratton, 1961, pp‘. 81-88. 1AFFE, and POLLACK, M.: Sociopsychological Factbrs Affecting Therapist-Patient Relationships. Psychoanalysis and Human Va'lues, ed. 1. Masserman, New York, Grune 8: Stratton, 1960. pp. 155-168. KAHN, R. L. and POLLACK, M.: The Relationship of Mental and Physical states in Institutionalized Aged Persons. Am. 1. Psychiat. 117: 120-124, 1960 (with Goldfarb, A. I. and Gerber, l. E.). KAHN, R.» L. and POLLACK, M.: Brief Objective Measures for the Determination of Mental Status in the Aged. Am. 1. Psychiat. 117:, 326-328, 1960 (with Goldfarb, A. I. and Peck, A.). KAHN, R. L. Staff Attitudes Toward Psychiatric Treatment in .a Voluntary Mental Hospital. 1. Hillside Hosp. KAHN, R. L.: 10: 97-106, 1961. KAHN, R. L., POLLACK, M. and GOLDFARB, A. I.: Factors Related to In- dividual Differences in Mental Status of Institutional Aged. In Psychopathology of Aging, New York, Grune & Stratton, 1961, pp. 104-113. and LEFKOWITS, H. 1.: Influence of Staff Attitudes and Environmental Factors on Treatment Selection. 1. Hillside Hosp. 10: 8496, 1961. KAPLAN, A. I. �Alterations of Visual Excitability in Patients with Lesions of the Cerebral Optic Pathways. KARP, E.: Trans. A.N.A. 156-159, 1959 (with Battersby, W. S. and Wagman, I. H.). Neural Limitations of Visual Excitability: Alterations Produced by Cerebral Lesions. Arch. Rural. 3: 24-42, 1960 (with Battersby, W. 5., Wagman, I. H. and Bender, M. D.). KARP, E.: ROSEN, B. H.: Case Report of Auricu- lar Fibrillation Following the Use of Imipramine (Tofranil). J. Mount Sinai Hosp. 27: 6, Nov.-Dec., 1960. Effect of Interpersonal Relationships Upon Verbal Conditioning. J. Abnormal I. Social Psychology 60: 241-6, 1960. SAPOLSKY, A.: KAVAZANJIAN, T.: The Role of the Clinical Psychologist in the Adoles- and STAHL, A. 3.: The Treatment Of “Provocative” Behavior in the Disturbed Adolescent. J. Hillside Hosp. 10: 67-81, 1961. 1960. STAHL, A. 8.: The cent Pavilion of the Hillside Hospital. J. Hillside Hosp. 9: 65-71, F.: Mepazine (Pacatal): Clinical Trial with Placebo Control KLEIN, D. and Psychological Study. Psychopharm. 1: 280-287, 1960 (with J. R. Whittier, G. Levine and D. Weiss). and GREEN, 3. L.: Treatment Program at the Israel Strauss Pavilion for Adolescent Girls. J. Hillside Hosp. 9: 14-24, 1960. KWALWASSER, S. LEVINE, A.: Appraising Ego Strength from the Projective Test Battery. J. Hillside Hosp. 9: 228-240, 1960. LINNELL, Z. M.: Authority as 3 Treatment Modality with Adolescents in a Psychiatric Hospital. J. Hillside Hosp. 9: 48-60, 1960. LURIE, A. and PINSKY, L.: Collabora- tion between Psychiatric Hospital and Community Agencies in the Rehabilitation of Mental Patients. Mental Patients in Transition, ed. Milton Greenblatt, Springfield, ”L, C. C. Thomas, 1951. Effect of Brain Tumor on Perception of Hidden Figures Sorting Behavior and Problem Solving Performance. Dissertation Abstracts. 20: 8, 1960. POLLACK, M.: POLLACK, M.: Comparison of Childhood, Adolescent and Adult Schizophrenias. A.M.A. Arch. Gen. Psychiat. 2: 652-660, 1960. POLLACK, M.: The Face-Hand Test in Retarded and Non-retarded Emotionally Disturbed Children. Am. J. Ment. Def. 64: 758-761, 1960 (with E. Gordon). and FINK, M.: Socio~ psychological Characteristics of Patients who Refuse Convulsive Therapy. J. Nerv. & Ment. Dis. 132: 153157, 1961. POLLACK, M. POLLACK, M., KARP, E., KRAUTHAMER, 6., KLEIN, D. F. and FINK, M.: Neuropsychologic Response Pat- terns of Some Psychotropic Drugs. Neuro-Psychopharmacology 2: 381384, ed. E. Rothlin. Amsterdam, Elsevier, 1961. ROBBINS, L. L. and WALLERSTEIN, R. 8.: Operational Problems of Psychotherapy Research: 1. Initial Stud- ies. Bull. Menninger Clin. 24: 164189, 19690. SCHILDKROUT, M. S. First Five Years of the Israel Straus Adolescent Pavilion Program. J. Hillside Hosp. 9: 5-13, 1960. WALLACH, S. S., WALLACH, M. B. and 6.: Observation of Involuntary Eye Movements in Certain Schizophrenics. J. Hillside Hosp. 9: 224-227, 1961. YESSlN, ZIE‘RER, E. and ZIERER, E.: The Integration Quotient in Creative Ther— apy. J. Hillside Hosp. 9: 156-170, 1960. �Administration and Finance 5‘ The extent of future development of Hillside Hospital will depend upon the readiness of the community to support its program. At this point it is not possible to project our budget for five or ten years in the future, but it is possible to choose a course of development and to have some general awareness of the fact that expansion of Hillside’s program . could easily double . . . the current budget. In addition to the staff augmentation, there will, of course, have to be a concomitant increase in housekeeping, administrative personnel and it is evident already that additional facilities, not only for staﬂ but also for patients, are required. The current dining facilities are already overtaxed and the areas for occupational, educational and rec— reational activities are much too limited and inadequate. Consideration must be given, therefore, to con— struction not only of a research building, but also more adequate facilities for patient activities, staﬁ meeting rooms, library and dining rooms.” The charts graphically illustrate the ﬁnancial operation of our hospital during the ﬁscal year ended June 30, 1961. Sizable deﬁcits were incurred in our in-patient and outpatient services because of the increase in the quality of patient care. As we continue to make progress and as we continue to improve wages and salaries, we believe that these deﬁcits will increase if we are to continue to meet our stated objectives. Without the ﬁnancial assistance of the Federation of Jewish Philanthropies and our Board of Trustees, the progress of which this report treats, would have been impossible. The professional development program has required corresponding expansion and improvement of administrative services. Housekeeping and Maintenance services have been enhanced through the application of industrial management techniques. HILLSIDE Hospiut GLEN OAKS KIFF. COLEAN, VOSS 3 SOUDER THE OFFlcE 0F YORK a SAWYER N, Y. ARCHITECTS �Work measurement, preventative maintenance, a planned painting program and modern equipment have been emphasized. These programs have resulted in signiﬁcant improvements in hospital appearance and services so important to the “therapeutic community.” To provide the base for effective organization to achieve stated goals of our hospital, an intensive personnel management program has been planned and implemented. Personnel policies have been developed, consolidated, and published, job analyses have been performed, a job grading program has been established, a merit evaluation program has been implemented, and salary scales were increased for professional and service staff. The results of these efforts have been an increas— ingly stable and efﬁcient employee group of high morale. Our most immediate need is for the space which will express the professional development program in physical terms. Psychiatrists’ oﬂice space is inadequate, teaching facilities including our Medical Library are limited, Activities Therapies areas are widely dispersed and insufﬁcient, and Research space does not meet current needs. To meet our space needs, we have developed a master plan for future construction. Our plans provide for construction of an Activities Therapies building, addi— tional research facilities, and a staff housing project. Following construction of these buildings, we will reconstruct presently existing facilities so that they too, may meet present and future space needs. SERVICE COSTS ln-Patient Service‘ COST $26.65 L088 $1 .56 INCOME *Average per patient-day SERVICE STATISTICS ........................ Number of in-patients treated ........... Number of out-patients treated .......... Number of out visits ................... ln-Patient days 69,941 539 659 14,614 INCREASE IN EXPENDITURES TREATMENT and TRAINING 1958-1959 $924,703 1960-1961 UP 42% $1,310,908 RESEARCH 1956-1959 1960-1961 $ 152,638 $ 198,275 UP 30% ADMINISTRATIVE SERVICES‘ 1956-1959 $ 729,595 $904,863 1960-1961 UP 24% MAURICE BACHRACH Administrator TOTALS 1958-1959 $1,806,936 1960-1961 $2,414,046 *lncludes Administration. Accounting, Food Service, Housekeeping, Maintenance, Office Services and Medical Records. �JANUARY 1, 1960—JUNE,30, Jeena' Attending Psychiatric Staff ATTENDING PSYCHIATRISTS Hyman L. Rachlin, M.D.‘ Lawrence J. Roose, M.D.* Samuel Atkin, M.D.* Frank Berchenko, M.D. Robert Savitt, M.D.' Martin Schreiber, M.D.* Isid'or Silbermann, M.D." Otto Sperling, M.D.t Aaron Stein, M.D.* Sidney Tarachow, M.D.* A. lsidor Bernstein, M.D. Arnold Eisendorfer, M.D.' M. David Epstein, M.D.I' Margaret E. Fries, M.D.‘t I. Peter Glauber, M.D.t George S. Goldman, M.D.‘T Paul Goolker, M.D.* Sidney L. Green, M.D.* William Karliner, M.D.‘ Sylvan Keiser, M.D. Sarah R. Kelman, M.D.‘ Emanuel Klein, M.D. Simon Kwalwasser, M.D. Samuel R. Lehrman, M.D.‘ Abraham S. Lenzner, M.D. Joseph s. A. Miller, MD! Martin H. Orens, M.D.: Samuel Z. Orgel, M.D.* ASSOCIATE ATTENDING PSYCHIATRISTS Renato J. Almansi, M.D. Alexander J. Friedman, M.D. SoIl Goodman, M.D. Abraham I. Kaplan, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. Geraldine Pederson-Krag, M.D. William W. Pike, M.D. Jay Stanton, M.D. ADJUNCT ATTENDING PNYCNIATRISTS ’lebur Jarvis; M D_. ‘ Edward R. Adelson, M.D. Herman S. Alpert, M.D. Alvin B. Balaban, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Beli’nkoff, M.D.. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Rita M. Chalef, M.D. Isadore H. Cohn, M.D. Irving J. Crain, M.D. Joseph H. Feldman, M.D. Jules Glenn, M.D. Albert E. Goldberg, M.D. Michael Gould, M.D. Lebert Harris, M.D. AIbErt Harrison, M.D. Thomas Hora, M.D. Martin Hurvitz, M.D. Eugene H.Kaplan,.M.D. .Paul Kay, M.D. George R. Krupp, M. D. Peter Laderma'n, M. D.. Myer D. Mendelson, M.Dd" David Milrod, M. D. Helene Pap‘anek, M.D Henry Rasner, M. Irving Salan, M. D. Frjéd' U. Tate; M. D. B. Frank Vogel, MDi. Leonard Weinroth, M D ‘ . D Herbert Wie’de'r, M.D. Consulting Physicians and Surgeons MEDICINE Lester Cohen, M.D.* George Sabrin, M.D. Louis Rosenblum, M.D. Jerome Weinstein, M.D. Wilbur 8. Brett, M.D. Arnold L. Berger, M.D. DERMATOLOGY Joel Schweig, M.D. Norman Goldfa’rb, M.D. Eugene L. Bodian, M.D. GENERAL SURGERY Sidney Hirsch, M.D.* Stephen Deckoff, M.D. UROLOGY Daniel Kaufman, M.D. Albert Sutton, M.D. ORTHOPEDICS A. H. Lewert, M.D. Julius Schneiderr‘n‘an, M.D. PROCTOLOGY Benjamin Warner, M.D. NEUROLOGY Kurt Adler, M.D. Joseph Siris, M.D. Martin Green, M.D. OPHTHALMOLOGY Edward Seretan, M.D. Robert Jampel, M.D. OTOLARYNOLOGY DENTAL sen VICLE Director Palil Schemari, .:D D. S.- ‘ Associate Director J. GordonRuDin, D'.‘D._S.. Associate Dentists Benjamin S'c'hwai‘d} '73-'Bernard: Lebow, D. D.S. Adjunct Dentists Lepn Bas'son, D. D. S‘Carl Blacharsh D Herbert Eormani‘ EISa Friedman, Henry Lewis, D. Martin Protéll, D S; ' Sam Clayton, M.D. Samuel Henken, M.D. ANESTHESIOLOGY Georges Bean, M.D. GYNECOLOGY Marie P. Warner, M.D. Bernard Greenblat, M.D. Jack Cohen, M.D. RADIOLOGY Bernard Epstein, M.D. Paul S’teinhorn, M.D. PODIATRY William Rieder, Pod.0. OPTOMETRYSERVICE Edward Steinherg, OJDf. Professional and Non-Professional Employees We wish to express our appreciation to the following professional employees, who helped make our progress possible. and non- professronal PROFESSIONAL EMPLOYEES ACTIVITIES THERAPY Judith Conrad Karen Diaslo Laura Dunlap Ann Elliott Miriam Gozali Phyllis Holland Mona Jones Mary Marrone Lila Martin Marion Sheffer _ Richard Thaler Joan Tucker Yaeka Umemura Alida Vasquez CLINICAL LABORATORY and x41" Kathryn Boone carolyn siegel DENTAL Bertha Sckipp MEDICAL RESEARCH Stephen Deckoff, M.D. Laura Zaves, R.N. PHARMACY Eleanor Palais RESEARCH IN BIOCHEMISTRY PSYCHOLOGISTS Howard Bogar'd, Ph.D. Eugene Friedman, Ph.D.. Benjamin Lapkin, Ph.D. Ira Rosenblatt, Ph.D. ‘Formerly Member of the Medical Board Allen Sapolsky, .Ph D‘. Stanley Schlff, P D.'-. Eelix Steiner, P Leonette V‘anderhost”. Florence Volkman‘ TR'es‘igneJ Robert Burnett . Vivian Fishman Ph. D. ' Audre Heater) Michael Rabinowitz; Daniel [White- wgeeasea‘? . �RESEARCH IN EXPERIMENTAL PSYCHIATRY Ira Belmont, Ph.D. Romeo .Cartolano llana Goldschmidt Abraham Kaplan, M.D. Eric Karp, M.A. Donald Klein, M.D. Jean Kolodny John C. Kramer, M.D. Hanna Mosquera Max Pollack, Ph.D. Arthur Willner, Ph.D. REGISTERED NURSES Marie Cafiero Isabelle Copeland Ann Dispensa Carol Enggasser Maureen Rolston Rose Schulbaum Helen Stein Zelda Feigenbaum Evelyn Feminella Marion Fitzgerald Millicent Goldberg' ‘Ilse Hurst Ann Kelley Joseph Kelly Patricia Kenney Elaine Kirs’chenbaum Ann Klemballa Mar'y' ‘Kohnke Kathleen Le'eFlora McCartney Joann Mastrole Martha Morey Janet Moses _ NanCy Steinhardt Gladys :Stokes‘ .Cfa‘therine' Szakmary Hele‘n Thrasher EditthitoIo Dorothy Urban Helen Zeigler LICENSED PRACTICAL NURSES Mar-y Corrigan Maud Drun'canson Heathlean English Theresa Homrd Betty Ann Kelly Luverne Reeves Mary Nigro Myra Pesk0witz MYrtle‘Re‘mbe‘rt Shirl‘eyi Piot’nic‘k Gloria Swan Ruth Thiele‘ Catherine Wall Sylvia :Riback Nancy Rosenbaum Lita Schmidt S'eymotir Silverberg Gisela Tauber Alice Thompson Ellen weinstein Isabelle Young; SOCIAL SERVICES Casework Division "Robert F ishman BeatriCIe Freeman “Sally Gold Regina G‘oldstein Beatrice 'Hartley Grace HaWKi‘ns Mildred Heller Connie Israel SarahKlionsky Sondra Match Anita Mehr :SOCIAL se‘nwces Group Work DiVision Ellen Brathwaite Deugla‘s‘Glangw Barbara ‘Goldstein Robert'Handman Elaine Heyman Geraldine’Lauter Beverly Luther Adele Orlinsky SERVICE AND NON-PROFESSIONAL EMPLOYEES BUILDINGS and GROUNDS Adam Biali'k Edward Brady John R. CivinSkas Edward Fitzgerald Gustavo Greco Frank Greene George Jungk Bernard Keena Salvatore Lav Manna George Loblein Nero Moyd Stanley Novak Walter Roland Jr. Albert Schmid Joseph Seagren’ Albert Senese John-Skinder Thomas- Slaton Ignazio Taormina Leroy Watkins CLERICAL and BDOKKEEPING Accounting Department Arline Fle’ischmann Lillian Ingbe‘r Lillian Schaeffer Ethel Siegelman Jeannette Silver Dorothy Streir Office Services Irene Attinson Mary Benesta’d John Borgner Diane Brafm'an Jane Buckley Elizabeth cox Irene Djinkin Claire Dubin Leonora Edelstein Eugenia Fievss Marlene Forman ,Norma’Friedman. Shirlee G'alanty Sara Gingold EdWard Golove Frances Gullo James Hand Norberto Medina Adele Harris Grace Hyams Ida NoVick Martin Novick Gaspari Orlando SyIVI'a Hymo‘witz Belle Kapner Edna Kappes. Rose Landgarten Esta Levy Dorothy McClary Inge Mai Yetta Mintz Catherine Muff Florence Offsie Aileen Olton Elinor Paur Mary Pignoni Regina Pi'lchick Gloria Podrid Rita Rodon Joseph Ryan Dorothy Saults, Rose Sa‘vader Dorothy ‘Schnirman Belle Schultz Charlotte Sinovoi B'ettyStarr Edna Telesca Walter Theisen Crannie Weinstein Edna Weis'sman Lott‘e Wollman BIanche-Zaitz rooo seninces Francesco Ca‘nnetto Emma Casamassima Walter Davis, Jr. Arthur DWyer Pardo Faro Alphonse’Gross Ella Jacobs Jimmy Knight- Barbera Alfred Lemaire Gustavo Lescouflair Sarah Littles Anna Lueatorto Michael McDonough Arthu’r Martin Fortunate La Arthur Pitts Irwin Powell B'azil Allen Rivers Walter Rodney Eva Schwartz Helen Thompson Tindel Thompson HDUSEKEEPINC Low‘ell Booker Louis Burgie George Cables Jesus Cora James Cuozzo Jimmy Lee Dasher Nathaniel Glover Charles T. Hill Gerard Honore Joseph Hope ‘ William Hyman Heie'n Jackson, Ruby Jackson Marion Johnson Ernest King Harry‘Lewis August Lo Piccolo Annie Miller Roosévelt Mitchell Robert Reddick Agnes Schuster Willie Lee Skinner Ray Warren Blanche White William Wood PSYCHIATRIC AIDES Olga Allen Marion Bell Althea Bing; George" ‘Bi n‘gha‘m William Black, Jr. Beatrice Blake Annie Bo‘n'd Joseph Britt Joan Brown Lawrence Burger Raymond Burger Frances Butler Sylvester campbell Malcolm carter Annie Clements Alma Clinton Frederick Coley May Conrad Teresa Cooney Hatti'e'Cummings Catherine Eames Annie M. ‘Ervin Ellen Es‘aw' Guillaume Esse‘rs Irish Ford Herbert Franklin Idella Gaston Nettie Gordon Dolores Griffin Juliet Haipern Mabel Harper Essie Harris Linda Hart George Heller Alberta Hopkins Ethel HopWood June Johnson Anna Mae JonesThomas Kelson, Jr. A‘s‘a’lee‘Kirby Helen Olsen Clemmie Palmer Joseph Petty Ida Pulliam Elizabeth Rodriquez Dorothy Schrantz Carltdn Scott Lessie Mae Scott MildredShaw Grace Shieh Virginia'Smith Chauncey smokton Henrietta Strachan Bessie Sumner Louise Thiell Marion Thomas Walter T. Thomas Clyde Trotman Jean Trotman Clarence Tully Thomas Valentine, Jr. Martha Visalli Martha Welch Hazel White Leona Willett LaWrence Williams Anna Wolfberg Leon Wolfberg Clarence Young Edgar Zephyrine . Barbara Knight Doris Kraemer Josephine Lafayette Arthur Lanier Leslie. Lee Miriam Lee .Alic‘e'Leliukevicz Georgina Lohman Grace Lozano Thel‘matMac‘k Mildred March Laura Matthews Dolores Mitchell waiter Moore Ronald Myles designed and IIIUstrated by VISUAL SERVICES Inc. �HILLSIDE HOSPITAL .. is licensed by the New York State Department of Mental Hygiene. g .. is approved for resident training by Council on Medical Education, American Medical Assmiation. American Board of Psychiatry and Neurology. . . is .. .. accredited by American Psychiatric Association. Joint Commission on Accreditation of Hospitals. is a member of American Hospital Association. Hospital Association of New York State. Greater New York Hospital Association. Greater New York Fund. Unite'd'Hospital Fund. Welfare and Health Council of New York City. National Conference of Jewish Communal ServiCes. cooperates with Adelphi College. Altro Workshops. Federation Employment and Guidance Service.Jewish Community Service of Long Island. Jewish Family Service of New York. Long Island Jewish Hospital. New York City Board of Education. New York State Employment Service. New York State Department of VacatiOnal Rehabilitation. Queens College of the City of New Yerk. The Educational Alliance . - _ is .. a partieipating hospital in Master Plan for Hospitals and Related Facilities: for The Hospital Council of Greater New York. A ‘ ~ ‘ A ‘ » Hillside Hospital is a constituent agency of the Federation :of Jewish: Hiii'li'aothirepies .of‘Neinork �for psychkunk:ﬂeaﬂnent haﬂﬁhg and research January 19, 1962 Dear Fellow Employee: of the Hillside Hospital's Progress Attached to this letter is a c read this As and 61. 1960 family your you the fiscal for Report year made toward have we that reminded of the be progress Report, you will the establishment of Hillside as a leading hospital for psychiatric treatment, training and research. been have would possible not which Speaks, Report of this progress, without the dedication, loyalty and effort which you and your fellow would we For few shown the have this, last during years. employees like to extend our thanks. The Cordially, W X. ”m4/69/ Lewis L. Robbins, M. D. Medica1.Director ', Maurice Bachrach Administrator LLRﬁMB/SD/mb �32nd Annual Report HILLSIDE HOSPITAL Glen Oaks,Queens,N.Y. �Hillside Hospital is a nonprofit, nonsectarian mental hospital for the treatment of voluntary patients, suffering from early and curable mental symptoms and admitted regardless of ability to pay. The Hospital is a pilot institution, pioneering in and advancing the scientific frontiers of the human and efficacious application of psychiatry to the mentally ill. Hillside provides organized training for physicians in postgraduate psychiatry and psychotherapy. Major emphasis is placed on advanced research in all phases of treatment. ��........... REPORT OF THE MEDICAL DIRECTOR ................... PROFESSIONAL AND ADMINISTRATIVE STAFF MEMBERS. 5 6 TREATMENT 8 REPORT OF THE PRESIDENT OF THE HOSPITAL 3 SOCIETY OF THE HILLSIDE HOSPITAL BOARD OF TRUSTEES. 4 . . . ...................................... 11 TRAINING ........................................ RESEARCH 14 ....................................... STAFF PUBLICATIONS PRESENTATIONS 16 ............. REPORT OF THE PRESIDENT OF THE 18 ...... MEMBERS OF THE 19 .................... REPORT OF THE ADMINISTRATOR 20 ..................... PROFESSIONAL NONPROFESSIONAL AND MEDICAL BOARD MEDICAL BOARD AND EMPLOYEES ...... 1959 32nd Annual Report HILLSIDE HOSPITAL Glen Oaks, Queens, N.Y. �______WHM._.._» This is my ﬁfth and last annual report as President of the Board of Trustees of Hillside Hospital, and I am happy indeed to be able to state that during this last L. Robbins Lewis Dr. of service, my year has become Medical Director of the Hospital. His broad gauged plans have been submitted to our Board, and accepted for the future development and general planning of the treatment, teaching and research programs of the Hospital. There have been many changes here at Hillside since the death of our founder, Dr. Israel Strauss in 1955, and my election as the second president. I am confident that the original ambitions of our founder to improve treatment, to instruct as many as we can, and above all to attempt to really learn the “why” and “what” of mental illness have been furthered. I believe that my able successor, D. Herbert Beskind, will follow these same general pathways. During this past year, among other interesting incidents, may be mentioned the adoption by Hillside of the personnel policy of the Greater New York Hospital Association, the conversion of our insulin recovery dormitory into offices and conference rooms for research, and the raising of the basic rate of compensation by New York City from $16.00 to $20.00 per day. Costs continue their unbroken upward course, and the day of the “lowcost” hospital seems doomed. Adequate service combined with low cost appears to be a paradox. The need for additional buildings is, of course, generally present with most progressive hospitals, and we are no exception. During this year it has become apparent that we simply must have an Activities Therapy Building, since we just do not have enough room for our patients in the present quarters; and a specialized research building is really necessary since research is so obviously demanded to improve treatment results. Both of these buildings will, hopefully, begin construction in 1960. We have been granted $125,000 from the estate of our former Trustee, Edwin Elson, for the Activities Therapy Building; and we have been able to match this amount with a grant of $150,000 from the United States Public Health Service, for a research building. An incidental, but most important effect of the construction of these buildings will be to create space which may be used for critically needed living-in quarters for our personnel. Such quarters will improve the well-being of our staff, something which has always been of great importance to us. Dr. Joseph S. A. Miller, our former Medical Director, resigned during 1959 with plans to enter private practice; he continues, fortunately, to serve the hospital as a consultant and teacher. We all wish him every success in the years to come. In closing this, my last report, I wish to refer to two principles affecting com— munity activities which to me seem important. One that has guided me in my own decisions, is that it is important to rotate top board ofﬁcers. Such action not REPORT OF THE PRESIDENT OF THE HOSPITAL Alvin E. Coleman only affords opportunity to more individuals 'to serve, more variety in ideas, but probably, more efﬁciency, on the basis of the old adage that “a new broom sweeps clean”! The second principle is possibly more important since it refers to the motivation of why “we seek to serve.” Laymen who donate their time and thought to community affairs do so, of course, to be of service to those less fortunate than themselves. However, an important additional motive is the gain of ego gratiﬁcation from having a controlling part in decisions vital to their institution. Such emotions bring satisfaction to us, and are no doubt an important part of the broader life. It is this drive which makes the boards of or— ganizations so effective, and I believe that the autonomy of each board of each organization is absolutely essential to maintain this effectiveness. It seems to me that any serious interference with this autonomy would greatly weaken organizational actions, would make board memberships a mere fiction, and would soon cause board members to lose interest and drop active participation in institutional activities. This would be calamitous. It is with mixed emotions that I pass along the gavel of leadership. Mine is not only a sense of great satisfaction and pride in having been able to serve such an outstanding institution, but also is a feeling of humility at the vastness of the horizon and the smallness of the job accomplished thus far. May I express my deep appreciation and friendship to the professionals of the hopsital, and to the members of the Board of Trustees who have worked with me and so greatly helped me, and with whom it has been a privilege and a pleasure to serve. �OFFICERS‘ President Alvin E. Coleman Chairman of the Board Roy Foster Honorary Chairman of the Board Leon Lowenstein Vice Presidents Dudley Shoenfeld, M.D. D. Herbert Beskind George W. Galinger Secretary Manuel Lee Robbins Assistant Secretaries A. Jacob Abrams M. Victor Leventritt Treasurer David Finn Roy Foster George W. Galinger Assistant Treasurer Arthur Garson Members: A. Jacob Abrams Jonas Adler Alfred Appel Meyer Goldstein Arnold S. Askin Arnold S. Askin John M. Bendheim D. Herbert Beskind David Bunim Alvin E. Coleman Martin Coleman Morris David Thomas Epstein Arthur C. Fatt David Finkle Arthur Gar-son Maurice Glinert Jacob Epstein Katz Carl L. Kempner Harold P. Kurzman M. Victor Leventritt Budd Levinson Morris L. Levinson Milton B. Loeb Sandor Lorand, M.D. Leon Lowenstein Charles H. Meyer Arthur Murray Charles Revson Manuel Lee Robbins Irving Rosenbaum S. H. Scheuer Walter Scheuer Dudley D. Shoenfeld, M.D. Harry Silverson John W. Straus Irving Weisglass Nathan Wigod Morton S. Wolf Walter D. Yankauer Morton S. Wolf Walter D. Yankauer CHAIRMEN OF STANDING COMMITTEES Executive Committee Roy Foster Medical Affairs Committee D. Herbert Beskind Finance Committee Arnold S. Askin House & Grounds Committee George W. Galinger Nathan Wigod Legal Committee Charles H. Meyer Social Service Committee Hilda N. Strauss, Honorary Chairman M. Victor Leventritt, Chairman Personnel Committee Meyer Goldstein Nominating Committee Walter Yankauer Gifts Jr Legacies Committee Walter Yankauer Committee On Administrative Savings Arnold S. Askin Building Committee D. Herbert Beskind, George W. Galinger, ‘As a/ Novenlber 15, 1959 Honorary Trustees: Saul Blickman Hilda N. Strauss Executive Committee Members Arnold S. Askin D. Herbert Beskind Alvin E. Coleman Arthur C. Fatt Roy Foster George W. Galinger M. Victor Leventritt Leon Lowenstein Charles H. Meyer Manuel Lee Robbins S. H. Scheuer Dudley D. Shoenfeld M.D. SOCIETY OF THE HILLSIDE HOSPITAL BOARD OF TRUSTEES A4. ‘,.. A �The function of an annual report is to look backward brieﬂy in order to assess how well one is looking ahead. Much that took place during this past year indicates that Hillside Hospital has been making steady progress toward achieving the best clinical program that current knowledge permits in order to provide a base for achieving its research and training goals. During the year, the staff was reorgan— ized into sections consisting of members of each of the professional disciplines: phychiatry, psychology, social work, activities therapies, and psychiatric nursing—and each section was given responsibility for all the patients living in a particular ward and/or cottage. The patients are no longer being transferred from one living area to another; they now remain in contact with the same personnel throughout the length of their hospital stay. This plan permits the members of the staff assigned to each section to integrate and co-ordinate their efforts much more effectively, thus further facilitating our goal of individualizing treatment. Through administrative changes in our intake procedures, we have eliminated our long waiting list, making it possible for many patients to enter the hospital within twenty-four to forty-eight hours. All patients who are approved are admitted within two weeks. At the end of the year, Hillside Hospital was ofﬁcially approved by the Central Inspection Board of the American Psychiatric Association and by the Joint Commission on Accreditation of Hospitals. These organizations regularly inspect psychiatric hospitals to insure the maintenance of high levels of patient care. The detailed report of their inspection indicated that, on all counts, our treatment program, staff and physical plant met their higher standards. In April of this year the Children’s Out-Patient Clinic was opened and is now in full operation. In addition to providing treatment for disturbed children and their parents, this clinic offers supervised experience in child psychiatry for psychiatrists practicing in the community, as well as for physicians in our residency training program. This additional clinical activity will also serve as an important part of future research. Hillside Hospital has long accepted its responsibilities for training psychiatric personnel. In July, we increased the number of psychiatric residents in training from eighteen to twenty-ﬁve and have developed an educational program to teach residents in each of the three years of residency. In addition, training beyond the residency level is being added for psychiatrists in the hospital as well as in our out-patient clinics. During 1959, the Nursing Department instructed students from several hospitals and nursing schools. The Psychology Department provided instruction in Vocational Counseling; Occupational Therapy had students from Columbia University; the Department of Social Services maintained its training programs with the New York School of Social Work and with Adelphi College. The Department of Experimental Psychiatry has been providing research training in connection with the psychiatric residency. All these and other departments have been most active in many aspects of training, further details of which follow. Above all, the staff of Hillside Hospital has continued its interest in advancing our knowledge through research. A list of numerous presentations and publications indicating research being done at REPORT OF THE MEDICAL DIRECTOR Lewis L. Robbins, M.D. Hillside is included in this report. It should be noted that it is our determined philosophy to carry out investigations in all these three areas; psychology, biology and sociology and to share our ﬁndings with others in the hope that much-needed advances in our ﬁeld can be achieved. It is also gratifying to ﬁnd our judgments about the value of our research activities and the competence of our research staff conﬁrmed by several foundations and other agencies. Among those which have generously supported our research programs are the Nassau County Commu- nity Mental Health Board and the National Institutes of Mental Health. Numerous other developments have taken place during the past year. We have altered our former insulin unit to provide class rooms, conference rooms, a one-way viewing room, and ofﬁces. We have inaugurated a careful study of all of our physical facilities in order to meet our developing needs. Our volunteer program has been considerably augmented and staff has been added in several departments to further beneﬁt our patients. Co-operative programs with Long Island Jewish Hospital have added to both our treatment and training programs and give promise of valuable further collaborative activity. All that has been accomplished during the past year has been based on the ﬁne work of many people over many years. Outstanding have been the contributions of Dr. Joseph S. A. Miller, who after many years of distinguished service, retired in August from the position of Medical Director. To him, and to all the staff, past and present, the writer is indebted for providing such a solid base on which to build our future. Also, to the Medical Board and to the leadership of its President, Dr. Robert A. Savitt; and to the Board of Trustees which, under the leadership of its President, Alvin E. Coleman, has given advice and support—~the writer is gratefully indebted. �ADMINISTRATION Medical Director Joseph S. A. Miller, M.D.* Lewis L. Robbins, M.D. Associate Medical Director Simon Kwalwasser, M.D. Administrator Maurice Bachrach, B.S. Assistant Administrator Samuel Davis, B.A., M.S. STAFF PSYCHIATRISTS William Benjamin, M.D. Muriel Benton, M.D. Calvin Cheek, M.D. David Graubert, M.D. Henry Lefkowits, M.D. Zenos M. Linnell, M.D. Gerhard Schauer, M.D. Barbara Ure, M.D. Morton Wachspress, M.D. George Yessin, M.D. PROFESSIONAL DEPARTMENT HEADS Creative Therapy Ernest Zierer, Ph.D., Director Edith Zierer, Ass ’t Director Experimental Psychiatry Maximillian Fink, M.D., Director Internal Medicine Arnold Blumberg, M.D., Director Israel Strauss Pavilion for Adolescent Girls Alice Slater Stahl, M.D., Director Laboratories Harry Goldenberg, Ph.D., Director John Croghan, R.T., M.T., Supervisor Nursing Goldie Krupa, R.N., Director Nancy J eﬁries, R.N., Assistant Director Occupational Therapy Eileen Fisher, B.S., Director Out-Patient Services Robert R. Luttrell, M.D., Director Harvey Goldey, M.D., Assistant Director Robert Navarre, M.D., Assistant Director Aaron D. Weiner, M.D., Director Child Therapy Unit Psychology Abraham Levine, Ph.D., Director Social Services Abraham Lurie, M.S.S.W., Director Louise Pinsky, M.S.S.W., Assistant Director, Case Work Division Arnold Eisen, M.S.S.W., Assistant Director, Group Work Division CLINICAL ASSISTANTS Lester I. Abend, M.D. Edward R. Adelson, M.D. Romano Antonelli, M.D. Marion Axel, M.D. Howard Boskey, M.D. Stanley Brodsky, M.D. Daniel Chansky, M.D. Fred B. Charatan, M.D. Lionel Chertoﬂ’, M.D. Ralph W. Clemments, M.D. Frances Colonna, M.D. Stefano Fajrajzen, M.D. Irving J. Farber, M.D. Philip Friedland, M.D. Ruth Fuchs, M.D. Harold Galef, M.D. Harvey Goldey, M.D. Sumner I. Goldstein, M.D. Clara Gonda, M.D. Eugene Glynn, MD: Director Adolescent After-Care Unit Lebert Harris, M.D. Martin Hurvitz, M.D. Gunthar Jacob, M.D. Norman Levy, M.D. Zenos Linnell, M.D. Buck Luria, M.D. Howard Mele, M.D. Daniel Miller, M.D. Meyer Monchek, M.D. Beatric Nachtigal, M.D. Maurice Nadelman, M.D. Iris Orens, M.D. Joseph D. Rosen, M.D. J ehuda Rozanski, M.D. Leon Tec, M.D. David M. Tillim, M.D. Clara Torda, M.D. PSYCHIATRIC RESIDENTS Bruno Bellinfante, M.D. Reva Berstock, M.D. Richard Brown, M.D. Sevin Eker, M.D. Richard Frenkel, M.D. Robert Glauboch, M.D. Feridun Gunduy, M.D. Halldor Hansen, M.D. Harry Gonda, M.D. Paul Hansch, M.D. PROFESSIONAL AND ADMINISTRATIVE STAFF MEMBERS Sherwin Harris, M.D. Raymond Hollander, M.D. John Kramer, M.D. Leslie Langlois, M.D. Jay Lefer, M.D. Genesia Liu, M.D. Dorothy Lieberman, M.D. Harvey Mandel, M.D. Mark N essel, M.D. Richard Resnick, M.D. Alvaro Rozo, M.D. Mollie Schildkrout, M.D. Jack Schnee, M.D. David Steinman, M.D. Michael Trupp, M.D. Shirley Wallach, M.D. Daniel Weitzner, M.D. ADMINISTRATIVE DEPARTMENT HEADS Accounting Services Dorothy Croghan Buildings cf Grounds Thomas R. Lumley Dietary Services Angelina Canavan, B.A. Housekeeping Sarah Travers Oﬁ‘ice Services Lillian Dailey ’Resigned I959 ��The function of the Hillside Hospital InPatient Service is to provide treatment to patients suffering from the early and curable symptoms of mental illness. It is not the intention of Hillside Hospital to meet the overwhelming need of the com— munity for psychiatric treatment facilities. Limitations of funds and the inability to provide an expansive treatment pro— gram compatible with the Hospital’s training and research goals make limitation of the number of in-patients necestherathe if be the This case must sary. peutic community is to be a real treatment modality. It is therefore our purpose to provide a treatment program which is consistent with Hillside Hospital’s image of itself as a pilot institution in the field of mental health. Basic to the treatment of patients at Hillside Hospital is a concept of the therapeutic community. The effective relationships between patients and staff, as well as those between patients themselves is a basic element of the treatment program. Moving psychiatric patients from nursing unit to nursing unit, as their conditions improved, meant changed relationships as each move was made. This structure did not provide the best therapeutic situation for our patients. Therefore, in 1959, it was decided to reorganize the treatment service on the premise that patients remain in the units to which they are admitted throughout their entire hospital stay. This arrangement provides further advantages to the treatment program. Not only are staff psychiatrists, psychiatric residents and nursing person- nel able to develop sustained relationships as a therapeutic team, but the patients are also able to develop such relationships with each other, without having to face the problems associated with a constantly ’s patient environment. Further, changing self—government is stabilized by this arrangement. Finally, the entire administrative organization of the hospital has been facilitated by this organizational change in that sustained accountability for the total treatment program is now possible. In connection with this reorganization, several signiﬁcant changes took place within the Nursing Service during 1959. Provision of adequate nursing care within the revised organization required the restructuring of staffing patterns. A major segment of the nursing service was reassigned to provide the equal distribution of technical, semi-professional and professional nursing skills to all patient units. In the effort to improve staffing patterns, two new personnel categories were created in 1959—Counselor and Senior Psychiatric Aide. As a result of changes in the hospital treatment program, there have been corresponding changes in the assignment of the case work staff of the Social Services TREATMENT TRAl N l N RES EA Department. Two psychiatric social workers are now assigned to each administrative unit. It is now possible to co-ordinate work— social the of work the closely more ers with the work of other members of the team. The casework division has been making increasing use of group counselling. The group approach is now used by the case work in the Hillside Hospital After-Care Clinic. Social workers who function in connection with the InoPatient Service are supplementing individual contacts with visits with patient ’s relatives with group counselling. The admissions policy of the hospital in radically and reviewed changed was 1959. By making it possible to accept appointments for patients applying for admission during any week day, the delay in accepting patients has been drastically reduced. In addition, excessive waiting lists for in-patient admission have been virtually eliminated through the efforts of the Social Work Division, and the staff psychiatrists. Assessment of patient suitability for admission and rapid processing of patients who are accepted for admission is now possible. 1959 saw further expansion of the services of the Group Work Division of the Social Services Department in the provision of additional social and recreational facilities to the in-patient group. Patient government, social clubs, service groups, special interest groups and the the from comvolunteers for program munity were considerably expanded. �The Psychology Department in 1959 continued its program of diagnostic evaluation of the patient, in keeping with its function within the treatment team. The Vocational Counselling Unit of the Psychology Department continued to provide vocational counselling, training and placement services to our patients. The Vocational Counselling Unit joined with the Group Work Division in 1959, in the establishment of a secretarial skills program which was taught to patients by volunteers. The Occupational Therapy Department saw marked growth in 1959. To enable this department to treat the entire patient population and to eliminate waiting lists for this service, the staff was increased from ﬁve to twelve therapists. This permitted more intensive function by occupational therapists in the therapeutic team. Further, a high level of individualized occupational therapy is now possible. An Art Therapy program was also inaugurated in 1959. The Creative Therapy Department continues to perform its dual function as a diagnostic and therapeutic unit. _ Nonpsychiatric medical needs of Hillside Hospital patients are met through the Intramural Clinic. The Hospital Internist participates in initial and dis— charge conferences concerning patients whose physical problems are signiﬁcant in the planning of the total therapeutic program. Consultants in every branch of medicine give freely of their time to the support of patient care. Further, the services and facilities of the Long Island Jewish Hospital are utilized wherever indicated. An excellent Dental Unit is also provided to meet the particular dental needs of the mentally ill patients. This latter clinic is also fully staffed by dentists who serve voluntarily. The Hillside Hospital Out-Patient Department provides psychiatric care to residents of Queens, Nassau and Suffolk Counties who cannot pay for private psychiatric care. In 1959 an average of over one hundred persons were treated each week. In addition to individual psychotherapy, three group psychotherapy programs were established. 1959 also saw the staffing pattern of this clinic improved by the addition of more highly qualiﬁed doctors to insure the provision of a treatment program consonant with the goals of the Hospital. The out-patient selection process, too, was revised to afford immediate consultation Within twenty-four to forty-eight hours for all applicants. On April 1, 1959, the Child Therapy Unit of Hillside Hospital Out-Patient Department was opened with the help of a grant from the Nassau County Mental Health Board. A pilot project in the provision of psychotherapy for children, this clinic is further intended to provide the base for the expansion of future child care services at Hillside Hospital. The staff of the Child Therapy Unit consists of a psychiatrist in-charge, three clinical assistant psychiatrists, a psychologist and a social worker. Major emphasis is given to therapy or guidance for parents of children under treatment. Such treatment is usually focused on considering the parents’ reaction to the child’s prob— lems, or the parents’ role in the origin of the difﬁculty. In the nine months of 1959 during which this clinic was in operation, forty children plus their parents were seen in complete diagnostic evaluation. Fifteen children and their parents were accepted for treatment in this facility. A variety of after-care services have been developed for Hillside Hospital’s former patients. The Foster Home Care Project with the Jewish Community Services of Long Island; the After-Care Clinic which is part of our own Out-Patient service and is provided at Mt. Sinai Hospital; a supportive social case work service with the Jewish Family Services of New York; and a rehabilitation center, “The Bridge,” which provides a resocialization program and supports the Hilda and Israel Strauss League of former patients. �x» �The need for well-trained personnel in the ﬁeld of psychiatry cannot be overstated. Recent years have seen the devel— oping awareness of the assistance which psychiatric knowledge can bring to the broad spectrum of human problems. All of the specialties of medicine are becoming increasingly aware of the psychiatric elements in the etiology and treatment of physical disease. In the ﬁeld of public health, education, and welfare, psychiatry is playing a role of ever increasing importance. Further, public acceptance of the practice of psychiatry and the advances made in this ﬁeld make mandatory the provision of suﬂicient personnel to meet the nation ’s mental health needs. Hillside Hospital, because of its relatively small size and carefully selected patient population, is ideally suited to develop and share psychiatric knowledge. In accepting its responsibilities for the training of psychiatric personnel, Hillside Hospital is helping to meet the need not only for trained psychiatrists, but also for related professional personnel in the ﬁeld of mental health. In order to meet the increased need for psychiatrists, Hillside Hospital expanded its teaching program in 1959. The number of psychiatrists in training was increased from eighteen to twenty-ﬁve in a teaching program that is expected to require three years for completion. The residency pro— gram itself was improved by the inclusion of training in out-patient care and in research. Historically, the In-Patient Service of Hillside Hospital has not only provided quality patient care, but has also afforded the means for the training of psychiatric staff. The reorganization of the treatment service in 1959 provided for better patient care. The development of discreet administrative patient units affords the psychiatrist in training an opportunity to develop sound therapeutic relationships with an integral patient group. Furthermore, this arrangement allows the development of equally sound relationships between resident and supervising psychiatrists, resident and nursing staff, and resident and activities therapist, thus providing not only a good therapeutic milieu, but a more salutary training milieu. TREATMENT TRAINING RESEARCH To provide for the training of psychi- atric residents in the treatment of other than the hospitalized patients, the OutPatient Department now provides the resident with a learning experience which is similar to that which the psychiatrist has in his ofﬁce practice. This program, which was initiated in 1959, provides for the training of ﬁve psychiatric residents, who function part time during the third year of their psychiatric residency. Supervision by the Director of the Out—Patient Department and members of his staff obtains in planned individual and group conferences. To provide for the development of increased knowledge and skills by practicing psychiatrists in the local community, a planned program has been developed. Clinical assistants who are actively in the practice of psychiatry, receive further training under the supervision of the Director of the Out-Patient Department and members of the attending staff. The Child Therapy Unit which was initiated in 1959, also serves a signiﬁcant additional training function for practicing psychiatrists in the community. Three clinical assistants, who spend half their time in this clinic, receive individual supervision as a function of the Director of the Child Therapy Unit and from other highly trained psychiatrists. Clinical conferences, seminars and reading conferences, team meetings, planning conferences and psychiatric staff conferences provide further for the teaching program. ��Research at Hillside Hospital in 1959 was carried out not only in three departments whose function lies primarily with re— search, but in addition, clinical studies were carried out by individuals of various professional departments. EXPERIMENTAL PSYCHIATRY The study program in the Department of Experimental Psychiatry increasingly focused on the drug treatment process. Based on an extensive experience with newer drugs for mental illness, a detailed drug evaluation study was started in the fall. The selection of treatment, and behavioral, psychiatric, psychologic, neurophysiologic and sociologic aspects of change are being investigated. These examinations are undertaken to learn how drugs inﬂuence mentally ill patients, and to test a theory developed in this Department in 1956. In this theory, drugs are seen to affect behavior by changing both brain function and the psychologic attitudes of subjects. In the experimental psychology studies, increasing emphasis has been placed on individual differences in perceptual and cognitive behavior as related to the type of behavioral response with treatment. Study of these indices as predictors of change in addition to the usual use of indices of the effects of the treatment has demonstrated signiﬁcant relationships. The introduction of an electronic frequency analyzer of the Ulett-Loeffel type in August, 1959—a device to rapidly measure the various electrical waves recorded from the brain—signiﬁcantly expanded the electro-encephalographic 14 program. An analysis of changes in the various patterns in the EEG made possible the critical and more precise determination of neurophysiologic effects of various drugs. During the year, 404 records were recorded, and of these, 59 were clinical consultation requests. The sociologic programs undertook an analysis of the differences in patient attitude to treatment of the various staff groups, as the resident doctors, nurses, social workers, etc. ; tolerance of the staff for different types of emotional upset and referral for somatic treatment; and changes in the Hillside Hospital patient population between 1957 and 1959. In order to understand the relation of social factors to the treatment of mental illness, an elaborate tri-hospital study comparing sociologic characteristics, treatment referral rates and discharge ratings in the Menninger Foundation, the Massachus— sets Mental Health Center and Hillside Hospital was begun. TREATMENT TRAINING RESEARCH In language studies—an area that is receiving increased attention in psychiatry—the staff organized and participated in a unique seminar at the New York Divisional Meeting of the American Psychiatric Association. Various psycholinguistic experts employing their individual methods of study, analyzed two tapes of an analytic treatment, and compared their results. They showed the value of combined methods in providing an objective measure of the psychotherapy process. Eighteen reports were published during the year and eleven papers were presented before the national societies. The staff was instrumental in the organization of the New York Divisional Meeting of the American Psychiatric Association, and presented reports at four of its symposia. The staff also participated in the International Conference on Depression and Allied States that was held in March in Montreal. Changes in staff during the year included the appointment of George Krauthamer, Ph.D. as neurophysiologist, and Donald F. Klein, MD. as psychiatrist to the Department. Dr.' Robert L. Kahn, after ﬁve years of service, left to assume the position of Head of the Section of Psychology, Division of Psychiatry of Monteﬁore Hospital. Dr. Joseph Jaffe, while continuing as an Associate in Research in this department, assumed the position of Faculty Member and Associate Director of Research of the William Alanson White Institute. �Continuing support for the program was obtained from the Board of Trustees, extensive program support from the National Institute of Mental Health of the United States Public Health Service, and with grants from the Mental Health Board of Nassau County. BIOCHEMICAL RESEARCH Biochemical research was focused on aromatic substances in the urine of psychiatric patients and on the metabolism of the newer psychotropic and hallucinogenic drugs. For many years, the possibility that psychiatric patients excrete compounds not present in normal subjects has provided the basis for special studies. This program analyzes urine samples for a wide range of chemical substances which are similar to known hormones. It attempts to determine whether psychiatric patients from Hillside Hospital and Creedmoor State Hospital differ from normal subjects. With the widespread use of new drugs in psychiatry, it has been important to determine the way these compounds affect metabolism. One program has been devoted to tracing the changes which chlorpromazine undergoes in the body. For this study, special techniques of analysis for chlorpromazine derivatives have been developed. The focus now is in relating the kinds of derivatives and the rate with which they are produced to their clinical effects. The metabolites of adrenalin are the object of another study with the Medical Department. In patients receiving the Mecholyl Test, urine samples are analyzed before and after the test for various derivatives of adrenalin. Blood studies to determine the enzymes responsible for changing adrenalin are in progress. Recently, a special colorimetric technique for O-methyl transferase was developed. In experimental animals, as well as in the laboratory, the metabolism of hallucinogenes has been studied. Derivatives of lysergic acid related to the vitamin B complex and have been produced and are being tested for hallucinogenic activity and metabolic pathways. MEDICAL RESEARCH The major efforts of medical research in 1959 continued to be directed toward an understanding of the mechanism of the Mecholyl Test. The reliability of the Mecholyl Test, using newly developed equipment for recording blood pressure, ﬁrst was undertaken. These studies demonstrated that the two initial readings of the test were reliable measures. They, furthermore, established the limits of change in the test as a basis for continued studies. In addition, in co-operation with the Biochemistry Department, a study of the relation of metabolites of adrenalin to this test was begun. In the drug evaluation program, the Medical Department assumed control of new medications and of a variety of physiological tests. These included the electrocardiogram and liver and thyroid function studies, as well as the Mecholyl Test. CLINICAL STUDIES A study of the factors affecting the selection of somatic treatment, Drs. A. Kaplan and H. Lefkowits noted that the recommendations for special treatment were as often based on extra medical factors as on the type of behavior of the patient. They described various degrees of symptoms and tolerances for different behaviors. In the Out-Patient Department, Dr. R. Luttrell and his staff have been interested in the prognostic factors in selecting pa- tients for Out-Patient Department treat- ment. Mr. Lurie and Miss Pinsky of the Social Service Department have done a follow-up study of Hillside Hospital patients who have been referred to The Foster Care Program. The results of this study have been gratifying in terms of the evaluation of the program and of the indication of future direction. In clinical psychology a special study of the psychological characteristics of post-partum depressive reactions was instituted. Toward the end of 1959, an extensive review of the Pavilion for Adolescent Girls, a pilot program in this ﬁeld, was prepared for publication in the ensuing year. I5 �efforts of the Hillside Hospital staff in the area of research will be seen in the following listing of publications and presentations. BLUMBERG, A.—Use of An Automatic Sphygmomanometer in the Mecholyl Test, Journal of Hillside Hospital, Vol. 8, #3, pp 179, An index of the July, 1959 BLUMBEEG, A., ROSETT, and DOBROW, A.—Severe Holland, Amsterdam, pp. 238-239 PINK, M. KAHN, R.L. and KORIN, H.—Therapy of Schizophrenia: Role of Alteration of Brain Function on Behavior, Congress Reports, II Int. Cong. Psychiatry, II: 492-493 and KORIN, H.—Relation of Tests of Altered Brain Function to Behavioral Change Following FINK, M. KAHN, R.L. In’duced Convulsions, The First International Congress of Neurological Sciences (III: EEG, Clinical of Internal Medicine, Vol 51, Neurophysiology and #3, pp 607, September, 1959 Epilepsy), Pergamon, 613-619 London, M.——Effect pp. of an PINK, Anticholinergic Agent, PINK, M.——EEG and Behavioral Effects of Diethazine, on EEG and Tofranil, International Behavior; Signiﬁcance for Conference on Depression Theory of Convulsive and Allied States, Montreal Therapy. Biological Psychiatry, ed. Masserman, PINK, M.—Language J ., Grune and Stratton, N. Y. Patterns as Measures of pp. 184—194 Behavioral and Neurophysiologic Change, rINK, M.—Alteration of Brain Function in Therapy. American Psychiatric Association, Philadelphia Psychopharmacology Frontiers, ed. Kline, N., FISHMAN-GOLDENBERG, Little, Brown 85 00., Boston, v., SPOERRI, mar—Coloripp. 325-332 metric Determination of Dicarbozylic Acid rINK, M.——Signiﬁcance of Derivatives as Hydroxamic EEG Pattern Changes in Acids, Anal. Chem. 31: Psychopharmacology. EEG Clin. N europhysiol. 2: 1735, 1959. Hypotensive Reactions to Overdosage of MeprobamatHThe Annals 398 (abst.) rINK, M.—Electro- encephalographic and Behavioral Effects of Tofranil. Canad. Psych. Assoc. J. 4: 1668-1718 rINK, M. KAHN, R.L. and GOLDENBERG, 11., FISHMAN, v., WHIT’I‘IER, J., BRINI'EZER, W. —Urinary Aromatic Excretion Patterns in Schizophrenia A.M.A. Arch Gen. Psychiat., in press GOLDENBERG, H, WHITE, D.L.-- Colorimetric Determination Factors Affecting Individual of O-Methyl Transferase. Diﬁerences in Behavioral Presented at the 126th Response to Convulsive Meeting of the American Association for the Therapy, J .N .M.D. 128: 243-248 Advancement of Science, 1959 December 27, Chicago, and R.L. M. KAHN, PINK, KORIN, H.—Eﬂ’ects of Diffuse GOLDENBERo, H., FISHMAN, v. Altered Brain Function on —Chromatographic Studies Perception. Proc. X V Int. of Chlorpromazine Metabolism in Man. Presented at the 126th Meeting of the American Association for the Advancement of Science, Chicago, Dec. 27, 1959 POLLACK, M.—-—Psychologica1 of Threshold and Duration of Social Attitude to Psychiatric Seizures to Degree of EEG Treatment, N.Y. Divisional Meeting, A.P.A., New York Delta Activity Induced During Electroshock, EEG. KAHN, R. L., with WEINSTEIN, Clin. N curophysiol. 2: E. A. and BERGMAN, P.——Effect (Abst.) of Electroconvulsive Therapy on Intractable Pain. JAFFE, J.—-—Communication A.M.A. Arch. Neurol. and Networks in Freud’s Psychiat. 81 : 37-42 Interview Technique, Psych. Quat. 32: 456-473 KAHN, R. L., with WEINSTEIN, E. A.——Symbolic ReorganizaJAFFE, J.——Symposium on ‘‘ tion in Brain Injuries, in Psycholinguistic Analysis Handbook of Psychiatry, ed. of the Psychiatric Interview ’ ’, Divisional Arieti, S. Basic Books, N. Y., Vol. I, pp. 964-981 Meeting, A.P.A. New York KARP, E.—Behavioral Changes JAF‘FE, J.——Social Backwith Different Methods of ground and the DoctorPatient Relationship, Acad. Induced Cerebral Dysfunction, Eastern Psychoanalysis, New York Psychological Association, KAHN, R.L. and BLACK, M.— Atlantic City of Application Prognostic Psychological Techniques in KORIN, H. and FINK, M.— The role of Set in the Convulsive Therapy, Dis. N erv. Sys. 30: 180-184 Perception of Simultaneous A. Tactile Jour, Stimuli, and R. POLLACK, M., L., KAHN, 384-392 72: Psychol. M.—Sociopsychologic FINK, KRAUTHAMER, G.—Form Aspects of Psychiatric Perception Across Sensory Treatment in a Voluntary Mental Hospital; Duration Modalities, Am. Psychol. 14 : of Hospitalization, Discharge 396 (Abst.) Ratings and Diagnosis, KRAU’I‘KAMER, G.———Personality A.M.A. Arch. Gen. Psychiat. Correlates of EEG, 1 : 565-574 Metropolitan EEG Society, New York KAHN, R. L., and PINK, M.— Personality Factors in LEVINE, A.—A Comparative Behavioral Response to Evaluation of Latent and Electroshock Therapy, Overt Schizophrenic Patients J. Neuropsychiatry 1: 45-49 with Respect to the Concept KAHN, R. L.—Socioof Ego Strength. Journal psychologic Factors of Hillside Hospital, VIII, Affecting Therapist-Patient No. 4, Oct. 1959, pp. 243-266 Relationships, American LEVINE, A.—“App1'aising Academy of Psychoanalysis, ego-strength from the Philadelphia projective test battery” KAHN, R. L.—Socio——Society for psychologic Aspects of Projective Techniques, Psychiatric Treatment, New York, May 1959 Eastern Psychological Association, Atlantic City Cong. Psychol., Publ. North- GREEN, M.—Relationship of KAHN, R. L.—Re1ation STAFF PUBLICATIONS AND . . 16 .m_............,,.... PRESENTATIONS LEVY, E.—The Role of the Volunteer In The Treatment Program of a Mental Hospital, Social Work with Groups, 1959, (New York Natl. Assoc. of Social Workers), pp 109-119 LURIE, A., HIRSCH, 8.— Establishing a Hospital Social Service Department, Journal of Social Work (Vol. IV, No. 2—April 1959) ‘ A.-—‘ Structure of LURIE, Field Work Training” Workshop, Council on Social Work Education, Philadelphia, Pa., January, 1959 LURIE, A.—“The Use of Group Process Within Medical Settings”. National Conference of Jewish Communal Service, Pittsburgh, Pa., May 1959 ‘Forecasting the Place and Role of the Aging in our Society during the next decade”. Little White House Conference on Aging, sponsored by the Community Council of Greater New York, LURIE, A.——‘ December 1959 POLLACK, M.—Effect of Induced Cerebral Dysfunction in Man on Tachistoscopic Perception of Embedded Color Figures, Eastern Psychologic Association. Atlantic City POLLACK, M. with BENDER, M. B., and BATTERSBY, W. s.— Complex Visual Perception in Patients with Brain Tumor. Proc. XV Int. Cong. Psychol., Publ. NorthHolland, Amsterdam, pp. 236-237 POLLACK, M.~—‘ ‘ Comparison of Intellectual Functioning in Childhood,” Adolescent and Schizophrenics, N. Y. Divisional Meeting, A.P.A., New York STAHL, ALICE—”The Role of the Psychiatrist in the Adolescent Pavilion. ’ ’ Midwinter Divisional Meeting of A.P.A. ��The past years has been one in which the Medical Board has shared in the period of transition now in progress at Hillside Hospital. Acting in an advisory and consultative capacity, the Board has aided the Medical Director and the Board of Trustees in bringing into sharp focus the aims and aspirations of Hillside Hospital : to become a leading center for psychiatric treatment, training and research. In keeping with the current spirit of transition at Hillside Hospital, the Medical Board has done considerable soul searching in order to reappraise its role in the affairs of the hospital. The Board is comprised of people who are outstanding in the ﬁelds of psychiatry and psychoanalysis. Some of its members are training analysts on the faculties of the three Psychoanalytic Institutes in New York City. Others have achieved aca- demic distinction as members of medical school faculties and hospital staffs. It is expected that gradual evolutionary changes will take place which will enhance the value of this reservoir of psychiatric experience and knowledge. In the past it has made major contributions to the academic deveIOpment of Hillside Hospital. Together with the devoted membership of our chiefs of Medicine, Surgery and Dentistry, the Board is a source of expert advice in the major activities of the hospital. The year has brought other changes, too. Dr. Sidney Tarachow, the first editor of the Journal of Hillside Hospital, has retired as the Journal’s guiding light, after ten years of unﬂagging devotion. Under his direction the Journal has become an outstanding contributor to the body of scientiﬁc knowledge and literature. It is expected that in the near future an issue of the Journal will be dedicated to Dr. Tarachow, as a token of our appreciation, esteem and affection. Dr. Aaron Stein of our Board has succeeded as editor. The various committees under the able direction of their chairmen have continued to function energetically in the many areas noted in previous years. To them and to the attending and visiting REPORT OF THE PRESIDENT OF THE 18 MEDICAL BOARD Robert A. Savitt, M.D. staffs I offer deepest thanks for their advice and co-operation. I particularly Wish to express my compliments to Mr. Alvin E. Coleman, the President of the Board of Trustees, and to Dr. Lewis L. Robbins, the Medical Director, for their valued and rewarding relationship to the Board. Conferences with these men and their dedicated colleagues have always been stimulating, informative and constructive. In closing, I take extreme pleasure in welcoming Dr. Sidney Tarachow to the Presidency of the Medical Board. He will give it the energetic devotion it so much deserves. �MEDICAL BOARD President Robert A. Savitt, M.D.* President-Elect Sidney Tarachow, M.D.* Secretary Sidney L. Green, M.D.* Treasurer Paul Scheman, D.D.S.* Eat-President M. David Epstein, M.D.* Psychiatrists Samuel Atkin, M.D. Arnold Eisendorfer, M.D.* M. David Epstein, M.D.* Margaret E. Fries, M.D. I. Peter Glauber, M.D.* George S. Goldman, M.D. Sidney L. Green, M.D.* William Karliner, M.D.* Sylvan Keiser, M.D. Sarah B. Kelman, M.D. Emanuel Klein, M.D. Samuel R. Lehrman, M.D. Joseph S. A. Miller, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D.* Lawrence J. Roose, M.D. Robert A. Savitt, M.D.* Martin Schreiber, M.D.* Isidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D.* Non-Psychiatrists Director of Department of Medicine Lester Cohen, M.D.* Director of Department of Surgery Sidney Hirsch, M.D.* Director of Department of Dentistry Paul Scheman, D.D.S.* CHAIRMAN OF STANDING COMMITTEES Adolescent Pavilion Sidney L. Green, M.D. Credentials Committee for Psychiatric Attending Staff Promotions Martin Schreiber, M.D. & Credentials Committee for Non-Psychiatric Visiting Staff & Promotions Paul Scheman, D.D.S. Education of Resident Staﬂ" Arnold Eisendorfer, M.D. Group Psychotherapy Samuel Z. Orgel, M.D. Manhattan A fter-Care Clinic Sarah B. Kelman, M.D. Queens Out-Patient Clinic Martin H. Orens, M.D. Sub-Committee for Child Guidance Clinic Isidor Bernstein, M.D. Research Committee Sidney Tarachow, M.D. Publications Committee I. Peter Glauber, M.D. Committee for Adjunctive Services I. Peter Glauber, M.D. Credentials Committee for Supervising Psychiatric and Resident Staﬂ‘ Lawrence J. Roose, M.D. CONSULTING, A‘ITENDING AND VISITING STAFF-'5 Consultants Psychiatry Leonard Blumgart, M.D.? Sandor Lorand, M.D. Nathaniel E. Selby, M.D. Dudley D. Schoenfeld, M.D. Medicine Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, M.D. I. Jesse Levy, M.D. YNeurology A. M. Rabiner, M.D. Hans Strauss, M.D. I. S. Wechsler, M.D. Surgery David Warshaw, M.D. Gynecology Julius Jarcho, M.D. Dentistry Morris Fierstein, D.D.S. Attendings Attending Psychiatrists Samuel Atkin, M.D. Frank Berchenko, M.D. Isidor Bernstein, M.D. Arnold Eisendorfer, M.D. M. David Epstein, M.D. Margaret E. Fries, M.D. I. Peter Glauber, M.D. George S. Goldman, M.D. Paul Goolker, M.D. Sidney L. Green, M.D. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Samuel R. Lehrman, M.D. Abraham S. Lenzner, M.D. Joseph S. A. Miller, M.D. Martin H. Orens, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, M.D. Robert A. Savitt, M.D. Martin Schreiber, M.D. Isidor Silbermann, M.D. Otto Sperling, M.D. Aaron Stein, M.D. Sidney Tarachow, M.D. Associate Attending Psychiatrists Renato J. Almansi, M.D. Alexander J. Friedman, M.D. Soll Goodman, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. Geraldine Pederson-Krag, M.D. William W. Pike, M.D. Jay Stanton, M.D. Adjunct Attending Psychiatrists Edward R. Adelson, M.D. Herman S. Alpert, M.D. Alvin B. Balaban, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Belinkoff, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Rita M. Chalef, M.D.:t Isadore H. Cohn, M.D. Irving J. Crain, M.D. Joseph H. Feldman, M.D. Jules Glenn, M.D. Albert E. Goldberg, M.D. Michael Gould, M.D.i Albert Harrison, M.D. Thomas Hora, M.D. Wilbur Jarvis, M.D.i Abraham I. Kaplan, M.D. Eugene H. Kaplan, M.D. George R. Krupp, M.D. Peter Laderman, M.D. Myer D. Mendelson, M.D.* David Milrod, M.D. Helene Papanek, M.D. Henry Rosner, M.D.t Irving Salan, M.D. Frederick F. Shevin, M.D. Fred U. Tate, M.D. B. Frank Voge], M.D.* Leonard Weinroth, M.D. Herbert Wieder, M.D. VISITINGS Medicine Director Lester Cohen, M.D. Visiting Physicians George Sabrin, M.D. Louis Rosenblum, M.D. Arnold G. Blumberg, M.D. Associate Physician Jerome Weinstein, M.D. Adjunct Physicians Arnold L. Berger, M.D. Wilbur B. Brett, M.D. Associate Dermatologist Joel Schweig, M.D. Adjunct Dermatologists Norman Goldfarb, M.D. Eugene L. Bodian, M.D. Neurology Associate Neurologist Kurt Adler, M.D. MEMBERS OFTHE MEDICAL BOARD Gynecology Visiting Gynecologist Marie P. Warner, M.D. Associate Gynecologists Jack Cohen, M.D. Bernard Greenblat, M.D. Rodlology Visiting Radiologist Bernard Epstein, M.D. Associate Radiologist Paul Steinhorn, M.D. Optometry Staﬂ‘ Optometrists Edward L. Steinberg, O.D. Bernard Attinson, O.D. Podiatry Staﬁ’ Podiatrist William Reider, Pod.O. Surgery Director Sidney Hirsch, M.D. Adjunct Surgeon Stephen Deckoﬂ", M.D. Visiting Neurosurgeon Joseph Siris, M.D. Visiting Urologist Daniel Kaufman, M.D. Adjunct Urologist Albert Sutton, M.D. Visiting Orthopedist A. H. Lewert, M.D. Associate Orthopedist Julius Schneiderman, M.D. Visiting Proctologist Benjamin Warner, M.D. Visiting Ophthalmologist Edward Seretan, M.D. Associate Ophthalmologist Arthur Minsky, M.D. Visiting Otolaryngologist Sam Clayton, M.D. Visiting Anesthesiologist Georges Bean, M.D. Dentistry Director Paul Scheman, D.D.S. Associate Director J. Gordon Rubin, D.D.S. Associate Dentists Benjamin Schwaid, D.D.S. Bernard Lebow, D.D.S. Adjunct Dentists Henry Lewis, D.D.S. Samuel Plotnick, D.D.S. Elsa Friedman, D.D.S. Martin Protell, D.D.S. Leon Basson, D.D.S. Herbert Forman, D.D.S. *Executive Committee Member f Deceased 1959 IAppointed in 1959 19 �The body of our Annual Report indicates that 1959 was a year in which the Professional Development Program, introduced by Dr. Lewis L. Robbins, was launched. The goals of the program have been outlined and the beginnings of its implementation have been described above. Additional personnel required by this program were initially engaged as of July, 1959, and were gradually added during the second half of the year, so that the 1959 calendar year data does not show appreciable expenditures for the Professional Development Program as such. COMPARISON OF COSTS 1958-1959 1958 — TOTAL OPERATION 1959 % INCREASE 16. Salaries $1,241,350. $1,442,458. 3. Food 127,142. 131,083. Maintenance and Grounds ( 8.) 78,914. 72,408. Administration 29. Expenses 111,300. 143,860. Medical Supplies 55,217. 49,289. (11.) Repairs and Replacements 48,101. 41,727. (13.) 13. Total $1,662,024. $1,880,825. This table shows that the total expenditures for all operations increased by 13%; the percentage increase from 1957 to 1958 was 11%. Salaries and wages increased by 16%. This is in keeping with our experience of the past ten years in which this item rose by ten to ﬁfteen percent per year. Almost the entire rise in this ﬁgure was caused by increases in rates rather than by the addition of new positions. The chief factors in this increase were the across-the-board increase of about 13% to all nonprofessional employees and provision of time and one-half for overtime for all employees. These actions were taken by the Board of Trustees in accordance with the “Statement of Policy Regarding Personnel Practices” promulgated by the Greater New York Hospital Association and subscribed to by the Board of Trustees. Increased salaries were also provided for all categories of the professional staff. The impact of the Professional Development Program as such was hardly felt in 1959 ; its further implementation will produce a more appreciable impact during 1960. . 20 Food costs increased 3% in accordance with the rise in the food price index. Out-patient services expenses increased by only 6% as compared with 30% in 1957 and 21% in 1958. This reﬂects the stabilization of this operation after a period of constant growth dating back to 1954 when the large Queens Out-Patient Service was established. The largest increase was in administration expenses which rose by $32,000, or 29%. The following were the chief components of this increase: INCREASE IN DOLLARS ITEM Ofﬁce Equipment $3,500 Medical Care Prepayment for Employees 8,000 Social Security and Retirement Contributions 9,300 Personnel Expenses 6,300, Medical Care Prepayment for employees (Blue Cross and Blue Shield coverage for the employees and their families) was initiated in July, 1959 as part of our over-all improvement of personnel practices. Social Security and retirement contributions rose both as to rate and volume. Personnel expenses rose in accordance with liberalized policies as to travel and other allowances for professional staff. SERVICE DATA: IN-PATIENTS Total number of patients treated Total patient days Average income per patient day Average cost per patient day Average loss per patient per day 1958 1959 % INCREASE — —— 536 70,691 537 70,219 $16.58 $18.83 + 13.5% $18.73 $21.69 + 15.8% $ 2.15 $ 2.86 + 33% REPORT OF THE ADMINISTRATOR Maurice Bachrach �With total number of patients treated and the number of patient days virtually unchanged, average income per patient day rose by 13.5% while average cost per patient day rose by 15.8%. The average loss per patient day rose by 33% over 1958. Thus, In-Patient Service developed a gross operating deﬁcit of $200,826 for the year in spite of an increase of $4.00 in the per diem rate paid for indigent patients by the City of New York as of July 1. Without this increase, this loss ﬁgure would have been appreciably higher, since 75% of our In-Patient Service (50,000 patient days) is assigned to indigent patients. Most of our deﬁcit both for In-Patient and Out-Patient Services was met by a grant from the Federation of Jewish Philanthropies of New York, while an increasingly large deﬁcit is being met by our own trustees. Our Board of Trustees meets the operating deﬁcit for treatment and training programs as well as for research, which is their sole responsibility. As we continue to put more and more of the Professional Development Program into action, our gross expenditures for the In-Patient Service will continue to out-run foreseeable increase in operating income. Closest integration of planning and effort between the hospital administration, our Board of Trustees and the Federation of Jewish Philanthropies of New York can lead to construetive solutions of the support problems which lie ahead during the next few years. The most potent ingredient of such integration is close agreement as to the hospital’s goals as they have been expressed in the programs promulgated by Dr. Robbins in 1958 and 1959. These goals promise the provision of the highest attainable level of patient care and are so incontravertible, that they must stimulate all concerned to meet them in spite of the difficulties to be encountered. The growth of the professional programs must be accompanied by parallel development of administrative services. Careful application of sound administrative procedures to every phase of all of our programs will tend to make these programs more effective and to introduce elements of management that can decrease cost without impairing service. During 1959, Mr. Samuel Davis joined our staff as Assistant Administrator. We willnow be able to plan for increased appli- cation of administrative processes in the professional areas. More time and effort will be available for improvement and intensiﬁcation of personnel administration. An important function for administration during the next year will be to develop major projects in conjunction with Dr. Robbins and the professional staff and appropriate board committees, a master plan outlining the physical development of the hospital for at least ﬁfteen years ahead, a survey of existing plant and buildings and a comprehensive site plan leading to the development of a research building and an activities therapy building. The hospital’s administration will continue to maintain constructive relationships with community agencies such as the Nassau County and New York City Community Mental Health Boards and the various co-operating social agencies, as well as Long Island Jewish Hospital. Efforts to intensify and improve the areas of co-operation will continue. The board has already authorized the creation of an effective public relations program which will lead to wider and more productive community participation in the life of the Hospital and greater usefullness of the hospital in the life of the community. The task of administration during 1959 has been a great one. None of our accomplishments and none of our plans for the future would have been possible without the devoted and intelligent assistance of the department heads who worked so closely with us. It is therefore more than appropriate to state that Mrs. Angelina Canavan, Dietitian; Mrs. Dorothy Croghan, Accounting Supervisor; Mrs. Lillian Dailey, Ofﬁce Manager; Mr. Thomas R. Lumley, Superintendent of Buildings and Grounds; and Mrs. Sarah Travers, Executive Housekeeper supplied the basic day-to-day services which provided an essential foundation on which professional programs are built. They worked unceasingly with sometimes inadequate staff, to meet the challenge presented by the growing Professional Development Program of the hospital. 21 �The following professional and nonprofessional employees supported the treatment, training and research goals of the Hillside Hospital in 1959: PROFESSIONAL Biochemical Research Dr. Vivian Goldenberg Grace Kittel Susan Rea Dr. Bernard Searle Daniel White Creative Therapy Edith Zierer Dental Technician Sheila Berger Experimental Psychiatry Romeo Cartolano Dr. Robert Kahn Eric Karp Dr. Donald Klein Jean Kolodny Dr. George Krauthamer Hanna Mosquera Dr. Max Pollack Dr. Nathaniel Siege] Intramural Clinic Laura Zaves Laboratories Theresa Midulla Medical Librarian Ellin Resnick Nursing Service Registered Nurses Frances Anderson Susie Mae Behlmer Marie Caﬁero Kathleen Cliggett Mary Cressy Mary Ann Dalton Ann Dispensa Jean Hendry Nancy Jeff eries Mary Jones Sandra Kraner Grace Lyons Eleanor MacPhillips Flora Mae McCartney Catherine McCormick Helen Murray Yolande Paquet Lorraine Schaeﬂ’er Helen Schippicase Rose Schulbaum Suzanne Smith Barbara Steinbach Zurline Thornhill Edith Titolo Anna Urbach Helen Ziegler Licensed Practical Nurses Alma Clinton Mary Corrigan Hope Fox Theresa Howard Alice McDonough Isabell Pierce Rosemary Stevenson Gloria Swan Catherine Wall Delores Williams Psychiatric Aides Martha Adams Olga Allen Marion Bell Patricia Bell William Black, Jr. Beatrice Blake Annie J. Bond Joseph Britt Lawrence Burger Frances Butler Sylvester Campbell Frederick Coley May Conrad Teresa Cooney Naomi Cotter Hugh Cracker �Catherine Eames Annie Ervin James Faulkner Janie Ferguson Marion Flood Irish Ford William Godett Margaret Griller Katherine Hammel Mabel Harper Linda Hart Pauline Hawkes George Heller Sandra Heller Lawrence Hood Alberta Hopkins Ellen Kennedy Joan Kelley Asalle Kirby Carole Kornfeld Doris Kraemer Josephine Lafayette Ernest Lambert Grace Lau Leslie Lee Miriam Lee Alice Leliukevicz Ella Mae Leonard Lillian Leslie Anna Lewin Georgine Lohman Ellen Long James Merrill Edith Minor Bertha Monroe Helen Olsen Clemmie Palmer Elizabeth Rodriguez Barbara Sang Lessie Mae Scott Samuel Scott Mildred Shaw Nancy Smith Virginia Smith Marian Thomas August Tosi Martha Visalli Catherine Williams Thomas Wolf Anna Wolfberg Leon Wolfberg Edgar Zephyrine Occupational Therapy Karen Beutlich Joseph Chase J udity Conrad Laura Dunlop Martha Ittelson Mona Jones Deanna Levine Mary Marrone Doris Metzger Helene VViller Pharmacist Robert M. Frank Psychology Ira Rosenblatt Dr. Allan Sapolsky Dr. Stanley Schiff Charles Silver Dr. Felix Steiner Leonette Vanderhost Florence Volkman Social Services Case Work Division Ida Baumstein Anne Connery Barbara Fishman Robert Fishman Beatrice Freeman Evelyn Furman Sally Gold Regina Goldstein Selma Hornstein Sarah Klionsky Sandra Match Anita Mehr Sylvia Riback Esther Sanders Lita Schmidt Seymour Silverberg Sylvia Solovey Gisela Tauber Lewis White Group Work Division Aaron Beckerman Frieda Bradlow Denis Dryden Judith Duﬂy Edward Fitzgerald Geraldine Lauter Eli Saul Levy Evelyn Mason Naomi Miller Holmes Morrison William Pressman Frances Rubinstein Philip Schwartz Virginia Zaremba NON PROFESSIONAL Accounting Department Arline Fleischmann Lillian Ingber Henrietta Lyons Ethel Siegelman Jeanette Silver Dorothy Strier Buildings & Grounds Erich Brau Walter Foley Frank Groene William Hannigan Robert Hill George Loblein Nero Moyd Stanley Novak Edward Reeder Frank Reinlein Walter Roland, Jr. William Roland, Sr. John J. Rose Albert Schmid Joseph Seagren Albert Senese Dietary Services George Canavan Francesco Cannetto Emma Casamassima Flozell Clarke Hubert Cooke Thomas Duncan Arthur Dywer Pardo Faro Elaine Fields George Fields Alphonse Gross Ella Jacobs Fred LaBarbera Alfred Lemaire Gaetano Mandala Arthur Martin Ida Novick Martin Novick Gaspari Orlando George Perreta Arthur Pitts Walter Rodney Eva Schwartz Broadie Taylor Thomas Tucker Ester Watkins Leroy Watkins Housekeeping Cle Anderson Betty Bruckman James Cuozzo George Czinczinger Stanley Durant William Garland Fulgencio Gerena Nathaniel Glover Joseph Hope William Hyman Robert Jones Harry Lewis Charles McLeod Richard Newton Roosevelt Mitchell PROFESSIONAL AND NON PROFESSIONAL EMPLOYEES Dorothy 0 ’Berry Arturo Orengo Booker Richardson Rafael Salazar Agnes Schuster General Walker Ray Warren Blanche White Oﬁice Services Irene Attinson Celia Bernstein John Borgner Janet Bowie Diane Brafman Manuel Brown Irene Dinkin Claire Dubin Regina Freedman Lillian Freifeld Norma Friedman Edward Golove Frances Gullo Adele Harris Sylvia Hymowitz Joan Kase Edna Kappes Yetta Levitt Inge Mai Sylvia Marcella Fradele Marcus Yetta Mintz Catherine Muﬁ Dorothy McClary Margaret 0 ’Connor Mary Pignoni Gloria Podrid Frances Roth Joseph Ryan Dorothy Saults Charlotte Sinovoi Miriam Slater Jeanette Sobel Edna Telesca. Walter Theisen Edna Weissman Lotte Wollman Blanche Zaitz 23 ��HILLSIDE HOSPITAL is licensed by. . . . . The New York State Department of Mental Hygiene. is approved for resident training by... . . Council on Medical Education of The American Medical Association The American Board of Psychiatry and Neurology. is accredited by . .... The American Psychiatric Association The Joint Commission on Accreditation of Hospitals is a member of..... The American Hospital Association Hospital Association of New York State Greater New York Hospital Association Greater New York Fund The United Hospital Fund Welfare and Health Council of New York City The National Conference of Jewish Communal Services cooperates with. . . . . Adelphi College Altro Workshops Federation Employment and Guidance Service Jewish Community Service of Long Island Jewish Family Service of New York Long Island Jewish Hospital New York City Board of Education New York State Employment Service New York State Department of Vocational Rehabilitation Queens College of the City of New York is a participating hospital IWhIle no precnse form ..... and Related Facilities for essential for making a valid bequest to HIIISIde Hospital, the following may be used: give to the Society of the Hillside Hospital, the sum of $ TheHospitaICounciIof Gr t rN wY rk HI::;DEeHO:PITAL I ISAMEMBER OF . . . IS . . . . . , I land or any specn‘uc property, such as bonds, stocks, etcetera, IS given, a brief descrlpH tion of the property should be inserted instead .of the phrase "the sum of If . . . . . . $____. THE FEDERATION or JEWISH PHILANTHROP'ES' �� 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 Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-007 Date A point or period of time associated with an event in the lifecycle of the resource 1960-1963 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 Hillside Hospital Annual Report (published copies), 29th, 30th, 31st, 32nd; Hillside Hospital A Report of Progress, 1960/61; Letter; 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 http://exhibits.library.stonybrook.edu/mfp/files/original/e06d90c86c34900cbfbc862c755d6567.pdf 15ada951bb078ffb8bea42b5be5e0745 PDF Text Text IV: 10/113/60 Experieeutel Peyehietrie Presreue et niiieide neepitni A The Review veeieue prostate in the Department at Experineetei W Psychiatry have been devoted to en undereiending e: the node at W‘iherepiu “tie: or thrush undies or hreiu taxation. the principal techniieel have been edepted tree deeoriptive peyehieiry, uenrepeyehoiexy, electreeeeeyheiecrephy, linguietiee, phereeeelour, end eeeielecy. In initial etudiee It reaction were round cenvuleive iterepy. ehenzee in brain it reiete beth to iepreveuent retinge end to pro-treatment peyuhelecic variables. in our enderetendin; e: ceevuieive therepy develeped, e centre: neerephyeieiezio-edeptive view e: eaeetie therepiee eeerted ( ). In this Suuka» view psychiatric treeteente ereﬁtherepeutieeiir exteetive to the degree that brein function in nee-trebly’eitered. While ehense in brein tenetien neeeeeery to: behavioral change, the irpe e: edeptetiee, it however, veriee depending upon pre-treeinent peyoheleuiigend eeeieiecieag charecterietiee er the subject. Thee, the node at eotien ie not eeen ee eiiher 'ercenic' er 'peyehelexie' bet tether ee the intereotion at both eepeete in the individeel. further, while behevierei change in �-2- ralatad to chanson in brain function; and the adaptiva pattarn to paynhologiéﬂoharaatariatic!t praotraatnant avalaationa at 'inprovaaant'; baing spacial typan at avalnatian or ahanga, ara darivativa Jadgnanta baaad an start and tanily anpaatatiana and talarannaa. Thin hypothaaia was dovalapad and anatainad in a aariaa at atudiaa at onnvulaiva therapy. concurrant atndiaa of insulin tuna indicatad that behavioral changa hora, too. van ralatnd to tha anaat and dacraa o: prolancad cana a: rapaatad aaiauraa - than. bainx tho nanraphyaialogiélnhanaa nanixantatiana at principal prolansnd in thin thanany. Tho node at action of tha nan paychetroyic asanta anpraaaad within thin hypothaaia ( aganta would III all. ). It ran anxgaatad that thaaa b. attactiva to the dasraa that tho: indnaad paraiatant chanxaa in brain fanaticn' and that tha typa a: bahavioral raaponaa vanld ha ralatad to tha type at brain nhanza, and to pranorbid pnyehaloxigﬁ(para¢nality) pattarna. rho praaant proxrann in tha Bogart-ant an. danisnnd to atndy than. ralatianahipa in datail. Canvnlaiva Tharazz Prooana or variaua anaanraa at brain tnnatian, tha anannt of slow vat. activity in tho alantronncnphalacran and cantabnlatory and �-3H dontal languago pottorno attor aaohorbital ( ) oonottivo indiooo in oonvaloivo thorany oohaoeto. voro tho aoot In tho firot oxporioont, improvooont ratings ooro round to ho oorrolatod dirootly with tho appoaranoo or high dogrooo o: ohango indicoo ( ). 1n thoao rhooo oboorvationo woro tootod in a douhlo-hlind study in which pationto rotorrod for olootroohock woro randoaly ao~ aignod to coorooo or oithor oonvuloivo or auboonvoloivo thorapy undo: poutothal pronodioation. nigh dogrooo o: nourophyoiologie ohango ooro oboorvod only in tho aonvoloivo group; improvonont ratoo significantly highor in this group; '02. and than oubconvnloivo oohjooto uoro ro-troatod by convuloivo appliaationo, tho improvoaont rota was oinilar to tho original convaloivo group. In tho oihconvnloivo troatod oahjoota, oonoidorahlo anonnto o: oloetrieol corront paoaod hotwooh tho hitouporal oloetrodoo. It woo ooncludod, thorotoro, that tho thoropoutio agont total oloctrioal curront, or no, but an all woo not tho or nono quality aahitootod by tho grand nal ooiouro. rho otgniticaneo or tho grand nal ooiouro was turthor olahoratod 1n otudioo of tho inhalant convuloont, hoxatluorodtothylothor (Indoklon). 31-11ar dogrooo o: olootrographio ohaugo, iayrovoaont ratoo, typo: o: bohavtoral �‘hV, change and ohanxee in neuropeyohologio teak behavior were obaerved in the inhalant and in electrically treated :ronpa. It nae anon apparent, however, that not all anbjeote aaniteetin; high decreea of physiologic ohanga were rated on 'inproved'. In a deeoriptive typelogio atndy, rive patterne were doeoribed, eaperioally teraed ‘enphorio', 'hypoaanio', 'eoaatiaetien’, ’paraneid-Iithdraval', and 'panio'. While the tirat adaptive aedea were ratod ae 'nnoh inproved', the aeen ae ‘uniapreved' or 'verae‘ ( two or latter theae two were ). In etndiee of peyoholegio variablea, it nae reported that patiente rated ae 'anoh inproved' and ’reoevered' frequently aanireeted peraenality patterne similar to that deeoribod by Heinatein and Kenn ( ) an the explicit verbal denial personality. In language patterna, they expreeeed the language of denial, when dittnae brain change denial, was indnoed, exhibiting anoh aepeote an niniaiaation, diaplaoenent, oliohee,|g§g. aere treqnontly than unimproved enhaeote. high I Stale eoore ( Other indioee related to favorable ontoeae were ), and Rorschach deterninante or color, abeent aoreaent and abaent torn-oeler ( ). alao, :avorable ontoeae nae aaaooiated tith lea In thin population, educationalaohieveaont �and revels: birth ). ( Antlehellner lea and Convalelve there Seeking a way EEG slew wave eae given te eucaent the degree at peet-oeaveleive activity, an inn-anneal: at antlehelinercle cenpoand, diethaaine, vex-1e“ “sea at the eemalelve therapy preeeee. Contrary to expectatlene, diethaaiae eaueed an iaaedlate and entrained decreaee in EEG alerting. Patleitl with dental language patterae rellnxqalehed than; Instead of euphoria and well being, the eibjeete were irritable, anxieue and expreeelve a: nre-treateeet patterne. In eubjeete prior to cenvuleive or drug therapy, elethaalne induced exciteaent, tenelen, anxiety and lllaeery eeaeatlene. Sabaeqeent etadlee with ether eentral antlohelinerglo oeapeeade (VII-2299, JB-318,336, beeaetyaine) abated behavleral and electrezraphle patterns alaalar te diethaelae. Stellar deeynohrenieatien a! peet-eenvulelve EEG aleeing wee aleo noted with central eynpathealaetie hallucinogene (euphetaaine, aeeoallne, LSD-25). and baa been reported re: antihietaainee (dephanlydraalne). Theee obeervatlene led to the eaageetlea that an increaee in central ehellnergie activity eae a biocheaieal haste tor the eenvalelve �therapy process ( ). Pszshotrogic Drugs and During EEO this period,the drugs aroused interest. node of action of newer psychotropic Following the concepts derived from convulsive therapy, the neurophysiologis ohenges induced by drugs were tested within the experi-ents in an EEG Ill. experimental setting or acute setting. It was observed that phenothiasines (shlorprolasine, pronssine, triflnepronasine) induced isation and a shitting o: the spectra: to the ERG synchron- slow frequencies; leprobanate and barbiturates , en increased synchronisation and a shift of spectra: to fast frequencies; reserpine, an inoreased slowing with synchronisation at low dosages, and desynchronisatien at higher levels. Inipraaine induced desynohrenisation with a shift of frequencies to the slow bands. Other experinental oonpounds tested included phenyltoloxaline (Bristol), Deaner and (liker), wx-21h9 (Wyeth) and its vsrions BL-HlBB and oongeners trenquel (nerrill). For eaoh, no consistent electrographis.patterns energed. It teens use suggested that psychopharnaoelogio agents provide a ‘lr eliciting a variety or nenrephysielogio patterns in �.7contreet to the eingle pattern of induced oonvuleione. Furthermore, the typo of neurophysiologie alteration, ee reflected in synchrony and Iroquoooy petterns, or hehoviorel edoptetion. elow :roqnonoieo wee Inoreoein; EEG related to epooirio types EEG eynohrony and e shift to or. oeeooieted with trenquillisetion, eedetion deoreeeiog ogitotion; while deeynohronisetion and e end shift to test frequencies in eeeooieted with oxoitenent, illusions, end delnlionol idoetion. These observations orooeaeietont with hypotheeoo or Hikler ( ). The merit of such teohaiqoeo for the eeeey or psychotropic agents hoe been doeorihod ( ). new �-8Pszchcpharaacologz Evaluation Prograa The present pregraa, instituted in October 1959, is based these studies and is on designed to answer the following questions: Is there s relation between aeasurable alteration in brain function and behavioral change with psychotropic drugs on chronic administra- tion? Are there pre-treatasnt clusters of psychiatric, physiologic and psychologic variables related to the type of behavioral adanptation? - to the type and degree of physiologic change? Method: is an initial approxiaation, fixed a double-blind, dosage rendoa assignment drug study was undertaken. Based on clinical experiences with various psychotropic coapounds, three classes were selected on the basis of their patterns of :30 response. ‘The selected agents were those eith predoainent desynchronicing patterns; synchronising and slowing; or niniaal or no effect. Patients referred for drug therapy, after medical examination, and after all other medications have been discontinued are randoaly assigned to one of three classes of compounds. Patients are predoainantly middle class, urban, with high educational attainment. Hillside Hospital is a non-profit, philanthropic supported psychiatric institution, admitting voluntary �.9patients for extensive psychotherapentic treatment. of stay is seven months. are prescribed by Kean duration Convulsive and psychotropic drug therapies star! psychiatrists on referral to the Department. All treatment is adninistered by Departaental start, so that the experinentsl variables or drug dosage, route of administration, assignsent to groups, 333. are readily controlled. All patients in the hospital are available for study. all patients receive After a testing period, ho cc of medication daily tron individually labelled bottles. increased in fixed weeﬂy etepe until a nsxiaua at date, 1&0 the study period. Dosages are After weeks. reotestinz occurs. two weeks on maximum dosage, To h liquid subjects have been referred, and 110 have completed Preliainary analyses of the data are new in progress 0 avieral Chan e5 In a survey or the behavioral adaptations of patients receiving phenothiazines er iaipranine, various clusters at behaviors were developed. The typology was based on the pre~treatasnt psychiatric the treatnent reepenee and profile. In the present study, various measures of behavioral change are under study. Therapist referral questionnaires and six week evaluatione; therapist and �-10- patient two Clyde Heed Scales; Lorr Scale evaluations in interview by research psychiatrist, and Lorr ward scales; patient eelta ratings including the Johns Hopkins synpten check list and the Chicago Attitude Scalee are ancnget the neaenres being explored. lenropezchelcgz: Paychelcgic tasks are viewed both as change variables and predictive variablee. In convulaive therapy, changee ), tactile perception in aencry tasks ( ), crr ( ( or figuree ( ), rignre ground tasks ) have been ( ), Recheler«3ellevne ( and tachietcecopic recogniﬂcn , ) related to the degree of induced neuro- For each task, the degree or decrement in physiologic change. taek pertornance has been positively correlated with the amount of EEG slowing. lollcwing treatnent completion, with the return of physiologic indicee to pre-treatnent levels, performance in these peychclcgic taaka also returns to prewtreatnent levels, or higher a betternent of performance ascribed to practice eitect. Denial scores on interview ( ), Rorechack deterninante ), 1 ), auditory feedback ( ),and perception of the visual upright ( ) have been viewed ae predictive indices of the behavioral changes following nor. various tasks are new ﬁbeing Scale scores ), language patterns after ancbarbital ( ( ( Theee asseeeed with paychctrcpic agents. �.11. In the convulsive therapy studies; the lieetreencezhalogrsghzs degree of EEG slowing was measured by counting the consecutive waves in selected samples. were studied, it was When the more subtle changes or druggeftects necessary to apply less tediens techniques. Electronic frequency analysis was introduced in August 1959. By asasurenent e! the pen deflection for various frequencies free 3 to 33 cps in ten second epochs, rapid aeasnreaent of apparently saall changes in total activity and and frequency spectra are not obtained applied. Other physiologic variables include the response of £30 to intravenous chlerprcnasine; blood pressure response to sechelyl; EKG; radioactive iodine uptake, and analyses or various blood and urine element ordinarily conceived ac protective of the patient'e welfare. �Pnzghuliggualtion: rollcving thy studios at syntgotio Iguanas. pattorns ( ) in oonvnlntvo thnrspy, 0th.: anpoctu or Innguagc cﬁndind for worn their ralatiou as 1361... st «hung. in intrnporlonll with nonltdurabln nun: .xplarctlou attnr bcinvior. attic, (1T3) thn‘ typewtokoa-rutio augxoltod 11:;«1-t19 nounurOI, or connoautivo 33-pin: a: dyldic apcoch 1.: bu A useful lunar. tppliud to writing toxta or tho Hull. ran had previously buon hung. nmlu ¢ individuals, Jute intuit-d ﬂat the two index (dyad) at a ounnunieutioa an: sicniriuant not. portal tho ltttc at tho intaraction than snnlytcn or ltplrt‘. Innplnn or the participantl. tpplytn; ‘htv technique to couralsivo tiara»: pntiunta, august: in ran nonn and atnndnrd deviation worn rclntod both to tn. dogroo 0: induced use slow vuvo nctivity and to lyutaatic lan‘unxa puttorns obtained in indop-ndoat structurod iutcrvicvnc Bpocch boa... new. rupctttivc (lovarod nag: 223) and Iowa vurttblc in connocutivo canplou (inoronnod standurd dovistion) ( ). �In tnttrvidvt tutor. &nd aft-r 8h. intravunoul administration of coutrully .ctivo ngcnta, 11-11;: chtnguu rare obaorvtd. Axtntu with a prcdauinnnt lynehronisatiou ptttorn tn. on EEG uxhibttod n docroaao tn tutu 218 and inarcuao in Itnndtrd deviation or soorcs,vh11n ataynchroniliag compounds olicitcd grnttnr variability in apooch pa‘torus (lﬂOrOll. in and accrual: 13 varidbility at conntnntivo 133 noun) neuron (doeronlo 1n It;adnrd dcvistion). 0th.: 1:33:33. nasuuroo under study includu dintronln r0110: quottontl, colt-rotoronco, tad potion. It 1- aucxoutod are potont tuchaxquos to: and poyuholusie ultorttioa 1n tuna. and that than. paycholinsutstte nut-urns ﬁho operational unnlyiun a: phylialogta crises: at payohopharnuoologic acunta C ). �aotiolg‘io Studio: 2h. cuncral prdbiun 0: tbs rolatiuu at liaitl tautarl to choico tad rocuitu o: parchiatrio troutucnt. and tho Ipoeitic prdblun at tho rolnticn at it... taatars pittcrnn, within tun instieutioa. and to a cutie: at population ), uduoatiun, ago. place a: birth In on: tinny ( utmdioa. 13d ta in. rorcrrul learn .3 tau California I nail. var. nixnitieuntly rciatod to thc type .1 thnripr roe-iv'd ind tho utiliuntion o! ndaunctiv. hoapittl nitric... ndnantod hid paiinntl uh. var. old-r, poorly Than, night: I acorou und warn tar.i;n-horn, pnrtieuinrly Einicrn lnropo, utro ngat 11301: to be rotorrtd fur oloctro— shook. Thou. rnlntianahipl were pro-nail: iudupondcut a: diagnnlol. within tho crunp at cloctrolhock putiontl, rottrrnl {or In rclltod to 36? vac .100 g cocond Iﬁuuy at this tin. tor in... factora. group ( ). durstioa or hospituliaation, dilohurxu ovuluutina and dincnoa¢n wars :0lniod to the can. 000111 taetcru. Fur «suspic, patiunta hoapituliuod tar Sh. Ihnrtolt patina var. oidoat, had thi icast oducution, war. nest likely to hivc and had in. high I again boon tornign born scar... titular, nativoaborn, str- �uduoatod, lunar 1 real. Ilﬁrl pttiontn v'ro hospltnllscd tho lnagost. Inn's rolttsonuhipl bald trnu within tronincnt typo and had thn rithln diutunaﬁao 31330. On allohurxo, .14.: pttttutu not! tavurubli rttlngo. In not, valiant. rutad ti rooovcrod or IIOh luprovnd htd thq hlxhott F scarce, lunat odnuuttou :ad var. acct likaly to ho rarclxn born. In a study at patlont rtrulal a: 30!, 01:11.: ro- lutlonlhtpu wort obncrvcd ( ). that. rolgtlounhlpi If. no! undo: ntndr in tho out-pttlantxdopartnoat, sad in a trlw hospital cunpnrattvc Itaay. In tn. lnttor Itudr. th- population! or thrco hunptlalc in which :11 thrupltu are equally arullnbla to all p¢tluata, - sonniugor roundatlau lllplttl (Ippir-cltll, Protoltant), nascaohau-ttn unnttl Xcslth c ntnr (lavdroclnao Catholla) and 3311314. noopltll (nlddln-clnnn Jalluh) boin; alaoaacd. It but Etna postulntod that lhunc rcl:t1¢ulhlpl rctlact tho tntlncncu at .00131 bunksround on plynhologlcnl pronoun, nah u hubltul undo: at axprcsslon. tho putt-tn a: nontal action tr. undo: Ir. ”turn or Th. onutwibution emulation um 0: than. tactorc to antaru tho tad patsont-thtrnpttt lllnsal, atlﬁr. �Exporinuutal Plyohiatrio Progr;ul nt Hillside ﬁespitnls A Max Review rink, H.D. the Depurtneut of Experimental Psychiatry, Kill-id. Hospital, Glen Oaks, 1.1., l.I. From V: 11/60 �v: 11/22/50 Experimental Psychiatric Prograns at Hillside hospital: A Review various programs in the Department of Experimental Psychiatry have been devoted to an understanding or the node of action or psychiatric therapies through studies or brain function. The prin(ipnl techniques have been adapted tron descriptive psychiatry, nenropeychelcgy, electroencephalography, linguistics, pharaacology, and sociology. In initial studies of convulsive therapy, changes in brain function were found to relate both to evaluations of improvement and to pro-treatment peyohologic variables. is our understanding or convulsive therapy developed, a general neurophysiologicadaptive view of soaatic therapies emerged ( l ). In this view psychiatric treataents are therapeutically effective to the degree that brain tnnction in measurably altered. While change in brain function is necessary for behavioral change, the type of adaptation, however, varies depending upon pro-treatment psycholozic and sociologic characteristics of the subject (2). Thus, the node of action is not seen as either 'orgenic’ or "psychologic' but rather as the interaction of diffuse neurophysiologic changes and adaptive mechanisms. further, while behavioral change is related to changes in brain function, and the adaptive pattern to pre-treatnent psychologic characteristics, evaluations of 'inprovenent', being special types of evaluation of change, are derivative Judgments based on start and {anily expectations and tolerances (2). The �-2... amine series "or studies of convulsive therapy. concurrent etudiee of ineulin ccna indicated that behavioral change here, too, was related to the onset and degree e: prolonged cone or repeated seizures - these being the principal aanitestatiens or prolonged neurophysiologic change in thie therapy (3,h). The node of action or the new psychotropic agente was also expressed within this hypothesis (5,6). It use suggested that these agents weuld be effective to the degree that they induced persistent changes in brain function and that the type or behavioral response would be related to the type of brain change, and to preeorhid peycholegic (personality) patterns. the present prograne in the Department are designed to study these relationships in """""'m. hypS‘iEiSii‘ﬁ; a.‘+‘¢i3§.ia'gua‘ .. .. «'WIfahlr‘ehnebtn ”1.5"; detail. GOHVVLSIvg IBERAP! PROCESS or various neaeuree of brain function, the aecuut or slow wave actiéity in the electroencephhlcgraa (7,8) and contahulatcry and denial language patterns atter anoberhital (9,10) were the sensitive nest indices (11) in convulsive therapy subjects. In one experieent, improvement ratings were correlated with the appearance of high degrees or change in these indices (7,10). These observations were thsted in a double-blind etudy in which patients referred for electrcehcck were randomly assigned te ceureee of either convulsive or subccnvuleive therapy under pentothal prenedication. High degrees of neurophyeiclcgic change were observed only in the cenvuleive group; improvement rates were significantly higher in this grog); and when snbconvulsive subjects �-3- epplicetiene, the inprevcnent rete wee sieiler tn the originel convulsive group (2). In the enbccnvnleive treeted subjects, ceneiderehle emanate er electric current pessed between the bitenperel electrodes. It sppeered that the therepeutic egent use not the totel electrical current, ger es, but en e11 or none quelity eenitested by the grend eel seizure (8,12). the significsnce cf the grend eel seizure wee exenined in studies of the inhalant ccnvnleent, hexetlnorodiethylether (Indoklon). Sieiler degrees at electrogrephic cheese, iepreveeent retes, types at hehevicrel change end cheeses in nenrepsychclegic tesk behevier were observed in the inhelent end in electricelly treated groups (13). It wee seen epperent thet net ell subjects lenitccting high degrees 0: physielegic chenge were reted es 'iepreved'. In e descriptive typelegic etndy, rive petterns were described, eepirieelly tereed 'enphcric', 'hypeeenic', 'seeetieetien', bereneidovithdreeel', end 'penic'. While the first tee of these edeptive nodes were reted es 'nuch inpreved', the letter two were seen es 'uniepreved' er 'ecrse' (It). In stndiee of psychelcgic veriebles, it wee reported thet peticnts reted es 'ench improved' end ’reccvered' frequently menitested perecnelity petterns siniler to thet described by Heinetsin end Kehn es the explicit verbel deniel personelity. In lengnege petterns, petients expressed the 'lengnege or deniel', when diffuse brein chenge wee induced, exhibiting such aspects es explicit deniel, nininisetien, displeceeent, cliches, etc. eere frequently then nniepreved subjects. Other indices releted to revereble were re-treeted by convulsive �4,ontooae were high 1 Scale ecore (15), and Rorechach deterrinante or color, absent movement and abeent torn-color (16,17). In thie population, also, favorable outcome wee aeeociated with low educational echievenent and foreign birth (18). ilfICXOLIEERGIO courovlnc one GGIVVLSIVE 2323‘?! Seeking a way to augment the degree of poetoconvnleive activity, EEG anticholinergic compound, diethasine, was given intravenously at variene stages of the convulsive therapy proceee (19). Contrary to expectations, dietharine caused an innediate and sustained decrease in EEG slowing. Patiente with denial language patterns relinquished then. Inetead of euphoria nelow wave and well being, tho on ethecte irritable, anxione and expreeeive of pre-troataent patterne. In subjects prior to convulsive or drug therapy, diethaoine induced excitement, tension, anxiety and were illusory sensations. Snbeequeht etndiee with other central anticholinergic coapounde (WIH-2299, JB-318,336, benactycinc) ehoued behavioral electrographic patterne eiailar to dicthasine. Similar deaynchrenination of poetaoonvuleive EEG cloning wee also noted with central eyapathoniaetic hallucinogene (amphetamine, neecaline, LSD-2S), been and hae reported for antihietaainoe (diphenylhydraaine). These obeervatiene led to the suggeetion that an increaee in central cholinergic activity wae a biochemical basic for the convulsive therapy proccoe (20). and PSIOROERGPIG DRUGS AND EEG this period, the node of action of newer psychotropic aroused interest. Following the concept: derived from During drnge convuleive therapy, the nenrephyeiologic changes induced by drnge �-5- tested within the sane acute experimental franework of the EEG setting. It was observed that phencthiacinee (chlcrpronazine, proaasine, triftuopronanine) induced EEG synchronisation and a shifting of the spectra: to the slow frequencies; neprebanate and barbiturates, an increased synchronization and a shift of spectrum to fast frequencies; reserpine, an increased slowing with synchrono isatien at low dosages, and desynchronizaticn at higher levels (5,6). Inipraaine induced desynchronisatien vith a shift of frequencies to the slow bands (21). Other experinental oerponnds tested included BL-H188 and phenyltolexaaine (Bristol), Deaner and its various cengeners (hiker), wr~21h9 (Wyeth) and frenqnel (Merrill). For each, no consistent electrographic pattern was recorded. It was suggested that psychepharnacclogic egents provide a means for eliciting a variety of neorophysiclogic patterns in contrast to the single pattern of induced convulsions. Furthernore, the type of neurophysiologic alteration, as reflected in EEG synchrony and frequency oatterns, was related to specified types of behavioral adaptation. Increasing EEG synchrony and a shift to slow frequencies were associated with tranquillisaticn, sedation and decreasing agitation; while desynchronieation and a shift to fast frequencies was associated with excitement, illusions, and delusional ideaticn (6,20). These observations are consistent with hypotheses of Wikler. The advantages of EEG techniques for the assay of new psychotropic agents have already been reported (6). were V �-6PSYCHOPHARHACOLOGI EVALUATION PROGRAM besed on present progree, instituted in October 1959, is these studies end is designed to ensver the following questions: Is there e reletion between eeesureble elteretien in brsin function end behevierel chenge with psychotropic drugs on chronic edninistretion? Are there pre-treetnent clusters of psychietric, physiologic end psychologic veriehles releted to the type of behevierel edsptetien? And, ere such clusters related to the type end degree of physiologic ohenge?Method: is en initiel epproxinetion, e double-blind, fixed dosege rendon eseignnent drug study wes underteken. Besed on our clinicel experiences with verious psychotropic coeponnds tree 195k to 1959, three clessss were selected on the besis of their patterns of EEG response.' the egents selected were those with either predoeinent desynohronising petterns, synchronising end slowing, or mini-e1 or no effect. Petients referred for drug therepy, etter nedicel exeeination, end etter ell other eedicetions heve been discontinued ere rendonly essigned to e conpennd in one of these three cleeses. Petients ere predominently middle eless, urhen, with high eduoetionel etteinnent. Hillside Hospitel is e nonnprﬂtit, philenthropie supported psychietric institution, ednitting volantery petients for extensive psychetherepentic treatment. The noen duration or stey for petients is seven months. Convulsive end psychotropic drug therepies ere prescribed by stetf psychietrists The �.7. referral to the Departaent. All treatment is administered by Departaental start, so that the experimental variables of drug dosage, route of adainistration, assignment to groups, 232' are on readily controlled. All patients in the hospital are available for study. After a testing period, all patients receive he so of liquid aediestion daily tron individually labelled bottles. Dosages are increased in fixed weekly steps until a aaxiaua at h weeks. After two weeks on maxiaua dosage, ro~testing oeeurs. Io date, 1&0 subjects have been referred, and 110 have eonpletod the study period. Preliainary analyses of the data are new in progress. Behavioral Change: In a survey of the behavioral adaptations of patients reeeiving phenothiasines or iaipraaine during 1958-59, various clusters of behaviors were developed. The typologies were based on the treataent response and on pre—treatnent psychiatric profiles. In the present study, the typologies are being tested, and various measures of behavioral change are being studied. These include therapist referral questionnaires and six week evaluations, therapist and patient Clyde Hood Scales; Lorr Scale evaluations in interview by two research psychiatrists, and Lorr Ward Scales; and patient sel£~ratings including the Johns Hopkins syaptoa check list and the Chicago Attitude Scales. lenrogszehelegx: Psycholozie tasks have been viewed both as ehanze variables and predictive variables. In convulsive therapy, changes in aenory tasks (22), tactile perception (23,2h), WeehslerBollevne (13), CF! (13), figureagronnd tasks (25): and taehistoseopie recognition of figures (26) were related to the degree or induced 0% �.8neurophyeiolegic change. for each task, the degree of decrement in tank portornance was found to be positively correlated with the enount of EEG cloning. Following treatnent completion, with the return or phyeiologic indicee to pre-treatnent levelo, performance in these paychologic tacks aloe returned to pro-treatment levels, or higher - e hetternent of performance ascribed to prectice effect. Denial ecoree on interview (27), Rorschach determinante (16,17), I Scale coerce (15,17), language patterne after anoberhital (28), auditory teedheck end perception of the vienal upright have been viewed as predictive indicee of the behavioral chengee following 36!. Thole veriene tasks are now being eeeeeeed with psychotropic egente, for their capacity to chenge with verione agents, or their capacity to predict change. Electroencephelogrephze In the convnleive therepy etndiee, the degree of RIG cloning nae neaenred by counting the consecutive waves in selected eenplee (7). When the more subtle changes or drug effect- are etndied, it ie neoeeeary to apply leee tedious techniques. Electronic frequency enelyeie wee introduced in inguet 1959. By neaenrenent of the pen deflection for vaﬁione frequenciea from 3 to 33 ope in ten eecond epoche, repid eeeenreeent of apparently enall chengee in total activity and frequency epectra are new obtained and epplied. Other phyeiologic variablee etndied in thie progren include the reepenee er era to intravenous ohlorprenaeine; bleed preeeure reeponee to neoholyl; the EKG, radioactive iodine npteke, end analyeee o: varioue blood and urine elenente. E 5 �PSIGROLIHGBISIIGS series of studies in the Departnent have been devoted to ternal lenguege patterns. Following the etudies of syntactic lenguage petterns (28) in convuleive therepy, other espects of lenguage were studied for their relation es indicee or chenge in interpersonal behavior. darts; otter considerable exploretion with verious linguistic neesures, nuggested thet typeutoken-retioe (2!!) of consecutive senplos or dyadic speech nay be e enetnl index (29,30). While 213 hed previously been applied to written texts or the language senples of indiriduels, Jeffe indicated that the two pereon eonnunicetion (dyed) wee e acre significent index of the etete of the interaction then enelysee or concrete eenples of the participants. Ayplying this technique to convulsive therapy petionte, changes in 21! neon end etenderd deviations were releted both to the degree of induced ERG slow ueve ectivity end to syntactic lenguege petterne obteined in independent structured interviews. Speech heeene more repetitive (lowered nean 113) and nkre verieble in consecutive eenplee (increesed etenderd devistion)§(31). In Another interviews hetero end otter the intrevenous edeinistretion or centrelly ective egente, einiler chengee were observed. Agente with e predominent synchronization pettern on the EEG exhibited e decreese in mean or: and increase in standard deviation of scores, while deeynchronieing conpounde elicited greater variability in speech petterne (increase in TTR neon) end decreeee in veriehility of consecutive eoorss (decreeee in etenderd devietion) (32). Other lengnege neeeures studied included dietrese~relie£ quotients, self—reference, and elteretion in tense end person. �«10- It was luggontod that then. psycholingukatic nonsuroa tr. techniques for the opcrational annlyaoa or physidlagic and psychologic ctr-eta of psychopharuteologic ugcnts (32). potent �.11 .3001030910 STUDIES In the course or these psychiatric programs, considerable interest wee engendered in the tenily organization to which patients returning. Also, the general problem of the relation of social factors to choice and results of psychiatric treatment, and the specific problem of the relation of these factors to the referral patterns led to a eeriee of pepnletion studies. In one study (33), education, ego, place or birth and score on the California I scale were significantly related to the type or therapy received and the utilization of addonotive hospital services; Thus, patients who were older, poorly educated, had higher P scores and were foreignhorn, particularly Eastern Europe, were most likely to he referred for electroshock. These relationships were present independent of diagnoses. Within the group o: electroshock patients, the tire for referral for BC! was also related to these factors; In a second study (18), duration of hospitalization, discharge evaluation and diagnoses were related to the eaae social factors. For example, patients hospitalized for the shortest period were oldeet, had the least education, were most likely to have been foreign» born and had the higher 1 Scale scores. Younger, native-born, more educated, lower 1 Scale score patients were hospitalized the longest. these relationships held true within treatment type and within diagnostic close. On discharge, older patients had the nest favorable ratings. In 30?, patients rated as recovered or much improved had the highest 1 scores, least education and were most likely to he foresighorn. In another study or patient refusal of nor, similar relationships knee observed (3h). were �Theee reletionehipe ere new under etudy in the Out-Petient Depertnent, end in e tri—hoepitel conperetive study. In the letter etudy, the population: or three hoepitele with preveiling differing cliente, in which e11 therepiee ere equally eveileble to e11 petiente, - Kenninger Peundetion Hoepitel (upper-ollee, Proteetent), Hheeeehueette lentel ﬂeelth Center (leverceleee, Getholio) end Hilleide noepitel (niddle-eleee, Jewieh) ere being eeeeeeed. It hee been postulated that theee reletionehipe reflect the influence of eociel beckgrouud on peychologicel processes, such ee hebituel petterne of eennunieetien and nodes of expreeeion. The contribution of these factors to the pattern or mental illneee, end the petient-therepiet interaction ere under etudy. �-13SEHMAB! . on. Dopartnontal programs are a clustor of intsrrslatsd studios toonssod about common population sonplos. Within Hillside Hospital, rosoaroh laboratories in Bioohonistry, and in Hsdieino are aotiro; and other laboratorios in psychodynanic psychiatry aro boing dovolopod. In this Dopartaont, various disciplinos aro participants,rsprssonting a gradual growth of six ysars. Furthsr growth and tho dirsotions o: ensuing studios sro dopondsnt on tho results of tho studios doscribod bars; as wall as tho growing institutional avaronsss that roooaroh is an intogral part or the hospital's operation and budgots - as such as troatnont and staff training. �”lh‘ Reterenaea Authors at the {alleving references include the following staff nenbere: Hex Pink, Hex Pollack, Robert L. Kuhn, Joseph Jette, xertin 3. Green, Eric Kerp, Hyman Karin, Doneld F. Klein, George Ireuthener, Arnold G. Blnnberg, Ittheniel S. siegel, Abrehen Keplen end Henry 1. J. Hillside Reap. 113, 19583 3. J. lééa 18h6, 1958) A Go., 325, 19593 J. Letkewite. 2. Die. Harv. 8:1. 12: Eilleide Heepitel‘gt 13h, 1955) h. J.A.H.A. Q} 197, 19571 5. Pszehozhernecolegz Frontiers, Little, Brown 6. Heuregazehozherneeologz, Eleerier, hhl, 1960; 7. A.H.A. Arch. Neural. Psychiet. 1Q: 516, 19573 8. Die. Kerr. 5:3. 12: 227,19583 9. J. Hillside Heep. g. 3, 1955; 10. Arch. lenrol & Peychiet. 1g. 23, 1956. 11. First Int'l can . leurol. Sc1., Pergenon, 613, 1959: 12. Jeur. Herr. Kent. Die. $29: 117. 19603 13. A.H.A. Arch. Gen.Paychiet. (in press); lh. Unpublished nenneerﬁﬁtg 13. Jenr. Herr. & ' Bent. Die. ggg: 187, 1960; 16. J. leurepeyehiet. 1: 2&2, 19603 1?. Jour. lerv. Kent. Die. ggg. 2h3, 19593 18. A.H.A. Arch. Gen. Psychiet. 1; S65, 1959: 19. A.H.A. Arch. laurel. & Peychiet. ﬁg: 20. EEG Clin. Neurophyeiel. 15¢ 359, 1960. 380, 19583 21. Gened. Psych. Aeeee. J. A: 1668, 19591 22. Cent. Neural. 23. J. Hillside Hoep.‘§: 2&1, 1957; 1g: 88, 19563 2k. Am. J. Psychol. 13: 38h, 19593 25. A.H.A. Arch. Neural g: 5&7, 19601 26. Free. 1? Int. Pezehel., lerth-Hellend, 238, 1959; 1%. J. Heuropeyohiet. 1} hS. 19593 28. Pezehezethelegz of Guaranieetien, Grnne & Stretton, 126, 19583 29. J. Hillside Heep. g; 207, 1957; 30. Psyehiet. 3;. 2&9, 1958. Gong. �.1531. Jour. lorv. Hunt. D13. 120: 235, 19603 Pazchiutric Drug Thorazz, 0.6. that‘s, 29, 19603 3b. Unpublished Hannueript. Boap. g: 216, 195?) 32. ngnnieu at 33. J. Hillsid- �lap-rtnaltal Fuyuhtutrac 2701:... at 3:11:14. luapitcls A title: In: fink, Fran tau ntpnrtuaut ”’F‘ul. 91“ “kl. 7!: U I, 1;!50 K.B. a: sxpurtnuutnl Psychiatry, 1111.14. 10.1.; '0’. �/ [, ‘e VI //y 11/22/60 layoviunntal ruyuhtutrto Procrnnn u‘ [1113140 loapltnlu A Icvtou It. Virtoun program: 1: an. nupartnant of xxpcrtnantal Payoh‘airy 531‘ but: dcvutod to an underttnndtn: of tho sad. at ﬂl‘itl at payuh1n$r1¢ thnruptta through studina at brtiu tunetiun. rho principal inshnign¢¢ invo boon adapted {ran doneriptiv. plyuilutry.vnanrapiyuhology, oloetronnotphnlocrnphy. lingututtcl, phuruaaolﬂtyg and socinlocy. 1n chungoa brats convululvu thcrtpy, at initial attain: functian nova round ta rtlatc both to ovuluution- o: inpruvaucnt In ptywholaciéﬁznrinblca. Al 0‘? undarnttudtnu and to pru~tr¢3tncut or eonvulaivw thcrupy dovelupad, a genera: nouroyhynialozic1 ( usergnd slanttw ). In this via: thorapxos a! vita udtpttvc uiif‘i‘rxplnttonlly thy dogtoo to ottactivo troutueutn payihtntrtu this brain function 13 uncuurahly nl‘nrnd. will. Chung. in brain function 1- noatnsary tar bchuvtorul ch:u¢o, the twp. or nd:p$¢tton, paywhologiédnna hurtvnr, vnrtoo «avoiding upon pro-‘rontncnt Itoiuloxliﬂcharactnrtutio: 02 sh. cuhdoot (2). Thus, tho use. or uotlcn 1. not soon as ulthar 'oralnle' or *poynhologic' but rathcr and chaugua of nourophyaiologio distant tan lattruaticn a. adnptivo 3008331.... turthcr, uh$lo bohtvtirtl chins. 1a rnluted to ohnngns in brain ttnottaa,‘nnd the nanptivt patio!» t0 prt-triatuont psychologte thirtetcricttot, 07:1nat10nu a: ’1Iprovcunat', but»: npuottl $79.! or uvlzuntiou or chnnxo, arc atrtvutivs stagnant. hated an :tatt and £1.11: oxpootutions and inlcrtaonu (2). �n2- ?hiu hypothuain Ill dovulopca and nuntstncd an a £021.! a! ntuditl qt cunvulstvn thnrnpy. ctncurrcnt aﬁudios a: tuuulia can. tnd1¢utod taut hohsvtor¢1 chant. horn. too, wua.r¢1ntod to tn. lutot ind accrue or piniongut can: a: ropaatod stature. - that. b.1uc tho prinaxpul manifestations at proloncod nonrcrhysioloctcaﬂ an that»: (ink). chm: in It: made if aoStoa of tho new pcyahotropio «goat; vac also nithta thin hypothesis (5,6). It nan ouggontod that ﬁhouo tgan%a would ho affectivc to tho 403:0. that ghoy induced paratatant ch:ugau 1a brgtn fanatian and that the typo at bchaviur;l rampaano Inuld to rolttud to tho typo or brain ohaagc, and to prcaorbtd payohologit (paruunultﬁr) patturnt. Tho prisont pruxruan in tin Btpartltat ‘20 4331¢u§d to study th.ue volitianuhipt in unprosuud _d¢tti1. E E III 13‘ £88 a: turtou: nanutrnn at brain tunusiaa, thc alount a: slaw var. atttvity ta ta. cinctrcunoupphagzrin (1,8) tad contcbulutary and 60.1.1 Inasmuch pattora: nttur unobarbital (9.10) not. thu unit uoaca‘:vc that... (11) 1a .0I7‘101VD thorny: subjects. In on. naportnont, tapruvclnnt ratings wire ctrruxttod with the upponrnacc .1 itch dgcrooa or change in thou. inexact (7.10). dtnbin-bltnd 1a 1n abnorvntiana tkntot a a‘udy ”‘2. it... Itiuh patiohta rotorrod for clootrguhock var. rand-n1: nustgncd to court‘s o: otthor ocnvulutvu 0r aubconvulttvo therapy under anurophytlologiénchaagt pqntothnl prcnodtonttal. nigh dugrtul or v!ra obuarvod only in tun convulitvn grnupg inprcvon-nt rutct varnixuitiouutly higher in this ﬁriﬁtj and vhaa subconvuluiv: nubjoeto �U). * v.20 ru-trontad by couVIInivo upyliuutiona, ﬁlo tuprovcnnnt rut. um: lintzsr to the orictual convtlaivt group (2). In the anboouvulaivo treated Inhannta, uuuutdar;b1¢ Quaint. or altntria «arrout yauaca hotuocu tho hitanporul cluotrodoc. It Ipptﬂrtd that the thorupautic taunt wan not tho total cloatrle.1 currunt, aggugg, but an :11 or non. quality nan££.ctnd by thc grand In: lotuuru (8,12). Th. algnittenuao at ﬁhc grand In! I'liir. van~cxan1uod in etudiat of tho inhalant aouvnlsnnt, insurlugrodtothylcth¢r (13692105). ﬁinilur 4.3!... of alsetro~ graphic ehsngc, ﬁngvovwnaut tutti, typos or bghgviortl ahtugo and changes In nourvysyuholoxtiﬂgatk bahavivr nﬁro observcd in tic tnhallnt tn ulcatrieally treatud groups (13). It at. anon npyaroat $hat act :11 tubjaats Ianiroatins high tugraou or physiologxc chnngo warn rttod ts '1npravod'. Ia a dcsaripttva typolngtn study, :31. ptttarna wire doacrihad, impartcnlly turned 'ouphnrlu', 'hypounnio', 'sonlttnatiuu', $0!!ﬂ.1£¢'1‘hdtlﬂl1'. and 'punlo‘. ﬁhtlo the ttrat tun of than. udnpt11¢ .04.: nor: rttud I. 'nugh taprovod', ¢ho latter two were noun as 'Iuinprovvd' or 'uoraa' (1%). In station a: ysyuh01031£#VIrinb1on, it run vaportod that pctxnnta rntcd as 'I‘ch improvud* and 'reaovurad' frequently ltnituntcd puruonnltky puttcrut liuillr ta that diaeribod by ﬁctuutnin and Ink: is ﬁhu laplacit vorbal 4.31.1 pornonality. 'In 1!:zunxo ynﬁtoras, patiantn capraastd thu 'lnazuugu a: doninl', than ditthln brain ohnagc In: Indueca, txhiblttus anon napocﬁa an txpltctt dintsl, Izaiuisataun, ditylne¢noat, cliches, g§g&_uorc traqu.ntly thug untuwravcd cubaoctu. Other 134130: taint-d to tnvorsblo and �.3. hash I 5341. acct. (15), and Roruuhaeh dotarnintnts «Olav, nbsaut novunaat and nbaont t-rn-calor (16,17). In thia popu1&tttn, also, :avurablo outatuu at. taaoctntod with 10v uduaattgnnl uahxuvannnt tad {truism birth (18). tutu... it?! at sitting a way to nuancat tun digit. of pentatonvulitvu :39 $1.! utvu nitzvity, ta anttahozanorciu coupltnd, «totEutzno, was giro: tutrnvonoualy at various :tngos or tht ccavulutvc thor‘py - proutll (19). doa$r¢ry to oxyaetntiaal, ditthnlinc eaunod In lunadiatd and «attained ¢aer¢aan in EEG cloning. Patiunta with donstl lagging. putt'ruu rulaaqntshad than. Inttcud or atphorin aha wall hasng, thc lubjoota vat. irritqblc, anxious and prrO181V. or pramtrnatnnnt patterns. In aubaastv prior ta eonvulaiva a: drug thnrapy, diothantnu andueod uxaitanont, tan-ion, anxiety and illusory nontatsunc. ﬁuhaoqncht ntndica with 9th.: «antral antioholinurutc ae-paunda (VII-8299. 33-318,336g hanaotyttno) aboucd behavioral sad cloctrogruvhlc pattarau elitist to daoth‘xino. atnilnr datynahrontnnttau o: postuconvulaivt 330 niacin; was ‘10. notod with «Mt-'11 amnion-tutu: hunuinnuo (nphounno, «suntan, nan-as). Ind ht: been rcpur‘od for tatihiatantnoa (diphunyihylrauinc). that. thiarvaticnu 10d $a tut mugxultion thtt «a incrtano 1n coutrnl ottltnargia activiiy VQI a btoahouscal haul: for thy convulaivc ttorapr greats: (26). rsmgonauo nma an no During this parted, tho mod. 0: sctlaa cf ucv¢r psychotrepic drug. trout-d intnrnst. rollcving tho caaouptc doravca tron ' J2 otavulntvu ‘harupr, thu nc‘rophgwiologio outage: inanood by drug. �.5... f tutti! I1th1n tun 3.x. aautc oxpcrinautu1 trunnuork at th. E39 usttinx. It It: thaurvod thtt phonothitslnos (ohlorpronasiac, any. prangnlnc, tritanaprolaaxna) :nduood axe ayauhrontauttou and a oh£tt1ng of tho upcetrun to tho .10! frequaaotts; Improbaghtc cad barbiturates, an incrouuud IyuchrnaxsatSOB and a shirt 0: spoctrnn to inst (recitation; roanrpiuo, an Inorouood ulcvtns with Iyaohrouw inattua at . dying... and douynchronisatioa at night! 10'010 (5,6). 2.133.313. tainted ﬁctynohrtnisnttua with a ah1:% ct :rcquauaicu fa the a!” but: (21). ”‘ng Gina: expirtnnatal annpounda tul‘cd inaludod nz~uxaa and phtnyaioltlslino (ariatol), nectar tad its variant aoneaaors (33:99), wtatlh9 (37"h) and trﬁnquol (lorrill). tor cash, an I0|tiutcut olnctrucraphia putters it. recordta. psyuhoyhnrtnollaciéwazoats wgu that staccatod It pruvtd. u nearaphyuiolotiéﬂpat§cran u for of 1a nasal eliciting varicty ctutraat t¢ tho sags}: psttura or induced scavalnionu. furthtrnouroyhyntolugidJtlttrttion, sh. a! type .02., I: rotlon$ad in as: aynohrcny and IFC‘ICRGI ynttcrna, nun rolnt.‘ to apoottiud typo: a: behavioral stuptntsdn. InorOtttuc nae aynchrony tad a shirt GO aluu fvnqncactou aura nauoatttud with trangutlltzn‘tua, notation uni docrnﬁatng agitatious stilt angynohraatua£tua and a shirt tn tu't tragucncloa It: antacxntta with excitouaut, tlluuionu. tad dolnntcntl ilcatton (6.20). than: aha-trutionu are conclt‘aut with hypothaloa o: Hitler. 2h. advantagon at are tuchntquco tn: the 300.7 or not payuhntropzc ugcntu haw. nlroady b¢0u reportcd (6). low �2h. presuut progrnn, instttnﬁod in Outabcr 1959. 1a banal an sh... attitua and in 6.113304 £0 .3380? $8. I’llavinc quantlultu In £3.90 t rolutlon hotutcn Innuurublo altovtttua in 53:13 tunc‘ian and bohnvtoral «hung. with payuho- airbus. unnaatatrttian? 120 that. proeﬁrtntnoatfqlua§oru gt paynhxatrao, ptyctulcciéinnd ptyuhmlc¢1£&variahzoa rolgtud to in. tropic drugs an typa 0: hohnviornl adiptntttn? And, art such cluntora rolntod to the typo and 403200 at phyutologle ohuuxo?# ‘gggaggs AI ua.1n1t1n1 ayproxinattcn, a doublnuhlind, sized Gonna. random Isntgnncnt drug study clinical In. undertnktn. luccd on our varitu' piyuhctropto coup-sud; tron 195k to 1959, thrco clan... unto 0.100%04 an tho 5‘31! or that: patﬁnrun or 310 ro‘ponao. tho slant. scloutnd wit. that. rich oxpcrzoncoa with caﬁhcr proloninan‘ dunynuhrouiutax pattcrnu, Irhahrontutng and nlyvinc, or nintnal or no errant. Pattoutu r-rorrud in: drug therapy, IItOf nudist: tun-auntaon. and art-r :11 other nodicntiouu hay. boon diucoattuucd are randomly usutgacd to ‘ compound.1n an. or that. ‘hrio «lacs... Pa‘icnto are pvodonlnnuﬁly Ilddlo eluot, urban, utﬁh high oiiontaonnl :t‘linlont. 1111.14. 80-pita1 1a a nou-pritit, philanthtopie supported psychiatric tnutttutton, .duitttng voluntary pattoutn {or txtonntvn puyuhothurcpoutie troitntut. fin loan duration or its: fer patients in novon months. convuiaivc and puychotropao drug thnrnpics It. pronortbud by star: payuhxntriota �.1. A11 thc trlatnnut in aduluintorad by to naparﬁutu‘. rottrrll Da’artniatul stuff, no that the axpcraanutal vartthlta or drag daoaco, rant. 0! adutaictrnttua, aaotguunut to groupu, 333, &r¢ roadtly controllod. 111 patiantu in thc hoapttal arc «v.113blu for titty. Attor‘a tutti»: ptrtod, 111 puticnt: rocuivc he so or liquid ‘nndtogttoa daily tron 1nd:vtd:ally inhallcd bettlco. Dos;¢o: at: incrcnscd in ttxnd tOIIII atop: tutti a u.x:uun at h ucnku. Artur tun wank: on nixtnau 4.111., ro—tnatlnx ¢o¢ura. to dn‘o, 1&0 vuhjaoto but. hon: rtturtod, and 110 have outplatod tn. study period. Proltniunry analyst: of tho data At. an: in on prozroau. Ichuvigral GhlI‘Oi In a tutti: u: tho bnhnviorul adnptnstonu of pt‘tuuta rcaoiviag pitucthiasiutl or inipruutua during 1958-59, variauc clustorn at bchnvtora var. duvolopad. 1h. typalocton wore but-d on tho trontatut rcapiaat and on pr0~trlntauut ptyuh1&tr1c protilus. In $3. pruncut sitar, tho typoloxint at. being tested, and variant scalarot at behavtoral ahtug. at. being atudtod. It... inaluac thorlyitt ritorrnl quortiouuairoc I1: cvaluntiono) therapiat tad puts-at Glyn. Road s¢nlang burr aoglu .valuntiona 1n int¢rviov by two rnutnrch psychiatrtnta. and Lorr Hard Scale.) and puttout unit—ratings 15013413: ‘ho Johan toutinl symptul about lint and the stints. Attstnda 50:10:. boon both vtcvod I‘Vl tank. as Psycholnglc lutrggangglogzg thing: vsrtnhlou sud pradlcttvo variablou. In convulsivo thorgpy, chingo¢ in Inner: tanks (22), tactile paraoption (23,2h), wcohnlcro Bolltvu‘ (13). err (13). flatro‘3rocnd talk. (25). ‘nd tachlntQUQOptu recognition a! figure: (26) war. relatcd to thy Court. or induocd and ﬂ‘Ok am �neurophyutczogaggihnngu. In: 9.03 tack, tn. dcxroo at docruuont tn rouui ta b. poatttvny ocrr'lutod with the ‘llk vortoruuncn nus assist a! :36 closing. lollewaac trout-oat aonalation, with the rotur: a: phybitloxialiaaauca t. prootroatnnnt lovnln, performing. payahologidﬁkasku in than: also raturnud to pro-trontnont lcvuln, or higher ~ a buttarntnt 02 purrornnnco ascribed to practi¢o afloat. Donia: start. on interviﬁw (27), aoroohach dotorl1nuntn (16,17), r 8.11. Idﬂvit (15,17), ltngunzu pntﬁarns attnr tnobnrbttal (28), andatary toodbuck and porcuption if the 11:ua1 Iyrscht have bcan v10v0d a: prcdlattvu attains at tho hchavioral outages following 362. fhauo vurinuo tank. are at: being Isa-anon with paychctropio :.£?:1.1p agon$s, alpncxty capacity to prudiot chaago. t. cling. wl‘h vurtona anout319igfﬁhotr §;I¢§ronniqggg;o‘gughzg In tn. convulttvn therapy ntndlnt. the intro. of as» slaving was latsurod by counting tho oonncauttv. wave- 1» lolcotad :unpi:a (7). lab.» ta. not. nubtlchohuazoo at uttoetl arc ltudiod, it in uooclaury to gyply lula'ttdionn toohntquoa. Iltctroulc Iroqutncy nnnlrlia wt: introduacd 1h Angint 1959. 8y nauaurounat 0: th. pun doticetion for vaﬁﬂoal rrnquoneius Iran 3 ta 33 8?! 1n ttn ataoaa epochs, rapid nanuurcnnat o: upptrintly nlnll august. in total activity nnd troguoncy aptctrl arc new obtatnnd drug tad applied. ethn- play-1.1.316" in thin program include tha rtlpautn I: :36 to iatrnvontua chlorpronnsinzj blood protauro reapnunu to the nut, pullout!" 1041” mute, and a: turtouv blo.d and urin. elegantl. man" “at“ ”any” “an“ w: 9! 115‘ 8 �tho atadlco in napnrtuont hurt beta dovctoa .: to torn;1 1.33133: puﬁtcruu. iylzoving it. stutits ct syntactic lung‘tgu pattern: (:8) tn asavulitvo ihsrapy, uﬁhor capogts at 11:51:30 vuru Ituaxod for tkcir r01:$£on an iudSQIa of change in intovpornonnl bohtvtor. .Jattc, urtnr oonoiiertblc omnlorutian with Various linguistic consecutivn or that suggcitaa typo~tokoa~rtttol (I?!) lilltrit, ho t 1nd»: (19.30). man. «mm: at and“ apneh it! hid prtvionoly §ncn npplicd tn urittua $311: or en. 1:ngungo nanplou of indivﬁdulil, 3.1!. indicated that the two pcrnou cou~ nuatcttton (47") was 1 nor. liznitignnt indox at tho itttn at tho interacting than auulylou or i¢paratu snnpxoa of tho ptrtitiplutl. tpplying than toohutque ﬁt convulltvu shtrnyy patients. chanson 13‘!!! noun and atundnrd «aviation. var. r01¢tnd both to in. deavco or induced 3:3 ulot wire aat1viti and to uyutnet1c lunxttxo pattern. ob$ttnca 1n indopondtut atruatnral interviouu. apauah 5.01:. no»: rupo‘tttvc (lowered noun If!) and nor. vartnhlo in coautcutivu nunplon (in-ruaI04 utnndurd d¢v1at10n) (31). In intarvtawl but-r. and alter tho mutrtvvaonu aduanlatrtttoa at ecutrally activa astutu, 31:11:: Ihlngil Int. obnurvod. taint. with n yrcdouinant lynchruatxgtion pnttorn on tn. £86 oxhibitcd a 4.120ntt in net: 191 cud inﬂfilti tn itandnrd duvxatioa o: necros, viii. dotynchrouising ealputuda 01101106 groatcr variability in tyccch pattcrus (1:090... in RI! Inna) tad dtcrunan in v.r1ub111%y of coauoeutiva scorn. (duorouun 1n ntandnrd deviatian) (32). 6th.: languaga notnnrnl atudiod includod diatroccurolior quttt¢ata, uclt-rutcruncc, and alttrntion 1n tunnu and paracn. Antﬁhar 30:10. m tutu �.19. nu: sagsoaﬁcd that ﬁt... yuywhcltnxutstta Inaiurcs tgo pa‘cat incantqutl for sh: operational unnlytns o: phyaiologig%und yi:¢h¢1¢¢1€?£ttactn a: ycychopharanaolugse taunt: (32). It �aggggaggzc $233133 It ta. court. at ‘ thou. plyuhta%r1e protraaa, comaidartblo InﬁnrOtt Ian unguudarcd in at. tantly organisation to which pttttnto turn rcturntnc. Also, its ginornl problem at tho ralntiou or stein! M chase. and a: pnychutric treat-out, and the Ipttifia prathn a! the rnlutiau of thtli factor. in tht rarogrul puttarna lad to a aortic at papulatian studsus. In on: study (33). ﬁduaattua. ﬂgi, plus: ct birth cud score on tho Galltarnia r Iallc wort ticnttioaatly ralctad to the may. at therapy rocoivod und the utilatniton at adainottva hotpttnl aortic... rhui, pgttont; aha var. older, pearl! uduantcd, had hishar I neuron And aura tarnishhnru, ptrtiuularlyranstnrn invent. wart neat ltkuly to be 90:0rfﬂd tar ¢ls¢trouhooh. that. rclationahlpl worn proaont indopiadont or atlxntnoa. within tic sunny 3: cluo‘ronhack patiuntu, $3. tins for rotttrnl for 3a: 3:: ulna rolntnd to ﬁhoau factora. In t nocand ntud: (18), dnru‘ton a! harpitnliantion, discharge uvnluattan and asucnoun: vova rolniod ta tho Ian. social flotara. fur uxauplo, patient: harpitlltuna for it. uhortcnt ported EOE. oldest, had in. lcaaﬁ education, v¢ro punt llkcly ta hnvc baou farcicaioru and had the hiahﬁr t ﬁnal. user‘s. 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II that ll trcntnnat and otutt training. �~13:- kahuna” fauna: uni-cue“ that“ m £0.11.ng rut: hum" m rink, ﬂu hunk. “but 1.. tum, Jinnah um, Int-u I. Erna, 3”,. Km, In" mu, ma: 3'. £1.13. Guru Imam, ”and a. auburn. “that“ 8. 33.301, abun- Inn: at! nary J. Mint“... Aim" at tho J. “11.1“ lap. 93 197, 1957; .3. J. mun. Hospital at 1958; 2. Ms. 3.. .113. In". 81.. 3:2: h. 4.1.11.1. 1.1m... Iron 131;. 1955; h 5. ms h “mule 1min”, a c... .325. 1339; 6. ¢h02m00§2u. naval". Mal, 19603 7. Add. not. loan)... a 1-31.31». ﬂ: $16, 1957: 0. Mn. In". an. '33: ”7.19563 9. J. i111.“- llup. g: 3, 1955: 19. Arab. 18116, 1958; ”my; 1.956. :3, rennin. t ﬁt 11. nm In“). 3” In“ 1. Sci. , Penman, 613. u. “an Em. that. 31!. 122' 117. 19691 13. 1.3.1:. Int-.1 Mm“. 1959) arch. Gun. pan); ﬁnalist“ autumn 15. Jar. low. but. ml. ms 15?, 1960: 16. a. lunpuehut. 3,: an, 1960; 1?. am. it". lat. M... m; 11:). 1959: 18. Mid. Arch. on. ”want. .13 555. 1959; 19. Add. Auk. Int-1. I: "youth £9: no. 1958; 21. g: (in 1h. can“. 8!, 1,563. usual. can Emlyn“. 9,3: 359. uni. Anna. 3. A: 1668, 1959: to. no 13. 3. Hanna. luv. g: 1950. 2:. 21:1, 1957: car. lmol. 2h. a. J. luau: g: Shh 1m; 8&. 17.19%: Gong. 238, 1959] 901350;” law-mama, m, 335. 4. 28. 19593 lmopoychiu. u. chhgzﬂhclaa at y «1-. 35.11.14. Buy. 5 1953; 126, Gun 29. Mutton, cwuuia, g: 207. 19573 30. urchin. 3.2») 2139, 1958. 1?} 381:. 19593 25. MILL. Arch. �. «150 ‘1-.. O 3'1. :"9: ‘.".¢ "”‘o ﬁt‘t > ‘ ‘ hip. g: 216, 195'!) g 31:. w! ”5’ 1,69} M', uranium-a Mnuonph 3.6; 2’. 196°, 3!. W 33. ‘¢ 31.11.14. �Experimental Psychiatric Programs at Hillside Hospital: A Max Review Fink, MnD. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. From VI: 1/61 �Experimental Psychiatric Programs at Hillside Hospital A Review various programs in the Department of EXperimental Psychiatry have been devoted to an understanding of the mode of action of psychiatric therapies through studies of brain function. The principal techniques have been adapted from descriptive psychiatry, neuropsychology, electroencephalography, linguistics, The pharmacology, and sociology. In initial studies of convulsive therapy, changes in brain function were found to relate both to evaluations of improvement and to pre~treatment psychological variables. As our understanding of convulsive therapy developed, a general neurophysiologicadaptive view of somatic therapies emerged (1). In this view psychiatric treatments are seen as therapeutically effective to the degree that brain function is measurably altered. While change in brain function is necessary for behavioral change, the type of adaptation, however, varies depending upon pre—treatment psychological and sociological characteristics of the subject (2). Thus, the mode of action is not seen as either "organic" or "psychologic" but rather as the interaction of diffuse neurophysiologic changes and adaptive mechanisms. Further, while behavioral change is related to changes in brain function, and the adaptive pattern to pre-treatment psychologic characteristics, evaluations of 'improvement’, being special types of evaluation of change, are derivative Judgements based on staff and family expectations and tolerances (2). �-2This hypothesis was developed and sustained in a series of studies of convulsive therapy. Concurrent studies of insulin coma indicated that behavioral change here, too, was related to the onset and degree of prolonged coma or repeated seizures - these being the principal manifestations of prolonged neurophysiological change in this therapy (3,h). The mode of action of the new psychotropic agents was also eXpressed within this hypothesis (5,6). It was suggested that these agents would be effective to the degree that they induced premorbid psychologic (personality) patterns. The present programs in the Department are designed to study these relationships in detail. CONVULSIVE THERAPY PROCESS 0f various measures of brain function, the amount of slow activity in the electroencephalogram (7,8) and confabulatory and denial language patterns after amobarbital (9,10) were the most sensitive indices (11) in convulsive therapy subjects. In wave one experiment, improvement ratings correlated with the appearance of high degrees of change in these indices (7,10). These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to courses of either convulsive or subconvulsive therapy under pentothal premedication. High degrees of neurophysiological change were observed only in the convulsive group; improvement rates were were �-3- significantly higher in this group; and when subconvulsive subjects were rc-treated by convulsive applications, the improvement rate .was similar to the original convulsive group (2). In the subconvulsive treated subjects, considerable amounts of electric current passed between the bitemporal electrodes. It appeared that the therapeutic agent was not the total electrical current, per sez but an all or none quality manifested by the grand mal seizure (8,12)o significance of the grand mal seizure was examined in studies of the inhalant convulsant, hexafluorodiethylether (Indoklon). Similar degrees of electroThe graphic change, improvement rates, types of behavioral change and changes in neuropsychological task behavior were observed in the inhalant and in electrically treated groups (13). It apparent that not all subjects manifesting high degrees of physiologic change were rated as 'improved’. In a descriptive typologic study, five patterns were described, empirically termed 'euphoric', 'hypomanic', 'somatization', 'paranoid-withdrawal', and ‘panic'. While the first two of these adaptive modes were rated as 'much improved', the latter two were was soon seen as *unimproved' or 'worse' (1h). variables, it was reported that patients rated as 'much improved' and 'recovered' frequently manifested personality patterns similar to that described by Weinstein and Kahn as the explicit verbal denial personality. In language patterns, patients expressed the 'language of denial', when diffuse brain change was induced, exhibiting such aspects as In studies of psychological �-h- explicit denial, minimization, displacement, cliches, 222. more frequently than unimproved subjects. Other indices related to favorable outcome were high F Scale score (15), and Rorschach determinants of color, absent movement and absent form-color (16,17). In this population, also, favorable outcome was associated with low educational achievement and foreign birth (18). ANTICHOLINERGIC COMPOUNDS AND CONVULSIVE THERAPY Seeking a way to augment the degree of post-convulsive slow wave activity, an anticholinergic compound, diethazine, EEG was given intravenously at various stages of the convulsive therapy process (19). Contrary to expectations, diethazine caused an immediate and sustained decrease in EEG slowing. Patients with denial language patterns relinquished them. Instead of euphoria and well being, the subjects were irritable, anxious and expressive of pre-treatment patterns. In subjects prior to convulsive or drug therapy, diethazine induced excitement, tension, anxiety and illusory sensations. Subsequent studies with other central anticholinergic compounds (WIN-2299, JB-318,336, benactyzine) showed behavioral and electrographic patterns similar to diethazine. Similar desynchronization of post-convulsive EEG slowing was also noted with central sympathomimetic hallucinogens (amphetamine, mescaline, LSD-25), and has been reported for antihistamines (diphenylhydraminc) These observations led to the suggestion that an increase in central cholinergic activity was a biochemical basis for the convulsive therapy process (20). �PSYCHOTROPIC DRUGS AND EEG During this period, the drugs aroused mode of action of newer psychotropic interest. Following the concepts derived from convulsive therapy, the neurophysiological changes induced by drugs were tested within the same acute experimental framework of the EEG setting. It was observed that phenothiazines (chlorpromazine, promazine, trifluopromazine) induced EEG synchronization and a shifting of the spectrum to the slow frequencies; meprobamate and barbiturates, an increased synchronization and a shift of spectrum to fast frequencies; reserpine, an increased slowing with synchronization at low dosages, and desynchronization at higher levels (5,6). Imipramine induced desynchronization with a shift of frequencies to the slow bands (21). Other experimental compounds tested included BL-M188 and phenyltoloxamine (Bristol), Deaner and its various congeners (Biker), WY-21h9 (Wyeth) and frenquel (Merrill). For each, no consistent electrographic pattern was recorded. It was suggested that psychopharmacological agents provide a means for eliciting a variety of neurophysiological patterns in contrast to the single pattern of induced convulsions. Furthermore, the type of neurophysiological alteration, as reflected in EEG synchrony and frequency patterns, was related to specified types of behavioral adaptation. Increasing EEG synchrony and a shift to slow frequencies were associated with tranquillization, sedation and decreasing agitation; while desynchronization and a shift to fast frequencies was associated with excitement, illusions, �and delusional ideation (6,20). These observations are consistent with hypotheses of Wikler. The advantages of EEG techniques for the assay of new psychotropic agents have already been reported (6). �97PSYCHOPHARMACOLOGY EVALUATION PROGRAM _______an.._________.__u~m._______. present program, instituted in October 1959, is based on these studies and is designed to answer the following questions: Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? Are there pre-treatment clusters of The psychiatric, physiological and psychological variables related to the type of behavioral adaptation? And, Method: As an are such clusters related to the initial approximation, a double-blind, fixed dosage random assignment drug study was undertaken. Based on our clinical experiences with various psychotropic compounds from l9Sh to 1959, three classes were selected on the basis of their patterns of EEG response. The agents selected were those with either predominant desynchronizing patterns, synchronizing and slowing, or minimal or no effect. Patients referred for drug therapy, after medical examination, and after all other medications have been discontinued are randomly assigned to a compound in one of these three classes. Patients are predominantly middle class, urban, with high educational attainment. Hillside Hospital is a non-profit, �-8- philanthropic supported psychiatric institution, admitting voluntary patients for extensive psychotherapeutic treatment. The mean duration of stay for patients is seven months. Convulsive and psychotropic drug therapies are prescribed by staff psychiatrists on referral to the Department. All treatment is administered by Departmental staff, so that the experimental variables of drug dosage, route of administration, assignment to groups, 323. are readily controlled. All patients in the hospital are available for study. After a testing period, all patients receive no cc of liquid medication daily from individually labelled bottles. Dosages are increased in fixed weekly steps until a maximum at h weeks. After two weeks on maximum dosage, re-testing occurs. To date, 1ho subjects have been referred, and 110 have completed the study period. Preliminary analyses of the data are now in progress. Behavioral Change: In a survey of the behavioral adaptations of patients receiving phenothiazines or imipramine during 1958-59, various clusters of behaviors were developed. The typologies were based on the treatment response and on pre-treatment psychiatric profiles. In the present study, the typologies are being tested, and various measures of behavioral change are being studied. These include therapist referral questionnaires and six week evaluations; therapist and patient Clyde Mood Scales; Lorr Scale evaluations in interview by two research psychiatrists, and Lorr Ward Scales; and patient self-retina including the Johns Hopkins symptom check �-9- list the Chicago Attitude Scales. Neuropsychology: Psychologic tasks have been viewed both as change variables and predictive variables. In convulsive therapy, changes in memory tasks (22), tactile perception (23,2h), WechslerBellevue (13), OFF (13), figure-ground tasks (25), and tachistoscopic recognition of figures (26) were related to the degree of induced neurophysiological change. For each task, the degree of decrement in task performance was found to be positively correlated with the amount of EEG slowing. Following treatment completion, with the return of physiologic indices to pre-treatment levels, performance in these psychological tasks also returned to pretreatment levels, or higher - a betterment of performance ascribed and to practice effect. Denial scores on interview (27), Rorschach determinants (16,17), F Scale scores (15,17), language patterns after amobarbital (28), auditory feedback and perception of the visual upright have been viewed as predictive indices of the behavioral changes following ECT. These various tasks are now being assessed with psychotropic agents, for both their capacity to change with various agents and their capacity ts predict change. Electroencephalography: In the convulsive therapy studies, the degree of EEG slowing was measured by counting the consecutive waves in selected samples (7). When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques. Electronic frequency analysis was introduced in �August 1959. By measurement of the pen deflection for various frequencies from 3 to 33 cps in ten second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are now obtained and applied. Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood pressure reaponse to mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. �-11PSYCHOLINGUISTICS series of studies in the Department have been devoted to formal language patterns. Following the studies of syntactic language patterns (28) Another in convulsive therapy, other aspects of language were studied for their relation as indices of change in interpersonal behavior}. Jaffe, after considerable exploration with various linguistic measures, suggested that type-token-ratios (TTR) of consecutive samples of dyadic speech may be a useful index (29,30). While TTR had previously been applied to written texts or the language individuals, Jaffe indicated that the two person communication (dyad) was a more significant index of the state of the interaction than analyses of separate samples of the participants. Applying this technique to convulsive therapy patients, changes in TTR mean and standard deviations were related both to the degree of induced EEG slow wave activity and to syntactic language patterns obtained in independent struuctured interviews. Speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (increased standard deviation) (31). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents with a predominant synchronization pattern on the EEG exhibited a decrease in mean TTR and increase in standard deviation of scores, while desynchronizing compounds elicited greater variability in samples of speech patterns (increase in TTR mean) and decrease in variability �-12- of consecutive scores (decrease in standard deviation) (32). other language measures studied included distress-relief quotients, self-reference, and alteration in tense and person. It was suggested that these psycholinguistic measures are potent techniques for the operational analyses of physiological and psychological effects of psychopharmacologic agents (32); �SOCIOLOGIC STUDIEE In the course of these psychiatric programs, considerable interest was engendered in the family organization to which patients returning. Also, the general Problem of the relation of social factors to choice and results of psychiatric treatment, and the specific prohlem of the relation of these factors to the referral patterns led to a series of population studies. In one study (33), education, age, place of birth and score on the California F scale were significantly related to the type of therapy received and the utilization of adjunctive hospital services. Thus, patients who were older, poorly educated, had higher F scores and were foreignborn, particularly in Eastern Europe, were most likely to be referred for electroshock. These relationships were present independent of diagnoses. Within the group of electroshock patients, the time for referral for ECT was also related to these factors. In a second study (18), duration of heapitalization, discharge evaluation and diagnoses were related to the same social factors. For example, patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign-born and had the higher P Scale scores. Younger, nativeborn, more educated, lower F Scale score patients were hospitalized the longest. These relationships held true within treatment type and within diagnostic class. On discharge, older patients had the most favorable ratings. In ECT, patients rated as recovered or much improved had the highest F scores, least education and were most likely to be foreign-born. In another study of patient were �refusal of similar relationships were observed (3h). These relationships are now under study in the Out-Patient Department, and in a tri-hospital comparative study. In the latter study, the populations of three hospitals with prevailing differing clients, in which all therapies areenually available to all patients, - Menninger Foundation Hospital (upper-class, Protestant), Massachusetts Mental Health Center (lower-class, Catholic) and Hillside Hospital (middle-class, Jewish) are being assessed. It has been “postulated that these relationships reflect the influence of social background on psychological processes, such as habitual patterns of communication and modes of expression. The contribution of these factors to the pattern of mental illness, and the patient-therapist interaction are under study. ECT, �SUMMARY Departmental programs are a cluster of interrelated studies focussed about common population samples. Within Hillside The HOSpital, research laboratories in Biochemistry, and in Medicine are active; and other laboratories in psychodynamic psychiatry are being developed. In this Department, various disciplines are participants, representing a gradual growth of six years. Further growth and the directions of ensuing studies are dependent on the results of the studies described here; as well as the growing institutional awareness that research is an integral part of the hospital's operation and budgets - as much as treatment and staff training. �~16- References Authors of the following references include the following staff members: Max Fink, Max Pollack, Robert L. Kahn, Joseph Jaffe, Martin A. Green, Eric Karp, Korin, Donald F. Klein, George Krauthamer, Arnold G. Blumberg, Nathaniel S. Siegel, Abraham Kaplan and Henry Hyman J. Lefkowits. 1. J. Hillside Hosp. 6: 197, 1957; 2. Dis. Nerv. Sys. 12: 3. J. Hillside Hospital h: 13h, 1955; 113, 1958; h. J.A.M.A. 166: 18h6, 1958; 5. Psychopharmacology Frontiers, Little, Brown 6. Neuropsychopharmacology, Elsevier, hhl, 1960; 7. A.M.A. Arch. Neurol. & Psychiat. 18: 516, 1957; 8. Dis. Nerv. Sys. 12: 227, 1958; 9. J. Hillside Hosp. A: 3, 1955; 10. Arch. Neurol & Psychiat. 16: 23, 1956. & Co., 325, 19593 11. First Int'l Cong. Neurol. Sci., Pergamon, 613, 1959; 12. Jour. Nerv. Ment. Dis. 129: 117, 1960; 13. A.M.A. Arch. Gen. Psychiat. (in press); 1h. Unpublished manuscript; 15. Jour. Nerv. Ment. Dis. 129: 187, 1960; 16. J. Neuropsychiat. l: 2h2, 1960; 17. Jour. Nerv. Ment. Dis. 128: 2h3, 1959; 18. A.M.A. Arch. Gen. Psychiat. l: 565, 1959; 19. A.M.A. Arch. Neurol. & Psychiat. 82: 20. EEG Clin. Neurophysiol. 13: 359, 1960. 380, 1958; J. g: 1663, 1959; 22. J. Hillside Hosp. 6: 2hl, 1957; 21. Canad. Psych. Assoc. 16: 88, 1956; 23. Conf. Neurol. 2h. Am. J. 25. A.M.A. Arch. Neurol. g: 5&7, 1960; Psychol. 13: 38h, 1959; 26. Proc. XV Int. Cong. Psychol., North-Holland, 238, 1959; 27. J. Neuropsychiat. l: h5, 1959; 28. Psychopathologx of �-17- m Communication, Grune ' & Stratton, 126, 19583 29. J. Hillside Hosp. 6: 207, 1957; 30. Psychiat. g3: 2&9, 1958. 31. Jour. Nerv. Ment. Dis. 130: 235, 1960; Psychiatric HOSp. Drug Therapy, C.C. Thomas, 29, 1960; 6: 216, 1957; 3h. Unpublished Manuscript. 32. ngamics of 33. J. Hillside �EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, M.D. Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume X ' Nos. 3-4 ° July-Oct. 1961 . �EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, MD. The dedication of Hillside Hospital as a Research Institute has been a dream of many of its students—a dream that may achieve realization in this decade. Dr. Tarachow was an early proponent of this view; and both in his sponsorship of the Journal, and in his encouragement of research studies, he presaged this development. He was also the inadvertent sire of the research studies in experimental psychiatry. While I was a resident in psychiatry in 1952, we collaborated in a study of the relation of the early separation of child from a parent to the adult choice of neurosis. Reviewing the hospital records of ﬁve previous years we concluded that there was, indeed, a relation— neurotic patients with obsessional neuroses had a signiﬁcantly, greater incidence of separation than patients with hysterical neuroses (2). This report was the beginning of the patient population studies described here. Since 1954 the various programs in experimental psychiatry have been devoted to an understanding of the mode of action of the psy- chiatric therapies of the hospital. The techniques have been adapted from descriptive and dynamic psychiatry, neuropsychology, electro— encephalography, linguistics, pharmacology, and sociology. This report reviews these studies and presents support for the creation of a Research Institute at Hillside. PAST STUDIES In our early studies of convulsive therapy, instituted with the 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. The studies reported here have been aided by the Board of Directors Research Fund; the National Institute of Mental Health (Grants M-927; MY-2092,-27l5, ~4798; MF-12,033); Foundations Fund for Research in Psychiatry (FFRP 56-151); Kaufmann, and Dazian Foundations; and numerous pharmaceutical concerns including Geigy, Bristol, Wyeth and Smith, Kline 8: French Laboratories. 159 �160 MAX FINK aid of a grant award of the National Institute of Mental Health, evaluations of patient improvement were shown to be dependent both on changes in brain function and on psychological factors. As our understanding of convulsive therapy developed, a general neurophysiologic-adaptive view of somatic therapies emerged (6). A change in brain function was seen as a necessary condition for behavioral change, with the type of change varying, depending upon psychological and sociological characteristics of the subject (22, 25). Thus, the mode of action was not seen as either ”organic” or “psychological” but rather as the interaction of neurophysiological changes and individual patterns of response and behavior. This hypothesis was sustained in studies of convulsive and insulin coma therapies (21, 22); and the mode of action of the new psychotropic agents was expressed within this hypothesis. It was suggested that psychotropic drugs would be effective to the extent that persistent changes in brain function were induced; and that the type of behavioral response would be related to the type of brain change, and to individual premorbid psychologic (personality) patterns (6, 28, 40). l. Convulsive Therapy Process: Seeking a measure of altered neurophysiological change that was sensitive and suitable for repeated retests, various measures were studied including changes in the face-hand test (1, 10, 13, 35), memory tests (17, 35), amount of slow-wave activity in the EEG (16, 23) and confabulatory and denial language patterns after amobarbital (3, 15). The latter two, EEG and amobarbital tests, were the most sensitive indices of change in convulsive therapy subjects. In one experiment, clinical ratings of improvement were correlated with high degrees of change in these indices (15, 16). These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to either convulsive or subconvulsive therapy. High degrees of electrographic slow-wave activity and positive amobarbital tests were observed only in the convulsive group; improvement rates were signiﬁcantly higher in this group, and when subconvulsive subjects were retreated by convulsive applications, the improvement rate was similar to the convulsive group (22). In subconvulsive applications, considerable electric current passes between the electrodes. It was postulated that the therapeutic agent was not the total electrical current per se, but the “all or none” quality manifested by the grand-mal seizure (9, 23, 42). The signiﬁ- �EXPERIMENTAL PSYCHIATRIC RESEARCH 161 cance of the grand-mal seizure was examined in a comparative study of the inhalant convulsant, hexaﬂuorodiethylether (Indoklon), and electrically induced seizures. Similar degrees of electrographic change, improvement rates, types of behavioral adaptations, and changes in neuropsychological task behavior were observed in both the inhalant and in the electrically treated groups (49). However, not all subjects manifesting high degrees of physiological change were evaluated as “improved.” In a descriptive typologic study, ﬁve adaptive modes were described, empirically termed “euH H phoric,” “hypomanic,” “somatization, paranoid-withdrawal,” and “panic.” While the ﬁrst two patterns were rated as “much improved,” the latter two were seen as “unimproved” or “worse” (50). In studies of psychological variables, it was reported that patients rated “much improved” and “recovered" frequently manifested personality patterns akin to the explicit verbal denial personality type (37). These patients expressed the “language of denial” more frequently than unimproved subjects, exhibiting such aspects as explicit denial, minimization, displacement and clichés (27). Other psychological indices also related to favorable outcome included high F Scale score (42), Rorschach determinants of color, absent movement and absent form-color (30, 45), and low educational achievement and foreign birth (31). 2. Anticholinergz'c Compounds and Convulsz've Therapy: Seeking a way to augment the degree of postconvulsive EEG slow-wave activity, an anticholinergic compound diethazine, was given intravenously at various stages of the convulsive therapy process (20, 24). Unexpectedly, diethazine caused an immediate and sustained decrease in EEG slowing, which was associated with marked changes in language and mood. In patients with denial language patterns (27), these could no longer be elicited. Instead of euphoria and wellbeing, the subjects became irritable, anxious, and complaining. In subjects prior to convulsive or drug therapy, diethazine induced excitement, tension, anxiety, and illusory sensations. Subsequent studies with other central anticholinergic compounds and sympathomimetic hallucinogens showed behavior and electrographic patterns similar to diethazine. These observations led to the suggestion that an increase in the cholinergic activity of the central nervous system was the biochemical basis for the convulsive therapy process (38). 3. Psychotropic Drugs and EEG: Following these studies, the neurophysiological changes induced by drugs were tested within an �162 MAX FINK acute experimental EEG setting. It was observed that phenothiazines induced EEG synchronization and a shifting of the frequency spectrum to the slow frequencies; meprobamate and barbiturates, an increased synchronization and a shift of the spectrum to fast frequencies; reserpine, an increased slowing with synchronization at low dosages, and desynchronization at higher levels (18, 26, 28, 40). Imipramine induced desynchronization with a shift of frequencies to the slow bands (33, 34). Each active psychotropic compound was thus shown to have a characteristic frequency pattern. Various other experimental compounds were also tested, and for these no consistent electrographic pattern was recorded. These compounds have since been shown to have either no or very limited clinical psychotropic activity. The absence of behavioral change with these compounds lent further support to the assumption that brain change is a necessary condition for the action of psychotropic drugs. These observations suggested that psychopharmacological agents provide a means for eliciting various types of altered brain function in contrast to the single pattern following convulsive therapy. Furthermore, the type of neurophysiological alteration, as reﬂected in EEG synchrony and frequency patterns, was found to be related to speciﬁed types of behavioral adaptation. The advantage of EEG techniques for the assay of new psychotropic agents and the technical merits of electronic frequency analysis were assayed and described (47, 52). 4. Insulin Coma Therapy: In our insulin coma studies we con- firmed earlier observations that persistent alterations of brain function were related to prolonged coma and spontaneous seizures; and saw in this relationship support for a neurophysiologic-adaptive hypothesis. With the availability of the new psychotropic agent chlorpromazine, a controlled chlorpromazine-insulin coma study was undertaken in September, 1955. As patients were referred for insulin coma they were randomly assigned to courses of either oral chlorpromazine for at least three months in doses adjusted to fall short of toxicity; or insulin coma, induced by a standard technique at least ﬁfty times in each patient. While a number of minor differences were noted in comparing the two therapies, the results at time of discharge showed no statistical difference in the effectiveness of both treatments. Neither treatment seemed to affect the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management (21). Concurrently, following the suggestion by the Creedmoor workers that �EXPERIMENTAL PSYCHIATRIC RESEARCH 163 divided insulin doses were superior to single insulin doses, Blumberg and Laderman (39) essayed this problem and demonstrated no signiﬁcant merit to the multiple-dose technique. (In 1958, following the general conﬁrmation of these observations, insulin coma therapy was discontinued at Hillside). 5. Neuropsychology: Various psychophysical tests were adapted from neuropsychology, where their signiﬁcance in brain-damaged subjects had been demonstrated. The early studies assessed these tasks as indices of altered brain function (35), and measured the range of performances of psychiatric patients, who are generally assumed not to be brain-damaged. Thus, memory function was assessed on immediate recall, after various interpolated learning tasks (17, 35), as well as during convulsive therapy (17). Tactile perceptual tasks were ﬁrst examined in the clinical population (1). Later, with more sensitive electrical tactile stimuli, Korin (10) observed the range of thresholds in different body parts, the changes with altered brain function (10), and the inﬂuence of set (instruction) on performance (36). We also studied the perception of embedded geometric ﬁgures (43), tachistoscopic presentation of embedded color ﬁgures (55), perception of the visual upright (55), critical ﬂicker frequency (49), and interference in reading time by delayed auditory feedback (55). For each task, the degree of decrement in task performance was found to be positively correlated with the amount of EEG slowing. Following treatment completion, with the return of physiological indices to pretreatment levels, performance in these psychological tasks also returned to pretreatment levels, or higher—a betterment of performance ascribed to practice effect. Concurrently, assessment of various psychological measures as indices predictive of behavioral change during convulsive and drug therapies led to studies of the Rorschach determinants (30, 45), California F Scale scores (30, 42), language patterns after amobarbital (27), denial scores on interview (37), and the perception of the visual upright and auditory feedback (55). 6. Psycholinguistics: Concurrent with the syntactic language studies (27), analyses of other language patterns were undertaken, both in a search for more objective indices of behavioral change and to gain experience in the technical problems of tape analysis for psychotherapy research. An index of variability in the vocabulary of speech, the type-token ratio (TTR) of consecutive samples of dyadic speech, was extensively studied (7,41, 44, 46, 56, 57). In convulsive therapy patients, signiﬁcant changes in TTR mean �164 MAX FINK and standard deviations were related both to the degree of induced EEG slow-wave activity and to syntactic language patterns obtained in independent structured interviews. It was noted that speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (41). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents which produced predominant synchronization patterns on the EEG were related to a decrease in mean TTR and an increase in the standard deviation of scores, while desynchronizing compounds elicited greater variability in speech patterns and decrease in variability of consecutive scores (44). Other language measures studied included distress-relief quotients, self-reference, and alterations in tense and person. It was suggested that these psycholinguistic measures are useful techniques for the operational analyses of physiological and psychological effects of psychopharmacological agents (44, 46). 7. Brain Damage and Schizophrenia: Following his studies at Ittleson Center, Pollack reviewed the relationship between age of hospitalization, intellectual functioning and prognosis in schizophrenic children and adults. He noted that initial hospitalization in childhood and adolescence was related to I. Q. scores in the subnor— mal range, deviant performance on psychomotor tasks, and more frequent ratings of “unimproved” at hospital discharge than was initial hospitalization as an adult. The early and insidious onset of the behavioral syndrome “schizophrenia” was thus related to brain dysfunction (54). Findings suggest that different subgroups of schizophrenia may be classiﬁed on the basis of neuropsychological deviancy. 8. Sociological Studies: Considerable interest in the family organization to which discharged patients were returning, the relation of social factors to choice and results of psychiatric treatment, and the specific problem of the relation of these factors to treatment referral patterns led to a series of population studies. In one study (8), education, age, place of birth, and score on the California F Scale were signiﬁcantly related to the type of therapy received and the utilization of adjunctive hospital services. In a second study (31), duration of hospitalization, discharge evaluation, and diagnosis were related to the same social factors, while in a study of patient refusal of ECT, similar relationships were observed (51). These observations suggested a comparative interinstitution study, and among three hospitals the relationships between social class and other demographic variables (age, sex, education) to the clinical �EXPERIMENTAL PSYCHIATRIC RESEARCH 165 variables of patient classiﬁcation (diagnosis), duration of hospitalization, selection of therapy, and discharge evaluation have been assessed. Three teaching institutions were selected in which all therapies are equally available to all patients—Menninger Foundation Hospital (upper-class, Protestant), Massachusetts Mental Health Center (lowerclass, Catholic), and Hillside Hospital (middle-class, Jewish). In such a comparison we have found the differences in designations of treatment, diagnosis, and discharge evaluation so marked as to make comparisons difﬁcult. While many relationships between social variables and clinical variables were observed in each hospital, no social variable was found related to the clinical variables in every hospital (53). In an outpatient department study, sex, age, and marital status were found to be related to the acceptance and rejection of patients and failure to complete the application process (55). These observations in population samples led to concurrent studies of staff attitudes in the selection of therapy (ll, 12). In a series of ward observation studies, Kaplan and Lefkowits indicated the signiﬁcant role of staff attitudes (especially nursing personnel) in the referral for subjects for somatic therapies, and in the transfer of patients from one ward to another. (To study the inﬂuence of staﬂ attitude on patient selection for drug therapy, we requested one ward be designated as a “no-movement” unit. This was adopted in September, 1959 and shortly thereafter by the whole hospital.) PRESENT STUDIES During the period of the convulsive therapy studies, many new psychotropic compounds were assessed clinically (5, 21), electrographically (34, 40, 48), and psychophysically (48). The present psychopharmacology evaluation program, based on these studies, was designed to answer the following questions: 1. Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? 2. Are there pretreatment clusters of psychiatric, physiological, and psychological variables which are related to the type of behavioral adaptation? 3. Are such clusters related to the type and degree of physiologi- cal change? As an initial approximation, a double-blind, ﬁxed dosage, ran- �166 MAX FINK dom assignment drug study was undertaken. Based on our clinical experiences three types of compounds were selected on the basis of their EEG patterns. In this study, 203 subjects were referred, and 149 have completed the testing program, from October, 1959 to July, 1961. l. Behavioral Change: In a survey of the behavioral adaptations of patients receiving various psychotropic compounds during 195859, a behavioral typology based on the treatment response and on pretreatment psychiatric profiles was developed (55). In the present study, the typologies are being tested, and various measures of behavioral change studied, including therapist ratings, self-ratings, and various ward observation scales. 2. Neuropsychology: Psychological tasks have been viewed both as indices of behavioral change and as predictive guides in convulsive therapy. Each of these tasks and a selected group of motor tasks are now being assessed for both their capacity to reveal change with various drugs and their capacity to predict change with the drugs in this program (48). 3. Electroencephalography: In the convulsive therapy studies, the degree of EEG slowing was measured by counting the consecutive waves in selected samples (16). When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques (48), and electronic frequency analysis was introduced in August, 1959. By measurement of the pen deﬂection for various frequencies from 3 to 33 cps in ten-second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are obtained (52). Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood pressure response to mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. 4. Data Analysis: To analyze the data generated in this study, we have sought the aid of complex statistical methods and computational facilities. Analyses of covariance, correlation matrices, factor analyses, and discriminant function analyses are computations now in progress with these data at the NIMH Psychopharmacology Service Center’s Biometric Laboratory in Washington. THE NEXT STEPS Favored by a national research climate and a cooperative hospital staff, these studies have proceeded vigorously. The assets for research in this setting have been great—a selected, intelligent patient popula- �EXPERIMENTAL PSYCHIATRIC RESEARCH 167 tion resident from six to twelve months, without individual economic limitation of hospital stay; a sophisticated administration tolerant of controlled studies; and approval of a Board of Directors who desire “research” as an institutional function. As Dr. Lewis Robbins noted in his ﬁrst hospital report in 1959, a specialty hospital can make little impact on the mental illness problems of the community by treatment alone. The successful treatment of 350 patients a year is but little comfort to the 40,000 resident patients in the state hospitals of Long Island. Nor will the annual training of twenty or thirty physicians in the arts of psychotherapy do much to help these unfortunates or the many thousands of ambulatory mentally ill resident in the nation. No, a therapeutic goal alone is salutary but inadequate to our needs. As he proposed, the answer may lie in the dedication of a “research hospital,” as it is here that a specialty hospital can truly excel. The charter has been written in the Board’s assertion of research as a hospital goal. With the assets of an exemplary therapeutic facility, such rededication can provide the stimulus for the continuous study of the cause of mental illness and of methods of therapy. Such dedication would provide the stimulus for comparative and controlled assessments of different therapeutic techniques. Continued study is urgently required of the selection of patients for various therapies; the application and mode of action of the therapies; and the role of social and milieu factors in supporting the effects of our therapies. Assessments require a meaningful classiﬁcation of subjects. The behavioral variables alone, which are the basis of our present diagnostic schemata, are unsatisfactory. Study is urgently required of the applicability of social and demographic variables; psychological task performance proﬁles; typologies based on behavioral response to deﬁned stresses or drugs; and physiological reactivity measures. Such classiﬁcations are also essential for any biochemical, physiological, or evaluative study to provide homogeneous samples and comparable controls. Assessments also require meaningful indices of evaluating change. Present global “improvement” ratings and socialization measures are inadequate. Whether the intervening variable be milieu therapy, psychotherapy, drug therapy, or time, the criteria of behavioral change require deﬁnition. The applicability of rating scales, language tasks, self~ratings, psychophysical change scores, family assessments, etc., require study and evaluation. Recent studies of psychotic subjects have provided the suggestion �MAX FINK 168 that there is a neurologic factor in a group of the schizophrenias. The high incidence of electrographic and neurologic dysfunction, the lack of behavioral response to all therapies, and the relentless course of the illness suggest an “organic” involvement in this cluster. Such a substrate must be clearly sought by the application of biochemical, neurophysiological, and epidemiological techniques to various clusters of young psychotic subjects. These are broader views of some of the questions studied in the programs in experimental psychiatry of the past seven years. These programs, and the contemporary projects in biochemistry and in medicine, provide models of bootstrap studies undertaken with limited support. A dedication of Hillside Hospital as a Research Institute will provide the needed focus and impetus for the scientiﬁc and humanitarian forces of the community to join in a common endeavor to resolve the problems of the mentally ill. Acknowledgment: Participants in these programs include the present members of the Department of Experimental Psychiatry: Ira Belmont, Martin A. Green, Abraham Kaplan, Eric Karp, Donald F. Klein, John C. Kramer, Max Pollack, and Arthur Willner. Former associates included Karl Andermann, Joseph Jaffe, Robert L. Kahn, Hyman Korin, George Krauthamer, Nathaniel Siegel; and Research Fellows Barre Alan, Fred Coleman, Harold Esecover, Stanley Friedman, Henry J. Lefkowits, and Robert Shaw. The cooperation of Arnold G. Blumberg of the Department of Medicine in the present program is gratefully acknowledged. The reports listed here are the result of the collaboration of these workers and the professional staffs of the hospital who gave unstintingly of their time and their good-will. REFERENCES (1) ' This Journal, 1:21, 1952; (2) ibid., 2:67, 1953; (3) ibid., 4:3, 1955; (4) ibid., 4:134, 1955; (5) ibid., 5:67, 1956; (6) ibid., 6:197, 1957; (7) ibid., 6:207, 1957; (8) ibid., 6:216, 1957; (9) ibid., 6:229, 1957; (10) ibid., 6:241, 1957. (13) Neurology, 4:211, (15) ibid., 76:23, 1956; 1956; (18) EEG Clin. (20) ibid., 10:207, 1958. (21) ]. Am. Med. Assn., 166:1846, 1958; (22) Dis. Nero. Sys., 192113, 1958; (23) ibid., 19:227, 1958; (24) Arch. Neurol., Psychiat., 80:380, 1958; (25) ibid., 80:73, 1958; (26) Neurology, 8:682, 1958; (27) Psychopathology of Communication, New York: Grune 8c Stratton, 126, 1958; (28) Psychopharmacology Frontiers, New York: Little, Brown, 325, 1959; (29) Proc. XV Int. Cong. Psychol, North Holland Publ., 238, 1959; (30) J. Nero. Ment. Dis., 128:243, 1959. (31) Arch. Gen. Psychiat., 1:565, 1959; (32) EEG Clin. Neurophysiol., 11:398, (11) This Journal, 10:84, 1961; (12) ibid., 10:97, 1961; 1954; (14) Arch. Neurol., Psychiat, 72:233, 1954; (16) ibid., 78:516, 1957; (17) Conf. Neurol., 16:88, Neurophysiol.,9:180,1957; (19) ibid., 10:162, 1958; �EXPERIMENTAL PSYCHIATRIC RESEARCH 169 1959; (33) ibid., 12:243, 1960; (34) Canad. Psychiat. Assn. ]., 4:1668, 1959; (35) Proc. Int. Cong. Neurol. Sci., Pergamon, 613, 1959; (36) Am. J. Psychol., 72:384, 1959; (37) J. Neuropsychiat., 1:45, 1959; (38) EEG Clin. Neurophysiol., 12:359. 1960; (39) Am. ]. Psychiat., 116:839, 1960; (40) Neuro-Psychopharmacol., 1:441, Elsevier, 1960. (41) J. Nerv. Ment. Dis., 130:235, 1960; (42) ibid., 1302187, 1960; (43) Arch. Neurol., 2:547, 1960; (44) Dynamics of Psychiatric Drug Therapy, Springﬁeld: Thomas, 29, 1960; (45) J. Neuropsychiat., 1:242, 1960; (46) Am. J. Psychother., 15:46, 1961; (47) Neuro-Psychopharmacol., 2:30, Elsevier, 1961; (48) ibid., 2:381, 1961; (49) Arch. Gen. Psychiat., 4:259, 1961; (50) ibid., 5:30, 1961. (51) ]. Nerv. Ment. Dis., 132:153, 1961; (52) Medicina Experimentalis (in press); (53) VA Conf. Psychopharmacology (in press); (54) Arch. Gen. Psychiat., 2:652, 1960; (55) Unpublished manuscript; (56) Psychiatry, 21:249, 1958; (57) Comparative Psycholinguistic Analysis of Two Psychotherapeutic Interviews. New York: Int. Univ. Press, 1961. ° Due to the length of this Bibliography, it is presented in an abbreviated form. ��IIIIIIII, IIII III IIIII, IIIIII I mill‘iﬂﬁl IIIIIIIIII IIIII 3,963.4. 16"”1WI m3 “It W “WI IIII. 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Pollack, n.:' 3.1. a: ltur01&¢tea1 Dyntunotlon 1n tho childhood schizophraninn, Lynx. arthapuyohiatric Auioc., 8.3., Burah. in Pollack, n.: scatnl £Ipo¢ta of Paytltnirtc Ironinout YA V1 Aunnnl Problcnn, Hothtdologia loupst‘la: first nsonareh can:., Bantinuaﬁt, Karen. “ or Sinnlﬁantous StimulaPullnck, H.s attordcrcd Pgraopt1¢n ttou a: rsoc-aad Hand: A Ravine and thaory, Sac. 3101. Payohtnt., Atlantic Gity, Juan. 810301, 1.: Diagnosis and truatnon‘ 1n Thrao Pnywhtntrto noapitala, An. Saelologtcal Lss¢o., 8%. Louis, Aug. �\ PUBLICATIONS OF DR. MAX FINK 1950 1. 2a. Subdural Hematoma Developing During Hospitalization, Amer. J. M. 1950 Dr. (With Green). 107: 381-383, Pszchiat. Patterns in Perception of Simultaneous Tests of Face and Hand, Trans. Amer. Neurol Assoc. 72: 250, 1950 (with Drs. _' Ereeni. & Arch. Neurol. ibid, Pszchiat. ﬁg: 355-362, 1951. M.B. Bender and M. .... 3. 1952 Test as a Diagnostic Sign of Organic Mental Syndrome, Neurologz, 2: h6-58, 1952 (with Drs. M.B. Bender and M. Green}. Tactile Perceptual Tests in the Differential Diagnosis of 1952 21-31, Hillside J. Hosp. 1: Disorders, Psychiatric (with Dr. M.B. Bender). A Clinical Evaluation of Carotid Angiography, Conf. Neurol. 13: 181-195, 1952 (with Dr. J.M. Stein). Exosomesthesia, or Displacement of Cutaneous Sensation into 1952 Amer. Assoc. 1Q: Neurol. Trans. Space, Extra-personal .B. Ben er . (with Drs. M.F. Shapiro an & 1952. h81-h90, Neurol. Arch. éﬁ: ibid, Pszchiat. .... Order of Dominance in Cutaneous Perception, Trans. Amer. Neurol. Assoc. 7h: 238-2h0, 1952 (with Drs. M.B. Bender and M. Green}. Patterns of Perceptual Organization with Simultaneous Stimuli, Arch. Neurol. & Ps chiat. 13: 233-255, l95h (with Drs. M.B. The Face-Hand '- Bender and M. areani. 1953 8. 9. HeDeielopment of Perception of Simultaneous Tactile Stimuli in 1953 (with Dr. M.B. 27-3h, 3: Neurologz Normal)Chi1dren, Bender . Perception of Simultaneous Tactile Stimuli by Mentally Retarded Adults, J. Nerv. Ment. Dis. 117: h3-h9, 1953 (with Drs. M.B. Bender and M. Green). �-210. 11. Spinal Fluid Findings Following Cerebral Angiography, Neurol— ( 1953 with Dr. J.M. Stein). 137, ogz'g: A Statistical Study of a Psychoanalytic Hypothesis: Absence of a Parent as a Specific Factor Determining Choice of Neurosis J. Hillside Hosp. 3: 67-71, 1953 (with Dr. S. Tarachows. 12. 13. Effects of Barbiturates on Perception, Trans. Amer. Neurol. Assoc. 15: 1953 (with Drs. M.B. Bender, P. Bergman and M. Nathanson). Homosexuality with Panic and Paranoid States (Case Report) J. Hillside Hosp. 3: 16h-19o, 1953. l95u Standardization of the Face-Hand Test, Neurology, h: 211-217, l95h (with Dr. M. Green). 1955 Test in Patients with Mental Illness, J. Hillside Hosp. 3: 3-13, 1955 (with Drs. R.L. Kahn and E.A. Weinstein}. Delusional Reduplication of Parts of Body after Insulin Coma Therapy, J. Hillside Hosp. A: 13h-1h7, 1955 (with Drs. R.L. Kahn and D. Graubert). The Amytal 16. 195 O\ 17. 18. 19. Relation of Amobarbital Test to Clinical Improvement in Electroshock, Arch. Neurol. & Ps chiat. 16: 23—29, 1956 (with Drs. R.L. Kahn and E.A. Weinstein). Evaluation of High-Dose Reserpine Therapy for the Relief of Anxiety, J. Hillside Hos . g: 67-77 (April) 1956, (with Drs. M. Wachspress, 1.5. Blumberg and J.S.A. Miller). Relation of Changes in Memory and Learning to Improvement in Electroshock, Conf. Neurol. lé’ 88-96, 1956 (with Drs. H. 20. Korin and S. Kwalwasser). Denial of Blindness Following Cerebral Angiography, J. Hillside Hosp. 5: 238-2h5, 1956. �-321a. Quantitative Studies of Slow Wave Activity Following Electroshock, EEG. Clin. Neuro hysiol. 8: 158 (abst) web.) 1956 (with Dr. §.E. Kahn). Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 18: 516-525, 1957 (with Dr. 5.5. Kahn). 1957 22a. Clinical Response to Megimide, EEG. Clin. Neurophysiol. 2: 180, 1957 (with Dr. M. Green). Clinical and Electroencephalographic Effects of Megimide in Patients without Cerebral Disease, Neurology 8: 682-685, EEG and 1958, (with Dr. A Green). Unified Theory of the Action of Physiodynamic Therapies, J. Hillside 26. M. Hosp. é: 197-206, 1957. Perception of Embedded Figures After Induced Altered Brain Function, Amer. Psychol. lg: 361, 1957 (with Dr. R.L. Kahn). Social Factors in Selection of Therapy in a Voluntary Mental Hos . g: 216-228, 1957 (with Drs. Hospital, J. Hillside R.L. Kahn and M. Pollacﬁ}. Role of Stimulus Intensity in Perception of Simultaneous Cutaneous Electrical Stimuli, J. Hillside Hosp. é: 2h1-250, 1957 (with Dr. H. Korin). 1958 27. Changes atholo grune & 28. 29a. in Language During Electroshock Therapy, in Psycho- of Communication, Ed. Hoch, P. and Zubin, gtratton, 1958, {with Dr. R.L. Kahn). J., Lateral Gaze Nystagmus as an Index of the Sedation Threshold, EEG. Clin. Neurophysiol. 12: 162-163, 1958. Effect of Diethazine on EEG and Significance for Theory of EEG. Clin. Neurophysiol. 19: 207-208, Therapy, Coggulsive 19 . Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 82: 380-387, 1958. �-uidem, Biol. Psvchiatr THE-195. 29c. New 30. 31. ‘ 32. 33a. b. Bha. b. YorE, ed. Masserman, , J., Grune & Stratton, Experimental Studies of the Electroshock Process, Dis. Nerv. Sys.. 12: 113-118, 1958, (with Drs. Kahn and Green}. Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis, J. Amer. Med. Assoc. 166: 18h6-1850,1958 (with Drs. R. Shaw, G. Gross, and E.§. Coleman). Electroencephalographic Correlates of the Electroshock M. 1958 Green). Dr. Nerv. (with Dis. 227, Bye. l2: Process, Experimental Studies of Convulsive and Drug Therapies in Theoretical Implications, A.M.A. Arch. Neurol. Psychiatry: & 1958 (ﬁEtE‘ﬁ?§T'§TE?'EEEE‘ 80: 733-73h (abst.), PSﬁchiat. an . . reEK). Alteration of Brain Function in Therapy, in Ps & N. Brown Co., Ed., Frontiers, Kline, Little, cho harmacolo y BosEon, 1958, Pp. 325‘3320 Effect of Anticholinergic Compounds on Post-Convulsive EEG Behavior, EEG. Clin. Neurophysiol. lg: 776 (abst.). Effect of Anticholinergic Compounds on Post-Convulsive EEG and Behavior of Psychiatric Patients, EEG. Clin. Neurophysiol. 13: 359-369, 1960. and 1959 35. 36. 37a. b. Effects of Diffuse Altered Brain Function on Perception, in Proc. XV Int. Con . Psychol., North Holland Publ., Amsterdam, [959, PP. 238-259 (with ﬁrs. R.L. Kahn and H. Kojéﬁ)..lk~u-Al Diff rences in Psychological Factors Affecting Individual Jwﬁfgvﬁt Behavioral Response to Convulsive Therapy, 2h3-2h8, 1959 (with Drs. R.L. Kahn and M. Po ac 128: Significance of EEG Pattern Changes in Psychopharmacology, EEG. Clin. Neurophysiol. 11: 398 (abst.) 1959. EEG and Behavioral Effects of Psychopharmacologic Agents, Neuro-Ps cho harmacolo y, ed. Bradley, P., Elsevier, REE-HES, T950. Amsterdam, 38ayr / Electroencephalographic and Behavioral Effects of Tofranil: Canad. Psych. Assoc. J. h: 1668-1713., 1959. v.9w. �-5; (abst.), 38b. Idem, EEG. Clin. Neurophysiol. 13: 2h3-hh 39. Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions, The First International Con ress of Neurolo ical Sciences (III: EEG, Clinical Neuro— and EEIIepsyi, Pergamon,‘fondon, 1959, pp. STE-519 physiology W a n and H. Korin). ran 1960. . a of Set in the Perception of Simultaneous Tactile Stimuli, Am. Jour. Psychol. 13: 38h-392, 1959 (with Dr. H. The Role Korin). Personality Factors in Behavioral Reaponse to Electroshock l: J. Neuropsychiatrz Therapy, Kahn . h5-h9, 1959 (with Dr. R.L. Wm: Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and Diagnosis, A.M.A. Arch. Gen. Ps chiat. """ _1_: 565-571., 1959 (with Drs. R.L. and M. Pol ac . 1960 h3. Efficacy of Divided and Single Dose Schedules in Insulin Therapy, Coma J. Am. P8 Drs. A.G. BlumEerg and hh. h5. h7. h8. 1960 (with Eaderman). in Verbal Transactions with Induced Altered Brain Function, JNMB-IBO: 235—239, 1960 (with Drs. J. Jaffe and R.L. Kahn).: S;uw.UUub‘Jua'but Drug Induced Changes in Intervi w Patterns: Linguistic and Neurophysiologic Indices, in ‘__Dynamics of Psychiatric Drug Therapy, ed. G.J. Sarwer-Foner, C.C. Thomas, Springfield Changes 9“ pp. h6. 116: 839-h0, chiat. %. ’ Jaffe 1960, (With Drs. Jo Social Attitude (California and R.L. Kahn). Scale) and Convulsive Therapy -JNMB 130: 187-192, 1960 (with Drs. R.L. Kahn and M. Pollack). 5.“,"wllua-Du‘ Figure-Ground Discrimination After Induced Altered Brain Function, A.M.A. Arch. Neurol. 3: 5h7~551, 1960 (with Drs. R.L. Kahn and M. PollacES. F Prognostic Value of Rorschach Criteria in Clinical Reaponse to Convulsive Thera 1960 2h2-2h5, J. Neuropsychiatrz y, l: Kahng. (with Dr. R.L. r .2” //£ .'V ' '.. / «n: Ln 1 I aré/a /->" -'- f, 4' _.” ‘. a“ ’34 45.114.” 7;” gay” n)/m / (j " 6.. ff) ,1"? ' "'4 K p (1 ‘ H y ,y /" m; «1" (rm *4 I 3 . , w V if“. r 51:3 ‘ /7w,« 5mm... x {5" ‘ ‘*' 4'" /‘ (a 3.1;,' A A.' g ”z " e, p/fivJ’J‘ “l ' W. “if 3 f/ a 3 (f ‘- , / ’5 K £9 / 3%» u �- 1961 h9. Modification of Psychotherapeutic Transactions by Altered Brain Function, Amer. J. Psychother. 1E: hé-SS ( with R.i. Kahn). Neuropsychologic Response Patterns of Some Psychotropic Drugs, Neuro-Psycho harmacology 3: 38l-38h, ed. E. Rothlin, Elsevier, Amsterdam (with M. Pollack, E. Karp, G. J. Jaffe, SO. H. Esecover and Krauthamer and D.F. Klein). 51. Problem of Antagonists to Psychotropic Drugs, 30-320 ibid, Inhalant-Induced Convulsions, A.M.A. Arch. Gen.Psychiat. h: 259-266, (with R.L. Kahn, E. Karp, M. Pollack, M.A. Green, B. Alan and H.J. Lefkowits). 53. Behavioral Patterns in Convulsive Therapy, A.M.A. Arch. Gen. Psychiat. E: 30-36, (with R.L. Kahn). Sh. Sociopsychological Characteristics of Patients Who 132: Refuse Convulsive Therapy, Jour. Nerv. Ment. Dis. —' """"“"“"""""""" M. 153-157, (with Pollack). SS. EEG Techniques in Study of Psychotropic Drugs, Acta of on Techniques for Study of Psychotro ic Int'l Meeting Drugs, Soc. Tipografica Modense, Modena, 1951. Withdrawal Symptoms Following Discontinuation of Imipramine Therapy, Amer. J. Psychiat. 118: 5h9-SSO (with J.C. Kramer and D.F. Klein}. 52. Experimental Psychiatric Research at Hillside: Review and Prospect, J. Hillside HOSEital 19: 159-169, 1961. Prediction of Individual Patient Response to Convulsive Therapy, VA Coo erative Chemothera y Studies in Psychiatry é: 317-325, 1951. Social Aspects of Psychiatric Treatment in Three HospiVA Coo erative Chemotals: Methodological Problems, 202-205, 1951 (with Studies in thera Psychiatry é: M. PoElack, N. Siegel and R.L. Kahn). Quantitative Electroencephalography and Human Psychopharmacology: Frequency Spectra and Drug Action, Medicina Experimentalis i: 36h-369, 1961. '7 -.\,A.-r-w, . -ﬁm... , _. ,, .1 . um.» . .4 m A~ a ‘R .1.” �1961 c" h9. Modification of Psychotherapeutic Transactions by Altered Brain Function, Amer. J. Psychother. 15: h6- SS ( with J. Jaffe, H. Esecover and R. f. Kahn).“ Neuropsychologic Response Patterns of Some Psychotropic Drugs, Neuro-Psycho harmacology 2: 381- 38h, ed. E. Rothlin, Amsterdam (with M. Pollack, E. Karp, Elsevier, G. Krauthamer and D. F. Klein). Problem of Antagonists to Psychotropic Drugs, 30'320 ibid, Inhalant- Induced Convulsions, A. M. A. Arch. Gen.Psychiat. h: 259- 266, (with R. L. Kahn, E. Karp, M. Pollack, M. A. Green, B. Alan and H. J. Lefkowits). 53. Behavioral Patterns in Convulsive Therapy, A.M.A. Arch. Gen. Psychiat. E: 30-36, (with R.L. Kahn). 5h. Sociopsychological Characteristics of Patients Who Refuse Convulsive Therapy, Jour. Nerv. Ment. Dis. 132: 153-157, (with M. Pollack). 55. 56. Techniques in Study of Psychotropic Drugs, Acta of Int’l Meeting on Techniques for Study of Psychotro ic Drugs, Soc. Tipografica Modense, Modena, 1951. Withdrawal Symptoms Following Discontinuation of Imipramine Therapy, Amer. . Psychiat. 118: Sh9—SSO (with JKlein}. EEG J. C. Kramer and D. F. CriticalEEGFlicker Frequency and EEG Alpha: A Reliability Clin. Neuro hysiol. (with E. Karp and Study, M. Pollack}. ‘ Neurophysiologic-Adaptive View of Convulsive Therapy, J. Neuropsychiat: Disordered Perception of Simultaneous Stimulation of Face and Hand: A Review and Theory, Biological PsychiaM. IV: (with Pollack). try, Factors Associated with the Selection of Applicants for Out- Patient Psychiatric Treatment, Social Issues. (with The N. Siegel and R. L. Kahn). �1962 I..— 61. 62. Critical rlicker Frequency and Alpha: EEG Olin. lenroghzeio1., __c Study, EEG and x. Pollack). A Reliability 1962 E. Karp (with , of Action of Convaleive Therapy: The Neurophysioe logic-Adaptive View, J. Neurogezchiats, ;; 231-233, 1962. The node Disordered Perception of Simultaneous Stimulation of Pace and Hand: A Review and Theory, Biolo icel Pe chiatr , IV Ede Jo 6h. Hortil, Ch‘pe 31, (With He P011.Ck)e Tachietoeoopic Perception After Induced Altered Brain Function: Influence of Hental Set, J.l.H.D., : , 1962, (with 1!. Pollack, 11.1.. Kahn and E. Kerp). Psychiatric Reaction Petterne to Inipraline (Torranil), 1962 D.F. Au. Jour. Pezchiat., __: (with Klein). , 66. Behavioral Reaction Patterns with Phenothiasinee, A.M.A. 1962 D.F. Arch. Gen. Pczphiat., __: (with Klein). , Quantitative Electroencephalography and Hanan Peychopharaacology. II: Drug Patterns, in EEG Correlate of Behavior, ed. 6. Glaser. 68. Iniprenine an an Adjunct to Phenothianine Therapy, Cong. Pezchiatrz, __c , 1962 (with J.c. Kramer end D.F. Klein). �69. Motivation in Psychotherapy, (with 70. H. Co . Po ohintr , z , 1962 Siogol). Rating Sooloo as Bohoviorol cpango Hoaauroo in Payohophorna1962 cology, v.1. Coon. Chonothor. St. in Pozchiat., 1: , (with DJ. Klein) . ��1. 195“ ~- 1 ‘ .3)... Standardlzatlm of the Faee=~Hand Test, 1H1 . 1. . . ~..‘-.~-:- 1- _. 1.1,..1 "9:“ .1: (mthM. _Neumlog:’21'1=12'17*,~ if} ‘ -.1955 ; 157° 1.'i That 1n Patlents w1th Mental Illness, J1 .axld . (With . R9 Ed A01m; 126111). Kahn Ly} of ‘Deltslmal Redupllcatlm of Parts Insuhn after «)1...’ R1 13911147 Kahn L1 D1 and (mth H0321“; i151 Coma Therapy, - . ' A I ' . - .3 . of ' Relatmn E17 1 ' 1 ~ . . f;-';tal ____ 19.1 mmlxla 201 . Denlal S1. _ = ' of Bhndness Pollowmg Cerebral Angh , cal .2231 1”” 'bo ‘ ’ Response ' ; to Meglmde, ﬁle ”j 1197:206 r 213-1 f; '1' ; 1. . 1... =1. ‘ 3. 1 1 1 ’ 3 , of Megumde in Patlents mthout (mth M1 Greenl1 »"."I_phalog'aph1c Effects Cerebral Insease, Neum'Ly 18;". 682-685, A Umfled Theory of the Aenm of PhysL; . 231 5.; ‘ 1957? - . «11 ‘ . 1 111111111311, .. J1 ,~ » 1 . . ; . 1 1 1. _ . Percep'aen of Enbedded ﬁgures After Induced Altered Iram hmctlon, Arlen -_Ps »12 361, (with R1 L1 Kahn)1 ‘“‘ﬁf_= _ . , 1 . E ' '1 2511 i 1 261: Soclal Factors 1n Selectman of - 3 17'.“- ‘3 " 3 , ‘ Quantltauve Studlee 80f Slow Wave Act1v1ty Follcmno Electroshock, 158 (Feb1) Absmct (with R1; L1 Kahn)1 . :,li .‘7 ' Evaluatlcm Of High-Dose Fez-35': Therapy for the Rehef of Annety, J1;;H:LlJ.81de_ M1. A1 G1.B (mth (Apml), Wadxspress, .1 3057515 57.77, 'Relatlcn of Changes 1n Learnmg to Improvement in Electroshodt, and ("3.11.12 'arld '85:." K' waSSer) (mm Hﬁ 88"96 '18” - 5? ~1 Test to Chnlcal Improvement 1n Bleetmshock,‘ Arch New?“ Psichlat1; Chmagoﬂﬂe23-29, (w1th R1 L1 Kahn and E1 A1 Welnsteln) 1 . 1955 ' .” ‘ lay an . a Voluntary kntal Hospltal, J 1 H11151de:. "i 3 �, _ j, . ,R-Pwmmgw;wwﬁssuu 955.3,umnm'», a. . . ,_ . hock ' fef'lheor‘y sP: Con " '- 4 ,l 5x2 Therapy, Po Koch and Jo Zubin (Edltors), {Gr-me s‘ Stmtton, New. .p 125-139, '1; wt, methazme, on EEG and Behavmr- SIgmfIcance unease . , g3; 380-387 . Q Q . ‘ :1:- . . ,s \‘..:- '- 1‘s u.“ I, ILJMMJI-L‘LL . ,' ' a . . : u QL‘_=A-uzca-m‘:& :‘ﬁ'u was '.Q“ ‘ ,.Q.- .ijhV‘. 19 227 ' , . ‘ (w1‘th ’Ms I ‘n)s, .“v Q Bwemnental Studles 'o‘f Oonvuls1ve and Drug Theraples In Psyclua} 'Inphcanons, Arch Neurol“ Psychlato, meaty, 80 733-734Abstract, (mth Alterauon 1:, of Emu Functlon in Therapy, Em s C00, mule, :uezs Effect of ArrtIcholmec No pp‘325-332 1959., and BehaVIor of 19600 359=339. "101ﬁ12 as an Post-Oonvu131ve Psyehla' a'ilfie Panents , Electr-éeneeﬂ f: ,. L EEG 1959 I ‘ ' 35-0) I as "Effects In Proc. ‘XV Into Kalm Ro and 238-239 Austerdam), L; Holland, pp Amt}: en Percepuon, 1:0 BehaVIoral Response IndIVIdual DIfferenees In Rio Psyduologleal Factors Affectmg Ls Ka‘r-m and 'Convulswe Therapy, J]° new mento msquzsjzuaszua (szth Mo was of mffuse Altered Bram thctlm Pode) 9 , I. \ SIgnIeranoe of EBG Pattern Changes In Psychhanralogy, Neum 111.551010» 11k. 398 Abs ' . H ' 1: ��1951 (tmued) ' M031”Kahn)e 1 is Who Refuse Cmvulswe Therapy, Somyeheloglcal maractemstlcs of Patlents M, Pollackh J3, mm n‘ento (mth 153457 2132 Tea‘zmqmu 1:: Study of Psyebopm Draws, 3x3, £13.,”31103 EEC 360: _; 7" 1 ‘ 5;; ' ‘EJS'EID . : '- Masque ‘ * _, one Pollemng mcontlnuauan C46 51‘9‘9550 (With - 159631:sta . insauz, E . Ele ' 60;; E Jo - ..-. _ ,. . :é'. « ,1 I ’* « :1 E? 1629; i. /63 1 Eggs ijhActlm elol wlswe of _N_:;3:3c::ruat13 23133233 The Mode (21": gist}; ‘ .j.-_. 650 - ilj. 1%.th 31,-- Mp 362-36 J o , : . 1 . _ ;~' , A 1:29 Fa Klemh " ' The NemphysmloglesAdaptlve View, . of Face and Hand: A ;{~i‘;:"_‘"fw5at':0n‘ " 7'" : “22"430, (Wlth Mo Renew " Press, Inc;..,_ (Elenmn "(-2 . 0n: Pellack, 3 rehens Inﬂuence Of Ra Lo Kat-1n ~3PM1;]th4!a“.179-173 (szth 1 1"*0. Reactim Pattems 1:0. Im:.jjf;":;i‘:: 2132:4138, (mth ‘ Rehablllty Study, Electroence’ho M‘. Pollack). and Karp 'Z‘iiMy: -i; _‘ _ 3'4“ 3...»... i: '7 -5' . ’ , 1 . 2 :Tadustoscoplc Perception After Induced Altered Brain Mental Set, :Lonerve '65:) KIM)9 "‘ ' Alter-o ' 80u63 (nth E0 and Theory} «Jo-worn" 3 ~ 3111- 'Dlsordered Perceptmn Of 51ml1‘1_‘{-Ifi; E61!» ' F0 sane-3690 "anneal Fucker Frequency and EG Alpha New York)Chapta E Impnamme Therapy, and 13-0 -» : - 1962 . 2* dMe- «maﬁa -Quant1tauve Spectra and Drug Acum, Mada . g 61 off. _, Expemnental Psychlatmc Research at Hlllslde Renew and Prospect, Ja Hlllszlde _ Ej’V j:.at £118 ‘ r ;-;- +2 {j - ’“V Nu and Slegel)‘, ��Publications - 1963 and Human Psychopharmacology, (Abstracts, 1961 Meeting, Mbntreal), Electroenceph. clin. Neurophysiol. lg; 133-137. 7/~ EEG 72. Multiple Item Factors as Change Measures in Psychopharmacology, Psychopharnacologia M: #3-52, (with D. E. Klein). 13‘ Quantitative Electroencephalography in Human Psychopharmacology II: Drug Patterns, In: G. Glaser (Editor) EEG Correlates of Behavior, (Basic Books, New York), pp l77~197. 74; Comparative Studies of Chlorpromazine and Imiprandne, I: Drug Discriminating Patterns, In: P. B. Bradley (Editor), NeuroPs chopharnacolo , Vol. III, (Elsevier Publ. Co.), (With KL—Pollack'rD-r—EizKlein, A. G. Blumberg, I. Belmont, E. Karp, (In Press) J. C. Kramer and A. Willner). Vii Comparative Studies of Chlorpromazine and Imipramine, II: Psychological Perfornance Profiles, In: P. B. Bradley (Editor), Neuropsychopharmacology, Vol. III, (Elsevier Publ. Co.), (with M. Pollack, E. Karp, I. Belmont, and A. Willner). (In Press) wia’ and Human Psychopharmacology, III: Changes on Acute and ChronicnAdministration of Chlorpromazine, Imipagmine and Placebo (Saline), :W. P. Wilson and G. A. Ulett (Editors), Applications Quantitative 76. SS (In Electroence ofHEEG‘andWHumaﬁ"Psychopharmacology, h. Bibliography clin. Neurophysiol., Supplement 23, (in preparation), (With L. 77, * “ﬁg. 7" .. EEG w» Bouthilet E. Cromwell, and M. Brown). and Im1pram1ne of Chlorpromaz1ne on Perceptual Analytic Effects Ability, Perceptual Responsivity and Memory as Revealed in Rorschach Responses, J. nerv. ment. Dis., (with I. Belmont, M. Pollack and A. Willner). (In Press) �Nm~£xpcrim1ts1 B. ‘9. 1. BookRevimdeattm 23m" use, 33 W W3 Diffcmtial Trcctmnt and R. D. Win: and w. Simon, 1:. c. sispringficld. Illinois); 1959." 121-122. in Schizoplmmic. m. Revicwqé' Amh. Experimental Studies of the Mode of Action of Electroccnvulsivs Therapy Jun-Otto. Ottosoon (Editor) . get; pm KIWI c ("ET—MW, {swam Scam. 6'39 PM The i A Symbol Wo_ ” V“ .. 3"me m 1 clin. .3. Will J. Hillside (Bateugf’: “' R. 001m 1956. 111.7. Home 8101. 1952, Psychiatry H. Bruin (Editor), Pittsbm‘gh‘ﬁ 1961. ENG. 11093., 1962, 31;: Review“? .. W Doomtraliutim of Psychiatric Services and Ccntinuity Milbcnk of Md, 1961, CmL3thliM Pictorial Fund, Na York. 1982. Ravi“. ”of mm of. mm: cad m._ War, 1963, 3.: Jm» Intmticncl Dicticnm ' ’ in Clinical Medicine, harm KUniv. Pittsb‘n‘gh Press, on 0 (Esmgfyﬂwkgaﬁi 1361. E: :52. MMMHMNWNL '15.!) Psychic Graphs-M. of Pour “yﬂxginsgiﬁwﬂmiﬂﬁ V 78-79. ”W, Us 1;)“, C. C. Homology and WWW, cog, . a“ Wit: for Electra; Indicgtdgrs QumtiStctua cmvulc wk 'Ihcmpy. latter to the tar. {an};m. of ﬁg. 23: 292-293. P " mm Mt m, Emmi/1953. in of Inubmctim to Physical chiam,"w: Scrgcnt and E. Slctcr ”"W, An» 4 ' a; 1983*; and Wilkins new, 1mm“ (In mas) Review-dahntcl Mitch. ' , Cap 42.: ! ”1/ @3234 � 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 [Hillside] Hospital annual report (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-008 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1960 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 Experimental Psychiatric Programs at Hillside Hospital - A Review (several). 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 http://exhibits.library.stonybrook.edu/mfp/files/original/2f72d717289d05cb684207e823cb7f30.pdf 566433f2c3abf4221015fe305a951903 PDF Text Text Psychopharmacology erVicc Center ulletin N IMH-Sponsored Collaborative Study of Phenothiazine Treatment of Acute Schizophrenic Psychoses, p. 1 January 1961 NIMH Grant Support for Early Clinical Drug Evaluation Units, p. 3 NIMH—PSC Outpatient Study of Drug-Set Interaction, p. 4 Research Conference on Drugs and Community Care, p. 7 Conference on Information Needs of Psychopharmacologists, p. 13 The Psychopharmacology Research Unit at the Downstate Medical Center, Brooklyn, N.Y., p. 15 Experimental Psychiatric Programs at Hillside Hospital, ' p. 18 Coca-Leaf Chewing in the Andes, p. 22 Publications, p. 25 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE - Public Health Service �Inquiries about the Psychopharmacology Service Center’s program are invited. Please write to: Dr. Jonathan 0. Cole Chief, Psychopharmacology Service Center National Institute of Mental Health Bethesda 14, Md. Correspondence regarding the Psychopharmacology Service Center Bulletin should be sent to: Dr. Lorraine Bouthilet Head, Scientiﬁc Information Unit Psychopharmacology Service Center National Institute of Mental Health Bethesda 14-, Md. The Psychopharmacology Service Center Bulletin is distributed at irregular intervals by the Psychopharmacology Service Center, National Institute of Mental Health, Bethesda l4, Md. It is issued for information purposes to investigators interested in psychopharmacology. It is requested that the Bulletin not be considered part of the scientiﬁc literature, and not be cited, abstracted, or reprinted. �NIMH-Spemered Collaborative Study of P/eemtbz'drz'ne Treatment of Acute Se/ez'gopbrem'e Pylcboyef The National Institute of Mental Health, through its Psychopharmacology Service Center, is sponsoring a collaborative study of phenothiazine treatment of acute schizophrenic psychoses. The comparative efﬁcacy of thioridazine (Mellaril) , fluphenazine (Permitil, Prolixin), and chlorpromazine (Thorazine) in the treatment of a large group of hospitalized acute schizophrenic patients will be evaluated at nine psychiatric institutions. Investigators at the collaborating hospitals applied for, and have now received, N IMH research grants which will support their participation in the study, which is expected to begin in February 1961 and to continue for 2 years. The grants were awarded to the following investigators and institutions on the basis of their interest and research experience, the availability of patients, and the geographical location and type of hospital organization: Principal Investigators Edwin M. Davidson Melvin M. Kayce Institutions Boston State Hospital Dorchester, Mass. Richard Steinbach Bernard Levy Georgetown University and D.C. General Hospital, Washington, D.C. Robert R. Knowles Edgar A. Moles Kentucky State Hospital, Danville, Ky. Kathleen Smith Washington University and Malcolm Bliss Mental Health Center, St. Louis, Mo. James H. Ewing Harold H. Morris University of Pennsylvania and Mercy-Douglass Hospital, Philadelphia, Pa. Frederic F. Flach Charles I. Celian Cornell University and Payne Whitney Clinic, New York, N.Y. Guy M. Walters Christopher F. Terrence Rochester State Hospital, Rochester, N.Y. Springﬁeld State Hospital, SykesVille, Md. George A. Ulett Martin Gross Irene L. Hitchman John Donnelly Francis J. Braceland Bernard C. Glueck, Jr. The Institute of Living, Hartford, Conn. The study is under the overall supervision of Jonathan O. Cole, Chief of the Psychopharmacology Service Center. Gerald L. Klerrnan, PSC Research Psychiatrist, *Prepared by Gerald L. Klerman, Research Psychiatrist, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda l4, Md. will serve as project coordinator. Other members of the PSC staff who are involved in the study are Eva Y. Deykin, Research Social Worker, Martin M. Katz, Research Psychologist, and C. Jelleﬂ' Carr, Chief of PSC’s Pharmacology Unit. The Planning Committee, composed of the principal investigators in the collaborating hospitals and the participating members of the PSC staff, provides for the coordination and execution of the speciﬁc projects. Because of the parallels with the Veterans Administration Cooperative Studies of Chemotherapy in Psychiatry, the committee maintains close liaison with the VA Central Neuro-Psychiatric Research Laboratory at Perry Point, Md. The Committee on Clinical Psychopharmacology, a group of outside consultants appointed by the NIMH, serves as the advisory and consultative body to NIMH on this project, as Well as on other aspects of the Center’s clinical program. Members of this committee are Henry Brill (Chairman), Deputy Commissioner of the New York Department of Mental Hygiene, Albany, N .Y. ; Sol L. Garﬁeld, Professor of Medical Psychology, Nebraska Psychiatric Institute, Omaha, Nebr. ; Goldine Gleser, Associate Professor of Psychology, Department of Psychiatry, University of Cincinnati, Cincinnati, Ohio; Leo E. Hollister, Chief, Medical Service, Veterans Administration Hospital, Palo Alto, Calif.; and George D. Ulett, Associate Professor, Department of Psychiatry, Washington University Medical School, St. Louis. Mo. DEVELOPMENT AND DESIGN OF THE STUDY The Committee on Clinical Psychopharmacology and the PSC staﬂ' designed this research project during the spring of 1960. Following general approval by the National Advisory Mental Health Council of the principles of the study, the Center staff discussed it with a number of clinical investigators who had previously expressed interest in such a project. In June 1960, representatives from more than a dozen institutions met to plan and clarify the research methods and aims of the study. A number of the investigators who attended the meeting subsequently submitted applications for an NIMH research grant to support their participation in the study. Thus the ﬁnal design and methodology of the study resulted from the combined efforts of the Committee on Clinical Psychopharmacology, members of the PSC staff, 1 �In psychiatry, cooperative research has been slower to and the principal investigators. The staff of the Biometric Laboratory of George Washington University, which operates under contract to the NIMH, will provide ongoing consultation on matters of research design and statistical techniques and will analyze the data from the study. The primary aim of the project is to evaluate the effects of two new phenothiazine derivatives, thioridazine (Mellaril) and ﬂuphenazine (Permitil, Prolixin) on schizophrenic symptoms and behavior by comparing them with the effects of chlorpromazine (Thorazine). Each of the 9 hospitals will study 40 patients (10 in each of the 4 treatment groups) . Newly admitted schizophrenic if the for selected will be 16 study 40 to aged patients they present two or more of the following types of symptoms or behavior: Thinking and speech disturbances, catatonic motor behavior, paranoid ideation, hallucinations, delusional thinking, disturbed affect and emotion, and disturbances of social behavior and interpersonal relations. The patients will be on the prescribed research treatment regimen for 6 weeks. A double-blind procedure will be used throughout. Improvement during the hospitalization phase will be assessed by the Lorr Inpatient Multidimensional Psychiatric Scale, the Burdock Ward Behavior Rating Scale, the Clyde Mood Scale, and clinical judgments. In addition to the primary aim, evaluating the efﬁcacy of the drugs, the study will also allow for the followup of 2 least for of at cohort patients schizophrenic a large made will be assessments 6-month At intervals, years. of the patients’ discharge status, psychopathology, social performance and adjustment, and treatment program. Social workers will interview family members for their perceptions of the patients’ progress, home conditions, and attitudes toward treatment. COLLABORATIVE AND COOPERATIVE RESEARCH Since World War II, collaborative and cooperative research, in which a number of institutions follow a common research design, has been successful in many areas of medicine. The trials of antimalarial drugs during World War II, the extensive studies of antituberculous drugs now in their 17th year, and the British-United States research on cortisone and aspirin in acute rheumatic fever are some examples. NIH experience with cooperative research includes the current extensive cancer chemotherapy program of the National Cancer Institute and the Collaborative Study of Cerebral Palsy, Mental Retardation, and Other Neurological and Sensory Disorders of Infancy and Childhood being conducted by the National Institute of Neurological Diseases and Blindness. 2 _ in of studies extensive penicillin the although develop, CNS syphilis during the 1940’s stands out as a notable AdministraVeterans the effort. In recent early years tion has developed its Cooperative Studies of Chemodemonhave studies VA now The in Psychiatry. therapy strated the value of cooperative studies as a means of clarifying important issues in psychopharmacology. From the scientiﬁc point of view, there are two major reasons for collaborative studies of psychiatric drug therapy. First, such studies allow one to increase the generalizability of ﬁndings. If the only question being asked is whether drug X is better than placebo, then the 40 of 20 with to obtained be often pagroups answer can tients. However, much larger groups of patients are discriminareﬁned make wishes to if (a) one necessary tions between compounds which are closely related chemically and pharmacologically, such as the phenothiazines; (b) to increase knowledge of predictors of drug response; whom for of a the patients deﬁne speciﬁc types to (c) or particular drug is best suited. Multihospital studies allow for comparisons among institutions. In the mental health ﬁeld there has been much discussion of the possible differences in the effectiveness of drugs given in varying hospital and clinical settings. A multihospital study provides both the number of hospitals and the number of patients needed to clarify these complex drug-environment interactions. The pros and cons of conducting large-scale, multihospital cooperative studies of psychopharmacological its and NIMH by been have weighed carefully agents advisory groups during the 4 years of the Institute’s proPSC. the administered by in psychopharmacology, gram The NIMH ﬁrst developed a wide program of basic and clinical studies in psychopharmacology, and has until now centered its major efforts upon the stimulation and support of individual research projects. While this program has resulted in a great deal of clinical drug research, it has not met the need for large-scale evaluation of widely prescribed psychiatric drugs. The several Cooperative Studies of Chemotherapy in Psychiatry which have been developed by the Veterans Administration in recent years have provided a great deal of useful information about some of the newer psychiatric drugs. The generalizability of these ﬁndings has, however, been limited by the special characteristics of the clinical material available to the Veterans Administration. The NIMH Collaborative Study of Phenothiazine Treatment of Acute Schizophrenic Psychoses has been designed to provide information on the effectiveness of new drugs in a population which will include female patients. The patients will, in general, be more acutely ill and will be treated in a wider range of hospital milieus than could be the case within the Veterans Administration. In addition, the study is designed speciﬁcally to explore possible interactions between hospital milieu and has than in systematic manner more a drug response �been possible in the earlier studies conducted by the Veterans Administration. The success of the Collaborative Study, a complex research endeavor, will depend upon close and continuing cooperation and collaboration between the research teams in the participating hospitals, the staff of the Psychopharmacology Service Center, and the advisory bodies of the National Institute of Mental Health. As this project develops, it is hoped that the participating groups will undertake a continuing series of investigations of the treatment of acute schizophrenic psychoses. NIMH Grant Support for Early Clinical Evaluation Unity Drag In November 1960, the National Institute of Mental Health announced the establishment of special grants for early clinical investigations of psychiatric drugs. The primary purpose of the grants is to broaden the present scope of early clinical trials of promising new compounds and to make it possible to screen more new drugs for effectiveness in the treatment of psychiatric disorders. The grants will be awarded to a limited number of carefully selected clinical units to support trials of promising compounds in patients to determine the safety, appropriate dose ranges, and side effects of the drugs, preliminary studies of their clinical effectiveness in the treatment of particular symptoms or syndromes, and small controlled comparisons of new drugs with known standard drugs or placebo. Because of the need for ﬂexibility in tailoring a clinical research design to ﬁt the types of drugs and types of patients under study, an attempt will be made to achieve an adequate balance between careful observational studies and small-scale comparative and controlled studies. This particular area was chosen for expansion because NIMH considered it to be more seriously in need of further support than either of the other two major stages of new drug development; i.e., (a) preliminary screening of new drugs in animals to determine safety and pharmacological activity, which is being adequately supported by the drug industry and by National Institutes of Health grants for basic research, and (b) deﬁnitive clinical drug research (controlled clinical trials and hypothesis-oriented clinical investigations), which is amply provided for by the existing NIMH research grant program in psychopharmacology. Expansion of support for early clinical drug evaluation was therefore recommended by the Advisory Committee on Psychopharmacology and by the National Advisory Mental Health Council, and the Congress subsequently provided funds for the establishment of special grants in this area. The program will be administered by the Psychopharmacology Service Center. �NIMH-PSC Outpatient Study The National Institute of Mental Health has recently awarded research grants to Karl Rickels, of the University of Pennsylvania, Philadelphia, Pa., and E. H. Uhlenhuth, of the Johns Hopkins University, Baltimore, Md., to support their participation in a special research project initiated by the Psychopharmacology Service Center. The study is a double-blind, placebo-controlled investigation of the effects of an active psychopharmacological agent (meprobamate) and physicians’ attitudes on a carefully deﬁned sample of neurotic outpatients. It is one of the ﬁrst known attempts to control experimentally the communication of differential attitudes by physicians when administering medication. The project is to be conducted at three clinics simultaneously, the Henry Phipps Psychiatric Clinic of the Johns Hopkins University, the Functional Clinic of the Hospital of the University of Pennsylvania, and the Neuropsychiatric Clinic of the Philadelphia General Hospital. The study was designed by the staff of PSC’s Special Studies Unit in collaboration with the two principal investigators, Drs. Rickels and Uhlenhuth, and was approved by the Committee on Clinical Psychopharmacology and the Advisory Committee on Psychopharmacology, both of which are appointed groups of consultants who serve the National Institute of Mental Health in an advisory capacity. The two principal investigators subsequently applied for and received, on recommendation of the National Advisory Mental Health Council, research grants to carry out the study. Coordination of the project will be handled by the Center’s Special Studies Unit, whose members are Seymour Fisher, Seymour H. Baron, Mitchell B. Balter, and Elizabeth Hackett. Under contract with the National Institute of Mental Health, the Biometric Laboratory of George Washington University, Washington, D.C., will assist in the analysis of the data. RESEARCH DESIGN AND METHODS The Outpatient Study of Drug-Set Interaction is part of a larger special program which is concerned with the effects of psychological set and social interaction upon drug response in both patients and normal subjects. The study has three main purposes: *Prepared by Seymour Fisher, Chief, Special Studies Unit, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda 14, Md. 4 of Drug-Set Interaction“ To determine whether meprobamate, administered for a 6-week period at a ﬁxed dosage, is more effective than an inert placebo in the treatment of neurotic outpatients. (See Laties and Weiss, 1958.) 2. To determine whether patients’ expectations or set (as induced by contrasting behavioral roles by the doctors participating in the project) have a signiﬁcant effect upon treatment course. Set will be varied by training one group of doctors (the “T” group) to maintain a positive, consistent, enthusiastic, “therapeutic” approach to their patients; another group (the “E” group) will be trained to manifest a more aloof, uncertain, “experimental” approach in relating to their patients. The “T” therapists will attempt to convey the belief that they are treating the patient with a known, efﬁcacious agent; the “E” therapists will attempt to convey the belief that they are evaluating the agent. 3. To determine whether a signiﬁcant drug-set interaction exists; i.e., to test the hypothesis that a “T” set will potentiate response to the active drug. Following a pilot study of 24- patients, a total of 200 patients will be treated for a 6-week period, 50 patients being assigned to each of the following 4 treatments: Meprobamate combined with “therapeutic” set; mepro— bamate combined with “experimental” set; placebo combined with “therapeutic” set; and placebo combined with “experimental” set. The basic research design is in the form of a 2 x 2 factorial analysis, with each of the two independent variables being varied in two ways. Table 1 shows the four-cell design, which permits an exact statistical test (by analysis of covariance) of the three 1. hypotheses. Patients will be seen biweekly for 6 weeks. In order to rule out the effects of the personality characteristics of the doctors in the study, a total of 12 physicians will participate, 4 psychiatric residents at each of the 3 clinics. Thus, interclinic‘ comparisons will be possible. An attempt will also be made to validate the role behaviors in the doctors. TABLE 1.—-Researc}z Design Medication (N=200 patients) Set Meprobamate ......... ........ “Therapeutic” “Experimental” 50 patients 50 patients ....... ....... Placebo 50 patients. 50 patients. �The dependent variables are ratings—patients’ selfratings as well as doctors’ ratings—on a symptom-distress checklist, on the Clyde Mood Scale, and of overall change. Dropout rate will also be considered. BACKGROUND OF THE STUDY The impetus for this study stems from the Psychopharmacology Service Center’s interest in various methodological problems involved in the clinical evaluation of psychiatric drugs, in particular the problem of attitudinal variables and their effect upon drug response. The basic thinking underlying this approach was presented in a draft paper prepared some months ago (Fisher, 1960). That paper also pointed out the kinds of speciﬁc research designs which would test for any unique interactive effects between medication and set (i.e., attitudes and expectations) . A review of the literature has revealed much clinical suspicion that patients’ expectations may interact with medication to produce differential clinical effects, but supporting evidence for such speculations is rather tenuous. Sabshin and Ramot (1956) note that: “Often the patient may interpret a change in his internal milieu in the context of being a change in the expected direction. It is thus possible for a subtle type of communication to take place . . . and this may potentiate the drug effects. Hence a relatively speciﬁc effect can be geometrically increased.” However, the investigators do not present empirical evidence. That a particular drug can have one effect under one psychological condition and a quite different effect under another psychological condition is well documented experimentally. This holds for animals (e.g., Brown, 1958; Chance, 1946; Gunn and Gurd, 1940) and for humans. In an elegantly designed experiment, Hill, Belleville, and Wikler (1957) clearly demonstrated a signiﬁcant interaction between incentive conditions and drug response in human subjects. Nowlis and Nowlis (1956) and Starkweather (1959), in studies of normals, report complex interactions between drug response and the subject’s perception of other subjects’ behavior. In the clinical setting, Feldman’s paper (1956) indicated that the physician’s attitude toward medication is reﬂected in his report of degree of improvement in psychiatric patients. However, that is not conclusive evidence for an interaction effect, since placebos were not employed for comparison, and evaluation of the patients was badly contaminated by the fact that each of the participating physicians made his own overall estimate of change The latter comment also applies to a clinical study reported by Kast and Loesch (1959), who similarly argue that the action of a psychopharrnacological agent can be made disproportionately more effective than an inactive placebo when the medication is administered within the context of a positive set (i.e., a given set can potentiate drug response). While their theoretical formulation is quite ingenious and heuristic, their experimental design does not afford a valid test of their hypothesis. A more dramatic study concerned with potentiation was published by Uhlenhuth et al. (1959). In a doubleblind, cross-over design using meprobamate, phenobarbital, and placebo, two physicians obtained signiﬁcantly different rates of drug-related improvement in their patients. One physician (who was “therapeutic” and enthusiastic) obtained signiﬁcant differences between the active drugs and placebo, while the other physician (who was more skeptical and “experimental”) found no signiﬁcant differences among the three agents. The results of this study are certainly suggestive, but they are difﬁcult to interpret since one cannot state deﬁnitively what the effective differentiating characteristic(s) between the two physicians was (i.e., in addition to “attitude,” they obviously differed in an inﬁnite number of ways), and because of the complication introduced by using a three-way cross-over of drugs. In March 1960, Irvin S. Wolf, of Denison University, and PSC’s Special Studies Unit tested the interaction‘ hypothesis on normal subjects who were given dextroamphetamine and placebo under three different attitudinal sets (consistent, uncertain, and inconsistent expectations). Analysis of covariance for a 3 x 2 factorial design on subjective and psychomotor dependent variables revealed a number of signiﬁcant or near-signiﬁcant trends (all in the anticipated direction) suggesting a drug-set interaction. The signiﬁcance of this research approach is perhaps revealed in the following considerations. When reference is made to a “place-b0 response,” it is evident that the concept is a complex one. In a placebo-controlled experiment, not only is there a general set of expectations associated with the symbolic value of receiving medication from a prestige authority, but there are also undoubtedly speciﬁc expectations about the nature, purpose, and action of the medication. These different kinds of expectations have been discussed elsewhere (Fisher, 1960), but one important implication is worth repeating here. The most frequently used model in controlled evaluations of drugs assumes that the “placebo response” (i.e., the amount of change attributed to nonpharmacological factors) is a type of “error” involved in assessing the pharmacological effects of the active drug: If one can accurately measure the degree of placebo response, that effect can be subtracted from the total effect, thus giving the pharmacological component. This assumes that the psychological (i.e., general and speciﬁc expectations) and the pharmacological components are additive in nature. As shown in ﬁgure 1, speciﬁc expectations 5 �CLINICAL IMPROVEMENT SET A FIGURE 1. SET B Hypothetical Data Illustrating Additive Model. (sets A and B) do affect the response, but essentially equally for subjects who receive the active drug and for those who receive placebo. Irrespective of the set under which the drug is evaluated, the conclusion is the same—— the drug is X units more effective than placebo. CLINICAL IMPROVEMENT PLACEBO\ SET A FIGURE 2. \\\ O SET B Hypothetical Data Illustrating Interactive Model. A quite different possible model, however, can be built on the‘ assumption that the pharmacological and psychological components are interactive. As shown in ﬁgure 2, the speciﬁc expectations in set A potentiate the drug response, and one cannot generalize the effect of the drug without taking into account the set under which it was administered. Note in ﬁgure 2 that if the drug were evaluated in an experiment in which only set B was operative, one would conclude that the drug was no more effective than placebo—a conclusion which, though 6 correct, would have to be limited to the conditions of the experiment. Figure 2 also shows, however, that under set A the drug was obviously superior to the placebo— an equally correct conclusion for the given conditions. Thus, if it were established that the interactive model is more appropriate for certain kinds of clinical evaluation, one would run the risk of rejecting as ineffective a treatment which really does have an effect (type II error) whenever the clinical trial is conducted under inappropriate conditions of set. A great deal has been written about the need for controls in clinical research. It has often been noted that new forms of therapy are enthusiastically received on the basis of early uncontrolled clinical impressions, only to be laid to rest by subsequent controlled evaluation (Cornell Conference, 1954) . Recent papers by Foulds ( 1958) and Astin and Ross (1960) show that a signiﬁcantly greater number of uncontrolled studies in psychopharmacology yield positive results than do controlled experiments. Undoubtedly, this difference can be partly attributed to such factors as lack of controls, faulty or biased measurement, faulty design, etc., in the uncontrolled studies, or to insufﬁcient dosage or duration of medication, or sampling bias, in the controlled experiments. On the other hand, it is possible that this difference is not all due to various kinds of “error.” If some genuine interaction effect should exist between physicianmilieu and drug action, that would go a long way in accounting for many of the apparent discrepancies between the ﬁndings of hardheaded researchers and those of equally hardheaded clinicians. In uncontrolled clinical trials, the patients may be exposed to a quite different “attitudinal” atmosphere: They more often see themselves as being “treated” rather than “researched,” and that might provide a quite different setting for drug action. In many controlled experiments, the patients are deﬁnitely aware that they are participating in a research project (implying “Let’s see if the drugs will help you”), and such a perception is probably reinforced whenever patients ﬁnd themselves periodically being observed, tested, and probed. The overall aim of the Outpatient Study of Drug-Set Interaction is to attempt to create experimentally these two contrasting attitudinal sets within the context of a controlled clinical evaluation. REFERENCES Astin, A. W., and Ross, S. Glutamic acid and human intelligence. Psychological Bulletin, 1960, 57, 429—434. Brown, B. Inﬂuence of inter-animal and environmental stimulation on action of central nervous system drugs. Proceedings of the Western Pharmacological Society, San Francisco, January 27—28, 1958. Chance, M. R. A. Aggregation as a factor inﬂuencing the toxicity of sympathomimetic amines in mice. Journal of Pharmacology and Experimental Therapeutics, 1946, 87, 214—219. �Cornell Conference on Therapy. How to evaluate a new drug. American Journal of Medicine, 1954-, 17, 722—727. Feldman, P. E. The personal element in psychiatric research. American Journal of Psychiatry, 1956, 113, 52—54. Fisher, S. Milieu controls in psychopharmacology. Manuscript, 1960. Foulds, G. A. Clinical research in psychiatry. Journal of Mental Science, 1958, 104-, 259—265. Gunn, J. A., and Gurd, M. R. The action of some amines related to adrenaline. Cyclohexylalkylamines. Journal of Physiology, 1940, 97, 453—470. Hill, H. E., Belleville, R. E., and Wilder, A. Motivational determinants in modiﬁcation of behavior by morphine and pentobarbital. A.M.A. Archives of Neurology and Psychiatry, 1957, 77, 28—35. Kast, E. C., and Loesch, J. A contribution to the methodology of clinical appraisal of drug action. Psychosomatic Medicine, 1959, 21, 228—234. Laties, V. G., and Weiss, B. A critical review of the efﬁcacy of meprobamate (Miltown, Equanil) in the treatment of anxiety. Journal of Chronic Diseases, 1958, 7, 500—519. Nowlis, V., and Nowlis, Helen H. The description and analysis of mood. Annals of the New York Academy of Sciences, 1956, 65, 345—355. Sabshin, M., and Ramot, J. Pharrnacotherapeutic evaluation and the psychiatric setting. A.M.A. Archives of Neurology and Psychiatry, 1956, 75, 362—370. Uhlenhuth, E. H., Canter, A., Neustadt, J. 0., and Payson, H. E. The symptomatic relief of anxiety with meprobamate, phenobarbital and placebo. American Journal of Psychiatry, 1959, 115, 905-910. Research Conference on Drugs and Community Care“ In September, the Psychopharmacology Service Center sponsored a “Research Conference on Drugs and Community Care” to bring a number of investigators together to discuss problems of research on the use of drug therapy in the care of psychiatric patients living in the community. The conference, held in Washington, D.C., dealt with studies of both acute and chronic patients, evaluations of home-treatment or day-hospital care, maintenance therapy, treatment speciﬁcally designed to prevent relapse in previously hospitalized patients or to treat relapsed patients in the community, and followup studies. The primary objectives of the conference were (a) to permit investigators whose research in this area is supported by NIMH to discuss problems and to exchange ideas and experiences related to solutions to problems; (b) to provide the Center, its consultants, and the participating research investigators with an overview of the nature of the research now being supported; (c) to determine what has been learned from these studies about the role of drugs in the community care of psychotics; and (d) to assess progress in dealing with the technical aspects of these kinds of research; e.g., the establishment of criteria and the development of methods for classifying patients and for evaluating change and adjustment. In addition to NIMH grantees conducting research on drug therapy in the community, the participants included investigators whose interests and experience were compatible with the aims of the conference and several who are just entering research related to this general ﬁeld. The conference was organized by Martin M. Katz, PSC research psychologist. The formal participants *Prepared by Martin M. Katz, Research Psychologist, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda l4, Md. were Dean J. Clyde, Washington, D.C.; Jonathan 0. Cole, PSC; Joel J. Elkes, Bethesda, Md.; David M. Engelhardt, Brooklyn, N.Y.; Leon Epstein, Sacramento, Calif; Seymour Fisher, Houston, Tex.; Norbert F reedman, Brooklyn, N.Y.; Sol L. Garﬁeld, Omaha, Nebr.; Goldine Gleser, Cincinnati, Ohio; Bernard Glueck, Hartford, Conn.; Milton Greenblatt, Boston, Mass.; Martin Gross, Sykesville, Md.; Leo E. Hollister, Palo Alto, Calif. ; Martin M. Katz, PSC; Else B. Kris, New York, N .Y.; Jordan Lawrence, Sykesville, Md.; Mark Lefton, Columbus, Ohio; Samuel B. Lyerly, Washington, D.C.; David Mann, Brooklyn, N.Y.; Richard D. Morgan, Sacramento, Calif.; Benjamin Pasamanick, Columbus, Ohio; Leonard Pearlin, Bethesda, Md.; Seymour Perlin, New York, N.Y. ; George A. Ulett, St. Louis, Mo. ; and Joseph Zubin, New York, N.Y. The ﬁrst half of the program was devoted to reports on six research projects, each of which was related to some aspect of drugs and community care. The papers reporting the projects emphasized aims and general research design, methodological and operational problems, and plans for future work. The second half of the conference was devoted to theoretical and practical problems of methodology. In many cases, new methods and methodological problems mentioned brieﬂy in the research reports were presented in greater detail and discussed more fully during the second half of the meeting. Some of the points made in each paper are summarized in the following paragraphs. These summaries do not, of course, cover all of the points covered by the speakers, but it is hoped that they will provide at least enough information to convey some impression of the overall content of the meeting and of the major issues which were considered. �SIX RESEARCH PROJECTS Home Versus Hospital Care for Schizophrenics. Presented by Benjamin Pasamanick, Department of Psychiatry, Ohio State University Medical School, Columbus, Ohio. This study is designed to test the hypothesis that acute schizophrenic patients can be treated at home when proper public health care is combined with appropriate drug therapy. All ﬁrst-admission schizophrenic patients referred to the Columbus Psychiatric Institute are to be considered for the study. Those who are suicidal, homicidal, or so violently disturbed that it would be impossible to keep them in the home will be dropped from further consideration. The remaining patients will then be randomly assigned to one of the following three treatment groups: (a) A group treated at home with drugs plus frequent visits by a public health nurse; ( b) a group treated at home with placebo plus frequent visits by a public health nurse; and (c) a hospitalized group treated with the usual methods of the hospital. The three groups are to be evaluated before treatment, after 1 year, and after 2 years by psychiatric and psychological examinations, and by reports and ratings from nurses and social workers (including interview data from patients and their families). Quality of housing and general home environment of all three groups will also be rated. A public health nurse, working in consultation with the psychiatrist and social worker, will frequently visit each home-care patient to give nursing guidance and counsel to the patient and his family. Patients in the home-care groups will be hospitalized when that is recommended, on the basis of previously established criteria, by a diagnostic council from the Institute. The hospitalized group and the home-treatment groups are to be compared for total length of hospitalization, psychiatric condition, and family reaction and receptivity. The two home-care groups—one on placebo, one on drug—will be compared for rate of hospital admission. Discussion of this study was devoted to such matters as control of medication in the home-care groups, degree of comparability of the hospitalized and home-treatment groups, and problems related to hospitalization of patients assigned to home treatment. Later in the conference, Lefton, also from the Columbus Psychiatric Institute, presented a detailed discussion of the interview schedules which will be used in the study. A Study of Ataractics in Outpatient Schizophrenia. Presented by David M. Englehardt and Norbert Freedman, State University of New York, Downstate Medical Center, Brooklyn, NY. This project was described as a longitudinal study of the effects of tranquilizers on the community adaptation of schizophrenic outpatients. Questions of interest in the study are whether continuation of medication after an initial gain will prevent relapse, whether further improvement is noted when med8 ication is continued, and, when there has been no initial gain, whether improvement will occur after prolonged administration of drug. Changes in symptomatology and in social behavior associated with drug therapy will be assessed after a brief time and after sustained administration of drug. The following criteria of outpatient adaptation are being used: Maintenance of outpatient status (i.e., avoidance of hospitalization), reduction in psychopathology, freedom from functional decrement, reduction in social dysfunctioning, concordance between social adaptation and psychopathological changes, and stability of clinic course during a prolonged period (up to 24 months) of continuous treatment with drug or placebo. Baseline psychiatric and psychological data are obtained during the ﬁrst week. The patient is then placed on promazine, chlorpromazine, or placebo. Dosage levels are ﬂexible and medication is administered doubleblind. Supportive psychotherapy is given, but the emphasis is on medication. Patients are seen in the clinic at frequent intervals. Detailed re-evaluations are conducted after 3 months and at the end of 1 year. Preliminary ﬁndings reported by Engelhardt show that the rehospitalization rate is signiﬁcantly lower in the drug groups than in the placebo group. Also, the number of patients showing clinical improvement at 6 months is much higher in. the drug groups than in patients on placebo, as is the rate of improvement of a group of patients who demonstrate severe thought disturbance on initial evaluation. Further, the amount of social dysfunctioning as reported by the relative has been found to be greater in the placebo group than in the patients on chlorpromazine. A detailed report on the accumulation and analysis of the data on social behavior was presented later in the meeting by Mann and Freedman, participating investigators in the study. Freedman also discussed the problem of dropout, which has been one of the major difﬁculties thus far. Attempts to distinguish clear-cut differences in personality or psychopathological features in the patients who drop out have not been successful, though the speculation is that there may be a complex interaction between the patient’s expectation concerning treatment and what he actually experiences in the clinic. Discussion of this project centered around the speciﬁc kinds of information obtained from the patient’s relatives, the handling of such data, problems of following up patients who drop out of the study, possible reasons for dropping out, side effects (which have not been a problem), the ethics of using placebos, and the possible relation between degree of social dysfunction and level of drug dosage. Drug Therapy in a Daycare Facility for Relapse Control. Presented by Else B. Kris, Manhattan Aftercare Clinic, New York, NY. The aims of this project are to evaluate �day hospital care plus drug therapy as a means of controlling relapse and preventing rehospitalization of formerly hospitalized psychotics, primarily schizophrenics. Acutely disturbed (relapsed) patients who would ordinarily be rehospitalized are randomly assigned to one of two treatments: (a) Rehospitalization and usual hospital care, or (b) drug therapy in a special day hospital afﬁliated with the Research Unit of the Manhattan Aftercare Clinic. At the time of assignment to a treatment group, the psychotic condition of each patient is determined by use of the Wittenborn Psychiatric Rating Scales. Patients assigned to the day hospital are immediately started on intensive pharmacotherapy, with drug dosage individualized according to patients’ needs. Length of time between onset of relapse and subsequent remission in the two treatment groups, and community adaptation following remission, are being compared. After patients are released from either the hospital or the day hospital, the investigators will study the patients further to determine whether remission achieved in the day hospital is temporary or lasting. Community adaptation is being measured by a set of scales developed by Katz, who described them more fully later in the conference. Kris reported that the most remarkable ﬁnding thus far has been the rapid achievement of remission in the day hospital patients, who return to their jobs far sooner than patients who were rehospitalized. She also noted that treatment in the day hospital seems to promote better community adjustment and that patients seen in the day hospital seem to have learned that they can discuss recurrence of symptoms without fear of being rehospitalized. Questions about the details of handling patients at the day hospital were discussed, along with comments about the liaison betwen the day hospital and employment agencies or vocational rehabilitation centers, possibilities of using the center as a training facility for physicians and psychiatrists in private practice, criteria for admission to the study, and the stafﬁng and physical layout of the day hospital. Termination of Treatment With Ataractic Drugs. Presented by Martin Gross, Springﬁeld State Hospital, Sykcsville, Md. This project, begun in 1958, investigated the importance of continuing chronic psychotic patients on medication after their release from the hospital. All patients in the study were ﬁrst stabilized on one of six drugs and then randomly assigned to either (a) a control group which was continued on active medication, or (b) an experimental group which was gradually transferred from drug to placebo under double-blind conditions. Patients who relapsed were removed from the study and placed on medication if they had been receiving placebo or were rehospitalized. The criterion for relapse was the clinical judgment of the treating psychiatrist. A rating scale developed to permit objective determination of the ' psychiatric condition and social adjustment of the patients was described by Lawrence during the second half of the conference. During the preliminary phase of the study, and at intervals thereafter, patients were evaluated by psychological tests, and their families or the people with whom they were living were interviewed by the social workers. Frequency of relapse while on active medication was compared with that which occurred while patients were on placebo. Summarizing some of the ﬁndings from the study, Gross reported that relapse occurred signiﬁcantly more frequently during the withdrawal or placebo period, the relapse rate being approximately three times as high during the placebo period as during the period on medication. He also noted that three-fourths of the patients who relapsed while on placebo did not require rehospitalization but were able to regain stability after medication was resumed. Among the problems of methodology and design which Gross enumerated were the difficulties experienced in dealing with six different drugs rather than with a single drug. He noted also that the generalizability of the ﬁndings was limited in that patients in the project—— chronic psychotics who were free from alcoholism and organic brain damage and who were able to attend the clinic regularly—could not be considered representative of the general outpatient clinic population. In reply to a question, Gross stated that he felt the low incidence of dropout was due to the personal contact between the patients and the social worker and physician. Other points discussed were the difficulties of maintaining double-blind conditions and of objectively determining the point of relapse, procedures for determining whether the patients took their medication, and techniques for switching patients from drug to placebo. Drugs and Social Therapy in Chronic Schizophrenia. Presented by Milton Greenblatt, Massachusetts Mental Health Center, Boston, Mass. This study was initiated to determine (a) how much of drug effectiveness is due to the drug per se and how much to other causes, and (b) whether there are signiﬁcant social and environmental differences between hospitals which may account for the differences between drug effects in one setting and another. Sixty chronic schizophrenics were transferred from a State hospital to an intensive treatment center (the Massachusetts Mental Health Center), where 33 received drug in addition to other therapy and 27 were not given drug. Comparison groups were composed of 55 patients remaining at the State hospital, of whom 25 were assigned to drug treatment and 20 were not. In neither setting were the patients assigned to “research wards.” The criteria on which patients in the four groups were compared were clinical improvement and discharge rate. �Findings reported by Greenblatt showed only slight differences between the State hospital groups and the MMHC groups after 6 months. At 18 months, however, there were differences which suggested the possibility of a beneﬁcial carryover of milieu effects in patients who had originally been transferred to the MMHC. In commenting on discharge rate, Greenblatt indicated that the State hospital criteria for discharge are much more stringent than those of the MMHC. He also noted that discharge rate was affected by the availability of a family or a transitional facility to which the patients could be released. Among other special problems which he discussed were the difﬁculties of incorporating chronic schizophrenic patients into MMHC treatment routines without changing the environment of the Center, the reasons for having decided not to attempt double-blind administration of drugs, and the possible signiﬁcance of any effects of “transfer trauma” in patients moved from one setting to another. The Eﬂeet of Ataractie Drugs on Hospital Release Rates. Presented by Richard D. Morgan and Leon Epstein, California State Department of Mental Hygiene, Sacramento, Calif. This project is one aspect of a much broader study of population movement in the California State mental hospitals. Morgan’s paper was devoted to the overall study, and Epstein’s to the parts of it which are speciﬁcally concerned with drug therapy. Morgan ﬁrst brieﬂy explained the system of cohort followup analysis which is being used, noting that it is essentially the application of individual followup analysis techniques to a group of patients who have one or more characteristics in common—cg, age, year of admission, sex, diagnosis, etc. Having set July 1948 as the beginning point for the collection of data, the California State Department of Mental Hygiene is now systematically coding and punching onto IBM cards detailed information on all ﬁrst-admission patients in the State’s 11hospital system. The records are not restricted to the period of ﬁrst admission, but cover residence during subsequent readmissions in the same hospital or in a different one within the State system. A wealth of information is collected for each patient: Vital statistics, diagnosis and details of treatment, and data covering current hospital entry, previous hospitalizations, leaves, etc. Thus, a patient’s complete record of hospitalization can be examined in great detail at any point during the followup period, and cohorts can be constructed on the basis of any combination of a large number of descriptive characteristics. Morgan observed that this technique permits analysis of the frequency or the likelihood of occurrence of changes in status during any speciﬁed interval in the followup. The status of a given cohort of patients can be examined for any period of time. Data being collected in this study are proving valuable in studies of current administrative policies and investigations of the 10 effectiveness of new or expanded programs. This system is also valuable in providing retrospective control data which may be used in lieu of a control group in evaluations of speciﬁc programs. Following Morgan’s report, Epstein discussed a particular set of analyses of these data in which the aim is to evaluate the role of tranquilizing drugs in the recent decline in State mental hospital populations, a decline which has occurred in California as well as in other States. For the period from July 1, 1955, through December 31, 1957, additional information (i.e., additional to that routinely obtained for all patients) on details of drug therapy was recorded for each patient in the State system who had received treatment with drugs. Name of the drug, total amount of drug administered, number of days on drug, and the reason for stopping drug treatment were among the additional data recorded. By looking at signiﬁcant subgroups—for example, ﬁrst-admission male schizophrenics between the ages of 25 and 4-4—the investigators hope to be able to draw certain conclusions about shortened periods of hospitalization and their association with drug therapy. Data concerning drug usage during the period of the study are now being analyzed. Epstein stated that investigators participating in this study are “painfully aware” that the data involve a variety of physicians, drugs, settings, and timings of drug treatment in relation to admission, as well as a variety of discharge policies among the 11 different hospitals. Despite such problems, the data do provide some reﬂection of what may be associated with drugs as they are used in a total system. A number of the conference participants were particularly interested in certain speciﬁc applications of data being recorded in the California studies or of cohort analysis techniques generally. Others expressed concern about the use of release rates as a criterion in studies such as these, questioned the comparability of present-day schizophrenics with those of a few decades ago, or asked whether the current “decline” in certain hospital populations might not be in part a reﬂection of the decline in birth rate which occurred during the depression. RESEARCH METHODS The section of the conference which dealt speciﬁcally with methods was devoted to technical and theoretical problems which arise in carrying out research on drugs and community care. In accord with evidence that drugs in combination with other psychiatric treatments are contributing signiﬁcantly toward. maintaining formerly hospitalized patients in the community, investigations have been initiated which are aimed at specifying the nature of these treatments and their effects. For purposes of the conference, the question of speciﬁcity was seen as having two major parts. The ﬁrst was concerned with the problems of specifying the kinds of �patients who are helped by a given treatment, identifying the clinical, personal, and social characteristics of patients which are associated with response to treatment, and identifying the “types” of patients who are most likely to respond to a given treatment. In addition to the question of types of variables which merit study with regard to this problem, the technical problems which arise here, such as coding and the application of multivariate analysis procedures, were also considered in separate papers. The second part of the section on methods was concerned with the problems of specifying the effects of a given treatment, of measuring clinical change and the various aspects of adjustment. Several approaches to these problems were described. Population Speciﬁcation Three papers were concerned with the search for signiﬁcant variables in clinical history, sociological characteristics, or personality of the patients. Clinical history was discussed by Bernard Glueck, of the Institute of Living, Hartford, Conn. Although several clinical and social variables have demonstrated some general predictive value in studies of response to treatment, Glueck observed that the search for speciﬁc prognostic factors in these areas has not been very successful. He reviewed some of the clinical history variables which have been linked to response to insulin therapy, electroshock, and lobotomy, and commented to the scarcity of such information in relation to treatment with drugs. His major criticism was aimed at the continuing lack of a common language to describe psychiatric conditions. Following a description of Q-sort techniques which he and his associates are applying to this problem, Glueck suggested that Q-sort methods provide a means of standardizing language and making comparable the ﬁndings from different clinics or hospitals. Sociological variables were covered by Leonard Pearlin, of the National Institute of Mental Health, Bethesda, Md. Arguing for greater speciﬁcity in this area, Pearlin observed that generic variables such as social class, age, and sex role are too global to be of much value in understanding the relations among variables. The need, he maintained, is for greater emphasis on description of the social context—i.e., the family, the community—and a descriptive system in which the “social characteristic in context” is the unit of analysis. The role of personality in the prediction of response to treatment was the topic of the paper by Seymour Fisher, of Baylor Medical School, Houston, Tex. His review of previous work in the personality area and his own experience led him to the opinion that the more simple personality variables have not been very helpful in the past as predictors and are not likely to be too helpful in the 580375—61—2 future. Increased emphasis should, he felt, be placed on theoretically derived conﬁgural measures of personality. Several possible conceptual dimensions were described. He acknowledeged, however, that the linking of personality variables to response to treatment is subject to a number of pitfalls, some of which he enumerated. The discussion which followed focused upon the issue of the single variable versus the conﬁgural approaches in attempts to relate personality and treatment response, and resulted in some clariﬁcation of the roles of each. The issue, however, was not resolved. Methods for dealing with population variables were discussed by Samuel B. Lyerly, of the Society for Investigation of Human Ecology, Washington, D.C., and Dean J. Clyde, of the Biometric Laboratory of George Washington University, Washington, DC. Lyerly, in a paper entitled “Interview Data: Coding, Scaling, and Selection of Potentially Useful Variables,” emphasized the differences in hospital and community situations which affect the collection and analysis of data, the characteristics of information which are essential to statistical analysis of data, and the importance of insuring that information collected is comparable from subject to subject. With regard to coding, he discussed different types of data and classiﬁcation systems, the role of the pilot study, ways of handling of “free responses,” and the application of simple mathematical procedures to patterning problems. Problems of weighting, suggestions for dealing with “does not apply” responses, and the application of different types of validity models were also considered. Clyde’s paper, “Multivariate Problems: Clustering Variables and Classifying Patients into Types,” focused on the role of multivariate models in drug research. He described the following three approaches and presented examples of the application of each: (a) Analysis of covariance, whose use was exempliﬁed in a study in which control of the pretreatment level of severity of illness was required; (b) factor analysis, which was used, in the example presented, to reduce a large number of items in a rating scale to two independent dimensions and thus served to clarify the composition and meaning of the instrument; and (c) discriminant function, which was applied to a problem of separating out groups of patients on the basis of their differential response to drug treatment. The relevance of the latter procedure to the problem of etiology was also considered. In discussing these papers, Goldine Gleser, of the University of Cincinnati, Cincinnati, Ohio, elaborated upon several approaches to separating subjects into meaningful groups. Three statistical models for accomplishing this kind of separation were described. She stressed that the state of knowledge in the ﬁeld is not sufﬁciently advanced to permit the prediction beforehand of the best way of separating groups, but pointed out that study 11 �of the outcome of such empirical separation can yield hypotheses which can then be cross-validated in other studies. Methods for Measuring Improvement Papers presented in this section of the conference described methods which are being used or developed to evaluate the adjustment of the patient and to specify ways in which improvement is manifested. Norbert Freedman and David Mann, of the State University of New York, Downstate Medical Center, Brooklyn, N.Y., described the manner in which they are attempting to measure psychopathology and social behavior. Emphasis within the clinic is on the psychiatric rating scale approach, and in their community studies emphasis is on a “naturalistic” approach. They have, through preliminary analysis of their psychopathology ratings, identiﬁed factors which improve with drug treatment and which predict drug response to treatment. In the area of social behavior, development of an extensive interview schedule covering such areas as family history, work history, and social pathology was described by Mann. He also discussed in some detail their coding procedures, the progress of their approach to studying the “typical day in the patient’s life,” and the dimensions of classiﬁcation which have been derived from the social data and which will contribute toward deﬁning “social remission.” It was pointed out that the deﬁnition of social remission is one of the central aims of the project. The details of a rating scale for measuring the improvement of outpatient psychotics treated with drug and placebo were discussed by Jordan Lawrence, formerly of Springﬁeld State Hospital, Sykesville, Md. The scale, which is completed by a psychiatrist or psychologist and a social worker following an interview with the patient, has three sections, one covering major psychopathology, one describing neurotic symptoms, and one concerned with social adjustment. Lawrence reported that the more reliable items in the scale have been factored and have yielded tentative dimensions of “schizophrenia” and “depression.” He also indicated that the three subscores and the total score have been found to discriminate well between pre-relapse and relapse conditions, but noted that further, better controlled validational studies need to be carried out. Progress on the development of a set of inventories designed to assess clinical and social adjustment was reported by Martin M. Katz, of the Psychopharmacology Service Center. He noted that the instruments are based on the need to integrate two points of view, the patient’s and the relative’s, in assessing the adjustment and per- 12 of the patient. The inventories represent atobtain objective estimates of (a) the amount of home and free-time activity in which the involved, and (b) the patient’s and the relative’s level of satisfaction with the patient’s functioning in the clinical, work, social behavior, and free-timeactivity areas. A validity study was described in which relatives were shown to be in very high agreement with psychiatric assessment (based on intensive clinical study of the patient) with regard to the level of psychopathology present and the extent of home, social, and free-time activities of the patient. Several trends in the data were noted: The relative is capable of providing accurate, objective information in certain areas; the sheer quantity of activity as reported by patient and relative reﬂects the level of adjustment; and the relative’s level of expectations at the time of assessment correlate highly with adjustment. More detailed study of the composition of the instruments and their general applicability is in progress. Mark Lefton, of Ohio State University, Columbus, Ohio, described his implementation of the interviewschedule approach, which had some similarity to others with regard to the areas of functioning sampled. Separate schedules were designed for the patient and the relative. The variables of prime interest in Lefton’s assessment of community adjustment are social participation, work performance, psychological functioning as measured by a relative’s ratings on a list of psychopathological indices, performance as a homemaker, and meas» ures of the relative’s expectations and tolerance of deviation. He reported that several measures have been found to discriminate between patients who were returned to the hospital within 6 months and those who remained in the community, as well as between patients who function well and those who function poorly in the community. During the discussion of these papers, one participant commented on the salutary effect that commitment to a particular approach has in this area, but he cautioned against inﬂexibility at this early stage in the development of the ﬁeld. The use of clinical judgment as a criterion‘has its advantages, but it was noted that areas of disagreement among raters can be just as important for understanding the nature of the problem. formance tempts to and kind patient is In an area that has seen only scattered attention in the past, the conference participants agreed that the diversity and extent of efforts now being directed toward assessing the clinical and social effects of various psychiatric treatments are very promising developments. �Conference on Information Needo A conference on scientists’ need for information, sponsored by the Psychopharmacology Service Center under contract wtih the Matrix Corp., of Arlington, Va., was held on November 25 and 26 in Washington, DC. It was a small, invitational conference of scientists active in research in psychopharmacology, documentalists, and other information storage and retrieval specialists. The aims of the conference were several: To learn whether the conference method of face-to-face interchange would reveal more relevant data about scientists’ needs in the ﬁeld of information and. communication than has hitherto been revealed in questionnaire and interview studies; to learn whether bringing the generators and users of information into direct contact with the experts in documentation would yield information of value to both; to obtain speciﬁc information about needs of scientists working in psychopharmacology; and, as a byproduct, to help the PSC’s Scientiﬁc Information Unit plan its future activities. The meeting was very informal. There was no prearranged agenda, nor was any attempt made to arrive at speciﬁc recommendations. Under the chairmanship of Roger W. Russell, of Indiana University, Bloomington, Ind., three speakers presented papers as starting points for the discussion. Robert J. Hayes, of the Electrada Corp., Los Angeles, Calif., reviewed the whole ﬁeld of information storage and retrieval, emphasing new methods and machines. He brought out that there are now machines that can be applied to almost any problem or situation in the ﬁeld of information storage and retrieval. Emphasizing the team approach to the problem, the cooperative efforts of users, operators, and machine experts, he observed that the application of machine methods to information problems is successful only when the machine specialists and documentalists have a clear understanding of the users’ requirements. Daniel X. Freedman, of Yale University, New Haven, Conn., discussed the use of information in his own research, reviewed the development of his research program and the role of information in the program, and mentioned ways in which information could be more useful. Murray E. Jarvik, of Yeshiva University, New York, N.Y., also reviewed the sources of information that he employs, including journals, monographs, books, reprints, review articles, conferences, the public press, science writers, drug company literature, textbooks, and other materials. In addition to these three speakers, several other participants described their uses of information, covering of Pyye/oop/onrmneologz'rtx kinds of information used, how it is used, and ways in which they would like to have it improved. Interspersed among the papers was lively and varied discussion from most of the participants. The following summary attempts to convey some of the ideas presented in the discussions, but it does not cover all the points that were made. Throughout the meeting one recurring theme was concern about the quality of scientiﬁc information. Commenting on the many problems of so-called scientiﬁc writing, one participant observed that much scientiﬁc writing occludes more than it illuminates. Most participants felt that many experiments were poor to begin with and should never have been published. They pointed to the need for editors of scientiﬁc journals to evaluate work more carefully and more critically before accepting it for publication. On the other side of the question were emphatic comments that strong efforts in this direction could lead to stultifying and untenable orthodoxy in science. One of the participants maintained that the problem was too much information, and that steps should be taken to cut it off at the source; i.e., to induce the scientist himself to be more selective in reporting his work. Another took the opposite point of view, saying that, as with farm surpluses, the real problem is not that of having too much information but of distributing and using information more effectively. A frequently recurring generalization was that scientists do not make maximal, or even good use of the many sources of information available to them. As each participant mentioned kinds of information he used, others remarked that they did not know of those sources. Similarly, when speciﬁc needs were mentioned, other participants often retorted that such needs were now being satisﬁed and the scientist had only to take advantage of available services. One of the questions raised was whether centralized, or even decentralized, information services could ever serve all the needs of scientists. One participant suggested that much of the seeming dissatisfaction with present information and communication is due to the unrealistic expectations of scientists, who often want answers to research questions that they themselves should submit to research. Information at the forefront of knowledge must be obtained by the scientist; readymade answers do not exist. A related comment was that information needs differ from one stage of research to another. A point that could be generalized from the discussion was that scientists perhaps do not know what they want 13 �in the way of information, and that it is, therefore, the duty of specialists in the information area to provide scientists with a wide variety of information presented in many different forms. If that were done, the scientists could then select what they need from what is offered to them. The usefulness of critical reviews of the literature was discussed in some detail. Although all agreed that critical reviews are valuable, they noted that ﬁnding really eminent scientists to write the reviews constitutes a major problem. Handbooks and other compilations of factual information that would be of particular value to the applied scientist were also felt to be of great importance. Many participants cited reprints, rather than journals, as one of the most useful forms of information, and felt that much could be done to make distribution of individual articles more feasible and more effective. In discussions of systems of handling information, it was noted that a scientiﬁc discipline is itself an informational system, and that some disciplines are, at different times, much more tightly organized systems than others. Physics and chemistry, for example, are at present rela- 14 tively more “organized” than the biological sciences and, therefore, in a sense, present fewer information and communication problems. This discussion, which occasionally bordered on excursions into the philosophy of science, brought out the paradoxical observation that as a body of knowledge or science develops and overthrows old concepts and formulations, it is in a continuous cycle of creating chaos out of order and then creating order out of chaos. In general, the conference participants agreed that the most important and effective means of disseminating and exchanging new information are by personal contacts at scientiﬁc meetings, by the “ﬁrst” type of scientiﬁc communication—the letter—and by visits with other scientists. In discussing the value of this kind of direct, personal interchange, it was suggested that tape recorders, which are now available in most laboratories and university departments, might be used to simplify and speed up the informal exchange of information. The practical value of directories of scientists and of indexed compilations of ﬁlms and other audiovisual aids was also stressed. �The Pylebep/aarmacolegy Rerearcb Umt State Unevem'ty of New Yer/e Dowmtate Medical Center" The Psychopharmacology Research and Treatment Unit of the Department of Psychiatry, State University of New York, Downstate Medical Center, Brooklyn, N.Y., was established in October 1957. From its inception, the Unit has been concerned with the study of the effects of long-term psychopharmacological treatment on the community adaptation of schizophrenic outpatients. In the selection of ambulatory schizophrenic patients as our study population we were guided by the wide use to which psychopharmacological treatment is put with such patients. By setting community adaptation as the criterion of treatment outcome we hope to emphasize that change in these patients must be deﬁned in terms of performance at home, at work, and in the community, as well as in terms of the usual criteria of psychological and psy— chiatric functioning. By assessing the effects of longterm, sustained drug action (1 to 5 years of continuous drug administration) we expect to determine to what extent such treatment may prevent relapse or lead to further improvement after an initial stabilization has been attained. The Unit thus focuses on the behavioral (i.e., psychological as well as social behavioral) correlates of drug treatment and tries to apply the method of controlled investigation to the clinical setting. Considerable effort is also being extended to the methodology of outpatient drug assessment and to the basic research task of developing objective assessment techniques which will allow for the tracing of changes in the qualities of community adaptation. These overall research objectives are discriminated into the seven speciﬁc studies outlined below. The overall project is in part supported by Public Health Service grant MY—1983. In addition to these long-term studies of chronic schizophrenic outpatients, a section of the Research Unit is speciﬁcally concerned with the testing of new drugs. In the course of the short-term studies we have an opportunity to test the validity of some of the assessment techniques developed in the longterrn studies. Finally, the staff of the Research Unit also engages in teaching psychopharmacology to undergraduate medical students and psychiatric residents. A *Prepared on request by David M. Engelhardt and Norbert Freedman, Psychopharmacology Research Unit, State University of New York, Downstate Medical Center, Brooklyn, N .Y. research fellowship program is carried out by the Research Unit with second- and third-year medical students who are expected to conduct their own experiments in psychopharmacology. The present staff of the Unit includes David M. Englehardt, Director, Norbert Freedman, Associate Director, Leon D. Hankoff, Research Psychiatrist and Director of the Treatment Unit, David Mann, Research Social Psychologist, and Reuben Margolis, Research Clinical Psychologist. The research design of the principal (long-term) project has the following essential features: (a) A free-clinic population of chronic schizophrenic patients is studied. Some patients come with a history of prolonged hospitalization, some with a history of brief recurrent hospitalization, some without previous hospitalization. The population is ethnically heterogeneous, evenly divided between males and females, and draws upon the lower socioeconomic groups. (b) Patients are given one of three commonly used agents, chlorpromazine, promazine, and placebo, and are seen in a setting which emphasizes a supportive doctor-patient relationship. The drugs are given under double-blind conditions, and drug assignment is made randomly. (6) Assessment of treatment effects is made by psychiatric ratings and psychological tests, as well as by detailed social behavior interviews administered to key relatives of the patient according to a predetermined schedule. Psychopathology and social behavior are thus independently evaluated, the former in the clinic by a psychiatrist and psychologist and the latter by the report of a relative. It is planned to assemble a cohort of 500 patients who have completed 3 months of treatment and a smaller number of patients who have completed 1 to 2 years of treatment under these relatively standard conditions. Study 1: The Role of Ataractio Treatment in the Maintenance of Community Status Treatment may affect both incidence of hospitalization and clinic dropout. Preliminary ﬁndings show that drug treatment (chlorpromazine) is associated with lower incidence of hospitalization. Our next goal is to determine the role of drug treatment in preventing hospitalization by separately studying certain criterion groups. 15 �Thus, we hope to deﬁne incidence of hospitalization on the basis of diagnosis, socioeconomic status, the relative’s tolerance for the patient, and previous hospitalizations, and to ascertain the probability of hospitalization for each of these criterion groups separately, for drug andplacebo conditions. Clinic attrition for reasons other than hospitalization is also being studied systematically. Analysis of dropout patients relative to patients remaining represents an important methodological task because of the potential bias that early attrition may introduce in the interpretation of results of change. Drug treatment does not appear to affect dropout rate. Instead, dropout appears to be affected by factors in the patient’s motivation toward treatment and certain factors in the treatment situation. Social (group membership) determinants also appear to be implicated. Study 2: The Measurement of Social Behavior and Social Behavior Change Emphasis is placed on the development of quantitative and qualitative indices of community adaptation. The instrument used is a detailed focused interview. This interview elicits from a relative a reportorial description of the patient’s activities at home and at work, covering a speciﬁed timespan. These detailed reportorial accounts by the relatives provide measures predictive of change as well as measures denoting changes per se over the course of drug treatment. Preliminary data have shown that the effects of drug treatment can be discriminated by a relative reporting on the patient’s behavior. This preliminary study has involved the use of a simple checklist of social dysfunctioning ﬁlled out by the relative. Patients on drug showed greater reductions in dysfunctional social behavior than did the patients receiving a placebo. Relatives having no awareness of the speciﬁc treatment the patient was receiving were able to make this discrimination. The meaning of these differential changes must await the detailed coding of qualitative behavioral descriptions. Study 3: Changes in Psychopathology and their Concordance with Social Behavior Changes Changes in psychopathology are evaluated by the coding of the doctors’ clinical judgments (progress notes), a detailed psychiatric rating scale, and certain psychological test performances. Psychological tests are used primarily to elucidate the meaning of changes observed on psychiatric and social behavior indices. A cluster analysis of psychiatric ratings suggests that psychiatric changes may be described in terms of two relatively independent dimensions of change, a cluster called thought disorder and a cluster called change in anxiety and treatment contact. There is a trend for patients on chlor16 promazine to show greater reduction of thought disorder than for patients on placebo. Once the social behavior indices of change are sufficiently developed, we expect to determine the degree to which psychiatric judgment and relatives’ observations concur or diverge. Speciﬁcally, we expect to inquire whether relatives and psychiatrists concur on speciﬁc aspects of the patient’s behavior (i.e., belligerence) or whether both concur that change has taken place but are in fact referring to different areas of change. Preliminary data so far indicate greater concordance of change on certain speciﬁc variables for patients on drug than for patients on placebo. Basically, this study seeks to attack the question of generality of the treatment effect. Is the treatment effect limited to change observed in the doctor’s office, or does it extend to the patient’s functioning in the community as this is perceived by a representative of the community? Implicitly, we are studying variations in the conceptions of mental health and illness as these are held by different observers. Study 4: Freedom from Functional Decrement The possibility that sustained treatment with psychopharmacological agents may bring about a decrement in the effectiveness of the patient’s functioning is especially important for outpatients, on whom the demands for effective performance in a community are greater than for inpatients. Psychiatric ratings and relatives’ reports on such variables as sluggishness, apathy, inertia, etc., are especially relevant here. Equally cogent in determining functional decrement are psychological test performances on measures of inertia and perseveration* and the Porteus Maze Test. Data on about 100 patients treated with drug or placebo for a 3-month period have been analyzed for changes in maze performance; so far we have not been able to substantiate Porteus’ general ﬁndings of a decrement with chlorpromazine treatment, but we have observed a decrement in one speciﬁc subgroup. The subgroup was characterized by a “more complex” level of cognitive organization. (See the following description of study 5.) Study 5: Prediction of Clinical Course Underlying our studies of the community adaptation of a heterogeneous group of schizophrenic patients being treated with drugs is the assumption that outcome is modiﬁed by factors within the patient and within his social mileu. Preliminary data suggest that several parameters other than drug must be considered in predicting clinical outcome: (a) The patient’s motivation toward treatment, (b) his cognitive organization, and (c) the attitude of the family toward the patient’s illness. The patient’s cognitive organization as gleaned from *See Cattell, R. B. On the measurement of perseveration. British Journal of Educational Psychology, 1935, 5, 76-92. �Rorschach responses (based on a scoring derived from Werner’s concepts) has been especially helpful in elucidating a “pattern of drug effects”: the direction of change in response to a given medication depended upon the patient’s cognitive organization. Study 6: Incidental (Nondrug) Treatment Factors In addition to the prognostic indices just enumerated, the role of several nondrug factors within the treatment situation has been observed. We have explored the signiﬁcance of the initial response to placebo and the doctorpatient relationship as they may affect the patient’s clinic attendance (dropout or hospitalization), as well as qualitative changes observed by the psychiatrist. Scoring procedures for the assessment of both doctor-patient relationship during the initial interview and response to placebo have been devised. These studies have emphasized the importance of nonverbal communication in the psychopharmacological treatment of schizophrenic outpatients. They have also delineated the contributions of the active agents to the treatment effect in some patients, but have suggested that in other patient groups the nondrug factor was prepotent. Study 7: Long-Term Drug Action Patients remaining in treatment for 12 to 24- months under drug and placebo conditions are observed at monthly intervals and their progress is then graphically charted. Our approach to long-term studies has been to select one of the more reliable change indices (psychoticism) and trace the patient’s status at successive intervals. In analyzing the time trends we have found it useful to distinguish two baselines, one at intake and a second after approximately 3 months of treatment. This second baseline permits the comparison of any further improvement or worsening in the patient’s adaptation after allowance for the initial drug effect has been made. It must be emphasized, however, that this study is always limited to patients willing and able to remain in treatment for such a long period of time. We are continually assessing differences between remainers and dropouts, so as to be in a position to detect bias introduced by the selective attrition of the sample. These long-term studies will also be corroborated by intensive case studies. Study 8: New Drug Testing The major efforts of the Unit are devoted to the study of long-term drug responses of chronic schizophrenic outpatients. Three relatively commonly used agents are employed. However, one section of the Unit is concerned with exploring the suitability of newer psycho— pharrnacological agents, speciﬁcally as they may be applicable to outpatients. Assessment methods which have proved to be useful in the larger study are also employed with the relatively brief trials of new drugs for outpatient use. With the study of new drugs we also hope to extend our information about the behavioral changes among outpatients in different diagnostic groups such as depressed patients. Studies of the following compounds have been completed or are in progress: fluphenazine (Prolixin), isocarboxazid (Marplan), imipramine (Tofranil) , and pyrbenzindole (IN—461, or 4-(1-benzyl-3-indolylethyl) pyridine hydrochloride) . In the course of conducting these studies we are accumulating a body of information about the methodology of outpatient drug testing; i.e., we are beginning to delineate the relative advantages and limitations of double-blind procedures in long-term assessment, the merits of simultaneous appraisal of an agent by the multiple clinic-community-member criteria, the utility of at least two baselines in the study of long-term trends, and the advantages of a drug spectrum of chemically similar agents which vary in presumed clinical intensity. Future Plans The ﬁndings so far support the view that the hospitalization rate tends to be lower for schizophrenic patients on active medication than for those on placebo; that psychotic symptomatology among these patients tends to be reduced by the drug; and that the adequacy of social behavior as judged by the relative appears improved, although we are not able to specify the quality of behavioral changes implicated here. Preliminary data on such variables as “psychotic thinking” also suggest that with prolonged administration of medication there tends to be less relapse with drug than with placebo. F urthermore, the data suggest that signiﬁcant variations in the effectiveness of drugs depend on the patient’s cognitive organization and his motivation toward treatment. In certain criterion groups, incidence of remission tends to be high regardless of drug treatment. In other criterion groups whose improvement is lower, the remission rate for patients on active drug exceeds the expectancy of improvement attributable to nondrug factors. Our next step in the project is to place these ﬁndings on a more solid foundation: We expect to study a sample of 5-00 patients who have received 3 months of treatment; we expect to cross-validate some of the speciﬁc predictions drawn from the initial sample; we expect to specify the meaning of the qualities of treatment outcome, particularly in the area of community behavior, through qualitative coding of behavioral descriptions by the relative; we expect to conduct certain control studies on the source of dropout, the patient’s condition after separation from the clinic, and changes in a sample of “isolated” schizophrenic patients, i.e., those not living with relatives. Finally, we hope to describe changes in subjective experiences among those patients judged by 17 �psychiatrists and relatives to be in remission. Thus, we hope to describe improvement from three vantage points, the community’s, the psychiatrist’s, and the patient’s. In most general terms, it is hoped that our Unit can contribute to the knowledge of the effectiveness of psy— chopharmacological treatment of schizophrenic outpatients by developing and delineating criteria of treatment outcome, by specifying expectancies of clinical change for speciﬁc patient groups, by indicating the role of the drug and nondrug factors in outcome, and by tracing the long-term consequences of treatment. Once this information has been derived from a large heterogeneous group of schizophrenic patients under relatively standard treatment conditions, it is hoped that newer agents can be tested more effectively; i.e., that the larger sample can be used as a reference group and that inferences can be drawn from smaller patient groups seen over briefer periods of observation. Finally, we hope that the accumulated data will increase our knowledge of the schizophrenic outpatient. Experimental Pay/chiatric Program: at Hillside Hospital, located in Glen Oaks, Long Island, N.Y., is a nonproﬁt, philanthropically supported psychiatric institution to which patients are admitted voluntarily for extensive psychotherapeutic treatment. Patients are from a predominantly middle-class, urban population, and most have high educational attainment. The programs of the Department of Experimental Psychiatry are a cluster of interrelated studies focused on common population samples. Other research laboratories in biochemistry and in medicine are active, and laboratories in psychodynamic psychiatry are being developed. The programs of the Department of Experimental Psychiatry have developed over 6 years, and are devoted to understanding of the mode of action of psychiatric therapies through studies of brain function. The principal techniques have been adapted from descriptive psychiatry, neuropsychology, electroencephalography, linguistics, pharmacology, and sociology. Members of the staff, representing various disciplines, are Max Fink, Director, Karl Anderrnann, Ira Belmont, Martin A. Green, Abraham A. Kaplan, Eric Karp, Donald F. Klein, George Krauthamer, Joseph Jaffe, John C. Kramer, Max Pollack, and Nathaniel Siegel. Former associates who contributed to these programs are Harold Esecover, Robert L. Kahn, Hyman Korin, and Henry J. Lefkowits. In initial studies of convulsive therapy, changes in brain function were found to relate both to evaluations of improvement and to pretreatment psychological variables. As our understanding of convulsive therapy developed, a general neurophysiological-adaptive view of somatic therapies emerged. In this view, psychiatric treatments are therapeutically effective to the degree that brain function is measurably altered. While change in brain function is necessary for behavioral change, the type of adaptation varies, depending upon pretreatment psychological and sociological characteristics of the subject. Thus, the mode of action is not seen as either “organic” or “psychological,” but rather as the inter18 Hz'ZZJz'de HarpiMF action of diffuse neurophysiological changes and adaptive mechanisms. Further, while behavioral change is related to changes in brain function, and the adaptive characteristics, psychological to pretreatment pattern evaluations of “improvement”—being special types of evaluation of change—are derivative judgments based on staff and family expectations and tolerances. This hypothesis was developed and sustained in a series of studies of convulsive therapy. Concurrent studies of insulin coma indicated that behavioral change here, too, was related to the onset and degree of prolonged coma or repeated seizures, these being the prin— cipal manifestations of prolonged neurophysiological change in this therapy. The mode of action of the new psychotropic agents was also expressed within this hypothesis. It was suggested that these agents would be effective to the degree that they induced persistent changes in brain function, and that the type of behavioral response would be related to the type of brain change and to prernorbid psychological (personality) patterns. The present programs in the Department are designed to study these relationships in detail. Convulsive Therapy Process Of various measures of brain function, the amount of slow wave activity in the electroencephalogram and confabulatory and denial language patterns after amobarbital were the most sensitive indices in convulsive therapy subjects. In one experiment, improvement ratings were correlated with the appearance of high degrees of change in these indices. These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to courses of either convulsive or sub' *Prepared on request by Max Fink, Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, N.Y. �»n-s,ww.- . . E convulsive therapy under thiopental (Pentothal) premedication. High degrees of neurophysiological change were observed only in the convulsive group; improvement rates were signiﬁcantly higher in this group; and when subconvulsive subjects were re-treated by convulsive applications, the improvement rate was similar to the original convulsive group. In the subjects given subconvulsive treatment considerable amounts of electric current passed between the bitemporal electrodes. It appeared that the therapeutic agent was not the total electrical current per se, but an all-or—none quality manifested by the grand mal seizure. The signiﬁcance of the grand mal seizure was examined in studies of the inhalant convulsant hexaﬂuorodiethylether (Indoklon). Similar degrees of electrographic change, improvement rates, types of behavioral change, and changes in neuropsychological task behavior were observed in the Indoklon group and in the electrically treated group.- It was soon apparent that not all subjects manifesting high degrees of physiological change were rated as “improved.” In a descriptive typological study, ﬁve patterns were described, empirically termed “euphoric,” “hypomanic,” “somatization,” “paranoid-withdrawal,” and “panic.” While the ﬁrst two of these adaptive modes were rated as “much improved,” the latter two were seen as “unimproved” or “worse.” In studies of psychological variables, it was reported that patients rated as much improved and recovered frequently manifested personality patterns similar to that described by Weinstein and Kahn as the “explicit verbal denial personality.” In language patterns, patients expressed the “language of denial” when diffuse brain change was induced, exhibiting such aspects as explicit denial, minimization, displacement, cliches, etc., more frequently than unimproved subjects. Other indices related to favorable outcome were high scores on the California F Scale, and Rorschach determinants of pure color, absent movement, and absent form-color. In this population, also, favorable outcome was associated with low educational achievement and foreign birth. Anticholinergic Compounds and Convulsive Therapy Seeking a way to augment the degree of postconvulsive EEG slow wave activitiy, an anticholinergic compound, diethazine, was given intravenously at various stages of the convulsive therapy process. Contrary to expectations, diethazine caused an immediate and sustained decrease in EEG slowing. Patients with denial language patterns relinquished them. Instead of feeling euphoric and experiencing a sense of well-being, the subjects became irritable, anxious, and showed symptoms expressive of pretreatment patterns. Prior to convulsive or drug therapy, diethazine induced excitement, tension, anxiety, and illusory sensations. Subsequent studies with other central anticholinergic compounds—WIN—2299 (2-diethylaminoethyl-a-cyclo- pentyl-a-(Z-thienyl)-glycolate HCl), JB—318 ( l-ethyl3-piperidy1 benzilate HCl), JB—336 (N-methyl-3-piperidyl benzilate) , and benactyzine—showed behavioral and electrographic patterns similar to those of diethazine. Similar desynchronization of postconvulsive EEG slowing was also noted with central sympathomimetic hallucinogens (amphetamine, mescaline, LSD—25), and has been reported for antihistamines (diphenylhydramine). These observations led to the suggestion that an increase in central cholinergic activity was a biochemical basis for the convulsive therapy process. Psychopharmacological Agents and EEG During this period, the mode of action of newer psychopharmacological agents aroused interest. Following the concepts derived from convulsive therapy, the neurophysiological changes induced by drugs were tested within the same acute experimental framework of the EEG setting. It was observed that phenothiazines (chlorpromazine, promazine, triﬂupromazine) induced EEG synchronization and a shifting of the spectrum to the slow frequencies; meprobamate and barbiturates induced an increased synchronization and a shift of spectrum to fast frequencies; reserpine induced an increased slowing with synchronization at low dosages and desynchronization at higher levels ; and imipramine induced desynchronization with a shift of frequencies to the slow bands. Other experimental compounds tested included BLM188 (which is 4-dimethylamino-3,4,5-trimethoxybenzanilide) and phenyltoloxamine, deanol and its various congeners, WY—214-9 (which is tropin-4-chlorbenzhydryl ether HCl), and azacyclonol. No consistent electrographic pattern was recorded for any of these compounds. It was suggested that psychopharmacological agents provide a means for eliciting a variety of neurophysiological patterns in contrast to the single pattern of induced convulsions. Furthermore, the type of neurophysiological alteration, as reﬂected in EEG synchrony and frequency patterns, was related to speciﬁed types of behavioral adaptation. Increasing EEG synchrony and a shift to slow frequencies were associated with tranquilization, sedation, and decreasing agitation, while desynchronization and a shift to fast frequencies were associated with excitement, illusions, and delusional ideation. These observations are consistent with hypotheses of Wikler. The advantages of EEG techniques for the assay of new psychiatric drugs have already been reported.* Psychopharmacology Evaluation Program The present psychopharmacology program, instituted in October 1959, was based on the studies described in the *See Fink, M. EEG and behavioral effects of psychopharmacological agents. In P. B. Bradley, P. Deniker, and C. RadoucoThomas (Eds), Neuro-psychopharmacology. New York: Elsevier Publishing Co., 1959. Pp. 441—446. 19 �preceding paragraphs. It is designed to answer the following questions: Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? Are there pretreatment clusters of psychiatric physiological and psychological variables related to the type of behavioral adaptation? And, are such clusters related to the type and degree of physiological change? Method. As an initial approximation, a double-blind drug study was undertaken in which subjects were randomly assigned to a ﬁxed-dosage schedule. On the basis of our clinical experiences with various psychotropic compounds from 1954 to 1959, we selected three classes of drugs according to their patterns of EEG response. The agents selected were those with either predominant desynchronizing patterns, synchronizing and slowing, or minimal or no effect. After medical examination and after all other medications have been discontinued, patients referred for drug therapy are randomly assigned to treatment with a compound in one of these three classes. Convulsive and drug therapies are prescribed by staff psychiatrists on referral to the Department of Experimental Psychiatry. All treatment is administered by the Department staff, so that the experimental variables of drug dosage, route of administration, assignment to groups, etc., are readily controlled. All patients in the hospital are available for study. The mean duration of stay for patients is 7 months. After a testing period, all patients receive 40 cc. of liquid medication daily from individually labeled bottles. Dosages are increased in ﬁxed weekly steps until a maximum dosage is achieved at 4‘ weeks. After 2 weeks on maximum dosage, retesting occurs. To date, 140 subjects have been referred, and 110 have completed the study period. Preliminary analyses of the data are now in progress. Behavioral Change. In a survey of the behavioral adaptations of patients receiving various agents during 1958— 59 a number of clusters of behaviors were developed. The typologies were based on the treatment response and on pretreatment psychiatric proﬁles. In the present study, the typologies are being tested and various measures of behavioral change are being studied. These include therapist referral questionnaires and 6-week evaluations; therapist’s ratings of patients on the Clyde Mood Scale; the Multidimensional Scale for Rating Psychiatric Patients, used for evaluations in interview by two research psychiatrists; the Lorr Psychiatric Behavior Rating Scales for ward behavior (AAMI: Level of Anxiety, Level of Activity, Mental Disorganization and Interpersonal Relationships); and patients’ self-ratings on the Johns Hopkins symptom checklist, the Chicago Attitude 20 Scales (self-perceptual scales devised to elicit attitudes of dependency, ﬁght, ﬂight, and pairing), and the Clyde Mood Scale. Neuropsychology. Psychological tasks have been viewed both as change variables and predictive variables. In convulsive therapy, changes in memory tasks, tactile perception, Wechsler—Bellevue, critical ﬂicker frequency, ﬁgure-ground tasks, and tachistoscopic recognition of ﬁgures were related to the degree of induced neurophysiological change. For each task, the degree of decrement in task performance was found to be positiVely correlated with the amount of EEG slowing. Following treatment completion, with the return of physiological indices to pretreatment levels, performance on these psychological tasks also returned to pretreatment levels or higher, a betterment of performance ascribed to practice effect. Denial scores on interview, Rorschach determinants, F scale scores, language patterns after amobarbital, auditory feedback, and perception of the visual upright have been viewed as predictive indices of the behavioral changes following ECT. Psychopharmacological agents are now being used to assess these various tasks, their capacity to change with various agents, or their capacity to predict change. Electroencephalography. In the studies of convulsive therapy, the degree of EEG slowing was measured by counting the consecutive waves in selected samples. When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques. Electronic frequency analysis was introduced in August 1959. By measuring the pen deﬂection for various frequencies from 3 to 33 c.p.s. in 10-second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are now obtained and applied. Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood-pressure response to Mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. Psycholinguistics Another series of studies in the Department has been devoted to formal language patterns. Following the studies of syntactic language patterns in convulsive therapy, other aspects of language were studied as indices of change in interpersonal behavior. Jaffe, after considerable exploration with various linguistic measures, suggested that type-token-ratios (TTR) of consecutive samples of dyadic speech might be a useful index. While TTR had previously been applied to written texts or to the language samples of individuals, Jaffee indicated that the two-person communication (dyad) was a more signiﬁcant index of the state of the �interaction than were analyses of separate samples from the participants. Applying this technique to patients receiving convulsive therapy, changes in TTR mean and standard deviations were related both to the degree of induced EEG slow wave activity and to syntactic language patterns obtained in independent structured interviews. Speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (increased standard deviation). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents with a predominant synchronization pattern on the EEG exhibited a decrease in mean TTR and an increase in standard deviation of scores, while desynchronizing compounds elicited greater variability in speech patterns (increase in TTR mean) and a decrease in variability of consecutive scores (decrease in standard deviation). Other language measures studied included distressrelief quotients, self-reference, and alteration in tense and person. It was suggested that these psycholinguistic measures are potent techniques for the operational analyses of physiological and psychological effects of psychopharmacological agents. Sociological Studies In the course of these psychiatric programs, considerable interest was engendered in the family organization to which patients were returning. Also, the general problem of the relation of social factors to choice and results of psychiatric treatment, and the speciﬁc problem of the relation of these factors to the referral patterns, led to a series of population studies. In one study, education, age, place of birth, and score on the California F scale were signiﬁcantly related to the type of therapy received and the utilization of adjunctive hospital services. Thus, patients who were older, poorly educated, had higher F scores, and were foreign born, particularly those born in Eastern Europe, were most likely to be referred for electroshock. These relationships were independent of diagnosis. Within the group of electroshock patients, the time of referral for ECT was also related to these factors. In a second study, duration of hospitalization, discharge evaluation, and diagnosis were related to the same social factors. For example, patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign born, and had the higher F scale scores. Younger, native-born, better educated patients who had lower F scale scores were hospitalized the longest. These relationships held true within treatment type and within diagnostic class. On discharge, older patients had the most favorable ratings. In ECT, patients rated as recovered or much improved had the highest F scores, least education, and were most likely to be foreign born. In another study of patient refusal of ECT, similar relationships were observed. These relationships are now under study in the Outpatient Department and in a trihospital comparative study. This study is assessing the populations of three hospitals, each of which has a prevailing patient population which differs from that of the other two. In each of the three hospitals, all therapies are equally available to all patients. The participating hospitals are the Menninger Foundation Hospital, whose population is primarily upper class and Protestant; the Massachusetts Mental Health Center, whose population is primarily lower class and Catholic; and the Hillside Hospital, whose population is predominantly middle class and Jewish. It has been postulated that the relationships mentioned in the preceding paragraphs reﬂect the inﬂuence of social background on psychological processes, such as habitual patterns of communication and modes of expression. The contribution of these factors to the pattern of mental illness and to the patient-therapist interaction are being investigated. Plans for Future Work Further growth and the direction of ensuing studies will depend upon the results of the investigations described here, as well as upon the growing institutional awareness that research is as much an integral part of the hospital’s operation and budgets as are patient treatment and staff training. 21 �Angler" the in Com-Leaf Chewing For many centuries, at least as far back as 1000 B.C., the inhabitants of the highlands in the Andean region have been habituated to the consumption of the leaves of Erythroxilon coca, a shrub growing in the Andean mountainsides at an altitude between 1,500 and 6,000 feet above sea level. At present, the production of coca leaves in Peru is estimated at 10 million kg. per year; approximately 40,000 acres of cultivated land are used, empIOying 25,000 workers (approximately 2 percent of the population devoted to agricultural tasks). The leaves of this shrub may be cropped on the second or third life-year, and the plant continues to produce for 20 years, yielding from three to six crops per year. The leaves are dried in the sun for several hours and then kept in cool, shadowed places until sold for human consumption. Marketing is essentially free, being only under the necessary controls for proper taxation and to avoid illegal exportation. Coca leaves are sold all over Peru, in any requested amount, from a few grams to several th0usand kilograms. Human consumption of the leaves, as such, is unrestricted. Industrial processing for the production of cocaine is forbidden by law, although frequent disclosure of illegal factories and cocaine rings calls for improved. methods of ﬁscal control. Coca leaves contain 0.60 to 1.80 percent of cocaine and 0.03 to 0.90 percent of ecgonine, according to calculations from different laboratories and varying also with the region and method of cultivation. Mention is also frequently made of the fact that coca leaves contain vitamin B1 (6 to 8 mg. per kg), riboflavin (10 mg. per kg.) and vitamin C (150 to 200 mg. per kg.). The high content of cocaine in the coca leaves becomes more meaningful if one realizes that the Peruvian people consume an estimated 9 million kg. of coca leaves per year, representing an average of 90,000 kg. of cocaine per year. The legally approved medical requirements of all the rest of the world amount only to 2,500 to 3,000 kg. per year. (This does not include the legally approved consumption in the United States. According to ofﬁcial information from Peruvian sources, the Coca-Cola Co. imports from Peru 140,000 kg. of coca leaves per year. These coca leaves are decocainized and the decocainized product is used in the manufacture of the Coca-Cola bevis turned obtained cocaine The as subproduct a erage. over to the proper authorities for legally approved consumption, the surplus being incinerated. The United States, thus, does not import or export cocaine.) The 90,000 kg. of cocaine contained in the 9 million kg. of coca leaves are consumed by approximately 2 million of the total 10 million inhabitants of Peru. These 22 million people represent 90 percent of all adult males in the highlands, 20 percent of all adult women in the highlands, and a large, but undetermined, percentage of male children over 12 years of age in the highlands. Consumption of coca leaves at lower altitudes is exceptional. The amount of coca leaf taken daily per individual varies from 10 to 100 gm. The average adult man takes approximately 30 gm. daily, but there are exceptional chewers who will take as much as 200 to 300 gm. every day. Although one speaks usually of “coca chewing,” the act of consumption may not properly be called chewing, at least in its complete process. The habitual chewer usually takes a handful of coca leaves and carefully cleans it from dirt, debris, and the main nerves of the leaf. He puts the clean leaves into his mouth and chews on them for 3 or 4 minutes until a bolus is well formed. Then he takes the bolus in his ﬁngers and pricks it deeply and repeatedly with a pointed stick which carries an alkaline powder, to be described below. The bolus is thereafter put back in the mouth and kept there, under the cheek, without chewing, for about 1 or 2 hours, during which the “chewer” sucks on it while he goes about his business. Finally, the bolus is either discarded or 2 swallowed. Usually, this process is repeated with 10 gm. of leaves every 3 to 4 hours, with interruption of current activities for about 45 minutes in order to prepare the bolus, in what might be called a “coca break.” It is exceptional to ﬁnd “chain chewing,” which brings up daily consumption to about 300 gm. per person. The addition of an alkaline substance to the bolus is a rather intriguing subject. The composition of this powder varies from region to region, ranging from plain quicklime to ground seashells or ashes of different plants. In exceptional cases, chewers do not use the alkaline subshow that evidence is to there but archeological stance, in one way or another it has been used for as long as coca has been known to man. One might speculate that this procedure increases the yield of alkaloid in the mouth, but there is conﬂicting evidence that this is a real fact. Gutierrez Noriega, one of the authorities on this subject, claims that the yield is increased by only 4 percent. Other explanations have been offered—improvement of taste, breaking up of the cellular membrane, etc.—but there is an obvious need for further research in this direction. *Prepared by Fernando Cabieses, Professor of Neurosurgery, San Marcos University, Lima, Peru. Mailing address: Talara 655, Lima, Peru. �It is generally accepted that cocaine is liberated in the mouth, being extracted from the bolus. Actually, that should not be a very difficult point to settle, but nonetheless different observers have reported very conflicting data. The actual yield, which should result from subtracting the amount of cocaine in the discarded bolus from the content of a similar amount of leaves, is difficult to obtain because of the rather frequent spitting, the swallowing of part or all of the bolus, and the different methods of titration. Published results vary from a 10- to a 90-percent yield. Also, whether the saliva contains free or bound alkaloid is not well known. At any rate, some form of cocaine is swallowed and, again, not much is known about its fate on reaching the stomach and intestine. How much of it is destroyed or further activated by the digestive juices is also in question. F urthermore, we have no information about how much is absorbed into the bloodstream or about the behavior of the gastric and intestinal mucosa exposed to bound or free cocaine. Cocaine absorbed into the bloodstream reaches the liver through the portal system, but no one really knows much about its metabolism at this level. There is some evidence that liver tissue will detoxify cocaine in vitro, and this has led to the thought that only a minimal amount of the ingested alkaloid actually reaches the general circulation. Here, again, careful evaluation is needed, since it seems that blood itself will partly destroy cocaine added to it in vitro. And, to complicate matters further, the results of determinations of cocaine blood levels in coca-leaf chewers are riddled with very difficult problems of interpretation, mainly because of the lack of appropriate methods of titration. Even if this information were available, absolute ﬁgures on cocaine blood levels would have but little meaning, owing to the lack of information on the level of neural toxicity of this substance. How high a blood level of cocaine can be tolerated without nervous effects in a normal individual, in a cocaine addict, and in a coca-leaf chewer is thus unknown. In spite of all these important questions, it is quite evident that some cocaine, or a cocainelike substance, reaches the nervous system of the coca-leaf chewers. This is easily concluded from clinical observation. Cocaine is perhaps the best antifatigue substance known to man. And it is a well proved fact that coca-leaf chewing is an excellent means of combating fatigue, both in industrial work and under experimental conditions. The possible differences between the effects of parenterally or orally administered cocaine and those obtained by chewing coca leaves, in normal as well as in habituated persons, and the action of cocaine and coca leaves on different types of fatigue remain to be experimentally evaluated. Cocaine decreases hunger sensation, admittedly through its central action. And this is also a very well known effect of chewing coca leaves, brought about either through a similar mechanism or, as commonly assumed, through local anesthetic action on the digestive tract. Whatever the mechanism is, coca-leaf chewing kills hunger. And this effect has an obvious social implication. It is said, on the one hand, that because of this action coca chewing leads to malnutrition. Other groups of sociologists claim the opposite; that malnutrition leads to coca chewing. And a third factor is brought into play when one is reminded that the coca leaves contain a fair amount of certain vitamins which are ordinarily lacking in other constituents of the usual diet of the dwellers of the high Andes. A pharmacological problem thus becomes a problem of socioeconomics and of social anthropology. Malnutrition, poverty, low culture, and coca chewing all go together, and at times it becomes almost impossible to disentangle one from the other. And if to this mixture we add high altitude, the problem becomes more and more intriguing and complicated. One cannot but wonder why, if the coca tree is only cultivated at altitudes lower than 6,000 feet, the habit of chewing coca leaves is found mainly above that level. Very few communities in the coastal area show the habit, which is mainly concentrated in the high altitudes. Futhermore, the habit of chewing coca leaves, a habit carried on continuously for many years, is usually abandoned when the individual is permanently transferred to lower geographical levels. And one cannot dismiss the frequent claims of travelers and of cultured dwellers of the highlands regarding the beneﬁcial effects of coca tea or coca chewing against the acute symptoms of mountain sickness. Unfortunately, no experimental evaluation has been made of these observations, which have been subject to much literary discussion in years past. It is true, of course, that high altitude is only one of the factors of a very complicated problem seen through the narrow light of an off—habit, on-habit proposition. But only a careful experimental approach will tell us what the real importance of this factor is, especially in the presence of a drug with as many unpredictable pharmacological actions as cocaine. It is commonly accepted that cocaine has a deleterious effect on the central nervous system when taken chronically. And it is only logical that this concept has been used in the interpretation of the mental functions of the coca-leaf chewers. This assumption, however, may not be entirely justiﬁed, since most of the alleged “facts” lack experimental veriﬁcation. The so-called effects of chronic consumption of coca leaves are always related to the other factors of the socioeconomic complex sur‘ rounding the coca habit; poverty, malnutrition, low culture, poor educational facilities, high altitude, etc. And although coca may be an important determining cause, the alleged low mental output of the Andean dweller should not be blamed only on this factor, as it frequently is. The appraisal of chronic coca-leaf consumption com23 �pletely separated from its socioeconomic constellation is, however, very difﬁcult to achieve. The acute action of coca-leaf chewing on mental processes also lacks sound and thorough experimental evaluation. A few experiments suggest that the effects are quite different in habituated and nonhabituated individuals, as would logically be expected. The extent and mechanism of these differences remain to be determined. There is also some indication that muscular activity during the process of coca chewing basically alters its mental effects. It is said that if the individual is resting, daydreaming and pseudohallucinations ensue, but that these mental effects can be prevented by physical activity. These observations need further experimental study, but this type of psychopharmacological study would meet with great obstacles in the markedly introvert personality of the Peruvian Indian, his resistance to participation in experimental studies of this type, the frequent language difﬁculties, and the lack of basic psychological and social anthropological studies in the Andean milieu. It is thus evident that there are many questions to be answered concerning the pharmacology of coca leaves and the socioanthropological aspects of this widespread habit. Differences between the chronic or acute effects of parenterally administered cocaine (a subject on which much remains to be settled) and the chronic or acute effects of coca-leaf chewing should be investigated. The 24 former leads to a rather well known condition: cocainism, i.e., addiction to cocaine. The latter leads to a habit, cocaism, which apparently does not follow the same psychopharmacological pattern, since a simple change in socioeconomic status or a change in geographical milieu leads to its spontaneous discontinuance; there is not a clear tendency to increase the dosage, as there is in cocainism, nor are there any evident withdrawal symptoms. Are these differences due only to the route of administration of cocaine? One certainly can provoke a clear syndrome of cocaine addiction in experimental animals (dogs, monkeys) by chronically administering cocaine by the parenteral route. But so far it has not been possible to obtain similar results by oral administration of this drug. Research Opportunities There are many stimulating areas for research on cocaleaf chewing. Facilities for research in this ﬁeld are potentially available at the Brain Research Center of the Armed Forces of Peru, of which I am director, and at the American Hospital in Lima, which has a good neurological and neurosurgical service. Investigators who wish to explore the possibility of conducting research related to coca-leaf chewing, or who wish to obtain further information, are invited to write to me at the following address: Dr. Fernando Cabieses, Talara 655, Lima, Peru. �Publications Tranquilizing and Anti-Depressant Drugs. Veterans Administration Department of Medicine and Surgery Medical Bulletin MB—6, September 12, 1960. Washington, D.C.: U.S. Government Printing Ofﬁce. This 19page bulletin is by Eugene M. Caffey, Jr., Leo E. Hollister, Alex D. Pokomy, and Jesse L. Bennett, all of whom are members of the Executive Committee of the Veterans Administration Cooperative Chemotherapy Studies in Psychiatry. It presents a general summary of current practices in the use of tranquilizers and antidepressives in psychiatry and in nonpsychiatn'c practice, and includes tabulations of generic names, trade names, and range of total daily dosage of drugs for outpatients and for hospitalized patients. The price of the publication is $0.15. Copies should be ordered from the Superintendent of Documents, U.S. Government Printing Ofﬁce, Washington 25, DC. Agressologie, an International Review of Physio-Biology and Pharmacology Applied to the Eﬁ‘ects of Agression, is a recently established journal that should be of interest to psychopharmacologists. In the preface to the ﬁrst issue, the title of the journal is explained: The commonly understood meaning of the word aggression is applied to the action of agents which harm the living organism by attacking it abruptly (from the outside or from the inside), including cold, heat, lack of air, surgery, disease, poisoning, and other causes of physiobiological disequilibrium which results in “more or less profound and lasting disturbances” in cellular metabolism. The purpose of the journal is to synthesize and integrate contributions which many basic disciplines are making to the study of the effects of “aggression” as previously deﬁned, and to the prevention and treatment of such effects. The journal is being published and edited by Henri Laborit, of the H6pital Boucicaut, 78 rue de la Convention, Paris 15, France, and P. Huguenard, of the Hopital de Vaugirard, Paris 15, France. Metabolism of, and Analytical Methods for, Phenothiazine Derivatives Used in Psychopharmacology; A Selected Annotated Reference List, compiled by the Scientiﬁc Information Unit of the Psychopharmacology Service Center. This list of approximately 65 references is made up primarily of articles concerned with analytical methods for the detection of phenothiazine derivatives used in psychopharrnacology, together with a few more general articles on the metabolism of these agents. The annotations are factual summaries of the articles, and are not evaluative or critical. The list is arranged chronologically. Copies may be obtained by writing to: Dr. Lorraine Bouthilet, Head, Scientiﬁc Information Unit, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda 14, Md. 25 U. S. GOVERNMENT PRINTING OFFICE: 1961 0- 580375 �� 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 Experimental Psychiatric Programs at Hillside Hospital, Psychopharmacology Service Center Bulletin, January 1961 (U.S. Department of Health, Education, and Welfare) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-009 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <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 Article based on Hillside Hospital annual report. One of nine articles in the Psychopharmacology Service Center Bulletin: NIMH-sponsored collborative study of phenothiazine treatment of acute schizophrenic psychoses; NIMH grant support for early clinincal drug evaluation units; Research conference on drugs and community care; Confernce on informaiton needs of psychopharmacologists; The psychopharmacology research unit at the Downstate Medical Center, Brooklyn N.Y.; Experimental psychiatric programs at Hillside Hospital; Coca-leaf chewing in the Andes; Publications. 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 http://exhibits.library.stonybrook.edu/mfp/files/original/ec4afc36e7130461e6211b8cf229b80f.pdf 15614c0aba92d94b8e5d0589849ccd08 PDF Text Text $57” 4’13 /?é,/~(22 ‘ may JUN HILLSIDE HOSPITAL Glen Oaks New 21 1961 York June 12, 1961 MEMORANDUM Victor Leventritt, Chairman, Medical Affairs Committee TO k Mr. M. FROM : Maurice Bachrach, Administrator WWW” SUBJECT: Proposed Research Request Budget for July'l, 1961 to June 30, 1962 income and the of proposed expenses Attached hereto is a presentation been has carefully Each 1961/62. request departmental research for for each schedule for There a is Robbins well myself. as reviewed by Dr. as Research Department. After the expenses are given for each department, we have Shown applicable and potential income from various sources that each of end At departmental the each department. for have been designated This the is "net deficit". shown the have department's we schedule, income that for designated less the for department, expenditure total department. will find the entire deficit picture which gives the from various income estimated each the of departments, for net deficit research the total to which Trustees applicable are the than sources other The research net departments". all and research "net deficit, program actual $53,250; our at was projected the for present year deficit Budget Research 1961/62 Request The $58,12h. estimated at expenditure is from this $h,250 of decrease net $h9,000, of a net deficit a projects actual from this year‘s decrease and $9,12h a Budget year's Request On page h you experience. �-2- June 12, 1961 HILLSIDE 1109131111, M wwnwm‘m 001. I Col. II - 1961/62 TENTATIVE REQEARCH BUDGET 1960/51 Budget I. 001. III 1951752" 1950731 Request Budget Experience est.) (2 mos. 001. IV Overage 001 III over 001. RE§EARCH IN EXPERIMENTAL PSYCHIATRY EXPEN§ES: l2 3 . . . 1 . Director . 7 . 8 . 9 . 1o. 11. 12. 13. 11. 19. 16. 17. 18. 19. 20. 21. 22. 1,500 3,100 3,100 3,113 2,163 600 600 600 3,311 11,011 2,817 10,126 25,000 17,000 3r. Assoc. Exper. Psychology 13,000 10,920 7,500 13,000 10,667 7,500 9,500 8,500 1,110 9,500 8,597 1,105 2,172 3,360 2,890 2,251 3,127 2,356 Assoc. in Psychiatry v - n n Assoc. EXPer- Psychology 6 . ‘Asst. Exper. Psychology S 25,000 17,500 9,000 11,000 13,331 8,100 7,218 10,000 1,120 1,800 3,600 2,185 3,192 2,710 1,500 3,000 3,600 3,000 25,000 16,116 u n (NEW) 11 Assoc. in Social Psychology Assoc. Exper. Psychology E.E.G. Technician, Sr. E.E.G. Technician Jr. (NEW) Psycholinguistic Technician Secretary Clerk Typist Technical Ass't. Equipment Travel supplies (office (NEW) & Medical) Director's Professional Expenses Training Expenses gocial security Overhead & Blue Cross Research in enses115351%§%151'9§23515177'7“' Total - - - - - — 251 1,838 3,500 11,010 - 1,081 9,000 1,000 2,111 (A) (B) (0) (B) 600 (C 7,218 (E) 500 (F) (7,080)(G) 390 (c) 3,600 (H) 313 (C) 132 (C) (150) 1,500 (I) (1,500) 200 (100) 1,838 (J) 186 2,999 ' 129,923 licable & Potential Income Researcﬁ in ExperimenEEI Psychiatry 122,839 7 159,797 29,871 A 23.'ﬁ?§7”565113 ﬁSEIEE‘EEFFTEE“"‘72,101 21. Drugs 25. Nassau County 26. Potential Income Total Applicable PotentiEI Income - 3,120 11,102 & Net Deficit, Research in EggerimenEEI PsycHIatry 78,000 1,800 - 111,708 5,089 - . 12,307 (K) 5,089 (L) (3,120)(M) (11,102)(N) 89,923 82,800 119,797 29,871 10,000 10,039 10,000 0 I �Memorandum re: preposed Research Budget June 12, 1961 ans-u. II. RESEARCH IN BIOCHEMISTRY 001. EXPEN‘EES: I 1960/61 Budget 27. 28. 29. 30. 31. 32. 33. 3h. .35 . 36. 3?. 38. 39. 80. Director 3r. Biochemist 3r. Biochemist Biochemist Biochemist Jr. Biochemist Jr. Biochemist 13,500 8,786 8,hlh 5,000 21, 500 8,168 h,000 gecretary (%) 1,680 Diener 1, 250 Laboratory Equipment 2,000 §upplies 7,000 Travel 1,000 3ocial Security & Blue Cross 2,h80 Overhead 2,h75 Col. II I96076I Experience (2 mos. 13,500 8,783 8,820 5,000 21,170 8,131; 3,972 1,692 1, 250 1,677 7,89h 1,000 1,776 h,2Bh est.) 001. III I96I752 Request Budget 13,500 9,883 1,816 5,300 8,600 8,868 h,h00 1,7h8 Col. IV Everage Col III over 001. I 697 (0) (6,998) 300 100 308 800 68 (o) (0) (0) 5,800 6,200 1,000 2,000 3,200 3,800 (Q) 300 (950) (800) 725 66,289 67,152 63,815 (2,83h) Applicable & Potential Income Research in Biocﬁemist MET—‘41:: 13"".9. Hea th service ET 82. Potential Income 18,162 26,087 111,317 - 37,900 6,515 19,738 hh,2h9 h1,317 hh,815 22,000 25,835 19,000 7,000 2,066 1,000 3,000 PatentiaI (19,572) & Woe Income h3. Net Deficit- Research in ems ry III. 166 (3,000)(R) MEDICAL DEPARTMENT RESEARCH EXPENQEE: 88. 85. 86. 87. 88. 1:9. Research Assoc in Medicine Research Associate Nurse-Technician supplies Travel & Publications 3ocial 3ecurity & Blue Cross w - 3,000 900 800 1160 - h,000 3,108 (7,000) 8,000 108 100 139 1,000 245 I425 (200) (35) 6,250 8,733 (3,027) - 200 Total Expenses - Medical Dept Research (0) (h80) Total E enses - Research in Biocﬁemlstry Total Applicable (O) 11,760 �Memorandum -h- re: proposed Research Budget £31. I 1960/61 Budget Applicable ,0. & Potential Income June 12, 1961 Col. II I95575I" Experience (2 mos. Est.) Col. III I§5I752 Request Budget Col. IV Overage III Col over 001. 1,510 5,000 u,000 8,733 h,223 (5,000) _2,510 h,000 8,733 (777) 2,250 2,250 - Net Deficits Forwarded §E§earc 1n . syc iatry Research in Biochemistry Medical Dept. Research h0,000 22,000 2,250 h0,039 25,835 2,250 h0,000 19,000 - (3,000) (2,250) Total Deficits 6h,250 68,12h 59,000 (5,250) 1,000 2,000 1,000 2,000 1,000 1,000 8,000 7,000 8,000 10,000 10,000 (1,000) 58912:: Egauw (E: 250) 51. 1c Potential Income . . Total Applicable PotentIaI Income .ervzce - & 52. Net Deficit Medical. Dept. ﬁesearcﬁ Unrestricted Research Income Henry Kaﬁfmann MemoriaI Funa scheuer Research Fund Contributions - Other than Trustees Total Unrestricted Research Income 11,000 NET RESEARCH - I DEFICIT; III‘DEEERTMENT§"‘“‘ 53, 250 (2,2SO)(31,_ - - (1,000) - _ �-Memorandum - - re: proposed Research Budget ane 1 1961 BUDGET COMMENTS I. RESEARCH IN EXPERIMENTAL PQYCHEgTRY EXPENSEB: projects total expenditures of $159,797, an increase of $29,87h over the approved budget for 1960/61. This increase is made up of the The Request Budget following items: Note A: Line 2-Associate in Psychiatry (Dr. Donald Klein)--Increase-----------—-—--$l,08h This increase represents tﬁo factors: a. Annual increment of $500 as of July 1, 1961 in accordance with stated increment plan. b. Salary adjustment made during the year in order to accurately reflect Dr. Klein's actual qualifications and experience. Note B: Zine §--Associate in Psychiatry (Dr. John Kramer)--Increase—---------------$9,000 During the current budget year Dr. Kramer divided his time between the research and clinical programs, being in charge of the Electro Shock Therapy services on the clinical side. He received part of his remuneration from the Operating Budget and the remainder of his salary was made up by a United 3tates Public Health Service Fellowship. His Fellowship terminates geptember, 1961 so that $9,000 of his total salary of $13,826 should be charged to the Research Budget. Note C: Line 5-- Senior Associate in Experimental Ps hole --------------------------- ncrease---~---------—-—-$1,000 Line 6--Assistant in Experimental Psychology (Eric Karp)—-Increase --------- $ 600 Line 10--EEG Technician Senior .................... Increase ................. $ 390 £§§§_}2--PS cholinguistic Technician -------------- Increase ----------------- $ 313 Line 13--‘Secretary-------------------------------- Increase----------—------$ 132 These repreEEnt regular increments for these positions. Note D: fine 5--Associate in Experimental Psycholo (Dr. Ira Belmont)--Increase---$2,hlh This increase represents two factors: Full year employment for 1961/62 against part year employment for 1960/61; increment from $12,500 to $13,500 as of September 1, 1961. �"Memorandum -6- re: prOposed Research Note E: Line 7--Assistant Budget June 12, 1961 erimental Psychology (NEW)--increase --------------- $7,2h8 personne? itEm grows out of two related factors in E This new in the program. 1. The volume of work in Experimental Psychology during the current year has risen to a point where it places a great strain on the two incumbents. In order to complete the number of psychological tests and experiments essential to the program it is necessary to add personnel able to do this work. This however would not require a full time worker. 2. This factor is related to the information given below in Line 11 which states that we have made a definite policy decision to make encephalographic studies of every patient admitted to the Hoapital instead of a selected sample of patients. This program of encephalography for each patient necessitates a corresponding increase in the number of associated psychological tests which are made concurrently with each encephalograph in order to complete the picture which we are seeking. These two added work loads qualified psychologist. will amply use the full time of a Note F: $ 500 Kelman)----increase (Dr. 8--Associate -----------in roial Psycholo Line or y the fact that the e 1 erence is accoun e new incumbent has higher qualifications than the present incumbent. Note G: Lin' e §--Associate in ppo n ment en 3 erimental Psycholo ugus , . w (Dr. Karl Anderman)-decrease--$7,080 Note H: fine IluEEG Technician Junior (NEW) -------------- increase ----------------- $3,600 The purpose of this new position is to enable the department to make complete encephalographic and associated psychological examinations of every admitted patient. At the present time we are making encephalograph studies on only a portion of the population related to our drug investigations. much found have we a however, these of studies, In the course been have we than abnormal of encephalograms incidence higher It has therefore been decided that it would be valuable and informative to make of instead each on patient study encephalographic a full selected patients in order to learn whether this high incidence of abnormal encephalograms will hold for the total patient population. In order to achieve this, it is necessary to add this position in to referred services additional psychological the well as as led to expect for our patient population. Line 7 above. �“memorandum -7- Note re: proposed Research Budget June 12, 1961 I: fine IS--Teohnical Assistant (NEW) ---------------- increase ----------------- $h,500 This positioﬁ‘is Being added in order to relieve higher paid professionals, psychiatrists and psychologists from statistical work and to provide a coordinating function in the department in the development of more efficient methods. This will give the top professionals more time and opportunity for the use of their higher skills. Note J: Eine 50~~Training Expenses ------------------------ increase ----------------- $h,838 Cost for didactic psychoanalysis, special courses, etc., for Dr. Donald Klein (Line 2 of budget); this expenditure is covered in full by United gtates Public Health Service‘Grant. Note K: line Income------ ------------~--~--a_~--increase—-------—--------$h2,307 Represents approximately $16,000 of additional funds for a con— tinuation grant from the United States Public Health 3ervice and $26,000 from the same source for a Career Investigation Grant to cover Lines 2 and 20 of the budget. 23--USEHS Note L: fine 25--Drugs ------------------------------------increase ----------------- $ 5,089 This {tam is for psychotropic drugs which the Hospital receives free of charge due to our extensive research studies. The cost of these drugs which the Hospital would normally purchase are charged to the Operating Budget and credited to the Experimental Psychiatry . Budget. Note M: Line 2S—-Nassau County---------------------------- decrease----------------- $ 3,120 Research projects supported by Nassau County have been completed and not renewed. Note N: Line 26--Potential Income ------------------------- decrease ----------------- $1h,h02 For I96I752 there are no pending grants or any other sources of potential income to be noted. II. REiEARCH IN BIOCHEMISTRY EXPENSES: Note 0: EIﬁes 58 and 30 through 3h------------------------ increase ----------------- $1,869 AII these increases totalling $1,869 are in accordance with the stated increment policy of the Hospital. the Line P: 29--§enior Biochemist------------------------decrease ----------------- $6,998 Kppointment ends August 31, 1961 �{Memorandum -8- Note re: prOposed Researdh Budget June 12, 1961 Q: ITEE‘36--Laboratory Equipment ------------------ ---increase ----------------- $3, 800 This expenditure is Toor one item of equipment covered Uhited States PUblic Health Service in full by Grant. a Note R: TEEE-E3--Net Deficit: Research in Biochemist ----decrease --------- - ------- $3,000 The decrease shown is the difference between the current year's budget and the budget for 1961/62. It should be noted that there is a decrease of $6,835 from our actual experience III. MEDICAL RESEARCH Note 3: Line §§--Net Deficit: Medical De Research-~decrease ---------------- $2,250 ent ¥or E? accountéd This decrease is the fact that Dr. Arnold Blumberg's full salary is carried in the Operating Budget as Hospital Internist and Employee Physician. All other expenses of this project are covered by a Federal Grant. �Memorandum OFFICE 01" 113E Frm The Mlmm June 30, 1961 Dr. Fink To: 1961-62 Mdget Re: is etateunt of the budget allowance for your departnnt for 1961—62; this is sent to you for your guidance The attached a during the coming year. If you have any queationa whatsoever, please feel free to see me about this femlation; I do not hear you I will assure that all of the figures and procedures are accepted by you. 1133130 Mel. if Ira �”7;” a Q ray—o“ meE 1961-62 WEARCH IN WTAL Salaries and Director Assoc. " nses " Sr. Assoc. Exper. Psycholoy Assoc. Exper. Psycholoy Asst. Exper. Psycholog I (new) I Assoc. in Social Psychology Assoc. Exper. Psycholog ' E.E.G. Technician, Sr. 15.3.0. Technician Jr. (new) Psycholinguistic Technician Secretary Clerk Typist 1961-62 Reguest (Kramer) 25,000. 17,500. 9,000. 25,000. 17,500. 9,000. (Belmont) (Karp) 13,33h. 8,100. (Fink) (Klein) (Pollock) "’ (Kellen) (Andersen) (Hosquera) (Kolo (Podrid Director's Professional Expenses Training Expenses Social Security & Blue Cross Overhead Research in Total nses ZﬁﬁeriggnEEE Egichiatii Potential Income licable & Research in EggngESEtal Pszghiatgz 3. Public Health Service Drugs Hess au County Potential Income Total tent Net licable Deficit Research in ﬁrﬁntg 111,000. 114,000. 7,2148. 7:2h80 Psichiat'i 1 r ,Afyc ﬂy}. ‘3 .. jar ~M" Deferred* 13, 33h. 8,100. 10,000. 10,000. h,800. 3,600. 2, h85. 3,h92. h,800. 3,600. 2,h85. 3,192. 2,710. 1,1120. 2,7110. 11,500. 1,1120. 11,500. 3,000. 3,600. 3,000. 600. 3,000. 3,600. 3,000. 600. h,838. 3.500. 1h,0h0. 3.500. 1h,oho. 159.797. 159,797. 11h,708. 11h,708. 119.797. 119.797. , 240,000. 110,000. . 5,0890 & ncome "? \ Approved 1961-62 Budget Technical Ass't (new) Equipnent (office & medical) Travel Supplies U. BUDGET \\\ {Lu [7/1, PSICHIATRI in" Psychiatry A HOSPITAL /' :1 11,838. 5,0890 cc: Dr. Fink Dr. Robbins Acctg. Dep . *These items requested may be restored to the budget during 1961-62 additional funds become available. if �Duﬂelmh C1707 9L“! v714x14 C 5. /£j>ur5r‘pf ~ "‘50 zaﬁ/ "‘.’U.'>V'“ ,I‘ June 12, 1961 HILLSIDE HOSPETAL TENTATIVE REsEARCH BUDGET Col. I. I - 1961/62 C01. II 1960761 1960/61 Budget Experience (2 mos. est. Col. III 195I75§* Request Budget ) Col. IV Overage 7001 III over Col. I RESEARCH IN EXPERDMENTAL PSYCHIATRY EXPENgES: 1 . 2 . Director Assoc. in Psychiatry 25,000 16,116 25,000 17,000 1 . 9r. Assoc. Exper. Psychology 13,000 7,500 13,000 10,667 7,500 9,500 8,500 1,110 9,500 8,597 1,105 n . 3 5 . 6 . 7 . 8 . u Assoc. Exper. Psychology “Asst. Exper. Psychology " (NEW) Assoc. in aocial Psychology Assoc. Exper. Psychology 1.13.0. Technician, Sr. E.E.G. Technician Jr. (NEW) Psycholinguistic Technician 9 . 10. 11. 12. 13. 9ecretary Clerk Typist '. 15. Technical Ass't. 16. 17. 18. 19. Equipment Travel supplies (office - & Medical) enses- Research in Ezgerzmeniéz Psychiagry licable & Potential 2'3. 21. Drugs 25. Nassau County 26. Potential Income Total Applicable FofenEIaI Income PS 0 rvice 3,113 2,163 600 600 - 1, 500 3,100 3,100 251 - - 1,838 3,500 11,010 2,817 10,126 . 1,081 9,000 1,000 2,111 (0) (D) 600 (C) 7,2118 (E) 500 (F) (7,080)(G) 390 (c) 3,600 (H) 313 (C) 132 (C) (150) 1,500 (I) (1,500) 200 (100) 1,838 (J) 186 2,999 129,923 atry 72,101 - 122,839 78,000 1,800 - 159,797 111,708 5,089 29,871 12,307 (K) 5,089 (L) (3,120)(M) (11,102)(N) - - 89,923 82,800 119,797 29,871 10,000 10,039 10,000 0 3,120 11,102 & Net Deficit, Research in EggsrimenfEI Psychiatry (A) (B) ' “Fawn .n erimen esearc U:.:S:.::m%c§ Income 7,2113 10,000 1,120 1,800 3,600 2,185 3,192 2,710 1,500 3,000 3,600 3,000 2,251 3,127 2,356 600 Expenses Training Expenses 30cia1 Security & Blue Cross 3, 311 Overhead 11,011 Total - 2,172 3,360 2,890 - (NEW) Director's Professional 20. 21. 22. An 10 920 25,000 17,500 9,000 11,000 13,331 8,100 ‘ �WWW Memorandum ~S- re: proposed Research Budget June 12, 1961 BUDGET COMMENTS I. RESEARCH IN EXPERIMENTAL PQYCHIATRY EXPENSEB: projects total expenditures of $159,797, an increase of $29,87h over the approved budget for 1960/61. This increase is made up of the The Request Budget following items: Note A: Line 2-Assgciate in Psychiatry (Dr. Donald Klein)--Increase-~~---—---—-~---$l,08b This‘fhcrease represen s we ac ors: a. Annual increment of $500 as of July 1, 1961 in accordance with stated increment plan. b. Salary adjustment made during the year in order to accurately reflect Dr. Klein's actual qualifications and experience, Note B: tine §--Associate in Psychiatry (Dr. John Kramer)~-Increase----------------$9,000 During the current budget year Dr. Kramer divided his time between the research and clinical programs, being in charge of the Electra Shock Therapy services on the clinical side. He received part of his remuneration from the Operating Budget and the remainder of his salary was made up by a Uhited States Public Health Service Fellowship. His Fellowship terminates September, 1961 so that $9,000 of his total salary of $13,826 should be charged to the Research Budget. Note 0: Line ﬁ~~§enior Associate in Experimgital Psycholo Drtéﬂax PoIIaCE--—-------------------—-::— ncrease ----------------- $1,000 Line 6--As§istant in;§§perimental Psychology (Eric Karp)--Increase 600 $ --------- Line lO--EEG Technician Senior-------------------- Increase ----------------- $ 390 Line 12--Psycholinguistic Technician -------------- Increase ----------------- $ 313 Eine 13--Secretagy -------------------------------- Increase--------~------~-$ 132 These repres§nt regular increments for these positions. Note D: fine §--Associate in Experimental Psychology (Dr. Ira Belmont)--Increase---$2,hlh This increase represents two factors: Full ytar employment for 1961/62 against part year employment for 1960/61; increment from $12,500 to $13,500 as of 3eptember l, 1961. �Memorandum -6- re: proposed ?esearch Budget June 12, 1961 Un- Note E: Line 7--Assistant erimental Psychology (NEw)--increase--------------- $7,2h8 personne§ item grows out of two related factors in E This new in the program. 1. The volume of work in Experimental Psychology during the current year has risen to a point where it places a great strain on the two incumbents. In order to complete the number of psychological tests and experiments essential to the program it is necessary to add personnel able to do this work. This however would not require a full time worker. 2. This factor is related to the information given below in Line 11 which states that we have made a definite policy decision to make encephalographic studies of every patient admitted to the Hospital instead of a selected sample of patients. This program of encephalography for each patient necessitates a corresponding increase in the number of associated psychological tests which are made concurrently with each encephalograph in order to complete the picture which we are seeking. These two added work loads qualified psychologist. Note F: will Line 8-~Associate in gocial Psycholc The difference is new incumbent has present incumbent. amply use the (Dr. full time of a Kelman)----increase--------~---$ at the iac accounts or y e higher qualifications than the 500 Note G: fine §--Associate in §%perimental Psychology (Dr. Karl Andermagl—decrease--$7,080 Kppointment en s ugus , /a . the H: Line I1--EEG Technician Junior (NEW) -------------- increase ----------------- $3,600 The purpose of this new position is to enable the department to make complete encephalographic and associated psychological examinations of every admitted patient. At the present time we are making encephalograph studies on only a portion of the population related to our drug investigations. In the course of these studies, however, we have found a much higher incidence of abnormal encephalograms than we have been led to expect for our patient population. It has therefore been decided that it would be valuable and informative to make a full encephalographic study on each patient instead of selected patients in order to learn whether this high incidence of abnormal encephalograms will hold for the total patient population. In order to achieve this, it is necessary to add this position as well as the additional psychological services referred to in Line 7 above. �Memorandum -7- Note re: proposed Research Budget June 12, 1961 I: EEEE'I§--Technical Assistant (NEW) ---------------- increase ----------------- $h,500 This position is Being added in order to relieve higher paid professionals, psychiatrists and psychologists from statistical work and to provide a coordinating function in the department in the development of more efficient methods. This will give the top professionals more time and opportunity for the use of their higher skills. Note J: Tine 20--Training Expenses ------------------------- increase ----------------- $b,838 Cost for aiHEE'icfEEychoanalysis, special courses, etc., for Dr. Donald Klein (Line 2 of budget); this expenditure is covered in full by United §tates Fublic Health Service‘Grant. Note K: Line 23"‘USH‘I9 In00me-----n-m-'~~—--——---ou—-~-.._..-a-increase—-—---—-—--------$b2,30'? Represents approximately $16,000 of additional funds for a continuation grant from the united States Public Health 3ervice and $26,000 from the same source for a Career Investigation Grant to cover Lines 2 and 20 of the budget. Note L: Line §E--Drugs ------------------------------------ increase ----------------- 3 5,089 This item is for psychotropic drugs which the Hospital receives free of charge due to our extensive research studies. The cost of these drugs which the Hospital would normally purchase are charged to the Operating Budget and credited to the Experimental Psychiatry Budget. Note M: Line §S--Nassau County---------------------------- decrease----------------- $ 3,120 Research projects supported by Nassau County have been completed and not renewed. Note N: Line 26-—Potential Income ------------------------- decrease ----------------- $lh,h02 For I95I752 there are no pending grants or any other sources of potential income to be noted. �T’Heﬁo ﬁranluh desk of 'L.ING.BE ‘ L Jun 21, 1961 to: Dr. Fink: of June 30, 1961, the changes you requested will be reflected in your net expenses. As will net expenditure of h0,000. at that time. we 114% show a M ”(M (L/ao/o/ 6’35? �Pg. 1 To: I Dr. Fink Director, Research in Experimental Psychiatry Fran: Accounting Dept. Re: Report of Expenditures 1 60 - H 31 1961 HOSPITAL 50331012110 ”Lac Fink Siege], Secretary Podrid Salaries 0 uses : Assoc. in Social Psychology Psycholinguistic Technician maize}! Kolodny Medical Equipment 113. Expense Account Total Expenses 1333: Income from Nassau County ' Donat i on of Psych 0 room Dru g s Net Expenses cc: Mr. Bachrach t 3,120. 2,172. 2,890. 1,500, Office Equipment Travel Supplies Social Security & Blue Cross Director's 25,000. to Hospital . 23,753' $33.?- :1 12, 3 . 18%. ES. 3’1“». 3 , hog. 920. 600. 1,0 . 2 38 . 143,120, 37,109- 3,120. 3:35;9 . {5%. 7 ' W, 0. ho,ooo, 31,859. �.1 Dr. Fink Pg. Director, Research in hcperhnental Psychiatry GRANT 2 141-2715 1/1/61 to 12/31/61 Grant. approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant 16 2 0 . approved for with: Amount hl,058.* 1960.61 to applicable hperience 1960-61 Budget . To Date ,. Grant. Balance 6/30/60 32,1105. 311,599- Additions: Amount applicable to 1960-61 1431053 -* bl 053. Starting Balance Salaries & ese nses: ssoc. n sychiatry Sr. Assoc. in Exp. Psychology Assoc. in Em. Psychology Asst. in Exp. Psychology Assoc. in 73,u63. Additions & Exp. Psychology Psycholinguistic Technician E.E.G. Technician Secretary Secretary 16 ,h16.~- \ Klein Pollock (Gittehnan 675. 6’8?” ’ 9’ 8,500. 7 ’ 890. 291. luhlo. 3,360. mm»... RM V . h 028 9,8112. " ’ 7'93: 106. ' Sspplies 2:5“). Medical Equipment Office Equipmnt Social Security 9 . 7.500. (Andermann Kolodny Mosquera Castalano ’ 10,920.-~r (Krauthamer % 15 583 6,1914.’ 7,333. (Belmont Karp v-1... 75 , 797 . 8: Overhead 382. 1,928. Blue Cross 9,681» " 1-1519‘ ,1 729. 3’ 259 1:100. “Iravel ”933' Total Expenses Unexpended Balance 530' - is 3!“an cc: Hr. Bachrach " Em 66,085. 9,672. if)? w, a 5, X“ I 3 41.3 6 7 3"? �Pg. 1 W m Director, Research in Ehperimsntsl Psychiatry To: Dr. From: Accounting Dept. Re: Report of Menditures J1EE}. HQ] .. 5323 39 mm HOSPITAL SUBSDIZED RESEARCH Experience To Date 1961-62 Budget SALARIES Fink Kramr 2% 6’25° Equipment Travel supplies 3. S. & Blue Cross Director‘s Expert“ Accmmt TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES CC: Hr. Baohroch $313“ ' 3 233‘ 5 350 “65 5,089. 5 335 h0,000. 1 g �Pg. 2 To: Dr. Fink Director, Research in hperinantal Psychiatry cam 141—2715 Mariana To Date Grant Balance 6-30-61 ’ Addition: Starting Balance and Additions _S__ALARIES Klein Pollock Belmont Karp Andermann Kolodmr Mosquera Zoller & Schniman Cartolano xrlmr EXPENSES Winner Goldaclmidt Supplies Equipmant Travel S. S. 8: Blue Cross Overhead TOTAL EXPENSES UNEZPENDED BALANCE 00: Hr. Bachrach Sept. 30, 196; 6,810 .57 20 529, 2 72 .. 1,000. 3 ,500, 3,203, 2,025. 1, 771. 619. 1,133. 625. ho. 2 ’2500 610. 263. 133, 1,01h. 301. 2 ,676, 21,168. 6,201,, ., .. __ ..__.. ._.... �av~ ﬂh T6: Dr. Fink Director, Research in Mammal Psychiatry W Experience to Date 3.21;. 302 1961 Grant Balance 6-30-61 Additions -’\ Starting Balance and Additions SALARIES Klein Podrid 3,500, 861. EIPENSES 8.8. 8: Blue Cross W @1135 0 Supplies row. Emmszs mm ,. 8,166. p.500.) BALANCE « W 00: Hr. Bachrach 5" 64“ ”‘5 27’? 6‘ ﬂex/4’" ﬁb (I M / . �d To: . .‘Dr. Fink Director, Research in Experimental Psychiatry (RANT HI-hl98 to Date Sept. 30, 1961 Grant Balance 6-30-61 Additions ___6.ééé..________.____..___ Starting Balance and Additions M Klein Podrid 6.666. 3.500. 861. EXPENSES S.S. & Blue Cross Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC: Mr. Bachrach 78. _______7_13‘_____________________ �"\ Pg. 1 x To W Dr. Fink Director, Research in Marianna]. Psychiatry From: Accounting Dept. Re: Report of Expenditures July 1 - October 31: 1961 HOSPITAL SUBSIDIZED RESEARCH Ebcperience ' To Date 1961-62 Budget SALARIES Fink Kramer 8.331.. EXPENSES Equipment Travel Supplies Blue Cross Director's Expense Account S. S. & TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES 00: Hr. Bachrach 221;. 116. 13. 8,990. 1 “55 5,089. I 525. 140,000. �Pg. 2 To: Dr. Fink Director, Research in hperimental Psychiatry GRANT 141-2715 Experience To Date Oct. 31, 1961 Grant. Balance 6-30-61 July Oct. Additions . Starting Balance and Additions §5_LARIES ""‘"""" Klein Pollock Belmnt Karp Andermann Kolodny Mosquera Zoller- Schnirmn Cartolano Kramer Winner GOIdBChEidt EXPENSES 6,810.57 20,529. 20,529. 147,901.57 1, 333. 14,666. M333, 2,700. 1,771. 906. 1, 510. 879. ho. 3,000. 1, 277 . 550. Supplies we“ 3'“ S. S. Blue Cross Overhead & '7 215. 6 . l’iog. 3,568. TOTAL EXPENSES 2Q UNEXPENDI BALANCE 19.,hﬂs.._______________ 00: we mach mg. _... �.M W Pg. 3 Dr. Fink To: Director, Research in Experimental Psychiatry W herience to Date - Grant Balance 6-30-61 July Additions Oct. Starting Balance and Additions W October 31, 1961 6 666. 6:66h. 13,330. Klein Pcdrid h,667. 1,280. Travel 111;. EXPENSES 8.5. & Blue Cross Supplies Overhead TOTAL WSES UNEXPENDED BALANCE CC: Hr. Bachrach 10?. 15. 950. 7 ,133. 6,197. _ ��Pg. 1 ‘ EEEQEEEEE! To: Dr. Fink Director, Research in Emerimental Psychiatry From: Accounting Dept. Re : Report of Ehcpenditures July 1 to November 30: 1961 HOSPITAL SJBSIDIZED RESEARCH Experience To Date 1961-62 Budget SALARIES Fink Kramer 10,u16. EXPENSES Equipment Travel Supplies 808. 205. 53. Blue Cross Director's Expense Account S. S. 8: TOTAL EXPENSES LESS Donation of Psychotropic Drugs NET EXPHWSES CC 3 “re BacmaCh 235 11,767 . hég, 5,089. 10 302, 130,000. 1 __ , �Pg. To: 2 Dr. Fink Director, Research in Khmerﬂwntal PSyChiatry GRANT 141-2715 Merience To Grant Balance 6-30-61 July Additions Oct. Starting Balance and Additions SALARIES Klein Pollock Belmont Karp Andermann Kclodny Mosquera Zoller- Schnirman Cartolano Kramer EXPENSES Willner Gold schmidt 6,816.57 20,529. 20,529. h7,901.57 1,666. 5,333. 5,1633,375. 1 , 771 , 1,117. 1 , 888 . 1,111. ho, 2 ,250. 1 , 9&3 . 83 7 . Supplies 108. Equipment Travel S. S. G: Blue Cross Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC 3 Mr. Bacmactl Date 1 . ’2?“ 11,1160- 3h 0h] 13,352.. ‘ ___-.- �To: Dr. Fink Director, Research in maximum Paychiotry mum HI-h 98 Exporience to Date Grant July Oct. Edam. 6-30-61 6 666. 61661;. Additions Starting Balmco and Additions p.330. SALARIES Klein Podrid 5,833. 1,575. Travel 209. 138. EXPENSES 5.3. a: Blue Gross mm: Overhead MAL MSES mm MCE 00: Mr. Bachrach 2?. 1,181. 8,969. 5361. �Pg. 1 To: Dr. Fink Director, Research in Experimental Psychiatry From: Accmmting Dept. Re: Report of icpenditmrea Jug: 1 to December 31I 1961 HOSPITAL SUBSIDIZED RESEARCH Experience To Date --__ 1961—62 Budget SALARIES Fink 12, 500. Kramer w Equipment Travel Supplies 629. 318 Blue Cross Director's Expense Account S. S. 8: 2683, 13,797. TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES . 5,089. 2 ,295. 11,502. ho,ooo / 2K CC: Mr. Bachrach ; 1' a.) ,7“. ‘ .1 " .. �Pg. 2 To: Dr. Fink Director, Research in Experimental Psychiatry GRANT tax-2715 Experience Tb Date Grant Balance 6-30b61 July Oct. Additions Starting Balance and Additions SALARIES Klein Pollock 20 ,529 . 20,529. WI 901. 2 , 000. 7,000. 6,583. Belmont Karp Andermann Kolodny Mbsqnera Zoller - Schnirman 1,771. 1, 327 . 2,255. 1, 310. Kramer 3,000. Cartolano Willner EXPENSES 6,8h3.57 Gold schmidt Supplies those. hO. 2 ,652 . 1 , 1214 , 1108 . Equipment Traﬂel S. S. 8: Blue Cross Overhead 1 . ’23; 5,352. TOTAL EXPENSES 1 000 UNEXPENDED BALANCE ﬁIQQ], CC: Mr. Bachrach _ �To: Dr. Fink Director, Research in Experiments]. Psychiatry GRANT “1:5198 Meme to Date Grant Balance 6-30-61 July Oct. Additions Starting Balance and Additions W MNSES my) BALANCE cc: Mr. Bschrsch 13,330, 7,000. 1,870. Travel 350. 171. Overhead “FUSES 6,6611. Klein Podrid S.S. & Blue Cross Supplies TOTAL 6,666. . ho. ____J_’),L2)J_.________________,__ 102855. 2.2.15, �Pg. 1 Dr. Fink To: Director, Research Wu“). 1!: From: Accounting Dept. W62 Psychiatry Report of Expemﬂtures Re: . HOSPITAL w SUBSIDI- RESEARCH Experience To Date Fink 11bit”- Kramer 750. 21h. 333. Schnimn W" chin Equipment Travel Supplies S. S. gig" 1 ,1h9. Blue Cross Director's Ehpense Account & 359. TOTAL EXPENSES mss Donation of Psychotropic Drugs NET EXPENSES CC: Mr. Bachrach 1961-62 Budget m , 213 2 225 5,089. 15 213 1.0.000. �Pg. To: Dr. Fink Director, Research in Emperimental PsyChiatry GRANT MY-2715 Experience Tb Date W 6 ,8h3. 57 Grant Balance 6-30b61 Oct. Additions Starting Balance Jan. and Additions 68,906. Klein Pollock 2,000. 8 ,083. SALARIES Belmont Karp Andermann Kolodny Mosquera Zoller Cartolano Kramer EXPENSES Uillnnr Goldldhnidt Supplies Equipment Travel S. S. & Blue Cross Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC: 20,529. 20,32 3. Mr. Bachrach 7, 628. h:6730 1,771. 1,522. 2,633. 1’3h3. 3,000. 3. 3061,389. 938. 3,315. 1,h37o 839. 6,100. 50 0h}. 2 �Pg. 3 To: Dr. Fink Director, Research in Mex-mental Psychiatry GRANT DIX-£1798 Experience to Date Additions July 6,666. Jan. 6,66h. Starting Balance and Additions 19 . 8 8. SALARIES EXPENSES Klein Podrid 21%;, Travel 350. Bur SOS. & Blue Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC : Mr. Bachrach 60. Cross 2%. 0. 1, 3, 12 555, Lugs», �Pg. 1 To: Dr. Fink Director, Research in Experimental Psychiatry From: Accounting Dept. Re: Report of Ehcpenditures July 1, 1961 to February 28, 1962 HOSPITAL NBSIDIZED RESEARCH Experience To Date 1961—62 Budget SALARIES Fink Kramer Schnimn 2% Klein Equipment Travel Supplies Blue Cross Director's Expense Account S. S. & TOTAL EXPENSES LESS Donation of Psychotropic Drugs NET EXPENSES CC : Mr. Bachrach 15,371. 1,500. 1428. 666. M0. 1,329. 232. ['22 21,858. 2 1225 5,039. 19 5§2° h0,000. _ _. �Pg. 2 To: Dr. Fink Director, Research in Experimental Psychiatry GRANT 141.2715 Merience Date To Grant Balance 6-30-61 Additions 6,810.57 July - Jan. 62 ,062. Starting Balance and Additions SALARIES "" ' 68,906. Klein Pollock 2,000. 9,166. 8,673. 5,296. 1,771. 1,716. 3,000. 1,316. 66. 3,000. 1,694. Belmont. Karp . Andermann Kolodny Moequera Schnirman mm Cartohno Dramer Goldachmidt EXPENSES Willner Supplies Trave1 s. s. a. Overhead TOTAL EXPENSES UNEXPENDED BALANCE cc: Mr. Bachrach 3 , i460 . h, 2 95 . t 1 ) 1:353’1‘.. Blue Cross 7,01h. ‘4 ’ 9. 13,},62. �To: Dr. Fink Director, Research in Ewerimental Psychiatry GRANT DIX-M98 Mama to Date Grant Balance 6-30-61 Additions July - Jan. . -—————l9-,991+.——-——————————————. .___J.2;22L_.____.____.____.. Starting Balance and Additions SALARIES Klain Podrid EXPENSES 9 11 . falls» 2 Baer 212 . Travel 5.8. & Blue Cross Supplies TOTAL EXPENSES UNEXPENDED BALANCE CC: Mr. Bachrach 350- 319. 11h. 1h,h22. __§,_S7_g_._________________ �Pg. 1 MEMORANDUM To 3 Dr 0 Fink Director, Research in Experimental Psychiatry From: Accounting Dept. Re: Report of Expenditures Jnl3Al..l£ﬁl.tn.laznh.31,—1262 HOSPITAL SUBSIDIZED RESEARCH __ ...____~_._.._w-. __ Iii“ hramer Schnirnan Klein Experience To Date 1961-62 Budget 18,307. 2,250. 6h2. 1,000. EXPENSES Equipment Travel Supplies Blue Cross Director's Expense Account S. S. LESS r CC: & Donation of Psychotropic Drugs 4...: Mr. Bachrach 1 052. 1:971. 302. 509 ‘__~.w_____ 2' ““2 23 713. 5,0§3:~*WWM . 513,960. �Pg. 2 To Dr. Fink Director, Research in Experinental Psychiatry GRANT Mir-2715 Merience To 6,813.57 Grant Balance 6-30-61 Additions July - Jan. §2 m2 Starting Balance and Additions SALARIES 68 Qgé Klein Pollock 13:33: gm“ A”? ndermam Kolodm' Mosquera w! Krmr Ichnirnn Cartolano Winner EXPENSES Goldachmidt Supplies Eq‘li t Travel S. S. 8: Blue Cross Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC 0 Mr. Bachrach Date 9,718. 5,919. 1 771. 1:911. 3,353. 1,310. 66 000: ﬁz6Sg. 1’36 . h,326o , i’gﬁ’ , 0 7,927. E] 555 ‘ �PSe 3 To: Dr. Fink Director, Research in herimental Psychiatry GRANT MI-h798 aperience to Date Chant Balame 6-30-61 Additions July to Jan. Starting Balance and Additions w EIPENSES 1‘1““ Podrid Baer Travel S.S. & Blue Cross Supplies Overhead TOTAL MSES UNEXPENDED BALANCE CC: Hr. Bachrach __J.9..22lL.__.__._.—_______ :2 22!: 10,173. 2,686. 352. I495. 397, 188. _____2.135.______________. 16,136. 3 68. �M Pg. 1 To: Dr. Fink Director, Research in Ehcpermental Psychiatry From: Accounting Dept. Re: Report of Ebcperaditures __EﬂaLJg—lﬁél_tn_hp=il_30,—1962 HOSPITAL sussmxzm RESEARCH Experience To Date _.._...._.__. 1961—62 Budget SHARES Fink 20,2m4. Kramer Schnirman 3,000. 81h. 1, 308.. Klein §§E§E§§§ Equipment Travel Supplies S. S. & Blue Cross Director's Manse i’éﬁi: 3% Account $99. TOTAL EXPENSES LESS Donation of Psychotropic Drugs NET EXPENSES CC 3 29 Hr. Bacm‘aCh ‘ . 2 8] 2 295 22 186 5,089. 140,000. __ _ �Pg. 2 To: Dr. Fink Director, Research in Experimental Psychiatry GRANT Mir-2715 Emerience To Grant Balance 6-30-61 Additions 6,816.57 July - April Starting Balance and Additions SALARIES Klein P°11°°k 29%“ ”P Andaman KOlOdW Mosquera MmSchnirman Kramer Willner Gold schmidt EXPENSES - Supplies Egamt 8“]. So So & Blue Cross overhead TOTAL EXPENSES UNEXPENDED BALANCE 00: Mr. Bachrach Date 8 3 , 065 . _.__...__..__. 52 292 1%??? 10,762. 6 , suz . 1 ’ 7 71 . 2 ’ 105 . 3 ’ 736 o 13%;: 3 , 000 . S . 3%; 2 o7 . , 1 12 O 3,315. 2 1468 1,h23. ’ O 8 ’ 8h0 . 52 212 22 5 3? . �Pg. 3 Dr. Fink 'Mmqum—‘m To: Director, Research in Ebzperimental Psychiatry GRANT PIX-M98 Experience to Date Grant Balance 6-30-61 Addiu‘ms July to April ‘ Starting Balance and Additions —-4515S8~————————————26 658 SALARIES K331“ 1. 2:9g9. 11 2 PM?“ EXPENSES Baer T 371“ 1 Sgt“; Blue Cross Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC : Mr. Bachrach ﬂit . 188 . 2 312 18,072. 8 ~86 �’ To: Pg. 1 Dr. Fink Director, Research in Experimental Psychiatry From: Accounting Dept. Re: Report of Ebcpenditmrea Jugs! 1I 1961 - Max 2]“ 1262 HOSPITAL SIBSIDIZED RESEARCH Emerience To -.....___ Date 1961-62 Budget SALARIES Fink 22,179. 3,750. Kramer Schnirman W 1 , 028 . Klein 1,558. Equipment Travel supplies 8. S. & Blue Cross Director's Ishcpense Account TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES U4872,032. 356. 519 22 262. Mr. Bachrach ho,ooo. 30.6%; * Transfers from Grants MY 2715 and MY 1:798 as per your to be entered on books as of June 30, 1962. CC: 5,089. 2 225 memo of 5/23/62 - �Pg. 2 To: Dr. Fink Director, Research it: Write; GRANT Psychiatry rib-2755 Ehcperience To We Grant Additions 6-30-61 LPN-1;! ~ . April """"" 89,909 . Klein Pollock 2,000 12,h16. 11,808. Behnont Kerp Andemm Kolodny Mos ere my: Certoleno Schnirman ramer 1mm. Travel S. S. 8: Blue Cross 2,601. 1,600. 9,753. Overhead UNEXPDJDED BALANCE 00: he WW 92. Supplies Gold schmidt EXPENS$ MOMS. 1,3}43 . Willner Equipment TOTAL 7,165. 1,771. 2,330. 3 ’ 000 , 6 , O36 . K EXPENSES 6,810.57 £33,063. Starting Balance and Additions SALARIES Date 2 A1; , 72 120, 11.112 . �To: Dr. Fink Director, Research in Mex-mental Psychiatry GRANT PIE-M98 Emerience to Data Grant Balance him Additions . Starting Balance and Additions _ 26,658 . 26,658, SALARIES Klein Podrid EXPENSES B8 er 12 ,36". 3,2h2_ 37h . Travel h9h. S.S. & Blue Cross Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE 00: Hr. Bachrach 2481;. 188. g 692 12 256 g 202 �July 10, 1961 H830 re: ﬁre. Groghan Front Dr. Pollaak nleaae aet aaide the annual increaent approved for July 1, 1961 for retirement or other annuity pnrpneee attentive Jnly 1, 1961. I understand that the neniea withheld rill be nade available to me at my raqneet. Thank ynn. Would ynn Sincerely yours, Hrszp 33E FoIIacE, 55.5. �July 10, 1961 HERO To: Mrs. Croghan From: Dr. Klein please set aside tho annual increment approved for July 1, 1961 for retirement or other annuity purposes effective July 1, 1961. I understand that the monies withhold will be made available to no Would you at my requoab. Thank you. Sincerely yours, Drtgp I on . o n, . �g .I Wm [bur/m. a; !‘ ll L~O-h-b-C-* .0i ' 604’. a") “wt 6 ? 0 u-' ......... " ﬁ WW 4:~-5‘."4‘I-.0J.I«----'Q.OD.I'.II'.--.l“lC u-ov -.... n _ )J’ 4 I I! A / ” ll , I , 1 ”I. II i II II ‘ II II II II ll ‘ i "W“ II II || . ll ll ll r/. 03 nu». a A. V ['2411/ /€/ - �L\.‘\I-"-\ \y Q. �July 13, 1961 HERO To: Era. Dorothy Groghan Front Dr. rink Max Subject: Aaaignaout of salary Itaaa, 1961-62 Plaaao aaoign tho salary itaaa in tho Departaont of Exporirontal Psychiatry aa tolloval (a) lon-Govoroaant 1. Director 8. Social Psychologist 15. Toohnioal Aaaiatant (b) Dr. Fink To ho appointad To be appointod: H. NY-2115 2. 3. h. 5. 7. 9. 10. Payohiatriot (shooo) Lazoc. 8r. Expar. Psychology Aoaoo. Aoaiataut_ '” * ' - 0.1. Kloih John Kranar Pollack Dal-out Ira V Eric Earp Arthur Willnorﬁ streettvum9f6t-w Assoc. Expor.'Payoho1ogy Karl Andoraanui Ends 9/1/61 EEG Technician Hrs. Haaaah-Hooquora EEG Taohnioian ll. - Hrl. Ilano Goldoohaidtr Bagino 9/61 12. Poyoholinguiotio Toohoioian - Hrs. Joan Koloday 1h. Clark Typiat - 32f. fygiawzollor Max ‘ . (o) NI-h128 y 2. Payohiatriat 13. Soorotary . - D.F. Klltn - Hrs. Gloria Podrid Sinooroly youro, ﬁtter - ﬂax FIBEI 3.5?“ �July 19, 1961 HERO To: Hre. Croghen From: Dr. Ire Beleont pleeee set eeide the annual increment approved for Sept. 1, 1961 for retirement or other ennuity purposes effective July 1, 1961. I understand that the monies withheld will be made available to me Would you at my toque-t. Thank you. Sincerely yours, 1331p Ire EeImonE, 55.5. �Novenber 27, 1961 MEMO To: Mrs. Dorothy Groghan From: Dr. Max rink Subject: Revision of Salary Assignments, 1961-1962 Budgot. 2nd half, Please assign tho following salary itoms in tho Department of Exporinontal Psychiatry offectivo Jan. 1, 1962 to Juno 30, 1962 as follows: (a) Nen-Govornmont 1. Director - Dr. H. Pink 3. Psychiatrist ,- John Kronor (O$9000/annlb 8. Social Psychologist - To be appointod 1h. clerk Typist ”Us Do schnirlm '15. Technical Assistant - To be appointed (b) HI-2712 7 ' -21rPoychtatrist7**“‘““m“““‘””m““““”3“DTFT“ttetn“tO$kooo/annuo 8r. Assoc. lxper. Psychology - ﬂax Pollack 5. Assoc. I I - Ira Bolnont Assistant I 'I 3 I Assoc. Expor. Psychology EEG Technician EEG Technician Psycholinguistic Technician (c) HI-h798 C}. Psychiatrist 13. Socrotary - Eric tarp Arthur Willner To be appointed Hrs. Hannah Hosquera Hrs. Ilana Goldsohnidt Hrs. Joan Kolodny - D.F. Klein (Total loss $h000) - Hrs. Gloria Podrid Sincerely yours, Mllgp HIE'TIEEI'HTET' �MIMOIANDA ,“ �[13/ Memorandum From The OFFICE OF THE ADMINISTRATOR December 20, 1961 To: Dr. Arnold Blumberg v’Dr. Max Fink Dr. Harry Goldenberg 1962-63 Budget Re: I am working on the budget for the fiscal year - July 1, 1962 to June 30, 1963. Attached please find budget'forms with expense categories pertinent to your department. The first column shows the budgetary allowance for the current fiscal year; in the second column, kindly indicate the appropriation you feel will be needed for the 1962-63 fiscal year. You may append any data or schedules which you feel will be of assistance. For each item of salary and expense contemplated for 1962-63, kindly indicate in the appropriate column the source of support for the expenditure. Before you make your please confer with for next year. Thank you MB:DC Enclosure M:- 7254' final determinations for purposes of this budget, Dre Rebbins for your cooperation. as to your plans and budget prospectives �~T0: DEPARTWNT 0F MERIMENTAL PSYCHIATRY HILLSIDE HOSPITAL �L F; , . a , ,3 ,.. L: ....q. a a; mg 3. :m.‘ :2,‘ ,Fman .3, .35 n 1 a.»v. GM ,r I. , 4 Ahrwwm. a. H..4. H. ”a?” mh. 4 .3. . A». Vt. 1 can , H k ”21., ‘5‘.» K 3.: , _, L f. L H ‘ , . . l , f. : . , hm H 1+ ..'I {IIIII i'l'l'll «Inlgilillﬂllwll it‘ll-Illlllllllllllll «I'll'llll.wu,llllll"l “EIIIIIIII! .flllllllll I'lllnlll .,II|l|IIl|I:|-|lll|l.lll. IIIII'III...,.Illlll'l. Ill'lllll. «IIIIIIII! «ill-I'll! ,Illl'llllw ‘llllllllll .Ill'l'llllll ll! ‘ - , IlinllA ¢ A x . , 1, I x I.“ l z. , M I“ 1 . / , i. f lI < . . 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'E.E1.G. metal": thlby I a m W4 ‘ _ 30016. m1! . _ ~ Pmbloq Exp". thploq .7 Tahitian, Sr. E.E. a. nemoimn, Jr. Hams " ‘ ~ 1 mar-onngmtio technician ‘Stcutuy_ HINHW. ’ =j smm inert-Typist“ ' - . fwd/h‘wﬁﬁ $92:me mun) if Equip-Ont w-mia ”PM” ' . ’ ‘ ' W Wantor'a Prozac-10nd ruining Enigma (hasnun) "__Se¢1n «Emu Gm Wt! 1' ‘ m 'j: 2/1/11 " . .m in (/5: WW3: )7 * _ ‘ J47_-' r5“ ' ' ‘ �H1llside Hoqpitii 1962—63 Salaries Director & Budget - Research in Experimental Psychiatry Assoc. Exper. Psychology Asst. Exper. Psychology . Kramer . ’Pollock » Belmont ' Karp Assoc. in Social Psychology Assoc. Exper. Psychology E.E10. Technician, 3r. E.E.G. Technician, 4ﬁdhlﬂr Moaquera Jr. ,(L14‘.ALaQ»‘ (office and Medical) Training Expenses (Dr. Klein) Social Security & Blue Cross thioaw Total Expenses Anglicable & Potential Inca-o U. 5. Public Health Service «Mr—“whoa”, Ire.“ lions 7/4/4. a. 5».«~ " ﬁfe" . Fﬂclv 1“ 7 4/0 3 Director's Professional Expenses r. r- lbowr Scott/‘nual (éI‘M) 7 ?"',4]; : 3"” 47;: r: 417. Supplies W m-~.— C) agaao. Podrid 1‘rawel «- v 5-» [9‘100 ,.r, n.. ' A/vi Kolodny . mm. Drugs Request Anderman Psycholinguistic Technician Sacretnry Clerk-Typist ~Teohnioa1 Asst. gout/”‘4‘“ m... Budget .37 Klein Nil/Mr Overhead $1.1¢¢1Lc.z 1962-63 Egggnees Associate in Psychiatry n. I Sr. Assoc. Exper. Psychology Equipment 1961-62 F‘s-u ‘44. 7‘9 JI-A ?,h85. 3,h92. 2,7h0. h,500. 3,000. 3,600. 3,000. 6) >640 J 70 / 39/4. 7~fec — , /.(on Juo, 300 "' IOOo h,838. 3,5001h,ouo. V! 3! .3'00 [76yj'h' loco 153,797. /?3/:9. 113,708. 5,059. [4U .43 2! as. �” V‘r/‘f/ f‘ﬁf/ �7-5- H ”I ‘ I0“ V. .4 . ll . Mﬂzr Th ﬂ e, [ll—Yr» I ‘ . ll ll I! I Corr/biz} o‘7 ' I ‘ * - . ‘ " ~ “W ﬂﬂanoa‘ 1 t 1.- 6110 Q Afﬂéeméudz" ,, , .V 7!!) 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Requiaitione dated: 11/61 ﬂax rink - expenaee 12/61 Max Fink - expenses 12/20/61 Max naailton 2/8/62 L.I. stenotape Co. (Royal Typita) 2/8/62 Joint Purchasing (aupplies) 9.75 b0.61 50.00 53.20 h6.55 W. ."' �oemnmtm or: arm» mcmm HﬂLﬂDEPKNFgﬂL Gumcnﬂhl99' May 23, 1962 MEMO To: Mr. M. ﬁachrach From: N. Subject: to MY Pink, M.D. Adjustment of Expenditures MY 2715 and July 1, 1961 - June 30, 1962 MI L798 Please reassign following expenditures assigned 2715 to “non-government”. 1. a. Salary of Jan. 1, 1962 - June 30, 1962 Jen. 1, 1962-Mey 31, 1962 Goldschmidt, Ilene 2. Please reassign expenditures charged HY h798 by transfer to “non—government" of the following items: a. Gloria Podrid Charge 2/5 to MY h798 7/1/61 - data lolodny, Jeen " 3/S/to Non-Govt. b. Mrs. Gertrude Beer Charge ell salary to Non-Govt. c. Requieitione dated: Fink - expenses Fink - expenses 12/20/61 Hex Hamilton 11/61 12/61 Mex Max 9.75 h0.61 50.00 53.20 2/8/62 L.I. Stenotape Co. (Royal Typite) 2/8/62 Joint Purchasing (supplies h6.55 Hex FInE, M.D. �6/11/62 Brain Function and Bohavior Rososrch Progoct Bud‘otagz Rocoonggggtiono -- 1262 ~ 62 - Rovisod 6/11/62 Following discussions or 5/22 and 23, a hudgst rooosnondation for oightoon months support was prosontod which did not lost tho Radical Diroctor's approval. In ossonco, it provided for an oxponditurs or $53.h10 for the first six months; $63,183 for tho next twolvo; and of those suns, 325.750 from Hillsido Hospital and $90,8h3 (including $9583 ovorhsod) from tho u.s.9.n.s. In lino with tho discussion of 6/11/62, tho following rovissd budgot is prosontcd for consideration. 1. It is tho intsntion of tho Director of tho Dopartnont or Exporioontal Psychiatry to resign fro- hia prsaont pooition' on July 1, 1962 to continue os Principal Invsstigator (Consultant) of tho Brain Function and Bohavior Rosoarch ProJoct (H! 2715) to Doc. 31, 1962. For this poriod, to Doconhor 31, 1962 his ssrvicos will ho conponsasod on a consultant stipond basis, tron funds providod by tho Board of Directors of Hillsido Hospital. 2. It is roconnondod that Dr. Belmont, boginning 10/1/62, bo continuod on a flat too stipond basic at an ostblishod rats oqnivalont in ootivity to ono day pot wash. 3. It is roconnondsd that tho following adjustnonts ho nadc in Dcpartnontal hudgsts to accomplish tho rsquostod soparation of tho Dopartaont into constituont unite. �-2- s. the expenses and activities of Dr. Donald Klein he continued under the direct supervision of Dr. Robbins, providing such secretarial and data processing services as his project may require. b. in EEG technician salary be provided by the hospital at a rate of $5,000/annuu for full tile. 1 would suggest 2/5 tine; but this should be based on s reconaendation of tho hospital Neurologist. For the period that Dr. Kramer is available, he will continue to read the records; but provision should be node for others to do this. 0. Dr. Kroner to continue in the sane relationship to end or 1962 continuing supervision or 30!, at Dr. Robbins' K! h798 and pleasure. 0. Present budgets (to 6/30/62) he re-ellocated to show estimated expenditure of approximately $30,000 in Board support, allowing the following a a) Estinsted balance 6/30/69 nr 2715 2000 Incone 2nd half 1962 h2001 stupoo 5. Budgets for six nonths 1962 and 12 nonths 1963, corrected for social security, blue cross and statistical expenses are shown on next page. These provide, exclusive or principal investigators 7/1/62 - 12/31/63 3h,260 Overhead 1/1/63 - 12/31/63 5,100 $38,960 50.500 �-36. Requeet 0.8.P.H.S.t $hh,000 a. 196? Income Expendituree 38.960 5.000 app. - carried forward b. 1963 50,500 -._.£&99_ hS.Soo Overhead 6.8gg $52,325 7. With theee adjust-cute, the budget ie reconnended inclueingt a. Continuation request or I! 2715 be aubaitted to U.S.P.R.s., requeeting the aaount of 52,325 to retain at Hillaide ﬁoapital for 1963 and the balance (app. 31.000) he made available for application of continuation at the Mieeouri Iuetitute or Paychiatry. b. iproval for transfer of EEG analyser and tape eyeten ee requeeted h/l/62 be approved. 6. Board of Directors approval tormfunde or 12,500 for period 7/1/62 - 12/31/62 aa continued aupport of Principal Investigator (Coneultant) on baeis outlined above. In the event coneultent tine 1- required in 1963, expenses and ccnaultation teee are to be paid by Hilleide Hoopital through {undo provided by the Board of Directore. A contingency fund in the amount of 86000 ie eugteeted for thia activity. a. U.3.P.H.s. be requested to approve Dr. Hex Pollack ea oouinveetigator. �7/1/62 - 12/31/62 1/63 - 12/63 1. Staff Psychiatrist I. Pollack, 8:. Res. Assoc. taper. Peychol. John Kroner, 3,956 - I. Bel-out 7,500 3,582 15,000 'Earn, Consultant 750 Res. Ass't. Expor. Fsychol. A. "illner, Res. Assoc. Expos. Psychol. B. Hosquereﬂ, EEO Technician 3. b.350 h,700 1,000 1,700 1,h57 1,315 0. Podrid, secretary Dr. schnirnanhe, secretsry J. Xolodny, technician 351 BC (OPP) 3,000 8,700 , 9,h00 2,000 3,800 ~ 2,600 950 Travel Supplies Conputaticn c Consultation ‘ Carried forward Net Overhead u.s.r.n.s. Total ' Board support Total Budgets: 18 nos. uspns Board 500 600 900 1;560& 1,200 1,800 1,500 3h,260 50,500 3h,260 5,000 u5,500 5.100 38,960 6,822 $2,325 12,599 16,000) $109,785 91,285 12,500 (¢ $6000 contingency). Notes 0 H. Hosquere: tins s 380 resesrch i and as ties statistician, clinicel EEO services recouaended by Allows one es Secretary-typistc Prograa (it sill Neurologist). not require second typist 1963. �6/11/62 I! Brain Function and Behavior Research Proaect Budgetarz Reconnendetions -- 1962 - 63 - Revised 6/11/62 Following discussions or 5/22 and 23, a budget reconnendation for eighteen months support was presented which did not nest the Medical Director's approval. In essence, it provided expenditure of $53,h10 for the first six nonths; $63,183 for the next twelve; and of these suns, $25,750 from Hillside hospital and $90,8b3 (including $9583 overhead) from the U.3.P.H.3. In line with the discussion of 6/11/62, the following revised budget is presented for for an consideration. 1. It is the intention of the Director of the Department of Experimental Psychiatry to resign from his present position on July 1, 1962 to continue as Principal lnvestigator (Consultent) or the Brain function and Behavior Research Project (M! 2715) to Dec. 31, 1962. 1962 December to 31. his services period, this will be cenpensaeed on a consultant stipend basis, tron funds provided by the Board of Directors or Hillside Hospital. 2. It is recon-ended that Dr. Belmont, beginning 10/1/62, be continued on-e flat fee stipend basis at an estblished rate equivalent in activity to one day per week. 3. It is recommended that the following adjustnente be node in Departmental budgets to accomplish the requested sepsraticn or the Departnent into constituent units. For �-2- a. activities of Dr. Donald Klein he continued under the direct supervision or Dr. Robbins, providing such secretarial and data processH! h798 and the expenses end ing services as his project require. b. in EEG technician salary be provided by the hospital at a rats of $5.000/annuu for full time. I would suggest 2/5 time; but this should be based on a reconnendation of the hospital Neurologist. For the period that Dr. Kramer is available, he will continue to read the records; but provision should be made for others to do this. c. Dr. Kramer to continue in the same relationship to end of 1962 continuing supervision of ICT, at Dr. Rohbins' pleasure. h. Present budgets (to 6/30/62) he re-allocated to show may estimated expenditure of approximately $30,000 in Board support, allowing the following: a) Estimated balance 6/30/6? NY 2715 2000 Income 2nd 5. half 1962 h2°?Z, thhpoo Budgets for six uonths 1962 and 12 months 1963, corrected for social security, blue cross and statistical expcnaes are shown on next page. These provide, exclusive of principal investigator: 7/1/62 - 12/31/63 Overhead 1/1/63 - 12/31/63 3h,260 - 3.100 838,960 50.500 �-36. Request U.S.P.H.s.s s. 1962 - Income Expenditures $bh,000 38.960 5,000 spp. - csrried forward b. 1963 * 50,500 §IOOO hS’SOO Overhead 6:825 $52,325 7. With these sdJustsents, the budget is recossended inelusing: s. Continustion request of I! 2715 be submitted to J.S.P.H.S., requesting the ssount or 52,325 to rensin st Hillside Hospitsl tor 1963 end the bslence (spp. 31,000) be nsde evsilsble for spplicstion of continuation at the Missouri Institute of Psychiatry. b. Aprovsl for transfer of EEG snslyser end tspe system so requested h/l/é? be approved. 0. Bosrd of Directors spprovsl forfﬂunds or 12,500 for period 7/1/62 - 12/31/62 ss continued support of Principal luvsstigstor (Consultsnt) on basis outlined above. In the event cousultsnt tine is required in 1963, expenses end oonsultstion tees sre to be psid by Hillside Hospitel through funds provided by the Bosrd of Directors. A contingency fund in the slount or 36000 is suggested for this sotirity. d. 0.8.9.3.8. be requested to spprove Dr. Hex Pollock ss eo-investigstor. �7/1/62 - 12/31/62 1. 1/63 - 12/63 Staff John Kraser, Psychiatrist Pollack, Sr. Res. Assoc. Bxper. Psychol. 1. Belmont Consultant I. tarp, Res. Ass't. Exper. Psychol. A. "illner, Ree. Assoc. Bxper. Psychol. H. Hosquerae, EEG Technician 0. Podrid, aecretary at. Schnirneneﬁ, secretary J. Kolodny, technician as, no (app) Travel Supplies Computation & Consultation H. ' ’ 3,956 - 7.500 3.582 15,000 750 3.000 b.350 8,700 h.7oo 1,000 1,700 1,h57 1,315 9,hoo 2,000 3,800 950 1,500 600 1,200 1.800 1,200 11500? Carried forward ,, Net ' . Board Support 03935 Board 50,500. 5,000 _., 3h,260 hS.Soo h,zoo 6,825 38,960 52,325 12,500 $6,000) 51,h60 58,325 Overhead Total Budgets: 18 nos. 9,600 900 3h,260 Total U.8.P.R.S. - $109,785 91.285 12,500 (+ $6000 contingency). Notes e i tine as research and i time as clinical statistician, EEG services (if reconaanded by Neurologist). so Secretary-typist: Prograa will not require second typiet 1963. H. Hosqueras Allows one EEG �Juno 12, 1962 Dr. Lowis L. Robbins, Hodioal Diractor Hr. Horbsrt Bookind, Prosidsnt, Board or Dirootors ﬁillsido Hospital Olon Oaks, !.!. Dsar Dr. Robbins and Hr. Bookind: It is with rogrst and with tondnsos for my stimulating and exciting ysars at ﬂillsids that I submit this lattsr of rosignation as Dirsotor of tho Dopartssnt or Exporiasntal Psychiatry stractivo Doooubor 31, 1962. I an aura you will ho ploaosd to know that tho prograss hora havo lad to tho invitation to ostahlish a rosoaroh and training program in a now cantor, tho Missouri Instituto of Psychiatry at St. Louis; as wsll as my appoint-ant as Rsssarch Protoosor of Psychiatry at Washington Unirsrsity School of Hodicino. I look back at thoss ysara with ploasurs, for I havo loarnod such and hats round snthusiastio and dodioatod co-worksrs. I as aratotul to tho contidonoo sxprosssd in my initial appointasnt by Dr. Israol strauss, and to tho Board or Diroctor's support during thoso yoars. During tho nsxt tow aonths, I should liko tho opportunity to coaplots as such o: my progras as possiblo hora, and for this roason hays askod to continua as projaot dirsotor or ths USPH3 grant H12715. is soon as tho studios hora psrait, I shall lsavs to ossuas my now dutiss in St. Louis. with my boot porsonal rogards, and assurancos of loyalty, I roaain. Rospoctfully yours, Hrsgp . ﬂax M IInE, 5.5. �HEHORAHDUH June 12, 1962 to: Dr. L. Robbins FROM: Hex Pink, M.D. With the disapproval of the proposed 18 nonth budget for the Brein Function and Behavior Project, and without a to submit the satisfactory alternative, I an conetreined enclosed letter of reeignation, dated Deco-her 31, with a recommended budget for the expenditures under HI-2715 during the renainder ot the grant period. I an dating the roaignation as of this time to permit the oonpletion of e major port or the progren. It in my intention to continue thie program of studies or the relation of brain function to behevior et the Hieaonri Institute of Poy‘ ehiatry, beginning early in September. For e treneition period or e few nonthe, while aone onelyeeo end write-up are in progress here, the continuation progrene will be eetabliehed there. AI noon on my tine is predoninantly in St. Louie, I will resign fully from the program here. I truet this is satisfactory to you. Roapeotfnlly yonre, Krzdto one. or M n , . . �June 12, 1962 Proposed Budget, Brain Function and Behavior Research Project Jnly 1, 1962 - December 31, 1962 Estimated Balance, 6/30/62 MY2715 Income 6/30-12/31 12,000 h2,007 $Sh,000 Expenditures l.2. Prin. Investigator Psychiatrist (Kramer) 3. Psychologist (Pollack) h. 5. 6. -7. 8. 9. 10. 11. 12. 13. lb. 15. ” EEG 12,500 3,956 7,500 3,582 (Belmont) 750 (Karp) '' (Willner) Technician (Moequara) Secretary (Podrid) (Schnirnan) Technician (Kolodny) Soc. Sec., Blue Cross Travel Supplies Cowputation and Consultation 0,350 h,700 2,000 1,700 1, h57 1, 315K ' Overhead 950 600 900 , ’ 1,500 h,700 $52,h60 Balance carried forward 1963 $ 1,5h0 �June 12, 1962 Proposed Budget, Brain Function and Behavior Research Project July 1, 196? - December 31, 1962 Estimated Balance, 6/30/62 H12715 Income 6/30-12/31 12,000 h2,oo7 $5h,000 Expenditures l.2. Prin. Investigator Psychiatrist (Kramer) 3. Psychologist (Pollack) h. So 6. 7. a. 9. 10. 11. 12. 13. lb. 15. (Belnont) 'I I . (Earp) (willner) ' £30 Technician (lacquers) Secretary (Podrid) (Schnirnan) ' Technician (Kolodny) Soc. Seo., Blue Cross Travel Supplies 12,500 3,956 7,500 3,582 750 13,350 ‘ h,700 2,000 1,700 1.h57 1,3155 . ' ‘ Computation end Consultation Overhead 950 600 900 1,500 ht7°° 3 2 h60 Balance carried forward 1963 ' 3 1,5h0 �June 1?, 1962 Propoeed Budget, Brein Function end Behevior Reeeeroh Project July 1, 196? - necenber 31, 196? V Settleted Belence, 6/30/62 HYZTIS Income 6/30-12/31 . 12,000 g2.oov $5h,000 Expenditures 1. Prin. Inveetigetor 2. Paychietriet (Ire-er) 3. Psychologist (Pelleok) * L. (Beleont) R S. 6. 7. 8. 9. 10. 11. 12. 13. 1b. 15. '' I (Earp) (willner) Technicien (Hoequere) Secretary (Podrid) (Schnireen) \ Technicien (Koladny) Soc. Sec., Blue Cross Trevel Supplies Coeputetion end Consultetion EEG ' Overheed 12,500 3.956 7.500 3.582 750 h,350 h.700 2,000 1,700 1.h57 1.315f 950 600 900 1,500 5&12Q 2 Belence carried toruerd 1963 h60 a 1,5h0 �glidilibﬂl Jan. 12, To. 1962 Dr. In Robbins ---.~-- -----”.-.-.with tho disapproval at the prchIod 18 nouth budget fur the Brain function and lohnvlnr Proaout, and without a tntlntuatory altornativc, I am eenstrainod to submit the with a Isolated lattar at rculznatlon, datod noun-bowII~5115 Jl roast-andod budgot for the Impoudlturuu and-r during tho ronnlndor or the grist porlud. I :m attlng rollcu:tlan In of ﬁhln #1:. to paralt the ounplo‘lon of a IIJOr part at in. progral. It 1- Iy intanllon to uoatlano tutubotavlor proxruu of It‘dlou of tho ralatlon or brain Pay— I1UIOIF1 tho or functlun $0 InstitutIt ohlntrr. bout-nan; early in Boptunhor. It: a truulttlou 902106 at I ran monthl, will. aqua analyacn and write-up are in prograan bars, the oonﬁlnnntlou prouru-l will be octablilhnd tiara. At noon an my tin. la produuiu:ntly 1a 3%. L§!1l. I will route: tall: from the progrum hcrc. I ‘rlnt til: 1. natiltlctozr to you. BprQoSShlly yours, ti. nmu “.0 n , . . �MEMORANDUM DEPARTMENT OF EXPERIMENTAL PSYCHIATRY June 1h, 1962 To: Mr. Bechrsch FROM: Dr. Hex Fink ..‘.~.“‘..--.-.“enclosed budget dated June 12, 1962 for 6 months under project support by MY-2715 is contingent upon the adjustments euthorised in my memorandum of 5/23/62, 3 copy or which is enclosed. The estineted belence or $12,000 for 6/30/62 may be in error by 10%, and if so, can be corrected by using the belenoe, or adjusting expenditures to conform with reality. Also, it is probable thst lines 1, 2 ere overestimeted. I have also indented this grent fully for Mrs. Mosquere (line 7). After Hrs. Croghen hes made the adjustments of 5/23/62, if she will give me e true balance, I will revise this budget statement. The Thenk you HFsdts for your cooperation. Sincerely yours, ﬁe: Fink, 5.5. �MEMORANDUM DEPARTMENT OF EXPERIMENTAL ?SYCHIATRY June 1h, 1962 T0: Mr. Bachrach FROM: Dr. Max Fink enclosed budget dated June 12, 1962 for 6 months under project support by MY-2715 is con— tingent upon the adjustments authorized in my memorandum of 5/23/62, a copy of which is enclosed. The estimated balance of $12,000 for 6/30/62 may be in error by 10%, and if so, can be corrected by using the balance, or adjusting expenditures to conform with reality. .Also, it is probable that lines 1, 2 are overestimated. I have also indented this grant fully for Mrs. Mosquera (line 7). After Mrs. Croghan has made the adjustments of 5/23/62, if she will give me a true balance, I will revise this budget statement. Thank you for your cooperation. The Sincerely yours, ﬂaw MF:dts Max Fink, M.D.' �MEMORANDUM DEPARTMENT OF EXPERIMENTAL PSYCHIATRY July 20, 1962 Pollack Co-Investigator M. Fink, M.D. T0: Max FROM: MI-2715 Project In answer to your question of 7/19, I plan to complete my active participation at Hillside on September 15 and shall request “vacation” time as terminal leave. For the past year I have accrued 16 days as of 9/1/62, and have carried forward 15 days from 1960-61. If my calculations are correct, my salary should be paid to October 26. Effective on your return from Europe in September, I believe you should assume full responsibility for the expenditures and management of MY-27lS. Until I leave for Europe, and in your absence, I shall continue to carry out these responsibities. I shall notify NIMH as to the transfer of responsibility as of September 15, and have notified Mr. Bachrach as attached memo indicates. In the event that you balieve my consultation will be of service to you, I shall be pleased to come to N.Y. However, reimbursement for expenses should be borne by the grant here. Good Hrtdts luck! Max Fink, M.D. �do ’ MEMORANDUM k DEPARTMENT OF EXPERIMENTAL PSYCHIATRY July 20, 1962 T0: Mr. Bachrach FROM: Max Fink, H.D. Principal Investigator, permit you to MI-2715 Project exact budget estimate for MI-2715 for 1962-1963, I should like to bring the following to your attention. At the completion of my duties in Europe I shall return to Hillside and complete such reports as may be necessary. This should be done by September 15. I shall ask that I complete my service on these programs as of that date, subject to reimbursement for accrued leave. is of September 1, 1962 accumulated leave time will be 31 days, which will be requested as terminal leave. Until September 15 I shall continue to exercise responsibility for the project activities, but shall relinquish these To make a more that date. Parenthetically, I would suggest a prudent bookkeeping measure for your consideration. is you know, the office of Director of the Department has never been supported by government funds. It is prudent to combine this course until the final termination of the office. As a record fully as of matter, if you exercise the prerogatives of your position you could so reassign items in MI-2715, and non-government for 1961-62 as to "carry forward” in non-government a sum necessary for the position. In the revised budget estimate you are planning to submit to NIMH, the item of principal investigator need no longer appear. Thank you for your cooperation. HF:dts ﬁax Fink, H.D. � 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 [Hillside] hospital budgets. (2/2) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-010 Date A point or period of time associated with an event in the lifecycle of the resource 1961-1962 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 Proposed Research request budgets; letters; report of expenditures 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 http://exhibits.library.stonybrook.edu/mfp/files/original/037717b3a94f66da3e9b2761caa9f3e2.pdf e23ad26e74d9d730dd0ebac94c7bdd05 PDF Text Text January 8, 1960. KIHORAIDUH 1803: 20: SUBJECT: Medical Director DOpartnent of Experimental Psychiatry Salary Scales for Professional Staff Over the past few years we have attenpted to establish reasonable salary scales based upon the conception of full tine work at the institution, without outside professional activity. By adninistrative pressures, a policy of equating Job positions both within the institution and between institutions has been grafted onto the full tine concept. This latter has been nade an integral part of the salary scales despite the awareness that so-called equivalent workers within the institution were not "full tine,’I and that institutional salaries are often different because of the nador.fringo benefits. Continuation of these fictions lakes further growth of this unit extrenely difficult. we are severely handicapped in recruitment; and the staff is restive, considering the opportunities they have elsewhere. We cannot provide university affiliation with graduate students as a source of new personnel; nor have we established an identification for staff persons with I the institution. For these reasons, among others, the following revisions of salary scale and work standards are reconnended for this Department, to be effective July 1, 1960. A. General Principles. 1. All appointments in Associate or Senior Associate categories are to be node on a full tine basis. �-22. All income tron ancillary eorvicee to accrue to the aeeeoroh Fund of the Hillside Hospital. 3. For Aoaooioto and Senior iseociate stat: neoboro ‘ aro in apeoial training toward graduate degree or oertitioatee, no enae to 83000 per anon: tor tour yoare lay bo approved by the Hadioal Director on roooaaondation o: the Director or the Dopartwho loot. h. aebbotioala Salary nay be paid up to .1: loathe after (it. years service and up to one year after oight yearoerrioa in the Dopartnont for etudy at another laboratory or ioatitotien. In the event that ouch eabbatioal in approved, travel and relocation expeneaa up to 3 looo nay be reqneetod. 5. Mentorohip in proteeaiooal eeoietiee and malpractice insurance oorerago to to providod by the Departnont. B. azeoifio Soolea 1e Pchhiﬂt’ye o. For accredited Alerioan Board or Peyohiatry, recent $13,000 - $20,000 with $1000 inoreaent, to 827,500; b. For :raduetoe, eligible for exaninatiooe, .16'000 ‘ .18,000a o. tor lellove (hth or 5th year) $12,000 “ ; ’1h3000 2. Payohelegy. a. Senior Reeearoh atatf ~ 31h,000 - $20,000 Ph.D. and ten or lore yoare orperienoe. .b. Pazaoaroh Aeaoeiate - $10,000 - $15,000 .D. o. Roeearoh iseietanae - $8,000 Phono G‘ndid.t..o ~ $10,000 �ca. 4. Roooorch Follow - $5,000 - $7,000 a. Job Sgociticotioa. 1. For itou la, b, ond to, b, o, tho doooriptiono in monotondun or ootobor 30. 1958, opply. i 2. For itolo 1n ond 24: ohoonto In tho or groduoto oohool otriliotion, tho troininc or our oqn otorr 1o Iondotory. With tho potontiol oupport of (routing ooonoioo oloo dooirono or providing troiaing tundo, thooo rongoo oro onggootod,'ond itouo oiil bo roquootod ‘in tho noxt budgot. 10. Poychiotriota Cooplotion or throo yooro in psychiatric rooidoacy, ond dooirono or otndyiatdhring hth ond 5th yoor. 2d. Ph.D. oondidoto or H.A. ooudidoto. Eorly in coroor, without thooio, would roquoot tnndo to pornit ouch oooiotont to oporoto within tho loborotorioo. \ Roopoettully onbnittod, IX ‘n, oo �\ Departaent of Experimental Psychiatry « April It, 1950. Director SUBJECT: Salary Scales fer Pretessienal Start. Correction of acne dated January 8, 1960. Here stands except for specified revisiens receanended: HEEORLIDUH Page 1. Page 2. T0: Medical General Princigles. 1. All appeiutsents er presetiens te senior Research Associate are made en a 'full'~tell-tiae basis. Appeintaents in ether categeriee are "fellotine" according to established standards of the Hospital. 2. All inceae Irea ancillary services of "full" full-tine start to accrue to the Research Fund of A. Eillsids Hospital. 3’ h, 5. B. 'tCte Sgecitic Scales 1. Psychiatry (a) Sr. Research Asaeciate: en agreeaent with the Medical Directer (b) Research Associates for accredited Aaerican Beard or Psychiatry, recent $18,000 . $20,000, with $1,000 increaent, to $27,500; for greauates, eligible for exasiuatiens, $16,000 - $18,000. (0) tellers: (hth & 5th year) - $12,000 - $1h,000 2. Psychology (a) Sr. Research Asseciate: stat. (b) Research Associate: Ph.D. and esperinental ,» experience $9,000 - $1h,000 (c) as. Research Assistant: x.i. or equivalent, three years experience, and candidate for Ph.D. at accredited university - $7,000 - 39,000 — (d) Research Assistant er Pelbw: H.i. or one year experience - $5,000 - $7,000 �Pug. 3 0. Job Sgociticatiana: while specificatians at 10/30/58 would apply, following changes arc rnqnvatnd. In original docignntion, Rcuoarch Lsaociata in Psychology was limited to Ph.D. and thrus ynnra or oxporicnec. this in hurdansonn, and :11 Ph.D. appointinbo designated 'Aaaociatc.' Assistant dasignation be subdividad to Sonia: Rnaonreh tall-tint and Roacurch Aaaintaut, as abovo pornittinx tho nmploynont or trainees 1nd aundidat-a, with origiu;1 cpcoificutiona applying. Roapodlully submitted, ‘EE§“FIEEI"HTET”~’"' 31:13 ��Pg. 1 Dr. Fink To: Director, Research in Emerimental Psychiatry Prom: Accounting Dept. Re: Report of Expenditures .131; 1 - October 21: 1960 HOSPITAL SUBSIDIZED RESEARCH 1960-61 Ebcperience To Date 25, We 8, 331e 3,167. 363. Dudet Salaries BC Assoc. 8c arises: Fink in Social Psychology Siegel Psycholinguistic Technician Secretary Medical Equipment Office Equipment Travel Supplies Social Security Director's Kolodny Podrid 118. ' Blue Cross Expense Account & Income from Nassau County Net Expenses cc: Hr. Bachrach h85. 1,500. Total Expenses Less: 3,120. 2 ,172. 2 , 890. 3,1t00o 3.1100. (67.) 920. 600. 119. 161. 237. 10,120. 12,796. 3,120. 1214. h0,000. 12 ,672. �Dr. Fink Director, Research in Experimental Psychiatry Pg. 2 GRANT biz-2115 5% to 12/31/61 Grant approved for $65,886. to 12/31/61 Supplemental Grant 16 2 O. approved for Amount applicable to 1960-61 6 151%: h1,058.* 1960-61 Budget quaerience Grant Balance 6/30/60 32,105- 3h,699. Additions: Amount applicable to 1960-61 1.12158 .* m, _ Starting Balance Salaries & Additions 8. nses: ese ssoc. n sychiatry Sr. Assoc. in Ehtp. Psychology Assoc. in Exp. Psychology Asst. in Exp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician E.E.G. Technician Secretary Secretary Klein Pollock (Gittelman (Bel-"nut Karp (Krauthaner (Andermnn Kclodny Mosquera Bowie Podrid To Date 73,1463. 3h,699. 16,1416. 5,667. 10, 92°. 7,500. 2 ’ 500. 2 ,500. 8,500. 2,931. h.l.10. 1,1426. 7,333. 3,360- 291. 1,123. 1.80. MM Supplies Iviedical Equipment Office Equipment Social Security 8: Overhead Blue Cross Travel Total Eutpenses Unexpended Balance cc : Mr. Bachrach 2,500. 382. 1,928. 101. 1196. 9,681.. 2,7hh. 563. 72,9330 20,8270 13,372. �1“ Director, Research in Experimm Psychiatry Dre mm Pg. 3 181-2092 Great. terminates 12/31/60; expenditurepicked up by Great III—2715 Supplement. mm m0 Starting Behnce 5 Additions We:PWIC" Salaries & Sr. Assoc. in Me Repairs to quipnent 800111 Security Overhead Tom & Blue Crone WW3 Wed We 6,&7e 7,h35e To Date 0 Additions Behave cc! Hr. Mhrech Wk be 1960-61 Bidet " 6/30/60 te 6,667. 7,h35. 5,667e 11,333. 130. 870. 1:3. 628. 6,667. 5,7080 0 7014. 1,727. �Pg. 1 ”MaDr. Fink To: Director, Research in kperimental Psychiatry Fran: Accounting Dept. Re: Report of Expenditures .1an 3 .. 393mm; 30, 1260 HOSPITAL SUBSIDIZED RESEARCH 1960-61 W'Lec Salaries nses: & Assoc. in Social Psychology Psycholinguistic Technician Secretary Medical Equipment Office Equipment 'l‘revel Supplies Social Security Director's Blue Cross Expense Account & Total Expenses Less: Income from Nassau County Net muses cc: Mr. Bachrach Experience Bidet Fink Siege). Kolodny Podrid 25,000. 3,120. 2 ,172. 2,890. To Date . 10, 338. 3,958. 5&6. 730. 1,500. 118- 3,h00- 3,1400. 920. 600. (55a) 173. 22h. 290. 10,120. 16,2014. 3,120,. 177. 130,000. 16,027. gm �M Director, Research in Experimental Psychiatry Dr. ( ' GRANT Pg. 2 111-27}; 1/1/61 to 12/31/61 Grant approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant approved for Amount applicable to 1960-61 W Grant Balance 6/30/60 Additions: Amount applicable to 1960-61 Starting Balance Salaries 8: ese uses: ssoc. n sychiatry Sr. Assoc. in Eng). Psychology Assoc. in up. Psychology Asst. in Assoc. Psychology Exp. Psychology Ebcp. in Psycholingzistic Technician E.E.G. Technician Secretary Secretary Klein Pollock (Gittelman Social Security a: Overhead 1960-61 Budget Experience 32,1105. 3h,699. 311,699. 16 ,hlé. 7,083. (Belmont Karp (Krauthamer 10,920. 7,500. 3,500,, (Andaman 8.500. 3,6140. Kolodny Hosquera h.h10. 1,783. 1,h06. 3 , 360. Bowie 2.500. 382. 1,928. Blue Cross Total Expenses Balance 5 d .- cc: n .n ﬁ.w ,...,..— I I Illll 291. 1:80. 165. 607. 3,130. 72,933. 26,185. 675: -IIIM' 530. ,. -Nv “A. 3,125... 9.681;. Travel "I'fn'expended To Date 73.h63. 7,333. Podrid Supplies Medical Equipnent Office Equipmnt h1,058.* 1413958 .* Additions 8. l "851%? 6 2 O. 8,51)» �..o~’ Drcl'ink Director, Research in mm Psychietry mm Pg. 3 III-2092 «when: 12/31/60; «podium» to be picked up by Great 141-2715 Suppl-lent Went 1960-61 Met Great Balance - 6/30/60 6.667. Belem. & mm» W Selene: I: Expense” 8r. Assoc. in Exp. Psychology S plies ‘greee Social Security Overhead Total To DI“ 7,105, 0 Additions mm Experience a Blue heme Wed Behme Pollock 6.661. 7,155, 5.567. S,h17. 130- SS. 725. 870. 785. 6,667. 6,982. 0 1:53. �' To: Dr. Fink Director, Research in Prom Accounting Dept. Re: Report of 119 Pg. 1 M mm herinentel Psychiatry nditures to December 31, 1960. A -._A -4tm ,.._ Assoc. in Social Psychol Paycholinguietic Technician Secretary Medical Equipment Office Equipment Travel Supplies Social Security ctor'e Tom Blue Croce Expense Account a: mews Less: Income from Nassau County Net Expenses Pink Siege]. Kolodnv Podrid 25, 000. 3,120. 2,172. 2,890. 112.3335. 14,750. 739. ”5. 1 500. ,118. (SS“ ) 3 ,hOO. 3,hoo. 920. 600. 233° 290’ 1‘3ng ”’566. 3.129.. 265. 130,000. ' ‘ ' �Dr. Fink Director, Research in Experimental Psychiatry GRANT Pg. 2 111-2715 approved for $65, 886. 1/1/61 to 12/31/61 Supplemental Grant approved for 1/1/61 to 12/31/61 Grant 1’20. ﬁg. Amount applicable to 1960-61 1960-61 Budget quaerience Grant Balance 6/30/60 32,105. 313,699. Additions: Amount applicable to 1960-61 1413958.!- ‘ Starting Balance Salaries & nses: Asst. in Exp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician E.E.G. Technician Klein Pollock 16,h16. 7,333. 8,500. Karp 10,920. 7,500. h,soo. 8,500. 31,3338. h.h10. 2,”.0. (61th (Belmont (Krauthaner (Aniormann Kolodny Hosquera 3,350- Podrid Supplies Medical Equipmnt Office Equipmnt Social Security 3h,699, Bowie Secretary Secretary 8: Overhead 2,500. 382. 1,928. Blue Cross Trml Total kpenses Unexpended Balance _ I cc : Hr. Bachrach To Date 73,h63. Additions & ese ssoc. n sychiatry Sr. Assoc. in Exp. Psychology Assoc. in Exp. Psychology _ hl,058.* ' I II. 3,750,. 291. 1,689. EEO. 278. 697, 9,68,4- 31,116. 72.933. 31,1170. 631. My 530- 3,229, Mum �Dr. Fink Director, Roam): in Experimental Psychiatry mm Pg. 3 31-2092 mus 12/31/60; Grunt picked up by Grant 141—2715 Wt. exp-Mite": to he 1960-61 that Balance - 6/30/60 ' 6,667. 3mm. 6 Additions W Salute: & Enema: $‘o To Date 71:35. 0 Additions Starting Met We “3°C. in m. won-m Supplies Social Security Overhead & 311:. Total. Expenses Unmanned Balance cc: Hr. Bum-ad: areas Wk 6,667. 71:35. 5,6670 6 Q a 130. 870. 63‘. 91-2. 6,667. 8,2138. 0 (813.) �W P80 1 W Dr. Fink To: ‘ Director, Research in Experimental Psychiatry Fran: Accmnting Dept. Re: Report of Menditures 1961 HOSPITAL SIBSIDIZED RESEARCH Salaries ec Assoc. & uses : in Social Psychology Psycholingulatic 'Dechnicien Secretary Medical Equipment Office Equipmnt Travel Supplies Social Security 8: Blue Cross Director's Expense Account Total Expenses Leas: Income from Nassau County Fink Siegel Kolodny Podrid 25,000. 3,120. 2,172. 2’890’ lb 181 5,5112. l ' ’912' D 220.0 _ 1,500. 118. 3,)400o 3,h00. 920. (SS ) 2714' 600. 397‘ 387: 10,120. 22,858. 34L 265. . l __________________________________._____———-——--——--—Net Expenses cc : Mr. Bachrach h0,000. 22,593 �Dr. Fink ‘ _.. ., Director, Research in 'hcperimental Psychiatry GRANT Pg. 2 IKE-2715 1/1/61 to 12/31/61 Grant approved for $65 ,886. 1/1/61 to 12/31/61 Supplemental Grant 16 2 0. approved for ‘B'iﬁi'ﬁ Mount applicable to Grant Balance 6/30/60 1960—61 .m Additions: Amount applicable to 1960-61 Starting Balance Salaries & Additions nses: ReseF-ch Issac. In Psychiatry Sr. Assoc. in Exp. Psychology Assoc. in Exp. Psychology . 1960-61 Budggt Experience 32,1105. 3h.699. ulzostm 20,529. 73,h63. 55,228. 16,h16. 7,333. 9 ,917. 1,083. 10,920. 7:500- 5,500, h,375. 8,500. 5,056., 291. To Date 8: Asst. in Ebcp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician W E.E.G. Technician Secretary Secretary Supplies Medical Equipment Office Equipment Social Security a Blue Cross Overhead Klein Pollock (Gittelman (Belmont Karp (Krauthamer (Ardemenn Kolodny Hosquera me Podrid 14,1th3 9 360. ‘ Total Ehcpenses Unexpended Balance Mr. Bachrach 2 ,517. 1, 972 ¢ 1:80. Cartolano 13s 2 ,500. 382. 1.928- 99681“ Travel cc : b1,058 .* 281;. 920. 5,009. 979. 72:933- 38,396. 530- 16 ,832. . �Pg. 1 Dr. Fink To: Director, Research in Experimental Psychiatry From Accounting Dept. Re: Report of Ehcpenditures 1: 1260 - Februagz 28I 1961 ng HOSPITAL SUBSIDIZED RESEARCH Salaries & 80 menses: Social Psychology Psycholinguistic Technician Secretary Assoc. 111 Medical Equipment Office Equipment Travel Supplies Social Security Director's Blue Cross Expense Account 8: Total Memes less: Income from Nassau County Net mpenses cc: Mr. Bachrach Fm Siegel Kolodny Podrid 25, m0 3,120. 2,172. 2,890. 1 500. ,118. 3,h00. 3,h00. 12,33: 1’09; ,, J £1455: 180' 13h. 61. 525. 920. 600. 1:17. 53:12“ 26,238. 3,120. “3,955. 10,000. 2 3 ,283. " ; 4-; A 3*) 7’ . �\ Dre Fink Director, Research in ﬁrperimental Psychiatry GRANT Pg. 2 PIX-273:5 1/1/61 to 12/31/61 Grant approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant approved Amount Grant Balance 6/30/60 Salaries & Eggnses: ese esoc. sychiatry Sr. Assoc. in Exp. Psychology Assoc. in Earp. Psychology Asst. in Ech. Psychology Assoc. in Earp. Psychology Psycholinguistic Technician E.E.G. Technician Secretary Secretary Electronics Technician Supplies Medical Equipnent Office Equipment Social Security 8: m Overhead Klein Pollock (Gittshnan (Belmont (Krauthamer (Andermann Kolodny Mosquera Podrid Cartolano Unexpended Balance cc : Hr. Bachrach Experience To Date 3h,699. M* 203529. 73,1163- 55,223. 16 hlbe 71333- 11 o 3:333. 10 920. 6 500. 3500- 5,765. 7:500- 5:000. 291. hyhloe 2.895. 2,255. 3’36“ 2480. ho. \a ’38:. 500. 295. 1,92 e\~\...1 9’68hN-h 5,3533.. Travel Total Ebnpenses 111,058.?!- 32’h05- 2 Blue Cross 11:15: 1960-61 Budget Additions 8: 16 230. applicable to 1960-61 Additions: Amount applicable to 1960-61 Starting Balance for 15029. 72,9330 [6,852. �Pg. 1 W MEMORANWH Dre Fink To: Director, Research in Merinontal Psychiatry From Accounting Dept. Re: Report of Ebcpenditnres 195] 3] 12m lamb 1. 3 Jul: W RESEARCH SUBSIDIZED HOSPITAL Salaries Assoc. uses: 6: in Social Psychology Psycholinguiatic Technician Siegel m Kolodny Secretary Medical Equipment Office Equipment Travel Supplies Blue Cross Expense Account Social Security Director's . Total Expenses less: Net Expenses 7’125' 1 500. 180' 3,1400. 151: 1’ 335‘ 1:681: ’118. 920. 600. . Income from Nassau County Donation of Paychiatropic Drugs 3,120. 2,172. 2,890. 3,h00. 8: Experience To Date 1960-61 Budget »» ~ x... ,, . 110‘ 626. 1117: 10,120. 2951.0. 3 ,120. 2,955. 2 :295: h0,000. 21:390. to Hospital ______________________________...——————————--- cc : Hr. Bachrach �Dre Fink Director, Research in farperimental Psychiatry GRANT Pg. 2 m~271§ 1/1/61 to 12/31/61 Grant. approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant 16 2 0. approved for T511137 Amount applicable to 1960-61 1_‘_‘_____ Grant Balance 6/30/60 Additions: Amount applicable to Starting Balance Salaries Essen 1960—61 Additions 3. nses: Issac. In Psychiatry Assoc. hp. in Psychology Exp. Psycholog Psycholinguistic Technician E.E.G. Technician Bud eet Experience To Date 32,1105. 3h,699. hl,058.* 20.5293 73,h63. 55,228. 16 ,h16. 12,750. M327. (Belmont Karp (Krauthamer 10, 920. 7,500. 7 , 5142 .. (Amiermann 8,500. 6,1173, Kolodny Mosquera , 7,333. h,h10. 3,360. & Overhead Blue Cross Travel Total Expenses Unexpended Balance Hr. Bachrach 5,625. 291. 3,272,, 2,592. 1:80. 93. Castolano Supplies Medical Emaipment Office Equipment Social Security Klein Pollock (Gittelman Em; Podrid Secretary Secretary cc : 1960-61 8c Sr. Assoc. in Exp. Psychology Assoc. in Exp. Psychology Asst. in h1,058.* 2,500. 382. 1,928. 9.968140" 3760 1,376. 6,1173n 14100" 72,933. 52,770.» 530. 2,158. �P30 1 Dr. Fink To: Director, Research in Emoriuontd Psychiatry W1 Fran: Accmnting Dept. Re: Report. of Expenditures w—WW m HOSPITAL wnsmxzm RESEARCH M Salaries ac Assoc. & gases: Fink in Social Psychology Siegel Psycholinguistic Technician Secretary Kolodmr Mics]. Equipusnt 1960-61 merience 25gme 19,7950 1,500. 180. 33’4me 5939 3,120. 2,172. 2,890. 118. Office Equipmnt bIVOI Supplies Social Security & Blue Cross 7,917. 1,57h. 1,906. 711, 3shme 920. 600. 163689. Total Expenses 1.3.120. 33, 308. less: Incaus 3,120. 2 ,955. Director's Expense Account from Nassau County Donation of Psychotropic Drugs to Hospital Net kpenses ~ 41;] cc: Hr. Backrest: 1417. 2: 295: 150,000. 28 ,058. �Dre Fink Pg. 2 Director, Research in "apex-mental Psychiatry GRANT ' a... 141-271; . $65,886. for Grant. approved 12/31/61 1/1/61 to 1/1/61 to 12/31/61 Supplemental Grant 2 0 6 1 . for approved 121115: Mat applicable to 1960-61 1960-61 Budget ... ’41, 058 .* Experience To Date Grant Balance 6/30/60 32,)405. 314,699 Additions: Amount applicable to 1960-61 glIOSBJ 111,058s 73,1163. 75,757. Klein Pollock 16,2116. lh,167. (30130111: 10,920. 7,500. 8,583. 6,250. 8 ,500. 7 , 181. Starting Balance & Additions Salaries &ﬁsoc.uses: In Psychiatry Sr. Assoc. in Exp. Psychology Hem Assoc. in hp. Psychology Asst. in Exp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician EOEOG. WWW Secretary Secretary 7,333. (Gittelmn Karp (Krauthatner (moment: Kolodny m W ughloe 3,360. HOWE 5,1111. 291. 3,6509 2,353.. LBO. 93o Oastslano ' Supplies pursuant Office Equipnnt 2.500. 382. 1,928. Medical Social Security 8: Overhead Blue Cross 9.681;. Travel Total MEMOS Unexpended Balance cc: Mr. Bechrach . 169. 1,5711. 7,366. $139.91 72,9330 593,458: 530. 16 ,299. ' �I [1W W Iu' [44/ : ~--—; I C. I / 1/ / ’W W K4444” ' LI“I X { ~//‘/. / I/L/ I I / 1 I, d — / / 7’ 'V e - ‘1 .__ �2.7 f 444/ Ms/ ,1. r a M dv //'. / .4 — ’ M1 h. 1 a... / 41%;»! / ’, [14,.” I If:/- (I t». AI'VA‘;_727 44' w W / .4 / / 4’15] / 5;! 1% ’ / {i I 440/ a a/ ”M7142: 72ﬁ;4h.&¢ igv M (A I» r], «Ac/47% ’ 3 I / (5300 if 1’ C II» a» W ﬁwm) 72. 13/ / one 53¢: 39 ace �5—0 90¢ �1/3/61 Dopartnont or lxpsriaantal Psychiatry 1961-62 Bndgot, Propoood I. 1960-61 Indgst (-ovsrhsad) $118,882 a. Inorsasos in salariss, annual inorsnsnts b. Additions in prograns: 1. Psycholingnist - to ba aotivatsd 2. Sociologist to tho proxraa 3, £80 technician Statistical tsohnioian, g.. Elootronio oqnipnsnt é. o. s. Status rslatinx to lndgst John [razors Irt. tron fallowship status to Rasaaroh Associats 9/1/61; snbjoot to approval of g. or‘g. Donald Klein: continnss as Isa. Assoc. but is to ba grant (Kh798) supported. that tho dittorsncs in It is axpsctod salary iton on grant and an lsvsl nay ha up to $7500. Grant providss 85000 additional for sscrotaria1 and othar sxpansss. Sabbatieal ~ lax link: 9/15/61-8/1/62 Visiting Soiantist support is roqnsstad. rhara is no salary ohangs during yaar. Amount is $15,000 par annnn. Expanss III. W %,650 1 000 Changas in 0. Souroas of Support (-ovsrhoad) a. Approved: 1961-62 1. HI2715 . ha P01161118: 2, nh798 rotal 0 12,000 170,732 12,000 182,732 72,231 - (323,000) out. 3. Visiting Soiontist c. To bs Raqnastads h. Snpplonantary H12715 126,282 10,000 10,000 6'800 tins tins llaetronios spacialist, II. 7.300 “17,000 13,500 30,000 r¢/~ gh,g§o �$0,000 a. Board or Daroetorl 1. it would Ilk the Board to apprevo I grant 0: $h0,000 to: {var ytara; with an lpyortunity to carry tarvnrd unoxpondod can: far 2 yn;rs. 2. WI wanld also ask for a credit tranltor tron operating budget funds of value of psychotropic drugs (to $10,000) roecivod in the progran. In 1959. the ' vulno was ontinntod as O11,000. Inconn Eutinato: 182,731 Exponae Estinatcs 182,732 ��V WWW—WM...‘ r L ///~/ 5 ”A Z 3%” ' IBKOO >3, W? + ' ————-'_f"——' I 23, We ’3 ’ (00 ‘ 2.00 ..—— I ~ I I v ’ 2“ 3f?” = ��May 5, 1961 Hrs. Croghan Departnent of Experieental Psychiatry Heme: Iron: Subject: Budget '1. In reviewing find budgetery expenses to date, I the following in the Beapitelised Subsidized Research: Expenditures 7/1/60 ¢ 3/31/61 $29,5h0 Less my credits (Nassau County) 5,250 (Drugs) Estimated Expenses nets sonths 3 $2h,290 I Salaries (3&00 x 3) Social Secutity Travel Other 10,200 300 1,000 _ 200 net: Less credit for teeching 900 Research Associete in Psychiatry (Klein) app. Secretary I! (Podrid) app. hSOO 82g $5,325 my calculations are in error, please call as. Thank yen. a Sincerely yours, HTzOP 11,100 35,990 ax n , . �5. 1961 May HOIO! Mrs. Croghan Irons Dapartaont of Expsriaantal Psychiatry Subdaota Budxat 1. In roviaviag a: budgstory oxpsusaa to data, I find tho following in tho lospitalisad Subaidisad Rasaaroh: nxpandituras 7/1/60 ~ 3/31/61 $29,5h0 Lass credits (lasoau county) 5,250 (Drug-v) __.______ not: $2h,290 lotiaatad xxoonsos 3 months salarios (JhOO x 3) 10,200 Social secuoity Traval ethar 300 1,000 200 not: Lass oradit for teaching 2. 11.100 35,990 200 I: this is iha approxiaatsly would you oorraot, ploasa assign following sxpandituras to this account, tron Grant l1-2715, attentiva April 1? nosoaroh Associats in Psychiatry (Ilain) app. ASOO Saoratary (Podrid) app. “33: I: ay calculations aro in Thank you. 85,325 error, ploaso call as. Sinosraly yours, IIsOP ax n , . . �Prcptlod ltdgot 1961-6! nevi-ad 5/22/61 Doparinont .: tsp-rtnonttl Plyuhtltry annuity: Exponloo 1961-62 $156,hh0 Inoolo warns _ Eonpttal eruditl 108,870 1.510 116.;50 lot Unuubcidisod ltloarch 8 ko,ooo �5/22/61 Bspcrt-sct ct lxpssissntsl Psychistry Prcpcscd 1961-62 ludxst (lsvtssd 5/22/61) Exp-uses: 1. Blrsctcr 2. Assoc. 1n rsychistry .AQE‘o/B. Assoc. 1n Psychistry h. is. Assoc. Expos. Psychology 5. Assoc. in lxpsr. Psychslcgy 6. Assist. in Expos. Psychslcgy ,rswo'7. Assist. in lxpsr. Psychc1cxy 8. Assoc. in Sosisl rsychclcgy 1960-61 1961-62 Apprsvsd hsqusst (3. link) 25,000 25.000 16,h16 17'500 Sllcta) lrsnsr) . 13.000 Pcllsck; lslncnt 10.920 1.500 Ksrp) . Villas!) 2'004' b‘; 1h,000 11,000 8.100 73200 (9) 9,500 10,000 (d) I,$oo 1,h20 (s) Elbsqusrs) lss) h:h10 k,aoo 3.600 (I) ) 12. rsychslingsistis rsshntc1sn élslcdn Psdridg 13. soot-tar: (Ibssclnsn) 1h. alcrkotyptst 1,172 3,360 2,890 2.300 - 2.700 3:500 16. [quip-cut (attics, nsdicsl 11. frsvsl 18. acrylics 19. nircctsr's Prstcsstscsl lxysnsss b.5oo 3,h00 3,hoo 3.000 3,600 3.000 3,31h 3.500 9. Assoc. 1s lxpcr. Psychology 33:6) Andsrssan) 8:. ”Eu/11. no lcchsicisn, Jr. 10. ans fschnicisn, AﬂE‘VlSs fcchnicsl Assistant 20. Social Bcccrisy/llns Gross (lcs) (sst.) 21. msrhssd «- 600 11.01;]. 20211 $129,923 33h80 (t) 600 11,200 kg 2,8h0 1 $156,hho �-2. Bopartnont at lxporincutal Prychiatry lxyoulon 1961~62 lacunae 0&56ikk0‘ ﬂ?{5.3,qzelo 1. warns 31.2115 (62) - 1/1/61»12/61 (1/2) Iroaght toﬁvurd (03%.) (1/2) (ca) - 1/1/62o12/62 h1,oso k,oeo 32.000 w 87,059 2. warns x.h795 natinutod 8.1.2: 1k,26h n.710 pr. 0701‘. 2.8!!6 21,820 (a) 3. 2cc¢htn¢ (But. he hrs. .181!!!) h. Bra: rrnnlror (13%.) ' 1,000 (k) 3,570 (1) 4E=4HHhIHHap6Iadtﬁ-GIaI-é-otalG~9010htt§rttt+jhﬂﬁﬂy4hér W ”3 Vs'ro lot lxpouaoa (Haunt-111104 lcncuroh) 3 ha,ooo �lgtoot Sagportod, in art, by l~h798, aa Garcon Iavoaticator, otfoctivo 1/1 61. Bixtoroaoc in inooao will to aooignod tron l1-27159 (b) loplncoo 3.). [loin in nx-avzs. In continuing onporvioion of la! prozroa would roqnoot continuation of clinical onpyott a! l/h otat: poychiatriot iton. low appointacnt, ottoctivo 9/1/61 at $8,500 for air nontho, $9,000 thoroottor. loo appointaont, to ho aado 9/1/61, at oatinatod $12,600 pot annna. ippointnont onco 9/1/61. Will not ho roplacod onlooBiroctor rocoivoa II! Vioiting acioatiat award. (t) (a) (h) (1) (3) (k) (1) Ion aypointnont to porait hoopital~uido onrvoyw plannod attor 9/1/61. low poaition to: ototiotioal ani onporviaory :nnotiono. lollovo a roooanondatioa at Aaoiotont idniniotrator, Hr. Bavio, tollowinc a Job convoy Icy 1961. evorhoad allcvoaoo on l1-2715. avorhood allowanoo on l-h798. n~h198 allowo $18,!1h for oalary ani roooarch cooto; $2,0h6 for ovorhood. rho-o'itoao aro applicablo to tho prograa. It aloo allovo Oh.838 opooitiod oo training cooto. Ihilo Dr. Kloin nay not ntilioo tho on: in tho conin; yoar, it nay not to nood for othor pnrpoooa without oxprooo provioion. It ia onticipatod that thio on: will to rotnrnod to tho warns. Incono ootinato boood on continuation of coarooo in Biological Paychiotry and in noooarch lothcdology. lininal oatiaato balod on 1959-60 and 1960.61 oxporionco. loqnoot continuation ot clinical crodit-tor clinical oorvicoo, followingll960-6l oxporionco. ‘ �5/!!I61 a.“ nupnrtuont at prorannatal Parnhtu‘vy ttovonod 19§1~62 nudgit (3011804 5/22/61) 196o~61 lupus-0.: 1. Blrootor H. fink) 2. assoc. 1a rnynhxntry x1013) J. Assoc. in Ptyuhtutvy tranor) Assoc. 8!. 8390!. Psycholtcy (Pollack) g. A‘s... in super. Psyuhnlocy (not-oat) . 6. Acoiut. 1n Savor. Puyehalogy Earp) 7. Alutlt. 1a Payah01n¢7* Willa-r) or. 8. Autos. 1: 3.0 :1 Payuholocy luv; 9. Assoc. in Expor. Psyuholncy Ila Ap’rovod 8:. Inna ' 15.133131», m 330 ruahaictna, Andlrllll) on) 25.000 15.h16 - 13.000 10,9:0 7.500 - . 8,500 10. 11. 1!. 13. 1h. 15. 47. ll! Pﬂytholtsgutattc rochniotna {301.43 ) 50ar¢$ary roarid Clark. 10% ftnuatlnan) rlahnie Lnatutaat 30v) . 2,112 16. 11. 18. 19. Equtpuunt (otttc..n¢di¢n1) traval Suppltca Dtruator‘c !rottultonnl lap-anon 800131 80¢n31$7llluo 0:03: (00‘) h.500 3.h00 3,hoo to. no: 21. Ovarhoau "f ﬁg?! {VFW 4‘ anf‘ <\ \J, a\. iﬂﬂﬂt 3,360 2,890 - $00 3.31h 11.0h1 $129,923 ‘155 0500 �“531.1190 Inna-0i 1. um :::: um 'mzz-wzzx . _ W , 01.059 I. um: MM “mm am “.000 10.850 3. latching (83%.) h. um.) S. m Wu- clilttti crolit (xerox/h 500 5.00.0 (a) Itttr plyth$n3rtnt1;‘ggg lit lliilill (I) (lhlniltltsod tinnitus) (a) \ W W ‘ 1505000 �(o) (d) (o) (f) (s) (h) sappurtod, in part, by u~h198. ll carter Invoc‘tcntcr. ottaottvt 7/1/61. Dittoronco in incon- v111 be assigned S!!! IY~2715. Inpltaoa 5.1. Xi'an in ur~2715. In contanuzn; unparttnion a: no: progran would mounts: aonttnuttton at tho 1/8 nt‘tt poynhxntrtlt. lav appcxntunut. «rtagtavo 9/1/61 at :0.500 for at: nontha, $9,000 ‘hnrunttur. lav appatatnnnt, t- be and. 9/1/61, nﬁ outiuttad $12,000 par gonna. Appointncnt and. 9/1/61. 3111 not he rnplnood talus: ntvactnr rﬁcctvbl III Vitittuc Scientiut award. luv appointuant.to pcrult hoapxtllavado survey: planatd utter 9/1/61. New position for azntintloni and aupnrviaurr tunotlcnt. Fallout 3 risen-audition of Assistant idlinistr¢‘ar. pr. navio, (allowing a Job I‘TVII law 1961. on continuation or court.- in Inc... ontinnto bland and non-arch nothodoloay. Bioloctonl Payohtutry (1) Kin1nnl catiunto based anti-stat. on 1959~60 and 1960~61 ' (3) noqscnt continuation or clinical credit for 01131301 suvvtauu. failurtuc 1960~61 o:pnr1¢n¢¢. �HILLSIDE HOSEFRHL WEGE & SALARY SCALES Scale # HIRING RATE SERVICE-MERIT INCREMENTS "‘if""‘i?“”"“"§"" MERIT INCREMENTS “ﬁf“"“‘3¢‘”"‘ l 185 193 201 209 217 225 2 205 21h 223 232 2&1 250 3 225 235 225 255 265 275 ,h 250 ‘261 272 283‘ 29h 305 5 275 2877 233' 311f 323‘ 335 6 305 318 331' 324, 357 370 T 320 355 320 385 hoo 215 385 200 his h30 nus 8 376 �9113 TITLES ﬁrm GRADES AND HOURLLRATES F0 a JON-PROFESSIONAL PERSONNEE #h #5 $250-$305 $275-$33é GRADE MONTHLY RANGE myTITLES ﬂed hr A JOB - $l¢55hr Accounting Clerk Busboy File Clerk §_; $1.32 hr Cook‘s Helper Housekeeping Dictaphone Operator II Asst. Gardener Counter Aide Leadman (days) Dishwasher 'Linen Asst. DriYBr [Store Keeper Haniyman Kitchen Man Maid C Room " $1.032 :Cook IV hr Clerk Iypist Mimeographer Receptionist Stenographer Telephone Operator B 'Porter Potwasher - $l.h5 hr Housekeeping Leadman(Nights) "Night Cook Linen Clerk watchman Painter N.B, All hourlz rates Room A - $1.71 hr Chief Telephone Operator Dictaphone Operator OPD Receptionist CaShier Seoretary,IIj Cashier B "' $1960 hI‘ Cook C III - $1.50 hr Licensed Practical Nurse Psychiatric Aide Maintenance Mechanic include 1 me§l_p§rﬂggz_§t_the rate of $10.00 per month I A - $1.8833 Jr. Laboratory Technician �SUPERVISORY & EWIEESSIONAL PERSOBYlé FOR RATES HOURLY AND GRALEE WITHIN TITLES JOB #6 GRADES , $37 $3110 - $h15§ $370 MONTHLY RANGE $05 - JOB TITLES A- $2.080 A- $2.31 Asst. Office Manager Bookkeeper Pay Master B- $2.02 Assistant Bookkeeper Registered Nurses ‘ hr hr A - Charge Nurse Supervisor $1.9h hr Asst. Superintendent Grounds Asst. Dietitian Gardener Housekeeping Supervisor 0- $1.82 hr Dental Hygienist N.B. All hourlz rates include 1 meal per day at the rate of $10.00 per (Nursing) Chef . Psycholinguistic Technician 8: §h10 ~ $510 $2.h2 hr Sr. Laboratory Technician Bldgs $1M $2.19 hr Executive Secretary B" #9 #8 #7 month �JOB TITLES WITHIN GRADES #2 #1 $15 - $235 , $1.20 hr. HOURLY RATE Ass't AND HOURLY RATES FOR NON—PROFESSIONAL PERSONNFL m $215 1§g§g Cook IV Gardener Busboy Counter Cleaner, File Clerk Housekeeping Cook's Helper Counter Aide II _ Man I Housekeeping Leadman Cashier Clerk-Typist Boiler Dictaphone Operator Chief Telephone Operator (days) Ass't. Leadman (nights) Maintenance Mechanic Dishwasher Linen Driver Psychiatric Aide II Painter Handyman Storekeeper Receptionist KitchenvMan ward Clerk Stenographer Maid Room II Mimeographer linen Attd‘t Room Room Supervisor Psychiatric Aide I Secretary II Cook III Dictaphone Operator Senior Telephone Operator Night Cook Porter Poiwasher *(Licensed Practical Nurses at_one incresent higher) *Watchman N.P. All rates include one meal per day at the rate of $10.00 per month. * Not included in Schedule A ' $235 - $31.5 Assistant Chef Accounting Clerk Housekeeping *Gateman . -, BET??? :. 9‘19? .51 s- 39.5.} Secretary I Jr. Laboratory. Technician � 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 [Hillside] hospital budgets. (1/2) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-011 Date A point or period of time associated with an event in the lifecycle of the resource 1960-1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <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 Proposed Research request budgets; letters; report of expenditures 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 http://exhibits.library.stonybrook.edu/mfp/files/original/9060c539e20c3ba0581d3baa1fe2596c.pdf 225bfe4d17bc385ee38289963bbb494a PDF Text Text l...“ I 3% Protocol for Pilot Project. on Effect of Drug on Corebrsl Emotion ‘ 1. Object: (a) (b) on of dmgn To study the effect To observe the emotional responses to such ohangca and the perception of sensory stimuli; in function. first drug selected is LSD-25 (Sandoa) - on erect preparation which, in very minute doses, produces a time state with altered perceptions, emotional reactions and occasionally hallucinatory phenomena. Studies or porcep’onol change-s in the visual, amnion", an! anaesthetic senses are planned. Special enmhasis is to be placed on the more complex functions of spatial and temporal orientation; discrimination of size and shape; body may; and the perooption of multiple Simmons stimuli .111. (1) (2) (3) (h) In the emotional aphoro, the following questions are oonsidorud: Are the emotional responses secondary to or simultanemm with the perceptual changes? Are the “spams: consistent in repeated exporinonta in each In each class of oubjoabo? subject? Are the emotional moponooa related to personality structure in Hal? any predictable fashion? In there any relation of the mouse to drug aotim and tho ability of the subject to utilize the mohanisn of denial? In addition, there are thornpoutio oonoidorations: Dona 131) have org arrest on depressions? fl; 2 Does 15]) have am- valun in eliciting pmhiatrio material in bloom,- impressed subjects? 2. Subjects: (a) ‘ The subjects are in "Normal” controln~ at three groups: hospital yeraomol or hospitalized patients a general hospital. (b) Psychiatric subjects at Hillside Hog) (1 Depression a» psychotic anti (2 Scbimphronin (3 N9W1Co ital: “satin. (o) Neurological subjects at Mt. Sinai Hospital: (1) Cerebral (119%,me or diffuse. cord disease. Spinal £2) 3) Spinal root disease. 30 W05! subject is to be heated in a similar fashion prior to drug ingestion) during the period of drug activity; and after. Subjects Each tmatodhyESTandinsulinmtoboexanimddmingaxﬂaﬁortho Repeated sessions with each subject course of such treatments As the drug action has a duration 0: 2 to 5 hours, arc planned. The testing new be divided testing proceduren my be extensive. into three mops: Neurologcal. a) gb Modical. c) tholoacal. ‘\ �3a.. Neurological: 1. Routine neurological.- 2" Visual. Perception of color mixed and ambiguous figures taohistoscopi celly exposed; and cation ion or relative size and distance. . , ‘ 3. Tactile. he Double simultaneous stimulation or various Amt”. Perception modalities. of latrines” identification of sounds and estimation of time intervals. 5. Special studies of bochr image. Bbo Medical: Observation of the subjects by members of the Department of Medicine has been ”quested (Dr. A. Blmberg) and is under consideration. BiocheMcsl studios of hormonal studios secondary to drug activity is under consideration, with emphasis on the possible role of adrenal function in the reactions as measured to the pattern of wxﬂtosteroid excretion. 3c. Psycholouoalt Clinical psychological testing is considered an integral port 0 The cooperation of Dr. M. Ger-vita has been rethis survw. An evaluation 0:: personality structure and habitual quested, methods of reaction to stress will be studied in each subject. In addition, special testing procedures to study the mechanism of denial are under stuck ha a. member of the psycholomstafrz:,-;LC (lire Antinoph). Specific testing procedures include the following tests: a Rorschach. b Bender Gestalt. c d TvoTl Special tests for denial. he Supplies, Foods, Eton: The drugs have been made available to me for experimental purposes; Funds for the at no charge kw Sundae Pharmaceutical Company. equipmt moesssry for testing have been placed at my disposal by the Neurological Research Fund of the Mt. Sinai Hospital. The following items are requested from Hillside Hospital: (1) Office space and the use of one room in Treatment Dormitory during experimental days. (2) Availability of records and permission to request occasional coowration of Homing Department and of the Record Room staff. � 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 Protocol for Pilot Project on Effect of Drugs on Cerebral Function, January 1953 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-1-001 Date A point or period of time associated with an event in the lifecycle of the resource 1953 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 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/4e44a5022aa24b8167f7810c1ba666eb.pdf 6c8bb654be03cc6faa66ea6f3e6b84ab PDF Text Text ��mm“mh«f.~«»-MM ��Patients with High Delta Activitv during Second, Third Weeks of ﬁeatmnt. Clinical Katina EEG Delta Both High High One None [ﬁramwr - high Moderatelz Imgroved Unimproved Much ImEroved (18) 12 (67%) h (22%) 2 (11%) (16) h (25%) 8 (50%) h (25%) ('20) 6 (30%) 7 (35%) 7 7mm] - (35¢ ��Clinical Ratings Cogpared to EEG and Amobarbital Test Results much Improved High Delta and Positive Amobarbital (29) Either High Delta or Amobarbital (26) Positive Neither High Delta nor Positive Amobarbital (36) [arm - x7414] Moderately Improved Uhimproved 25 3 1 10 ll 5 5 10 21 �and Ruth. Mt: M (29) man: or mum Mu ('16) mm may am: at num- Etc: man Mm mg: (36) �mm. (29) min: mm: W mu a:- mum - Mus m! “WW“! (3% �EEG Delta - Amobarbital Test Delta Activity; Records Middle Low High EEG Amobarbital Test Positive Negative [ﬁﬂ'ﬁ/ - Ifxg' (15) (346) 29 8 8 10 16 20 �(cast rbi Positive (’35) , (M) negative ,.. ! i ,‘ [I \ . I A ’ H' -,‘ I x ‘\\| x\.‘. \ x K i r ‘ 1 (j. ‘\ ; 1 I z E 10 16 20 ��A.m..‘+l__-.A_MA;.“__ A... < �; a M ��uhL—JCICHXU m I Prepared by “MS WEEK IN CHICAGG {DE—JD C) {SINH “ﬁg“ “UL—:X‘Cl A W «LE .00 N ��MURRAY 11an 8-2077 S. F. KURZER VICE-PRESIDENT IN CHARGE OF SALES GRUNE 8: STRATTON MEDICAL PUBLISHERS 381 FOURTH AVENUE NEW YORK 16. N. Y. ��M Merri/ébﬂ M HOTEL WILLIAM HENNING RUBIN PRESIDENT FAMOUS FOR THE "5"" OZMMMC ' — CHICAGO JOHN B. GRANDE GENERAL MANAGER WHERE FAMOUS PEOPLE EAT ��ESRA No. 37 1957 Program -1- ELECTROSHOCK RESEARCH ASSOCIATION SCIENTIFIC SESSION- Thirteenth Annual Meeting Sunday, May 12, 1957 Hotel Morrison Chicago, Illinois Chairman: Ernest B. Parsons, M.D., Pres. Cotillion Room A.MJﬁ: 9:00 Registration \v 9:30 A.M.' 1. 9:45 10:00 2. 3. rNeurophysiology Studies of EEG change with EST with or without Atropine in Man and Rat. Tetsuo Fukuda, M.D., John A. Stern, Ph.D., George A. Ulett, Ph.D., M.D. Discussion opened by: Bernard L. Pacella, M.D. . A.M. A.M. . 15A X/ MIL u 10: Mm" “2?? 30 W1? A. M. Psychological Aspects Personality Factors affecting Clinical Responses to Electroshock Therapy. Robert L. Kahn, Ph.D., Max Fink, M. D. An Evaluation of the Peculiar Selective Quality of Pos Electrotherapy Amnesia. Aloysius S. Church, M.D., 5}t Psychopathology of Electroshock Therapy. W“ ,,. 10:h5 A.M. Bernard L. Pacella, Discussion of 2, 3, 5. 11:15 A.M. Technigues Current Patterns in Cerebral Electro-Therapy. 6. 11:30 A.M. l1:45 A.M. M.D. & 4 opened by: Leo Alexander, M.D. Gerhard Hirschfeld, M.D. Further Studies on the Analeptic Action of Peripheral Electrical Stimulation in Hypoglycemic Coma. Charles H. Jones, M.D. Discussion of 5 and 6 opened by: William L. Holt, M.D. R. Embassy Room P 12:30 to 2: 30 PM 105/” Annual Luncheon and Business Meeting. �' -1- EJJ .. » .u ..., 111'. .j,. . . 4 . ,.‘... ,, - . v 7. ‘ 6‘ r: . . -. - ....£x~ ~ . .“- . .." ' ‘ . -. ‘ ;-‘ . ' . ,.. ... ' -. : I , .-. ..‘ d.I ’ "x - s 1' .- ., L «i=2» '_ " . . f‘: .1)- 1'! 1 ~ I \ WOV'.J“%£M{1A .. ‘ t 4. '- .' . :- .- .- \‘J.'\ .r. . ‘ :' ..:.'.-.3 .~... .. .. ”-0.“.-. : . ' . n}. I . . -,-.L z .‘ ' . 1‘ ' . ‘ ‘ . 5“ma...— ’ ‘I ‘ - -- ‘ ' " ' . . �ESRA No. 37 Cotillion 1957 Program -2- Room 7. 2:30 P.M. 8. 2:45 P.M. 9. 3:00 P.M. 3:30 P.M. 3:#5 P.M. 10. 4:00 P.M. ll #:15 P.M. #:30 P.M. Clinical Aspects Clinical Applicationscﬁ'Nonconvulsive Electro-Cerebral Stimulation. John D. Moriarty, M.D. Indications for Electroconvulsive Treatment in Office Psychiatric Practice. Paul H. Wilcox, M.D. Discussion of 7 and 8 opened by: David J. Impastato, M.D. The Use of Electra-Cerebral Stimulation in Mentally Defective Patients. Harold H. Berman,M.D., Milton ’ Jacobs, M.D., and Joseph Spielman, M.D. Discussion opened by: Charles Buckman, M.D. Drugs and ECT A Comparative Evaluation of the Safety of the Use of Chlorpromazine and Reserpine in Conjunction with Electroshock Therapy: A Review of the Literature and a Clinical Report. David J. Impastato, M.D., Seymour Berg, M.D., Anthony R. Gabriel, M.D. Electroconvulsive Therapy Combined with Chlorpromazine and Reserpine. Frank J. Ayd, Jr., M.D. Discussion of 10 and 11 opened by: Herman C. B. Denber,M.D. ��___.._——.————~—————-————-—————— _m, —-———~———_.———..——————-————-——-——— �mm“. Wm -_ w— _———~——————————_— ! —-——-————-—————__—____.__.._.— p.4— ““—.— __.._._____.. ————————————___——-——____—._— _____ ‘ . __ __ ~ ___.___ .____ ._..._ _ ...___.__._. .— ��w v«w 1. w VW. . ,_ . . wv ﬂ . 9 «x; M“ a? s. ks \ x\ W”. x ‘ \ tn .\n. as .9: ��l L. . x, 93‘1“” nerT/‘wr'y . ‘ V. t i Mm,» ,‘(Z R �rwﬂ‘mrﬂ~“w~&uwwé_é< Wn:~'5~‘~".m . l _ __-. A—e ,...r‘_;..,1... , �PUBLISHED BY INFORMATION SERVICE VOL. 9, NO. 10 OFFICE OF THE MEDICAL DIRECTOR Available to non-members at 35.00 per year. JUNE-AUGUST 1957 (SUMMER EDITION) Dr. Alan Gregg Dies APA Honorary Fellow Dr. Alan Gregg died at his home in Big Sur, California on June 19 at the age of 67. He served as Vice-President, Division of Medical Sciences, Rockefeller Foundation for two decades and in this position of national leadership made psychiatry one of his major interests. Few men have had so profound an effect on the advancement of medical sciences as he. He will be sorely missed by physicians the world over and by psychiatrists most particularly. NINTH MENTAL HOSPITAL INSTITUTE For the ninth year over 400 staff people from all types of mental hospital installations in Canada and the U. S. will come together at the Hotel Cleveland, Cleveland, Ohio, Sept. 30 Oct. 3 to consider common problems and directions of progress. Major topics at this year’s Institute will deal with the problems of the open hospital, revision of commitment laws, management principles, role of private hospitals, mental deficiency as a psychiatric problem and many others. Prof. James L. Hayes, Department of Business Administration, St. Bonaventure University, will deliver the Academic Lecture. The enrollment fee is $50. See program and registration form in Mail Pouch. - All who plan to present papers at the 1958 Annual Meeting in San Francisco please note Form for submitting proposals to the Program Committee in the Mail Pouch this month. NOTICES 1. THE ANNUAL APA DESK APPOINTMENT BOOK FOR 1958 WILL BE OFF THE PRESS THIS SUMMER. USE ORDER BLANK IN THE MAIL POUCH. DEMAND EXCEEDED SUPPLY LAST YEAR. SUGGEST ORDERING PROMPTLY. ($3.00 PER COPY). 2. WE HAVE A FEW HUNDRED COPIES LEFT OF THE BOOK OF SUMMARIES OF SCIENTIFIC PAPERS OF 1957 ANNUAL MEETING, BUT THEY ARE GOING FAST. ($1.00 PER COPY). THE AMERICAN — GRADUATE TRAINING IN PSYCHIATRIC HOSPITAL ADMINISTRATION Two outstanding courses in psychiatric hospital administration are now available and merit the attention of all psychiatrists concerned with advancing professional standards in this area. One is at Columbia University and the other at the Menninger School in Topeka. The Columbia University Course This course, which leads to a Master of Science Degree, is under the auspices of the School of Public Health and Administrative Medicine and the Department of Psychiatry of the Faculty of Medicine. It encompasses basic courses in administration, specialty courses in the Department of Psychiatry, and supervised field work. Recognizing that mental hospitals are hard put to let a staff doctor leave for prolonged periods, Columbia has made every effort to tailor the course to meet candidates’ needs. It extends over 20 months, but ei ht of these are in academic residence broken into four quarters of 2 months each. The preferred plan is for the candidate to spend four months in academic residence, followed by 12 months in a supervised administrative residency or in a position already occupied by the candidate during which time he may carry out a special project. This is followed by a final four months in residence. For candidates who already occupy key administrative posts and who cannot be away for more than one quarter at a time, special arrangements can be made. As for costs, each candidate’s need is likewise evaluated individually. The total tuition for the 8 months of academic residence is $900.00 and Public Health Service stipends are available which will pay this plus ordinary living costs. Frequently, state funds in the state where the candidate works, are available to pay travel costs. There are some openings for the year starting in Sept. Write for details to: Exec. Officer, School of Public Health, Columbia University, 600 W. 168 St., M PSYCHIATRIC . ASSOCIATION Office of Medical Director, I785 Mass. Ave., N.W., Washington 6, D.C. Canada Office, 2I6 W. St. Clair Ave., Toronto 5, Ontario Office of Executive Assistant, I270 Avenue of the Americas, New York 20, N. Y. PLEASE ADDRESS ALL NEWSLETTER COMMUNICATIONS TO OFFICE OF MEDICAL DIRECTOR �The Menninger School of Psychiatric Hospital Administration This School offers a one-year integrated course, leading to a Certificate, which draws on the resources of the Menninger Foundation, Winter V.A. Hosp., and Topeka State Hosp., supplemented by other Kansas state hosps. and schools, an industrial concern, a general hospital, two universities, and several state government agencies. The curriculum consists of didactic instruction in basic administration while clinical experience is provided by systematic rotation in the departments of participating institutions accompanied by seminars with department heads and special projects. With regard to costs, applicants may apply with state sponsorship. The sponsoring state may pay the stipend with the understanding that the applicant will remain in the employ of the state after he completes training. A limited number of stipends at $625 a month are available to unsponsored applicants. The next course starts in September. For full information write to the School, Menninger Foundation, Topeka, necessary. (work on the new home is expected to start this month. Hope is to have it finished by January 1). . Approved setting up separate fund for receiving miscellaneous gifts (such as royalties from publication of lecture series of North Shore Hospital) with proceeds to . be used to add to APA library. . . . Authorized and appointed Committee to work with planning group for the Jamestown Festival this fall which will celebrate Williamsburg State Hospital, the oldest in US. Drs. Zigmond Lebensohn, David Wilson, David Young, and R. Finley Gayle, Jr. are on the Com. with Robert L. Robinson of this office as advisor. . . . Approved contribution of $50 to the National Society for Medical Research. . . . Continued APA membership in the World Congress of Psy- chiatry. . . . Designated Francis J. Braceland as official delegate to the General Assembly of the International Society for the Organization of World Congresses of Psychiatry. . . . Approved in principle proposed constitutional amendment prepared by the District Branch Assembly regarding election to membership in APA through the Branches; and also another proposed amendment incorporating present practices regarding creation and operation of District Branches. . . . Approved recommendation Kansas. of Medical Director to consolidate all central office APA Position services for mental hospitals and to explore ways to Our Association has always insisted that Supts. and finance increased services in this area. . . . Suggested Med. Dirs. of institutions for the mentally ill should be appointments of APA representatives as follows: Dr. Frank J. Curran to World Federation of Mental Health psychiatrists. In doing so, however, it rec0gnizes the need for special training in administration for those who meeting in Copenhagen; Herman C. B. Denber to Congres de Medecins Alienistes et Neurologistes de France et wish to qualify for these positions. des Pays de Langue Francaise at Lyon, France; Rudolph The courses described above have been established with the encouragement and support of the Committee on C. Novick to Advisory Com. of National Congress of Certification of Mental Hospital Administrators. Only a Parents and Teachers. (These appointments were made handful of psychiatrists have completed them thus far. by President Solomon). . . . Recommended to Council The courses are expensive for the sponsoring agencies to reappointment of Dr. Henry Brosin to the American Board of Psychiatry and Neurology. . . . Directed that problem offer and experienced persons have put great effort into of improving dental care in mental hospitals be explored at curriculum development. Commissioners, superintendents, and others in admin- next Mental Hospital Institute. . . . Received announceistrative positions, as well as those who aspire to these ment of retirement of Dr. Frederick L. McDaniel as CIB positions, would do well to give serious thought to sign- inspector and expressed appreciation for his services over five years. . . . Changed dates for fall Council meeting to ing up for these courses. Available financial support should be an encouraging factor. November 23-24 (Sat.-Sun.) in Boston, Massachusetts. . . . Selected Saturday, October 26, as date for next meeting of NIMH GETS $4 MILLION INCREASE: The US ConngS}. has voted $39,217,000 for the Nat. Inst. of M. H. under/h" Robert Felix’ direction. This is $4 million more than/ last year—remarkable in view of general economy dri e. Testimony of Dr. Braceland for the APA and Mike Go of National Committee Against Mental Illness played i portant part in explaining need for additional monies in these areas to the Senate and House Committees. Senator Lister Hill and Representative John F ogarty, always strong supporters of mental health, spearheaded the effort to get the appropriations through Congress. EXECUTIVE COMMITTEE ACTIONS them \ O A pilot training and research program stressing the interrelations of biological and physical sciences as key to better understanding of the nervous system and human behavior has been set up at Albert Einstein Coll. of Medicine, Yeshiva Univ., (Eastchester Rd. and Morris Park Ave., N.Y.C. 61) with a $1,700,000 grant from the Nat. Inst. of M.H. There is provision for 36 pre- and st-doctoral fellowships. The grant covers a six-year d. Write to Labe Scheinberg, M.D., Dept of Mediher details. ° FALL COMMITTEE MEETINGS: Woodner Hotel, WashThe Exec. Com. met at the APA Central Offices June ington, D. C. The following Committees will meet all 29. (Unusual and pleasant feature was that most of the day on Friday and Saturday, Oct. 25-26: Standing Coms. APA staff members attended to become better acquainted on Technical and Community Aspects and Professional with the Com. members and general affairs of the AssoStandards. Also Standing Coms. on Budget, Ethics, ciation.) Among other things, the Com.: With regard to Program and Nominations. Ad Hoc Coms. will meet only financing remodeling of new home, delayed taking out any on request of the Chairmen and with clearance of the mortgage unless and until expenditures appear to make it Coordinating Com. Chairman to whom they are assigned. . �~\ The Council this year will not meet to receive Committee reports until November 23-24, but the Executive Com. will meet with the other Coms. on Sat., Oct. 26. Canadian Mental Hospital Institute Plans for the first Canadian Institute are shaping up nicely. It will be held at the King Edward-Sheraton Hotel in Toronto, Jan. 20-24, under joint auspices of APA and the Canadian Psychiatric Assn. This Institute will be patterned after the U.S. meetings. Major theme will be “The Mental Hospital and the Changing Community," Dr. Mary Jackson is Chm. of the Program Com. with Drs. C. Buck, W. Boothroyd, J. Griffin, J. Hagan, A. Miller, D. Lewis, and Drs. C. Roberts and J.Gilbert of the M.H. Section, Dept. Nat. Health and Welfare as advisors. Since it will have a clinical orientation, this first Canadian Institute is planned for psychiatrists in senior posts in all types of Canadian mental hospitals and for the administrators of Federal and Provincial mental hospital systems. More details in the fall. New Printing of Glossary With the first printing of 30,000 copies of A Psychi- ASSEMBLY OF D,B, NOTES . . . .Met May 13-14 during Annual Meeting. . . . Installed following officers for 1957-58: David C. Wilson, Speaker; Walter H. Obenauf, Deputy Speaker; John R. Saunders, Recorder; Policy Com., (Area I) Albert M. Biele, Frank P. Pignataro (Alt.); (II) Lester E. Shapiro, Ulysses SchutZer (Alt.); (III) J.G.N. Cushing, Edward H. Williams (Alt.); (IV) James L. Sagebiel, G. Wilse Robinson (Alt.); (V) Alfred Auerback, Edward G. Billings (Alt.). . . . Volunteered to assist Med. Dir. in obtaining accurate information to publish obituary notices in Newsletter. . . . Revised Procedural Code. . . . Suggested Council action to seek extension of MEDICARE program. . . . Commended Dr. Wilson for Assembly exhibit at Annual Mtg. . . . Decided to study inspection of psychiatric facilities and depts. of psychiatry in gen. hosps., and facilities of public mental hosps. . . . Submitted two proposed Constitutional amendments for consideration by Council. . . . Will investigate planning of Divisional Meetings. . . . Scheduled next mtg. for May 12-13, 1958 at St. Francis Hotel, San Francisco. PERSONALS. . . S. Spafford Ackerly was honored by a atric Glossary exhausted, a new printing of 22,000 copies Testimonial Dinner on June 19 in recognition of his 25is now available. A limited number of copies have been year contribution to psychiatric education and community health in Louisville and Kentucky. . . . Paul V. Lemkau made up with a hard-cover library binding for libraries has returned to Johns Hopkins Univ. as Prof. of and others who would like it in more durable format. The Public Health Admin. (mental health) at School of Hyhard-cover copies have no cover design—merely the 8: Public Health following a 2-year leave of giene of title the book. They sell for $2 per copy. The paperbound edition remains at $1 per copy. Order from Mental absence. . . . Baruch Silverman was presented a Canadian Mental Health Award on Apr. 17 in recognition of “his Health Materials Center, 1790 Broadway, N.Y. 19, N.Y. outstanding contribution to the mental health of the CaDid you know that the following Isaac Ray Award nadian people,” . . . Alan D. Miller, Dir. of MH Study Lectures had been published and are available through Center of Nat'l Institute of Mental Health, was transferred to England on June 18 for advanced study and reany bookstore? The Psychiatrist and the Law, byL Overholser, 1953; Psychology of the Criminal Act and search. Stanley F. Yolles has succeeded Dr.Miller as Punishment, G. Zilboorg, 1954; The Guilty Mind: PsyDir. of the Center. . . . Major admin. appointments in N.Y. chiatry and the Law of Homicide, by judge John Biggs State on July 1 were: Arthur G. Rodgers (LF) as Dir. of Syracuse State School; Ulysses SchutZer as Dir. of Jr., 1955 (all these by Harcourt Brace 8: Co.); and The Urge to Punish, H. Weihofen, 1956 by Farrar-Straus and Binghamton 8. Hosp.; Charles Greenberg as Senior Dir. Cudahy. The latter publisher will also publish the of Rome State School; and William C. lohnston as Dir. lectures by Dr. Philip 9. Roche given at the Univ. of of Craig Colony. . . . Franz j. Kallmann received an Michigan this year. honorary medical degree as one of 6 scientists in differfields honored ent Third so Int'l Congress of Medical at The General Practitioner Education Project now operQ Arts, Turin, Italy during 1-9. June program, . . .17; from the Office Central E. ating (Charles Goshen, Projand Gantt Harold Horsley Rosen were Visiting Professors would information about psychi- for ect Director) appreciate 2 weeks this spring at Univ. of Arkansas Dept. of atric courses for GPs now in planning stage. It is sugDon D. Psychiatry. . . . Jackson appointed Asst. Clin. gested that when a course is being planned effort should Prof. of Stanford Univ. Med. School and Psychiatry at be made to have it approved for credit by the Amer. elected of Pres. Mid-Peninsula Psychiatric Soc. . . . of Acad. General Practice (through its local or state William H. Kelly has accepted position of Asst. Dir. of branches) as inducement to attendance. Dr. Goshen of Mental Health and Head of Mental Hygiene Div. Dept. will be glad to assist in publicizing such courses. for State of Michigan. 0 The Smith, Kline and French Foundation Fellowship NEW PRESIDENTS 8: SECRETARIES . . . Ark. D. 8.: Committee awarded 19 new Fellowships in May. 13 of Robert G. Carnahan & Leroy D. Lamm. . . . Cent. Calif. them will enable medical students to participate in reWilliam S. Fife & Arnold Sheuerman, Jr. . . . N_o. D.B.: search and training programs this summer. Among other Calif. P. Soc.: Thomas A. Gonda 8: Maleta Jo Boatman. Fellowships announced, one doctor will study research . . . .Kings County (N.Y.) D.B.: Morton H. Hand 8: organization at Boston Psychopathic Hosp., another will Abbott Lippman. . . . Hawaii P. Soc.: Robert A. Kimtake a Master’s degree in public health, and two lecture- mich 8; Robert S. Spencer. . . . Md. D.B.: Leo Kanner & ship programs will be established. Applications for Charles Ward. . . . No. Pacific D.B.: Herman A. Dickel consideration in October this year should be submitted 8r D.E. Alcom. . . . Quebec D.B.: Graham 8; Taylor 16. and Information forms by September application may Henry Kravitz. . . NP Soc. of Va.: Thomas F. Coates, . be obtained from the Fellowship Committee, Box 7929, & W.D. Buxton. . . . Washington P. Soc.: Seymour Jr. J. Philadelphia, Pa. Rosenberg & Marvin L. Adland. . . . Del. P. Soc.: George I �DeCherney 81 Walter Davis. . . . East Bay P. Assn.: Louis B. Boyer & Marion E. Roudebush. . . . Long Island P. Soc.: Edgar D. Congdon 8: Harry H. Gonda. . Milwaukee NP Soc.: David Cleveland 8: Edward C. Schmidt. . . . No. Pacific Soc. of N&P: D.E. Alcorn & Robert M. Rankin. of P. at the Univ. of Miss. under Floyd Moore and Oscar Hubbard. Also visited State Hosp. at Whitfield where . Wm. L. Jaquith and John Head have built up a fine program since 1949. They have a high patient turnover now and a new building for maximum security patients especially worth seeing. Also renewed acquaintance with Beverly Smith and Willard Waldron in Jackson. . . . On BRIEFS. . . . All who attend the World Congress in Sept. June 21 went to NY to speak to Bd. of Directors of will be glad to hear that Nat’l Committee Against N.A.M.H. APA members present were Hon. Fellow Mrs. Mental Illness, Inc. has (through APA) made funds availHenry Ittleson, Walter Baer, G.S. Stevenson, Jules able for simultaneous translation of papers. . . . Herman Coleman, Marion Kenworthy and Paul Lemkau. Was B. Snow, Supt. of St. Lawrence State Hosp. in NYS, pleased by much support from the floor for closer ties writes that 90% of his patients are in open wards exand strong Support for APA’s programs. . . . On June 28 cept at night. . . . Iago Galdston, Chm. of Com. on Int. joined Ewen Cameron’s Com. in Boston on future planRels., has sent over 100 copies of the Summaries of ning for the CIB in Pres. Solomon’s office. Drs. BarteAnnual Meeting Papers to colleagues abroad. . . . I have meier, Ewalt, Braceland, and Yerbury also there. . . . prepared a little pamphlet about my favorite vacation Flew back to Washington to meet with Joseph Barrett on haunt called ”Day Sailing and Cruising in Mahone Bay, planning for celebration of opening of Williamsburg N.S.” and I’ll send you a copy if you write. . . . Chas. State Hosp. (1773) in conjunction with Jamestown FestiBush and David Gaede are inspecting hosps. in Mich., val this October. . . . After the Exec. Com. mtg. Pres. having just finished up in Mo. Hope to start in NYS in Solomon and I flew to Nashville to participate in dedicaa few weeks. . . . Warren Johnson, my asst., recently tion of magnificent new admission and treatment building conferred with Cyril Ruilmann, F. Williams, and O. S. at Central State Hospital named after the Supt. O. S. Hauk in Nashville on psychology legislation in Tenn. . . Hauk. Wm. S. McCullagh, Pres. of the So. Psychiatric Smith, Kline & French Labs. have just granted $10,000 Assn. and Frank Luton also were among the speakers. to the Nat. Acad. of Relig. and Psychiatry for fellowAsst. Supt. White presided and Cyril Ruilmann introships for clergymen who want to become mental hospital duced the speakers. Gov. Clement gave the main chaplains (there are over 300,000 clergymen in the address. The Tenn. program has improved remarkably in country). . . . Sorry to hear of the death in June of Miss the past two years. . . . Forgot to mention last month that Dorothy Clark who rendered such valuable service as in course of Mental Health Week speaking tour I particiAPA Nursing Consultant from 1949-1951. . . . Write to pated in inspiring award ceremony for employees at St. Dr. Leo Alexander for details about the fifth Annual Louis State Hosp. where over 700 have served for 10-25 Institute of Psychiatric Treatment to be held in Philaof Nurses Dirs. his Kohler, Supt. Congratulated years. delphia Oct. 17-19. . . . A lady reporter at the Ann.Mtg. and Volunteers who organized the program. . . . Mike in Chicago was overheard to say, "Next to the White Gorman and I had stimulating talk with Robert Felix and House crowd this is the nicest group I’ve met.” . . . . Seymour Vestermark recently concerning NIMH programs Chas. Goshen and I attended meeting of APA Liaison in coming year which will be expanded with increased Com. with Amer. Acad. of General Practice in NYC to appropriations. . . . Also attended meeting of Wyoming discuss Gen. Practitioner Educ. Project. (R.Matthews, Valley M.H. Soc. in Scranton, Pa. where I met APA Chm., Frank Luton, Phineas Sparer, and Merritt Foster members Robert C. Murphy and Emlyn T. Davies. . . . were there for APA)....On June 6 spoke at Ann. Mtg. of Received notice this month that NIMH Advisory Council the M.H. Soc. in N.J. and on the 10th at the opening had turned down our application for renewing M. H. session of the M.H. Institute at Lansing, Mich. where Architecture Study grant; but funds are available to V. A. Stehman had brought in representatives of all Mich. continue it to end of and in meantime effort will be year hospitals. It was an outstanding meeting well attended. made to find other ways of keeping it going. . . . Expect . . . Went from Lansing to Battle Creek with E.F. Jones, to be off to Mahone Bay, Nova Scotia by end of month for Mgr. of VA Hosp. there, and showed his staff pictures of a few weeks of sailing and loitering. . . . Happy vacationforeign hospitals. . . . Did same thing for residents at ing to you all. . . . The next Newsletter will be in Sept.... Ray Waggoner’s Institute in Ann Arbor a few days later where also talked with Moses F rohlich who (as Chm. of Com. on Nomenclature) is hard at work on system for recording case data on IBM cards. . . .With Robert L. Robinson met in Toronto with Program Com. for Canadian Mental Hosp. Institute to finalize details on June 21 and was also able to visit Homewood Sanitarium at Director Medical Guelph (A.L. MacKinnon, Dir.) where the Ontario Psychiatric Soc. was meeting on the 22nd. . . . Also recently spent several days in Conn. with Chas. Bush where we consulted with the Governor on the mental health prohas Blasko that reJohn there. to Sorry report gram signed the Conn. Commissionership for another job; but P.S. Don’t forget to order of the Desk 1958 copies your his efforts to have the law changed to give the Commisand Book of Summaries the the (33) Appointment have been successsioner more administrative authority Scientific before the (81) Papers supply runs out. the 19 On Dept. visited expanding rapidly ful. . . . June ��WV-..— -»——————. ———_,—_a—.__.._—_,-__ ._________, __._ —_________.___._. _ __ .__- .__.__._. _____... —*_ ��October, 1956 vs Age EST # 1 & 2 - h Below 115 us yrs. over Changes - Reiter - £9 pts. 6 7 H L M 5 S 8 (id—ﬂ) 7 3 10 (50%) 13 5 10 (35%) 6 h 19 (65%) L yrs 50 over yrs 8: Distribution Age — H M 8 h 16 (57%) 12 3 6 (28%) 5 3 13 (61%) - EST 1 & 2 patients h9 5 3 31 - [10 yrs. 1 3 I41 - SOyI‘S. ll yrs. over - 6 5 10 2 3 Reiter vs Medcraft - .ii:;.L_ Reiter (EST # 2) H 12 (h8%) yrs. yrs M 7 30 & L 6 - 61 H 7-2 20 51 " 60 9 M h-6 Below 50 - L yrs. & EEG 25 Medcraft (EST # 3) 16 ptS. pts. LWC - h all ages 6 _Z_:_2_ L M H L M H 11 5 9 7 3 15 2 5 9 1 6 9 �Beiter vs Medcraft h Reiter (EST # 2) ‘17 Medcraft (EST # 3) CONCLUSION: 9 M pts. 8 3 Pts. 2 1 all ages and at h—é and at 7-9, xrs. from left to right. - over - 7 9 L M H 6 h 2 11 6 1 3 5 H older group only) whereas with Reiter Medcraft produces maximal change early in treatment and in changes & 6 L Both groups ( same - MS % it H records with.Medcraft increases. Therefore later changes consist only ��95 (I M hWé/Mv/ém W W/f 44’me Wm" PHI/M41; be M 52/15 ’4 gal/ﬁe): MM) 686cm; Mwwﬁﬁw ��\. \ Séwrﬁ‘sax «wk? '».,_ *Mﬁw'yr-Ea ”138:3? ‘ ��4‘ .' .ﬂu/W aw ' , . b; Izaak?“ wumad, W ’ 147? Xv 520’? ��Ti? V 1‘ s: I. 7:. V Z 1 - \_ rm . 111374;? : 7'“: _ ‘ " - . > v, ‘ y; ’ * Winn-n35 "W" ______ r - “22:! ‘ - -——~‘——‘ . ‘ ~ ' . ‘ ’ ' ‘ ‘ ( ‘ ‘ . I J ‘ 7 ‘ I v ' - ' V n I l ' ¥ ‘ ‘- ��', ’03. Alll‘llll �. ,7 — v Q ,.. r. ‘ _ T TrK. u _ ,.., . V, 9.. 1 , . ., a ‘ ,_. ‘ w, w . n 5 . . , . . i .A . :i.» ,. ...L. I, ( :4 . , ,. . < 5,: _. . . . . z .,. "“ ; .; 'n’hr ' ‘ 1 V 13—, ., awh'A_ “,1 “1.“..«2 , ‘ n .‘ r r 1 . . .a . _ _ ‘ ._ u... , a, h J _, N ‘ '5 _, ‘ v F :. , 'v h, .7 . ‘ 4‘;- _‘ , . x; x , .31.. , u . . . , .. ,2 .. _ "1 , A . ..a h .u '. A ... . i , , . N m. u . 1 , J 1-: I :. r. , , ‘ r ._ ; . . . . .ﬁ . . , rJ . :., I ‘ V, sv,._______-_._..:_:>..7;_.;_T t.« n—' n a. r r , :J: I. I; » .n .= . . II\ ' ' J any. ‘_.‘ , 2 Mr .7 . _ . .3 ‘l ,_ g» ..‘ I .a‘ . ,~ L, m .H _ J ,V , --.,-_.' r, 7 , n .T» . 1 H . — , . ”37:-.." \.L. \I Z" W“ ‘ K A [“97 '. .1:..." , .u: ._, Nu L x; ' ,- , . .. a w H _ H _ _. .,. . . .> . 7 wm _, . . . ., l , ,.. ., ,. . m "W”. 5,2 , , ' .3 1 ., . j A . g ‘ ., i. .. . ‘ V.,, Hutu” ﬂ A, 1 ��.g.W- an}, , 3 ‘ \——r —- --m I-L I I I I ' Mr n/f r? l' 2, 7 6 1 ‘. é ' / ./ o -’ I ' _» ’ //,,../ ’ ‘ , * Q 3 5* �W INDIVIDUAL PSYCHIATRIC TREATMENT INDICATIONS Paul H. Wilcox, M.D. Revised Nov. 21, 1953 Li PREDOMINANTLY NEUROTIC if and Org., B.P., F, otherwise IF start Nm, Ag, 3, 0-0, G, HqA, with Sequence Ir, Un, Of, or Par, start with Sequence I III PREDOMINANTLY SCHIZOPHRENIC if and D or Ag, otherwise I5 (Psychosomatic symptOms, anxiety or reactive depression) start start with with Sequence Sequence I PREDOMINANTLY ENDOGENOUS DEPRESSION start with Sequence Sequence Sequence I Sequence E.S.nc. II III Sequence IV E.C.T. COznc. 002 II \/, \ \ ___, 4______e 93 MANIC _, COznc. ___, E.C.T. ___, ___, low E.C.T. 1: Eu if Tr ______+ 602 \ifD ._____, II ifC 1:0 if c __, if t _____, if 'r _, ___, (III) (for termination of trance) 002m. (II) \<: (III) high E.C.T. C02 (IV) E.S.nc. (I) E.S.nc. (I) ifT if t plus 0...? terminate D if _____, E.C.T. (II) Note: Appropriate psychotherapy should accompany all phases of treatment wherever indicated. The goal of therapy is for the patient to have a mild 002 reaction (t) and be essentially symptom-free (O) for an observation period of at least two months. £21 - anxiety increasing Ag - agitation B.P. - systolic B.P. over 170 mm. Hg., systolic c - brief confusion (e.g. only 5 min.) C - prolonged confusion (e.g. more than AS min.) Cf - clinical confusion coznc. - non-coma 002 (whiffs) C02 - coma 002 D - persisting or increasing depression E.S.nc. - non—convulsive electrostimulation E.C.T. - electroconvulsive therapy Eu - euphoria F - marked fear and anxiety A H-A G Ir - Nm 0 — - severe guilt feelings - marked hate and aggressive tendencies marked irritability severe nightmares symptompfree - for 2 mos. or more obsessive-compulsive features Org. - organic changes Par. - paranoid trends O-C s - sleepless tT - mild tension - mounting tension Tr - prolonged trance state Un - unreality feelings ��52 m - �MAX F'INK. M. D. 275 MIDDLE NECK ROAD GREAT NECK. N. Y. HUNTER 7-4542 \; . :\ \ \ . w . .\\\ a h {zitgiisézirié \ ,5:11:15rfie1 v, flhhugavwx.§.1 at»; J. 3.11.. , _ if NDD‘ $5.. . J 3.25.1.5 4.51 1. $313 £511:er “V :2 1! ��a M.“ .7 �-7 r. v my .‘__r,\~. ‘_,_ an" .7 ”amt , 0, .7.— ..w . x 7 , ,...r,_ ‘_— v-4 . . ,_ w “K- mﬂ.w~..—-~_‘nr—._;_i , _ 7 _ 7V -_.-N,...~ . 1,-.. ~..~._.V..,.v .,_‘,.r_._h., V . if"? ��mw "">‘- aw ﬁn ’4_l4 I; Ant“ . ��4...»... ”Mu-L" ��Ft: £13 3"! HM (M) ��i 3 i E .1 i ��. _ a-‘v—{WWG’W’W‘tVF‘r‘Fw—ugfva , WNW—“W “WW. _ , . , . , ‘ W. . , _. ,' , ‘ A,.V,.. 3m, .zwu -..m~w~ W «RM-4mm "F v :i‘\ @ﬁ - A» \\\ 'l ‘3“ l." ..,. ‘ “ \.§;‘.§g was. wig-33;; __ ‘ ' _ ‘ A Em ' axis: .3, ��(L ALLA 4 4T ��;; i ��For creative activity, as possibly, for problem solving, the hyperh alert state must be avoided. In the alerted individual, discrimination is more focused, acute, and differences are sharply maintained. Under such conditions, old pathways are clearly maintained and the possibility of new associations is less. For creative work, pathways must be connected ected before. This can only be accomplished were not con; discrimination is diminished. reverie; by fatigue (creativity late at night); by isolation; by alcohol; etc. Perhaps in the EST situation, the cerebral state induced This ? is if that done by is similar to drowsiness (Surely the EEG - perceptual effects are similar) patient is able to use ("create") available before. and thus the new defenses which were not Also, in the tachistoscopic situation, the presentation is a hyperalerting situation - but, the reverie state (or dream) afterwards, permits of greater elaboration of the memories (greater range of imagery - greater creativity,). I/e3ﬂd �January 7, 1957 Role of Altered Cerebral Motion in Behavioral Change Following Induced convulsions m m, 14.9., Babe” In M; 31.3. m Hm Karin, 31.1). role of altered consciousness in the clinical behavior of epileptioe, patients with mental disorders, and in the diagnosis: of dis-orders of the central nervous system is unclear. Recent studies of the electroshook therapy process amonamtcd the crucial nature of persist.ent alteration in brain fxmction for the behavioral changes induced. In the course of theee studies, an appreoietion was obtained of the types of alteration in behevior induced 120' diffuse cerebral dysfunction; the role of the pmoz‘bid personality in the behavioral pattern; and the smith. 1w of various tests on indiooe of altered brain function. To define and measure the effeotc of alteration in consciousness Pmblem """"‘""'"" (manning rm diffuse control dysfunction) on clinical be. havior patter-no. The Kethod: Subjects on a voluntary paychiatric hospital referred for electro— shock therapy were studied concurrently by psychiatric, psychologic and neuroplwciologic techniol. Alteration in brain function (the demo of organic mental I; sycamo- was measured by four indicee: (a) Eleotroenoophalogm, moored for per cent time delta under nesting and activated conditions; (1:) Diaoriontetion, confabulatm-y responses one language changes following intravenous mobarbital. (c) Dininution in perceptual discrimination of simultaneous tactile threshold stimulation touts. (d) Interference with recall of 3 letter words after interpolated looming of nonsense syllables (”retroactive inhibition of recall") . mound by repeated psychiatric intent and reports of therapists and hospital personnel timing 2) Behavioral ohengec were views with subjects; and after the period of therapy. pmorbid percoaolity was eotimted by Cstructured interviews with relatives and by Rorschach tests (scored for H o reopens”). ROM“! 1) Modification of twavior is related to the dogma and persistence of alteration in hrm function, as measured by the electroencephalogram, amobarbital teats and perceptual discrimination teats. 3) The �in! 0' J c‘u pattern at the induced behavioral change, manifested by ahnnges in lmguags, mood, attitudes and symptom, is related to the preamorbid personality structure. Such behavioral patterns as euphoria, donisl, withdrawal, severe wry loss and disorientation, paranoia, WMrzitability and installed musty, have been obsemd. 3) Various indicss or altered cembrsl function have different sensitivities to modification depending upon the extent and activity (recent or old) at the dysfunction, and the personality of the subject. 2) The ’ leusiem 1) Behaviors]. nodii‘icstian in canditims inducing altered brain fanatics is ths adaptive response of tbs argmism under the conditian of an aims-stint: in the state of camcioumss. 2) has type of adaptive response is dependant upon tbs premorbid pemomiity of tbs subject and the milieu in which the behavior occurs. altered brain function mt be interpreted in tons of thsir sensitivity; their time of application in the ongoing process; and the pmrbid persmlity “the subject. This significance of them observations in tha understanding of epilepsy; the treatment. or mental illness; and in medsfinition 5f altered states of consciousness will be dissusssd. 3) Tests 01‘ Iron tbs Heumplwsiolom‘r Laboratory, Department of Fotperimental Psychiatry, Hillside Hospital, Gian Oaks, New Iork, U.8.A. �January 7, 1957 Therapy of Schizophrenia: Effect of Alteration of Brain Function on Behavior In the course of experimental studies of the mechanism of actidn of electroShock therapy in patients with psychiatric disorders, a hypothesis was elaborated regarding the mode of action of other therapies in patients with schizophrenia. 1t has been demonstrated that the essenp a electroshock is in therapy behavioral change to pre-requisite tial EEG defined by function as of brain delta, loss altered sustained degree of discriminatory ability on perceptual tests, and disorientation followThe behavioral response sodium. amobarbital of administration the ing under the conditions of an altered state of nervous system activity is an adaptive response of the subject, dependent on the premorbid person, ality . who and the environment. Similar factors have been demonstrated as operating in patients Show sustained improvement following insulin coma therapy. studies of drug therapies in schizophrenia demonstrate that the therapeutic efficacy of the newer psychopharmacologic agents demonmechanisms which brain are to the degree to related is directly strably altered. Conclusion: The mode of action of the various physiodynamic therapies (ICT, EST, Drug) is directly related to the degree of sustained alteration in brain function induced; such alteration being defined by changes in the resting and activated electroencephalogram, disorientation tests, and perceptual discrimination tests. , Ongoing ��can ﬁrsthand for the pemeption 01‘ words momma anti aubjem were unable to Mantify m wows with increasing degrees at cerebral 3-) Wmotim, We: in percoptim were highly sex-minted with other boo Moral chug”, inﬂiaaﬁve of an alumni interaction with the omirmmt. Minimum 1) Diffuse alter-nuns: in brain mum, as measured by elactrmcaphalomﬁzm 631%: mad emanation tests after mammal, results in altemtiw at pamytm pat-toms by an increase in threshold, impaired Metamucil: of stimuli, of which the ability to diacriminato a rignre from a. comply: backgromxd in a 5min h) ' ma We! ' 2) Alteration in pemepbim mpmanu sweet an m rather than a speciﬁc as? altered behavioral interaction with the envirmnt, Maialogieal defect, This factor sham be considered in peroeptnal 112.20.00.21. brain lemma as will. nudist {51% Ion-k, ”.34: m W; mar”?! �December 17, 1956 Concept of Cerebral Localization vs Mass Action Effects Certain functions ascribed to 1) CNS are "localizable", as vision, motor power, motor aphasia; While others, as memory, judgment, insight, cal- culation, figure—ground, are non-localizable. (more peripheral than central); have marked effects; and EEG damage The is generally first group are cortical permanent; small lesions is usually not pathological. lesions are generally deep or basal; recovery of function is possible; small lesions have no effect (i.e. a mass action law is applicable) and EEG effects are prominent. The non—localizable It results in a non-localizable lesion - with diffuse dysfunction. is the technic par excellence to study such mass action lesions. 2) EST 3) Psychological measure mass tests of "OMS” are positive to the degree that they action effects rather than focal - except if focal dysfunction interferes with performance as in lesions affecting vision, motor power and speech. h) Concept of Active vs Static Lesions: In studies of head injuries, lobotomy and post operative cases of six or more months duration, the studies reflect localizable (cortical) defects mainly: for the deeper activities nd are longer active. Any defects in fun- ction are expressions of specific cortical localizable damage. In contrast, studies of brain tumors, immediate post-traumatic states, post- (early) are studies of active dysfunction - a combination of the focal and the diffuse defects. The degree of dysfunction depends on the mass lobotomy, and EST effect, plus the localized defect. m away. ”cw-u W7»: 6% 2.2 .-W M- ��«M m a» mum at :1“er bum mum the dun» Mariam mum sum and chm a! me: aluminum; m vat-um a! the mmw‘mpu and tho «the submit ammmmm mammmmﬁg mumammnwmmm. Mmumafmw mun Winemwnuwm at them mm“). mm 1»th mm mu with annWtupmhupmrbm uwamwmmwwmm, the Mine of at a act-Latin Wm m by th"W”, WV. the an dwaﬁmt mm mm»: Mum Mow, m W: m that mum and. at my m Mum; torﬁumohanin WWMemlmm meettheu MWMWMWMNW¢ » �(July 2, 1965) Jan. 3, 1958 HOLE OF ACTION OF BIOCHEMICAL AGENTS The CNS is IN BEHAVIOR dependent upon a umber of enzyme systems for cholinestemseand including fmction, mtabolisn proper acetylcholine, gluoose-pkwsphetase, etc. CNS function and, thereby, affect of that agents variety behavior- is large, since processes in equilibrim may be shifted The in either direction by increasing or decreasing the available quantity of a metabolite . A. For drug action, therefore, the following are considerations in potency: (a) Does a drug affect an enzyme system in a reliable it way? to affect the system? (c) What defenses does organism process to block CNS? in action once limit drug's or (b) Can B. Secondly, get to mile (NS an agent may directly affect the metabolism CNS the dependent upon the is extent that to of a specific system, system? Is the defect thw induced simificant for the netsbolism of CNS underlying behavior? that defenses can body cell into play when system is affected to substitute other energy system? Thus, the variation in drug effects in behavior depend upon: (a) Behavior at onset; and predisposition (personality) to response; (b) Drug dosage - availability to has on an enzyme system; CNS and the effect it �(c) Dependence of organism on specific enzyme - and organismic defenses (i.e.,-~ substitution for affected system) . Whether effect was gmdual (allowing for system ((1) defenses, i.-e . , alternate mtabolic system) or acute (not allowing defense). Imividual diffemnma in response may be due, thus, to differences in: (a) Dosage, mtio S mute of Ministmtim (b) dependence on the affected system (c) adaptive ability to biochemical changes. To these clauses, EEG is a gross approximation and indicator, reflecting the homeostatic balmce in various enzym systems of the CNS. ��Personality-O.M.S. Tests of O.M.S. 2-5-57 The All our tests of changes in cerebral function tapas continuum. degree of cerebral dysfunction at the time of examination will determine which tests will The degree of “ show changes in patterns. cerebral dysfunction is dependent on numerous variables including; Rate of develogment of dysfunction Premorbid state of functioning on the tests employed Stress of the examination- needs and motivation of the subject Localization of the cause of the dysfunction (local vs. diffuse) ' factor, the premorbid state of functioning, as characterized the present evaluations of personality organization by the Rorschach One by test and by interviels, graphic fashion; can be pictured as operating in the following ‘ ��V E F E E F E ;‘ ﬁs‘;’*;)¢¢2\ _ a '“ﬁ‘ �� 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 EEG (notes), 1955-1957 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-3-003 Date A point or period of time associated with an event in the lifecycle of the resource 1955-1957 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: EEG notes 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 http://exhibits.library.stonybrook.edu/mfp/files/original/d01fea06dd83b521f86d15c567b14a69.pdf 5db07271542a5e11cdde7c401a2c6afa PDF Text Text ��s [.9 227mb, ‘5)04 ..: L M ~17!ou ' m ,1 Z 0 is ,« , 042454 “11“., m «:4 ’ ‘ ,J‘vmw& —!—.‘W_ ��W ﬁfw_“______‘______Wr r M l)CZ¢/vw€u M“ @WLE; $54: W gm . KW C Z’W ‘TN’M 2r 3) am! Vn. Fr‘e—L WW’ Am); Maﬂuﬂ/EW/ �INDEX TO ADVERTISERS _ PAGE AAAS ........................................................ 5, 394, 396, Inside Back Cover American Tobacco Company _____________________________________________________ Back Cover Columbia University Press _____________________________________________________________________ 6 Ford Instrument Company ______________________________________________________________________ 391 International Equipment Company _____________________________________________________ 398 Johnson Research Corporation..--__________--_.____-________________-_.-____; ______________ 5 Macmillan Company _________________________________________________________________________________ 8 Measurements Corporation _____________________________________________________________________ 6 Microcard Foundation _____________________________________________________________________________ 392 Oxford University Press, Inc ________________________________________________________________ 391 Rinehart & Company, Inc ________________________________________________________________________ 394 Ronald Press Company ___________________________________________________________________________ 2 Schwarz Laboratories, Inc ______________________________________________________________________ 4 Ivan Sorvall, Inc ______________________________________________________________________________________ 7 Taconic Farms, Inc __________________________________________________________________________________ 394 University of California Press _______________________________________________________________ 393 University of Chicago Press ___________________________________________________________________ 3 D. Van Nostrand Company, Inc _____________________________________________________________ 395 John Wiley & Sons, Inc .......................................................................... 397 399 ��£32 » . x : ‘ . . . , V ( - 4 ‘ V ‘ ‘ ' . , \ . , - '1' ”:5. .9. ,2; «E a‘ ,7;- 7- \77 ‘- . _ mtg if} m: 34ifv; 5:32;: ;. ‘ , er?” is VF» ‘ﬂh‘flaz: ”r: 91‘;._;.;..,.::_:.»’~~:_V ;‘;,».+~:-.éé ,5». ifp. ,, ..~- .393, - ,_-_».;,-,-« r .- - ' - 2 . . �DEW? 17; 1956 Gamept of Gamma]. Localisaﬁm to Hana Action Effects 1) Certain functionnascribod to CNS are "localiaable", as motor power, motor aphasia; while others, an memory. Judgment, Mm, insight, m1- culation, figure-ground, m nmlocaliuble. The first. greup am aortical (mom pariphemi than antral); damage is generally permanent; will lenient! have maimed exam; and EEG is usually not pathological. lam-vloodiubla lesions are generally deep or basal; mowezy at m:ctim is possible; null lesions have no effect (1w. at mass wtian 1am in The effects are pmﬁnmt. 2) m results in a nonuloealiuble lesion .. with diffuse Mfmcﬁwa is the teahnic gxgalleneo to study such mass whim lesiom‘ applieabla) and It 3) EEG a; Psychological tests ’of ”OW” am positive to the dogma that they measure mass action affect»: ram” than focal - exaept it focal interferes with pexfbmnoe as in lesions meating 75.31011, actor power and mum speech» 1;) Concept of Active vs sum Lesions! In studies of head insulin, lobotom and post. apex-nun me! of an or more mths duration, the atudiaa reflsct 100311111313 (cortical) Meats mainly: for the deeper activities am no lager active“ Any defects in hm» cticm am expresaima of speciﬁc certioal laculinbla W» mtmst, studiee of brain tumors, immediate post-tnmtie statues, post-v 19mm, and EM (early) are stud-m or active dysfunction - a. cambinntim of the focal and the diffuse defeats. m degmo of: dysmnction depends on the ma In offset, plus the localised defect. �J.A.M.A., Dec. 13, 1958 PNEUMOTHORAX—MAURER ET AL. 2014 ination revealed adherence of the fundus and nodules throughout the adnexa. A diagnosis of pelvic endometriosis was made, and on Aug. 18, 1955, total hysterectomy with bilateral salpingo-oophorectomy was performed. The patient’s postoperative recovery was again uneventful. In the four and one-half years after the thoracotomy, the patient has had no recurrent chest symptoms or pneumothorax. Comment Aberrant endometrial islands have been reported in many locations, including the ovaries, uterine ligaments, rectovaginal septum, sigmoid colon, urihernia umbilicus, bladder, laparotomy scars, nary sacs, appendix, vagina, vulva, cervix, lymph glands, and small intestine, and in bizarre locations, such as the upper and lower extremities, lungs, and pleura.l Sampson’s2 original theory of transtubal regurgitation of menstrual blood and endometrial particles, published in his original paper in 1921, could certainly explain the method of implantation of endometrial growths on the pelvic and intraabdominal viscera, as well as on the inferior aspects of either leaf of the diaphragm. The lymphatic and hematogenous dissemination theory of Halban would be necessary to explain distant endometrial implants in the thigh, lung, and pleura.1a Distant spread without passing through the pulmonary capillaries could occur only by way of the vertebral veins or “lung shunts” which have apparently been demonstrated between the pulmonary arteries and veins bypassing the lung capillaries. In view of the concomitant ﬁnding of pelvic endometriosis and the involvement of all layers of the right leaf of the diaphragm, with perforation and supradiaphragmatic seeding demonstrated by thoracotomy, in the present case report, it would seem logical to conclude that the endometrial involvement of the diaphragm must of necessity have occurred as the result of transtubal regurgitation and transperitoneal dissemination. Exact explanation of the method of development of the pneumothorax on the right side is more difficult. However, the clinical observation that all episodes of pneumothorax occurred only during the time of menstruation, and the inability to demonstrate any source of lung leak or primary disorder in the lung which could explain any possible leakage of air into the pleural cavity, would suggest that the recurrent pneumothoraces in the case reported here were the result of erosion and perforation of the right diaphragmatic leaf by endometrial implant and the fa]of the from the of air by uterus way passage lopian tubes into the peritoneal cavity and then by way of the opening in the diaphragm into the pleural cavity, with consequent pneumothorax. Although we are unable to ﬁnd any reports of spontaneous pneumoperitoneum occurring during the menstrual cycle, the practical possibility of this is suggested by the free anatomic communication between the cavity of the uterus with the peritoneal space by way of the fallopian tubes. Practical application of this knowledge is regularly used in the so-called Rubin test for patency of the tubes. During this procedure, carbon dioxide is passed into the uterus and then by way of the tubes into the peritoneal cavity. During the test, patients may experience shoulder pain and present roentgenographic evidence of pneumoperitoneum. Summary Chronic recurring pneumothoraces resulting from erosion of the diaphragm by endometrial implants during periods of menstruation occurred in a young woman. This was surgically corrected by excision of the involved portion of the diaphragm. The un— anticipated ﬁndings encountered at operation in this patient present an additional indication for exploratory thoracotomy in all cases of unexplained, constantly recurring, spontaneous pneumothorax. 827 Union Central Bldg. (Dr. Maurer). References 1. (a) Novak, E., and Novak, E. R.: Textbook of Gyne- cology, ed. 5, Baltimore, Williams & Wilkins Co., 1956, p. 546. (b) Nunn, L. L.: Endometrioma of Thigh, Northwest Med. 48:474—475 (July) 1949. (c) Hartz, P. H.: Occurrence of Decidua-Like Tissue in Lung: Report of Case, Am. J. Clin. Path. 26:48-51 (Jan.) 1956. (d) Hobbs, J. E., and Bortnick, A. H.: Endometriosis of Lungs: Experimental and Clinical Study, Am. J. Obst. & Gynec. 4:832-843 (Nov.) 1940. (e) Nicholson, H.: Endometriosis of Pleura, Thorax 6:75-81 (March) 1951. 2. Sampson, J. A.: Perforating Hemorrhagic (Chocolate) Cysts of Ovary, Arch. Surg. 3:245—323 (Sept) 1921. FUNCTION OF THE BRAIN.-—Any biological view of the function of the brain leads us to an unavoidable conclusion: consciousness is not unique to man, to the primates, or to the mammals: it goes back to the roots of vertebrate history and has been progressively elaborated in content, coloring and complexity roughly in proportion to the evolution of the neuromuscular system. It cannot even be argued that consciousness is a unique vertebrate invention—the crab, the octopus, the butterﬂy, the ant, all possess sensory devices imparting to them the awareness of their world; all demonstrably engage in integrated time-binding, self-serving action, and it must be presumed that all participate in some proportional measures in conscious awareness of themselves and their environment—H. W. Smith, The Philosophic Limitations of Physiology, Perspectives in Physiology, Washington, D. 0, American THE Physiological Society, 1954. �2013 Vol. 168, No. 15 TO DUE PNEUMOTHORAX SPONTANEOUS RECURRING CHRONIC ENDOMETRIOSIS OF THE DIAPHRAGM Elmer R. Maurer, M.D., James A. Schaal, MD. and F. L. Mendez Jr., M.D., Cincinnati Chronic recurring spontaneous pneumothorax is results which disorder usually common relatively a from rupture of subpleural blebs. Endometriosis of the diaphragm, on the other hand, is an exceedingly has be determined, lesion as and, nearly can as rare never been reported in association with, or as a cause of, unilateral recurring pneumothorax. The following case report is presented because of the extreme rarity of the lesion involved and the unusual association of pneumothorax with the menstrual cycle. It is the ﬁrst recorded instance of successful surgical treatment of chronic recurring pneumothorax by excision of a defect in the diaphragm that has resulted from endometriosis. communicated This diameter. in 2 cm. was an aperture freely with the peritoneal cavity. The area of disease in the diaphragm, along with the defect, was widely and completely excised. The consequent diaphragmatic opening was 0. size of cotton, sutures mattress with interrupted repaired Examination of the specimen showed that the disease had involved the complete thickness of the diaphragm. Final inspection of the superior surface of the diaphragm revealed which 1 in diameter, nodule, cm. purplish-red a solitary obviously represented a supradiaphragmatic endometrial implant. This also was completely excised. Following reexpansion of the lung and the placement of an intrapleural catheter for water seal drainage, the chest wall was closed of endometriosis diagnosis was The postoperative in layers. the right leaf of the diaphragm resulting in perforation and Report of a Case A 35-year-old woman was ﬁrst seen in consultation on March 13, 1953, because of pain and dyspnea resulting from a spontaneous pneumothorax on the right side. The patient had had two previous spontaneous pneumothoraces 1952. Nov. 14, occurred ﬁrst on the having the right, on Findings on the general physical examination were negative except for distant breath sounds over the upper right part of the chest and hyperresonance of the percussion note due revealed chest of the Roentgenograms pneumothorax. to a a very minimal pneumothorax (15%) over the extreme apex and the base of the right lung. No emphysematous blebs were apparent in any portion of either lung. Because of the small quantity of air in the chest and the absence of serious thoratube thoracentesis or of air the by removal symptoms, costomy was not thOught to be indicated. The patient was discharged from the hospital for follow-up care by her attending physician. She was again seen in consultation on March 20, 1954, approximately one year after the original examination, because of 12 new episodes of recurrent pneumothorax on the right side. All pneumothoraces were associated with pain and mild dyspnea and had been veriﬁed ﬁrst the chest. For of the examination by roentgenographic 15 all that information the volunteered the patient time, episodes of spontaneous pneumothorax had come during the period of menstruation. The important clinical signiﬁ— time. the at appreciated not observation this of was cance Because of the chronicity of the lesion, open thoracotomy with possible talc poudrage and excision of any blebs that examinaroentgenographic been on have apparent not may tion was recommended. Right thoracotomy on March 31, 1954, revealed a persistent moderate pneumothorax on the right side. Careful examination of all lobes of the right lung revealed no evidence of blebs. Testing of the lung with positive pressure, while saline solution was dripped over the surface, disclosed no points of air-leak. The lung parenchyma grossly presented a normal appearance and consistency. The most re— markable ﬁnding involved the right diaphragm. Near the point of emergence of the inferior vena cava and extending radially and laterally in the central portion of the right leaf of the diaphragm was a circumscribed, oval-shaped area of attenuation which measured 4 by 3 cm. in diameter. Numersurface. this modulations on apparent were purplish-red ous In the central portion of the diseased area in the diaphragm Photomicrograph of excised lesion, showing, endometrial stroma and glands extending through ﬁbromuscular structure of diaphragm. implant of endometrial nodules on the intrathoracic surface of the diaphragm. Microscopic examination of the surgical specimen showed extensive involvement of the ﬁbromuscular stroma of the diaphragm by nests of endometrial stroma and glands (see ﬁgure). The single nodule on the supradiaphragmatic surface was composed of endometrial tissue. The postoperative course of the patient was entirely uneventful, and she was discharged from the hospital on her ninth postoperative day, being afebrile and ambulant, and with her right lung completely expanded. Because of pain in the pelvis and dysmenorrhea, the patient was seen by a gynecologic consultant. Bimanual exam- � 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 Consciousness studies (notes), 1956-1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-5-005 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1958 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: notes: consciousness studies 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 http://exhibits.library.stonybrook.edu/mfp/files/original/866335cd8b6a0e848ec4f05bda1e57d7.pdf 610411ecffe18c07ab2ae5b0c8adcc8c PDF Text Text ZJ’W 4r 9, I; /y’7'.rf [E Wsﬁ%w‘> In a series of investigations of the role of neurophysiologic factors in the changes in behavior induced by convulsive therapy, that an alteration in brain function prerequisite, for behavioral it was concluded necessary, though not a sufficient was a change and "improvement" ( ). Changes in brain function were measured by a variety of indices, of which alteration in the waking was EEG induces a the most satisfactory shift in the EEG ( ). convulsive therapy consistently Spectrum to slower frequencies, with the development of runs and bursts of high voltage delta activity. m frequencyI? per-cent ‘ The degree and rate of development frequ However, there is'uide variability in the I‘ A voltageandr‘degree ,t/ ~e£-~h2rstr time treatment process [lay activity different subjects. With-equal—numbers—and developed ’7 at various stages of delta activity have been related to the age of the subject of treatment 1 Yet, when 1’ ), and mode ), frequency of induction (electrical, chemical, photo-chemical). the degree of delta these factors are held constant, variability in activity is it” ( ( of the still manifest (. ). Previous experience has danonstrated that both the behavioral reSponse Y and ratings of improvement to convulsive therapy a perceptualm processes as may be related to various " . number and type of Rorschach responses ( ), �score on the California F scale ( , ( ), and errors on figure-ground tasks dud. ); and to such sociologic factors as age, education level, place of fail.‘ W‘ M treatment m to explain the degree of the EEG the variability, this W W“? their perceptual-psychologic aﬁﬁability wt mm “a“ pie-treatment ofA W subjects, Ma ‘ ‘ EEG M“ characteristics WWWWMWW» Was“ can—ad. this M. It is the purpose of j study m~--~m to elate pre-treatment. SUBJECTS AND METHOD : W Gonsecutive patients referred for convulsive therapy in a voluntary psychiatric hospital were studied. 22 to so with a median of 149 c and depressive, schizophreniﬁ The patients ranged in age from years; and were diagnosed as suffering from psychotic cyclothymic reactions. While the range of conventionally applied diagnostic categories was ML 5" broad, the population exhibit} the cannon characteristics. MAI. (7414:444aA4;€7 a single ethnic f“ �OBSERVATIONS: l. Quaint. Variability of Induced-Beita—Activityt In the patients receiving convulsive treatment and investigated Mimi Mm , a} 1 M/b/ by the methods outlined, the variability in the Wed-Wotivity is considerable. We have summarized the observations in 1146 patients in Table I0 While the per-cent of records in the high degree category increases with successive treatment given at three tines a week, half the population has Aral“, a; Z:/£ not achieved..:the’ degree of—éelta activit}; in the third week, and in the fourth week. in all subjects. By the fourth week, however, 5% m ‘ y 140%“ is apparent �TABLE I £24 4314/4. Degree of Inducedﬁsihe Activity With Gonvalsive Therapy gPerﬁzem of Groug, Name) Treatment Period W ~lHts-Aetjjri’ox Mao—k ## First Rx High Degree Moderate Degree Low None Degree # Week Second Week ‘l‘hird Week Fourth Week 1-3 h-b 7-9 10-12 ‘ 14% 28% he?! 60% 12% 21% 27% 2275 68% h8% 25% 18% 16% 3% 2% 0% HH 3/58 �-72. BA «MM Relation of Pre-Treatment Rorschach to 3.4.3 *4 Variabili ”“2" In the analyses of parable-meat 21:3... Rorschach 7%). the number of responses andAqualitative aspects *ann—Iimaw.._ .. i’movement Mbﬁuywa/‘iée' related to the degree of induced tel-ta activity. Wm—uummuw z.»_..mM.m.w.w—m:"g:od Me “mum—.9... h re were signiﬁcantly fewer cup-us t W EEG and color were WWW ‘nv mu» magnum-u “a...“ m.» .own-ru‘m-v-u-m: ”4/. ML. m mm.mm wulmw‘w.m mm,,. ‘ that With gh "‘ were observed. WW We activity \ manifesting moderate and low degrees of such activity. degrees of Be W 133121911135 m deem-96") in patients with highNRgrees of -.._-----_---_:.§ w on those activity t , 3* - van.” w rv: .-mm—Nw-w,.bv,W M. In patients who were observed) avid; taéeported signii‘'ican significant differences in Mw‘m.mmq_,m.m-.~=m~ failed to report 44». M ”iv! movement WK ﬂy fewer EEG Low reactivity "égher degrees of 7 ”WW’ / , �... -_’.. .ymrw—W‘w~——-- -w'r“"" ~- v-vwam- / W- --»—',.w erw w �W-num z 19*; III ff ; “¢“-'—-h nqh-II-uylL-" '51? A expressed y‘TAIB'I-E ------ similar relationship is noted for color responses. Patients form-color“ in the Rorschach developed lower degrees of delta activity with treatment than those l or a , greater degrees of human movement who W4. expressed color, coior-forxnll . olor responses. Combining both 1W My who & movement and b color) 4“, Wobserved in patients w who gave nor form-color reSponses, than in those patients who neither expressed either or both these responses. Analyses for number of whole responses (W), per-cent of good form responses (F‘s-$5), significanttx 444% populago) and per-cent oi responses, failed to demonstrate Sawwuﬂ—v M relationships 1; the degree of induced an» activity. �II TABLE Relation of Number of Rorschach ReSponses to Induced wide-«4L EEG 9* Mean Activity $.13. Diff. Number High Degree Moderate, am Low Degree 3m 114.2 7.2 20.8 15.0 High Degree Moderate, b... Law Degree h. of Resgonses 6.6 Number 2.9 3J4 5.0 5.]. ’0 2.8 4L SR2 (.01 of Movement Reagonse 2.1 2.3 wE305 gM+Fm+m2 �TABIE Relation of Movement and To A/ Induced III Rorschach Responses golor EEG M» Activity Ht High Degr_ee .— 9* Moderatesz Degree h Sign; . Human Movement (M) 3? 20 (53%) 18 (147%) Other Movement (FM-m) 2f 20 (71%) 8 (29%) I? 16 (814%) 3 (15%) 33 17 (52%) 16 (h8%) x2== 39 (75%) 13 (25%) P 93 11 (148%) 12 (52%) x2= 7.60 25‘ 15 (60%) 10 (140%) p L .05 37 3o (81%) 7 (19%) No - Movement Form Color (FC) Other Color (C, or None Both mm Either M Neither M or FC nor FC CF 0-0) 52‘- X2= p 6.19 4 .05 3.88 4 .05 �.11.. 3. Relation of Pro-Treatment Errors §g§§gglo"1Variabilit In a previous study ( ) related to changes in the degree of on drug: is scored bveo Smx to q errors on the hidden-figures test were EEG ,1, $.4va eel-be activity and positive reaponses the amobarbital test for cerebral dysfunction physiologic responses into a to on Hidden—Figures Test % ). ( Combining the index, a range of changes from zero (Table Did)- The larger the pre-treatment error score, the greater the degree of physiologic change with treatment. The triserial ILL correlation is +0.3h, significant atA .05 level. TABLE IV In a similar analysis of the pre-treatment errors to /\ the difference just fails of significance Relation of Pre-Treatment 1;. Considering the Spectrum made. An initial some EEG Pattern to amongst EEG ( Variability. ) or these and frequency the subjects, an analysis of the of these characteristics and the study variabilityﬁlm./ (Table Nb). variability in modulation, voltage, in the pro-treatment relation between EEG EEG patients EEG nesponsivity was whose pre—treatment EEG �TABLE IV Relation of Pre-Treatment Errors in Hidden-Figures Test to Physiologic Variabili 132 (a) Combined EEG - Amobarbital Index: Miologic Changes Mean # Errors 6+ (8) 13.3 3+, u+ (19) 11.2 0 (lb) 7.9 5+ ) , 1+, 2+ ~= p +0.31; 4.05 34.» Mark (b) EEG Ma Activity nghﬂai‘ha No Highiﬁ: 5.13. Diff. 3,2, (31) 11.1; 7,7, (13) 8.2 4.? t p M, ms. �.13... manifested slow wave activity had demonstrated that high degrees of delta activity appeared earlier such activity, As was as per-cent M confirming earlier report} of Kennard and W'illner 1" Jawwnw correlated with the degree of induced dean activity, time/)del-ta- activity.* MIX; / in patients without ( ). 13h; pre—treatment per-cent time alpha one approach to the problem, activity h and were sustained longer than measured In 44 subjects, a correlation of +0.35) ‘05‘ week (10-12 treatment). treatment the observed fourth during level/was DISCUSSION : In these studies, the degreeof induced EEG delta activity during convulsive therapy has beer- related to pre-treatment perceptual and dwwations ure, patterns. “i limited and are scope in \\ 2' / concluszwgarding I these\ and d bservati theor data with clini of s th\consistencz \\ explomtiglng; ,2; 1,7 further warrants constructs "”” ‘"‘ ”” "W“ ‘ EEG [While {a 1m.“ reports the behavioral patterns of euphoria, hypcmania and denial were shown to be consistently inter- preted by the psychiatric observer or family as "improvement," While somatization, ).Improvement "unimproved,"( and in excitement rated were as paranoia panic, convulsive therapy has been related to such lire-treatment variables as high * Previously demonstrated as a correlation of +0.81; with degree of delta activity ( ). �scores on denial personality indices anal-eerie the California F scale )t , ( W M ); absence of ( cam-W color, human movement, form-color responses, low number of responses, or high number of whole and tests good form responses on Rorschach and foreign birth ( most highly esteemed, educational ( ) ). Thus, ( ); and low educational attainment in an environment where verbal therapy is patients least like the therapist in social Mattributes W are referred for somatic (or non-verbal) therapy. Under the conditions of induced altered brain WM function, those subjects with least ability Wm hypomania, '\ WW ‘ " , she I; reapond with non-verbal behavioral mode; of euphoria, denial, displacement and minimization, and are rated as M "W ” "“76"“! while Subjects with greater perceptual and linguistic discrimination respond with the more verbal patterns of paranoid, panic, somatization and anxiety, and are I/ rated unimproved. II In the observations reported here, the pre-treatment perceptual also related to the degree of physiologic response. 4 discrimmtion and verbal discrﬁptive ability degree of induced gum» The greater the mode is M“! on the Rorschach, the lower the delta activity; the fewer the Rorschach responses, the less ., �.15discriminating and the less the ability to separate figure from ground, W the greater the physiologic responsivity to induced convulsions. difficult to formulate a causal relationship fer—the—eepeetc—e£ It is clinical behavior,(both pre and post-treatment) perceptual patterns and physiologic response. But M M behaviors it ’L“’Z° is operationally meaningful to interpret these various W of the subject tainteraction with the environment, with each measure of behavior representing an abstract or sample of subjectexaminer relationship. In this framework the problem of the relationdhip between personality and physiologic measures is transformed "whether" to one of "how" and ”under What ccnditions." from one or In these series—aﬂ- subjects, heightened perceptual discrimination appears related to low degrees My» W25 MW Wluf / of alpha activity in routine, suite recording and decreased delta-activity- f06ﬂ””‘$ responssnity to convulsive therapy. In clinical behavior sudn subjects are prone to A tutu: introspection, anxiety and ideastional disturbances; and show poor improvement ratings to convulsive therapy. These observations are and EEG consistent with previous studies relating personality a5pects by Kennard, Ulett and Shagass. Kennard and Schwartzman related resting EEG spectra of low alpha index ( to schizophrenic personality, ) �~16- psychotics , non-mm, while high alpha index to Ulett gt_ a_l_. ( ) psychopaths and young individuals. indicated anxiety prone7ness was ﬂying: correlated with v M poor alpha activity, slow and fast activity in the resting record, and poor response to photic stimulation the sedation threshold amplitude of beta ( ), ), ( activity and with poor in the alpha range. In Shagass' studies of low was responsivity to barbiturate as measured by positively correlated with anxiety clinical response to convulsive therapy ( ' ). and tension Thus, behavioral reaponsivity and interaction, reflected in personalitytheoay ltheenyand psychiatric nosology by EEG may be m related to neurophysiologic reactivity as reflected patterns, within the limits of the sensitivity of our measurements or methods of experimentally altering (activating) both behavior Inherent in neurophysiologic responsivity are all and EG. the aspects of the internal milieu, as reflected in individual differences in biochemistry, and in the pre-treatment continuum as EEG record characteristics; the individual environment reflected in perception, motor patterns, mood’ and verbalization; but also the sociologic aspects of the individual's experience. In the series of patients studied here, an ardysis of educational level with degree of . responsivity demonstrated a I.‘ 24.,q me $45 a: D . 3 EEG V] ( - p< .02) relationvship. Subjects �years of formal education had a lower percentage of high 6&b’tgd7’a" 56w! degree records than subjects with less than eight years or education. \ with nine or m more /CONCLUSI ON: The variability in the degree of induced 5am) mm deb: activity manifest during convulsive therapy has been related to technical factors of the treatment. Yet, when these are held constant, (regs-365%; ' ' y has studies, been patterns. Patients with fewer variability is still manifest. In these related to pretreatment perceptual and EG number of responses, fewer movement responses, and absence of human movement, color and form-color responses on the Rorschach; greater errors on figure-ground discrimination alpha activity 026m) 00'“ ' had higher degrees or induced eel-te- activity. 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M) ' as (W) 13 (253) x2 .. 3.31: P < .05 ‘ (hﬁii) n (52%) x’ .. 1.6a w (W) p < .05 7 (19) �4h or m mm an to we at damn mar human mt mm clawing were chance! in mr’tmlar magma, and cow. petunia we saw with» than in than put-nu who mm: or both that names. Analyses We: Cm rum-Ia. boﬁh‘mmt. for (Mi). m:- and of than pm mm” porn-am or good ram (P) man, mud to with m m.- of at pomhr Wane ummm autism (W, am new we 10121718: mamwltudy( immqu-tm mmwwmmmc: MW mm mum m mm the physiologic sun an activity andtopoﬂtiw for uranium We (macro toaixpluammrad Em «swam 3. into a single 1min. a range of (Table In). The chum manhunt 11er .mm,mmmmmﬁmwcwummam. 1:» W .05 at. the 40.31;, in signiﬁcant. correlation M. �0») W WW K0 MW (31) not} 702 (13) 3.3 has 3.2 1.5 Fast �DIBOUSBIOII In theee etudiee, the degree of induced EEG delta eetivity during cenvuleive therapy hee been releted to pre-treeteeut pereeptuel end 380 petterne. In eerlier reperte the behevierel patterns at euphoria, hype-enie end deniel were eheen he be ceneietently interpreted by the peyehietrie tenily eheerver e! ee 'ieprevenent', while eenetieetion, penis, pereneie end excite-eat were reted ee Inniepreved( ). leprevenent in eenvuleive therepy hee been releted te each pre-treeteent veriehlee ee high eeeree deniel pereeneiitw indicee (e )3 eheence Beele ( ) end an the Geiiternie r or been: eeveeent, color, toreoeolor whole or anther high nether 1e! e! er reeveneee, reepeneee, end seed for: reepeneee on lerecheeh teete )3 end ( lee edecetienel etteineent end tereign birth ( ). Thus, in en environment where verhel therepy ie eeet highly eetee-ed, petiente 1eeet like the therapist in eoeiel end edncetienel ( ) ettrihutee are referred for eeeetie (er nonuverbel) therepy. Under the aenditiene of induced �altered hrein reaction, thoee eanecte with leeet diearieineo ve tiee ehility reepend with non—verbal hehevierel Iedee o: enphorie, hype-enie, deniel, diepleceeent end linieieetien, end ere reted ee 'eueh improved”, while enhjecte with greeter peroepteel end linguietie dieerininetien reepend with the mere verhel petterne or pereneid, penic, eoeetiee~ tiou end enxiety, end ere reted 'uniepreved.“ In the ebeervetione reparted here, the prentheeteent perceptuel node ie elea releted to the degree of physiologic reeponee. the xreeter the perceptnel diecrieinetion end verhel dieeriptive ehility on the Boreahech, the lower the degree of induced elew were activity, the fever the hereeheeh reepeneee, the ieee dieerieiheting end the 1eee the ehiiity to eeperete figure In: ground, the greeter the phyeielosic reepeueivity te induaed aonvuleiene. It ie difficult to rereelete e eeeeel reletiehehip between clinical hehevior (both pre end peetetre%teent) pereeptuel �pottorno and phyoiologic rooponlo. But it in oporotionolly looningtul to intorprot thou. various tasks to rolotod behaviors of tho oubjoot in hit intorootion with tho onvironnont, with ouch nonsuro or bohovior roprouoating on obstruct or Io-plo or oubaootuoxoninor rolotiouohip. In thio tronowork the problon of tho rolotionship botvoon poroonolity and physiologic noosuroo 1| transfornon tron on. or 'whothor' to can of 'hov' and 'ondor what conditions." In than. Jobs-eta, hoizhtouod porooptuol disoriuinotion dogrooo of alpha oppooro rolotod to low activity in routino, waking rooordo and docroosod amount: of inducod slowing in such bohovior In oonvuloivo clinical to thoropy. coupons. ond idootionol to anxiety introopootiou, oro subject: pron. dioturhouooo: and shot poop inprovolont voting: to oonvnloivo thoropy. an... 1/ oboorvotioao oro conoiotont with proviouo studio: toloting personality and EEG oopooto by Konnord, Ulott and �shagaae. Kannard and subvertaaan EEG ( ) related reating apectra of low alpha index to aehinophrenic pereouality, while high alpha index to non-paycbetice, payebopatha and young indiviﬂuale. Ulett g§_5;, anxiety ereneneea and elow and wee ( indicated ) correlated with peer alpha activity, feet aetivity in the reating record, and poor reapenea to phetie atiaulatien in the alpha range. abaxaae' atadiee at the aedatien threshold ( In ), lav reepenaivity to barbiturate aa aaaaurad by amplitude of beta activity teneien wee peaitively correlated with anxiety and ), ( aonvulaire therapy and and with peer clinical reepenee te ). 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Inc... m mm 1mm. . �February 21, 1957 Individual Differences in EEG Responsivity Fink, MJD. to present observations Nbx 1) Problem tonight is in the laboratory of Ex- made perimental Psychiatry at the Hillside Hospital and then try to discuss their significance. we have no the clarification The problem explanation but wish to present this material for it may bring. is to account for the variability in EEG re3ponse to electroshock. The Observations: 1) Repeated EST induces EEG changes. These are of many kinds includ- ing disorganization of frequency; decrease in beta frequency, amplitude; increase in delta % % time and amplitude; delta bursts; spike charges; increased sensitivity to hyperventilation, amobarbital, There 2) is a direct relation in group data of (a) with degree of induced EEG time and dis- - # of treatments changes (b) frequency of treatment (c) type of ' treatment Note (gm or pm). that our analyses are devoted to one aspect of the EEG response - i.e., delta. quantitative measurements The and myself and included were bursts; slowest frequency 3) % and were described here time delta, highest 1955 by Dr. Kahn time delta, duration of highest amplitude of delta. But analysis of our records, so classified as high, middle and demonstrated a definite relation between the ment" % in EEG response and the "improve- in the behavioral\response. Presented at the Metropolitan EEG low Society, February 21, 1957. �In the first 2h table the was obtained: following patients, % High Abnormality 1-3 h—o 7-9 10-12 25 80 91 88 Moderately improved (6) o 16 so ho Unimproved (7) 0 0 O 20 (ll) Much improved first we were struck by this correlation, and, devoted the subsequent year to demonstrating the significance of this relationship. our conclusion - that, improvement You may know of in electroshock therapy requires the induction of a state of altered brain fUnction, of which the EEG-delta index is a cardinal sign. recently, More notes that 3 we at the part of our table which of 2h patients had high records within 1-3 treatments, and that after 10-12 treatments 5 ord! Why Let took a second look patients still had not achieved a single high rec- this difference? me demonstrate some of our records to show the difference in EEG responsivity to electroshock. It is first series all treatments were given in the in the latest by Medcraft - three important to note here that by Reiter instrument; and times a week. That extraneous ulus was eliminated, all factors as threshold or suprathreshold stim- recent treatments have been given at threshold stimulation, achieved by Dr. Green by repeated PM a seizure resulted. 1) . High EEG 2) Moderate 3) Low EEG response. EEG - Lesnick response. - response. Baum - Silverwater in increasing dosage until �To what can we ascribe the difference in response? immediately come to mind, and I will discuss each one A number of factors briefly: (a) .553: is a factor in this varying responsivity, but not the sigIt is true that some younger patients achieve high EEG abnormal- Age nificant one. ity early; as first two patients over 60; but an analysis of the data of our electroshock studies, for which I am indebted to Dr. Green, indicates do some age to play a small role. Analyzing the records of h9 patients, Dr. Green divided the results in- to those above and below hS; above and below 50 - as significant cut-off points. There was a tendency for the older group to have lower EEG ratings in the h-é period; but by the 7-9 period, the differenCe was gone. ' (b) ‘ §_egc_: Clearly not a factor. (c) Clinical diagnosis: is difficult to assess. As you know, clinical diagnoses have no independent reliability. They are approximate descriptions of experience, clinical states and depend largely‘on the examiner's‘bias, setting This factor [of the examination, purpose,etc; also on the patient's age; and only incident- ally on any operationally defined observable pattern in the patient. For these reasons, this analysis is deferred. However, gross more inspection shows that patients with low reactivity have often been called schizophrenic and paranoid, than involutional depress- ives and manic depressive- and that patients with high reactivity have more often been called involutional depressives and manic depressives than schizophrenia-paranora. -_-——-————————-——— of treatment: �-h- significant factors, and since we are describing the results of individuals treated in groups in whom these factors were constant, we are Both are not going to explain this further than to say that stances, to convert a low a high EEG it is possible, in some in- response to three times per week electroshock to response by going from Reiter to Medcraft; or by going from three EEG times per week to five times per week or twice a day. But these factors only amplify further the variation in response. Egg. DeFede We have assumed abnormality We is have looked appear that the development of cerebral changes, of which delta a prototype, for is the logical outcome of repeated electroshock. an explanation, therefore, of the after adequate courses of It may be may reSpond by failure of delta to shock. that not all patients respond to brain trauma by delta, but other changes (as increased beta voltages and frequency; or increased disorganization; or increased responsivity to hyperventilation). Regardless of the construction, a difference in responsivity exists, and is manifested in our series. we have The factors conceptualized the problem as one of "cerebral reactixdty." we have already outlined are important in such reactivity, as have described, but we believe that more is involved. Out studies are we new in the progress along the following lines: 1) 222 Factor of Personality: In the course of our study of factors which bare on the type of behavioral response euphoria, paranoia, withdrawal define personality -), we to electroshock (i.e., denial, undertook a study of personality. To is extremely difficult. But Dr. Kahn in our laboratory has done so by the use of a variety of indices. The Rorschach; an interview with relatives designed to elicit premorbid behavior, eSpecially denial; figure-ground perception; tachistoscopic recognition of words, 32g. �To our surprise, significant correlations between the degree of delta abnormality and two Rorschach factors I score were achieved. 63 and the patients, EEG have listed the table of in the h-6 score reflects a low or middle The IS as well as the denial interview M & C initial in scores our responsivity. The EEG's were done CHART (M & C) EEG and 7-9 treatment period. The negative response; the plus, a high reSponse. THEN REFERRED TO significance of this chart is in the "apparent" diverse phenomena that it purports to relate. If borne out by future observations, it states, that patients who'have no movement responses and either no color or color-form responses have hh% chance of high EEG delta reSponse in the 2nd and 3rd week of treatment; while patients with Form-color reSponses have only a for such a 16% chance result. it be that one's perception of the world is directly related to one's cerebral respOnsivity? Or, do the conditions which permit delta to appear, that is, those that require an ability to withdraw and assume a passive Could ree Ostow described attitude as by for alpha index, also midify the patient's sponse to the Rorschach? we have become increasingly interested in this problem of passive choose to describe attit- it - in the problem of "vigilance" - "alertness.“ In our laboratory, Drs. Pollack and Kahn are engaged in developing psychophysical ude, or, as we measures of such "vigilanceg" while we have become increasingly aware of the influence of the observer's activity on the ongoing 2) A second factor which EEG. interests us with regard to the problem of in- dividual responsivity is the concept of physiologic reactivity. Electroshock �EEG (17) ResRonsiviﬁz to ECT or R (58) GM 00 2 OM czyc h (33) h (33) 7 M CE/C 3 (30) u (no) M 00 1 (25) 2 (50) OM M m FC 5% level of conf. S (71) 9 (50) h (22) 12 10 �is a way of inducing certain diffuse chemical changes in the nervous system. So is metrazol - barbiturate - activation technics it is show - hyperventilation. significant variation in responsivity. hypoglycemia Each of these For example, that hyperventilation induced delta readily in some patients - eSpecially children - but in others, no such response is noted. Dr. commonly known Green of our laboratory has hypothesized, and is now studying, the possibility that a degree of physiologic responsivity - which is measurable - is an inherent characteristic'of organisms. To this end, he is carrying out pretreatment activation records in all our subjects; as well as measuring their threshold for in EEG depend. electrically induced convulsions. I am confident that there are other "factors" on which responsivity to electroshock - and perhaps to all activation - we the variation may the ones described, namely personality, vigilance, are excited by and physiologic responsivity. tonight, not the common characteristic of the EEG response to activation, but the individual variability and the factors on we have emphasized which this depends. 'We have tried to exemplify our problem by our data of the variation in delta response to electroshock. Further study of each act- ivation technic to relate the role of personality, vigilance and physiologic reactivity to the variation in EEG responsivity. �-3and middle (lower socio-economic upper lower (Jewish)! ' j , ~ first The generation, group. and _ ideation‘ mood , responses. W; in the first hospitalisation, of Psychiatric . psychiatric bellman” «read-tune class), immigrant and were ' patterns we 114' W. They use voluntaﬂeﬁon‘ar predominantly 1, with a short period (few months to few years) illnesjzlectroconvulsive treatment was administered three «W “M'- _ times a week using 1hr % WM mthods. rﬂ L3 r . suprathreshold unidirectional or alternating current A“n*”"t ”WA a Jayne/1nd“! 11’ ﬂat man !0 ti 3.: Wig Ml’" {M-dtun ﬂit/“23‘ Within a week prior to treatment subjects were tested with Rorschach and figure-ground discrimination for presence or absence of j ,x’”‘\_, [I 2 responses and total (H + EM+ tasks. The Rorschach human movement protocol was scored responses (M), total m), type and number of color responses (0, movement CF and F0) In the figure-ground discrimination task, a, () modification of Gottschaldt's hidden figures, the subject number of responses (R). L niacin-mam is presented with and below it a page containing two forms a cmnplex figure in which the - a simple geometric figure, simple figure is embedded. The task is to outline the embedded figure in the complex figure. I' ”A4€ "- ad‘ Electroencephalograms were obtained prior to treatment, andweekly“ on a day following a Mamie, treatment. Patients whose pre-treatment records contained �measurable delta activity were excluded from the study. slow wave activity frequencies of and 7 W MW was measured 04, wave actiﬁty, Based on these activity in the record. of induced by determining the per-cent time of and—less three selected in cps, highest amplitude of slow The amount and leads; the slavest frequency / longest duration of burst indices, records were classified as pan/40M "low," "moderate" or "high" degree delta- W previously described of high degreesdeébba ( activity, according to criteria ). In the observations reported here, the activity in the second and third development weeks of treatment treatment intervals) was used in the tabulation. Patients who M. (We, developed high WWactivity during either or both these periods were classed in 3 of delta degree the high degree group. Those whose records did not demonstrate activity in either ,week were classed in the moderate-low class. 7-9 tt%gree or" �watt—baa WI? “H.“HQ mammmuormmmummmwm "mu alum, that «warm ant m1: of “Mom (W m). In Guide“ the “mummy in mum, vellum, m rmwmmwmmmmmtm mm,“ Wsamunugmmwmmmmmumum mﬂWNudl. MMM3M( )orthmputmtlm mmzmwmnmcmutmwmammwmtw mama in aetiﬁirapmﬁ muormdmmmalmthm such with“ «mum mm mmm< mm an «mu- apart at W )., «mapmwmmmmpmmmm ”mtg-lam muey m “rant-d nth tho W W ma of as pass-mm was at such wuvﬂyw In mum «1' ”3.“, +0.35, " m1: {'“4‘. ..., am “tax”; 44”.. a l1" an activity. tom-rm autism, tho .05, w a WW 2.3.2.1.“ Wmudu‘mumormduummwmu � 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 Individual Differences in EEG Responsivity Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-6-006 Date A point or period of time associated with an event in the lifecycle of the resource 1957 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. Drafts, one with Martin A. Green and Robert L. Kahn 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 http://exhibits.library.stonybrook.edu/mfp/files/original/371617534179d54e66d61621a46020c8.pdf 6e55d00563bbed3481f9a9906c445b08 PDF Text Text therapy, we hue ahead-red at individul wide response. Subjects duomtrete sue to equivalent number: or induced veriebﬂjkgy 1n digress of minim. EEG the EEG delta ee’dvity In the observations observed the to teeters of to be reported, the reletien webologic variability is amend. mam Ed Hethod: referred patients consecutive heapi’oelized malty-dive slammed.“ M with wire tested Subjects studied. therapy were ‘ im’TA‘MVvV «Ov1 M W the tor Bottleneck end ~ ~ within a week prior to treatment. ﬂeetreemphllo— wmdompriortotreemnt,endetweek1yintemledunng treatment. The records were wt! for the degree of induced deeoribed< previously indieee £5} activity using quentitetive Bad; petienh wee or imml’bbq Medea-eff. 5? Gem flaw. Reﬂexeither using week, times a three trotted instruments. I «M—-W-nuzwm: .4- HH' an. -\'. [UK/W Clo.) f‘ru’f a?) �heults: 1. Subjects with 1! and FC human moment (H), fem-color Rorschach responses showed induced delta (PC) signiﬁcantly lesser activity than subjects who had no such or bath amounts of responses. 2. Subjects with fewer Rorschach responses (R) and fewer total moment (Home) teaponses of delta activity. m 3. . The .. higher the malted simificantly greater degmee Wmmt «L test, the greater the «rot-beers on the degree of induced delta activity. gnawing: These studies describe a consistent tram perceptual responses and 041v w relationship between pre— obeemd degree of phtsiologic alteration following repeated induced cerebral trams. While factors of current, skull resistance, inherent responsivity of brain, 239. may affect the manifest physiologic alteration, that the subject's usual test eeores) affect the the EEG nodes of adaptation (reflected in his pemptnal physiologic response to cannot be viewed as it is also probable tram. In this context, in isolated physiologic index but is seen �Conclusion: Individual differences in the ma activity are related to have Insurer as latter the” differences in perceptual petteme. been shown to reflect pereomlity differencee, we would the individual'e node of adaptation ('persomliW') ﬂ“ Wﬁest chengef mtg; Physiologic ‘76 5359:: (me). suggest thet Wed—be We EFFE‘ ’1 \ would conclude that those aspects of experience and edaptetion that effect perceptual trauma. me the to at affect also responsivity tests �It't'f7 7-..“. Psychologic Factors in EEG Reactivity to Induced Cerebral Dysfunction In the course of an investigation of the role of alteration in cerebral function in the changes in behavior induced by convulsive therapy, we have observed a wide individual variability in the wide denonstrate degrees of Subjects response. EEG EEG delta activity to equivalent numbers of induced convu1310ns. In the observations to be reported, the relation of pSychologic factors to the Observed variability is assessed. Subjects and Method: Eightyafive consecutive hospitalized patients referred for electroconvulsive therapy were studied. Subjects wire tested with the Rorschach and the Gottschaldt embedded figure Sinai Modification) within a week test (Battersby — prior to treatment. Electroencephaloat weekly intervals during grams were done prior to treatment, treatment. records were measured for the degree of induced delta The and activity using quantitative indices previously described. Each patient was treated three times a or Medcraft instruments. week, using either Reiter �Results: 1. Subjects with H and FC human movement (M), Rorschach responses showed induced delta form-color (F0) or both significantly lesser activity than subjects who amounts of had no such responses. 2. Subjects with fewer Rorschach responses (R) and fewer total movement (MWFM+m) responses Showed significantly greater degrees of delta activity. 3. The higher the nambeehefepre-treatment error.score on the Gottschaldt test, the greater the degree of induced delta activity. Discussion: These studies describe a consistent relationship between pre- trauma perceptual responses and the observed degree of phisiologic alteration folloWing repeated induced cerebral trauma. While of current, skull resistance, inherent responsivity of brain, may affect the manifest physiologic alteration, that the subject's usual modes EEG etc. also probable of adaptation (reflected in his perceptual test scores) affect the physiologic the it is factors reSponse to trauma. In this context, cannot be viewed as an isolated physiologic index but is seen �activity interpersonal in the setting by influenced as one that is of the test situation. Conclusion: to related are EEezeactivity the Individual differences in have these latter as Insofar differences in perceptual patterns. been shown to reflect personality differences, the individual's mode we would of adaptation ("perSOnality") is related to (EEG). index the physiologic in manifest changes that those aspects of experience and adaptation tests suggest that also affect responsivity of the EEG ‘We would conclude that affect perceptual to trauma. ��_..,,, WWw-w ,, .w ”m.“ "Wm“. ‘WW..‘M_ . ,, ’w m—w"'1"‘mr-' W'sw-m-v-ni w ar— w..,._r..._.c ‘11ij ��EE 4» mm 0%; MW I'quw. ”a Mme-(W “,de '. d2. M + F6. Eneu. MwFt 0“ 2° (FMm) 2o " H. M ‘37) H’ (1.9.) e (:42) 6’40. 3 (I57. ($71 “-— .1 E4“ O'C) H I§ «2.) I2 Suﬁ.) (4°74 lo (“74) ‘— oS' - Esr' 0-4 .154; -3": �W M l4. 2 ,2, mm“ ' ”W 3‘!!- 4.6 ”M -?.I 2-! c. 2. 3 .0! non-I- ”*Fm-Ihs (a: EJfI-‘Il .(«y-h ��// 7%2.4“; M»! é 4,4...» r9 x‘W W. 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II 4+"I II III \' ' u {I � 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 Psychological Factors in EEG Reactivity to Induced Cerebral Dysfunction (research), 1957 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-9-008 Date A point or period of time associated with an event in the lifecycle of the resource 1957 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/547dda87f02e63e10815bbd8bd8b58a3.pdf 2de3623b012b67ce51e9e637220d0b84 PDF Text Text Role of EEG Frequency Shift in Behavioral Effects of Drugs mmmm.* During the past few years we have been interested in the interrelation- ship of changes in various measures of brain function and the behavioral response of psychiatric patients to somatic therapies. were devoted Our initial studies to the changes in tactile perceptual tasks in patients with organic psychoses. This study, carried out at Bellevue Psychiatric Hospital, demonstrated that patients with active organic psychotic reactions made repeated errors in the simple task of reporting two simultaneously applied cutaneous stimuli. The persistence of such‘errors was interpreted as an index to the presence of an "organic mental syndrome." In the initial studies at Hillside Heepital in 1952, the same patterns of errors were observed in patients receiving convulsive therapy. we then became interested in the role of altered brain function in the "improvement" induced by convulsive therapy. we In our first group of patients followed consecutive electroshock referrals with weekly measures of changes in brain function of brain function: and memory clinical interviews. tests, simultaneous we used four indices tactile tests, the amobarbital test for organic brain disease described by Weinstein and Kahn, and the degree of induced delta activity in the EEG. It was soon apparent that neither the memory scales nor the tactile tests were sufficiently sensitive indicators of alteration in brain function to be satisfactory for our purposes. The amobarbital test, however, was a sensitive indicator. In this test, the subject is asked a series of questions regarding his illness the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Island, N.Y. Read at the Section of Neurology and Psychiatry, Queens County Medical Society, June 3, 1958. Frcm Long ‘ �.2and orientation for place, date, time and person. Following the administration of intravenous amobarbital until the patient has nystagmns, the questions are repeated. Errors of confabulation and disorientation are scored as "positive" tests, and have been found almost exclusively in subjects with active cerebral dysfunction. In the patients in the electroshock series, a significant relationship was observed between changes in this test and impmvement ratings in convulsive therapy. Amobarbitﬂ Test EST - Improvement #1 “----‘--- u..---.--—----—--——-we in the also measured the changes in EEG. ﬁne degree of induced delta activity Examination of a series of preliminary records, as well as the description in the literature, demonstrated the early development and ‘persistence of Slow wave activity in the EEG during convulsive therapy. this preliminary information, we obtained weekly records during and ‘We measured of treatment. a after course specified leads for the per-cent time delta, the slowest frequency, highest voltage of delta and the duration With of burst activity. Using these quantitative indices 180 records activity. in The we ranked the initial patients according to the extent of the induced delta upper third were classed as ”high degree delta records," 2h the middle third as "middle or'moderate degree delta" and the lowest third as "low degree delta activity." High, Middle and Low Delta - EST #1 �.3 When we related the development of high degree delta activity to improvement rating, a signiﬁicant relationship Fig. EEE was again demonstrated. 5 Delta - Improvement - EST #1 ---—-—------ -—------ yo--— --—‘-..- ~- In subsequent months development of high degrees of third to EEG delta activity during the second and ratings. In the next table, these observations in the next Sh patients. weeks of treatment have summarized a predictive study, relating the we embarked on improvement F1 . we 6 Table: Patients High Delta 2nd, 3rd weeks of Treatment EST 2’ 3’ ’4 -_------- ----—----‘u-n-—---------_-----m-‘-----—----By this time we believed that EEG delta activity was related to the behavioral changes in convulsive therapy, and its significance in a control convulsive-subconvulsive study. Of was tested consecutive convulsive therapy referrals, randomly selected patients were subjected to a course of subconvulsive therapy instead of the convulsive therapy. This to the patients or their therapists. 0f the substitution was unknown subjects received convulsive therapy in this series, high degree delta who activity records were observed in of treatment. Of the 27 Subjects 3h during the second who to the fourth h? weeks received subconvulsive therapy, however, none demonstrated either-high or middle degree delta activity �.u. EEG . records during any week of treatment. In concurrent behavioral evaluations, of the h? subjects in the convulsive group h2 behavioral change, while only showed such 3 showed marked of the 27 in the subconvulsive group a change. In clinical improvement ratings, 2h of h? were rated "recovered" and "much improved;" 15 "unimproved or worse." But as "improved" and 8 as of the subconvulsive group,only 3 were "recovered" and "much improved," 5 as "improved" and 19 rated as "unimproved cr'worse." we were now convinced that high degree of EEG delta activity reflected the physiologic changes essential to the behavioral change in convulsive therapy. An alteration in brain function, sufficient induce considerable - and of the kind to activity appeared to be the prerequisite, not sufficient factor - in the convulsive therapy EEG a necessary, ﬂaough slow wave process. Perhaps a similar relationship was observable in other somatic therapies? we next examined insulin activity is induced, hours after gavage. receiving deep or prolonged which Not coma therapy. During each coma, EEG delta usually persists for a few minutes to a few infrequently - in approximately 1/3 of patients insulin therapy in our hospital, seizures, aphasia result. After such events, EEG changes of delta activity coma coma persist for days, The relation ' and in cases of prolonged between prolonged coma, coma, for weeks and months. altered brain function and behavioral response has been discussed by numerous authors. Revitch reported eight cases and concluded that improvement was related to the induction of organic brain damage, similar to lobotomy. Yaeger et a1 �-5. noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of of prolonged coma. EEG In reviewing our insulin abnormality in 12 cases coma experiences, noted we that our best clinical results have been observed in prolonged coma cases. As a result, it has been the intention of our staff to induce such a state. Persistent coma EEG delta activity has been observed in a small subjects, and only in those with prolonged neurologic signs. Thus, in insulin coma number of our or persistent also, a relation between delta change and behavioral response is indicated. Concurrent with these investigations, We had begun clinical EEG coma investigations with the newer tranquilhers. Initial study of Raudixin in 1953 He were failed to indicate any clinical efficacy. able to administer large doses - up to 10 With mgm. reserpine, however, At these levels, behavioral change become prominent but so also did neurologic complications. Parkinsonism was readily induced, and seizure induction and increased clinical depression became prominent. The EEG changes on chronic administration were small. With our doses, desynchronization was apparent, but at higher dosage hyperSynchrony was also noted. With chlorpromazine, however, we were more fortunate. we had undertaken a control insulin coma-chlorpromazine study, in'which the experimental dosage called for levels sufficient to induce clinical parkinsonism. In three of the thirty patients grand mal seizures were induced. In all patients significant changes were observed in serial EEGs. These consisted of increased modulation, increase in per-cent time alpha, and in twenty patients lOW'voltage theta and delta activity. On hyperventilation, delta �burst activity was observed. In reviewing the experiences of others, noted numerous reports of chlorpremazine inducing seizures; exaggerating seizure activity in epileptics; and activating seizure available for reserpine. EEG we records. Similar reports are review of the electroencephalographic effects of various phreno- A tropics demonstrated that not all newer agents induced Meprobamate, in clinical doses, induces an increase in activity. slow wave EEG fast activity, with increased voltage and Spindling. The records are most similar to barbiturate records. Benactyzine (or suavitil) induced neither slow nor fast activity but desynchronized the record, with flattening of voltages and loss of wave whatever rhythmicity was present. clinical experience we were impressed that chlorprcmazine and reserpine were the most effective modifiers of psychotic behavior, with benactyzine and meprobamate as relatively inefficient agents. It From our seemed appropriate therefore to extend the neurophysiologic adaptive hypothesis of the it was mode of action of convulsive and insulin EEG frequencies to the delta range would active in modifying psychotic behavior; while those that induce a shift to the beta range, or As a corollary it was desynchronize the record would be less effective. suggested that agents that induce no change in brain function or changes so small as not to be reflected in serial have therapies; suggested therefore, that agents that induce a change in brain function reflected by a shift in be most coma little EEGs would behavioral effect. Thus, a classification of newer phrenotropic �-7drugs based on their EEG effects was suggested: (3) Increased slow wave activity with hypersynchrony (b) Desynchronization with voltage and frequency irregularity, .and (0) irregular theta Increased high voltage fast activity In reviewing the available literature reports of promazine and perphenazine would indicate delta range. that these agents induce a shift in the Mepazine has minimal EEG effects, EEG spectrum to the and these are largely desynchronization. Information regarding other newer agents was not available. we EEG have undertaken two studies based on changes to behavior. One is serial EEG this hypothesis relating studies of patients receiving chronic tranquilizer medication at the hospital. a study of the relation acute administration: between the EEG and A now second is the behavioral effects on the data of our chronic administration studies are not yet available, but the acute studies have progressed sufficiently to danonstrate the applicability of the hypothesis. Fbllowing the observations by Denber derivatives, diethazine, elicit some EEG when that one of the phenothiazine administered with chlorpromazine, would activity similar to convulsive therapy, we undertook explorations of this compound. In the EEG laboratory with continuous 31 w wave recording, varying amounts of diethazine from 100 to 250 mg. were administered intravenously over a 10 minute period in psychiatric patients at various stages of the convulsive therapy process. Instead of hyperynchrony, patients who were pretreatment and without EEG delta activity, demonstrated significant desynchronization of the record. �-8Fig. 7, EEG - Diethazine - Pretreatment interesting, however, Most 8 was the effect of diethasine in patients with increased slow wave activity during convulsive therapy. Here, too, desynchronization became manifest, and there was a decrease in the voltage and per-cent time of the induced delta activity. EEG - Diethazine - Delta Activity effects, we observed distinctive behavioral changes. Patients became more irritable and restless; they Concurrent with these complained of sensations of extremities. In some, EEG unreality, visual illusory and of dysesthesias of the phenomena and delusional thoughts their illness, the setting of the test procedures or our identity. There were changes in their language patterns opposite to that previously about described for amobarbital, so that denial, minimization, cliches, third person mode and past tense were less prominent. The duration of these behavioral and language changes was from one to five hours. changes were of similar duration administration and disappearing The EEG - appearing during the period of when drug the behavior had apparently reverted to the pretreatment state. The ability of diethazine to activity led to an evaluation of induce other illusory known and hallucinatory hallucinogens. In checking �-9the literature we noted that that mescaline reversed the Denber and Merlis had previously described EEG changes induced by electroshock, in a fashion identical with diethazine. Pennes had observed hallucinogenic activity for another experimental compound Win 2299. We obtained some of this material, and repeated our diethazine studies. Here, too, Win 2299 induced EEG desynchronization associated with clinical patterns of restlessness, excitement, hallucinatory and illusory activity. Fig. 11, Win 2299 We repeated these studies with was a - 12 EEG LSD, and again the same patterns. There difference in the time constant, but concurrent with the behavioral effects we observed EEG changes. Recalling the ability of benactyzine to desynchronize records, this compound intravenously, and again, we observed the same we EEG administered pattern of desynchronization, associated with restlessness and excitement. While not observe the illusory and hallucinatory patterns, kinds of language changes in these patients that we we did note the we did same observed with diethazine. �Fig. 16, 17 Benactyzine The chemistry of these compounds Thus, from each of these agents, - EEG is noted in the next figure: EEG desynchronization was induced, and hallucinogenic or excitatory activity was observed. we can.now amplify our initial hypothesis to encompass hallucinogens. like to refer first to conclusions described in l9Sh by Wikler in a study of the effects of mescaline, n-allylnormorphine In-this regard, I and morphine in would man, in which he stated: ".... regardless of the drug administered, shifts in the pattern of electroencephalogram in the direction of desynchronization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronbation.with euphoria, relaxation or drowsiness." ‘We would now generalize our observations of EEG changes and behavior to note shift to the delta behavior. Agents that and that agents that induce EEG synchronization range are potent agents in the control of psychotic induce synchronization in the beta range are relaxant, euphoriant and sedative, while agents that desynohronize the record tend to be hallucinogenic. This hypothesis lends itself to a variety of applications. It provides a bases for the understanding of the mode of action of various organic �-11- therapies in psychiatry. EEG analysis may also provide a basis for the assay of new drugs and therapy procedures. Finally, these observations permit a more rational management of the somatic therapies. to explore each application in summary I would like fashion. application of the neurophysiologic adaptive hypothesis - for that is the rubric under which we subsume the relationship between the The in brain function, reflected by the EEG, and the changes in behavior - to insulin coma therapy has already been described. we have changes applied this concept to our studies of phrenotropic agents, and have been able, both It is predictively and retrospectively, to assess new agents. possible to understand lobotomy therapy, and sleep therapy, within this framework. As is for the assay of drugs, our explorations into hallucinogens that each of the potent hallucinogens a biochemical similarity in a common tertiary amine radical connected one example. have new we have recently noted by an ethyl linkage to a large nucleus. compounds with this linkage. One On this basis, we sought for group are known anti-parkinson agents with anti-cholinergic properties as parsidol, artane, kemadrin, panparnit and benadryl. we have not yet tested these compounds for their EEG or clinical effects. Recently, Pfeiffer reported at the Academy of Neurology that these compounds, in trained subjects, were identified most with LSD. In 1956, Gottlieb reported that benadryl desynchronized the patients, much as we saw this evening. available in the literature. shock EEG of electro- Thus, some confinnation is �.12With regard to the third therapies - this hypothesis ammﬂication may - the management of somatic be of considerable help. In convulsive therapy and in drug therapies, the patient'who responds in a favorable fashion is‘no problem. But what of the patients who responds poorly, or not at all? Could the failure of response be related to inadequate dosage? In electroshock, when a patient manifests paranoid or withdrawal behavior, or no significant change, an If the record we may assume fails to EEG provides a guide to management. demonstrate high voltage slow wave that treatment has been inadequate, activity, then and continue the treatnent course or increase the frequency or alter the convulsant method. If EEG changes are present, then we would assume that other factors - personality, sociologic or interpersonal - are not conducive to "improvement" by electroshock, and other remedies sought. Similar applications are possible for phrenotropic agents. In summary, we believe that somatic therapies in psychiatry exert their effects primarily by altering brain function. Changes in the EEG Spectrum are one reflection of sudatalteration and are useful as a guide to the mode of action, effectiveness and application of somatic therapies. � 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 Role of EEG Frequency Shift in Behavioral Effects of Drugs, 1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-12-011 Date A point or period of time associated with an event in the lifecycle of the resource 1958 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/18207735ad5546b08aac89618232e7bc.pdf 66f756c9dd21d0500a4b4e9773773d3e PDF Text Text ��Wm « . . ”1%! W3 l/W W "79"! - duh [cow ~ 4444...; n— wlamaZu-ﬂ nag ‘3 073 /3 W _———_—_é¢%0u_LL__p_J_ 1w... mug: . j” / 3 H4 Ito :98 ��'VfJii MMud‘vue I7M¢2+ ? la Mal. .max Q ,4”; . 9:19 M00 4/73 ,“ K We; /a¢/If ,, (14.2...e‘23m,“ L DF/Wdﬁ ﬂan" 714 - “7‘ 44.4.5 44W r M , %W(“ W77 27/56:.) xéa/av-p 2/3“; 413»; Ma... 7w,» #1W 1‘ I; a.“ me: ‘M‘M w 4‘ 7‘ WWW/3,1:I/7 w»! AWL—«awe; CK’S") mm) M �7 7 4%? % ,4» 014/.- a‘,‘” __n ”ViV W ,, (A. 2‘ MW "5 11M; r W ��‘ WMA (“Av/Jaw AJa—lnw.m.5¢nﬁ¢ ��M Wf - I7 ‘70 [Lav/2.». 5’52 31 ,9: d3: ��ﬁbrw Dr? ' D.- £44415" Iv ~43 VP-’YV MED-thaw Masha“. -6” 'DFP- m 51am JV 1 ‘ ��\ \-_' <f/ e4 AM (3 ��73/4 r 4/»! / 4? ��" ,; . “A; 7 m 7V ��Ph. i74800 MECHOIYI® CHLORIDE (METHACHOLINE CHLORIDE U.S.P., MERCK) a SHARP DOHME MECHOLYL* Chloride produces the same physiologic response as does acetylcholine, which, when released at nerve endings, produces parasympathetic stimulation. In therapeutic doses, MECHOLYL slows the heart rate, lowers blood pressure, constricts the bronchioles, dilates the peripheral blood vessels, constricts the pupils, Increases intestinal tone and peristalsis, causes salivation and ﬂushing, and stimulates the detrusor muscle of the bladder. In general its eﬁects are the opposite of those produced by epinephrine. Its action is much more prolonged than that of acetylcholine and it is, moreover, devoid of the nicotine-like effect of that substance. METHODS OF ADMINISTRATION MECHOLYL Chloride is a potent substance and careful consideration should be given to Its dosage and method of administration. For *MECHOLYL is the registered trade-mark of MERCK & CO., Inc., for its brand of methacholine. [i] stopping an attack of paroxysmal auricular tachycardia it should be given by subcutaneous iniection (never by intravenous or intramuscular injection), and the same method of administration may be used in treating scleroderma, chronic ulcers, Raynaud's disease and other vasospastic states, although in the latter conditions better and more prolonged eﬁects are obtained when it is administered by the method of ion transfer For administration by mouth (iontophoresis). the less hygroscopic MECHOLYL Bromide is supplied in tablet form. Atropine intravenously immediately terminates the action of MECHOLYL. A syringe containing a suitable dose of atropine sulfate [0.6 milligram (l/iOO grainI] should be available for immediate intravenous iniection if the dose of MECHOLYL Chloride causes undesirable symp- MECHOLYL Chloride is supplied in ampuls Since MECHOLYL constricts the bronchioles containing 25 milligrams (0.025 gram) of the powder. Solutions for subcutaneous iniection are prepared by dissolving the drug in sufﬁcient sterile distilled water to make it possible to measure accurately and administer easily the dosage desired. WARNING Injections of MECHOLYL Chloride should be given subcutaneously only. lniections should never be given in- travenously or intramuscularly. PRECAUTIONS The patient should be lying down during the administration of MECHOLYL Chloride to minimize the effects of lowered blood pressure. [2] toms. Overdosage of MECHOLYL may produce momentary cardiac arrest. The Trendelenburg position, to give the cardiac center the beneﬁt of any circulation present, is sometimes beneﬁcial in such an emergency. and may produce an asthmatic attack in those subiect to this condition, it should be used with extreme caution, if at all, in cases where there is a history of asthma or hypersensitivity. Substernal pain following the administration of MECHOLYL is said to be rare. However, the use of this drug in patients subiect to angina pectoris is not recommended. USE IN PAROXYSMAL AURICULAR TACHYCARDIA One of the most efﬁcacious uses of MECHOLYL Chloride is in terminating attacks of paroxysmal auricular tachycardia. It is, however, not effective for prophylaxis or for continued treatment in cases of frequent recurrence of the arrhythmia. [3] �not recommended for the treatment of auricular fibrillation, auricular ﬂutter, or paroxysmal ventricular tachycardia. It is DOSAGE The initial subcutaneous dose of MECHOLYL Chloride should be limited to IO milligrams (0.01 gram) to test the patient's tolerance. Careful preliminary testing of the patient with a small dose will not nullify the effect of a subsequent dose, and is advisable if there is any doubt of the patient's ability to tolerate the drug. treating paroxysmal auricular tachycardia in patients under twenty years of age, IO milligrams given subcutaneously usually terminates an attack. In older patients, 20 to 40 milligrams may be required; obese patients sometimes require more. In Slow absorption of the drug due to inadequate local circulation may interfere with the therapeutic response. If the attack is not terminated in two minutes, compression of the vagi, together with gentle massage at the site of iniection to promote absorption, is suggested. Conversely, if absorption is found to be too rapid, further absorption may be retarded by applying a tourniquet above the site of iniection. The eﬁects of MECHOLYL may be terminated immediately by atropine. [4] and larger dose (if that given ﬁrst fails to interrupt the attack) may be given 20 to 30 minutes later, providing no severe reaction has occurred following the ﬁrst dose. Quinidine in moderate doses (not more than 0.2 gram four times a day) usually does not impair the MECHOLYL effect. Larger doses tend to inhibit its action, although MECHOLYL has been known to “break through" the depresr slon of quinidine. 174800 For oral administration or administration by the method of ion transfer (iontophoresls)—Ph. A second I Gm. bottles. 10 Gm. bottles. MECHOLYL BROMIDE (for oral administration only) is supplied in Boxes of 24—200 mg. (0.2 Gm.) tablets Bottles of 500—200 mg. (0.2 Gm.) tablets OTHER USES OF MECHOLYL CHLORIDE been used (by suba number of other condi- MECHOLYL Chloride has cutaneous iniection) in tions, particularly in certain vasospastic diseases, such as Raynaud’s disease, in chronic ulcers, and in scleroderma. If a test dose of IO milligrams of MECHOLYL Chloride has been well tolerated, the subsequent dose may be increased cautiously up to 25 milligrams (0.025 gram). In these conditions, however, the much more prolonged eﬁect produced by MECHOLYL Chloride administration by the method of Iontophoresis (ion transfer) or by the oral administration of MECHOLYL Bromide Tablets is preferred. MECHOLYL CHLORIDE is supplied ,snm DOHME SHARP 8: DOHME as follows: Philadelphia, U. S. A. For subcutaneous iniection— DIVISION OF MERCK a: CO. Inc. Boxes of 6 ampuls each containing 25 mg. (0.025 Gm.) of the dry powder. I 5 I P- IB-413 [6] Printed in U.S.A. �For the Medical Profession only ‘ANECTINE’® CHLO RIDE BRAND SUCCINYLCHOLINE CHLORIDE INJECTION 20 mg. in each cc. Multiple-dose vials of IO cc. (for intravenous use) ; n’l ' ix, use 'v 6’ ‘ " ' e .,'alysis. While respiratory depression is usually a r single dose of the drug, or following ’M‘uV-r-mtous administration, cessamore prolonged respiratory there may on occasion be depresoion requiring adequate respiratory exgen by the administration of supplemental or controlled . - -. . ‘ANECTIN E’ Chloride brand Succinylcholine Chloride Injection is an ultra-shortactmg skeletal muscle relaxant; that is, following intravenous injection of small procedures. The quick return of spontaneous respiration is a deﬁnite For more prolonged relaxation advantage. ‘ANECTINE’ may be given by continuous intravenous drip; tachyphylaxis does occur and cumulative action is not seen. The degree of relaxation not be ordinarily may controlled by the solution. Upon stopping the intravenous drip, adjusting the rate of ﬂow of narily resumes within a minute and spontaneous respiration ordirecovery is complete within 5 minutes. CHEMICAL PROPERTIES Succinylcholine chloride, also to as diacetylcholine chloride, is odorless, crystalline substance referred a white, which'is readily soluble in succmic acid bis (ﬂ-dimethyl—aminoe‘thyl) water. Chemically it is ester dimethochloride, and its formula is as follows: i ' ' ’ Cl CH2COOCH2CH2iV(CHa)3 CH2COOCH2€H2N(CH3)3 :I'he ester linkage is rapidly hydrolyzed in alkaline solutions but is in acrd solutions. In order to relatively stable promote stability, solutions should be refrigeration. It appears that succinylcholme is rapidly hydrolyzed kept-under followmg its PHARMACOLOGICAL ACTION ‘ANECTINE’ causes muscular transmission at the myoneural paralysis by producing a blockage of nervous junction.This action was ﬁrst reported et al.1 Independent studies by Bovet The at Wellcome Research Laboratories have been conducted on the synthesis2 and pharmacology“7 of the drug. de Beer and his associates3-7 have found that doses as low as 0.05 mg./Kg. given cats are effective in producing intravenously to muscular relaxation, and that intravenous doses of 0.1 mg./Kg. or more produce and complete muscular characterized by short durationprompt paralysis which is of and action extremely rapid recovery. Repeated injections produce reproducible and phylaxls nor signiﬁcant cumulative predictable muscular paralysis, neither tachyeffects being seen. When given by intravenous drip, a predetermined degree (scratic of relaxation in a cat nerve-gastrocnemius muscle) could be closely approxrmated by adjusting �The administration of doses of ‘ANECTINE’ sufﬁcient to produce complete neuromuscular blockade has not caused any signiﬁcant. ghange in blood pressure (except for the typical asphyxial pressor response in the absence of adequate respiration). No,evidence of any histamine-like depressor action has been found, thus differing from observations with d-tubocurarine. The ECG of the caﬁ was unchanged during a 2-hour infusion maintaining complete paralysis. ' ‘ ‘ Acute toxicity studies in albino mice showed the intravenous L.D.5o to be 0.55 to 0.59 mg./Kg. Complete paralysis resulted, with marked dySpnea and anoxia; death was apparently due to respiratory failure. Those mice which survived the initial symptoms exhibited disappearance of anoxia and dyspnea in 2 minutes and had completely recovered within 30. minutes. Chronic toxicity studies on albino rats showed that the intraperitoneal injection of -1' mg./Kg. or less, twice daily over a period of 4 weeks, produced no evidence of toxicity. important.diﬂ‘erence‘between ‘ANECTINE” and d-tubocurarine is that the former is not antagonized by anticholineste'rases. On the comrhlti’, 5.14.911 drugs as physostigmine, lThis rostigmine (neostigmine) and procaineaapnoli‘asgmthg 5;th 1:8 :11 would support the theory that syuccinylcholine'is hydrogze succinylcholine. by cholinesterases and that interference with this enzyme actiOn results in per- -. sistence of activity of the drug. Edrophonium (Tensilon) also prolongs the action of succinylchohne. An- ' ,. ' CLINICAL INDICATIONSUKNI) DOSAGE ‘ 1 Short Duration: ‘ANECTINE' Chloride brand Succinylcholine Chloride Injection is indicated for the production of muscle relaxation during surgical procedures, 3,9,13il5-17 and in conjunction with electroshock therapy.13,14,16 In view of its very short duration of action (usually about 3 minutes following a single intravenous injection) succinylcholine is ideally suited for procedures ;requiring 'only brief relaxation, .such as endotracheal intubation, endoscopic examinations, orthopedic manipulations, short surgicalvprocedures such as tonsillectomies, and electroshock therapy. As described previously, intravenous administration of the drug produces relaxation within a minute, which lasts about 3 minutes and is quickly followed by recovery of spontaneous respiration in those cases where apnea hasoccurred. Dosage for. Short Procedures: The average dose for’relaxation of short duration is 20 mg. (1"cc.) ‘ANECTI‘NE’ Injection given intravenously (Foldess)... The optimum'doSe will vary among individuals and may vary from =10 to 30 mg." for adults (0.5 to 1.5 cc.). Following administration of doses in this range, relaxation develops in about 1 minute; maximum muscular paralysis may persist for about 2 minutes, after which recovery rapidly takes place within the next few minutes. However, very large doses may result in more prolonged apnea. ”-21 Obviously, facilities for supplemental or controlled respiration with ,adequate exchangeoi oXygen should be available at all times. In order. to'avoid carbon dioxide accumulation and hypoxia, supplemental or controlled respirationgshould b? provided during respiratory depression without waiting for the development 0 apnea.. , Prolonged Relaxation: Although ‘ANECTINE’ isfshort—acting, prolonged relaxation may be obtained by repeated injections or, preferably, by maintaininga continuous intravenous drip.8,3o By adjusting. the rate of ﬂow, the desired degree of relaxation may be obtained and maint‘air‘ie'd‘, and the degree of relaxation can be changed within 30 seconds by changing the rate of ﬂow. Upon stopping the ﬂow of the intravenous drip solution, relaxation. quickly disappears. In those cases where respiration has been depressed it usually returns to normal_within a. few minutes upon stopping the intravenous drip, V. Dosage for Long Procedures: The-'aVerage dose for continuous intravenous infui‘ sion is 2.5 mg. per minute for adult patients. For convenience'in preparingsolutions for intravenous drip there are available ‘Anectine’ Chloride Solution, 50 mg. per cc., 10 cc. ampuls and 100 mg. per cc., 10 cc. ampuls. The, contents of one 500 in mg. 10 cc. ampul may be added to SOD-ecstetileiisotonic saline solution to an prepare (1 0.1% mg. per cc.) ‘Anectine’ Chloride Solution; the contents of one 1 Gm. in ’0 cc. ainpul‘maybe added to 1,000 cc. to prepare an 0.1% ‘Anectine" Chloride Solution. This concentration is suitable for continuous intravenous infusion, See literature accompanying ‘A‘u‘ectine' Chloride Solution,’5_0fn‘1g./cc., 10 cc. ampuls, and 100 mg:‘]cc.,«10 c‘c‘. animals for details regarding use of'r'this‘product for obtaining ' ' r‘elaxatiOn. Solutions for prolonged intravenous drip jay also be‘ prepared. for a dilution of‘An‘e’ctine’ Injection, 20 mg./cc. in appioprrate proportions. ‘ NOTE: Succinylcholine is rapidly hydrolyzed by alkaline'solutions and therefore loses potency rapidly. it mixed with thiopental sodium (pentot‘hal sddium). Such mixtures, if used at all, must be used within a few minutes ofvprepatationq however, separate injection of ‘ANECTINE’ is preferable. Succinylcholine chloride is quite stable when storedqunder refrigeration. 0n long standing at room temperature potency gradually decreases; however; solutions may be kept as long as 3 months at room, temperature without signiﬁcant loss of potency as determined by biological assay. , , ' !~- ‘ �.m . . CONTRAINDICATIONS AND PRECAUTIONS The drug should be used only by those skilled in‘ the administration of sppplemental *oecontrolled. respiration and facilities for this procedure, including adequate respiratory exchange with oxygen, should always be immediately .. available. “'V ' 'ANECTINE’lis not an anesthetic agent and should not be regarded as a substitute for anesthesia; 'its‘Ause“ does not take the place of givmg an adequate amount of anesthetic agent. Some anesthesiologists believe that rapid injection is responsible for the muscular twitching that is seen just prior to relaxation. These fascrculations may be due to the‘rate’of injection of the drug, and may be minimized or avoided ‘by giving the injection more slowly/,8,”8 While respiratory depression is usually of very short duration following a 'single dose of the drug, d" following cessation of continuous intravenous administration, ‘LiiCl‘C may‘e..-.§ribcc{i.iongespeaially with excessive doses, more prolonged respiratory depression 1.9-2]- requiririg controlled respiration and the administration of oxygen. The duration of the effect of ‘ANECTINE’ may depend on plasma-cholinesterase activity.94,2°,27 Patients’with severe'liver disease, severe anemia, severe malnutrition, and possibly those suffering from' polyphosphate insecticide poisoning may have a decreased plasma-cholinesterase activity which may intensify and prolong the action of ‘ANECTINE’, especially if large'doses are used.23,29 In such cases, in addition to the usual measures of controlled respiration and administration of oxygen, it may be desirable to administer plasma or whole blood for the purpose of restoring cholinesterase activity,” Neostigmine and other anticholine’sterases, as well as edrophonium (Tensilon), do not antagonize the action ,of~‘ANECTINE’, but on the prolong its contrary eﬁ'ect. They are therefore contraindicated as antidotes for ‘ANECTINE’. Intravenous injections of proCaiiie likewise may prolong and intensify the action of ‘ANECTINE’. There is evidence that intraocular pressure is increased slightly following injection of ‘Anectineflﬂ “This effect is seen immediately after the injection and during the fasciculatory phase; it' subsides as complete paralysis supervenes; it appears to be the result of brief contraction of the extraocular muscles. This suggests that ‘Anectine’ should ’be usedl‘with caution, if at all, in intraocular surgery. The opinion is expressed that the effect is probably not sufﬁcient to contraindicate the drug in general, surgery or electroshock therapy for patients with "' glaucoma. ‘ r‘ .- .KBIBIZIOGRAPHY 1. 2. Bovet, D., Bovet—Nittl, F., Guarino, 3., Longo, V.G., and Marotta, M.: Pharmacodynamical property of certain derivatives of suc’cin'ylcholine with curate-like action: esters of trialkylethanolamine of dicarboxylie aliphatic acids. Rendieonti Istituto Superiore di Sanita 12:106, 1949. Phillips, A.P.: Synthetic curate substitutes from aliphatic dicarboxylic acid aminoethyl esters. J. Am. Chem. Soc. 71:3264, 1949. Castillo, J.C., and de Beer, E.J.: Poteii‘tiationbl' curarizing action of diacetylcholine (succin lcholine) by aliphatic dicarboxylic acid aminoethyl amides. Federation Proceedings 9:262, 19 0. Castillo, J.C. and de Beer, E.J.:_The neuromuscular blocking action of succinylcholine (diacetylcholine). J. Pharmacol. 6: Exper. Therap. 99:458, 1950; de Beer, E.J., Castillo, J.C.,1.Phillips, A.P.,3Fanelli, R.V., Wnuck, A.L., and Norton, S.: Synthetic drugs inﬂuencing neuromuscular activity. Ann. New York Acad. Sci. 541362, 1951. Wnuck, A.L., Norton, 5., Ellis, C.H;, and- de Beer, E.J.: Production of controlled neuromuscular block by infusion of diacetylcholine. Federation Proceedings 11:403, 1952. Ellis, C.H., Norton, 3., and Morgan, W.V.: Central depression by drugs which block neuromuscular transmission. Federation Proceedings “11:42, 1952. Foldes, F.F., and McNall, P.G.: Succinylchélinei A new’a‘ppréach to muscular relaxation in anesthesiology. New England J. Med. 247596, 1952. Brucke, H., Ginzel, K.H., Klupp, H., Piaffenschlager, F., andWerner, 6.: Muscle relaxing effect: of bis'echoline e'sterof dicarboxylic‘acid in narcosis. Wien. klin. Wchnschi‘. 63 :464, 1951. Ginaiel, K.H., .Klupp,.H.,; and Werner, G.: Pharmacology of ”bis—quaternary Yammonium a, compounds. Comparative tests withisome aliphatic dicarboxylic acid esters. Arch. int. Pharmacodyn. and Therapy. 87:79, 1951. 7Gi'7nzzei,9§(l‘.H, Klupp, H., and Werner, G.: A‘dicholine ester with greater curare effect. Experentia . a. Arnold,‘0.H., Bock-Greissau, W., and Ginzel, K.H.: Wien. med. Wchnschr. 101:492, 1951. Thesleﬁ‘, S.; Pharmacological and clinical tests with LT 1. (0.0—succinylcholine iodide). Nordiak ’ Med. 46:1045, 1951. Holmberg, G., and Thesleff, S.: Succinylcholine iodide as a muscle relaxant in electro—shock treatment. Nordisk Med. 4621567, 19SL‘Abst. in J.A.M.A. 14821064, 1952. Dardel, 0.37., and Thesleﬁ, 8.: Clinical results with succinylcholine iodide, a new muscle relaxant. Nordisk Med.‘46:1308. 1951. Thesleﬁ‘, 5., and Dardel, O.V.:'Clinical report on succinylcholine iodide. Presented at 26th International Congress of Anaesthetists, London, September 3—7, 1951. Abstracted in J. Am. MJWom. Assn. 7:58, 1952. " 3. 4. 5. 6. 7. 8. 9.' 10. 11. : 12. 13. . - , ‘ 14. 15. ‘ 16. ~ ' �I7. Mayrhofer, 0., and Hassfurter, M.: Surgical risks in patients with cardiac and vascular disorder. Wien. klin. Wchnschr. 63:88.5, 1951. 18. Holzer, 1-1.: Wien. med. Wchnschr. 102:112, 1952. 19. {IggerfgIséKd Prolonged respiratory paralysis after succinylcholine. Correspondence. Brit. MJ. 20. Love, S.H.S.: Prolonged apnea following scoline. Correspondence. Anesthesia (London) 7:113, 1952. 21. Gould, R.B.: Succinylcholine. Correspondence. Brit. MJ. 1:440, 1952. 22. Bovet, D., Bovet—Nitti, E, Guarino, S., Longo, V.G., and Fusco, R.: Investigations on synthetic 23. 24. 25. 26. 27. 28. 29. 30. 31. curarizing drugs. III. Succinylcholine and its aliphatic derivatives. Arch. int. Pharmacodyn. and Therapy 88:1, 1951. Poulsen, H. and Hougs, W.: Letters to the Editor, Lancet 2:199, 1952. Foldes, F.F.: Letters to the Editor, Lancet 2:245, 1952. Kay, H.T.: Letters to the Editor, Lancet 2:200, 1952. Evans, F.T., Gray, P.W.S., Lehmann, 1-1., and Silk, E.: Sensitivity to Succinylcholine in Relation to Serum-cholinesterase, Lancet 1:17.29, 1952. Bourne, J.G., Collier, H.O.J., and Somers, G.E-:ASuccinyIchoIine (Succinoylcholine)—MuscIe »S[« Relaxant of Short Action, Lancet 1'§2.£5, 1952. Lehmann, 1-1.: Letters to the Editor, Lancet 2:199, 1952. Hampton, L.J.: Personal communication. .L . ,r .:l Diacétiyilchdlihe I" and Little. M., Jr , Hampton, L.]., Grosskreutz, D.C.'. (Succin’yIcIroIine): A Controllable Mu'scIe Rel’axant. Presented before the Twenty-seventh Annual Cpnzress of Anes‘ ” ‘h thetistSyVirginia Beach, Virginia, Septemher 22-15,..1952. " " ‘1 ' Lincoff, H.A., Ellis, C.H., DeVoe, A.G., de Beer, E.J., Impastato, D._I., Berg, 5., Orkin, L., and Magda, 1-1.: The EEect of Succinylcholine on Intraocular Pressure. Am. J. Opth. 40:501,1955. — PREPARATION FOR IMMEDIATE INJECTION OF SINGLE DOSES FOR SHORT PROCEDURES ‘ANECTINE’ CH LORIDE mo SUCCINYLCHOLINE CHLORIDE INJECTION 20 mg. in each cc. multiple-dose vial: of IO cc. For intravenous i'nieetion V Also available: FOR PREPARATION OF INTRAVENOUS DRIP SOLUTIONS ONLY ‘ANE CTINE ’ C H LO R I D E m SUCCINYLCHOLINE CHLORIDE STERILE SOLUTION 50 mg. in each cc. IO cc. ampuls (Total contents 500 mg. Succinylcholine Chlorlde) To be diluted before using FOR PREPARATION OF INTRAVENOUS DRIP SOLUTIONS ONLY HIGH POTENCY ‘A N E C T I N E ’0 CHLORIDE SUCCINYLCHOLINE CHLORIDE STERILE SOLUTION 100 mg. in each cc. 10 cc. ampuls (Total contents I Gm. SuccinyIchoIine Chloride) To be diluted before using ‘Aneetine’ Injection is supplied in the form of a sterile isotonic aqueous .rolution. ImtoniCity 15' achieved by the addition of a :uitable quantity of sodium chloride. \\ .” p,“ BURROUGHS WELLCOME & CO. (U.S.A.) INC.,TUCKAHOE, N.Y. Associated Houses: LONDON BOMBAY by 731 MONTREAL BUENOS AIRES Printed in u.s.A. SYDNEY CAIRO JOHANNESBURG DUBLIN AUCKLAND 41 I o o 6 �Poloni, A.: L'Acetilcolina nel liquor dei malati di mente. Hancenze di effetto curarosimile del liquor di echizophrenici sul mnecolo acetilcolina e en dorsale dell: saga, I1 Gervello g1: 81-1oh, 1951. Translation of EEEEEEE‘ author, using the method of Tower for the conservation of acetylcholine in spinal fluid, and the dorsal muscle of the leech for the test, has made the fol» lowing observations in several trials, making use of the spinal fluid of 10 normal subjects and 110 mental patients, of whom 50 were schizophrenics, 10 progressive paralytica and 50 subjects with other forms of mental disease: The (1) That the spinal fluid of normalaubjects cistains acetylcholine in a to 1:1G' concentration varying from 1:1 (2) That the spinal fluid or schiaophrenice in 9h$ of the case: does not contain ecetyloholine bet a substance which produces an action antagoMstic to acetglgholine, 7; weble to that of ”curare", in a concentration of 1:1 to 1:1' .... (3) In the spinal fluid‘of the progressive paralytic: one encounters the some curare-like subetance nut in a lower concentration than in that of schizophrenics. (h) The spinal fluid of persons affected with other forms of mental sick— ness, as well as that of normal subjects, did not contain the curerelike substance in a discernible quantity, but only acetylchcline, which was found in greater concentration in the hystericale and epileptice, in lower concentration in senile psychotics and alcoholics. This emphasizes the pathologic vale of the report obtained from the spinal fluid of schizophrenics and progressive parelytics and suggests the hypothesis that the curare-like substance is trimethylamine, product of the excessive catabol~ ion of choline, of which the author has found an abnormal urinary excretion in schizophrenics; (In the some paper, in a footnote, the author eliminates trimethylamine, since does not have aurora-like properties.) it �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY Max Fink, M'.D. �\ From ‘ the Department of Psychiatry, Washington University School of Medicine and the Department of Psychiatry at the Missouri Institute of Psychiatry, University of Missouri School of Medicine, SUOO Arsenal St., St. Louis, Missouri 63139. MH-072u9 and MH—2715, MH—927, grants part, IVE-11380; and the Psychiatric Research Fomdation of Missouri. Aided, in IX: 65-8 2-25-66 by USPHS Revised for the Jowmal. 06 vaouA and Manta! Disease. �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY While the mode of action of convulsive therapies remains enigmatic, one theory holds that the early development and persistence of changes in brain function are requisite to changes in behavior.“3’21,22 useful index of neurophysiological change is the appearance of high voltage electroencephalographic slow wave activity.22 '23 While the biochemistry of this activity is A poorly understood, demonstrations that it is inhibited by anticholinergic corrxpoundsl9920’3""56 suggest that cholinergic systems may play an active part. The EEG patterns and the response to anticholinergic drugs in convulsive therapy are similar to experimental and clinical head trauma and to a lesser extent, to spontaneous seizures. impulses has been extensively studied since the early descriptions by Dale12 and Loewi.38 A constituent of nervous tissue in a acetylcroline is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of aoetylcholinesterase and is rapidly reconstituted by the bound form, �choline—acetylase system.‘+5 Free acetylcholine has not been measurable in normal cerebrospinal fluid despite the rapid breakdom of bound acetylcholine during periods of activity and excitement.63 But the normal have measurable cholinesterase cerebrospinal fluid does activity.“1 ChoLéneILgic Mme/ta 06 CILanLoce/Lebm mena. Free acetylcholine was found in the cerebrospinal fluid of cats within a few minutes after experimental head trauma and persisted for varying periods up to 1+8 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 gamma/ 100cc and the amount was related to the degree of induced trauma.6 Concurrent electroencephalogram first demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was succeeded by-a short period of flattening of all recorded electrical activity. These phases were followed by prolonged periods of high amplitude sharp waves in the delta frequencies. The behavioral changes related to the degree of induced trauma and to the amount of measured free acetylcholine. With higher levels of acetylcholine, Bornstein reported greater degrees of EEG abnormality and greater changes in consciousness. Spontaneous post-traumatic seizures were also amount related to the of free acetylcholine measured in the cerebrospinal fluid. �Bornstein applied acetylcholine to exposed cat cerebral cortex. When the concentration of acetylcholine was or less, high amplitude sharp the electroencephalogram. to 2 waves When of low frequency appeared in the concentration gamma/100cc, the electroencephalogram parallel to the post-traumatic records. Investigations in neurological patients McEachern demonstrated 1 gamma/10000 was increased flattened in a fashion by Tower and free acetylcholine in the cerebro- spinal fluid only in patients with recent head trauma, recent grand—Hal seizures or after electroconvulsive therapy.63 Free acetylcholine varied from 0.2 to 100 gamma/ 100cc. In assaying spinal fluid cholinesterase activity, they noted a sharp rise in the butyrylcholinesterase fraction and a fall in the acetylcholinesterase fraction in patients with head trauma and following convulsive therapy. however, the cerebrospinal although it ' After spontaneous seizures, fluid did not exhibit such inversion contained free acetylcholine. They concluded that the level of free acetylcholine varied directly with the degree of cerebral damage and that reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �Increased acetylcholine in rat brain after traumatic shock was also reported by Kbvach, at a£.35 This acetylcholine activity vitae. was inhibited by the administration of atropine tn electrographic, behavioral and neurologic signs of head trauma were blocked by the parenteral administration of The atropine, as were similar clinical changes occurring after the intracisternal addition of acetylcholine.6 0.5—1.0 mg/kg applied these observations to the treatnent of closed head injuries. In 20 patients with varying degrees of trauma, he administered atropine subcutaneously in doses of 0 .1 mg/kg, Ward noting clinical improvement in some and electrographic effects in others.67 a reversal of the The same changes in the' .*-‘_ post-traumatic electroencephalogram were reported by Jenkner and Lechner in a study of diethazine, another anticholinergic single intravenous dose in forty patients resulted in nornalizing the abnormal electroencephalogram in twenty—two drug. A and marked improvement in six others.33 Similarly, in experiments of post—traumatic shock and cerebral edema in animals, Denisenko reported a blocking of the clinical changes by such anticholinergic compounds as methylbenactyzine and adiphenine (Trasentin).13 ThuA, the amount 06 Mae acetytchloune may tamed/52 éptnat ﬂuid 60110“)th cmtnocuebaat mama and the tn the, amount 06 - ‘ -A,‘r �ghee acety£cho£ine, the degnee and type 05 e£ecthoencepha£nghaphie in carded/C behavion abnolzmablty, and changed phenomena, which may be deduced by appear/L aA the adminibtnation Lute/mutated anti- 06 chounugie daugb. Bluuln acetylchoﬂéne and antéehounugic dhugb. The effects of the direct application of acetylcholine to the central nervous system may also be blocked by anticholinergic drugs. The administration of the cholinesterase inhibitor di—isopropyl fluorophysphate (DFP) elicited high amplitude rapid frequency patterns similar to status epilepticus and some posttraumatic states.2'*’31a32a68 These EEG effects were blocked by small doses of parenteral atropine and scopolamine. The' EEG geat increase in acetylcholine after tetraethyl (TEPP) was measured and pyrophosphate related to the toxic effects and the induced convulsions .29 ’59 Chatfield and Dempsey prepared exposed animal cortex with prestigmine and evoked electroencephalographic spike activity. prior administration of atropine blocked the appearance of spiking, or if present, this electrical activity could be The eliminated by atropine.9 In contrast to these findings, Brenner and Merritt applied topical acetylcholine in concentrations of 2—1/2 to 1096 to the exposed cortex of cats and noted no effect. on the electro— encephalographic changes after intravenous atropine (1 mg/kg) .7 �The concentrations of acetylcholine in these experdnents, however, were higher than the topical applications (1-H gamma/1000c) and the intracisternal (0.2-10 gamma/10000) injections of Bornstein.6 Brenner and Merritt also noted electroencephalographic effects similar to acetylcholine after methacholine (Mecholyl) and carbamylcholine (Doryl) in concentrations much lower than the acetylcholine concentrations. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral cholinesterases. 6mm Atady a necuAa/Lg Ceaebao¢pina£ Fluid Acetyﬁchoﬁine and Seizuneb. One view Thug data M9, conﬁuwxg and to quaiiﬁy thié iAAue. of acetylcholine metabolism finds it in nervous tissues in an inactive and bound form. During periods of activity, acetylcholine is liberated at the cell membrane where it is rapidly deactivated by cholinesterases. The amount of bound acetylcholine is the resultant of the continuous processes of synthesis, liberation 'u and breakdown.15 It has been postulated that the level rises falls during waking activity.15’29’“5’6° at al. reported increased free and total acetylcholine during sleep and Tbbias after chlorofornland pentobarbital anesthesia in rat and frog brain but no changes after strychnine or picrotoxin convulsions.5° �(microacetylcholine of level the neasured Richter and Crossland in and rat sleep anesthesia during tissue) brain gamma per mg. brain to be 300% The difference levels. post—seizure than higher rate resynthesis the as however, transient, in tissue levels is gamma/gm/minute).“5 (7 high is brain in rat for acetylcholine Crossland a£.16 and at Elliott confirmed by These observations were and Merrick.11 Giarman and Pepeu reported the increase in be roughly to various depressants following acetylcholine nervous central the of of depression the degree proportional to Buck, and Maynert activity.29 motor in system and the reduction sedation during levels acetylcholine brain however, studying elevated with associated were sedatives concluded that some existed.39 relationships rigorous brain acetylcholine but that no of. observations In part, this may be related to the earlier in measured synthesis acetylcholine McLennan and Elliott that narcotic of low dosages by accelerated rat brain slices is dosages.”° by-high inhibited but drugs, in fluid the in spinal Free acetylcholine was reported an patients, epileptic patients with epilepsy.1°’63 5.0 0.02 to of in quantities demonstrated free acetylcholine Of 56 Acetylcholine gamma/100cc. 1.0 of with an average gamma/100cc extent the seizures, of the frequency to related levels were since time the and to abnormality, of electroencephalographic �the last seizure but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliott at al. also noted free acetylcholine in the spinal fluid in concentrations up to 3 gamma/100cc after pentylenetetrazol (Metrazol) convulsions.16 Tower and McEachern viewed the increased acetylcholine as a by—product of the seizure and not causal.63 Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Tbrda neasured the level of acetylcholine in brain tissue after pentylenetetrazol convulsions. She noted a rise in the acetylcholine content of brain before and a fall during the convulsion. Below certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in . tissue acetylcholine during a convulsion was due to the inhibition of acetylcholine synthesis by increased concentra-’ tions of metabolites such as annenium ions.51:62 Giarnen and Pepeu also measured changes in central nervous system acetylcholine following various stimulants.29 Only after nethacholine and 3, 5—dimethylbutylethyl-barbiturate was there a significant change in the acetylcholine level. They noted a decrease in association with induced convulsions. With other drugs which they classified as stimulants (LSD, iproniazid, iproniazid + hydroxytryptophan, and iproniazid were no changes in the acetylcholine level. + DOPA) there They concluded that �despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied by convulsions. (The between these observers and Cone may be differences in observations at at. related to the differences in measurenents, fOr the latter and Tower and McEachern methods measured changes of biochemical reflecting free acetylcholine only, while Giarman and Pepeu measured total acetylcholine including bound and free forns of acetylcholine.“°). Thane btudieb Auggebt that aae accompanied by an tncteaee tibeaated 6aom tté Apontaneoub on tnduced 4etzune¢ tn tnteaeettutaa ﬁnee aeetytchottne bound ﬁonm whtch may be aeﬁteeted tn the Aptnat staid. Ceaebnat activity and eetzuneé enhance aeetytehottne deatAuction, toweatng txnbue teveZA 06 aeetytehottne, white eteep and anebthebta augment aeetytehatine paoduetion ineaeaetng ttbbue tavetb. ' Centaat Menuoue SyAtem Cholineeteaaeee. Tower and McBachern also measured spinal fluid cholinesterase activity.63’5“’65 By reporting cholinesterase activity as a ratio of the rate of hydrolysis with two substrates compared to an acetylcholine substrate, acetylcholinesterase/acetylcholine and butyrylcholinesterase/ acetylcholine ratios are derived. Normal cerebrospinal fluid contains these esterases in the ratio of 33:17. �-10In patients with head trauma, Tower and MCEachern reported an inversion of the cholinesterases with an increase in the butyrylcholinesterase of the spinal fluid and a decrease in acetylcholinesterase activity. The extent of the cholinesterase related to the severity of trauma and to the degree abnormality. A similar reversal was observed in patients reversal of EEG was undergoing convulsive therapy. In patients with elevated spinal fluid acetylcholine spontaneous seizures, however, no change in the after ratio of cholinesterases or total cholinesterase activity was found. Changes in cholinesterase activity may be related to changes in cell membrane permeability. Acetylcholinesterase is found in highest concentration in the central nervous system while butyrylcholinesterase predominates in other tissues, especially blood serum. With increased cerebral acetylcholine, vasodilation predicted, with vascular fluid transudation varying with the extent and duration of the vasodilation.35 Spiegel, Spiegel—Adolf, and their and increased cellular perneability may be co-workers demonstrated such perneability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassium and phosphate) in the spinal fluid following electrically induced convulsions.5"'58 electrolytes as nucleic-acid splitting enzymes Such non- also increased. �-11- Changes in cellular permeability may be the basis for the high concentrations of acetylcholine and increased concentrations of butyrylcholinesterase after induced seizures or head trauma.65 That changes in cholinesterases may be large and measurable is suggested tte recent demonstrations that neural stimulation by and learning produces changes in brain weight and acetylcholinesterase reports, Pryor and Otis studied the effects of repeated induced seizures in Wistar rats.“3 After Following these activity.37’“9 as little as u weeks they observed increases in brain weight and in acetylcholinesterase activity which was related to decrements in behavioral perfornance. persistance of acetylcholine in spinal fluid after head trauma and after seizures despite increased cholinesterase The activity may be acetylcholine— the of the related to sensitivity acetylcholinesterase system to concentration relationships.8’“1’55 At "physiologic" concentrations, hydrolysis of acetylcholine is rapid (3—H ndcmoseconds) but at higher and lower concentrations, the activity falls off quickly. In contrast, the butyryldholinesterase~acetylcholine relationship is non—specific rate of hydrolysis increases with increased concentration. These relationships relate to theories of the induction of seizures. While the usual concentrations of acetylcholine at and the cell membranes are destroyed by the specific activity of acetylcholinesterase in a few microseconds, an excessive concentration following excitation may exceed its rate of �-12- hydrolysis. The seizure threshold induced, with the seizure itself may be reached and a seizure adding to the amount of free acetylcholine. Increased acetylcholine affects vascular and cellular perneability altering the concentrations of various ions, including butyrylcholinesterase in tissues and in the cerebrospinal fluid. Through the activity of this esterase, though of low efficiency and depending on concentration acetylcholine is reduced in tissues to levels for the action of acetylcholinesterase. ChoZanAzcnaAeA appcanb in the Apina£ 6£uid kinetics. more direct a4 a ncﬁﬂcction 06 theta incncaAc in inzcnchZuzan gluidb ac6u£xing diam changcb in cc££ mcmbnanc pcnmcabizity accompanying incncabcd EEG Hypcnbynchnony and Induced Convu£5ion4. of high voltage EEG slow wave The acctchhoanc. significance activity for the convulsive therapy process has been repeatedly described."’?-’23’50,51 In the usual course of convulsive therapy, interhtreatment electroencephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment continues, delta activity appears in bursts and eventually is the dominant activity in all leads. These changes are directly related to the number and rate of induced convulsions, and is not specific for a method of induction. While some relationships to type of electrical current has been observed, all seizure inducing methods —- electrical, intravenous chemical or inhalant -— exhibit the same type of EEG pattern changes.21’22a23:3° �-13The early appearance of high degree hypersynchrony and its persistence throughout a treatment course has been found to be prerequisite to improvement. Both the electrographic and the behavioral changes of induced convulsions are transiently reversed by the acute administration of experimental anticholinergic compounds.19’2° The intravenoue injection of diethazine, bonactvzine, the piperidylbenzilates JB—318, JB—336 and JB—329 (Ditren), and subjects. WIN-2299 induced EEG These EEG desynchronization in psychiatric changes were associated with behavioral alerting, anxiety, tremors, illusions and hallucinations. In patients who had recently received electroconvulsive therapy there was a reduction in slow wave activity and a reversal of euphoria, denial and confusion. Atropine, in low doses, was also associated with EEG desynchronization accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchronous slow waves followed by lower voltage, poorly organized delta activity with superimposed beta activity was accompanied by progressive confusion and disorientation. effect of anticholinergic drugs on the slow wave activity of convulsive therapy was also assessed by the chronic administration of atropine (5 mgm per day) and scopolamine (1-3 The during the weeks of treatment. The amount of EEG slowing was significantly less than in a control group.66 The samples were too small for a clinical correlation but the data is consistent mg) �-1uwith blocking of the clinical effects of electroconvulsive therapy. Marked improvement was reported in treated, none of scopolamine-treated and in 5 controls receiving unmodified replicated ECT. of 2 1+ 7 atropine— of the 6 This study was not by the authors who suggest or population changes may have results in a second study.“ that dosage factors contributed to the different - AA tn cueblcat tJLauma, the demographic changes induced convuutoms may be modiﬁed by the 06 antichounugtc dlLugb Auggebting 06 Want/cation that tncneeued amounts acetytchoune on tncneated chounugtc aecepttvity ts amounted with the htgh voltage Atow wave activity. 06 Acetytchoune and Induced Convutbtont . Despite a constant application of treatments, however, there is great variability in the time of appearance, the duration, anount, and sensitivity to modification by alerting, hyperventilation and barbiturates of the electrographic slow activity in psychiatric populations.30 These differences relate to differences in central cholinergic activity. The failure of certain patients to develop hypersynchrony may be associated with the absence of free acetylcholine and with minimal changes in cerebral function, wave �-15thus precluding a clinical response to induced convulsions. Tower and McEachern in their study of craniocerebral trauma, included observations of six psychiatric patients undergoing convulsive therapy.63 Studying the patients ments they reported free spinal after 3-7 fluid acetylcholine in treattwo patients; and an increase in butyrylcholinesterase and a decrease in acetylcholinesterase with a reversal of the ratio of cholinesterases in five of the six patients. Concerning the one patient in the series who failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal fluid, the authors stated; "It is interesting that this patient was the only one of the six to show no response to treatment." From these observations they concluded that the spinal fluid' <3; changes in induced convulsions were more like those of 4 ‘4‘ craniocerebral trauma than those of spontaneous epilepsy. «3-.3‘ Other evidence of alterations in the perneability barrier may be seen in the demonstrations of an increaSed concentration of cocaine in brain tissues three days after a series of induced convulsions.1 The change 12 in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynclu'ony (delta bursts) in the electroencephalogram, �1 -.,,-_..._. -15Fhom theae oboehvationb we would conclude that induced convuibioni, like chaniocehebhai thauma and Apontaneoui Aeizuheb, ane aAAociated with an incheaie in ghee acetyichoiine in inten- cebtuiah 6iuidA, attuing cuebhai pumeabifity and enhancing the appeahance is maintained Lb . one 05 cholinebteJLaAeA. The Level 06 ghee by hepeated induced Aeizunei . heﬁiection ieveu 06 aLCULed aitehed pehmeabiiity 06 06 EEG acetyichoiine hypmynchlwny acetyichoiine and the eiecthoiyteb and otheh Aubitanceé, inciuding choiineAtULaAeAs. The changeé in intuceuuiah elect/w- .oi.m_m_._._.. _ ..l.__a u.- iyteé, inciuding aeetuichoiine phovide the biochendcai AubAthate 601:. the pelwibtent behaviouai changed and EEG hypwynchnony ﬁoaowing induced convuibianb. An ww...-._.~__.-m~ 06 application the phedietion o6 06 these conciuiioni is been in the btudieb the convuiAive thehapy heéponbe and the ctaiiisication as psychoaei. ~--....-_ Choiineétehabei and the Ciaibiﬂicatian 06 PAychOAeb. ._‘ 4» .. V Punkenstein at at. reported a relationship between the blood pressure response to methacholine and the clinical response to convulsive therepy.25'27 Immediately after the injection the blood pressure falls, usually returning to the baseline within 5-20 minutes. A return within 5 minutes Of methacholine places the patients in Groups after- 20 minutes \‘ \e I, II or III; places'the patient in while a return Groups VI and VII. �-17Group I and Group II-III respectively, while and 97% have a 9% and a 35% Gkoup VI and Group VII recovery rate, subjects have 89% recovery rates to induced convulsions.27 Group I to III reactors may be looked upon as patients in whom is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. (The response to injected epinephrine was suggested as a second criteria in the classification, but is of limited discriminating value.”8) methacholine While we have no biochemical explanation fbr the differences in the metabolism of methacholine in these psychiatric groups, it is possible that the blood and tissue cholinesterase activity levels of Groups I—III is high while that of Groups VI-VII is The low compared to general psychiatric populations. differences in blood cholinesterase levels in normal and mentally ill subjects have been extensively studied. Despite differences in nethods,“’5 elevated cholinesterase levels compared to normal populations have been reported for depressive subjects,"""’5"‘7952 schizophrenic subjectslh’28’53 and a mixed psychiatric populations .“2 Alpern reported lowered cholinesterase levels in schizophrenic subjects.2 While these studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater and frequently elevated in the mentally ill. Negative reports include the failure by Ellman and Callaway” to confirm Rubin's study; and Altschule's review of the data suggesting �-13no abnornality ' of cholinesterase levels in the mentally ill.3 that cholineAth play These Atudteb AuggeAt meaAuAeA may a signiﬁcant note. in the thuapeutéc aupome to canvutatve the/mpg and in the pathoggnebta 06 paychobu. �-19; CONCLUSIONS This review summarizes some of the available data suggesting that cholinergic mechanisms may be central to the convulsive therapy process. Induced convulsions are associated with cerebral vasodilaticn and increased cellular permeability, followed by the appearance of increased amounts of enzymes and electrolytes in intercellular and cerebrospinal fluids . The increase in acetylcholine, vasodilation and increased permeability appear as interrelated phenomena associated with ' trauma, seizures and induced convulsions. These biochemical changes acconpany increased hypersynchrony which is recorded as EEG slow wave electrical activity in scalp electrodes and which can be nodified by the acute and ' chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl— benzilates . In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures. in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects . Failure to induce persistent biochemical changes, including the The changes concentration of acetylcholine, results in failure to produce behavioral change. �-20There is, as yet, no consistent evidence for differences in the sensitivity or dependence of populations on cholinergic mechanisms. Differences in the rate of development of cerebral changes to the sane number and frequency of induced convulsions classifications of the nentally ill based on the blood pressure response to methacholine suggest, however, that such differences may be significant in the pathogenesis of different and .._..__...V ___,‘~,‘....____... ' «uAW—‘wﬂﬂw ,1“ psychoses . �REFERENCES 1. Aim, B., Strait, R. L. A., Pace, J. W., Hnenoff, M. K. and Neumphysiological effects of electrically Bowditch, S. C. indnced convulsions. Arch. Neurol. Psychiat., 75: 371-378, 1956. 2. Alpern, D. O. i kholinergicheskaya Aktivnost kholinesterasy reaktsiya kmvi pri shizofrenii. 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D. and Effect of trimethadione (Tridione) and other drugs on convulsions caused by di-isopropyl fluorophosphate (DFPj . Amer. 33. J. Psychiat., 106: 816-820, 1950. effect of Diparool on the electroencephalogram in the normal subject and in those with Jenkner, F. L. and Lechner, H. The cerebral trauma. Eleotroenoeph. Clin. Neurophysiol., 7: 303-305, 1955. 3M. Johnson, L. c., Ulett, A., Johnson, M., Smith, G. K. and Sines, J. o. ElectroconvulsiVe therapy (with and without atropine); effect on electronically analyzed electroencephalogram. Arch. (Chicago), 2: 35. Gen. Psychiat. 32u—336, 1960. Kabat, E. A. , Glusman, of the albumin and and Knaub, V. M. ganma Quantitative estimation globulin in normal and pathologic cerebmspinal fluid by inmunochemioal methods. Amer. J. Med. , 4: 653—662, 1948. 36. Kovach, A. G. 3., Fonyo, A. and Halmagyi, M. Acetylcholine content of the brain in tratmatic shock. Acta Physiol. Acad. SCio Hung., 37. '3: 1-“, 1957. Krech, D., Rosenzweig, M. R. and Bennett, E. L. Effects of envirormental complexity and training on brain chemistry. J. 38. Carp. Physiol. Psychol., 53: 509-519, 1960. Loewi, 0. ﬁber hmmrale Ubertragbarkeit der Hemmemdirkxmg. Arch. Ges. Physiol., 1898 239-2‘J2, 1921. �39. Maynert, E. on H0. W. Effects of C.N.S. depressants and Buck, E. G. brain acetylcholine. Phamtacologist, 6: 191, McLennan, H. and Elliott, 196M. Effects of convulsant and K. A. C. narcotic drugs on acetylcholine synthesis. J. Pharmacol. Exp. “1. Ther., 103: 35-u3, 1951. Nachmansohn, D. and Rothenberg, on Specificity of enzymes M. A. Studies on cholinesterase: in nerve tissue. J. Biol. Chem., 158: 653-666, lSHS. M2. Plum, C. M. Study of cholinesterase mental disorders. #3. Pryor, T. and G. nervous and in activity Clin. Chem” 6: 332-3H0, 1960. Otis, Effects of chronic administration L. S. of electroconvulsive shock on behavior, brain weight and brain Presented chemistry. at the American Association for the Advanoenent of Science, Berkeley, 1965. an. Ravin, H. A. and Altschule, M. D. Serum cholinesterase activity in mental disease. Arch. Neurol. Psychiat., M5. Richter, D. and 58: 6‘45-650, 1952. Grassland, J. Variation in acetylcholine content of the brain with physiological state. Amer. J. Physiol., M6. 159: 2u7-255, 19u9. Richter, D. J. Sci... 88: I‘28-‘43“, Ment. and Lee, M. Serum choline esterase and anxiety. 19M2. �H7. “8. #9. Richter, D. J. Sci., Ment. and Lee, M. Serum 88: 1135-439, 19H2. Rose, J. Acta Psychiat. Scand., 38: T. Rosenzweig, The Funkenstein M. choline esterase and depression. test - a review of the literature. 12H—153, 1962. R., Krech, D., Bennett, E. L. and Diamond, M. C. Effects of environmental complexity and training on brain chemistry and anatomy: a replication and extension. J. Comp. Physiol. Psychol., 55: l4294437, 1962. 50. Roth, M. Changes in the EEG under barbiturate anaesthesia produced by electro-convulsive treatment and for the theory of ECI‘ their significance action. Electroenceph. Clin. Neurophysiol. , 3: 261—280, 1951. 51. Roth, M., Kay, D. W. K., Shaw, J. and Green, J. Prognosis and Pentothal induced electroencephalographic changes in electro-convulsive treatment. Electroenceph. Clin. Neurophysiol. , 9: 225—237, 1957. 52. Rowntree, D. W., Nevin, S. and Wilson, A. The effects of diisopropylflmrophosphonate in schizophrenia and manic depressive psychosis. J. Neurol. Neurosurg. Psychiat., 13: 53. 167-62, 1950. Rubin, L. S. Acetylcholine hydrolysis in psychiatric patients. Science, 128: 2510-255, 1958. . -1 �5Q. Spiegel, E. A. and Spiegel-Adolf, Permeability changes in M. the brain induced by Metrazol and insulin convulsions. J. New. Ment. 55. Dis., 93: 750-755, Spiegel, E. A. 191*1. and Spiegel—Adolf, Physicochemical effects M. of electrically induced convulsions (cerebrospinal fluid studies). W5. 56. A880, 70: 130-132, 19“”. AHEI‘. NeUI‘Ol. Spiegel, E. A. and SpiegeléAdolf, Physiological and M. physicochemical mechanisms in electroshock treatment. COnfin. Neum1., 13: 38-63, 1953. 57. 58. Spiegel, A., Spiegel—Adolf, E. and Henry, G. .M. Physicochemical changes in the brain accompanying electrically induced convulsive discharges. Trans. Ass., 68: Amer. Neurol. Spiegel-Adolf, M., Wilcox, P. H. and 171+, 19'42. Spiegel, E. A. Cerebrospinal ﬂuid changes in electroshock treatment of 59. psychoses. Amer. J. Psychiat., Stone, role of acetylcholine in brain metabolism W. E. The and function. 60. Amer. J. 'IbbiaS, Jo Ml. Lipton, 104: 697-705, 19%. Phys. Med., 36: 222-255, 1957. Mo A. and Iepinat, A. A. Effect Of anesthetics and convulsants on brain acetylcholine content. Proc- $Co Exp. 61. Torda, C. B11010 Mdo, 6': 51'5“, 19145. Effect of convulsion inducing agents on the acetylcholine content of the brain. 173: 179-183, 1953. Amer. J. Physiol. , �62. Torda, Effects of single injection of corticotropin C. on ammonium ion and acetylcholine content 63. Tower, D. B. and McEachern, D. of brain. (ACTH) Amer. J. Acetylcholine and neuronal activity. I. Cholinesterase patterns and acetylcholine in the cerebrcspinal fluids of patients with craniocerebral tram. 616. Canad. Jo Researdl, Sect. E, 27: 105-119, lgugo \ Tower, D. B. and McBachern, D. of cholinesterases in human The content and characterization cerebrospinal fluids. Canad. J. Research, Sect. E, 27: 132-145. 1949. 65. Tower, D. B. and McEachern, D. II. Acetylcholine and neuronal activity. Acetylcholine and cholinesterase activity in the cerebmspinal fluids of patients with epilepsy. Canad. J. Research, Sect. 66. Ulett, G. A. E, 27: 120—131, 19u9. and Johnson, M. W. Effect of atropine and sc0polamine upon electroencephalographic changes induced by electro—convulsive therapy. Electmenceph. Clin. Neurophysiol., 9: 217-22u, 1957. 67. Ward, A. A... Jr. Atropine in the treatment of closed head injury. J. Neurosurg., 68. Wescoe, w. The 0., 7: 398-402, 1950. Green, R. E., McNamara, B. P. and Krop, S. influence of atropine and scopolamine on the central effects of DFP. J. Pharmacol. Exp. Then, 92: 63-72, 191.8. �for Ihe Bio Sciences Informgﬁon Exchange. . . . . NoI' for publlgnhon pubhcahon or Prepared j DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE ——1 m”: PUBLIC HEALTH SERVICE NATIONAL INSTITUTES OF HEALTH "one: or ; . s SUBMITTED TO! ‘Public Hoalth Service. NeIionaI lnr+i+u+es of 'n-r OF Paganini “mmame ‘ and Give names. department. and ofﬁcial Win ‘l'ifles RESEARCH Hulfh. ' ‘ ' rnoJEcIr;”.-\ Div. of Research Grants. Bofhesda l4. Md. ' , in Spinal Fluid § 7 a—sm. (022 , ' , PROJECT NO. (Do no? use this space) and. U lemme} l Read" Injuries“ ' , I of PRINCIPAL INVESTIGATORS and ALL OTHER PROFESSIONAL PERSONNEL engaged on the proiecf. 11.9., Rmsurgem, mums: Gluing Instructor in NeuroIn. surgery. Dartmouth Radical School Smutﬁadgs. i. . John P. Wilson, Ph.D., Assistant meensor 1n the Physiological Sciences, Dartmouth Medical School I NAME AND ADDRESS OF APPLICANT INSTITUTION: ' Hitchcock Fomdation Hanover , New Hampshire SUMMARY OF PROPOSED WORK — (200 words or less —- Omlf Conﬁdential data.) In In Bio Sciences lnforrnaﬁon Exchange summer!“ of work In progrcss are exchanged wlﬂn qovernmonf and privan agencies supporﬁng research In modiul and rant-d ﬁelds and an forward“ to invosﬂqaton such informnﬁon. Your summary Is to be usod for rhese purposes. vbnqm study of in. neq'tylnholine MW: of spinal fluid mama“ in hudinjxaﬁu, utilizing the biéh'nsa'y author! am! Young; Mariana, has A, bun Wt“ tale .mn. In! study Indiana the presence put of «cannon», smtonin.‘ and one. unidentified in the period following head injury. mezpmponod “any: is an extension of this Mainly ml: u.m1n tissue as will as tpifail fluid. and ~11; aging. in addition chain: 'analysis for these one 3mm” (spectrephntnnuomter). during tha We“ f.‘ Silbmitted beginning SIGNATURE OF PRINCIPA INVESTIGATOR for periOd I. September 1956 A , ldenfify fhe Professional SchooI (medical, dental; public healfh. graduafe. or ofher) wifh which this proiecf should b idenfiﬁed: mm, INVESTIGATOR —— mm Romanian .. Do NOT um:- Ti—u: :nnn'n- I 11 ed. �12/17/56 smmc comm wanes WW3 rwml :5an or ~ may mam Acrmr! IN BLOOD ml mm... m) mma: )5.“th for the at mum of t papa-1m mutation mod for): Gil-13:1 mm th Mien, in Matt“, Mm mum Samar, Brooklyn, «.2... Pom-my 15, 1957. A with. m mom-mm nth-ad in ”portal for tho «5mm; a! W My W m W tar um» 91' m «mu-cm» Minty. Though of W31. “14 «mm-nan (2.39) and on m thalliutan» in min-.1 fluid. the mum. in nanny applaud. to the may.“ of and and «11:, um mm, m. on» biological num. Only 0.3 um, :1. of 13311:]. fluid at 0.001 I1. at m mu «um: knyltuooblno 10 why-d a lmdng incubation, m um is nquirod for a in dnmtion. W but”, pa 8. 1! “Situated by am“ 51 tol- trickle”— mm into a calorimeter tube. notummm¢1smwwnmmrm~wmmm «.1331. uotio acid, cum-1mm, ind daunting m thus Whom. Thu than that map mu :m an: m mt: with ”Miami” to product Absorption mm a. 510 tho a. ma to format ton, color with an New”. want, m m M. or new in. y. an be both may.» mum the cam in not by Adding *Mn 1397" u in spin]. ﬂuid, um sham-mu 1: n «1mm Wu: mum-m), (lawnmmmwmmm dot-ruin“ 0! W “machinist-mu. mm of mm in various Mansion. fluids at. amounts-nod and coup-rd to tho ﬁndings in pun-nu with mm dim». Th. nor-:1 W “01ka Yb Ind!!! W10»). alto mu .ployd to “My «batman. that action, no): u LSD, which is a mum inhibitar of 10 �WW. Wham” mtahmtortothnmnmwwwcm hr this mu the awyummm - hm“: - WOJn1¢romoerquythu¢ummmmmtof tm»mmlibcatdhyumc lauwrkmwamwmawmmmnmm mum at m mm, 9.3. mm mu m... 3 601m, 3., m4 Gold-abut, m, a. 3mm. My», 1, 21.6 (1956). �we «mwmman. m: 31.3mm, wmmmc cmmms, m 1'3ch W W, W W. 'm .m no Magnum - Lon; Inland for of a n.‘., 3661“,, 1) m ”may, not M1» on an. ”WW- mm» harm), and for tho Illa; than 111:“ mu u spam. mum mum“ of and and ”both“!— mum.» 1mm in fan madman. a: aninitiou 1: Mm a. "mm m mm and tin-Sr to u» » W in mu W. W]! ma ‘ wat u Wtimﬂu York Mm, 11.0%ch cm 15, 19,7! “W nautical mm: m mm. mu that: m s: muons; mm; (nmalm, mom. mm of atypical alkaloid- m- mm», mthmuumbounafmuc mp: mkummcut 1n thiamine, and Wow. I'm: sum in : Mia «fat mm, 2) awn-s in ”WM 111le 20mm rm- the 91‘ m from macros! M Marina. municidanﬂmdtmmdwmﬁkh wish alkaloid! W I” be much. duration at diam-ranting nut-win 1:: tbs who «Wu. to We 03:10:13.1" I couple“ uh“ for henna; m6. mutating than and hack «mm ma mum-1a, «man. um, mad tmtm into a. null value at cthylm mum“. Tho aim a truncated m M Wu to dryness, thin upon-d out on mt» pupa. Separates: of tho 1: want either by handing cur-anaemia an; Mme).- 1anmmppmu1n mmmnarmmuostmtmamm mum. at mun, ms. mu. am.» 3min. m �“ cam mum «an an a! mt thomh with H» (521:1), or by in 1n 1:: m3. m- petition :5me“ W (m bola). At oommdm mum m «a «a: 1m puma). um ﬂax-1p: , the. club“ with 1106M, tht «ma by mpontm in «11ﬁlth ﬂaking. mud tub», than mm. arms. and Wm mama. m this point than W WI m MinnaﬁyotwlwtomdbthnMaunm«maintain-momma mummuawxomumqmmutmmmu W. M Mal-Inﬂux com-mm; 1m «mum at out amen my be gland mm, thmhthMmWw5uw, mat. mad ”imam, mmtmu, WWI» W mama. W W bah structural {mm at th- '13., and to! 16 drug: tar in pasture m dam-trusting the with ml: w. metric Rub dag mhmtmthmmmoﬁhmcamwath WWIMtMO. Amioutm of tin mm to ﬂu arm. a! “Mum“ prior to m {allowing 4mg than” will I» mean“. �(Effect a! In a Was Mona an 3% Theory of convulsion for amriigmﬂme report to this society we noted the relational” between the degree of induced delta eetidw during the course or therapy and the behavioral response to electroshock. Thane patients, in when big: éegreee of delta nativity were induced early, and were sustained, miteeted the greatest. degree: at helmvieral change, as well as a significantly greater percentage of inprovemrt. and recovery than these patients in when only law degree: a: delta activity were We (Fm: m: m. 1957). In the past few years, a variety of reports relating changes in £me( 1‘) leetylchoum and oholineeternae in the spiral fluids of patients (Subs, Herd) 1rd minis 0 (Bernstein, Teller and HeEnohern) following head the obsem’cime that cholixm'wbic agents may by trauma (32mm, Bard, Jemmr) alter the EEG m; putterne induced and by electreeheck (Inuit), led us to investigate the role of autylcholine-eholinestemee metabolism in acctroeheck therapy. In 1956 Ulett reported that atropine or schpclmne, when administered row! the clock schedule blocked the appurme of the delta activity on a. we hm com to mandate with electroshock therapy. meet. noted, however, �that his patients nurtured numerous madcaiubla aide effecta during these mutations. (19%) had Previously, mm (1950 ramming the suggestion of Bernstein new that atmpine mama bath the EEG patterns and the mumlogm signs induced in an by head trauma. Here, too, the side effects wen marked. In 1953. W:- md Lechmr ropertad that mum-a1 effects similar to atropine mm intend in patients with 610W 11-. in tram, head on also reported the effect at normal subjects. the EEG hypothesis of the we of nation lanthanum is a soluble We: Wr “was: dry with. at“ comlaiva mama» aethnsm the bmdyoardia, «11m: moment neumplvuiolagicnqdapﬂva than”. coupow with Wologic to atropine. In maximum animals. hymns 335; Media 1.1m. and 111mm: of patients ﬂaring electroshock Warsaw; and to relate than them findings to the ham and whim by Maine min- we purpose of this repwt to describe the effects of is dicthuine um; Thcy EEG blocks slowing of the heart; Wasp-m, «ﬂatten. induced by ucatylcholme, main ugal uni hypotenaion. m ma fasciculation e and pilocarpmﬁ and induces �~3- m: shock ﬁreﬂy-two paymttric patients, in-vurioua stages of electron- treatmnt in an studied. the EEG these 351 upon-ward. voltm’ury purchiatric hospital have been WW Follow laboratory. Wtemd intmmny at a routino amtration, 4mm” both the were 25 mm the habtwioral m per minute, for a total errata. Prior and a to the W Mahatma, period were upeonaordad. Running 'dmg record again tested in recording, diamante unstmtured historical intervicw regarding, and meordeﬁ EEG EEG an BEG at the rate or 290 to 250 nan, depending upcn drug maximum, aubjoots Imam periods were mntinued until mummm Wanna patterns on visual \. inspe ction. m m: (a) Neal: follwed by n fooling of Q. 11!. subject; manifested spontaneous gouging initially; dryness of the mouth and, a thickmsa of speech. They nohd heaimde and makneu of the increased mathsmou and difficulty in W were Psychiatnc/cleaﬂy mnifoctad in between 13 and 30 mm attaining mm am noon rammed by eyelid closure. subjects. In the not. pound titer drug mutation, ax subjects spontan- �.3. 0011333” med fouling: of «mm mums mm amnion illusions, about than" 111mm, the setting of the «auras or our icientity. by the um: and Myrtle Such and m: pm- patterns were transient and had diaappuamd‘ of the expat-meat, usually vitiun three hours. In um subjects, mesing august-loan and panic led to, a «mum at an wrung. amt Hero, too, mummm at minimisation War was mum: tune hours. (b) In previous studies, we had noted the intimate rolaﬁommP hem ehangan in syntactic language 1:3th with mmm induced by allotmm. changes diothaaino inﬂamed In In subjects alteration in mm prior to abatmshook, in syntactic pattern at an “lurking” musty. 3&3er with tielta activity, We}: clinical amnesia {anthems of an ”alteration in cerebral function, diathaninu induced a appearance or animation of amt: languaga ambnl patterns. indicative tmient. dis- The pct-5.06 01' ohms” in language in mum-rent with 63mm in eloetmmephalom. (a) Patterns: In all words, than dosymhmiaaum or fmqmneics. Them m. M 15 in 3. MW in wltage and a decrease in pruinamo at In patients without. delta activity (magmas), �.5. me «mum ‘ppannoa or small by the T123543 5.- W8 of 198 voltage 6-? cps uctivity. are Monstmtcé in Slidoa 1, not. appear slower to be alterad. 0131.2. The basic alpha rate does Mishap in voltags and appaamnoe of The fmuweies with mwmtmtion in blockad. In patients with vu'ying ”thaw waiting voltages: W 1m voltage m and burst «halite. in 3 is a decrease ntdxitw diuppoun; and 31m and am Wotan hem This change It wants times {bits or Maud high voltage dean from convulsive urea-am, them are now: in Sudan ham. «W «mm Manny and voltage 1m, 15mm. mm Ghana's Ind h. mm: is West in all 6100mm imam. during drag mumum, and persists far one Concurrent with electroencephalogram changes, uillon}. and language patterns at the pm-dnjoatioa language in 313% m putter”, Nauru: awn uppured. ciascxﬁbed. With the to three as the ho- mum the para-injection behavioral and �as w: ﬁtness obaorntions confirm the report of Jeanne: and Manner of tho affects af diethaaim altars moot-d: subjects. in’*uonm1" we also note that diam II‘ with mammal: induced delta activity in a fuhion dearth“ similar ta atropine and ocopolnmine, l5 ty- Ulett. Memo". Shea patterns are similar to the affect of these anti-showman conpaw-ads in records 1'0le head tram. In the» subjects, intmvma ammo caused immediate changes bath in the we and in behavior. It is appsrmt, Wafers, and that. it; its: duration of activity is most mum). for the @0an mm. mutual: aim audits by mmus obumra at new man attracts of head ﬁrm point to an inﬂate of muralagie dyst‘motion, the :2» mwlohonm 1n the the madly affects the centre). nervous when, basis fer the owned EEG alteration; and the 1m). at spinal fluid. the effmt at ttmpine both an mm a» continuum tin-tho: support to ﬂu chm: of relationship batman the dome an mm» m wbjoets with heaé mm mm Wim Em putt-rams. of mmm. In those studies of Wain. and u the patterns and has nutylcholmo chatmahook, the intimate relationship 13¢qu EEG bonnie: �.7. m trauma... m ﬂuid m mama. beam On We the bases note the parallel to we observations» in head of, these observatim, as wall as studies at spinal chanmmmu lavela, would magi-st that [the (Tower and mwem, Mammal substrate in similar to that. of head tram. Fink and W22), of the electmshack promos: Electroshock my be Ionized upon as a continua-d mothod of inducing cerebral dysfwc’oian for its bazaviaml “Tact. Purim pmidas 13m atudiaa have (1th that. alteration in cerebral mm: pbyuiologic basis for the behavioral changes in electmahock (Fink and Kahn, 1957). Such altamtion in embm mum pmidol m milieu for a change in the eat-mum's adaptation to his environment. aspects a? behavior, in pemaptim, mum lama, mood, recall, memory, m affect, the basis for the therapist's ovalmtim ate. Margo mange, and of immanent. studies of ﬁiathudm amplify this neumplvnolegia mm“ The hypothesis of electroshock by suggesting the type of Minute mat. Marlins both the Wuhan biennium and the beluvioral chm. �m: Dicbhaam, a patent mﬁwohcainergic unwound, 1:1th was upemmntnny intuwnmsly in wyuhiatric subjects in various sages at commlaive thanpy. mectmmcephalogma minimum theme in voltggs, a. and observatmm or éeaynchronixatim of fmquencioa, hyperventilation Manson in mean}: mmmt print dnlta activity. accords with delta activity sham! ammu- changes with mama‘s-anus of delta burst activity. Gmmt pat-amass with the ahetrogmﬁxic effects, behavioral and language indicative of a reversal of the electroshock affoct. were charred. It is maelndod that: (a) Disthuine is a patent anti—cholimrgia amount! that readily enters the antral not—mus system upon intmmm ministration. (b) The Modalities}. butts ras- Fm changes in electroshock is to this of head trams; and (s) therapy The may biocheniml lie in buis of the mode of action or m cmﬂsive the acetylchounoocholmatemu system. ��(glum‘ﬁrzr Wﬂ «/¢V7/‘ “W“W WMWW— #MZ ; _WMQ!4¢W MM ‘ é; 7% WM/ 64331” .461 ha— @fﬁ/If/y EEQaQ/JW gag/M1114. ﬂ 64x7 ��14.3.,“ , / -4I/ . .. M... �é“; sessé c W ﬁg? ngz/ & W‘Za- MWX m ’55 2 “a! gégil Mara. 461/ 4. .4“) ¢ MM: Wu W Jeni #M“ K/m 1» 14:44::____ ��/Z¢, Aﬁfﬁgg L££A4AIZI~ mWMmQ ("43 2% 2 . @a M 3" ��/ / 'v-—-9:' wpw'.” v -' MIG/’4 4trsmg+¢zi9 - ._ ~‘ ~ . " . Dr ��10/ M‘ £77. ~———-—-—-————-——__ / 1 w W? WW M tr M WM mu 5 m; Mar fir WM ltra in x1“! EEQ. 32 ' #2 Cf; .- .20 _ Wa MAX—«l 4.4.!” . #34“... 4'“ ‘7 AIM xcreq cwé‘.’ :4. ('3) M44. Min-A- ��“0011/ /;4a+ a” ._—————-9 ,4¢,,‘“‘“':_:=, l/aw M #u/t. 410/ ﬁ’é‘fu’” S“ v MM ��[f7 x, W/ r{ /¢C// A"! wax / (31) I) 2 %%l -———-> MIL. ”cw / ) ��ﬂew- �O EST —_WU. ”WXW IK. Bag 11“» “~ f ‘ 4W Iy .NQ W .CW ‘e’ Iaéas/uue' ‘ MM? c) jivfeaﬂﬁuﬁp 041.. � 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 Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 1/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-001 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1966 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/9528d68ea90232ebce57ade28fbef74f.pdf 93461c25c5f8ae971bd4c1aadc2a1278 PDF Text Text I; I Mnémc . ' Recent studies changes in the 7&4 ’demonstrated that a necessary change in behaviort was the development of early mg sistent signs of altered cerebral function of slomgga ”a was a “f7 in these laboratories re-evaluating the role of cerebral mechanism of electroshock pie-requisite for ?. [ours Wt (Fm/IL indeay and per- which electroencep/alographic and/(ah , r:f.:'6) any. mes may of this observation remained unclear until the recent reports of Ulett describing the ability of premedication with high doses of atropine to pre- We wt}; (WMI‘Collowing 5 vent the appearance of the EEG suggestion of this report, we delta abnormality a . nth the investigated the roles of acetylcholine and cholinesterase in electroshock therapy. The data amply demonstrates a close relationship between the degree? and persistence of the ele ctroencephalographt‘cr abnomality and the appearance of measurable quantities of free acetylcholine in the m ‘ mm“ as“ as well {:5mm of. to ﬁcholyl-cholinesterase, The I q ”'2 ('7’de } Loewi u W? normal ratios of” cholinesterase WW of the ‘ p $.00» . 1 f .— p. role of acetylcholine in the transmission of nervous impulses has been a subject Edi} W x 072/) Q). for study since the first description of The arguments as «If theWeﬁ‘ects 4 (ﬁes r’ to whether actylcholine is the main or only �agent in the transmission of the nervous impulse are not of primary concern It is sufficient to here. of nervous tissue; that note that acetylcholine it excitation process; that exists in a it is bound form and a normal constituent is librated during the a is rapidly hydrﬁlyzed through the specific action S of cholinesterase; and as rapidly reconstituted by the choline-acetyléueg fluid iﬁ: Richter Crossland - 1916). Furthemore, normal cerebrospinal I‘M? Mariam ”‘?¢‘94) 4.94mi m‘t‘uﬁv contains no free acetylcholine deSpite the rapid breakdown of system ( & a, bound acetylcholine during periods of activity and excitement. The cerebra- spinal fluid normally has a definite level of cholinesterase activity, which is principally of the "true" or mecholyl hydrolyzing type{ IVMﬂM/“V 4“} "Romsuetkg. any). .111 the absence of free acetylcholineﬁand under the ”normal" conditions described! ﬁe electroencephalograms fail to (a) Effect of Cranlocerebral Trauma: variables was lationship of described by show any . The consistent abnormality. earliest changes in these 0 glmstein (l9h6) in a classical study of the re- changes, degree of experimental head trauma, and levels of cad/w»?!grew oft! cats free acetylcholine in the 09!. stu subjected to varying degrees EEG 0 a of head trauma, B/mstein first showed that free acetylcholine appeared in {Yaszwm the CSF ‘ céE. within a few minutes; and persisted for varying periods up to M hours. There was a positive relation between the degree of 17am and the quantity �-3gamma 9 per cent. cu- electroencephalograms demonstrated patterned changes. Initially, the of free acet’lcholtne which w Eg-rwﬁﬁal varied-khan 2.7 and 9.0 Ocn Com-raw records were filled with high voltage .fast activity, 516 int'preted as an intense neuronal discharge; only to be followed by a short period of flattening of all #01 recorded electrical activity. These periods were "followed by prolonged periods of high amplitude sharp waves in the delta frequencies. Mt 0 Ulth thes/e'zlectroencephalographic changes, Bﬁrnstein fur- ther noted that behavioral manifestations w{ he werencorrelated with degree of the of as as free level well acetylcholine traumal/ ”in; highest levels of acetyleholine; he noted the greatest degree of abnormality as well as the greater severity ””77? M u/ the of WW t'anges a the appearance ofAseizures. _ W, diva EEG alteration in consciousness, 7393!. rnnumnrm further substantiate these observations, B/grnstein applied acetylE Y 105553 choline to the cat cerebral cortex. When the concentration of acetylTo and choline was 1 gamma per cent or less, he observed high amplitude \sharp waves of low frequency in the electroencephalogram. creased to .7lmaém WAC/c! the concentration was in- he ~Wana Mada per-cent, the electroencephalogram we. fad-w 2 gamma 74: When Tower and McEachern (1919 a) flattened,‘ m repeated thﬁe studies in human cases: w �cere‘rospinal in the fluid only in patients following head trauma, recent grandmal seizures and electroshock therapy. to 100 gamma In cent. addition, per terase activity of the. ific cholinesterase spinal fluid. (benzoylcholine Specific cholinesterase ( mecholyl The free acetylcholine varied from 0.2 Tower and Mc Eachem assayed the choles- They noted a sharp - splitting)fraction rise in the nonspecand a drop in the - splitting) fraction in the patients head trauma and those following electroshock therapy. No with such inversion was demonstrated in the fluids containing free acetylcholine following spontaneous seizures. These authors also conclude that the level of free acety- lcholine varies directly with the degree of cerebral damage; adding, however, that the degree of reversal of the cholinesterase fraction is an even sensitive indicatbr of cerebral more damage. In most of these subjects electroencepéhlograms were taken at varying intervals following trauma. Here, too, as in Bernstein's experimental study, there Was a direct correlation of the extent of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal Thus, we may conclude that craniocerebral fluid. trauma results in the appear» �-5. in the spinal fluid; and that a ance of increased amounts of acetylcholine direct {KN rJ relation “between the amount of acetylcholine, the degree and type of electroencep‘llographic abnomality and clinical behavior. (b) Effect of Atropine on post-tramuatic EEG and Behavior: In his studies, Bernstein, administering 0.5 0 atropine, demonstrated a reversal or a blféking of the EEG - 1.0 mg/kg. effects of trauma, depending on the relation of the dose to the trauma. Atropine also modified W the behavioral and neurologic signs of trauma. In the experimental condition of [Mrﬁﬁc/UEPNM acetylcholine, which induced EEG and clinical ﬂanges similar +1.14 to head trauma, Bornstein also demonstrated the blocking and reversing effect of atropine. Ward ( 1950) applied these ideas to the treatment of human cases of closed head injury. In 20 patients with varying degree‘ of trauma, he admin- istered atropine subcutaneously in doses of 0.1 mg/kg.. In selected cases he noted dramatic clinical improvement which action. He \ .traum.we. also noted, alographic effects of IA) lg. m M ATTRI Ben-5;} to he atropine selected instances, reversal of the electroenceph. In the study of another anti- �To“) f \DIW I cholinergé' drug, "DIPARCOL" ‘6' (diethazine), Jelkner and Lechner( 1955) re- port significant alterations in the post-traumatic electroencepbdogramio A single intravenous dose in no instances of abnormal electroencephalogram re- sulted in nomalizing in More 22 instances and marked improvement in six others, recently, Ulett and Johnson (1956) demonstrated the of peripheral atropine IL’ .0 to block the same effect occurrence of slow wave activity follow- ing electroshock therapy. This study suggests the possibility that the same biochemical condition underlies the electroencephalographic abnormalities in head trauma and One in electroshock. report stands out in contrast to these findings. the§5 In ex- periments Brenner and Merritt (19h2), applying topical acetylcholine in con- centrations of to 232‘ intravenous atropine to the exposed cortex of cats, noted no effect of 10% ng/kg) on the electroencepahalographic changes. It is important to note however, that the concentrations of acetylcholine in these experiments was significantly higher than the topical applications “a, 0.: ML andnmtra-steruc (0.2 Merritt, however, make - 10 gamma) (1-34 g7ama%) injections of Bomstein (19h6). Brenner aha-4.1L note of electroencephalographic effects similar to ace- 0 tycholine from mecholyl (acetylbetamethylcholine) and d’iryl (carbamylcholine) , ‘ each in concentrations much lower than the acetylcholine concentrations. �-7. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral cholinesterases. A - variety of experiments utilizing DFP (di-isopropyl fluorophosphate) a compound with irreversible anti-cholinesterase effects - demonstrate‘ the developnent of high amplitude rapid frequency waves similar to status epileptic“;s as well as lesser degrees of abnormality noted in post-tramnatic states _ wich et a1, 1950; Frefdman _e_t_ a}, 1929; and Hampson gt a}, 1950.) A! .. (Hit In these studies, too, the electroencepahalographic effects were blocked by small doses of atropine. In another laboratory study, Qhatfield and posed animal cortex with activity. The Me PR0 ST! Dempsey (l9h2) prepared ex- NW and evoked electroencephalographic Spike admestratgﬁof prior atropine blocked this spiking, or if present, the alnormality could be eliminated by atropine. Thus, from a clude variety of experimental and clinical studies, that electroencephalographic activity as a result of trauma, To PM; AL ‘5“ we may con- induced by acetylcholine, either application or interference with normal cerebral metabolism, can be blocked or eliminated by atropine. �-8(c) Role of CembraSpinal Fluid Acetylcholine in Seizures Acetylcholine is normally present in nervous tissue in a bound, in- active form. During periods of activity, the free acetylcholine is liberated at the cell ”I; The membrane, where it is rapidly deactivated by cholinesterasmﬁ- level of central nervous system a acetylcholine is this ant of the processes of synthesis, liberation and breakdown. It the result- may be post- ulated, there/jars, that the level will rise during sleep and fall during act- ivity. this hypothesis is tge That (1949) and Elliott, , was demonstrated by Swank and Henderson (1950) liquid air quick-freezing methods, Etc.“ ter ANIM in “8.1 experments. was 300% higher than ' micrograxmna the post seizure level. tissue levels is transoi'ent, however, as the 7 in rat brain is high (1 gr: . and Crossland demonstrated anesthesia and sleep level of acetylcholine (measured as brain tissue) Richter and Grassland ’R’tSW ”thesis The By using that the per mg ' difference in rate for acetylcholine J Elliott 33 a; confirmed thez'e (I950) gaxmna/gm/minute). observations. In addition, they noted that after metrﬂzole convulsions Jﬁi FK’EE acetylcholine was always demonstrable in the spinal fluid in concentrations up to 3 gamma per cent. In spinal fluid studies in Tower and Me man, Cone, Tower and Me Eachern (19h8) and Eachern (19h9 B) also demonstrated significant quantities of free �.9acetylcholine in patients with epilepsy. 0f 56 epileptic patients, meaSurable demonstrated/free acetylcholine in quantities of 0.92 to 5.0 with an average of 1.0 gamma per cent. gamma “¢¢ ‘7.) ()7 per cent, acetylcholine level was directly The related to the frequency of seizuresf/ the extent of electroencephalographic abnormality, and the relation of time of / n01 ., M sampling l 14¢, tonlast seiZure. It bore I relation to medication, type of epilepsy or level of cholinesterase act- ivity. As to whether the acetylcholine appeared in the spinal fluid is a by- product of the a M V“ ' s I o n / conclusion; or whether C the increase in acetylocholine was a is problematical. a, increased cause of the seizure, lieve that the Tower and [{cetylcholine liberation itself but related Me Eachem (19h9 B) be- is not due to the seizure to the basic process causing the seizure. I In a study of thfhypothesis that the accmuulation of acetylcholine is basic to the seizure process, Torda (1953), induced convulsions in animals by met zole. She determined the level of acetylcholine in brain fore and during convulsions. She W tissue be1' ' . noted that convulsions are preceded by a rise in the acetylcholine content of tissue; that the content gradually $118 during the convulsion; and that * 5423..) occur. Furthermore, she postulated convulsions u WAS 8. certain levels, convulsions failed to can?» send 3 factor} which in physostigmine probably acetylcholine, but in electroshock seizures was not. �Shendllu concluded was due that the fall in tissue acetylcholine during a convulsion to inhibition of acetylcholine synthesis by increased concentration?- Sec” of metabolitesnas ammonium ions. While considerable argﬁihent waxes about the significance of acety- lécholine in the mechanism of seizures, it is apparent that free acetylcholine appears in the Spinal fluid following seizures; that activity and seizures enhanceﬁiacetylcholine; dfstruction/lowering tissue levels of acetylcholine; while sleep and anesthesia Aﬁgment acetylcholine production increasing tissue levels. �W!"— " WM—w-"ﬁ ' TNT <- Mm; E Aest‘ I. / I w- . , » urr u ' , M 0' - ,,._ -m—~ I 4,4 " 6Z7 v - ,1 5 M 1,;“414, m. -w—.‘ —V<.._—. .Avv»/— up ~~r .-———:v mm” M: . ~ . w.,-- ”v7 /’ W“, .. -v. .. . . . wﬂnm .,,_.V,r, _.._ .<‘._,._r_.__.=_,,m,_qw ' -. ‘ EE < ,. ’ I I: l -7' ['4imzzm4m-‘ean-,g-gﬁc ‘ ~ — ‘ , / -~—...:.;_.-f.._ Mg; ((244.4'4/pv A , , ,.. / /' l . ’ / 3 ‘ j Z e" . ��-« ”tum-35$: 434.. \2 as: {525% mthhw ‘3‘ M . {3%. «3%. Ma g. 7 \i‘xw _. , n ﬁwkﬁkxﬁhﬁ \.m§\. 5n Q“ W; ‘53 h}. 41“; 7 53.3% _ x w x ”‘1; (“VM , «$ka ��the level of free acetylcholine and should follow a decay rate equal to the EEG WWI-£6 rate of in desthtion. Since previous studies demonstrated that Ron hypersynchuy was a necessary pre-requisite to clinical response to electroshock therapy, it may be stated that the absence of free acetyl- choline precludes changes in cerebral function and thus precludes a ical response to electroshock. Certain assumptions 61M (1/ .WQS in \mﬁxam em . may be made regarding M‘ W£%,ML 4W; Cholinesterase I is found in clin- WM“; all 4 {a ;ﬁb€,¢.¢£ £0»£u64* ' ' highest concentration in the central W, W nervous system; while cholinesterase II is predominant inAblood serum. With the increase W! M/mx.dv£[7 in acetylcholine levels, in the intercellular fluids M Wftoaow M 6i mm ‘5‘”; vs odilation and increased cellular permeability degree of transudation of vascular fluids may be I: into the dependent on the extent and duration of the / predicted, with a intercellular spaces tasodilation, (Kabat gt 3;.) 19118); ration changesggﬁztlt high ncentrations of 15?; , enzymet, th 4/ rate of hydrolysis idndecreased, ' achnﬁnson and Rothenberg, �@ Tit/4M ﬁgﬂﬂﬁ W05! M. r ' ”1“." I (m0 4» w- ar A » W M L’ M.%u 7 . WW1 ’53), do W MW; - ’ . - W I44"! %_ /o¢ /ZM"‘ �2% Mwaﬂ.‘ éﬁ 7M/Cc 42 d a >/~7‘$[ 6a 56) iwwwh‘ 4M 444W ' 'wZ/zé 9“. ﬂ A—ﬁr7:9%__~_ ��__ _%j%i%% __M __~__ Meg/Eran!» , , M W/ 8&9- afﬂt ‘9 _4€§./_""f. ' 1% ﬁﬂwjg; W M; ___-#__ ��F:+r§¥¥33~%¢;*‘ '77 , "“37 ' \. *Q W~~ -~’ vM—w7ﬂx-«7A 77.7.«7-«7 . .ﬁW-M 1'} f MW~ §' \»M ‘ \ ﬂ r \- j "39% \~§\-&3~ .uxawk , 7 - 7 «.77; 7 777 , 77.7—7— ...-< w... 7- W - 7 7 7 7 77 77.3, 777 a Q7 M353; --:-..___7—a.7..7 ' 77.7.7 1377-3 ~&\ 71;;7.}7c§?§37\7:s7 sw C\ hﬂa§»3~§~3~ 77-.. 7.7.77 ‘ 7- 7., 7 x 77 5g .v‘wz\ if»; ~ \ f ��I: she/ﬂ ammunummmmmmmmemw at our.Mating um 'mmsmmmmaozmmmmmmumu Meat 11: than Inherited“ ﬂu 1-01. mmpn—mquuiuformmhmurnammtot mhwpmtsim ddﬁndocobulmuondmam Wcummawmmm(mmmv$6h topmtmawotthamdalhtmutw(mttmdm 1956). rationing the Inseam at this report, In investigated the , of acetylcholm Ind cholinoatome in diam-tutu n clone of w’ My. «f ﬁfe? ":9- ‘ therapy. as. data amply the dean. and persistm of the ham 1".th 010W 113109 mm 75:, role: “humility math- I'm acetﬂdwlim in :ppm of measurable quat- the cerebmpinal fluid as wall as an in- moralenrucetvlchdjnohthotmumornemmpnmm Mamamrormsmmtmtmumotmwxm affects by Dale M1 (1911s) Ind/(1921). ' rho W: n to another «1th 4 ' �“wwwmmmtu‘mdmammmm of M 0mm hon. It in affluent to who that mtyldmnm 1| nmmlmtitmtofmmmmy mtnmmmabmtmaaa is liberated as. an mum normal cut-Ironing]. 1.913%) than“ th- or activity and that m ﬂuid contains an hm saga-mt. no true of bdund 1?. iallnpidly mtylchoum (faster and McEachorn new periods The comma-121ml dummy; nomliy has ﬂuid lenl of Munster-nae activity, Men is principally of the mM W was; a: Manning and .- mam mmtitutod mun (mm-a 6mm - 19M). Funk-awn, «citation W through by during thy W (W n “two" deﬁnitm- and Rothanborg: 1935). hmmdfmmtylchonmmdwwrthc'mml"condium (a) fact. :10 mmbrd Tm: th- mliast chug» in than Wmaomumwaommmwmuauummdm vngaumpdEmm,mdoxpommhudtm,mdm otrmumymwminthoembmpamnm. human-numbMtedtonqingdogmluthomtrm,homu1nnruahamdthattm �v r A—w— WWW—«WW. W-_-m_w..__quw$ mtmmmwnmcsruuunarummmmm per-1m for varying poriodl up to Mm. that m a. pain» mum ‘mmmmammmmwnttnomwmma mamaandsammmh human; mum, W was rm activity{ inmlytohtoﬁmdbyawm tbs records won filled with high voltam urpntodalunmﬁeuo neuranldiachatgoy period of mtumd We. {humus of :11 room-dud Glacial-191 activity. Thou period: ~mwwwmm—n -M." mthntoﬂmndbypnlowmothighwnwbshammmh fw. summogmmc . tbs delta. than With that behavioral as wen u . i changel, - Barnum 11mm:- new Nautical! an duo 00th with dogma of tum, with the 15931 of tree mtylclmline. with highest levels a: mmmmwmmuudagmotmmnmwumuum the in alteratim in seventy gm‘bar ma the 1'0 Wmu.» o: apontanam farms:- ahounotothnupoud mam, change! Wanna: animus. those chain-mum, in m. Bantam applied acetyl- «teen-balsam. Unauthomntntimot amylmmlgmporom.arm,hooblemdhighmpntudu �Mmsdloufnqumyintheauctmmoplhlom. manommutation an increased to 2 gun pen-cont, the ﬂattened; in a tnhiun pal-Inn}. to the Tatar,“ kaW mammpmlogm pout-twat“ a) repeated mm. § rum. mm mum-um otnxwingtmofwmandoﬂm»wm¢nsordem. 13112 mmmmmmmrmmmmmnmwm mummmwzm,mmiummmm therapy. murmmtyloholimuxﬁsdhuOJwMgmmrmt. In muQMrmm-aemmdmmmmmiuwatmm ﬂuid. Mm:MmmmmpMcmmmM(m wmmntm) - (tn-chem fondling dug: in the lpociric chainsaw emitting) fraction in the pntiantl with head trams mm W. tho fluids outlining mean faction m a lo s'ugh hint-310nm and We Wadi: rm antyloholim tanning mutations mum. more also conclude ﬂat the Laval a: nu agctymm uric. Wummmotumbmmgm,mr. than: Mmdnﬁmldmmnmmmtnmummmw sitiw indiutor of mm m. �Inn-tatuaumjomwmrmunmnmh— iamla tanning. m. Hun, too, an in Bernstein's W cm, Mmammwmumamumtdmmwwum adenwmmmaﬁWMd. mmmmmludnmtmmnmmnmunthaw ”ammuarmmmmmmnudgmum adfmtrahﬁondmhomﬂnmtofmwlm,ﬂum mmdwogmowwmmhémmﬁ Banners gm Am 9&th of (12) In u.- on BEG and mms, Barnum, maturing 0.5 - 1.0 lag/kg. um, mumudamdor&umdmm¢hm¢tmb Mam'unumorunmmmm; Atmpimdsomdm tho Word and usablogic aim of tum. In tho maximum eon-.- .wmgm mmmwmm,mmaumnwmm dmm of mmcistam induced Km and clinical m: rmrsing arrest. or «3mm. m<m>mmmmmmmathmm¢ WWW. mmpumummmotmhmintend atropin- aubomunly in data «(0.1 W0. In about! an! �.__.. _“_«, _._.__,,....<.,.___,. W7. w _. mmwmmummmmmmnmwam actim. ”waww", .. __._ 7 bmmnmmma,mrmafﬂualectw 'exmpmpmpmo effaahl .w M” wwwmmwv—WWWWWV.W_ 0239113301110 «um. hmsmammu- am, Inn-mm (mm). mwmuﬁﬂ mmamwmmwmmnm.” AWWMHMMWOIWW mmmmmmammwwmmomn: IMW,Mtandemm(1956)Wthume£fm -A——.~-T.v _ ofpoﬁpheglatnﬁminﬂocﬂngthemmotdmmwacﬁuw following unattached: the sm Wen]. mm. 00:811th mm saw mggom tbs Minty any mm. the mmmmmmum WWW mu- MWMdsmmnmmnmmgﬂndi-nga. Inmates- 3m: W mmmm in Wmmdzimloﬂwtmmedmnaotmu,wbudmdfm parjnants and Hewitt (1913); topical .ofinWatnﬂmﬂM/kﬂmthooloatmmmm xtumrwmmmhmr, thatthecmnmumofmamwm mmmnmamswmwmmmmmmappuuuéu (Mm$)mmmmmm(o.2emm)mmatnom �thin (W). 3m: and ”.11“. of hm“, mar, WW]:- ognplun affects 81:11” to noetycholino (WW), chonu) and duty]. than th- mmm mmm. 1mm at that. cholinorgic drugs mums. IA - n van-Low ma at expert-ants nah in commutation! Inch lover my mum ﬂu 1mm attach thou-lack.“ to um with incur-11:10 2m mmm (awwmﬂ- DFP muutytomhnl (div-1W}. Imam“) cumin-stoma. strum - mum- thadaubmtnthighmpnmdonmdfuqmymvelmumm mnpueusuuuumm dugmoxabmmutymmnmt-W mm 919;. (Es-non. museum, too, 1950; mag, 192m and Ema-ca mmmmmnphicoftoctImnWby Inn dot» at am. In W as. 1950). mama-y mm, tantrum and 3-way (191:!) pm mud dwtmmphdomplﬁc m1 mmuw. ﬁnpriarWtimotnmpimelm, expand cox-u: with procugdno md ovum, mmmntyoomuonmmmbyatm. m.rmanneworupommae1mmam.mmm and. tint datum-MW activity induced by mtyldzoune, um �tuna, uI combs-alum unbeblocbdoralmmmbyatmm. topical tpplmuen or interference with mum. of am run. may. mummpnmtmnemuamuam, mmmotacuuty.mrmmmunhenuumw maxi-,1Ihonit1lnpiﬂym1nudbycholmmnu. thunder Wmmauwlm ilyﬁnnﬂaruulhntd’ﬁbpmm at manna, ulnar-1510:: and mmmuuuu - this mm is true um It N ha mm, Wm. dudngnlupmdhﬂdnﬂngmiﬂw. nut m Maud by aches:- and 02-083de (1919) NW§.mmﬂdeM'(19SO)mmupemu. 11mm: on quash-trauma methods, Riches: and cm wining dam-mad um (many-dam mwmmmxamwm prn.mmm)ulwmmmmtmm an wmmmmnmymnummm rats. for Micheline 1n nth-11:1 18 high (1 gulp/mu). Elliott ggmmjmmunu'obsemum. 111mm, thqmtndthat snot-mm mmmrmmwmmmmmn �_...—_——___w wv—wwrvnvr—ﬁwwv—wvw th‘smmnmmmtmﬂmuptoJEtmmm Intpdmlﬂuidotﬂiuinnn,“m,Tmrundﬂon(19hﬂ)md mwhmmm alumnae-ad mimt managed rmmmmupumuumomm. 0t56wihpthpt1mﬂ.hh (1919 B) (Wmmmnmmmwmnm'mmuuudoawa mmoem,umqmndeJMWM. magnetism:- mmmnmpdmmmotmymmot WWw,wmnuumor‘motmm¢ “Whitman“. Itbonmnhﬂmtomdicgﬁm,typadepﬂsply armaehammnuacuuv. hummumtymwmmmamuam mammumrmmmmamwmma _munofthaac1mn,1apobmm rmrlhdmmm (19193)» mmmwmmnumumtmuwm iwmmnudhthohsdcmumth-mum. ht’ahwdmlwmmmdmdmw lib-intact): «13m process, rm (1953).1ndnoodoauvu1d.min mwmtruoh. Sheatoxudmdtholmlofmtyldxolim 13an - �”memcm. mmmtommmmm,addbytmommmmmmmmtdusmj anthem” Mfmsdumgwmmgwdmtmmmmh,m Wmn,mmudtmtm, .MhWWumpmmyaummm,bﬂh mmmmtmrmnmm WWWM. maimhiladtoopw. Wmammmmmummumotmtymmm that: by increased mam-cums ﬂ ”tam“. such a min in. M13 mm nrgunent mm the significance of newb- ‘Wmﬂnmcmdms, niaappumtﬂmttmmwh mwmmmmdrmmm; thitmvityuﬂ mummammamum, «mm; mm sloop mug-mm, M W mammal-19701.net tum @tyldzonm product“ mm with than muse: 80m omimumdchmgummmm,2mrmdncm(mwhw (a) , Walnut! ”1:413:de «shun-ammo activity. «Wmaammmrmmmmmm Twin.- Minster». �"w ——_<__~___..——ww—m_mw—.wrw “—vwr , wwwv I (”ta-m“, .. ”apedtic',: for Mahlﬂgdw mid: he a ma: Spain-o{r 21w for WW; and «shaman-a II ('psendo", ﬁes-Specific,“ a!" WW Warsaw-MW). m have 6133mm ram «Wrormmawmmmoum. differential a..—vnv—_——-_ nu cholimteme activity an mm he» 083 Bach/Ann and mm 1133a, This qualitative dintlnctim. W Rpm-ting the 138111158 substratu’to mtylchonnc, but a ratio of the activity mtylcholm mum-nu, an Wm (mu Wm - me). autumnal m the zonal as: consist: a; mm necholyl and haul- m nuns are found: In mch ntiol non-1 of 33:17 for lack/10h to sub/Ash. manor “pawn" amt-Suez- with a mi]. ‘ non-speciﬁc eaten“ emporium. In patients with hand .‘IZ chainsaw” activity. tram, I'm and kitchen report a sweat may, manu- mum. the county of mammmm eorrdnﬁm between ﬂu extent at tho th- dagm of Wu. tuna and usert. that. there in a definit- mend both with �r,_._W__,__.___._... Inpuumvith mmmmammuvmru: unatotopmmuiznm,hmr,mm1nthonuodobd139mm or total audits-Item activity“: round. Imrandlhmm (191:? g), in than study érudounbnl at tram, n- W‘mmmtmmtmmmw. 3m» &pm WW, zuwnzmmmnmmmgmmmmmw ﬁmw decram c‘Wmﬂthnmerulofth Wotan“, amr 3-? am Mupomd rm mtylchanm m..1? ratio at abolition-M7411 ﬁve pt tho :1: patient.“ Fro-than ohm» nmmwmmtmmtmwmmmmm nor: 1113 than. of crunooerehnl um than that: found in opium. kmtmmpmmmmmmmmmwum Momtmwaweamna ratio reversal,- fb-ymwﬂn ummmmtmnpcmntmaaamlymotmmumwm to want." W �mrmmyaahmmmu. Alia, fmmcwdmrmﬂ pungent m ot’l'mrmdgcﬁcehcémb), mtthctcguths fwdtoMspimlncid WWW thalamus tomcat-ant, penuts us to considor the yummy basic to the anaemia of the um:- that such hm 9:.th pmceu. Ghana‘s: .g. . ocmlusians Certain further deauctiom and agaafalectric m mmmgmmma mum. The pmscuce intcmnnhr ﬂuids Mean alcctmcn Maximum; The pen-- mduccaachangeinccn— ﬂax-activitywith‘anmmu when acetylcholina induce; to gradual pastime. tom: “trim ofﬁo mtylchaum inﬁll WW, nﬂwted in tb nudomeofhwanmmncmtelymﬂm �»;y- mmarmmwmmmwwrmamnuoqmmw an at new destruction. 31m. pm” IMO? Mutated tint lmonnnnmmmnmausaxnmumuypnhunmxuwintnhumnxmqmmnijhmbmahock thonpy, it my be stated that the absence a! {mo acetylchcnne pm- cludu chmgu 1n eczema]. {motion and thus pracludu n clinical aspen-e to electroshock. ‘hﬁhhnummmummsnybomwbrqpnnmgdumpainaﬂluuwmmepmb usability at! explaining the increald 1n Ghanaian-Ame activiw. I is round in highaat cannuntrttian in the central narvoun estemse Quintet-rue aystaum while n is pram in other games, especially blood serum. choline- With the increase in mtylchoum levels in the inter-cellular ﬂuid: as a result. of stimulation and convulsion, “sodium and increased cellular pemeability may bawm¢mum,muhacbgmouttnmmmmmaaatwumnurﬂmuh1Mmibuhﬂmm celluhr spaces dependent on the extent and duration of the ﬂuctuation, (but �r_"__. m,_m into tbs spin-1 fluid; and that thus the electrolytes increased, than siwmsnt increase in changes . mm in permsbmty of calls may ﬂms such u nusledc‘soid Splitting was s amps“. pmids the basis for the sppomncs of high concentrations of scstylchouns and for increase concentrations of Cholinutsrus II, (Tatar sad With the increase HcEschom 19h? in cholinss’oerssa activity, should not the free sooty. lchouns be rapidly destroysd? ﬂuid after trams a). To what melanin cam it's persistence and seizure be «embed? An explanation is available in the for this discrepancy observations 0: Hush-am and Rothsabsrg (191:5). continue! by Tower and Ks ﬁschsm (191396) and Burgaa and the Intosh (1955), tylchouas - shonnsstersse I system “humanips. At ”physiologic” extremely rapid (3-4.1 1vity in spinal is cmcsntrations, mdrolysis microseconds) but falls of! very ﬂuidly extremely sensitive to (Haldane at higher and lower of, ill-t the sea- montrstion acetylchonne is consentmtims, set.- tbs Cholinesusrass II cum). In contrast, acetylchonns uhtionship 1s non-specific, and the rats at hy€re1ysis incmsss with concentrsum. 0011 mums, insstarase this I, in the 11:53 acetyai‘shonm functional with nouns]. st. 1m_ls o: soatylsholins is dsstmysd by the specific. oMsr 0! milliseconds. Where wvity of chol- the excitaﬂea is such as to - �1nd. to an of “casein mm by concentration of sootyloholino in nervous tissue, the rots momma. ‘aooodoo. choline mounts, the ssisuro threshold dissociation in sootyloholino - unt vaaouur ad As is ruched the oonoontntion o: oootyiand c soisuro occurs. 1h. _ cholinostorsse I motionﬂzip vaults in s per- sistonoe of acetylcholine. rho «ism-o, In. acotylchouns. ‘ itself, perhaps adds to the Ian]. at inc'mmd mtylaholino airing.” rapidly. with result- 1'1» permeability connineffects and the appearance of increased names») mmoimnuooohomonom II. Itumoouvuyorwo onlym, though of lot sfﬂciomy, roduoos tho sootyicholins ~«mum of cholinostonso and 69th on concentration aworim, 1on1, InAhours to kinetics that - to levels for the plvsiologic I. Altontionintlnbloodbnin pewbmty humorbyths cantimingsutim omo observed in pout-electroshock oioctmooophnogrm. 1: evident in the mount apart no Aird 33 g (1956) Such s possibility- «annotating a significant increase in tho concentration or odd-inc in bmin tissuo 3-day: utter s ashes of 12 elects-om. an on. shows #olooulo, ordinarily obsent in brain tho clung. tism, in omcantntion of this mg. to b. con-eluted with the spposmoo �, w— _, N‘erm—. #179 WW ducal unu, however, the 1:: mt subjects. the ma 1tuntoa 311 com awumum of trout- «‘WW AM» 7 ms extent; miuuw to «- Despite a Maﬁa: nry may in the of high dogs-ea hypersymhmy, m: by Alerting, mule the duratiamdﬁ' hypnrvmtmum populating. me and wly appearance m persist-mo Wont the tmtamt cont-u, has been described In a neceﬁnry pu-requinita for imprwmmt following shook( nuke: Kuhn. 1956). Batman certain patients to dovdop 137”“an aholine Ind Manama: Assuming my be um mechanism Perhaps and gloom- of.macs-mug the failure them staring of acetyl- nﬁud. is. that a gnnd m1 leisure indicative of the developmnt of tissue 1min or free acetylchonm in mass at the I; hub- at. at hydrolysis by Mae-unl- that the electroencephalographic Wrenchrany in a reflection of tbs persistence of this almond. concentration of acatylcholineg than tho diffemnco in paint: who maintain hypermchrm and those in when it rapidly (tumour-O Ida] disappem, 15 a nﬂactim of the theta.“ of the wonmatemmcetyldmum hydrolysi- Byataa. Persistent. Mommy "cults non decreased "to of �rw‘“. a“ + V ‘. , “m---“vmw hydrolysis of acetylcholim. .Ismbmmmmmdm'oomct, dWrmorbothof the following postulates m opantin an patient: with persist-mt hyper”:— chm. 1) Western” spread batman the the tiam. opt“ ammunition, so that than in a great Imam.- substrate concentration and those present in with high gootylchaline) Ind/[Y 2) Gunmetal-nu m I~1a in 108 1113.1”, lo that the cmntntian kenotion a: this mm opemtim, thong) at a slow decay rate. Conversely, in patients with short ed lampemymhm, cholineatomaelandnintismandspimlﬂuidm Anthem, at” the appunnce of high oomentratiom of acetylcholine stuns!» the production or tissue cholinestemse I in the central Frau tho lucid studies of ”am-noun (195$), a stated in depnasive psych” induced mtylchonne my pncnorbid m1. (1 nervous system. dim rahtionahip batman cm— Mutton of tum cholinestcmse‘ I and level . /) luv-750.. of nervous nativity can be mmpnuul depression) , than the choc:4 . g.» alumni“ I to production a maul. Waters” amt. m �g; hmmmmmwmmumummm _atummuv1ty. Wuﬂaweiwtnmwmmmd WWNWPGW. Itilmww mmmxmmbymmmxx. rhpbhodpmmnotnb mrmcmwmohdmmumbéomuam matm.g.g.nntommzomm. hummus-Wm” mmumuimmsmwmmmducmx,n,mmm Mgmwmmsmuﬁamwmm tomato: Wumumdmmum. mmxnﬁmmaﬁw mtnuuummmmmamnumw;sssmnm �4t). awn-mwmm. the l «tutor cautnlnorvm ”Input Immuoimumm” 1, human tn: of our): and sustained ma levels of :cotylnhouno m Khan, the Wencﬂlhareaaidhrpndicumnm data Wmnohm and 910nm spinal ﬂuid mum to a slow 1nd of chainsaw” activiw. at peripheral “mat-.1431 w chained: neat: 1| thn hypotheti- roaming central nervous syntax nictivity to “rte elect—reducer. �thmmphmdem, 1) mammmamnmmmnud. It'snhuato 3) Whmdduudbwhmcuaoﬂurmmﬂmﬁxm ﬁn" memm—Wrww. «swim 1nd... W tht ‘3) a) shamans activity and patterns ethical norm all at up blame mm a m” a) ‘) 1’) at. of W at M “1 frequency at emu-mu (patina-1) mung; Momummy. mm 1 .7 �NEW» J? I i . , \J Danae ReleefAeetylchenne / bu]. ' E ”Km m Mm at i E Wvulsulﬂ 45% (”<— thenpyﬁdmtnted thet/ Gen-change in behevie 6 wee the development or slowing up he"? as f Wheat oheervetion W - we. index (Finkw and ﬁlm, mined unclear until the «out report! J’ the than; at Mention with high deeee of atropine s f1. E «‘1 E {E ""1? ijmtmg Week WWM”) ﬁcdw- View. describing "‘" hum-tomemﬁemmenw E)W” “M" “ W131- '7: the role of care- Wrelrequeite , ?:- Conan/.hve in the melanin o: WW0 E F amazes - 7'3""‘ early and persistent eight of altered cerebral Mention 2 E 15:7 umrmwwww22". 'W‘m~" "M" m-dbe’prevent the appeennce of the EEG delta abnormality (meet um John-on, name“) 1d; 1956). Following the mggomm at this report, we role/ Convu' | £09 of eeetylchame and cholineetereee in therepy. The data up]:- m E W ”‘35“: e m clue relationship ehetreeneephalogrephic S‘ounvxﬁ ities of free eeetylchonne 1n Wane ~> between the degree and persistence of the led the appeuenee of measurable quant- the eerebreepinel fluid as wall as an inn. vereim of the annual ratios of bensoycholmemlinemme to monomehenmetereee . W he role. of ecetylehenne 1n the bum tea! study since the Loud tnnuﬁdan first eﬂeﬁe—by m1. (1911:) and/(1921). the 3 description of We. W of nervous impel-ea he: as to whether gmmm "’ �lawmanaalyﬁgentmthomaiuionofmuwmmmmmt cf pm", man: here. It in mnmnt a normal constituent of nervous is liberated m it mm in n baund torn and tiuuo; that during the excitation process; that through the specific notion of that mtyldzonm 1: Minute” 11'. in rapidly hydrolysed aid as rapidly raconttitutod by tho Wtyhu‘ Bysm (Righter h mainland - new]. «3&0;me ﬂuid 191m) damn W W contain- no 1910).. in» mtylcholim (Tower and 1493116th mo rapid breakdown o: bound acetylcholine during periods of activiﬁy and excitement. cerebroapiml fluid manually has The chain-stance activity, principauy ”ohm hydrolysing typo (Warm and of the ducribed, eloobmemelﬁdlogma Effect. :3 crab fail to 'tm‘ or w condition- Wm Show Tram: W Bothenborg. 1915). In tbs shame of fmo «Mammalia- and under the (3.) Fummm, any conailtant abnormality. 506-) ﬁﬁMU Jeotad to varying degree: of had tram, Bomtainﬂﬁut abated that (I 4 In. �‘1'. acetylchmne uppeu'ed in the 08? within a _ few aw” minutee etterhtnme and Wm up“: Wﬂoeitiwhnktm persisted for verying periods up to he hams. hw_¢,_e./ ”MK“ at tame/:1 ﬁe quantity of tree W... W”-~Nu '{L versed heaven 2.? and 9.0 pm per cent, Mi 'Wgne 7__ ‘ , “MM . Wu} Mm amount-m. electroencepﬂlogrm 1111:1113, the Vracorde were mud filled with all patterned changes. high voltage recorded electrical fut Witty. 1n:1 short mm in immune. my!» mum F. - activity. mane periods then Inﬂated by prolonged perloﬁe a! high amplitude sharp the delta “V, z.- terpreted as an intense neuron-J. discharge; only to he followed by m “I. were 0.190 correlated with degree of tame, WW mtylcmhemthegmteetdegneotmmmntylmthe M seventy-M WM. as well all with the level of tree mtylcholine. with highest levels W MA. 5(- in containment-change- in greatef and '20 J gamma“-/' ‘ period of ﬂattening of Iﬁ‘J‘ eponteneoue of. name, poet~tremt1c eeimree/ 0/1/24. Wow furtmr substantiate these abstention, Bemetein applied ecet choline to the apoeed cat oerehrel cortex. acetylcholine use 1 gm When the concentration of per cent or lose, he observed high mutude �W“ sharp ms at low frequency castration m immune! to mum . m (£2, patimto therapy. gm pan-09111.; Eu mount "(19349 a.) :1me mpeutud was found Wham the can. the electmcaphalogm in a fashion pummel to the poototnmtic Tower and @ 2 in the electroencepmom. ”com. by}; WI W ”arm. thou studios in in up «rebroapiml ﬂuid only 13' '7 adtmm,moentgmm«1uuure3}nd’m that :m neotylchguna varied IMOA to .100 gm per ant. In ”1 addition. Inner and Mencken-n assayed the cholkutenu activity at the spinal “Maternal M (W ﬂatwf/ m. W W fluid. They noted a sharp rise in the mamaiﬂc oholinesterase (berm. Molina-splitting) .WW” with”. taunting thanpy._ Ho such inversion m dmmstrated 1n the fluids containing tree acatylohonm following Spontaneous seizures. than: authors oL ‘ do. concludcﬁt the m1 of tree acetyloholm varies directly with the degree of cerebral W P. .._ ‘ 3% dam; Mr, rover-:1 of tho ohalinenterue slum inﬂate:- nt con-bra dunno. adding, tau a, that the traction/tram non m �W -5- want-)Ww an m at (g m of those i P 5 tervala tanning MA mm, direct cox-“hum of the _of Em Mommy m appearance of true uoo‘ylgaolmo in the nnbmspzlml Tf (-l [I m. I' that. eminent-b211, traum- WM ﬂ” W/ m I 1" m?! mes-d a in- the ﬂuid. . min-11mm- ofﬂaoctyldmnno in tho Imus]. ﬂuid; and, that the” bemoan mum the dim: degree pthmtylcholiﬁ, aim wt at and type ()3) {“49— . ‘ varying 1 . lA~ mammognphic nbnomlity/ an!" clinical War. am Am g. mtg-swan at EEG and Behaiorz ﬁw‘x mu Mud- W u“ /w mama-d {munching at mam attests/Mb— . W j—h‘ “1.31m °£ 3th. 6‘“ W ”ﬁshnet-n1 a and neurolcgic {.1336 of W *h tum. trams. 4;; W ”1.574; Mn“ 2 “:86 awn/9 Men of 'mtncistorml acetylchoune, which induaod Em and clinical . W effect of utmpdm. closed head In 20 clung” 11:11:: to had Ward (1950) tum, Bgmatoin applied axons 1331117. 1m: 06 31.10414. _ Water! ibis—W to the trentmt of 0... human pttienuuith varying agree of iatarad atropine subcutaneously in dam o: 0.1 when In cues 9f m, , be achin- M can! �r WWWmmmm—W’mmww E aux. mmmmmmlmm'mmm rmml at tho electro- ,_ .W. . A E. enceprmlognphclc effects . W ~vm1Wv—wr E m. cholinergic drug, a! alterations in the report 31mm Inﬁm study of author anuJaguar and Loom (1955) 915::th We Ammumtmnmmhommammmmm E E «(At a_ 833”“me r A-..“ ‘ m . __V W tu: 9.11.4447 M W mudmmmnmgmzzmmmmmdwmmcmm of atropino in blocking the following the 010% and Johnna (1956) WW w W and I in m Wm of that wave activiw therapy. this study suggest; an biodmictl in head mm.- Mutated the smith“ ﬂat uﬁdeﬂ; th- chctmnoepkﬂommic \ I \\ E I ‘ _ manpoz'tstandaoutinconmsttothuennmngarlnﬁwhm_ ' \ pennants Brenner and Merritt. (19M), applying topical aoéﬁyldzoline 1n concentratiomctﬁtomitoWWcomdmu,Wmdfm i or intmenma atropin- (1 E E It is important to not. the r ‘ 1r E nag/lag) on hmr, oloctraomphnlom that the concentrations of “Mabel!” in thésa expemnta ma signiﬂmﬂy higher than the topim¥ upplioationl . r E . L E «hang». (1-1; game. S) and than intncistamn1(o.2 . - 10 N , Born.of gum)1njecti%a 1 .:/\_ .\ �mm Banner and (19115). ognphic affect: 01101130) and than tbs imu hunt, annu- to doryl hunter, m not. of 0100th :cetyuholina from mecholyl (nootylhetmthylo (Micheline), not: in mneontrations 193$).de concentration. mh 1m:- Thq ascribed the manned effect- at those abolinergic drug: to their lack of maitivity to cerebral mums. mm high «11 u n epileptic”, mm In (W, ﬂan at 913;, am. In author 1950; degrees a! abnomlity noted in mhtmmtie boom 339,, 1919; and Emma 23$.19So). m1 if present, ﬂu», mentor} The tho in: warn W by ‘ study, Ghntﬂald and aorta with prosuwm 39m activity. or 1075531; studios, too, the olectmneoﬂnlognphie effects .1111 date! exposed W «puma. npid fnquencykw similar, to status Dempsey (19152) and «oh-d pnpmd eloctmemoptnlomma prior aduiniatntim of ntropinn blocked this spiking, Ibnomlity could be 15leth by atropine. a variety of upexdmntul and clinical elude that eloctroenuphnlogmphic nativity induced by studiu, u- my con- uctyldmuno, nth»! �w .—-——\W- W.. 'WM as e result at Btu-Lug tram, topical application or interference with nee-all period! of aetiviﬁy, 3% free acetylcholhe in liberated W, mm, when it in rapidly Mum by 01103111081283”. {mu—ML WAammchmne 115M101: at ma We, hm. that the than the Th9 10701 mint, of remnant of the processes It may be postulated. therefore, m1 mm rise during aleep and run mmiﬂw. this methane is true and is at the cell That we: denountrehd by Richter and Cree-land (19h?) Swank and Render-eon (1950) in animal uporlmntn. m using liquid air quick-freezing methods, Edema: and Greenland denomtrated that. mm the anesthesia and sleep 1M1 at wetylehonne (manned ea per a. brain tissue) was 300% difference in ﬂame level: rate for acetyleholme in 21g f” (1950) Maw, “ _ Vﬂ ' *~-~r-—.._ (ﬁtter mtmole camﬂei brain is however, an the meynﬂxeeia high (7 W‘“ observation» The game/alum“). Elliott W‘mey H“ , 0,94» A noted that ”W «J'N'n‘ﬁ' a free mtylohnline was always demmatrabh WW”, x. is tme’imt, at 6611th these higher than the poet eeiaure level. in - �-7 w» mmmwmm_—-— '“ " ' - : qumm unmadﬂﬁdmmcmquptoBmwmt. m, In ’lpin-J. ﬂuid audio. in fear and Kahuna!!! (191:9 B) Illa Geno, Tan:- and He Enohem (191:8) and mmm woman!) in patients with opuspay. free (77%) mud lignuieant quantum: at Of 56 OpilOPtic W mammal.- rm miyloholine directly ranted to the momma to the last minute. W ‘in quantities of 0.02 to 5.0 at cultures, the extent It hon no mention to mansion, cm emulsion, orwhetharthe «nun, that. the 3pm ﬂuidisabyb mummammoamumd-s is prom-untied. Tm: and When: hem-ad mtylchoum liberation in not itself m‘mntod to the mic is buie to the scum process due mung ﬂu ”inure.” process, Torch (1953)/ induced» animals by metruole. She dctomined mm; type of epilepsy mm.“ line ot‘ I “ﬂammumymmmauzymm or the mo-ammm af-f;m abnormality, ml the mung»: of or lavai of choljnaatemne activiw. product of the M; J gum per cent, with In may at 1.0 gum per cent. 16791 ﬂuent“, tin level 01' (191:9- B) to up be. “ism § mm Won: 1:: mammalian in bran �Mam berm nadduring W Wm. mm¢me convulsions rise in mintymmum Mutant of tissue; that tho by a my» mum Mfﬂndudngﬂwcmnlﬁm3umﬂutbomcemm15,m whim failed to occur, )hrﬁzem/de a - \\\_~_,_.H_. than” K.’ as during u convulsion We»; H111» duo V‘; to inhibition at aoetylchenno mama; martial. argument” about. the MWWM’ZMMM choline the W Mum mﬁummum Inch 3: ram-m; ' mtylchaum; while sleep and W . mtautivity tum 1m].- nf and - 15min. WW magma: mem- mum 0.th mtylchoum produnﬁan abut-ration: of change: in mtylchonm, armor and of of W»! Gmtlnt War/wed...“ 03m. Mun 1m. W Mb... in clam ﬂuid Jan-L, dostmcum, lowering mowing J.» —_‘_..~... . ,‘_‘ manned concentration- at by tum, /" prob-Lb acatylohouna, but in m msm"ﬁot¢&nmumtthofmmmmw in mm poetuhud /,:v’ . ‘ whim: z” with When: (1916),..— min-1 fluid cholinemmu activity. are normally fwd 1n the spinal fluid: than Two W Minuteman-I �\ } 0m”, - ~apec1nc',§ or ity for wetylcholine; and hm mxéming)mm Bath W W Wyn for Mom and differential rite pend” qualitative distinction... cholirmstame activity a, memo. has a high cholimtarwo 'II (.“psaﬁdo', 'nm—apecitio,' or Mam-manning). dittemnt. rates a! madam—1 1 .éetymxoam, but Mandamus. By Thin ‘ ”porting the M ratio of the activity ”errand and prf W(mﬂ1M/Aah Wk”: bent. oylcholiué swam—ates to an aoetylcholim substrate, m_ meio- are round: WMw-‘C/WLW M osr contains antenna in an _ Thus, normal 68! consists ntio - /1,u?l’zjdua.2 mo)‘ In such 0133:17 for n“ non-specific ester-nae component. In institute with hand tram, Tour and Warn report ‘5 dwinzfTr W the dog-reset mmtyg ﬁzz-J2 65.x; tram and‘tho “Av-o: ”” mu it" ,g 3 nAsimﬂmt correlation batman the extent of the chalkenamc reversal “in with ' 1 WW a)”; M minly of imposing" octane“ with a . no I , the oWncomalogmphin 33 3 Jr”? �In patients with 130de mu ﬂuid hétylcholm activity a I result of Ipcntenoouc seizures, hammer, no change in the ratio of chol- inestemea or total cholineeternae activity an Wm Manx:- Tower and a their study of creaioocrehral (19w 3), in ‘:A six portede psychiatric phtienta mapping in: * ﬁle rm. W); W patients utter 3.7 troatmntc, theymported {1; m M decrease cholimntame, a “I. tram, re- therapy. ﬁtm- rm ioetylohonne act- a: cholinectemco with a revered of the 5 W We: W ratio of chcnneetoru? in five of the six patiente. Fro: tho/e oblont “time more (V they concludejthnt the apinﬂ. ﬂuid Wax: are- “Du—4 ' in lib those of cmniooemhrel tum than then found in opucpcy. haul-ding the one patient in the series who {tiled to show either 1“ﬁeyW“ tat "It {mnwetylcholim or a cholincaterace ntio reversal, 0 u mum-ting that this patient was the only om o: the six to chow no recponce to treatment .' �Ducunm m , but than variant obnomtiom, In my comma that therapy induces spinal ﬂuid changes mm otrmrandwchem (191:9 rum to maps»). ﬂuid b), ﬂu W 111m cerebral tram amt. that onlytho gamma, railed ta show a response to peanuts us to consider the pwnibmty that such biochemical “t, basic to the machinist o: the W at alas-uric current through brain ular activity with an .inemaae to inﬂuee a grand mal'acisun. in m. Thu tmtnant, We m process. cnmlusiom certain further deduction: and ‘ago than than. an mamas poasibla. the pun-- manna: a change in cell- mtylnhnuno to level: uranium. presence at! free :1lech in tho �enema—II in Mt in other tam, W blood anew man. With a. 1mm in acetylcholino levels in the inter-canning fluids an a result of . mum amm'umnmdtmundmmmmmmmm annular ms dupendantm ma ottoman duration or themuon, (mm. ngm)vltmwpmwmwmbmmsmmmmw 81:6.me in mm mom (19M. "s2. W» M. '53). Thu I!!! convulsion, 3111:9301 and modihﬁna and nomad annular pemahility my �throws mumm;mmtmbmehmmud, luxuriant mmmmmmumw-m splitting m. 4 mummramtydmmmmmﬁomtormtw _ wwmumamwmmwtermmmtma ﬂmmm ’n. (rmr w mm 1916 B). mammmincholmMmae activity. mummfmmwb 1mm replay be ﬂuid nth-r m doatroyud? and re whet We. ”ism I» «edited? :1: can . . it’- pal-datum in in amplmtim for this (1180mm ammuntheobumtmormmmmm.mm" tyrower and He Enchun (1919c) and Bax-gen me monoun- At ”physiologic“ mantmtione, m «2% (m rapid (3-15 dam) mtnﬂm. mm: but at. higher and fans acetylnhoum nation-hip 1: with (195$). thet the 33.6w sensitive - chonmteme-I cyst. is mtienehipe. 1v1ty he Intonh cm). Wu, mg. with hem-1 ne- to concentrationor. acetymhenne 1s Mr concentmtiona, set- In contrast. the [hasten-e411 and the mm rd: of hydrants 11mm levels of acetylohnnna et eettutyoreheaamteytheepune «name-nu, theseemohenne inseam-I, 1n the order or nimucom. . more 3% annotation W - �loaf» In main menu-luau or mwlaxolm in mm tissue, at hydrolysis Mascara-2‘1: by ehouneumtn, my As tha rah an mutation at acetyl- thaimnthrydzouu mammalian”. occurs. In. dissociation inpootylcboum - Ghanaian-a I whammy results in a par-- mm,1tu1f,par}upalddstothtlmlof unﬁt-#61:. with munnu mom-ea untmoeofaoetylchonne. nu ﬁtym. mm gym: pemmuw grim .W 1mm muesnmnummmmnmumﬂ.'1t1umauuwottua ant. vascular and 0mm, aid the or mummcm,mmmmnmmmmmt, ypuulbi uduoeathnm‘ylcholmm, action at ' mmudm,umrermmo1agu muons-I mm,muhasentumm,ubccomnmummw �all?» . ! I W dwwm{mubm)nmmmmm hmumnamwaotmmmmmmuu Wuhnecmﬂmdmmpnvmmmmtmmm due” mu, )2pr m, extent) its in lost abducts. Ila-pelt. n m up at uppunnoa mum: m vuy greatly in of mg: dogma WW. nut.- daumua: m 2171 to modiﬁcation by ﬂex-ting, ituntosa- has bean W applicatiu: of b mmmﬁan and hub-- w psyuhntzic popﬁhtion. me and 1t! any appearance courts, trait“: Want yum the 63mm u n uncanny pn-mquuiu for Mt following 01.0m— m( ampmumwmm'z Pcmmiomudwm. M&Km,1956). ButmtutbcmhmiumucﬂnngtheMnno! dialing and Mentor-Ion m be nut-d. Assuming that a grand Ill is. seizure indicative of the MW of tism le'nlloffmo mmmnm-«mnudwwwmm-I/ ’md ehctmphdognmc hyperqnchmil a reflection at u: um. the per-31m of thin abnoml commutation a! Micheline; than the difference upmummnmmmmmmmman W(Mhouni Wm, 13 a nﬂactian of tho mm m W «we. d tho dammsuwtymm Persimt types-3mm units m- M nt- of �.vp—v—vW—yw—qw—nw « W ‘13mzmmmmmmm.dummorwd WWW. of ! ﬁn {ma-mg postulates are opontiiu k £3 menu with pom-tons E chm; l E W . Westerns-i 18 in low cWﬁﬁ;u tint 12W in a great 1) . spread tho hm tho amigo]. mum- aubatmh Mutation and at Wanna-II 131m. no that tho concentration 135mm. of chum on oporatiw, [and hi. W1: a lion docq nu. Camel-loin in patients with short hypersy'mhm, Whoomrnae-I and-II in tissue mm and spinal a. ”7 fluid am we produotion of tissua cholimsteaé-a-ao-I 1n the oentml nervous syntax. W mm WW ame-I my“ aim-rm tho lucid studio! o: (1955’), mutation of Mam? cholimateroao-J ﬂ ‘ 35 4‘— high. \Purmemon, the appeal-once or nigh concentration of acetyldxouno am in I new with high mummy 2) and those pmsent and a direct mum}: between on» level of aetiuty can deMa’o be ‘ do... 91»th 1M Manon» my stunts chainsaw-1 pmduotion to o m zoom. stated 1:: Massive psycho-3 (fungus-.1 60pm). than tho Wu! mu. Eﬁofji 1 �‘ .53.- In moth-r cutout, those studies of outcome reactivity. “Eadie: _ In have opplioation imp-W by to the woman Watch an! other: havo damn-tram a mhtiomhip between the blood pressure reopen-o of patients to inject“! mohohl and ahock. Namely]. Ward“, is ﬂair mama). naponaivity to alcoho- a potent oholinugio agent which induces sweating; and vuadﬂation, momod peristalsis. It is rapidly cholimutoma-I and slowly by cholinostam-ﬂ. Tho W 15'de w pressure of sub- mu an: arm- mused menoml and Muml to the baguun. 1n n variablo length of tin, 3.3. the to natal-unto ' 20.119112“. more than Patients whoa- blood pressure “mummswmmomieduaroupl, II, QMIII no notions; those whose blood pressure “has 20 or more 11mm to rotum to o MWImotonhwooﬁm WM M”! mt ntouitthdthonupII-vmructomaﬁimute. hmmmmnmtonmoMmmmwpﬂIn9ﬁmmxy buoﬂmueroupvlmdmmcum. , g" Wilt-v rats. (momma at, 1952.) ' hmmmzummuummupumumm-mmA Wmédmlylio a lion npiﬂyhydmlyudy than the W81. nu. V. may Gmumm potiontahan m» predict. Hanson, that tho tholinoutenu ‘ uuuwmnmdwxammuldbohighyuhuoﬂmmuvﬁy \va x �a. dwnamwum. Homnhnrcaamrpnmnm mmurwmmmmdemM4,mumuu mammmmwmmmnmmmm mammmmﬁarhmammmmmum mmaudpwmmwmmmumpmu mwnmmuammmmuwumm. �Wmmamnﬁanummotmm-oraammmm W emmwmuummamyummtmwmm l quire #11: veriﬂmtim. 1mm For this purpose mutionahipo ho WM Wash-at 1) it in anaemia. ' murmumaammmmmnm. typo, OllQWﬂogrlI patterns. m and magnum at suggest-d that an mam. 1‘4an A1», the “mum 2)Rohumdmchmty1choumuvohtothomnicalmd patina“. 3) mung» 1:: indie” or mama brain nmcuon othorthnn mama: such mtylrhmao 10701:. h) mums; of cholinoatenae actimy and patterns or blood spinal ﬂuid to: 41)le b) We!“ a) ram otdwoloznant of 3m , d) amber and frequency of tmtnentl a) antennae (perimnl) mativity f) 60mm]. meti‘rityo 14 .& 7’ 5. Wm n... WWWM? éIJMW~ 4* , um and �111: 7-3-6A (I: on rue ROLE or AcsrrtCHOLrue ' ' 'vh .d) AND CHOLINESTERASE 'IN'OONVULSIVE THERAPY -« IStudies evaluating the role of cerebral changes in the mechanism of cenvulsive therapy have demonstrsted that the develogpent of early and persistent signs of altered cerebral. function are prerequisite to changes in behavior (Pink and » t A ~A. . at ': n . ' .c. ‘ I: ‘c .' V A s ', <:-~t ‘ Kahn,‘l956), In these studies, electroencephalographic slowing was the nest significant.index This ohzrvation remained un-v clear until the reports of Ulett describing the effects of pre- medication with high doses of appearance in the atropine preventing of the EEG delta abnonnslity (Ulett and Johnson, 1956). Following reniewed the suggestion of the we report. role dt acetylthis cholinestersse in-‘convulsiva' therapy. ‘he data suggests a close relationship between the degree and persis of the electroencephalographic slowing end the appea ence of and choline measurable quantities of free acetylchnline in theygnrebrnspinal / influid as well as an inVersian of the aerial ratios of benenycholine. . 'cholinesterase to lecholylcholinesterase. that: The role of acetylcholine in transmission of nervous the impulses has been studied since the first descriptions of Dale (1915) ..snd Loewi (1921). The srgunenta as to whether actylcholine' is the main or only agent in the trans-ﬁssion of the nervous, impulse are not of primary concern here. .It is sufficient that acetylcholine is a normal constituent of nervous tissue; that it exists in a bound torn and is liberated during the excitation is that process; it rapidly hydrolyzed through the specific'action~ - A ‘ " . A .1 F .v «an ‘ -< _- : .V. l antes-.3 var-I‘m.- ,, . “be”: wMYJ/I'" 44:: gauges-5mm �. .1 of cholineeteraae and as rapidly reconstituted by the choline- I ' acetylaee system (Richter &.Crossland, 1969). Furthermore, normal cerebrospinal fluid containe _ free acetylcholine despite the rapid breakdown of (Tower and HcEechern, l9b9a) bound no acetylcholine during periods of activity and excitement. 'The cerebrospinal fluid normally has measureeble cholin- esterase activity, principally of the "true" or mecholyl ’ hydrolyzin3 type (Nachmeneon and Rothenberg, 1965); ' In the absence of free acetylcholine and under the conditions described, electroencephalograme_fail to consistent show any ‘ I abnormality; .. ‘ i (a) Effect of gregiggerghggl . 3 Exagggz .1n n study of cats subjected to varying degrees of head trauma, Borenetein (1946) reported that free ecetyltholine appeared in the CSF within a few udnutes after experimental head trauma and persisted for varying houret acetylcholine quantity of periods up to £8 free _The varied between 2.7 and.9.0 gamma percent, and-the amount weeV poeitively related to degree of trauma...‘ Conconntant electroencephalo3raes demonatrated patterned chan3ee. Initially, the records were high , filled with n fast activity, interpreted as voltage intenee neuronal discharge; only to be followed by a short period of flattenin3 of ell recorded dectrical activity. These periods were then followed by prolonged periods of. hi3h amplitude sharp waves in the delta frequencies. The . behavioral chan3es were also correlated with degree of trauma, as well as with the level of tree acetylcholine, with ,higheet levels of-acetylcholine. Bernstein reported the greatest _‘-_... �_, ‘ 1 , _ ,. .3 w. a yawn-mun?” lift!“ .1»? . .. my vmr in?! 0...“, yr,“ y». my -1,“ 'V'W'FM' cream-ls“. . _ . .~ > I -3degree of m abhor-slit” the greatest. and thence; in consumes ' furthermre. spontaneous post-Ftrat-oticseisures livers also related to the of tree aco'tylcholino- appearing iii the apical fluid. 1 “t l..,‘_.‘.__.. l... V A t ‘ ’ further substation ,theae‘ohsarvations, Bonstsin applied .acetylcholine to the eiposed cat cerebral cortex.' "h. the concentration of sutylcholine use percent or less. he To , ‘ . . ' EI - . line ‘ observed high amlituda sharp waves of low froqmncy in tho electroencephalogram. When/the concentration ‘ves increased to 2 3—: perceot,’ the electroencephalogr- flattened in. afashion parallel l to the post-trematic records. ‘ . Tower and HcIIchem(l9lo9a)'-Iropa_ated neurological pstients. thssa studies in Irse acotylcholins ass 112 foond in the cerebrospinal fluid only in the patients with. rocoot hood trams, ~recent grand-ml seizures or convulsive therapy.- The free acetylcholine varied from 0.2 to lOO' 3‘s perceot. lnladdition, Tower end lichchern assayed the cholinesterasa activity of the spinal fluid; They noted ashsrp rite in the “nonspecific cholinesters'se ‘ fraction '(hensc'ﬁiholine-splittiog) and a drug in the specific choliioesterasefractiou (escholyl-splittioc); in the patients ‘ with head trams and those'follwiu in Mlsive thereby. no ~ - such inversion was ’d-oustrstod it: the fluids containing tree acetylcholins fondling spontuooos soisores; These authors concluded that the level of tree acetyleholino varies directly} the degree of cerebral dance; «nesting, haever. that with. the reversal of the oholinostersse' frantic: cos ‘a sore sensitive indicator ot-esrshral donate-V ,' I. ' _ ' ’ �7-1-2 intorvalo following varying at cm in loot of theoe anhjeeto. .‘lhe nthore reported a direct Electroencephalocrnooere trano - m and the appearnce of the of ahnorn'lity degree correlation oerobroopinal fluid. in the of free acetylcholine _ two Theoe ' increeoe the etudiea indicate. that crnioeerehral tron-a nay nomt of free acetylcholino in the opinal fluid; ’wt of froo that a direct relation eniota between tho acetylcholine, the degree and type of eioctroondphalouraphic and abnormality. and changeo in clinical behavior. ' Bornotein adainiot'ered O.5-l.0 tog/its atropine after hood traumawae tho induced anddennatrated blocking of mifeot no effecto. Following the experitrana.~ induced intreciotornal which ecotyldlouno. addition of jof and neurologi'c eigno behavioral nntal 2 clinical change. oililar to head trouno.'lornatoinohoerved 1 blocking effect or atropino. zoo and , Vardf1950) applied theoe idoaa to tho treatnont caeeo. .. of hulah ' of closed head injury. .In 20 patiento with varying degree of trau'oa.‘ he adminioterod atropine outmoly dooea of in 0.1 tog/kg. In one eaoao'henot'ed'clini'éel ignorant. and in tho of electroencephalographic of the 1 othero, revoroal effocto am: ntioholinargic of 'otndy a another dm. tragna. In Lechnar (1955) reported oinificant altoretiona in the poet- and » tranatic electroencephalogrn. inota‘nceo ' in 22 of A. oingle iatrovonooo dooe in abnornal electroenoeph'aloorno reoulted in inatoncea and unto-a iaprovooont 1. eix othoro. ‘ 1.0 nor-dieing ! o , �. 3 Iv. . . p 5 u ' .. ' ‘ , . V“ U - 'F ‘ ‘ ' r ‘‘ Ulctt and Johnson (1956) donoootntd tho I... ’oﬂoct'ot Antroptno 1n blocung tho oppnronco of no: 111601” couwlo1n. oct1v1ty vi. than". an' mood: tho study oouuto tho that 0.- Motbdcal .chauo. oloctMuphoch on... 13 hood ; m... cod 1: ,.- i . “owl-1o...1:: oootrut t6 thou 11.11:. In an: out undo noon 0. mod-onto Broom: .d Hordtt _(1m).__m1y1og top1c‘11'ocoty1f161111.11 ,' - 1 ’ thou. of tom! 1o concoctrouooo o1-2-1l2 «to; noted no offoct of clocttooocoohologuohu that tho mtntw. no “unfunny atom an... 11: to tho otrop1. of oootylohou. 1o than tho tinted lad-or tho .rooot) ,m :5 ~ ' I m2. W at onoophalogtophic otfocto won Modal by . ‘_- A #ﬁ.1w-_ ‘ moot“. . -V . in ﬁ...___‘..-% 1.,mr-4gmv4._.ﬂ 41V W to 6.1;.an about:- ‘Wq 1950) 11.. 1950).. Inothou 3 . 1 «duty of 1.011qu nth choumtoruo' 1nh1b1tor on (614.9:ny (Imam-photo) Mutton 1113b qutodo 1‘.“ (Money pot... “-11“ to out. 1n opuoptmoo. u -11 u 1.3.: «lop-o. of no.6 .' 1969; and v _ tho potont post-truth: . _' . ototuﬂlltnttcmuot 11., - on tho h w ‘ motion. to. thutlod o1 logo1t1v1ty A . _ . tut1oom1hoyucﬂbold01Wdfott1Mﬂthou- at"... ‘ 1"...“ § (mutants). I _. '34; (oatylutuothylcho1bl a“ by: -chol'yl 111 commutati.oh 1.» ti.” on. .otylobu. concou“ch ennui-31c. drugs to w...h- hM-—mbvwmmr wWe... am (OJ-IQ ‘ A quuuuu'u (1-1 3-1 oloctroooooohologrqluc oflocto 011111: to 4 ﬁlls) to ooto. '- ‘ (1 1-..... earth: Mt tho. Wu 1; atria-tuna 'o’z Wain (1946). mm: .11 smut. potent) at] ow w. m new”. at .1... too, tho “cotto- 0.11 dam of otrop1oo. �- 6.In another_laboretpry study, Chetfleld and Dempsey (1942) 'ptepered exposed animal cortex with proatlgnlne and evoked electroedcephalographic spike actlvlty. The prier.edu1nlstratlon of V . _ ‘ 'atroplne blqcked’thls spiking, er if present, the abnormality could be elimlnated-by ettopineuv Thus. from a _ variety of experimental end cllnlcnl studles; __ we A may conclude that.eletttoencephaldgtaphic aetlvlty_1nduced by ‘ acetylchallne. either as a result of trauma, topical applleation qr [ntefitxcnce with cerebral metabolism, can be blocked gr ellmﬁnated 5y atrnpxne (a) ‘Role of Cerebtnaplnal Fluid W...‘ " Acetyicholtne normally appears to be present-1n nervbus tissue in bound. inactive farm. 'chollne 15 activated thus the During periods of liberated at the cell by Ac cholinesterese. activity, free acetyl- membrane, where The it is rapidly de- level of-bqund acetylchcllne ls resultant of the processes of sinthesis. liberation breekdpunw It may be and postulated, therefore, that-the level wlll rise during sleep and fall daring ectlvity. ‘That this hypothesis '15 true was demonstrated by thhtet and Crosslend (19a9) and Elllatt. Swank-and Henderson (1950) in anlmal experiments. By using ltquld-alr‘qule-freezlug methods. Rlcﬁter_and‘Croaslapd demonstteted that the anesthesia and sleep level of acetylchollne {measuted as microgtemﬁe per mg: brain tiesue) was JCCZ higher- poet thaﬁ the seizure level“ ‘The d1£fetence_1n tissee levels is trapslent. however. as the tesyntheels rete for acetylchollhe 1p rat brain is high (7 gimme/gm/mlnute). lﬁlllett‘et a1. (19$0l; a �- 7 _ AIter metrezole convulsions, confirmed these observations [they also noted that free acetyl~ was choline ttatione always demonstrable in the spinal fluid in concen. up to 3 V . l genus per cent.> ln spinsl.£luid studies in and and Tower (1948) Cone, Tower and Menschern men, Mcéechern.(l949h)-slso denonstrsted significsnt of free eoetylcholine in pstients with quantititCe 56 enileptic patients. 49 epilepsyl"0f (77X)'demonstrsted’messursble free acetyl— chuline in Quantities of 0;02'to 5;O genus oer cent. with an average per.cent. lhe acetylcholine level was directly reletedl extent eelzures; of electraencephslogrephic the to the frequency of ebnormslity..snd the telation.of the time of coupling to the last of.l.0 gamma seizure. It hare no relation'to indication, type of epilepsy or“ .Ievel of cholinestetese sctivity.ll ' . , Whether the acetylcholine appesttng in the ~ '. A 3 g. spinal fluid is a by-broduct of the convulsion, or whether the incress} in acetyl- I]choline is'n cause of the seisure, is problematitel. McEachern (l949b) Tower and believe that the increased scetylcholine libetstion' ls not due to the seizure itself but related to the basic procees' causing the seizure; In a s“dy of the hypothesih that the accumulation of scetylcholine is basic to the seizure process, Terds'(1§53) induced Canvaeions'in animals by nettezoles She_determined the level of scetylcholine in brsin tissue before and during convulsions. .She noted that convulsions ere preceded by s " rise in the scetylcholine content of tissue; that the coucanc‘grueuaiiy fells'durins the convulsion; and that below certain levels, convulsions failed to ‘occur.v She suggesteﬂ that the fell in tissue scetylcholine during convulsion use due to inhibition of see.tyleholine synthesis by concentrstious of metabolites such so smunnium ions. increased a ' �While ebout erguneut the role of acetylthere.ls considerable choline in the mechanism of seizures. it is probable the: free acetylcholine ie increased during seizure. and appears in the cerebral spinal fluid; that activity and eeizures enhance acetylcholine destruction; lowering tissue level. of acetylcholine;‘ WW while sleep and enestheeie.eugmeot acetylcholine production, . increasing tissoe levels. 7 l. . rd) Concomitant with their observations of changes in acetycﬁbline. Toqer and Mczechern (1949) oeaeured spinal fluid cholineetereee activity. ‘rwb types of cholinii lesteresea are normally found in too ebinel fluid: .cholioeeteraee-I ("c-me". "specific" or-necholy'l hydrolyzinﬁ), which has a high: ' nod specificity far eeetylcholioe; cholineeterdIo-II ("peeudo"." epecific". or beozoylcholine-hydrolyzine). -Both coupounds hydrolyze' - ‘ ecetylchollne, but have different rates of hydrolyeie ftr mecholyl "and beoZOylcholine. -Thioldifferehtiel rate permit! duelitetive' distinctionse of the .By repertins the cholioeetereoe ectivityJee e ratio. activity with uncholyl and benroylcholine substrates to on retidio ere found: cholinesterene-l/ choline-tereue-II[acetylchbline.(with Ash/Ash - 100). acetylcholioe substrate, acetylcholine and ln-such ratios normal CS? two contain: eatereeee in the ratio of 33:17 ‘ior choliuentereee-I to cholioeetereee-II. Thus; noruel CS? consistedllllllli with of "epe¢i£ic” utterance a euell non~apecific eetereoe component. mainly ' i In patients udth heed tron-I. Toner end Holechern reportm m inverting of the eniupte of dbollniptirg‘le with d lignIIiCInt meg. mime unionist-nan meme decreaue in choline-cerebe-I ectivity.- betweenthe current or the cltolihbotereee of mm fluid and e They eleogreQOrted a Mﬂel correlation with the severity �of cm... W the of electroencepheloirmhic and with the degree I II I abnormality; '- . ,I" In patients with increeeed result of spanteneoue eeieurne. of. 1 e 395-1221: r" , eoihel'tluid ,ecetylchoiine howewet. no cerebral ad Tower tum, ee e thmge'ingthe ratio. cholineste'raseslor total" cholineetereee ectivity‘ w _ wee found. nonethern (194090. in their etudy of crazie- reported obeervetione in eix peythietrit petiente undergoing convulsive there", \Studyiegthe patients otter 3-? treatments; they. reported tree ecetylcholtne activity in the Iepinel fluid in two petiente; end en increeee in cholineetereee-II and e decreeee' in aoli‘neeteree'e-I with e revel-eel of the retio of cholineetereeee in five 6! the eie petiente. In: the,” Nobeervetione, they - like thoee of ctmiooen‘hrel tron-e epilepe'y. petient in the Veeriee who foiled to ehow. free eoetyltholine or e cholineetereee retio either Mani-in _ Regarding the one the eoihel fluid. they Petient wee wtou:_"1t.ieinteteetlnsthet thie no" one-of. theeie tee-me. to only. to a... the tree'tneut". .. . I 1 ' I DISCU§§ION . Fran theee verioue met-yetioneQwe hey contlode thet canvuleive therepy iodueee epiunl fluid like cerebrel sore ehmgee emtw thn than of maintained. we chpredtet trans” , epilehey. If the perhllel ie‘ ot the degree ehhtitn new electroencephalogrmhic ebnouelity, the acetylcholine, end e— , thaaee the thetfluid epinel in cootlmd induced céwuleione were sure thihkthoee found in . “arena of free revered of cholineetereee ectivity retioe �-.10 _ the splnal field and the nunber and frequency of lnduced cone vtlslons., Also, item the observntlans of Tower end McEachern 1n (1949b), the cemment thst ohly the patient who failed to shew. -§pinal fluid changes-talled'to show a response to treatment, ptrmits us tu consider the possibility that such biochemical bas1c therapy of the the chmges are to ccnvulelve medical“ process. cpnClualonsiare pnsslhls'. ad The hasssge of electric current: through breln sw‘stencesilnduces in change sctlvlcy with an increase 121 free a deductions Certain further mm“ . acetyl-. choline to levela'suffictenti‘to1nduce a grand nsl seizure. The . presence of ' ' free acetylchollne 1n the intercellulsr fluids electrical hyperaynchronyr‘renscted lathe .386 as delta? slwlng-r The degree of hyperaynchrow sc'mrate-ly reflect} the, decay acetylchollne of should fonds! free a ad rate equal level S1nce studiesthe purines of deatrhctlon. acetylchollne rate to demonstrated. that EEG hypersﬁchtony use: a, necessary ﬁrvrequlsite induces. ' . ' ' to the cllnlcsl respome 1n central‘slvsthﬁapy. it my be stated .mu'mm chances that the dunes of free aestylchollne in cerebral fulcrum ad thus prilud'es s clinical rem the 1ndueed convulsions. tn Certain eat-muons nay be ends regardles changes In cell embrace permeability as emlal’nlng the incresse in theme-:- .estetasd activity; Chollnesterase-l ls feud m htgheat concen- ' tratlran . 15 ~- 1n the centre} nervms system; predominant in other tlesues. especihlly the increase in eoetylchollne ‘ anus chounfcsmrsse-II Innis blid serum With 1h the 1ntercel§lulsr cerebral fluids as a result of stlmletlon and cmwlslhn, vasodilation and increased cellular permshillty be Pradicted’;’ my ' D E .MLr-JM: 4‘ . ‘ . M. -. . t a ‘- . �~11} thﬁ inch:vasculdglfluids'tnto with a degree of ggancudatian of dnrittan of thg'. and ch. on dlpcndcnt spaces nxtcnt cellulnr vnddtlptlio-n _do occur numétous wag (um 0:11., 19m, anpiy.dcnonstrstcd ‘Ihnt ouch ”manna chm ' SﬁlejiIFAdolf 8910331 1n and by répofti (1961; '62, 'bb,"£§;.'53)é - . . denunstrat§d They cdnductivity cbhvulsldnn e1.c:r1c.11y_iuaucgd tacguased.che that Idikqgo pot-saint as ﬁargous of ions. 1n n cf the clouue; resultud thh lldid§ el§ctgolyths the while phbiphatQ, that and ipingl into and nan-cltcirolytés nngsnittcant 1n .tncraalcd. incrpaso 1h Gunﬁght prﬁibiliﬁy nucleic-acid abutting 'enzyus. of £011; may'thtu prﬁvida thé basil for-thudappoarahco of high ‘w-u 'contgntrati§u§ of a¢§tylch611ns and for lqcrcnand cancantgattons' of cholineaterasefll (Tower 1nd1HcBIéhern.19b9c)." _ . within. 1n;glil%;1n‘ch011héytct‘ne‘acglgitz; free act-tylﬁtoiiné _rnp1d1y> b0 dutioyoih? T.“ wit ohoﬁﬂd not tﬂe $phdnsn can ind uéttbed? agitate-ht. sbtml' fluid. arm: ugh; m panache-e. in. 1‘ qbuertitiann. EB. thin‘diactcpcdcf nvnillbla in An éxplanattqn.for ' Sy :kuurgxl (19.005). Nachuntoh of Mun-ad and__loth¢nber3 . McEdchcm (1969c) .ind poison and HuprtoIh (1955),.{thaf the acetylcholinc-cholthél'brabe-I'uyatﬁu is vary aanptttvi~co:¢on¢aq4 itdtibn relpttonshlpq; At "physiqlogic" éoncentrdtlons, hydtolysis , - and, buc'd: 1i higher of ncntylcholigi tdpid‘(3—6’nucranecoudn) qu1c¥1§itiL}dqno off cutv,). activity £111: lower cqngcptrgtionl. rtiatiénﬁhip to chbltneutaraac-Il-acutylchollno In conraac. the rafd with egocenttaiian. hydrolyita-tncfgases of the and non-specific. i . 'um. nor-.1 um. {mama mu- n: «manna. a cell ' Qéttvity' chi geocylchbltnn ipqctftc by thidgntioﬁjd npnbr-neny tho f ;_1 ‘jt �.i. V-“ wry...” m.“ r'rr'l r . v: _, r“'\7ﬁ"x.:r'7m¢rm., _ ’0"; 3 Of cholineaterase4l ithhe order of niliiseconds. . _Where - . . 'l excitation 3 A a , lead% to an'excesaive‘concentration of acetylcholine in nervous tissua the :nté othydtnlysia I by cholinesterase-I is F 4A A 'A’Q": exec-eded. thu con:enrration of acetylcholine mounts, the seizure threshold is reached and a seirure cccurs. The dissociation in ncetyichoiine- A3 m}! 1 “+4—ow cholinestern5u—Z zclationahip chnlinn The neiznrej liree acetylcholineul itself, The results in a perniatcnce of acetyl— pernapa adds to the level of “gt“..i. increased acetylcholine diffuses rapidly,» with resultant vascular-and cellular_permeability effects and the iPPEﬁvahcé cf inzréaaed ions in CéF; ﬁnd also etficiencf, increased cholin- r LAM; astsrawemii. 4 Aﬂnmnmm. It 15 the activity of this enzyme}.th0ugh'cf lqw- 3 and dependent on concentration kinetics that rdduceﬁ’ the acetylcholine leval;yaperiod I . j ' , of houra to days. tb levels - .__\._-xw-:‘.mz...' for the p‘Eaiologic action of cholinesterase-I 1“ Alteratian in the blood brain permeability barrier by the f ~continuing action of acety-lchoiin e may be the biochemical aub'5trntc {or the hvpcrsynchrony so often obServed in past~electro~ «nu—“\me'mut maﬁw—«A .hnck-electraencephalogramst Such a possibility is evident in the' I 'i ' ' report by.Aird et all (1956) demondtrating a significant increasn in the concentration of cocaine in brain tissue 3 days after a' 'seriea'of 12 induced convulsions. ‘ g of concentration tiisued to he His data about the change in i, . 1M . ' - ' In ..—.u..‘,~«.r.n.v.— 9-1.4.L — .1. “F... thi a large molecule, ordinarily absent in brain torrelatcd with the appearance of bypersynchrony ’ I (delta.bursta) in the elecnroencapnalogran. In our studiea of thc appearanca cf clactroencepnalographic he, have confirmed tire many changes with acmvulaimi .previous reports tnat convulsive thctapy induces hyparsynchrony in most subjectst Despite a constant application of treatments, ‘ a �«.13-‘ electro- however. the time-of'appeatancé. duration and extent of the graphic slow ' 1' A . 'ventiiation it; its sensitivity barbiturates - all QAV$f and populations. and - The to wodification by aierting,'hypervary greatly in psychiatric appearance degree of hypersynchrony, high early beeﬁ has the course; tieatmeﬁt persistencv throughoﬁt described as a necessagy prerequisite for improvement following Electroshock(Pink and Kahﬁ..1956). But what is thé~mec§anism" "undcrlying the failure of certain patients_to deielcb hyperaynahrony?_ Perhaps-thgse studies of aceryléhollne and cholinEstﬁraﬁes may be rélated. ‘Assumiug that a grand mal seizure is indicative of the at‘ttssue levels 9f free acetylchnline In eicess of "' ﬁhu fate of ﬁydzoiysis by cholinesterase~I;-and_thét the electroencephalographiC.hypatéyuchrony.13 a reflection of the'peraiatenCe, development ' of this.abncrmél concentration of acetylcholihe; than the differencé 1h pugzehts who maintain.hyperaynchrony"ind those lh'vhom it ‘rnpidly (fgv hears) disappears. is a reflection 0f the kinetics of the ch01tngsterase-acegylnhollne h§dtofysis systeﬁg Persistént.. hypersynchrbnj Insult; from dccteiqéd rate of hydrdlyeﬁs of ’cboline.v ¢ ‘arahstn-nﬂ acttyl- ,. _If the hypothclla~prevtouely'deducgd are cattact; nithér-ane» ‘ . . V ' . , f u-ww-xa..yrmwméw.w}v-JH‘ or both bf the felLowlng postﬁlateg‘are operative in patients with 99 tslsteﬁnt hypersy nebr‘ony: (1) is a ‘ . Chaitaeﬁteraseél is in low great.spread betweén the apt! thosé preéent '_and 1n cancentratton, an that théte' trace concentration the ttésue with high acctyicﬁolxne;vandlor' '(2) Chalinesregage-Ii is a1 enzym¢~aub low, so that the concentration Ltwetzks cf chis‘system are opcratxve, though at a slow decay .. .13...- ...,.__..J rate“ �‘ _ fonversoiy. :u patientc with short-lived hyper:yuchruny. Cholin- cetetaee-I and -II in tissue and spinal fiuid may be unusually - Furthermore, the‘appeatﬁnce at high concentrations of acetyl-~ Ichcline stimulates the production of tissue chclinesterdse-i in the(antral nerVDus.system.- From the lucid studies of Nechmanaon (1955). a direct relatzonship bétwéen concentration of“tiesue cholin-- estethee~1 and level of nervous activity can be deduced. It 109' ievels of cholinestereaeél can be dull- demonstrated in depressive 'psythoseé (? menonaueal deptession), then the electrcshock_induced _acetylcholine may stimulate cholineetetaee-I production to a mare normal. pre~morbid leverm , cantext, these studies 1n_enqrher problem of autonomic reactivity. may have application to the. ‘Rncent qtndies by Funkenltein and others have demonstrated a relationship between the blood presents of patients .respbhsefto injected mecholyl and their event-n1 reopensiyity to ' :i' ” ' - 'Hecholyl which a induces“ cholinetgic potent is agent electsaShack. ' “ ~2i: tachycatdia, ic?‘ perietaISist sweating. incteaeed and vagadilation. chnlin~e hy hydraitzed cholinestetaseél and slowly by ls rapidly estetaee—II. 5;.. atter injected fails vatinb'le length of time, blood pressure of subjects return. to the baseline in a five to more than 20ninutee. Patients rthalyi i The and presiﬁre'l whose blood 5 the minutes are classified as Group I. baseline in to returns those whose blood pressure takes 20 or more '21! ':an reactions; minutes II to return to‘a baselineg‘es Group The Gtoup 1 reactors have a 92 improvement ' VI and VII reactions. 'IlllI-I-I - rate with canvuisive {1- - H; i ~ therapy. and the Group II, II-III reectorl : 352 rueovery rate In a i contrast, the Gto up VI reactors have a 892 and the Group US;da~9§1~agent-uzeaauuzyq:ate.£runktntto&n-otqe3~y¥$953-- I ; 1 �“ VII a 97! recovery as patients in 2W4"??-:'£€i§:?fjw*ja 15 _ Groupu_ I to may llI may be looked ubon the injedted mecholyl is hydrolyzed; rapidly while the Group V! and VII patients have We a slow hydrolysis rate. predict, therefore, that the blood cholinestereee ectivlty.-' levels of Grouce l-III would be high; while the activity of Groups Vl-Vll would be low we recall here a similar prediction cholinthe date central for of nervous levels item Iy regarding esterese~l, in which the develovuent df early and sustained EEG hypersyhchrony and elevated epinel fluid levels of acetylchdline related to low level of cholineeterase activity. _Thus, the date of peripherelystlmulatiou by cholinergic agents is A ,was congruent to the hypothesiq regerding central nervous‘system‘reP activity to electrcahock. cammsmus: This survey of the literature of the roles of acetylchollne of cholinesterase in convulsive therapy hue led to a number speculetione which require yeriflcetlan. 'For this purboee, it and 3 is ‘ suggested that en-investigetion of the following relationships, 'be undertaken. (1) Level of free_ecetylchollne iu the epiqal fluid. 1‘3. type; cbnvulalye frequeucy. to number and therapy relation Also. the essociated electroencephalogram'patterns; Reletidn of such ecctylcholine levels to the clinicel (2) behavior of patients. (3) than z‘ 3;“:Ww’gwwm‘us rate (Funkenetein $5321" 1952); ;Patients in Funkeaetein whom .24; EEG in indicec of altered brein function other with such ecetylcholine levels. Changes ’ , .7 ., _ �{4); Reiéttoh chalineate'fﬁe gétivify of blpbd scrim andpspinu fluid to: (I) ﬁattémﬁ of and ‘ age, , (b) alméta (c) rate bf deveiwopt'zent of‘ EEG (d). numbg: ,md fréqqencyof . f ‘ treamhts . (e) ,aﬁtbn'omc (heriphgnli reactivity -(.f)',cerébu1 reacthﬂty‘ ‘ ‘ , 3 . gpexfsonauty Run: ofatroptne“. physos‘tiglnlne'admini‘attatian on (’8‘) (5) hypersyhchrony ‘qliﬁical behavtdr. , _- ‘ ~‘ E36,“, j 4 �III: 7-3-6A ‘r (1:, ﬂab-(i) ‘ ON THE ROLE OF ACETYLCHOLINE AND CHOLINESTERASE IN CONVULSIVE THERAPY Studies evaluating the role of cerebral changes in the mechanism of convulsive therapy have demonstrated that the development of early and tunct persistent signs of altered cerebral are prerequisite to changes in behavior (Pink and on Kain, 1956) - was the most In these studies, electroencephalographic slowing s significant index. This obhrvation remained un- clear until the reports of Ulett describing the effects of pre~ meo11ation with high doses of atropine in preventing the appearance of the EEC delta abnormalitv (Ulect and Johnson, 1956). ’Followlng the suggestion of this report. - we Eg 5: reniewed the role of acetyl— choline and cholinesterase in convulsive therapy” {é to data The lg; ve x close relationship between the degree and persistence? of the electroencephalographic slowing and the appearance of Suggests a T: .¥ measurable quantities of free acetylcholine in the cerebrospinal {g fluid E; as well as an inversion of the normal ratios of benzoycholine- cholinesterase to mncholylcholinestersse. I h:§ . . Ihe role of acetylcholine in the transudssion of nervous impulses has been studied since the (1914) and Loevi (1921). first descriptions The arguments as d of Dale to whether actylcholine is the main or only agent in the transmission of the nervous impulse are not of primary concern here. .It is sufficient that acetylcholine is a normal constituent of nervous tissue; thst exists in a bound form and is liberated during the excitation process; that it is rapidly it hydrolyzed through the specific action g) �oi cholinesterase and as rapidly reconstituted by the choline— acetylase system (Richter normal cerebrospinal a Crossland, 1949). Furthermore, fluid contains (Tower and McEachern, 1949a) no free acetylcholine despite the rapid breakdown of bound The acetylcholine during periods of activity and excitement, cerebrcspinal fluid normally has measureable cholin- esterase activity, principally of the "true" or mecholyl hydrolyzing type (Nachmanson and Rothenberg, 1945); In the absence of free acetylcholine and the conditions under described, electroencephalograms fail to show any consistent . abnormality. Effect of Craniocerebral Trauma: .In a study of cats subjected to varying degrees of head trauma, Borenatein (1946) (al reported that free acetlehcline appeared in the CSF within a few minutes after experimental head trauma and persisted for varying periods up to 48 hours. The quantity of free acetylcholine varied between 2.7 and.9.0 gamma and the amount wasl percent, positively related to degree of trauma. Concommtant changes. electroencephalograms demonstrated patterned Initially, the records were filled with high voltage fast activity, interpreted as an intense neuronal discharge; only to be followed by a short period of flattening of all recordedeaectrical activity. These periods were then followed delta frequencies. behavioral changes were also correlated with degree of‘ trauma, as well as with the level of free acetylcholine. with highest levels of acetylcholine, Bornstein reported the greatest The m �consciousness in change the greatest degree of EEG abnormality, also seizures uere and furthermore, spontaneous post-traunatic the in appearing related to the amount of free acatylcholine spinal fluid. applied' Bernstein observations. these To further substantiate when the cortex. cerebral exposed cat scetylcholine to the he gamma 1 less. or acetylcholine percent was concentration of waves of low frequency in the electrosharp observed high amplitude encephalogram. When the concentration'vas increased to 2 gamma parallel fashion in-a flattened percent, the electroencephalogram to the post-traumatic records. A 112 in studies these Tower and McEachern(l969a) repeated the found in was Free acetylcholine patients. pneurological head trauma, with recent the in patients only cerebrospinal fluid The free acetyltherapy. convulsive ‘recent grand--nal seizures or from 0.2 to varied choline lGO gamma percent. In addition, Tower spinal the of and HcEachern assayed the cholinesterase activity cholinesterase the nonspecific in rise fluid; They noted a sharp fraction (benzcyhholine-splitting) and a drop in the specific the in patients (mecholyl-splitting), fraction cholinesterase therapy. No those convulsive following with head trauma and in free containing the in demonstrated fluids such inversion was acetylcholine follouing spontaneous seizures. These authors directly acetylcholine varies concluded that the level of free that however, damage; cerebral of with the degree suggesting, sensitive more a was fraction cholinesterase of the the reversal indicator of cerebral damage._ -' �- 4-following intervals varying taken at were Electroencephalograma direct a reported The authors most of these subjects. trauma in of the of degree correlation EEG abnormality and the appearance cerebrospinal fluid. the in of free acetylcholine trauma craniocerebral indicate that These two studies may fluid; spinal in acatylcholine the of free amount the increase free of the between amount and that a direct relation exists electroencephalographic of type and acetylcholine, the degree behavior. and changes in clinical abnormality, (b) Effect of Atropine on Bernstein administered 0.5-1.0 pggt-grggggtig mg/kg EEG 5&4 thgviog; atropine after head trauma- EEG effects, manifest of the blocking demonstrated and induced was the experiFollowing of trauma. behavioral and neurologic signs mental addition of intracisternal induced which acetylcholine, trauma,“Bornstein' head to similar EEG and clinical changes observed a blocking effect of atropine. human of treatment the Wardflgﬁo) applied these ideas to degree with varying 20 In patients head injury. closed of cases of doses in subcutaneously of trauma, he administered atropine and in improvement, clinical noted he some cases In mg/kg. 0.1 the of effects electroencephalographic the of others, a reversal Jenkner anticholinergic drug, trauma. In a study of another the in putreported.simificantl'alterations (1955) Lechner and 40 in dose intravenous traumatic electroencephalogram. Asingle normalizing‘ in instances of abnormal electroencephalograms resulted others. in 22 instances and marked improvement in six _ �- 5 - atropine effectwof Ulett and Johnson (1956) demonstrated the sane conVulsive‘v illoﬁing slow wave of activity the in blocking appearance biochemical‘nechanisnl same the therapy. This_stndy suggests that ’ . V ' under£:5the electroencephalographic changes in head cranes and in . *-',._—s Mov ~...,_..-—~ in contrast to these findings}: In their i _. M. . experiments Brenner and.Herritt (1962), applying topical scetyle in concentrations of 2-1/2 to choline 102 ‘ to the exposed cortex of cats, noted no effect of intravenous atropine (l nglkg) on the electroencephalographic changes. lt_is iaportant to note, however, that the concentrations of acetylcholine in these experiments than significantly the topical applicetions (1-4. was higher 3“. I percent) and the intracistsrnal (0.2-10 galls percent) injections Bornsteind(1946). Brenner and Merritt. houever5'slks_note of of electroencephalographic effects similar to acetycholine free mecholyl (acstylbetanethylcholine) and doryl (carbanylcholine), each in concentrations Inch lover than the acetylcholine concen- effectiveness of these incteessd the ascribed trstions. lack drugs cholincerebral of to sensitivity to cholinergic their They ‘ estereses. A I variety of experiments with the potent cholinestarsse' inhibitor DFP . .31. induced convulsions. due report stands out a.m- fluorophosphate) demonstrated high (di-isopropyl amplitude rapid frequency 885 patterns similar to status epilepticus, as well as lesser degrees of abnormality noted in post-traumatic stete!!(ainnich, et el., 1950) Freedman et a1., electrohempson the 1949; and et al.. 1950). In these studies, too, encephalogrephic effects were blocked by snail doses of atropine. -——.‘ Cs- �In rustle? labcratbry study. Chétfield and Dempsey (1942) evoked and anxmai prestigmlne :ortcx expasud ytch prepared r9103hdlU.YJDF1C Spiﬂe autlwtzy. electro- prior.admznzs:ration of The 'uzrcane biotk\d this 5:1 1:5. a: if present, the abnormality v?u.d be viim‘:1th by atrepir~ 7C 1 trtn 'hu.. a variety of experimental clznlcal scudzcs, and 'har eie-ttnuvcethIographic acti;1cr ._:ti;:hrr;:¢. irhc: -T;t'!‘!". ‘th as 3 wﬁ tnd¢¢¢d bv reswlt of trauma. topical appl;astict or :rrvzral m;:a‘clzﬁn, can be blscked ur elzmztated ltz'tln|k‘ -. (r) ‘3}.: 'x '.;re:.cwg:n31 ~ a:e:yL.n;1;1¢ ﬁcrtully appnars :; “Jqu, ;v¢;ttae iczm. It trcaxd;un {L58 Ln 4 The level of spund acetyichclinc is v c: the pro: I! 3325 cf synLEcsig. liberation an; may be Lcscuiat is true :45 npmanstratpd 1W: -. nex.{;3;. pr-Sen: 1: vezvous 11554t a I u . therefore, that the level bill during «lead and fall duslng activity {111352. 9v'xn a“ ‘T ac:1;i:;, r:ce acatvicell membrane. where it is rapidl; de- Activated ty challnestarase. c::.:an; bv . Du::n3 pazxud$ of :hu;in# is liberated at the ;h;. the .,‘.‘.:l Au€£.luld.;‘£- "‘ r.u.J 2 by thhte: Pyzdur$;n (1950? and La That this hypothesis Crosaiand {19u9b and aagzyz uxanrimun;s Sy Richter and Grassland qu1ck-freézing methods. asxrg liquid air deﬁoﬂSLYdtzd that the anesthesia ard sleep level of acetylchoiin‘ .Lgustcd mi:ragra:13 per 25 :Fdn fn» Ln»? uvi;urc lcvc; Itdnxieﬁt .. ?. .5 (D N mg. The brain fiSbUd} was 3092 hich? difteteECe in tinauc levels 13 .5 the resynthesis rate for azetyluhclihe in m rat braxn is high (7 gammaigm/clnute). 'Elliott er a1. (1930} :. par-- �After metraeole convulsions, free noted that also XIhey acetylobservaticne, these “K ;3r?ic~‘i n ; chul;ne :ws always demunstzable in the spinal fluid in concen- tratians to up In spinal 3 gamma per cent. man, Cone, Tower and HtEechern fleid studies in ahd Thuer and McEathern (1949b) ‘1348) ti quantititls 86 also demonstrated significant free acetylcholine in patients with epilepsy‘ 'Of patiehts. epileptic Lhuiine in quanti'iea 49 (7723 demonstrated 0:02 tc of SP0 gamma naeeurable free acetyl- per cent. ith an average was related level directly acetylcholine pu:.cent. Ih: (L the frequeﬁcy cf seizures; the extent of electroencephalzgraphic t6 the last of relation of time the sampling and the abnormality, cf 2 O gamma It bore seizure. no relation ta medication. type of epilepsy or level at cholinestetase activity. Whether the ', a . a the in fluid is spinal appearing acetylcholihe ty—prcdcct of the canvulsion. or whether the increase in 9 - catae of the Seizure, is prshlenlticela acetyl- Tower and chachern (1949b) believ that the increased e;e:ylchcline liberation (T; itself but related is not due to the seizure caaeing the seizure. A“ In a to the basic preceee s“dy ef the hypOthesls that the accumulation acetyleheline is basic to the seizure process. Torda (1953? indured convdsxcrs in animals by metzazcle She determined the level of acetylcholine in brain tissee before and during convulsions.» convulsichs byla She noted that preceded are rise in the acetyicholine content of t:ssue; the: the content gradually falls during the convulsion; and that below certain levels, convulsions failed to occur. 3 She ccnvulsioc suggesteﬂ that the was due fell in tissue acetylcholine during to inhibitien of acetylcholine synthesis by incrcdeed reagentratiacs of mezabclites such as ammonium ions. �While there is considerable orgumcnt about the role of the machanism of seizures. choline in it is acetyl- probable thot free atetyltholice is increased during seizures and appears in the spinal fluid; that cerebral activity and seizures enhance acetyl:hcline destruction. lowering tissue levels of_acetylcholine;while sleep and anesthesia augment acetylcholine production, V inLrGaSXSg (d) tissue levels. Svstoo Nervous Centrai Cholinestegase: Concomitant with their observations of changes in acetycholine, measured spinal fluid choliuesteraee activity. Tower and Hcﬁachern Two (l9é9) types of cholinii esterases are normally found in the spinal fluid: cholihesteraso-I i"true". "specific". or metholyl hydrolyzing), - which has a high specificity for acetylcholioe; and cholinesteraBe-II ("pseudo","nonspecific”, or beozoylaholine—hydrclyzine). Both compounds hydrolyze acetylchcline. but have different ratio of hydrolysis for mecholyl and beozoylcholite. distinctions of the .By This diffexehtial rate permits qualitative reporting the cholioesteraso activity as 5 ratio activaty with mecholyl acetyicholine substrate, two and benioyloholine rati$ are found: substtates to an cholinesterasevl/ acetylcholine and cholinesteraoe-II/acetylcholine (with Ash/Ash - 100). in such ratios manual CSF contains esterasea in tho ratio of 33:17 for cholinasterase-I to cholineateraee-Il. Thus, normal ‘ CSF consists- inly of "specific" eaterases with a small nonhSpeciiic esterane component. traoma, with head Toner and Kcﬁachotn report an patients inversion of the amounts of cholineoteraies with a significant In increoae in the cholinei‘trase-II fractiOn of spinal fluid and a decrease in cholineatorase-l activity. They also reported a correlation between [la extent of the cholinesterasc rcvérsal with the senority �the electroencephalographic of trauma and with the degree of ‘ abnormality. scetylcholine a as patients With spinal‘fluid increesed .In however, the ratio in change no sponteneous of seizures, result found. actitity was cf :holinesterases or total cholinestereee (e) Effect of ﬁle trnehock on at A Tower and McEachern’(l9493), esterases: it oline and Ch in- in their study of cranio- psychiatric trauma. in patients six reported observations cerebral Studying 3-7 after the patients convulsive therapy. undergoing the they.reported in activity free acetylcholine treatments, . ’spinsl fluid in increase in cholinsstersse-II patients; and a decreaee in cholinestarase-I vith a reversal of the rstio llron'thess Of the six patients. of cholinestersees in five and an two in changes fluid the concluded spinal that they observations, cdnvuleions trauma craniocerebral those like more were at induced than those found in * epilepsy. Regarding the one patient in the series who failed to show cholinestsraee in ratio reversal or s free scetylcholine either the spinal fluid, they wrote: "It is interesting that this response shun to no of to the six one the was only patient treataen.." . DISCUSSION From these various observations, vnlsive therapy induces spinal fluid we may conclude changes more that con- like cerebral is. 'trauma than those of spontaneous epilepsy. If the parhllel of. the degree maintained. we can predict a relation between of abnormality, the appearance free electroencephalographic qcetylcholi1e. 3nd ; ra"97331 of cholinestcrane activity ratios ' �‘“ the L-L Fpl'd: fizid and the number and frequency of induced-con; xtisisrs. Alsu. irsm the Observatians of raver (1959b), 1hr ccmnent that cnly the patient suing? ELUiJ ;hangua us in ptrmits :hnngcs are filled who and McEacharn failed to Show to show a response to treatment, cozsider the pcssibility that such biochemical basi: to the :cchanism of the achuleive therapy process. Certain further deductions and conclusions are possible. rhé brnin subrtances of induces through electric current passage change a in cellular activity with an increase in free acetylchclinc to levels sufficient‘to induce a grand mal seizure.i The preaence 3f free acetyltholinc_in the intercellhlnr fluids electrical hypersynchrony.ref1ecced in the induces , slaving The degree of hyperaynchroqracturately reflecth the level of free acetylcholine and should follow to the rate of acctylcholine destruction. demonstrated that 1c the as delta EEG a decay rate equal Since previous studies hypersynchtony was n_neccssary pre-requisitc EEG clinical responsc in coavulsive thcrapy, it may be stated that the absence of free acetylcholine suggests minimal changes in cerebral function and thus pracludes a clinical reapanse to the induced convulsions, bc made regarding changes in Certain assumption: may membrane cell permeability as explaining the increase in cholinf esterasd activity“ Cholinesterase-I is found'in highest concen- trarian in the :entral nerQOus system; while cholinﬂesteruse-li is predominant in other tissues, especially bloba sdrum. ~With the increase in acctylcholine levels in the intercellulur terebral ilwids as a ‘ xesult'of stimulation .-J.-;'..L ..i ;w::tjs;; and convnleibn,‘ :uliuau: gartelhllzty may be predicted, �.. 11.. interthe fluids into of vascular with a degree of transudstion of and the duration the on extent dependent cellular spaces vssodilstisn (Rabat et all. 1948). 'Ihst _do such permeability changes in and Spiegel-Adolf by Spiegal demonstrated amply occur was ; . demonstrated They '53). 'é8, '6h, '42, (lQél, numercus reports cenductivity the increased that electrically induced convulsions cf the tissue; resulted in a leakage of various ions, as potassium and phosphate, into the spinal fluid; md that while the electrolytes iignificsnt increase in non-electrolytes permeebility in Charges nucleic-acid splitting enzymes. i .creased. there was a Wes of cells may this provide the basis for the appearance of high :ﬁccentrations of acetylchdline and for increased concentrations - oi chalinesterase-Il wt ch~he (T owe: and Mczachern l9h9c) incevihy in cholinesterase activity, shculd not the free acetylcholine be rapidly destroyed? To what Mechanism can seizure be ascribed} its persistenze in spinal fluid after An explanaticn for this descrepancy is available id the ebsersetidns trauma and cf Nachmsnson and Rothenberg (l9é5), hy confirmed McEachetn (1949c) end Bergen and Macintosh lever and ' (l955),lthet the scary!:hcline-chclineglerssc-I system is very sensitive to concen- tration relaticnships. of acetylcholine At is rapid "physiologic" concentrations, hydrolysis (3~4 microseconds) but at higher and quichly_(hsldene off curve). lower concentrations, activity falls relationship is In conrast. the chdlinesterase-Il-acetylcholine nGt'EpCCllli, and the rate of hydrolysis increases with csncentration. Thus, with normal functional levels of scetylcholine membranes, the scetylcholine is destroyed by the at cell specific activity �where'exzxtJZLcn -:41 in the Urdu: of "111;3dC9ﬂdi '!;U&uLVc '1..‘q;. :rL:.:1"-"wf cchaevtratton of acatylcholisu in “Bfiohs is Hytirwﬁxw ‘; ‘b: ‘*::e:tr3:icn f :lr311rﬁ:ster.19a—I t.s ex;cc:J¢d_ Ev: {Htéskrld the seizure uf acatvlzholivc mount:, The :2 I tree acetylahoiine t"r‘1"; -~'.' *1 I: ~~II .r‘;c1nn;y. The “erhaps adds to the level of rapkdly,« diffuses ucstylcholtne increased a; the actlvtzi cf thia enzyae. Jun LCgﬁﬁduﬁt ad Lu CUCLUDCYaCXCn A ‘Lc acetylcholice level’ f): fke shwcx persistence of azwtyl- a the and pctmrubility effects vaatulax-ind cellular £53; cholxn~ Inzteased 413: and .v‘retued inn. 1n 1" t.~':t"’ '¢ ’.vnshiv rzeults in nex:;ra. itself. The Etna 'W' disscnlation in acet/isholtné~ a tﬁOugh c1 low klnolizs that lchls period of heurs to days. to p cholineatetaRP-I. of action /w;alcgic (lottrtcnvcphgiagraMs Suuh a posstblllty xs ev.5c:t in the' I Tcpﬂ$2 by Axrd e: 1n 1n-.e;ae a democdttating (1936) sxgniticact 1;. erin gdcszte in of cuvuent::;103 the ‘ 12 L9LC€RTT¢L10a itisund Cedutuw ’v‘ tiesue is data induced convulsionq. 3 da,; af e' shows the change in brain in absent tﬁis ordinarily nnlecule. large ct of wﬁtﬁ hypersynchrvnv the ;nTT91aLcJ Appearance ta be eleCtroancephaiogram‘ the in (deitu bursts} electroencephalographi: of of the appearance In 0d: stLdica nuwbuni' the many confirmed have we changes nuth hypersynchtony induces therapy convulsive previoug reparas that of treataents. application constant a Deepitc in maqt Suh‘c~(w ' #cmwnlsiozs, _ �FLHCLICof the Jnd 54r3:1cn extra: ILmv of Appearance, (it “VlﬁVﬁf, ‘rT'XXATXOH 315 *"ri‘::w“" . ‘ {v hyperaler21u1. c;d1‘i:1L1‘" tc senaazxvzty its Qaca graph;; 5ch I herb:tgrates all cgrly appearrnce TLQ vary greatly in géyzhiatric of?.igh degree hvpe: vnchrany. bwaa has tzcatmunt the ::.r:‘~‘ 1:* ::§ 33:1IHEE'CV (Lfvgghiji 31¢;Yihﬁﬂ as a nuccaaary E'sctrgﬁﬁ”( t-tr': 'quh:iwlrr 2H: and Kihn. 1956). Bu: what 1: ch; meghanism' imitate of caftain pﬂttents_zo deveiop n3persy1.Lrauy be and acccyléhriine may chottneqterases of <tgiiee - L%ewﬁ 9:;L4y3 greraqgtsira to: inprrvcmeu: folluwing \s-uﬂ.' .la "Z¢piwﬁx seizuze ls :ndznattnc o: thy *EA: 4 armnd m;. ; {13:uc KQIHL; 2f {tee a»:'{2.chv'LHv in ‘HH and ghnlznugcaraae-i; by ," -«;c *nd~a;;z‘s n. erlag'-.5;; hypetsyncnrcnv La 1 iKSQ$E a! that the alertrc— ref\r\::LLn cf the pvrstazunce the ditfctence then 3f acetylcholinu; c~rven‘:¢;2cn Phﬁ”':d1 ‘32: 9‘ u. :rﬂ-tr:: -in ra:a;¢1r ry;c:e,n :n:;r.v in- at in whom it Persistent .frizzc=2-r3we-QLPn;l;bol{we hydrolysln system. {La 3 Lh of ace:"Lhvnral of atu I decreased fr3a rate I h5“a7annchtnn", resulcs K . . V s-prrvlousiy deduced are correct, ezther one 'J 9" 0' LI V 1 rv- in .A 0‘ t r9 n ’ I‘ ‘1 ,— P" patients with (a as are operatlva pcstula: suing .cr'xst.uz hyﬁvrzy nebrbny: (" 1% :‘i attrast-I IS in law s: rte er: in LF: tisSue t2) h‘ Yh<‘ 2 Cb'litugrpzata—II is :oﬁc=n£r3££nu , «12L h1gh Kev, so %: that thc:e a;¢:ylchclzne; and/3r that the noncancraziou at though are 02e241122. g; 5. suqtyt 'h:..- 1 slaw decay rash o �I ‘, f)‘:W-‘rvrs. t“: " st: gfztzl Ira in» ‘.-* “2:- 1" 2 ~ 3 :: "ca proqz tlcn <th .L . Fran Chv a:v:yl- nzgh cgnawnLratiors or :"l':us:eraae—I stuchn suuid . attivit" cad be (;Q55!. . of Wacnmunsan ill-n If can be deduzcd“ 13w demorstracad in dapre:?£ve yzr~xe5 g‘ acnopausal depr¢sszct), then the electroshock induced ' $:L:V1-‘QIIUL 1¢v-:rimula:2 ;%;l;ne {grasp-I graduation to a more usn“ku: Eu ,4 -\ \ v 1‘! :g: - - cgﬁu"'crac#3 c r .t “.CE Ha4.3: xu“ « chhriy. 2 z: ‘“"gi;ia:: r, tzarv122d;3, an r31): l éﬁn y‘;rra L) txue to more than -;‘.c;- upnli:ation cm Rucent szudius by Funkeaatein and. rglarlcsshlp Fatwaer the blond p:e>3ure a "aren* L!(11FP:51~ ‘gegt whicb iﬂduces swancpag, and in;:¢n.cd peristalris. 20 minutes. 5 minutés are :lauSLfied as Gtaup 1. .1, 20 or were c ‘JYI .3. 'daczsrs have h.'..~¢‘ax:u.-, ax a 92 Improvemant C’W‘Tiht, the Group ‘,~.. , .._..- V1 sir-.1 GK'C‘J-P charapv, and the Group II—III reactors a 'IIIII-III I: Patients whcsa bleed preséﬁre 'na.r1:#e: zhcsa vF‘ue blaod presecrc zukej 92:13:: 2:. (ha :1: b43313: in.a varlnc;e {ength of time. t;ﬁh.ﬁ$ to [J3 baseline in xrd .L‘ :1J11e3_may hive untrrgvi: [EdQLIUity ‘Ezm 01 '\ Iiﬁ.~it. tigsc 4 if tiaaué ;nclltester85&—E in the ogzuac‘ ctaLentrat on 0‘ chxuu 'hcixn— aid snvgi cf rer"ccs 3t _ _‘ c..". x‘ _ "\c_r..e— ‘ ’P?‘ é ratu with Louvulsive 35% recovery rate reactor: have MW. -......»n.a.cac textzmw a 892 and the Group I‘*'Hal-*mHO‘vw-Iy9ﬁ-’ ' In ,- �ﬁll a: 31., 1952). :e:c"crﬂ rate (Funkensteln 9—“ -Pa7;ean in Fuzkensteln Grcups l to Ill may be looked 972 a ;: Ew;l;ui- :1 "him ET n 'J' m C‘. '1 de Ch: 1716 and VI; V1 upon tad weuhalyl is r2p;dly hYJrolyzed; patients have a-slow hydrolysis rate. predict, therefore, that the blood cholinesterase activity. levels of Grorps I~III w0uld be high; while the activity of Je may Grazps Vl-Vll would be low We recall here a siuular prediction rega:ding the ds:a fur central nervous system levels of cholin-A 11 which u‘rergse~l, the development of early and sustained EEC hyperaynchran) and elevated spinal fluid levels of acetylchclinc relatvd to was a law level of cholinestarase activity, 1. 43"¢ cf 9:11pﬁnral ‘u: V \ u \ . azngtuast 0y 8 cbslincrgic agcntz is the hypotheeib'regarding central nervous sysrvm re? :5 aztivitv :2 :zzm‘;atl>n Thus. a ., ”w“ “a ~c:r.shuix. a A,~‘ ,.-."..( 'c-~ :AJ'L H—-—.- as... ThLG survey of the litarature of the rJlos acetylzholin (f "V .o. :hclinestarase in ccnvﬁlslve therapy has led to a aﬁd speculations which require verification. For number of this purbose. ‘t L Rdgglilhd that an-investlgarion of the ftlivwing relationships :elztlon :c :3Evulslve therapy - type, ,0 J I v o 9 L." I in 14" number and fttquency. .ociated oleczrcencephalogram'partarns. h Relsclcn of such a;eryl:hollne levels to the clinical behavior oi patients. (2) (3) Llaé BE“ Changes in lndices of altered braih function other with Such acetylchcline levels �(L) 'Relaciou of :holinesherase accivity 1:03 serum and splnal and patterns of fluid to: (a) age (b) diagncsis (c) rate at development cf (d) number and frequency of EEG hypersynzhrocy t:eatmehts reactivity (e) autcacmlc (peripheral) reactiﬁity [csrebral (i) if») «g; _pe:sona11ty Rut at" :nLrIL Eshxvic: atropine. 'physcgstigmine adrainistmticn on ’ EC,“ � 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 Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 2/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-002 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1967 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/22ce0e2ce2b39aba2aae8d5d1394cc60.pdf 2c9db7ac17279fda4146fb703f39bab1 PDF Text Text ' """ "r ' " WWO WW WW3. IN Max Rink, -*-' '"I’W v“ ”kw "FWHWOMV'.’ v.3. "m qr min...“ .7... W 14.1). mthofPoydmiatry of School Missouri Meir» , of MRI-nit}; Psychiatry, at the Nissan Institute of 63139. Macaw}. St. Innis, Annual Street, and Vii—072w, bin—927, m—zns, usms in part, by gums Missouri. of Formation :3 Iii-11380; ltd the Psychiatri 5WD W. VII: 7—25—65 Ram ��Wm, lQNQe) . The activity md emitement (Tracer and oembmepiml fluid does have measurable cholinestemse activity, however, principally of the ”true” or maholyl hydrolyzing type (Madmen and Rothenberg, 19%). In the absence of free acetyldroline and mder the cmditims described, electmenoephalogrm fail to (e) Show almorulity. mummy: Meta of Crmiooembml Trauma: Free mtylcholim was found in the cembmepiml fluid within a few minutes after experismntel head trauma in cats and persisted for varying periods up to #8 m9 (Bernstein, 19%). The quantity of free mtyldmline varied between 2.7 and 9.0 gamma percent, and the was related to the degree of induced trauma. wt electmemeptulogmm demstmted patterned Carma-rent charges. The records were first filled with high voltage fest activity, interpreted as evidence of an intense neuronal discharge, com to he succeeded by a short period of ﬂattening of all recorded electrical activity. These phases were then followed by prolonged periods of high amplitude sharp waves in the delta . freqmncies. The behavioral changes related both to the degree of trauma wt of mtylcholine, md the of measured free acetyleholim. With higher Bernstein reported greater degrees of abnormality and greater charges in omecioumess. poet-tnunetic seizures were levels EEG Spmtmeoue also related to the ammt of free mtylcholine warring in the spinal fluid. �Bernstein applied amtylcholine to exposed cat cerebral cortex. men the concentration of acetyldroline was or less, high wlitude shup the electromoephalogrm. waves When of 1 gm percent low frequency appeared in the concentration was increased tOngmepemnt, theelectmencephalogmflattmdina fashim parallel to the post—tramtic records. Investigatims in neurological patients by Tower and HcEadrem (1909a) damnatmted free acetylclwline in the cerebmepinal fluid only in patients with recent head recem grind-mu seizures or after electmvulaive Free acetyldxolhe varied from 0.2 to 100 gm tram, therapy. percent. In assaying spinal fluid dnlineetemae activity, they noted a sharp rise in the nonspecific dmlimsterase fraction (bmwyldwlineaplitting) sad a drop in the specific dwlinesteraee fraction (mdmlyl-eplitting) in patients with head trauma and following convulsive therapy. The cerebmapinal fluid did not exhibit such inversion, although it contained free acetylcholine, after spontmeous seizures. They cmcluded that the level of free aoetylcholine varied directly with the degree of cerebral dmage and that reversal of the cholimvterase W was a m sensitive indicator of cerebral (image. Electroencephalogrm, taken at varying intervals following EEG of between the degree relation indicated a tram, also abnormality and the appeamce of free acetylcholine in the cerehmeﬁinal fluid. �. r -; o-Tn- "W wu-rm- V“ 7 ~ MNIWWF‘. «wwwnmw' . ”3-.— :Nr‘ ‘mw— l‘.«nmw~.—WMM v-y »".\—- (max .9 w— , r‘ "murmur 1 Wm" q‘ 4;. These observations were recently oonfimd by Kovaoh, wounded increased aoetjldxoline in o: 1.1;. rat brain after traumatic shock, and an inhibiﬁn of this activity by the ministration of atropine to the muscle preparation. Tim the «want 05 {no aootgtchoune may ammo in tho who Aptaol staid {cunning WWW mum and the. mount 05 (no acugwwune, the dean.“ and typo cg mmmcapmogwuc «bloom/aim and «Maya in clinical bohavion appeal: cu Wound phenomena. (b) Antioholinegﬂo m and tram: oleotmgr'aphic, The bohavioml and neurologio signs of head trauma were blocked by the parenteral achinistmtion of 0.5~1.0 m/kg atropine (Bomtein, 19%), as were similar clinical changes: oomrring after the intmciutornal addition of acetylcrnlino. Ward (1950) applied these observations to tho treatmm: of closed head injuries. In 20 pttiants with varying dogmas of tram, he amtiniotomd atropine subcutanowsly in doses of O .1 mg/kg, noting clinical in soon and a reversal of the oleotmgraphic effects in others. Similar alterations in the poat-trmnnatic electroimprovement encephalogram were reported by Jenkner and Igdmer (1955) in a rtudy of diethaxino; amthor antidxolinergic drug. A single introvomm dose in forty patients maultod in normalizing the ' abnormal electroencephalogram in six othom. in twentyi-tm and marked ingrovemt .mr—‘xv �T-W‘vw 'h'mivu‘ -.-. ~.w—w.y‘~ WVMMW'Wn-uvw‘w—W 1."'"q'( v -— m7 "In“? - "mmwuﬁwuwmw‘vu “m""vw -WW’-xm -~ wr: TW'f..‘-|‘.Yr 1m Sinilar oboewatiam have been reported with mthylbezuctyzine md in minal exporimnts of post-trumutic shock and man 03mm}. Odom: (mm, affect of atropine Thu 1&5). assessed in the convulsive therapy was process by Ulott and Johnson (1957). With the administration of mnpordaydvmtngmwoeksthepatimts moeivnd oleotxoshodc therapy, the of slow wave activity atropinewto mt oigxificmtly lass than in a omtrol grow who had not monivod tho atropine adhinistmtion. (In a later study these was authors failed to replicate this study, suggesting that dosage factors or popllatim ohms-m multo [Johnson 93; &, may haw contributed to diffemnt 1960]). Similar affects mm obacmd with experimental antioholixnrgio was diothaxim, banaotyiim, the pipaddylbenzilates (Pink, 1958, 1960). The intruvonms injection of and JB-329 (Ditm), lid WIN-2299 JB-318. JB~336 111de ES damchrmizatim in psychiatric subjects. Those EEG ohmgos were associated with bahaviml alerting, anxiety, tram, illusions, and hallucina— tions. In patients the than had recently received eloctmomvulsive a reductim in slow wave activity md a manual of euphoria, denial md oonmsim. Atropine in low thumpy, dam, was was associated with tadnvoardia, mass E88 desyndumization acoarpmiod and Maxim. by At higher dosages, hypcnyndum slow wows, followad by lower voltage , poorly omitted delta activity with super-imposed beta activity wm associated with progressive confusion and disorientation. ”I..- —w m hwy”.-- �.erw—spmﬂlwtvnvamnw." w— r..«wwruun-x...—..,«».w..i. in combat Both Wguphtc mm"._., w-uvw-m .7..-7._~.-—v-—wwww..— um ~— ._.‘...,W wan rvw—Hw. ;W.——»—.- w—u w "r - , -— wwv—ku.“ and induced convulsions, the. ehahgu my be modiﬁed by the. WWMOR antichottuugte MA, Auggutbig that tamed manta 96 acetytehaane on. chawvigtc unpuvttg 4'4 undated with the. high vauaga Alon) wave activity. 05 Wed (0) Brain Similar EEG mﬂlcholim and mtfahnlimggzc ahmgaa and similar blocking by my mticblinergic drugs has been obserwd following the direct application of amtyldmoline to the central nervous cystem. The achinistmtim of a cholimtemse inhibitor Df'P (di-isagpmpyl fluoroplvsphate) elicited high unplitudn rapid frequency EEG patterns similar to of poststatus epileptiws, as wall as changes similar to M stma (Madam £314, 19‘69, Samson gt 9;” 1950, mid Hindi-m 333b, 1950, and Weasel 93.31;, 19%). These EEG traumatic effects were blodmd by small. dose: of parenteral atropine and in amtylcholim after awpolmim. The mat tetmthyl pyrophosphate (TEPP) was masumd and related to the toxic misfostatims and cmwlsims induced (Sim and inm Pepcu, 1952; Stone, 1957). Chatfield and W (1M2) prepared exposed miml cortex with pmstiminn and cvdcud oluhmnoephalogmphic spike activity. Thu spiking, or prior mismtim of atmpim blocked this if present, thc «mutuality could be eliminated by atropine. In contrast to that: findings, Bmmor and Merritt (19%) applied tepical acetylduolim in concentrations of 2~1/ 2 to to the exposed cortex of cats, and noted no effect on the 10% w- «ﬂu-xwa—VVlwu- ��“mun-ny- rw-WV‘VKwnZw'w—w "1W:wmwvtwwav 1W”'_<1>vwnv.<_wum,vwwv ]- ‘_ VFW, .. .- w n - ~-....Vr.ﬂ.--“ “W,- ..‘,_.,‘......_,.,.‘ -.v—--Y‘. ,-. -3- Elliot gt. 5}; (1950) md Crosslmd lid Herridc (195“). 61mm and Popou (1962) fomd the increm in aoetyldnlm following various dapmssants to bc proportional to the degree of depmssim of the central nervous system and the mduction in motor md Buck (196:4), turnover, studying 13min activity. My W lavas and sedation omeludod that some ”dating agents are associated with devoted brain aoetylomline, but that no dawns mlatimxshipo existed. In part, this may be mlated acetyld'xolina to the earlier obsorvatims of Wu: Elliott (1951) that acetylcholine synthesis unsound in mt brain slices, is accelerated by low dosages of mootic drugs, but inhibited by and him dosages. Pme autylcholim patimts with epilepsy was mported in the spinal fluid in (Cone, Tower and Wm, 19%; Tower an (7‘3 epileptic patients, Mom, domtmted free aoetylcholine in qumtities of 0.02 to 5.0 percent with an average of 1.0 gm percent. Acetylcholine and 191mb). 0f 56 gm lawla Hem related to the fmquonoﬁ of seizures, the extent of electmmplulogmphio abnomality, and to the time since the lam: soizum, but bore no relation to mdication, type of epilepsy or lawl of cholinesteme activity. Elliott at al. also noted that :1: fm acetyldmoline was dennnstmble in the spinal fluid in cmoentmtims up to 3 gm permnt after mmzoln convulsions. 7 .w .. "urn“... �.7.~w.. V. - V ,, “my",w 1...,"— 4~.vn,w—._._.m~,m raw-w": '— 0.. ”75v.. .— _‘ . ‘wwm‘ ,van... ..__.,.Wry.~.~ m-Zwm-V'I—r‘wn W.W ”-mw-w.w.mwr~m - n—r.~~—. >¢r:'l.irmv --"‘v-w-V‘MVSWVP -9Tower and McEachem (19'4933) viewed mm the increased acetylcholine of the seizure, and not causal. Studying the hypothesis that the acmlatim of acetylcholixm induced seizures, Tom (1953) masumd the level of acetyldxoline in brain tissue after mtmnolc convulsions. She noted a rise in the as a aoetyloholim content of bmin, before a soizum and a fall during the convulsion. Below certain levela of acetylcholine, cotwulsiona failed to occmr. that the fall in tissue aoctyldaolim during a convulsion was due to inhibition She suggested of aoatylcholim synthesis by increased concentmtims of metabolites such as mimn ions. Gianna!) and Pepeu also measured chmges in cantml nervous system acetylcholine follwing various stinmlanta. moholyl and 3, S—dimthylbutylcthylobarbiturate Chly was after them a significant chmgc in the amtylmolim level. may noted a decmase in association with induced convulsions. With other drug: which they classified as stimlmts iprmiazid 1: (LSD, hydroxytmyptophan and iprmiaxid a ipmniazid, DOPA) tum war: no changes in acetylcholine level. may omcluded that despite intense excitatim produced an by these coupomds, them in acetylomline levels unless trace mm by convulsims. (The differences in obscrvatims no changes Wand between these MomdemcgggléandTmranndEaduem muted to the differences in mthoda of biochemical monuments, for the latter measured chmges in spinal fluid my be mflocting the free acetyloholim. while Gimmn and Pepeu «way—.- —-—.\. �T- - w;—----w~~~.~ .7 um . r - xu ‘ r v,m__.mwa,mﬂmuwwr~pw m~'mvv'v—rﬂr vav-u—w. ---—w ~ ,~ .ﬁﬁr'A—HIwmmrrw‘(Wr-1Inr’mwmr"W'mv-w’ total acetyloholim reflecting band and free fame and Elliott, 1951]). of amtyloholim. The“ mom augguz that Apart/tango“ an. induced su'zwtu by moanpmécd in intercom 6n: mag/Maine an m abound 6m La bound {own which my be inﬂected in the (Laid. Cmbm activity and Auzwtu enhance magma” «lawman, awaiting wine Levels 05 Mots/Moan, Mule “up and muthuia my augment acetytchoune paoduotéan inc/away about mm. measured the [mm We W ’ (:3) Central Nervous sttem Cholinostemes: Tower and Worn (19%) also measured spinal fluid molinesterase activity. The typos of cholimatemnos are nomally found in the spinal fluid: mimestemoe-I (“tm,“ "opecifio," or macholyl—hydrolyzing), whim haaaa high specificity for aoetyldaoline; and cholinestemse—II ("psexido," "non-Specific," or banzoyloholine~hydrolyzing) . momds Both hydrolyze aoetyloholim but have different rates of hydrolysis for monolyl and benzoyldzoline . 'mis differential rate permits qualitative distinctions. By reporting the cholinestemsc activity as a ratio of the activity with a moholyl substrate and with a benzoyldioline substrate compared to a substrate of acetylcholim; two mtios are found: crolinestemse-L/aoetyldlolim and clnlimntemoolllaoetyldiolim. In such mtios normal oembmspinal fluid contains astemsea in the ratio of 33:17 for molimstome—I to dialinestcme‘ll . _ In patimts with head trauma, Twer and Mcanhom reported an inversion of tho cholinestemsea with an increase in the VHF-"147 �».———w ~. r... >qu . 'v—vv—W n» “W...“ mm xwwu-w_~ WY— . “-7 mrmm wnwW—u—mr- w...” maum—w—w—y w «W . unv'r“! "31A“ man-.wvvmw "w” w~:- -11.. dtolimtum—II fraction of the spinal fluid and a decrease in cholinesteme-I activity. Tho extent of the dualinssterass reversal was related to the severity of trauma and to the dogma of the electrocnccphalogmphic abnormality. In patients with elevated spinal fluid acetylchclins after $1)th seizures, however, no change in the ckmlimstomscs or total armlinestemse activty woof was found. in cholinestcms activity may be undamtood in relatim to ohmgcs in cell neutron: permsability. C'holixnsteme—I is fmmd in highest cmmntratim in the The charge cmtral mmus system whilc d'xolinsstemse-II pmdaninatss in othcr tissues, especially blood serum. With an incmm in acetylcmnnc levels in cerebral intcmellular fluids, vasodilatim md incmased cellular permeability may be predicted, with a dsgme of tmsudaticn of vascular fluids into the intemsllular spaces varying with the extent and duration of the vasodilatim and their (W g, 31:. 19%). Spiegsl, Spiegel-Adolf, oo-woﬂcem (19“1, 19M, 19““, 19148, 1953) demonstrated and: pemeability changes and inmassd conductivity of the titauos associated with the appearance of various ions (as pctassim and phosphate) in the Spinal fluid following electrically induced convulsims . Such nm~clcctrolytes as nucleic-acid splitting cellular psmability enzymes may also increased. in Changes thus provide the basis for the high concentrations of metylchclim and the increased concentmtims of duclinesteme-II in induced seizures or head trmma (Tcww V 4nd HcEcchem 19n9c). . persistence of acetylcmlim in spinal fluid after head dmlimstencsc dcspdte and trauma «fur seizma The imam . vmr Var" .muw ��rw ~—.r< —-._..'—v-w__ ‘- ,m Am w—w— WW 7- v nan—1"“ w—u-n w v mm mug; '- wmn—uw—v W v mm -- ,mmmm‘u—n w a"... mm -13- «mum m mm 5M nuvocu Mama 0‘ mbmu nmuimy «a WWW at «may. (a) Aceﬂldaolino, EEG 13mmmd‘wmy and Induced Oonvulsims: Alteration in the blood—brain permeability barrier by the cmtinuing action of acatylcholine may be a biochemical substrate for the postwlectmshoa hypemynchrmy of the electroencephalogram Sud: a possibility is evident in the damnation of an inmm in the mmtmtim of cocaine in brain tissues thme days after a series of 12 induced cmwlsims (Aird We g: .1332., 1956). The in emcentmtim of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of syndimny delta bursts) in the electroencephalogm. We hove oonfimd the many hyper— pmvious reports that convulsive therapy induces electrogmphio hypersynchrmy (Pink and Karin, g 53;, 1961) . Despite a constant applicatim of treatments them is a great Variability in the time of appeanmce, 1956:, Pink the duration and the extent of the electrcgraphic slow wave activity as well as the sensitivity to modificatim by alerting, hyperventilation and barbiturates in pcytidaﬂxic populations. The early appearancn of dagroo hypersynchrony and high persistence thmugzout a prerequisite to mamnt cause has its been described as improvement following electmshodc (Roth, 1951; Roth, §£_g£;, 1957; Pink and Kahn, 1958). the differences in the dogma of induced It is EEG possible that hypersyndurmy mlated to differences in central clmlimrgic activity. The failure of certain patients to develop hypersynchrony may be associated with the absmce of fame aoetyldroline being related may be to him). changes in cumbml function and thus producing .a » “V.lvf"——Iw vu.- "a'v �WW. _. 7: .my- "“ .~..v.,W ”" . , . “V WW 7*MW--—- ‘-u :u wr—u ‘V-U-lw‘-um- WWWW‘,”._¢.~K—.wvﬂﬂ m”. ~"m--'~w , e ~ * .7 _,.,. , v ,7, , (lawn), in their study at” cmniocambml tmmna, included observations of six psychiatric patients undergoing cmvulsive trumpy. Studying the patients aftar 3~7 tmatmnts they reported free spinal fluid acetyldmline in two patients; and an increase in cholimstemse-II and a decrease in dwlinestemsesl with a reversal of the ratio of dialinestemses in five of the six patients. hm those obscrvatims they concluded that the spinal fluid changes in induced convulsions were more like those of amniocembml trump. than those of spmtmeous epilepsy. described the one patient in the series failed to show either fme mtylcmline or a dmlixnsterase ratio reversal in the. spinal fluid as: "It is interesting that this patient was the only one of the six to shrew no response to treatment." They If olectrogmphie hypersynchmny who is a mflectim of increased fme mtyldxolim, subjects who maintain hypersynchmny and those in whom it disappears rapidly may be exhibiting diffemnaes in the kinetics of the dwlinestamsawoatyldmoline hydrolysis systcns . Persistent hypemyndumy may result from a decreased rate of hyd‘olysis of wetylcholine , associated with low mntmtims of either- cholinestarase-I or cholinestemse—II . (Conversely, in patients with short-lived hypemymdurony, dmlimstnmse-I md -II in tissue md spinal fluid may be unusually high) . Fm thug chuwacéoM we would conclude demon; m mediated M an Mme in in W, mm enhancing 2th: MW“ that induczd {we acetyichouue Mg Momma. naming mutual 06 The and Lava as ﬁne 1:; . ru- » m. “mmvw-w' - , v- �"w aw-"m, wrrwnw“—5— mmrwmwm._ . mallow 426 Wad m wm—w—w w. "mm-v m-u—v—v— nw—wuw- gwmy"w_mw u- m. -55.. by muted induud autumn. EEG hwynchlwny a one. Reﬂection 05 abtmed {even 05 Managua and muted 05 01h“ momtym. It 11A pubabtz that that chaugu in movide the mam mngw mm“ pwibtwt 4mm: Mochwécaﬁ 50mm 56!: {nomad the bohemian“ changes mm“ . (f) malimstezm md the Classification of Psychoses: mesa studies have application to tho problem of autonomic reactivity and tho classificatim of the psychoses . Manstein, 91:. 31;. (19%, 1951, 1952) have demtmted a relationship betwaon the blood pmaaum maponse to injected mthacmoline (Macholyl) and the clinioal response of spydtiatric patients to convulsive therapy. is a potent cholimrgic agent which induces vasodilation, tamycardia, mating; and increased peristalsis . 11:53 rapidly Phﬂmacholinc hydmlyled by ermlimstemse-I and slowly by duelinesterase-II . mo blood pronouns of subjects falls after injected macholyl and returns to the baseline within five to whose blood pressure 20 Grow VI and VII have a 9 and a am recovery and Group VII mactom 1133;” 1952). patients in 20 89% to nﬁnutes. Patients 5 those whose blood Wine, Group II—III rate, respectively, while and 97% minutes have recovery mtes as reactors Group VI (Wotan GmupItoIII mactommybelohkeduponas whom while Grows v1 I, II, or III reactors; ormm minutes to motors. Group I and 35% than returns to the baseline within how classified as Gmup pronoun takes more the injected mdwlyl is rapidly hydrolyzed; ‘and VII have a slow hydrolysis rate. It is probable, themfom, that the blood and tissue oholimstemse activity levels of Grows I-III is high; while that of Groups - unr �.- n. .— . VI .wr-. .,m-w.w-,,. ..- - VII in low. A mwkwmr “or a mum: mviow, similar analysis systom levels of "'"ww—ﬁi-m may in mud: r—nmﬁm.mn-‘mrmrp.’ "nu—mu“wl'r-_'In. m Rose, 1962.] mgarding central nervous dwlimammo-I in the dcvelqmnt of EEG hypmyndnmy and spinal fluid levels of acetyldxoline, providing the built for a hypoﬂuais mgarding contra}. nervous cyst-m periptnral mt Inactivity to induocd convulsions and to momma agate. Arm �. ”V7“ :vn-r— www- 7.". New“- mu..~ “Av ‘:~vv-'me~'v xwmm~m.__en.sw—_. mm _.m immv—rmc "cw. .ww-‘rwwm-u-ﬁ—Wrw—_ml -17- see significant in the convulsive therapy ptccess. The published data indicates thlt induced convulsions ame.associated with an inczease in intercollulsr scetylcholinc to levels greater than can be destroyed by cholinsstensse—I activity. Vascdilstion and increased cellular permeability are fblloued by increased amounts cf cholineetersse—II electrolytes in inter» and other enzymes and cellular fluids. These changes are hypersynchwcny which reflected in the increased electrical is recorded as EEG slow wave activity in scalp electrodes, and which can be modified by a wide variety of enticholinerzic drugs. In these reasrds, induced convulsions are more similar to cerebral trance, than to spontaneous seizures. The changes in the onrebmel biochemical milieu alter cellular activities sufficiently to be associated with altered behavior of subjects. Failure to induce high and persistent concentrations of ecotylcholine and Illiuwe to induce concomitant fbilume to produce behavioral electrolyte changes results in a ‘ change. Difﬁerences in the rate of development of cerebral changes reflect differences in the dependence of subjects on cholinergic mechanisms or in their sensitivity to changes in acetylcholine 1mm. mm differences provide the basic for the classification of the mentally The the mode ill by Funkenstein and by Pink and Kahn (1961). observations provide a rational biochemical basis for of action of induced convulsions in altering the �m" 'A "VI-v Ww—vv—n—u—m—«rrm mum-mam mm with tho mm «truer mmmmwrmawm -13.. of pomtie subjactn. 'nnu mm view mwopmsiologie—adapﬂm (Fink, 1957, 1962). an mistmt wavy expressed �_.,. m...“ ... .4. .. .ﬁ-a v “3-..."- w..——_ww «av—m... ”VWFI-WquwLH-‘M‘AW‘K' w-v'lw . . "m." Inn—www-Iw‘m v. "uvw -wu v rays-y‘— :—.- me‘n—I'“m 32mm Aird, R. B... Strait, L. A., Pact, J. 91., muncff, H. K. and Witch, 8. C. Neurophysiologic effects of electrically indwed convulsims. M’ch. Newt. rum. scum, 1956, 75: 371-373. Pram and actim cf acatylchclinch experimntal Bomstuin, NJ). trauma. 1. Nuanpkyuatu 19166, 9: sue-355. min Horritt, H. B. Effect of certain choline dcrivatim clactrionl activity of the cortex. Auk. “want. (6%.). on Runner, C. and mm. Human, A. S. V. and NacIntosh, P. C. The physiOIOgical significant of acctylcholim. In K. A. C. Elliot, I. H. Page and J. H. Qustcl C. C. Thoma, Springficld, 111., 1955: 37I4~375. (Editors), uwmmuw. mtfield, on Dewy, cortical potentials. Mu. Cam, W. “Viv P. O. and Tm, in epil’psy. V., Worn, Jo‘oquo. 1&3, 73: D. B. Grassland, J. 1950, 162: “SQ—MW. E. w. Effects of prostimine md acetylcholine J. Pkg/«20L, 19142, 135: 633~6u0. and D. I. Acotylchcline and mammal 59.639 effect of anaesthesia on the matylchclim commit of the brain. J. Phydob, 195%, 125: 56~66. Dale, R. H. Th action of certain «tau and ether: of choline. and their relation to maxim, J. Plummet. Exp. Thu., 1913, 6: 1'47. Elliott, R. A. (3., Swank, R. L. and Henchman, N. Effects of mﬂmtics and cmvuhmts on acctylcholixn content of brain. W. J. Phgual... Pink, H. A and Merrick, A. Tm unified meaty of the cctim of psychodynmic therapies. Pink, H. Effect of anticholimrgic agent, diethazine, cn EEG and behavior: Iimificm for theory of convulsiva therapy. Mch. Newt. (cued, 1958, 80: 380-4587. was “ch. Fink, H. Effect of mticholinomic on pcat—cmvulsiw electromccplaogm md behavior of psychiatric patients. can. Humming 1%0, 12 (2): 359—369. Emeh. ’ Pink, view. m. of action of cmvulaivu therapy: the mm'ophysiolosic-adaptivc J. Nwaoplgcuazu 3: 231-233. M. Pbdo Pink, H. and Kahn, R. L. thtintive studies of slow wave activity following cloctmstnck. Bactuzuccph. can. "wuphyuotn 1956, 8: 158. Pink, 14., mm, R. I... Karp, 2., Pollack, M., Gm, H. A., Alan, B. and Lafkcwita, H. J. Inhalantuinducad convulsions. ma. Gen. mama, 1961, In 259-356. mm, A. PL, Bales, P. D., Willis, md Himwich, H. 8. Experimental pmdwtim of electrical major convulsive patterns. Amen. J. PhyuloL, 1&9, 1H6: 117—1218. Mkenstuin, D. H., Gmmblatt, H. and A. new Mutt. 0.3., 801mm, H. C. Autmmdc chins“ ramming electric shock Mutant. mm 19%, 108: #094122. J. New. �.- “ 'E'mr u-men... Mountain, wumW,mu“... 1~w‘mww.w“~-mmmern“—"~—IJ...- mm, amnesia H., paralleling peyoholoﬁo 1951, 11”: 1‘18. D. qvp- —..,. WW me‘w ”Va-WV“..— mwmmwmvmuww W3 mantally ill paﬂlnts. 1. How. m. 01.6., H. and Solomon, H. C. Autonoiuio Menuhin, D. it, emenbhtt, M. and 301m, H. C. Autammio nervous system out of prognostic simfioanoe in mlation to alactmskndc treatment. P‘ymm. Mo, 1952. 1“: 3“?“3620 Gianna, N. J. and Pepeu, G. Drug-induced charm in bmin aoetylcholim. W. J. Fitment” 1962, 1% W233. A. and Hiwich, H. E. Effects of Mam, J., 33313, C. P., Manley, di-iaopmpyl flmmptmplmto (DEF) on alectmanoephalogm and cholinastarase activity. ,Eumamcph. can. “Mphysutu 1950, 2: Mil—ha. Basis, C. F... C. F. Hampson, J. L. Balsa, P. D. and Effect of trimthadima (Tridima) and other drugs on Madam, oonwlaions caused by di-isqwmpyl flmmplmphata (OFF). Ame-A. J. mum. Himioh, H. 23., A. H. 1950, 106: 816-820. Jonkner, P. 1.. no ladmer, H. The effect of Dipamol on the olectmmoopmlogrm in tho normal subject and in time with canme tmuna. EWmuph. can. ”meto' 1955, 73 303’3050 6., Ulett, G. A., Johnson, H., Sﬂth, K. and Sines, J. 0. Eleotmomwlsive thrapy (with and without atmpim); affect on Johnsm, I... analyzed ahctmanoophalogmm. chemically 2: 32u-336. 1960, Melt. Gan. Paychiot” alum, M. and Knaub, V. Quantitative estimatim of the Kabat, E. A., albmin and gamma globulin in actual and paﬂmlogic oembmspinal fluid by nomads. MM. 1. Mad" 193:8, *3 (5): 653-662. Wm Kovada, A. G. 3., meo, A. and Halmagyi, M. hm Hamid"Wit Aoetyldiolina‘omtmt of the brain in traumatic smdc. Aotc Phyaiozaglca (HungJ, 13: fiber Lou-vi, 0. Meir. £. 4. gas. 14. our Hemmnwﬁkmg. 1921, 189: 239-»2u2. Haymrt, E. W. and Buck, E. 6. Effects of C.N.S. Dapmsmts on Brain Aoatyloholim. 19M, 6: 191. Wtagut, Heisman, H. and Elliott, K. A. C. Effects on omvulsmt and narcotic drug on aootyldxolim aynﬂnus. 1. PM. I Expat. Thump" 19513103: 35. mam. Wm, specificity of We in mm D. and Studies on cholimtama: on tissue. 1. Biol. (than, 191:5, 158: 653—666. M. A. Ridxtor, 1). mad Crossland, J. Variation in acetyloholim’oontmt of the brain with physiological stata. J. Phyatolu 19%, 159: 2h7-255. W. Rosa, J. '1'. 'me We; Menuhin hat in the ~ A mview of the literature. Add mdor barhitmte anaesthesia produced by twain-mt mad their simificmoa for the theory of M clam-awake actim. Enougmuph. can. Managua" 1951, 3: 261480. Roth, )4. EEG �Both, 15., Kay, D. W. K., Show, J. end (keen, J. Prognosis and pentothel induced electmnmplulogmphic changes in electm—omvuleive treatment. summaph. can. Nemphy‘iol” 1951, 9: 225-237. Spiegel, E. A. and Spiegel-Adolf, H. Permebility chmgee in the brain induced by tamed and insulin cannﬂaions. J. Nuv. Max. 91.5., 19‘31, 93: 750—3755. Spiegel, E. A. and Spiegel~AwlL H. mysiooodieuionl effects of electrimlly inclined cmvulsime (mmbmepinal fluid studies). Tum. Mu. mm. 1455., 19%, '70: 130-132. Spieaal, E. A. and Spinal-Adolf, H. Physiological and phyuicodwmicel mechanism in electroshock treatment. Conan. Newt” 1953, 13: 38-53. Spieael, E. A., Spinal-Adolf, H. and Hem'y, G. mysiooodxdical changes in the brain electrically induced convulsive discharges. marina Tm. m. Newt. Au" 19M, 68: 17h. Spinal-Adolf, M., Wilcox. P. H. and Spiegal, E. in electrmhodc treatment of psydxoees. Mae 19.48, 10“: 697-406. Stem, We Tom, H. E. 1. Pk”. The mole Me, A. Cerebmspiml fluid m. J. mama, of acetyldwbline in brain mtebolism and fmctim 1957, 36: 222'255. Effect of omwlsion inducing agents in the amtylcholine content of the brain. J. Phyeutn 1953, 173: 179—183. (2. m. Effects of single injection of corticotmpin (ACTH) on We, ion and emtyldxolim ambmt of bmin. Ana. 1. Miguel” mnim 1953, 173: 1764.78. C. Wm, and patterns wetyldmline in the oemhmspinal fluich 0011th a. Aoetylclmline ma neumml activity. I. ﬂower, D. B. and of patients with maimmbml mm. CW. 1. Quench, Tatar, Wehem, 27 lQuQa, (Seat. E): 105-119. D. B. and dnlimstemes in hm 1949b, 27 (Seat. 13): mutant and characterization of mmbmspiml fluids. Canad. J. Rum, D. 'Ihe 132-1'45. Acetyleholine and neuronal activity. Worn, II . Acetylmolim and dwlima‘hmsa activity in the Tuner, D. B. and D. fluids of patient: with epilepsy. szm'. J. (Sm. E): 120‘1310 Ulett, G. A. and mbmspiml RPAWA’?, 27 1mm, datum, M. W. Effect of atropine and soopolanﬁne upon eleetmenceplulogmphic charges induced by electm-oonvulsive therapy. Euwameph. can. Namaphguot" 1957, I: 2174224. Ward. A. A. Atropine in the treatment of closed head injury. J. Newsag” 1950, '7: 398-402. Ueeeoe, H. C., Green, R. Wm, of atropm md aoopolauim on the 3., B. P... and Kmp, S. central effects of DFP. Wt. The J. inﬂuence �DEPARTMENTAL CORRESPONDENCE DATE Julx 29z I965 SUBJECT Cholinergic Mechanisms in Convulsive Therapy To.“ Max Fink FROM George A, Ulettz MODo A most interesting paper, well put together and documented and with which I MoDo DEP'T DEP'T am in the main in agreemento There is one minor typographical error on page l2. GAUzlz �CFDLINBMC W315 WV!) IN Max W Fink, PM). mmmpmmotpmmnmmsmmmma Paydaiatzy, (immunity of Iii-semi. Sdml of Medicine SHOO Arsenal Street, St. Innis, Missouri. 63139. , Aided, in part, by usms grants ”44.921, 114-2715, ail-mus, md Iii-11380; ad the Psydiiatric March Fomdntion of Missouri. �VI: 7-17-65 WCWHWIVEW Despite mm application and study, the nod: of action ofﬂnccnwhivethmpmmnminsuﬁmic. Matudy mmmdtomumphysiological( paydwlogical( social ). clinical ( ), ( and aspects, elucidating me pmaent nam— ) phyaiological-«laptiw ). View of the process ). ( 'lha amply dnvalcpmnt and persimmon of signs of altered cerebral fmctiun mm mpomd to be requisite to (Pink md Kahn, 1956), with mess in behavior 0100*:ch slow wave activity as the mat significant index of altered brain function. Thu this Mien slow um that pmddcatim with ampina inhibited ‘Jormcn, 1957) and the report activity (Ulett and that antidxolimrgic a mm nursed these clinical ahatmgmphic alarms (Fink, 1958) 311mm that .me biodmnical basis for the convulsive therapy process the clnlimraic m as wall may be in of the central nervous system. This raviaw discusses the available data agarding acatylcholim ﬂ �and the dwlimstemes in the convulsive therapy process. Acetylcmline has been extermively studied m an active agent in the transmission of dowdptiom of Dale mm impulses since the It is (191A) and Loewi (1921). first a comtitmmt of mmm tissue, existing in a bound form which is liberated during the excitation process. It is rapidly hydmlyud thrwgh the specific action of duclinestarase and in rapidly momstituted by the ohcline~aoety1ase system (Rid'ater and Crosslmd, 19W) . In noml cembmspinal fluid, free acotylchclim is not present despite the mpid bound and breakdown of acetylomline during periom of activity and excitement (Tower Wm, 19u9a). The cambmspinal fluid does have measurable dwlinesteme activity, havever, principally of the "two" or mdwlyl hytvlyzing type (Madam and mm, 19%). In the absence of free aoetyldxomle and mdar the conditions described, electroencephalom fail to show abnormality. �(a) Grahame ﬂats of sootylcholim was found Crmiooembml Tram: Prue in the osmbrospinal fluid within a few minim after sxpsrimtsl Mad trauma in cats md persisted for varying periods up to “8 hours (Bomstein, 19%). The quantity of ﬂu the amtyldmlim varied W1: was (:th between 2.7 and 9.0 gm pennant, and related to the degree of induced mum. shotmsnoephalogmms amazes. me mooxds were demtmted pattmd first filled with activity, immuted as svidsnoo of high voltage fast an intense neuronal distant-3e. soon to be sumedsd by a short period of flattening of all recorded electrical activity. These phases wen then followed by pmlongod periods of high mlitude sharp waves- in ttwdcltafmqusnciss. 'msbehaviomlohmgsswsmmlatsdboﬂitothsdsgmsof mmmd to tho want of mmd fme amtyld‘nline. Vth highcr lovels of amtyldlolim, Bomstsin reported greater dogmas of EEG Why and water changes in consciousness. �31>th wt post-traumatic seizures ware also related to the of fme acetyldwlim appearing in the Spinal fluid. Bomstein applied amtylctnline to exposod cat cambml cortex. When the concentration of amtyldxolim percent or lass, higx amplitude slurp waves appomd in the electxmmaphalom. When was W6 t0 2 gm percent. was 1 gm of low frequency the concentration 01.0meth the 1000160 fashion the patetzmnatic flatumed in a parallal to Parallel investigatima in neurological patients by and Wm (mm dumtmtad free Tower acetylcholine in the cerebmspiml fluid only in patients with meant head tmuna, meant wand-ml seizures or after alectmcmvulsiye therapy. M0 amtychlim varied fluid spinal assaying from 0.2 to 0310111103001”: 100 gm peasant. In activity, they noted a sharp rise in the nonspecific dwlinesteme fraction (Mmoylcholim-splitting) and a dmp in the specific cholinesteme fzmtian (mohaiyl—eplitting) in patients with had tmma and sanguine convulsiva therapy. The cambmspinal fluid did not �exhibit such invemion, although after it contained free acetyldxolim, spontaneous seizums . They concluded fr“ mtyldzoline varied directly with the damage and that the level of degree of cerebral that reversal of the dualimeteraae fmetims was a mm sensitive indicator of cerebral dmgc. Electmencephalogrmna, taken at arming intervals fellowing minim between the dagme of tram, also indicated a EEG-Wt); md the appoamm of free amtylcmline in the cerebmspiml fluid. mm Wkwwm Tim «the, 4;me We! mm 0‘ due magma-u. may tame in the (cumming {m autgtchouu, abnombbty, and WW «the. Mg“ W“ W. «tam and the want chalk.“ and type 0‘ 4'.» 05 demomuphalogmpuc dialed mm); «ppm «6 �Antietam} (b) bahavioml and mutual m and trauma: mmlogio signs of mum The m electrogmphic, blocked by tbs awninistmtion of 0.5-1.0 Wkg ntmpim (Bernstein. I 1986). as was similar inmcistml clinical change” mowing after the additim of aestylchcline. Ward (1950) applied injtmida. those oboemtima to tbs tmatmnt of closed head In 20 of patients with varying dean-e3 trauma, ha administamd mopim WW1); immt in some and in doses of 0.1 m/kg, noting clinidal a mml effects in others. In a study of diethnxine. Jonkner and the W at the W forty patients with anticholimgic drug, altemtiaw in (1955) mportad post-mmtic aloctmcmophnlnm. dose in electroencephalographic W A sinﬂe intmvamus electroencepmlogrmm resulted in normalizing in twanty-tm and marked inpromnt in six otham. Similar observations have been Imported by Denisamco (1965) using mthyl‘bamctyzim and poat-atrmmtic mmtin in animal that and 03li em. ewinmta of �Truss obssmtims were assasssd in the convulsive therapy process by Ulstt and Jornsm (1957). These workers administersd dosages of atropine w to the patients waived that the mt: mm slsctmsm of slow wave per day during the weeks therapy. They downstmtsd activity prodmsd in those patisnts ms significantly less than tbs control group who had not received the atropine ministration. (In a 141th study these authors fdlsd to mplicats this study, suggssting that dosage factors or population changes have contributed to different msults [Jormsm These observations provided the basis g}. 31., 1960]). for studies with othsr imam anticholinsrgic mounds (Fink. 1958, 1960). hummus JB—336 arid Wins. the pipsridylbsnxilntss JB-329 (131mm). and WIN-.2299 induced dssmhrmiutim in psychiatric subjscts. These Hum The injection of smrimntally active anticmlinsrgic camels as disthssim. JB-ala, may EEG EEG changes associated with barnvioml darting, anxiety, tramm, illusions and hallucinatima. In patients also had mently - �mind elootmoonvcnsivs the achsinistmtion of throw, these Imomds was associated with a mduotion in slow awn, mm wave and 'eonnnion. activity and reversal of Aunpim was also examined in low doses, and in these administmtims, EEG dosynctumizstion ms obsomd nervousness sod tension. At highnr dosages, hypersynchrmous slow waves, followod by lower activity with menisci by tachycardia. mimosa wings. poorly organized delta bots activity melamine: by pmmssivo confusion and disorientation. Both in oleotrogmphic annual tum and indwed convulsions, the 0W8 may be mdified by the commont (hogs, administratioh of mticholinargio thus suggcoting that immaud smarts of aootylohlim or inorusod oholimrgic receptivity is sssoointod with the high voltage slow wave activity. (a) min and iomlino anticholimm gm m: SimilanEGorangesandtublookingthmmnobumd following the dinct application of mm systm. sootyloholixu to the mm]. �The aministmtim of a omlineeteme inhibitor- DP? (di-isopmpyl fluoroxmospheta) elicited high amplitude rapid frequency We 19mm, EEG patterns similar to status epileptious, as well as similm to those of post—hmtio states (Freeman 33 11., Hanson Egg, effects were blod<ed 1959; and Himioh by small doses 339;, 1950). These EEG of parenteral atropine. 'me great increase in aoetylcmoline after tetmtthyl pyrophosphete was (TBPP) manned and related to the toxic misfestetims and omvulaims induced (mm and u: thfield and Dempsey 1952; Stone, 1957;) (19%) prepared exposed animal cortex with pmstigmim md evoked electroencephalographic spike activity. The prior mistmtion of atropine blocked thio spiking, the almomality oould be eliminated present, by or if atropine. In contrast to those finding, Emma!" and Merritt (19%) applied topical aoetyldxolim in concentrutima of 2-412 to to the exposed cortex of cats, and noted no effect on 10% the electroencephalographic changes after intmwnous atropine (1 mg/kg.) 'lhe concentrations of acetyldtoline in these experiments, �10 however, were higher than the and the gm topical applications (l-‘t intrusistemal (0.2-10 gm percent) percent) injections of Bernstein (19%).. Burner and Merritt also made note of elem- encephalogmphic effects similar to acetylcholine from motion/1 (emtylhetmthylcmline) much lower than the and cloud (oerbanyldlolinﬂin mtyloholim concentrations. They cmoentmtims ascribed the increased effectivems of these diolinergic drugs to their lack of sensitivity to cerebral almlimstemses. These data are conflicting and further study is museum to qualify this issue . (c) Oembxnsgiml fluid Amtxlcholine and Seizures: of aoetyldiolim metabolism indicates that it is One View fomd in nervous tissues in an inactive band fem. hiring periods of activity, amtylcholim is liberated at the cell dsectivated rapidly by mm, dwlinestemse. The where wt it is of bum asetyldmolim is the resultmt of the continuous processes of synthesis, liberation and bredcdmm. It has been postulated that the level rises during sleep and falls during activity. (Richter and Cmssland, 19%; Elliott, Swank and Hendersm, 1950; Giaruun �Pepeu. 1962). By using liquid air quick freezing methods. Richter and Grassland measured the level of acetylcholine (micro- gem per brain tissue) during anaesthesia and sleep to be mg. 300‘ higher than post-“12m levels. The difference in tissue levels is tnansient. however, as the resynthesis rate for acetylcmline in net brain in high (1950) confirmed m1. the” owemtiom, also Pepeu (1962) fomd an increase 3 noting that after gm per cent. Gimmn md in wetylcholine named by a central nervous mum depressants to be roughly reduction in and no mm activity. acetyloholim we reported in the spinal fluid in patients withepllepey (Cone, and PbEeahem. 19149 1)). 0f 55 'Ibwer and mascara, 19%; epileptic patients. demetmted free acetylcholim in quantities of 5.0 M proportiml to the degree of depression of the central nervous system m :3in convulaims free wetylcholine me demustmble in the spinal fluid in concentrations w to 1;! gm/gm/minute). Elliot (7 with 1.0 of an cent average per gem gamma Tower an (77%) 0.02 to per cent. �12 Acetylchclim levels were related to the frequency of seizures, ﬂnextentofelectnnncemelogmphicmmlity,mdtothe the since the lat seizum, but bore no relation to medication, type of epilepsy or level of clnlinestense eotivity. Tower and Maﬁa-hem (1904912) vimd the increased acetyldwlim a by‘prodmt of the seiem, Studying the hypothesis that the and not camel . emetim of ecstylchcline indmed minutes, 'l‘orde (1953) measured the level of ecstylclwline in brain tissue netmmle convulsims. .‘ She noted a rise in the ,_ V V ecetylcholine content of brain, before a seizure and a the cmvuleion. Below fall (bring certain levels of ecstylcholine, convulsims failed to comm. Stu suggested that the fall in tissue acetylmolim during a oonvulsim was due to imibition of ecstylcholine synthesis by increased concentrations of metabolites such as mnium ions. Wmmmmumdohmgesmmmmm system acetyldmolim following various stimulmts . Only after �13 unholy]. and 3, S-dimthylbutylcthyl-barbitmte significant chmge in the acetylcholim level. damn. was They noted a in associatim with induced convulsions. drugs which ﬁrearm as stimlants Md mmmdumainmtyldmlim + other With 133mm, (LSD, hymoxytmyptaphm and iEprmiazid level. there a + DOPA) them WWW daspito inﬂame excitation produced by these commie. them wan no dung» in mtylcholim level unless than were accompanied by convulsions. (The differences in observations botmmmuwerkmmdmggglmdmmrmdﬂcﬁadmm my be in diffemnaas the to related mummnts, for thc latter methods of biochemical wand changes in spinal fluid w 61m and Pepeu mﬂecting the fun acctyldxolim,‘while 12; bound and reflecting acetyldwlim mumdntatal true form of aoetyldzoline.) Thu: Atuau wages: that on: Wed by an sputum Lame. in an. induced 1mm law 5n: awtytchaunc �”mm—“hr“ V» 3- ‘ v w» . m w 1-: “r. 0... ~ W "n , nr-r-w, ..-.p:..u<ﬂv.»rrw-¢.M “av—w. . .,. 4. ....“.,_. w... ,, 'zs-sznr-W"“air‘quvww'ﬁ'qmti'd‘u. w. » ,‘rv —.».‘ wm‘ , w - 1n abound 4m in bound (on which my wind. (Laid. Cmbm nativity Micheline dalmatian, manna. Lemming mum 15qu in #1: enhauu tame (cum 9‘ Me blew and Mama auguwut mallow: madam“ 42mm aunt (d) Comm]. Nervous Wm and be mm . Sgt” ('holinostemes: (19%) also uncured spinal Tower and ﬂuid cholimsturase activity. No types of dnlimstemes are normally found in the spinal fluid: dwolimstemad ”true," "Specific," or Molyl-hydmlyzing) . whim has a high specificity for acetylcholim; and dxolimtemacu-II ("pseudo," or bonmyld'uolim-hydmlyzing) . "mpacificﬂ Both oompomds hydrolyze acetylcholim but have diffmnt rates of hydrolysis for mcholyl and bonzoyloholine . 'mis differmtial mta permits qualitative diatimtiom. By reporting the cholinostemse activity as a ratio of the activity with a mocholyl substrate and with a homoyldmoline substrate compared to a substrate of acetyldmlim, two ratios are fomd: dzolimsteme-I/wetyldzoline . --- v r v , -- ‘ ~- a"; . ��rmw, 16 vasodilation and increased with a degree of cellular permeability may be pmdicted. amudetion of vascular fluids into the inter. the of duration md with extent the varying cellular spaces g: vaaodilxtutim (Rabat mad their comma pomability such 51;, 19%) . Spiegel, Spiegel-Arblf, (19%, 19W, 19%, 19%, 1953) chm demtmted and increased oonchwtivity of the ions (as various of with the associated appearance tissues potassium and phosphate) in the spinal ﬂuid following electrically indwed convulsions . Such non-electrolytes , as nucleic-edit: splitting mama , also increased. Ganges in cellular permeability @6011th may thus provide the basis for the high of aoetyldzoline and the increased concentratiom of aholimstemse-II in induced animus or head and We!“ The head 1989c.) . persistence of acetyldxolim in spinal fluid after tram activity tram (Taver- and may be after seizm'es despite increased cholinesteme related to the sensitivity of the acetyldxoline- dxolimsteme-I system to meantmim relationships (Nadmm W. , ~1— ~- A” .—,.- �17 and Wu, 1935; Tower and Wm, muse; Burger: and McIntosh, 1955) . At "physiologic" comantmticrns, hydrolysis of mtylcmlim is rapid (3-4 lunar com—um, MW) but at higher and the activity falls off quickly . In contrast, the dialinastemaun acutylchclim relatimship is map-cite and the rats of hydrolysis incimma with increased: ammunition. 0m view of these mktimhips suggests that while the usual concentrations of mtyldmolim a cell dostmyod by the specific activity of few Wounds, my «and the seizum are dnlimstomeJ in a m excessive concentration following excitation the mate of hydrolysis by coir-m Mahala mnbms may be itself cholimstcmeJ. m reached and a seizure inclined, with adding to the mum: of free amtylcholim. The immune! acctylcholine diffuses rapidly, affecting vascular and annular pumability and imam; the mntmticns of various iom and dmlinentemmn in the of molimateme-II , though of low 031". The activity efficiency and depending on ��in brain tissue, associated with the appearmoo of hyper- (delta bursts) in tho electroencephalogram. syndmrony We was have oonﬂmd the many pmvim reports that convulsive thumps: induces elootmgmphio hypomyndarony (Pink and Kahn, m 1956; 93. 93;, 1981) . mutants than is mom. slow by m Despite a constmt application of a great variability in the the W103! and the exam of the alcotmgmphio mitivity activity as well as the alerting. hypeantilatim synchrony and in psychiatric dew hyper- its persistence thmmlmt a treatmt has boon described as pmmquiaite to It is to mdifioatim and barbitumtes populations . 'lhe early appearance of high Week tins of (Roth, 1951; Both 93.2%, mm 19531;th possible that the £15.fome in EEG-hypemynduw my be of central oholimrgio following and @,1956) . induood the dogma of muted to differences in the activity ”Wm . patients to develop hypomyndmmy pnoluding a clinical me name me failure of certain may thus be associated to Wood convulsions. Tower �.. 7.7. wrunvx—u— 20 and Will“ (lauea), in ﬂair study of mommbml tram, included obaawations of six paydziatrio patients mdergoing convulsive therapy. Studying the patimts aftor 3.7 momenta aootyldaoline in two patients; may mpootod free spinal fluid and an imam in (momma—II mumstomod with and a demase in a reversal of tho mti-o of mono-stoma: in five of the six patients. hm those observations they minded that the spinal ﬂuid dmges in induced convulsions mmmliketmmofcmimmbmltrmmanﬂmoof spontaneous epilepsy. Boarding the one pttient in the series failed to who show either true wotyldmlim or a duolimoocmse ratio reversal in the spinal fluid, they wrote: patimt was Mt." "It is interesting that this the only one of the six to show no rospouso If electmgmphio hypemyndxrmy is of inommd {me acetylcholim , subjects whammy and those in whom it who to a reﬂection maintain hyperh disappears rapidly may be exhibiting diffemnoes in the kinetics of the d1011nestemse~ wm. w,- Nx‘vrpl .1 �-\ “ --~w an» .7 r'v-vww-‘ 1". -.r Ti'prp"-ﬂ-=Au‘n “-6.“..- ~-‘ ‘31 . W W . , “‘7.dvzw‘". V... mu. metw'w—mwmlv‘lu":.e.vrlvn—“Atm-‘mWW w-xm “m.- Y‘a""' 21 acutylctwlim hydrolysis system. 'Fhmistant hypemyndumy result dsmd {mm a may rate of hydrolysis of acetylemline, associated with low mnemtmtions of either molimatemsea-I with shortin patients '(Oonwmly, dlolimutcmc-II . or lived hypemynduw, dxommteme—I md -II in tissue and spinal fluid PM: be mmually him) . may that: anomalous was 0&0:va «wanted “W‘m, «shaming the We. an: WWW a EEG 51prwa 1.5 a; Lgtu at WWW paovtde We in We mwmum.‘ wumtuuu. Mad one WW W pubable that saw! an that induced Wag embmcpweabuétym and It a on would coucmde aw by The Level. 05 upcmd Mad .5qu . mama of pmabuéty Mud Law 05 exhale. ﬂzuc changes in 05 «anaemia. mm deem- m mama: 4mm (an m pmumx chugu foaming induced 0.0qu . w ..—-.w-w~.-w... �K. i [ ‘ v. ,7 W .. f m .l . V, ». V, ,,,,_V -. .o “:2 ....V ﬂu, ”w...“ - w-wﬂl’m'." ”no”. .7 ..n “w... amp-“mm- "...v'vmm. ._, f.v-w—«-—v~—— v0?" m—v‘ wkumu. , 3‘“ .7 a run ,. . -- 22 (6) Gaolimtemes Thus studies may and the Classifimtim of Paw: also have applicatim to the problem of ‘ automic Inactivity mum and the clansiﬁcatim of the psychoses . and athora ( a «Miami-nip between ) true blood haw ”castrated pmssum response to injected madmlyl an! the clinical mponae of psychiatric patients to ammlsiw whim ﬁlmy. lel is a potent cholimrgio agent mm, mama vasodilation, tadxyoardia, peristalsis. It is rapidly hydrolysed by and W6 diolinesteme-el and :11me by dzolimstemse-II . Tbs blood pronoun of subjects fall: after injected mohalyl within five to more than 20 md mtums to the basolina minutes. Patients whose blood E l I i plum returns to the baseline within classified as Group panama takes 20 Group VI and VII 5 minutes have boon I. II, or III mentors; those whose blood armors minutes to mtum to baseline, as rumors. Group I md Grow; IIoIII motors �23 have a 9 and a 35% recovery rota, respectively, while Group and Group VII reactors 9:92;, 1952). Group patients in whom 89% and 97% recovery rates I to III reactors may be VI (Menorah looked upon as the injected morolyl is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. We may predict, therefore, that the blood cholinestamsa activity levels of Groups I-III would be high; while the activity of Groups VI A - VII would be low. similar analysis may be made mgarding central nervous uysten levels of cholineatemmel in the development of Em hypersynolumy and spinal fluid levels of acetyloholim, providing a basis for a oongment hypothesis mgarding central nervous system reactivity to induced convulsions dmolimngio agents. and to peripheral �. ..— .—\..‘ .. .—Vw-~'. 7...... "any.” “.7 lmr.r"vv,~ .. ...~ y.. . _,_,‘ , ~~,.. m. .WWV mm. rm. ~ v-y ‘ WV W H .wa-ﬂq 2'4 CONCLUSION : Central oholinergic Insomniac: appear nah- W in!» in the convulsive therapy process. ‘ significant The published data [that induced convulsions are indicate associated with an increase: in interoelluler acetyloholme to levels greater thm can be destroyed activity.“ Veeodiletim and increased are followed by increased other enzymes and by cholinestemse-I cellular permeability wants of cholinesterese—II and electrolytes in intercellulsr ﬂuids. These chmges are reflected in the increased hypereynchrmy which can be modified by is electrical recorded in scalp electrodes, and which mticrnlimrgc drugs as atropine, benactyzine, and diethazine. The changes in the cerebral biochemical milieu alter cellular activities sufficiently to be associated with altered behavior of subjects. Failure to induce high and persistent cmcentrttions of acetylcholim and failure to induce concomitant electrolyte changes results in a failure to produce behavioral change. 4'u-L...» 1.x. —~- -- 7 �2S Diffcmnoos in the mates of development of reflect diffemnoea in mbml that ‘0me of subjects on ohangas cholinergic ruthenium or in their sensitivity to changos in aoetyloholixm levels. Then diffemoes provide the basis for the classifica‘ tion of the mntally “most: the mode ill by Pmkonstein and by Fink and Kahn (1961). observations pmvidu a rational biodnmical basis for of action of induced mnvulsicns in altering the buhavior of psychotic subjects. These views are consistent with the mom general neurophysiologio—adaptive theory expressed earlier (Fink , 1957) . �REFERENCES M, R. Bo, Stmit’ L. A0, PM, do We, “muff, Mo K. ma Bowditch, S . C. Nemphysiologic effects of electrically induced ccnvuleicm. Melt. Peyehiet. 1956, 75: 371-378. ”Wt. (cum, Bomstein, M.D. Presence and action of acetylcholine in experimental brain trauma. 1. Nwophyeutn 19%, 9: 3%«366. Bummer, C. md Merritt, H. H. Effect of certain choline derivatives on electrical activity of the cortex. Mch. Munoz. Psychmt. (cum, 19ﬂ2, H8: 382~395. Wu, of ecctylcholine. A. s. V. and Macintosh, 1-“. C. In K. A. C. Elliot, The I. physiological sigiificancc J. H. Springfield, Ill... H. Page and Queetel 1955: 37u-375. (Editors), Numchmmg. C. C Thomas, Omtfield, P. 0. and Way, E. W. Effects of proatigmine md acetylchcline on cortical potentials. Mu. J. P11544201... 1m, 135: 633~6H0. Cone, W. V., Toner, activity in Wm, D. Acetylcholine and neuronal and epilcpey. J.A.M.A., 19%, 73: 59-63. D. B. Dale, H. H. The action of certain esters and others of choline, and their relation to marine. J. thueol. Exp. Thu... lSlu, 6:1»7. Elliott, R. A. C., Snark, R. L. and Hmdemcn, N. Effects of mathetics end ccnvulsmts on acetyldmline content of brain. W. J. "15161.0(" 1950. 162: ass-hm. PM. M. A unified theory of the action of paydzodynmic therapies. J. Hill‘idl H06p., 1957, 6: 197-206. Pink, M. Effect of mtichclinergic agent, diethezine , on behavior: simﬂcance for theory of convulsive therapy. Adah. Mental. Paychiat. {Ch£c.). 1958, 80: 380‘387. EEG and Fink, H. Effect of mticholinergic compom$ on poet—convulsive olectmencephelogxm and berminr of psychiatric patients. Eummuph. cu... Nauphyuot" 1960, 12 (2): 359-369. Pink, H. and Kuhn, R. L. Qumtitati-ve studies of slow wave activity following electroshock. Eucmemph. can. ”canophyaiat” 1956, 8:158. Fisk, M... Kahn, R. 1..., Ken), 2., Pollack, H., Green, M. A.. Alan, and Iefhowits, H. J. Inhalmtoinduc-d convulsions. Mch. Gen. 1961, “:259-266. mm, ' m, Bales, P. p., Willis, A. md Hinwich, H. B. Experimtel production of electrical major convulsive patterns . W. A. J. ”twin-L" 1%9. 1%: 117.12“- B. hymn ��an'V-WI' -3Spicgol, E. A. and Spinal—Adolf, M. Physicochemical effects of electrically inclined convulsims (cambmspinal fluid studias) . Tm. MM. Newt. AAA” 19%, 70: 130-132. Spicgel, E. A. and Spinal-Adolf, H. Physiological and mysicochomical Marxism in tmatmnt. Conga. NewwL, 1953, 13: 38-63. 013::th Spiegol, E. A., Wm Spicgclmlf, changes in the brain H. and Benny, G. Physiococl'xcmical electrically induced convulsive discharges. Tum. ML. Haunt. MA... 19%, 68: 17a. Spinal—Adolf, 14., Wilcox, P. H. and Spiegel, E. A. Cembmspinal fluid menses in electroshock treatmnt of paydzoces. Mu. J. mm” Stone, H. E. The role of acatyldmolim in brain metabolism and “mm. Tom, m. J. M0 M9, Effect of convulsim content of the brain. Man. J. C. 1957, 36: 222“255c inning agents much, on the acetylcholim 1953, 173: 179.183. Tonia, C. Effects of single injection of corticotmpin (ACIH) on manium ion and acetylcholine (intent of bmin. MM. 1 . Myuol" 1953, 173: 176-178. Acctylcmline and murmal activity. I. Warm, Gnumtomso pattcrm and acutyldwlim in the cembmpinal fluids Tower, D. B. and D. of pationts with armiommbml trauma. 27 (seat. E): 105“].190 I cm. 1. Rucauh, 19u9a, cmtent and dmmcteriatim of cambmspiml fluids. Canad. J. Rumch, Tow-r. D. B. and McEachcm, D. The hm 27 (Sect. E): 132-1u5. dwiimatcmes in Rush, w Tower, D. B. and HcEaclnm, D. Amtylcholino and neurmal activity. II . Acetylcholim and cholinestcme activity in the cembmspinal fluids of patients with cpilnpay. Can“. J. Image, 27 (Seat. E): 120~131. Mum. “We Ulott, upon Rum, Effect of atropine md scopolminc changes indumd by electm—conwlsive G. A. and Johnson, H. w. can. MthyAioL., therapy. Ward, A. A. 1957, 9: 217-22u. Atropine in the treatment of closed head injuzy, J. Nwww., 1950, 7: 3984402. �cmLINElEIC WIﬂiS, AND BEHAVIOR CONWLSIVE TIERAPY Max hm tha Pink, M.D. Wt m1 of Psychiatry at the Miami. Institute of Psychiatry, University of Hisawm'. School of Hedicim, suoo Stmet, St. Louis, Missouri. 63139. Aided, in part, by USHiS grunts $1.009”, I‘m-2715, ”ii-07239, and Mil-11380; and thc Psychiatric Recent-h Poundaticn of Missmri. 'mismportispartofﬂnstudypmmminhmctimand Behavior" undertaken New York. Hillside at Hospital in �n -.v-..ww.nmipv~.. NJ, mi V: CHOLINERGIC MECHANISMS, CONVULSIVE THERAPY, AND BEHAVIOR Studies of induced convulsions have m that the early develommt and persistence of aims of altered colonel function are prerequisite to chmgee in behavior (Pink and Kenn, 1956). Electmemptmlogmphic slow new activity was found to be a significant index of altered bmin ftmction, and the dmnonetm- ticn that premdiceticn with atropine inhibited this slow activity (Ulett and Johnem, 195$) suggested a wave relation to cholimmio melamine. In the following review the mle of acetylcl'olixn and the axolineetemeee in convulsive therapy is diamond. Aoetylcholine he: been extensively studied as an active agent in the transmission of nervous iwulses since the descriptions of Dale (1911;) and loud. (1921). It is first a constituent of nervous tissue, existing in a bomd form mich is liberated during the excitation process. It is rapidly hydrolyzed through the specific ectim o rapidly reconstituted by gelimetemee and is the cholimﬂeoetyleee system (Richter s V 6~28~65 , �Croeslmd, 1909). In normal cerebroepinal fluid {me eoetylcholim is not present despite the rapid breekdom of bound ecetylcholine during periods of activity and excitement (Tour and HoEecMm, lease). The cerebrospinal fluid does have neasmble ctnlineetemee activity, beaver, principally of the "true" or mctwlyl hydrolyzing type (New and ibthenberg, m5). In the absence of free acetylcholine and under the conditions described, electroencephalogram fail to show abnormality. (e) Effect of ﬁrmiocerebral was Item: Free eoetylclnline fomd in the cembroepinal fluid within a few minutes after- experimntal heed periods up to '58 tram in cats and persisted for varying hours (Bernstein, 19“). The quantity of free ecetylcholim varied between 2.7 and 9.0 game percent, and the mount me related to the degree of induced Concurrent electmmoephelogrm The records were first filled he followed by e demetreted patterned changes. with high voltage fest interpreted as evidence of an intense to tram. nemel activity, discharge, only short period of flattening of all recorded �alactriaal activity. periods of high 'Iha These phases were than followed by prolonged mlituda sharp wam in the delta fmqmncies. behaviml chmgea wan nlatad both to the dame of amt of masmd trams and higher haul: of acatylcholine, of amornality and EEG to tha addition, spmtmaous to ﬂu matar With Bernstein uportad snatcr degrees (mange: poet-Me aunt of free fm aoatylcholim. in consciomnass. In aaixums «am also ralatad amtyldlolina app-axing in tha spinal ﬂuid. Bomatain also applied acatyld'zolim to exposed oat cambml cortex. ”Mt When 01‘ tho omeantmtion of mtg/lanolin. 1808. fraqmncy in the was inmasad to ht EX: vaporized high amplitude sharp waves electmphalogm. “man ’7 2 was 1 gm pamt, wam by Towar- and HoEaeham of law the oonoantratim the alactmonoaphalogrm flattened in a fashion parallel to the Pamllal studies ' post-Mic ram. can'iad out in mlogioal patients (19%”. Pm: acatylcholina was fomd in 7 1 {wéli 14?”! [6cm �«1—. . ;_.... 7,. rm. . ‘ 4‘1"“.7 .. run-- «m w, raw-"aw ~~.w.:-v-w—.--lam—www—nv-rwww - the cambmopinal fluid only in patients withmoent Mad wv .r'. r tram mount pond-m1 seizures or aftor convulsive trunpy. Free ...;—--°-"“' " aootyldioline varied from 0.2 to 100 gm __ ~ peroent. _,,./ Tour ~ v. m3...» Mom also assayed spinal fluid oholimtome activity, rating a sharp rise in the nonspecific cholinestemse fmctim (benzoylclwlimqmitting) and a drop in the specific oholinestemse the oeubmopiml fluid did not exhibit such invasion, although it “dined fm mtyloholim. of They concluded fm mtylcl'nlim varied directly with the damage huge. taken at varying intervals following Kantian batman the dome of {m EEG was a mo Electmmoephuomm, tram, also indicated a abnormlity and the appeazmoa aootylcholine in the umbmspinal fluid. Thu, ﬂu spinal dogma of oombml andhat reversal of the dwlinesteme fraction sensitive indicator of cerebral of that the level want as 549.: Micheline. my {mug in the (Mdéaltmiugmuocmbwmmmdmmuntaé Wt / W“ _4___._.._..-' follavdng oonvulaivo mommy. Pollovim spontaneous soizums 01W, 4a.: \ and fraction (mohalyl-splitting) in patients with had 12mm and , �.5and the degue acotylchoune, (no Wenuphdogmﬁic «type 06 abnambbty, and changu in clinical bellow»! my be {Wad phenom. (b) antioholm Am1m, o behavioral and neurologic aims of pamtenl m mm and The EEG were blocked by the Mimic»: of 0.5.1.0 lag/kg atropine (Bomtein, as were similar clinical charges counting addition of mtyloholim . to the tram: W1: Ward (1950) after the intmistenul applied these observations of closed head injuries. In varying dogmas of tame, he 20 patients ’with ministered atropine subcutmly indousof0.lnglkg,notingclinioelimrovmntinsommda Md reversal of the eloctxmoephalogmphic effects in others, In a study 09m, mower uﬁtmolinergio Inchner (1955) reported altemticns in the moephalogm. W A p‘tvtremtio electro- single intravenous dose in forty patients with aleotmpmlom resulted in normalizing in twenty- ), �F i H4 ~37». .V v . “WW. awn" V l -.—.p..r \':v';"'r~~ gw~-_.....—m .— ...r 1"" “v: n n‘ , , , m. ,- two and marked , . , .- ,,_ _ , , __.,,_3._.7,,_,._ “,1”, ‘4‘._,V , an- a www-ruymumrm-e ,, ., .F ‘7...arm'Hﬂ ,_ ya,V. a“W. .. ﬁauawﬂl.‘ .w-qﬂw’ uvwwwrvw-1': -r~)\w‘nw . . . I 5.1119th in six others. In subjects following convulsive therapy the (feet of atropine inblockingtheappeamceofelwwaveectbdtywaemported (mm 139 :Iohnsm, and 1956). (In a later study these authors failed replicate this study, suggesting that dosage factors or population changes [Johmcn gel“, “niece may have mntributed to different results 1980]). observations provided the basis for studies with other loom mticmolimrgic canpcunth (Pink, 1968, 1960). The intravenous injection of experimentally potent antidwolimrgic momds as dietlmine. bemctyzine, the piperidylbenzilates JB-Bls, and .— JB—329 (Ditm), Wution. VIN-2299 and pmcyclidine induced The EEG chmgea were alerting, anxiety, trauma. illusions and JB—336 EEG associated with behavioral hallucinaticna in peyduietric subjects . In patients with recent induced conwlsims these «awards resulted in a reduction in 31m useciated with a reversal of euphoria, denial wave and activity cmfmion. .3 “‘11 i a 5161,! . ﬁg?“ �“Rpm, .,,,,..( ,“_.,. ,.. , N" .37.. 7”,. v Atropine was also Md, . ”a“, N mined in y:~.uf..~r\v.“r - o—r- .. n «v low doses, maniac] by todnyouwdia, “any "n www-mur - voltage, poor-1y organized delta activity with activity was Mum.” ._..-t m... who .er ixﬂu’Joitor, I)?!” elicited high anplitude rapid 935;, post-tmmtic states 1950; andHiwidx 5.3;. m as (mm 1950). These 3: 2.1.2. m; offoats won block-d by small doses of parenteral atropine . Qutficld Tho - “law‘vpm-x- superimed beta patterns similar to atatm epileptious, as charges similar to those of with .-- slow waves . followed by lower mumatarau (di—isopmpyl flmmphooptute) Hanson .,.,, associated with pmgnssive confusion and disorientation. mo administmtimoof a 191:9; , nervousness and tension. At hyporsynolm £1qu ...,,.,..;. dosynohmnizatim was BEG higher dosages, BBC V and Dupscy (19“!) pmpamd exposed animal cortex prostim and evoked eleotmenoaphalogmphic spike prior aministmtion of otmpinc Hacked this spiking, or present, the abnormality could be olimiratcd In contrast to those findings, Mr activity. by and if atmpim. Darrin (19%), applied topical aoetylobolino in concentrations of 2~ll2 to to the exposed cortex of oats, and notedno effect on the 10% «- �ehatrmnaphlomxic The damages after intravenous atropine (1 mg/kg) . concantmtims of acetylcholim in those encperimants, however, were higher than the and thc topical gpplioatims (1-4 intraeistemal (0.2-10 gm gm pement) percent) injections of Bomstoin (19%) . Bmmmr and Merritt, also made note of electro- enceplnlognphic affects similar to aoetyldxolim from nacholyl (mtylbetmt‘m‘lmoline) much and doryl (carbmldlolim) in concentrations lower than the amtyldtolim concentrations . may ascribed the increased effectiveness of these dnlimrgic drugs to their lack of sensitivity to cambml dzolincsterases . 11qu nativity Mamie The“. W and war. 0‘ man, mama induced by autgzehaune 46 can be. backed out maﬁa, mama“, of mtyloholim antebellum indicates that an oak“ as Wed a imctiw bound by anti.- etc. (a) Cambrmghnl Fluid Anglcholine and tissue in that!» topical application, M lintuéowm. with chum-Amt activity 49M studio» tuggeat that it is 34513112.: Ono View fomdv in nervous fem. Wing periods of activity, mtyldxolinc is liberated at the cell membrane, where it is �.v. .mTr,--m.,—,w..‘_-w.. ”“51“,”, wwryw , . "a". 7.,“ -\‘-yuv;-vv—n—-,17'zr'~.m"--r mm.-- .ﬂ‘vv—‘r- - MW‘VW'v'bn-‘Imwx‘y ,. ..,,..‘v-_.v..—-u.-~, ,- -10.. rapidly deactivated by molmesteme. acetylcholim is the remnant of oontinm lihemtion and brim. rises dining sleep was amputee! and mmt The and It processes of synthsis, has been postulated that the level falls during activity. This hypothesis in miml experiments Elliott, Sunk of bomd by Richter and Crosslmd (19%) and Hmdemm (1950). By using liquid air quickffnezing methods, Richter and Grassland observed the level of aoetyldmolim during metathesis and sleep (unsound as W per levels. mg. The basin tissue) to be 300$ micro— higher thm post-seizure difference in tissue levels is tmsiont. however, as the msynthssis nuts for aoetyldaoline in net brain is high (7 gum/Walnuts). Elliott 939;, (1950) confirmed these observetims. After utmsole convulsions they also noted that free aoetyldaolim in concentrations m always demnstmble in the spinal fluid up to 3 gm per cent. In spine]. fluid studies in mm, Cme, Tower and (19%) and Tower and HcEsctnm (19am) reported Wm simificant �quantities of free eoetyldwline in patients with epilepsy. or 56 epileptic patients, an (77%) in quantities of 0.02 to 5.0 gm per cent. The gm mmted free acetyldxolixu per cent with at average of 1.0 eeetyldroline level was related to the frequency of seizures, the extent of electroenceplulogephic ehmlity,endtothetiusinoethelutseizm. Itboreno relation to mdioetian, type of epilepsy or level of dmlimstemse activity. Mather tr: ecetylcholine appearing in the spinal ﬂuid is e by~prudmt of the oonvuleim or Mather the increase in acetyl- cholim is e eeuee of the seizure is pmblemeticel. HeEeehem (19%») suggested Tower and that increased acetyleholine liberation ismtdutotheseizureitselfbuttothepmoese causingthe eeimre. In e study of the hypatrueis that the mmlation of mtyldtolim is causal for seizures. in urinals by mmzole m (1953) induced convulsion and determined the level of acetylcholine in brain tissue before and during convulsions. cmwleime are preceded by She noted that a rise in the acetylcholine content of �M- iv“... “.0". ,_ v Hr. “7 a.“ rm . . ~.— ,VT .m", ...,. ‘mr—v-,~7..‘..v.».. . , ..,_ 1mm- ’77.. ., w.‘ .5, 1. .w, 'TVV'WHP-‘ ‘(n'ry Humannnruu .. . ww'" v-vm ‘r‘ ~ , 1-v.‘.r—~-.- r---v um”... mam-awn” -12- tissuc, abut the content fills during the convulsion, below and that curtain Invals of acetylcholinn,‘eonvulsions failed to occur. She sugspstod that the fall in tissun aeotyldholine during a canvulsion was due to inhibition of acutylcholine oonc¥ntration incroaéed synthnsia by the of mutaholitns/ such as ammonium ions. Seizunzb nan aceompanizd by an lacke¢4¢ {act aettytchclluc libeaatld {Ann (:3 in inteacnllutan bound £03m, Amucmybeumuedinmwud (Md; and’liit this Mammal nativity and Atizultb cnhanct acatyteholluc debthuction, lawtning 125£u¢ (cvelt as aettytchalilc; ukilc Attcp W and ancsthetla acaywwm wanton Alumnus tune. mm . (d) Cuntral Nervous SystaEKCholinestcnanas: Oanoamitant with their~obaervarions of changpa in aestylcholine, waor and HhEaahorn (19kg) neasunod Tho spinal fluid cholinnstcraso activity. types of cholinnatexuscs are normally found in the spinal ,, -~a 1 Wm "F-Ir «rm-“r Tau—w �fluid: cholimter-ase-I which has a high Wm," ”specific,” or mdnlyl-hydrolyzing) , specificity for acetyldzolme; and cholinesteme-II ”punch," "um-specific," or bemoyldiolim—hydmlyzing). Bath mama-uh hydrolyze wetylclnlim but have different rates of » hymolysil form‘mdiolyl and hmmyldxolim . This differential rate permits qualitative distimticns . By reporting the cholinestemse activity In a ratio of the activity with a maholyl substrate with two on Walnut» substrate mated and to substrate of wetylcholim, ratios are found: dwlimstemso~1Iacetylcrwlim and oralinesteme-II/metyldaolim (with WM'IOO) . In Inch ratios noml cambmepinel fluid contains estemes in the ratio 33:17 of for dwlimtemee-I to eholimtemedl . In patients with head tram Tower md Wan reported an inversion of the cholimstemee, with an increase in the dxolimstemeI fraction of the spinal fluid and a decrease in cholinesteme-IL. (ctivity. me extent of the duelinestemee reversal was related ��u. wc- 15": w“: w—qggywww—mqw 'vwﬂvw‘r' w'w. ;~m«w usedatcd with the plum“) . we “c- ,‘ rm-“ ,n, mvmr "W_.,“-..‘w .ﬂ. appear-am: of variws isms (as potassium and in the spinal ﬂuid follwing electrically comm. than was electrolytes u cellular an. ._- ~———~> also a significant increase in such nan- music-acid splitting mama . Minty may aluminum-41 in md madam ‘13:. with the and the induced mixtures or hand km may be in cholimstem activity should of true mtyldxoline. be associated The persistence L a“? M man md after commas: relationships 1945; Tamar and Wm, mummtiom, microseconds) but Men (Nadmnsm and ”MA n5 and laser matmﬁms, contmt, the dzolimstemo-II— 5e 5 5744 (K biz k 4% 4: Mute-h, hydrolysis of mtyleholim at higher the activity falls off quidtly. In 19169; . é'dééﬂloéj“(.1 related to the sensitivity of me mtylahomu-v 1955) . At ”physiologic" (3—43 (Tamr- 54’2“” [w mid damnation Murmurs, is rapid than muse). dmlimstcmsed system to and in incmmd concentrations of mtyldaolim in spinal fluid after hand mum‘s Oranges thus provide the basis for th- high cone-stations of matyldxolim of inctuoed �. “N-r —~ n. 7., VFW..-” W _ a. .. vw—w-‘w— 7..- .—-..~,-— :7 tm'w“‘n‘.mm"\ "Va-"er-rwswrwnh‘ Inwr'n'ra'" ., "mu-wmu» m y'WWW—m. w~~vw-'VI"-’wr11‘xn—n‘ ~ .x v . .. ”rip-“73“‘miwl‘wuw1vv'1‘y; NV”; —,—-.-r~.. .nr w "WWW,— «.v “ «mu—v..."- ‘ . .15acctybholino rulaticnship is non-specific and the rate of hydrolysis inexact-a with cone-ntratian. Mi 1‘“ ; Aum£-‘£o’%}4i 4;; ‘T f? dnatrcyud by tho spocific activity of cholinnsteraseol in faw lasso-.aondn, an excessive concentration fallowing excitation may canned tho by cholinesterase-I. The L¢¢1¢4 A¢M4 ‘ acixurn thrushold nay be reached and a noifnnu indueen, with thc stizumi f i rats of hydrolysis Thu itself adding to the amount of free acetyldholine. innrnanod acutylcholins diffnoos rapidly, affecting vascular i and cnllulnr poxlnability and increasing the concentrations of various ions and cholinnstnrusc~11 in CSP. The activity of dholinnstoraao-II, though of law efficiency and depending th- mmmm kinetics, Mass on the mtylcholim in the tissuns in hours to days to lavels for tho physiologic action of cholinnatonuae.1. 422;“ 42351“ �‘vr , wwvw—M. . ‘ «ruuuv <t—V'1vwv “—w—ww wwwmwrwwnw. raw—em: un.mnv:.-.Wm "WW—.1» yrmlmx-N ltd-www'ﬁa'wmw'guw‘I‘v ~ 1.. —_ '~V"(—m'v M.Wr>‘\'m‘ .17- Choumtmu «ppm in nu mind We! as a acumen 05 their. 41mm: in Lu ceu. The mm: gammy ma m swam 6;;th (e) 5mm», muting 5m mentioned by changes 1,2:qu Midtown. momma; m pout of the eybmetéc mechanum awn-(muting the 604 Ante/Lem Me 05 «mama»: at was mainland: mu‘uy WW9. Mainline EEG! and Induced Ccmvulsiam: . Almmtion in the blood~brain pemability barrier by the cmtiming team of amtyldaolim may be the biodwmical substrate for the post-ehetmshod: hypcmyndmmy of the alectxmnmphalogrmn. Such a possibility is avid-at in the report by Aird «mutating an increase W 23; 3141955) in‘the concentration of cocaine in brain . tissues thme days after a series of 12 induced omvulsiom. His data Show the change in mnemtmtion of this large animals, ominarily abaerrgu: inbrain tissue to be mociated with the appeamnoa of hypnrsyndzmy (delta bursts) in the electm~ W. , �. inn-ha -'!SA‘-’-"—'r-.“ viva... ..».-~=v—-nn , wan-.wp» ‘ wn “-1....er ﬂ.” .7,» :w .r x» In studies of induced convuleime, many ﬂaw-u. we WW“ -; ‘v w "M”,Vrmm “ w... -wA.we--wﬁm~mvav" . _ ‘1 dump-.— have confirmed the pmvioue reports that convulsive therapy induces electmgraphic hypersyndxmny (Fiﬁ: and Kahn, 1956) . Despite a constant applica- tion of mutants, the time of appeamsoe, the dlmatim and the extent of the electromphic slow sensitivity to modificatim by wave activity as well as its alerting, hypemntilatim barbiturates vary greatly in paydxiatrk: populations . appear-awe of high degree hypereyndumy and Too and early its persistence through- out the txeatmnt name has been described as prerequisite to iapmvemnt following electmehodc (Fink md Kahn, 1956). The failm of certain patients to develop hypemyndmmny may be related to differences in the activity of central aeetylcholine and dwlineetemeee. with the absence of free acetyld'xolim beingmlatedtoninimalehangesincembmlfmctimmdﬂnm precluding a clinical response to induced convuleime. Tower and HeEaehem (mum, in their study of Madembml trmma, included observations of six peydmiatric patients mdergoing mleive therapy. Studying the patients after 3—7 treatments "- mpg-w“... �.ww pwzwrn . 7 .19... thay reported free two 41lede patients; and an 1mm activity in the spinal fluid in in duelimstemae-II md a dome in dummtomee-I with a mammal of the ratio of dwolixnstemes in five of thn six patients. ms that the spinal fluid like those of From mica-tubal these observations they concluded in induced convulsions m Ragar'dim the mo patient were mom than those found in epilepsy. in the series who failed to show cithcr me mtylaholim or a cholimstomc ratio reversal in the spinal fluid, thcy wmte: "It is interesting that this paticnt an the only can of the six to show no msponse It a pawn that induce! mama» £6 mmuu i/ t:”PM/1AA ﬂy ff-WLL AW by 1.6 3 0‘ JA mm, sums. Law 96 me EEG Fm «commune hypwyueMony mama“ and 1.6 mm on: mm ascenumcngm. uuuueehuguzazmouummm- AMM‘W was that plowidc ﬂu. biochemical. 60.be (on the pmaaut V WW) mamnt." mm mm pmabuuy m Mug the. mam a; mumamu. W W Wilma mm “#19” ( in Wt to bchaviom changes {allowing inland canmuiau. w;- �(f) Choline-tomes moss studies may and th- Classification of chosos: also have spplicatim to the problem of catatonic reactivity and the clmificntim of the psychoses . Mkonstoinsndotlwrs( )havsdsmxstmtedamlatiom ug ship botwun tin blood possum response to injectedﬂm) (dd‘é’ﬂﬂ and the clinical mpomo of psychiatric patients to convulsive W. lbchclyl is a potent molimrgic agont which induces vasoﬁmion, tachycardia, mating, It is and harassed peristalsis. mpidly hydrolyud by mournstoms-I and slowly by clmlinutcmc-II . M, injoctod m m blood pmssum of subjects falls aftor udulyl and 2‘th to the five to m bssclinc than 20 minutes. Patients Mobloodpmsmmtxmtothbaulimwiﬂﬁnsmutos are classificd as Groups blood possum takos 2O I, II, or III auctions; arm aszprIdeIImctims. imprcvomnt mactors a minutes to mum to baseline, mexoupIrssctorshawa9% rats with conwlsivs therapy, 35% those whose and the Group II—III memory mtc. In contrast, the Group VI �_.__.. ”(ya-v —— . h\'~rvhl."ll'F reactoreheveasstm'themupvnasﬂ recoveryme (human-1n 35;. Patients in an patiente in 1952). “main Groups I to III may be looked upon whm the injected maholyl is rapidly hydrolyzed; VI and VII patients heve the a slow hydrolysis rate. 41121311. 65‘ Weny predict, themfoze, that an blood ahalimateme activity levels of I-III would be high; while the activity of WV” y ’ ,-. u... V,._V.......,m--.-n—nw ’0 ﬂy” 6/” W W hypersynchxuny and spinal In studies of EEG fluid levels of acetylcholim. ahengee {uncaring induced omvuleicne subjects were identified in when e few seixme resulted in e greet of elm wave activity; mile other subjects exhibited mat few changes to my and to frequent seizures (Pink and Kuhn, 1956). If electmgrephic hyper-gum in e reflection of incremd (Conversely, in patients with short-lived hypereyndxrmy, dwiineetense-I be unusually and high). -II in tissue Thue and spinal ﬂuid these epeauletime provide may �-22a basis fcr a congruent hypothesis regarding central nervous system reactivity to clactroshock, and to peripheral éholinergic CONCLUSION: Ccntral dholincrzic nadhanismsqmpoar to be a significant flycﬂu«’g factor in the convulsive therapy process. ”Inc published data {unrinriznlmymnandhto indialté;that induced convulsions are associated with an incruasa in intarcallular acetylcholinn tn 4L¢¢4Eygd4£5414¢¢¢délAbiﬂ— lnvels greater than can be dustxoyed by choiéanoturuneéE— nativity. Vascdilatian follouod and and innnuasud callular'permnabilitylin«a4wc. 71L‘5@ﬁ¢.4;«xu> g aibcgérﬁyxapglugu‘542;;wmatvi byﬂincrnascd amounts of~ehoiinnaﬂcuuao~¥l~ other'enzymas clactrolytas in inturunllular fluids. ��n, w~. «v— ‘w—rr‘Y .r uy-nmvv—mwum-mn "vv'. rwzm—r w—uw-v-mw-wztwvm... a ~II'-v-'<w-:'W.\1v;w'rku'svmv‘mv'nvﬂwv wwww CEDLIWC WV}: mm. MD mum Max w;— .n»;_...v W... "on." ,vurw»; M Pink, H.D. W at th- Pﬂnmi Initiate of -Pmthanapmntof Psychiatry, admity of Miami School of Midas, 5800 Annual St. Louis, Missouri. 63139. attest, W, W mm. Wmismofthnwm"hinhnatimm York. Hillside Hospital in Ethnic!” at mm in part, 2:57 aunts iii-00927, iii-2715, W72“, md $11380; and the Paydaiatric- Renard! Fantastic: 0! New - - w—n mu, mung—.w an �CHOLINEMIC W, AND V: CONVUISIVE BHWIIOR 11W, StudiuofinMdmwldmhnwmmmuﬂy dwalopnntmdpmittmofsiguofutomdmwmmm mpnmquiaitetoahmguinbahavinr (Maximum, 1956). Wesleyanwmivitymfommm: aimificmtinduxoflltondbxuinfmctim,andﬂndemmticn that Mention activity (015th album-sic and Jdmm, W. mtylcmum and with atropine inhihimd tho 196’) this slow wave muted a minim to In the following review the dwlimmruas in mole of Waive ﬁnnpy is discussed. Mutyldnlimmwcmivelystudiedummive amtintrnmmuimofmmusimluusimsmﬂm It is a dcnmiptions of Dale (191k) and Load. (1921). mtitxmrtofmtium,uistinginaboundfommida illibnmtcdmmwiutimmm. )J and is action of culimmme specific hydrolyud m Itiarupidly W rapidly matitutcd by the cholimmtylau cystem (Richter 8 sum-55 �wan-r”... Grassland, 19%). In actual autumnal fluid has mtylclnlim Emmanpitemupidmmofmmmm (Town-mm, Magmaoaofactivitymdcmitmt 19%;). The activity. ”Mimi mm, fluid does but Inﬁnmoffm 19%). matylahonm md undnr the conditions than cholimatcraso principally of tho “tan” or medulla wdmlyzing typemmsmwibﬁmbcrg. fail to gamble Whoa, cleatrunmpimhgrm Witty. (a) Effcct of m Mint}: W hm: hm acetylctnlim mun-951151 ﬂuidwiﬁﬁnafwninuua after demmmtsmdpmiuedforvmina periods 2.» m as hours (Win, 1”). The qumtity of fun gm mtmmumdmthdumeofimmtrm. mtylcholim vanhd between 2.? did 9.0 The W accord. chcmewaphalogzu um first filled with percent. and th- mutated patterned W. high voltage fast activity, intorpmtad as alderman of an intern. mm). diam, only tobfoﬂmdbyadmtpexiodofﬂmingofmmcomod ﬂuv - v > .. �-- .vwru V.—.Ym'> electrical activity. Thou phuu wen then followed - 'u-uwuﬂxm n. ww- by pmlmgod mamamummmmmmmmms. mwmsmnmwmthtothedameof mmmmmtafmmdhumtyldnﬂm. highs:- levuln of mtyldnlim. Romania 911‘th "Modulator dew ofmcmntymdmmrctmpsinmcimu. In addiﬂm, apcntmn post-We aim wan also muted totbmmtoffmmtylebomnapparingintmspiml fluid. Wain also :13le acntyldxolim to expound out 03:11me W. Mthommmimofmtyldmlimmlgm pamtorhu,hnpwtodhighm11tudoshupwmoflm fmmncyinthocloctmmmplulogﬁm. mmmnoentmtim mimmdtoZmpcmt,ﬂnchctm-naplulogm Whafuhionpqﬂhlmﬂnpon—tmicm. Parallel studios m wr carried out in analogical patients byrmmunsmnumw. Pmautyldnnmmfmxdin - r-w» ' 'c . ' -' ' �- the Main]. mount grand-ml mtyldwlim 7...» 7w wn>wwv 'v'vcv’ ku- w. VII-"I'M‘WW ﬂuiﬂ mly in patients withncmt head 1""!t-W'J" \‘vv- "ram-V" tram 301nm or afar convulsive trnmpy. Fun vadedmeﬁtolOOgmpcmt. Tomrmd Wm also assayed spinal fluid cholimstcme activity, noting a map rise in the mpocific cholimtcme factim (WW-cpnttim) and a drop in the specific mailman” fmtim (metnlyl-splitting) in paticnts with had mm and following minim W. Followhu sputum calm the cornucopia-l fluid did not exhibit such it comma {no mtyldmlixn. inwaim, Thay cmcluded 11W that the lavel of {no mtylcmnm varied d1mct1y with the dame of comm}. Manama: mnnlofﬂnedlolimctem fmﬂmmam with» indicator of Gambia]. m. madam, talcmatvuyingintorvalsfonowingmm, mimic-med: mhtionbctmcntkmdcmeofﬁmmntymdtheappem of In: mtylcholim Thu. due in the annbmspinal fluid. want 0‘ We autylchounc my (me. in the ‘mmgoummwwmmmmmog ' 'v "F “'4‘“ �, 'V'lvw—‘U‘ w‘ war.- —',~3 nan—- u ,w--y_.n..-. u. ‘ ., .- ww,———w~.wm_w—w-q ‘1‘ wwm “- v-~.-W . a..“.~,~.-u . q. . WW -..' .m “Fwy-Fumwyv,‘ “15;.” .w, , .7 “mm .-.» 7w.v--m»w~uu-——. .3... 51m. “Wotan, abunuty, MW. (2)) «the «glue and type mmmmgupuc a; mmummmmamumw m, WWMO m and m: The EEG aim ofmmnmmodadhyﬂu behaviomlmdmmlogic (Bnmstein, pun-nun). examination of 0.5-1.0 ug/kg atropine mmmmcunimmmmmmmmum addition of mmmu. Ward (1950) applied mmmdmmmm. We m, Wand of varying ho m'obumum In20patiantswith ntmpim 3W1)? hduudOJq/kynothmdhﬁmliqmtinmmda mutual of the 013:!ch effects in om. In a smdw.muﬁamwm¢Jmm Loam (1955) meoph-‘logrn. m1 W am A single 5.an WW in the pit-atrmmatic ghetto— dose in forty patients with resulted in normalizing in twenty- ), was” w, �two and marked Wm: In subjects in 35.): mm. £011ng conwlsive therapy the affect of atropine inbloddmmappemotslmwmuﬁdtymmmd (um and Jdmsm, 1956). (In a Later smdy these mﬁm failed maplicmﬁxiastudy,suggastinsmatdouge facumuw popnlldmdwgauyhmmtdhumdtodiffemntmulta [Jemima $5, 1960]). Moumatimpmvidedtmmformwithm hum “idioms: Wad: (Pink, 1958, 1960). me hummus injection of Wm, and Wm “WW. durum, may, We mamas mum-yum. thn piperldylbmzilnm JB-318, (Dim), JB—329 pan-m: mticholinergic VIN-2299 and an JB-336 3% 1mm mendim MMWmm ammﬂﬁabduvioml truism, illusion whim. and mlminttims in In patients with mount induaad mnvulsium Mqultodinamdueﬁminslwm activity Wuiﬂzamdofmplmia,dmidmdommsim. ��-. _«.w...-.——~.m. w, .u . . r” v ﬂaw-v v "'wA“"‘f'N‘" . wrv-r-P electmncepiulogmphic The concentrations of were higher than Win W arbor _.. w-av. rwa-mvnw—wvm- v-.-~ TWZ'Awyvq-u'n‘Vtvmw‘T“ "Ann—w- 1::th th- topiml appliantims (1-4 (19%). atmpim (1 Myldlolim in these oxpeﬂmts, imiatnml and the , (—7.“ ~;—v—u~.~~.—.u—pv.—.—~nn:,+-ra.-w—u w... (0.2-3.0 gm pennant) gm '-‘a nag/kg) . however, parent) injectim of Exam md thud“, also made note of chat-.m- axmptulngmphic effects similar to amtyldwlim ﬁrm mcholyl mtmtiom (WWW) (mtylhetmﬂxxlmonne) ascribed mmh Mrthm tho amtyldnomn M Wm. in and duty). Wimqffmimwmwmmcmmm lack of mitivity to rumba]. duality-sums . ThuewmmmmmsuggutmuumWWWWWbyMWu/tmua man 9‘ aqua, tam Won, imam on. with WW¢Mmbebum¢ueummdbgma~ WWHMAn-gmnmmdmw «new (c) a mm, mm. etc. Onoviw «mlmuWMwa-smnnfomdiamm Winnimatiwbmfom. Wyﬁnchofactivity, WWhnmmdatthno-ummm.m1tia r umnnmv~wv yr.- -~ �“Hwy-v .7 m. » ._v .W”...w.— —...‘..r,.u...,...._...,-, Hm..."- va,unlum‘w‘hi‘wv'mvmwv;'QX.‘""“ W ~n-- v “w a”... ‘ ,7 ,v W---w mw_.-r—... Wt “‘1': run”... -- - ww» v" ‘7. "‘ ww.-,-_p.w.~.wmw. midlyduwtimdbydwlknmo. mamtofbomd mm is the resultant of continuum 1122mm lad mm. promotes of synthuis, It has bun pastuhtad that the rdmduuingslmmfnummuctivity. level Thishypaﬂmil mwmmwwmrmmammum) mm,mmmm(1asm. Byusing liquidair qumumm.mmmmmmmmm ofamtyldwlimdndngmﬂmiamdalup<mamdumim www.mmm)mhaocthigturthmpoum hurls. nudiffminmmmlaiatmsimt,hmm, uthnmthaismforamtyldacliminmbminism (7 gums/gallium). Elliott 539;, (1950) mnfimd than obsorvntima. Afﬁrm}. mum-ism Malacnated that {no mtyldxolim am always «washable in the spinal fluid mmwmagmparmnt. Insphulﬂuidstuﬁuinm,ﬂam,lbwnrmdmm (use) md fear and Wm (19m) “perm dwicam: ��m.uﬁumtfansmgﬁumnmdm,mdm balmeevuin lawn of mm, convulsions failed to om. Stunumudﬁntﬁnfanintium Winona: Wamwhimmdummiﬂmofmtﬂdmnm m‘md mm byst- anemia“. We! sud: mtabolim, Bummwwnmeumm mmmmwwwmmwm Wmuumam¢mm MW mmm;mmmuuyzmuummmn,zmmg rmumumzmum W MW WW madam» (d) §xg~ an MAMMWthuLa W (new: tutu. Lena. Cmocnitam: wimﬂnirohamtiam ofchmm inuntyldaolim, Wm (1939) Tutor-mt! name! spinal fluid dolimtcrm activity. Mtymofdnumemmmmnyfminﬁmspiml �» ‘am-V ”II-"Iv ."V'a. ~,.1- . u -;— V’V~-¥'U'~‘v‘<~u Tam—xv... mw—uL-ww-"wv Wanna-I ﬂuid: mich .V m ("pocudoﬁ W as nu-mq-wnwh-..“ .,.,ﬂ_. .. Um," sﬁociﬂcity for him "rm-amiﬂc,” ow two .,. ,... .. n. ..~-. - . ..- ’r .,.,_H. .\..v7,..,,..~—V.TM ,wv, .,.,.< V . a a ‘ , , v.“ .w: _v_ ”specific," or manlyl—hydmlyzing) , Micheline; and “museum-II WWHMWIM) . Both for udzolyl and bemoylduolim. This diffomtial me panda qualitatiw dintimtims . with 3 ”a.“ hydmlyu amtylcmmn but have diffmnt arm: of mm activity ,. By I: a ratio of the activity with MW!» ratios an found: sub-mu mind mpovting the dwlimstumsc a maholyl substrate and to mm of amtylcholim, mumm—I/amtyldxolim and Wm-II/mtylcmnm (with Adi/@8100). In much nudes 'mlm‘bmupimlﬂuidmuimuminttumioofﬂzu for Grantham-J to aluminum-II . mpnﬁmwimmmmmﬂcﬁadmmdm invasion of th- daolimumu, with an We in the cholimammac-II fmtim of tho spiral fluid and a dam in circumstance-I. iathity. m mam: of the WW maul was related �we: --r"vr— mr ww- ~r-r—vrm...‘ v .—-1«w‘ms¢—ae.—r ”"7.“ mgr-nus, r, mm, a." 'W nve- “w, -~. w n r...“ mwv “van" e w.— ‘1‘“ m‘r‘nvwvﬂﬁ‘l'v—vV-v ”Wuwx—m‘me - vuvax wmmrityofmmmdmmawofﬁuem- WWOWW. Inpatim with eleveudspimlﬂuid acetyldxolim other WW,Wr,mminmmioof dulimetemesortommlimtem wdvitymfomd. ‘meimmindxsmnetemeactivitymbemdentood mnmmmmmnmpemmmty. mW-Ihfmmhimmtmﬁminﬁn mud nervous system while duelineweme-II pram inwartiam,upooianyb1mdsem. Hiﬂamimas fin atyldnnne m1: in intemelluler mum fluia stimledm, communion: or hm, modiletim oellulmpemeabilitymybepmdiotod, Wﬁm and We! withedewof of wonder flunk into the inter-0011M spaces vuyingwdmthemmddm'etimofthevasodimion g g, 19:0). Spiml pun-Ability following W 1953). may cheer-val no Spinal-Molt in mm (Rabat m mm reports (19%, 19%. 19W, 19%. memo mndactivity of the tissm , ~~y-..‘.--~_~~.m-mm-v, �av“ y."— ww_"v-w.w . w «mum...»- a. 4 W cm van—n: . Wwmwum u wI-ww—t'h wmw—wmew-mw ..-,m.— w --u-- mumps—m mum-PV- Hw'ms a: w :w-n r- "rm usociatadwithﬂaappemofvuiwsm (apotmiummd W) in the spiral fluid follwing chemically inducad mm. Mmdmasimiﬁmthmminsmhm- electrolytes as madam-acid splitting cums. Chang-s in alluhrWilitywthmpmviwﬁabasisformhm demmmmmmmm ofdnumumeIinirmmdmoermmﬂw MWIMQGJ. mmmmmwuwmammm with the mid «instruction of hue mtyldxolim. me punctuation rammummspimnudmwmmm aims any be minted to the dxolixastuaso-J syntax m and Wm, 19%; mitivity of the mtyldzolinc- Widen mummy (um Tm adﬁcﬁadam, 19%; Burger: and martian, is rapid (3-H mama) but at high» and lunar 1955) . At ”physiologic” helm-h, hyckolyais of amtyldxonm the activity falls off quidcly. In contrast, the mm, chainsaw-II- �«.18.. “mum nhtimMpismn—spociﬁcmdﬁumof mmmwiﬁzmmim. mmammmsummmmm WWWOfac-tyldmmnnmnmm We hy the spadfin activity of him, an massiv- WW4 mﬁm in few billowing excitation mmmmdmmlmwmum-I. The uhmuthruhuldmhomadndnﬂamimindxmd,with mmimuwngmﬂnmtoffnomtyldnﬁm. n» and W murmur: durum 'mpidly, cellular pambﬂity and humming tho vmmmdwlimm-Ilmw. alum-II, W affecting vaswlar mmtim of 'nnactivityof of lowcfﬁcisxwy mt! chpcnding m ﬂammﬂgmkhnua.mmm1mmm dominhammdlyatohwhforﬁnphysiohgmmﬁm of <21»me . �“.1. -. _. n "w' .~. -»~ uv- r—r-wu. szﬂ‘”R—vu'w.vw w-W-wt mm- W-w—mwwswwmwwrrwmxmm’mv-mwmmun-m zmwm-Wm “W A. A. V. AW mmmuWuM¢mmuaumm _\_A_._V_-__‘__.__~V.A,__ ‘-_,__,A__________ 05mmc&W.W, Wad “WWWW m put“ ma Wm“ waning smut-Maya by The {named the waywam. Wade. madam-u ammmoguagmumauumw WW ‘MMWMAmMWW. (a) mymm. HE‘S MWintbblmd—bnin mm permeability and Induced 000mm: bmiwbytheconﬁmm actimofmtymnmmybaﬁlebiodmimmtmfwﬁn chphuogm. _m.mmwuommmmmbymgggy(ms} pout-electroshod: hypemymsm of 13m Wmmmmmumormmmm tummaysamrambfnmdmmm. mmmmmmimufthismmhm, ordinarilyabsmtinbnintissmtobemociamdwimm W orhyponyndm (delta bursts) in W. the electro- at: . �- Inmofﬁmmhm,whmcmﬁmdﬂn mpmimnpmﬂthﬂmwhiwwmchcmmuc Imp-W (Maxim, 1956). myimamtmt applica- www.mmaw,mmmm Wtdﬂunhmmdcslmmaadvityuwnuim sensitivity to mdiﬂwtim by muting. tamer-ventilation whim‘ vary my in manta: Wow. The and only memwmmmiupu‘ismmghmumthmmasMupmmmium W 1‘0le «loam-rm (Fink mm, 1955). m «land in diam {dimofamainptdmtodnvolaphymymhmxymybo Nahum. 1n th- activity of annual mtyldxonm withﬁnmoffmemtyldmlim mmmmeWMmmm mamammmemnmmmm. W (19‘8“), inmiz‘ttudyofcz‘iimbml Tmrmd trauma. imlududobumtimofdxpsyctﬂatricpaﬁm underpins mad“ W. Ming the patimts afar 3~7 mam-ms u I'vv: WW7 ~,-- a'ﬁr‘f �mwmmtymummutymmspmunudm mmmsmdmimmmmm-Hmdams in “11:33th with a mammal of the ratio of WW3 infiveofﬂnuixpatm. mmmWaﬂamﬂnyomclmed wmspimlﬂuiddminhumdmhimsmm mmwmmnbmmmmrmmcmy. wmmpatimtinmududnfdhdmm dmmmldnnmwacholimummmmalin thespimlfluid,ﬁuymz“1tisinmtingﬁutﬂﬁa WmmmlymnofﬂuaixtoﬂIwmmpm-emtm." Itammwzmwmuuuzm¢m mamgm,mmmm mmmWoammu. 1%...qu umbyupuudAumu. EEGhyme/uom umo‘mmwumgzmmmmmwxy at Mumwuqm. Radian muammmmmWMWWWWM‘MMMAM 6:!wa Mu 60W Mad «WM. ��-21- WanamaeﬂmtthmaSﬂmmrym 1952). 93a]. (Wain Patimtsinhmuinmltonlmybclmdupm when the in is injected rapidly hydmlyxed; putientl mdmlyl u uhiln ﬁn Groups VI and VII pctimts but a slow hydrolysis rate. V. my pndiat, theni‘on, that tha bleed dulimatem activity huhofWI-lemﬂdbohiﬂu mihﬂnaotivityof WAdlihrunlysiouyboudumaxdingmtnlm VI - VII walla be 1m. mmmhofdwmmm-Iinﬁummtofm Wynclumy and spinal ﬂuid hwls of amtyldnlim. Instadiosofﬁﬁﬂdumgu followingixducudmnvulsim subject-wan idlntifiodinmmafwsoimmultedin a mat mat of now an. activity; while othox- subjacts mind mammmymmMu-Muim (Pinkmdm, 1956). IfWWionntbctimofmd Inbjommuintainhypcnynm in: mm, inwmitdiupp-m them did mpidlynybccadﬁbitingdiffgmnccs in th- kimtim of the dwiimntm-mtylmolim hydrolysis mm. Panhtcnthypcnyndmyuymultfmamd Mcofhydmlysinotmtyldwlim. mociatcdwithlow I mutation of cithcr choline-tumult or mummy-II . (W13, in aheﬁrutcm-I In many paints and «II high). with m—livod hypnmyndmmny. in tissue and spinal fluid any Thus thou mutations provide �. ..‘-.,—r >17 ,...v v“ » , may .1 ~w ~ v....<~u-.~,nz‘y«.r.-~, w‘wrr' ,. ~_»w—-w-y- ash-:1" ~ want »-.1N" vmn www-z-‘w BMW-“‘1‘;- n ~wm~wvv qu-w-m-w- wrumrwS—V-‘a W-xmp‘rvww .22... amumamhmnmmmmm reactivity to W syntax: em, and to poripmm dwlimrgic WON: mmmmmmawmt _1’minﬁn mmiwﬁmupypmu. 1119me whimdmiﬂmomtimdmmmm Wummmmmmnmmmw MhWMmbodntmyodbydmlimmI nativity. Vuodilatimaﬂimuodmllulupmbﬂityis follmdbyimuodmxtsof diam-II, strut-am and electrolytes in int-”114mm ﬂuids. - "r' :1 Wyn-mu wr “unawa- "I“ �mwmminmmdumm mmmnmamswom.mwmm Mmeiduﬁuminbiodmicalnﬂiwwhidz alters cerebral «11.qu activities sufficient to Alter the 1m behavior of subjects. Failure to mountmim electrolyte dim. of acetylebalimi lid W, high md pmismm: {aim to 1m tht results in a failun to produce behavioral ”mummuofdowlmntofmw reflect differences in th- 63ch of subjects «1 dour-remit: admin”, or in their sensitivity to changes in acetylemlinc lawn. tim of M tho diffcmm ﬁnally in W by Mountain These observations provide a the mode the Win for the classificaand by Pink and Kuhn (1960). rational biochemical basis for of action of induced convulsions in altering the behavior of psychotic subjects. These views are consistent with the more general neurophysiologic—adaptive theory expressed earlier (Fink, 1957). �IFn->"'v'—-'—vnu—w— w—r—v-r—u ”ﬁt—W‘- ".9. ‘- -. u » V . WWII-.11“: CI-DUINEIBIC . , nv— rm mw- WIN, WWOR Wmvw—qmvmmpwmw'm x.xm~.;w~ww-ww mum—w". CONWLSIVB AND 13%”, Stalin of cerebral changes accounted with (Pink and Kain, 1956). convulsive trump}! In these studies, electroencephalographic slowing was the most siyzificant index of altered brain function. The dematmticn that premedicetim with prevented the appearmce of slow 1956) suggested a wave high doses of atropine activity (Ulett relatim to ctnlimrgic meﬁiims. and Johnson, The role of acetylcholine and the dmlineatemaes in convulsive therapy is mlified in the following review which summizes the published am. The role of acetylcmline in the tmsmissicn of nervous imulsea has been studied extensively since the first descriptions of Dale (1914) and Loewi (1921). Acetylcholine is a normal which form bamd is in a tissue existing of neurons cmstituent �.,, ~21- ' - "~va ":murmmrnur-v— «m . Ernie-'4 ‘ ,. v “War W'r’W-erd - 4wr‘; Wr' .w-nv 1'5“”uH-I'J. .1m- ,.w;uwv‘.m,w.‘. liberated mixing the excitation process. It is “m ...Y.,_.,. F“. -v-v—.ﬂ, ,. . t .. 7 m" ,..,nvrv.w._,,m_1w V,.w.,‘.,.,.,,v rapidly hydrolyzed thrmgh the specific action of eholinestemee and as rapidly reconstituted by the momﬁiaeetylase system (Richter 19“ 9) . No a Croeslmd, free ac}tylctoline has been reported in normal mmbnospinal fwd despite ﬂu rapid bmakdom of bound acetyl— eholine during perioa of activity and excitement (Tower and McEechem, 19u9e). The oembmpinal fluid normally has measurable cholinesterese activity, however, principally of the "true" or mcholyl hydmlyzing type (Neelmensm and Rothenberg, 19115). In the absence of free acetylcholine and under the conditions described, electroenceprnlogxms fail te show any consistent ehxornality. (a) Effect of Cranioeerebml Them: Free acetyleholine was found in the cambroepinel fluid within a few minutes after experimental head trauma in cats and persisted for varying periods up to #8 hours (Bomstein 19%). The quantity of free aeetylcholine varied between 2.7 and 9.0 gamma related to degree of induced percent, md the ammt was tram. N" ._., , . V.‘ ,.. . �F‘s—“ﬂ 4 w .iv-IJ'n-urr'wlv'i- \I'-w-v|n"r" ».v 21‘.- .IN w— rh- W Th! records were u. . - ~~w~mvww. a?“ : aux-rum W...“ m“- - ‘vv‘ w—a—E.ww~r_~w um... g‘vi- wn-rv-w mun» r: 1- K—‘Irw' «a...» ,. w... w” ‘quw u,- 1,- \w electroencephalogms demonstrated pattern-d changes. first filled with high an voltage fast activity, intense neuronal discharge, only to all short period of flattening of electrical activity. mesa recorded phases were men followed by prolonged periods of high amplitude sharp waves in the delta frequencies. The to the behavioral wt mrﬁzlated 13%:ng of clmges trauma and of seasoned free eoetylcholine. With higher levels of eontyloholine, Bernstein reported greater degrees of abnormality and greater charges in cmscicusmss. spmtanecus . -3- interpreted as evidence of be followed by a -~ post-tmmtic seizms were also EEG In additim. related to the want of free acetylcholine appearing in the spinal fluid. Bernstein $31- applied aoetylcholine to exposed cat cerebral cortex. men the concentration of acetyloholixm was or less, he observed high mlitude sharp the electroencephalogram. When waves 1 gm percent of low frequency in the concentration was increased to �-- <vw'x' >1:- 2 '.‘W',WWV\Wmm/'FP a». an gm . W v- .n ‘n'uv 7 ~m—w-w..». v m... .vvc'wTV-t or v'.‘.wwuwxnn_r'~u—l’v»wy wrv-suw‘ mw~wwn~w~mnpmmm .- »— -nnmmw—rr-muwawu nvre --u w percent, the electmenoephalogm flattened in a fashion parallel to the post-tramtic meant. 11.1% stndies wemWin neurological patients by Tour and Hohdmm (19am). Free aoatyloholine the oumbmspinal fluid only in mam, The 1.: patients was found in with recent head mount grand-ml seizures or after omvulsive therapy. free acetyloholinc varied from 0.2 to Tower and HoEachem of the spinal fluid. 100 gm percent. also assayed the molimsterase activity They noted a sharp rise in the nonspecific cholinesterase fraction (benzoyloholine-splitting) and a drop in the specific cholinesteme fmtim both in patients with head .trmma convulsive therapy. amd 'me oembroSpinal (moholyl—splitting) in those following fluid following spontaneous seizures containing free aoetylcholine did not exhibit such inversion. 3-2:. and-II: concluded that the level of free aoetylcholino varies directly with the dogma of cerebral damage - �that the reversal of the cholinestemse fraction sensitive indicator of cerebral (image. and was a more Electroencephalogrem, taken at varying intervals following mum in most of these subjects, indicated a degree of EEG relation between the abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. ‘hecstmﬁu Watt. an to. mom 0‘ (no. aaetzﬂdwdne m1 incuae in #:24me {Md 4011ng Macadam tum and me a «wad: lactation my mwowa, duomug, (b) «in. degm and dumgo Effect of anathema“ ﬁe and type as in Am mount 05 ﬁne demamcmuagmic dialed bdrawloa. on ﬁb-traunatic EEG and Behavior: Bernstein aministered 0.5-1.0 lag/kg atropine parentually after head tram and denmstmted bloating of the EEG, behavioral and homologies signs of clinical tram. changes occurring Similar EEG and after the experimental addition of intruciaternal aoetylcholine were also blocked by atropine. �w. --r.-~r-v—~--ww- w-Im-vmm 'mm' "-W‘mmv'm" Ward (1980) 'memnmw applied tmse observations to the hum cases of closed dogmas of tram, head injury. In tremnt of patients with varying 20 he aaninistamd atropine subcutmzsly in doses immt in of 0.1 rug/kg. In saw‘oam he noted clinical and others a reversal of the eloctromoephalogmphic effects of the tmma. In a study of .1er and War diethﬁf’ mother mtidmlimrgic drug, (1955) reported sigmificmt alterations in the post-tmmtic elactmmoephalogm. dose in 1&0 patients with in normalizing in The same slow wave 22 A single 1:1th ahmal electroencephalogram subjects land marked «act of atropine in inmt msul’cad in six others. blocking the appearance of activity wm reported in subjects follwing convulsive therapy (Ulett and Johnson, 1956).. (In a later study thé‘authors failed to mplicate this study, suggesting that dosage factors or population mass” may have omtributed to the different results [Jdmm 559;, 19603). M... �8: These obeervatiom provided the basis for a series of studies with other Imam mtidlolinemic ooepomde (Pink, 1958, 1960). The intuvenom injection of experimental patent antidmolinergic «mantis es diethezim. (Dim). Maine, the pipeddylbemiletes, Jana, J8336, and pmoyclidine were shown to induce EEG illusions deeynotmiutim and behavioral alerting, mxiety. J8329 WIN 2299 end md helluoinetiom in nm—ehotmehodc subjects; and e reduction in allow new ectivity associated with e mvemal of the Wm; euphoria, dmiel ma omfmion in these with prior meant induced omvﬂsiom. In these studies, atropine was also emineddn low doses, EEG desynohrmizetion was observed, eoooepmied by considerable peripheral tachycardia, mmaenese and tension. At higher dosages, oonfmion and disorientation min! hypemyndzmm slow a mduction waves and of-hmmiutiea their replacement by lower voltage. poorly organized delta activity with superimposed beta activity. . �~. . a" ~~_,—vn~m«~p.-~W» A q ”We," W. _ ,_. 1..“ ., ,. w." .-—...n-r.. t ,, . u ,t. .( m...w-,V -—..~— _\|=V-\w:w.~a ~FVJH-ﬁ'u—p‘muwt »‘wb‘wﬂ- 7.;r._‘,.,v,wr _ﬁuv;a_n.‘--,,.p‘m .w-wunw... \ .,.—_,.....~ variety of experiments with a potent duolinesteme inhibitor, D}? (di—isopmpyl frequency EEG fluorophosphate) denmstmted high amplitude rapid patterns similar to status epilepticus, as well as lesser degrees of abnormality similar to that noted in post-tnunatic states (Munich 333;, 1950). 1950; Pmdman 3331., 19:49; md Hampson 93.51,. These electroencephalographic doses of effects were blocked pumteml atropine. Chetfield md Dempsey by small (19%) prepared exposed mimal cortex with pmtigmine and evoked electroencephalo- graphic spike activity. 'lha prior blocked this spiking, or ministration of atropine if present, the abnomality could be eliminated by atropine. In contmt to these findings, Brenner md Merritt (19%), applied topical aoatylcholine in cmcmtmtiom of 2-1/2 to to the exposed cortex of cats, and noted no 10% effect after intravenous atropine (1 rig/kg) on the electmmcephelogmphic changes. The montratims of acetylcholine in these experinmts , hmever, was significmtly higher than the topical applicatims (1-4 game percent) new v” rm— ‘7“ .wv-u- �and the intmcisteml (0.2-10 gamma percent) injections of Bernstein (191.6). Bmmer and hmzitt, also made note of electroencephalogmphio effects similar to soatylduoline from macholyl (aoetylbetmthuldsolinefmd Meryl (wbaxyldloline) in oonosntmtims moh lower thm the aoetylcholine cmomtmtims. inmd They ascribed the effectiveness of those oholinergic drug to their lack of sensitivity to oembml dualinsstemses. FM a waist; conduct: that and MAW“ Wencapdz Logaaﬁtic activity Mu a a “nu mu! upwwtaz 06 as deans tome. Manama agent induced by acwjzdwu'm, appuc'mon'og Mam, topical be. backed can it was; a (Lt/topaz, we may on. Magma Wand by humans, as. (c) Carebmsginal Fluid Amylcholine md Seizures: Aostyld'xolino bomd form. is nomally present in mrvous tissues in an inactive wring periods of activity, free acetylcholine is �. ; .m, . .. ..., , m .. .ﬂzwuwﬂurww—w 1.... y ..‘ , v ".4 .4 .. J, vV—I-N‘r W. . . ._... dwlimstorase. The v—- "’W\‘,a(')~\ro" >m»":qnaArv-n3l.!' 'r ~w.'vu.* '4.-:--wr~vr g~u~wr~a~~u~w> www.1-v-u mm it is libemted at the cell madame, by K." w- level of “mum rapidly deactivated bound aoetyloholine is thus the resultant of the prooosses of synthesis, liberation and It breakdom. may be rise during shop and pootulatod, therafom, that the level will fall during activity. lhis hypothesis was support“ in animal emunants and Elliott, by Richter md Cmasland (19%) Swank and Henderson (1950). By using liquid air quick-frosting mthods, Richter and Crosslmd observed the mtl'nsia and sleep gm per levels. mg. The level of aoatylcholim (masumd as brain tissua) to be 300$ higher than poet seizure difference in tissue levels is transient, however, as the “synthesis rate for aootyloholinc in (7 mimo— mulmlﬁnute). Elliott gt 5;, mt brain is high (1950) omfimnd these oheowatims. After- mtmzole oonwlsiom, they also noted that free mtylcholine was always fluid in concentrations up to 3 domtmble in the spinal gm per cent. v -.~~v~ , . .- �- .... nut, v-wwgg—w mauw-Vr‘ u-~0'iv-a—. n... mg. ._, -:Jpag-.'~vw1 4mv..l.‘N'-rv-~Vr‘-\ ﬁrm—um r“ nmww-r w WM- "— w—rw" .“ - -wmv~—-w--m.. -v.‘ F»; "-v-q .~ www-rwt:.v—.m.-v .10In spinal fluid studies in man, Cbne, waer and (lSMB) and waer and McEachern (laugh) reported McEanhern significant quantities of fro. acntyldholine in patients with epilepsy. 0f 56 apilnptic patients, an (77%) dnmnnstrated measurable acetylcholins in quantities of 0.02 to 5.0 «warns» of 1.0 gamma per cunt. The gamma free per cent with an acntylcholine level was directly related to the frequancy of seizures, the extent of olnctronnccphalogruphic abnonunlity, and the relation of the time of sampling to the last seizure. It home no relation to mndicatian, type of epilepsy or level of cholinesteruse activity. Whethcr>tho acutyldholino appearing in the spinal fluid is a byiproduet of the convulsion or whother the increase in acetyldholine is a Wu!!! cause is of the seizure prublamatical. (1939b) suggested Tower and that the increased wetyloholine liberation in not due to the seizura itself but is related to the procnss causing the seizuma. In a study of the hypothesis that �11 the acommlstim of acetylcholine is basic to the seizure process, Tonia (1953) induced convulsions in animals by mtmzolc and dotsmined the level of acatyloholine in brain tissue before and during comulsions. She noted that convulsions are pmcsded a rise in the acetyldmolim contsnt of tissue; Wily falls during the cmvulsion; levels, cmvulsims failed to occur. and an that the content that bolas curtain She suggested in tissue acotylctmline during a omwlsicn by was due that the fall to inhibition of aootyloholins synthesis by increase! concentrations of metabolites such as In. mim Likely ions. #:215de m mmwbg mm {m mam; ohm «:3;qu an wanted (m it inmate in bound tat t3 isms my be inﬂected in sum 5%; ands wanes «wanna: do 5m, and that cumbmt auction, taming and Leap nhuu an to in augment Minoan; tin no. touch as “mum“ pmduoaon imam ing “A as touch . �v......,.,.w.,. ., 7.“..- www. min-w: .~-.Twr-r.~a y: m nvmw-m ...v 'Nwwmu‘agnar' "n T“.1.,1~V;’§mm- ,M m..., . .u..." .“WWFV . m: or..‘m--.w-,.-W,‘_..< WW. m.ﬁwl... .V w‘~...oww»..wm-_v m_w,ﬁ WWW-A“ .12. central nervous slaten Cholineetoraaeez Concomitant with their observations or change: in ooetyioholine, Tower (d) fluid oholinoateraae end noanhern (1949) mnaeured epinel activity. Two types or oholinoetorenoe ere normally found in the epinnl fluid: oholinoetereee—I ('true," "specific,” or neoholyl hydrolysing), whioh has e high specificity for aoetyloholine: til oholineetereee—II ('peeudo.””non~epeoitio,” or bensoylcholineohydrolyging). Both compounds hydrolyze eoetyioholine but have dirforont rate: of hydrolyeie for This meoholyi and tensoyoholine. qualitative dietinotione. activity as a By differential rate permit: reporting the oholinootoraee ratio of the nativity with meohdvl end with bonzoyioholine outstrnten compared to an noetyloholine lubetrete two ratios are round: oholineeteresoai/aoetyicholine and cholineoterooo-II/aootyioholine (with retﬂoa Initials! norMul 08F th/th: 100). In such contains eeteroeeo in the ratio of 53.17 for oholineatoreno-I to oholineotoroee-II. Thus. normal 08? consist: , ,»-.- .- �_.w.W—-« “mu-wow. arr-u- ﬁmwmmm "WW?“ me-‘Ww‘wmvjrimwmmrm )5 s: mainly of "specific" estomes with a small mn~specific ostemse want. In patients with head tram Tower and McEnchem report and inversim of the dualinestsmos with a simificant increase in tbs daolhnsts'mse-II fraction of the spinal ﬂuid dualimstems-I activity. They and a «mass in also observed a relation batman the extant of the momentous” manual with the severity of trans and with the dogma of the olcctmmceprmlompie In patients with 5.an spinal fluid acetyldzoline as a result of spmtmom saizms. howswr. of cholincstsmss or total Why. no change in the ratio duelinsstss-ase activity was found. Certain usunptions my be mad. mgmding changes in cell mm psmability as explaining the humans in duelinsstcmse contamination in found in highest is Gaolinsstcmse-I activity. the antral mm systm mile molinestemse-II in atlas:- tissues, especially blood sewn. pmdminates With an increase in �,7. ,.~.n_..._..‘..,.q—. 7. v . ...,~ “NW... . «g..- Wv-slv'n-nrrh w-rw-muwwwmmmwwvaWmn-mmmmmv‘wvwrvhmv w -w~'r v- acutyloholim levels in interoellular cerebral fluids following stimulation, convulsions or trauma, vaaodilatim md increased cellular pomability may be pmdiotad, with a degree of transudatim of vascular fluids into the inter cellular Spaces dependant on the extent and duration of tha vmodilation (Kabat 33:. 9;, 19%). Spiegal and SpiogebAdolf dummtmted such pamability ohmgas in nmorma "ports 1953). Thay reported inmmd (19141. 19%, 198%, 19148, oomhzctivity of the tissues associated with tho appearance of various ions as potassium and phosphate in the spinal fluid following convulsions. more was also a significant as nucleic-acid nm-clactmlytes cellular pamability mtmims electrically inmoed may imam in such splitting mzyms. Chases in thus provide the basis for the high of acetyldxolino and the managed omoantmtions of dwlinostorasaJIﬂTmr and Hoanhem muse) . '5 �— m‘ w «'7'- M-mrwrvva-mmmw.mw m The increase in ammnstcme activity should be associated with the rapid «stamina of free mtylcholim. Its persistence in spinal fluid afar tram ad 931m related to the sensitivity may be mtmim of the amtyldwlim—dmﬂmstm-I system to ships 5mm (mam md Rathmbarg, and lowar Midtown Mauritius, ad mo mnemtmtims, tha nativity falls off quickly. In contact, of hydrolysis mm minimip «sciatica mm who in few isdestroyedbythe udlliuomds. where bmoentmtim of mtyldwlim in tiasun. tbs mm of hydrolysis by dwlixnstome-I is W. com. m WWW—I to an is nut—specific with concentration. Thus, the mlhwnbfmtyldxonmatmnmbm specific activity of Wm, 19kg; is mpid (3-3 mimeoonds) but at higher th- dnlimanmc—II-m‘tylcholino the m and At "physiologc" and HacIntoah, 1955). hydrolysis of 19445; mktim~ mmmMMMmybemadndmdaseizm me disaoaiatim in ship nouns in a pemiatm amtylmoummﬁneamml relationof mldwline. The seizure may �16 itself in add wt to the of free acetyloholine. 'lhe increased mtylctnlim diffuses rapidly, affecting vascular and cellular permeability and increasing the cmocntmticns of various ions and dmolincstemse—II (SF. activity of cholinsstemsc—II, though of The on the concentration runs to days to efficiency and dependant kinetics, reduces the acetylcholine in the tissues in in! levels mm” 1c»: for the physiologic action of cholinescemse-I. #:1st am Manuela manta 5M, «may 5m «ppm in {Add dowsmaa someway in. «was {on mm 05 ma past a a gestation dzangm “mad Mwouﬂne. Mme. madman; om «toned by (named in 06 «he :1ij (ﬂ 05 in cut 'hc mechanism mun-um at sou moms nausea; system sanctioning. (c) Agglchclinc a EEG WNW and Induced Convulsicns: Altamtion in the blood brain permeability barrier by the continuing action of acotyloholine may be the biochemical substrate for the post- olectmsbock hypemynchrmy of the electroencephalogram. Such a possibility is oviduct in the upon an increase days by Aird 93 9_1_, 1956, W denmstmting in the cmocntmtion of cocaine in brain tissues three afar a series of 12 induood convulsions. His data shows the change in �-17concentration of this large molecule, ordinarily absent in brein tissue to be seeocieted with the eppearence of hypereynchrony (delts'burets) in the electroencephalogren. In studies of induced convulsions. we have confirmed the neny previous reports that convulsive therapy induces electrcgrephic hypersynchrony (Pink and a constant Kuhn, 1956). Despite time the or however, or treetncnts. epplicetion slow the and of extent electrosrsphic duration eppearence. wave activity; its sensitivity to modification by alerting, hyperventilation and barbiturates psychiatric populations. degree hypersynchrcny. end The - s11 vary greatly in early appearsnce of high its persistence throughout the treatment course, hes been described as prerequisite to improvement following electroshock (Pink and Kuhn, 1956). The failure of certain patients to develcp hypersynchrony may be relatedto differences in activity of central seetylehcline and cholineeteraees. may reflect The degree of hypereynchrcny the level of tree ecetylchcline and should follow s decay rate eqael to the rate of ccetylcholine destruction. �vuzvnc—v-w: —. Since previous studies demonstrated thnt ens prerequisite to the it may be EEG hypersynchrony clinical response in convulsive therapy, suggested that the absence of free soetylcholine suggests minimal changes in cerebral function and thus precludes s clinicsl response to induced convulsions.Touer snd their study of creniocerebrsl trauma, hoEedhern (1949s), in included observstions of six psychistric pstients undergoing convulsive therspy. Studying the pstients after 3.7 trestu meats. they reported free soetylcholine activity in the spinal fluid in ten pstients; and en increase in cholinestersse-II and a decrease in cholinestersse~l with a reversal of the ratio or cholinestersses in five of the six patients. From these observations they concluded that the spinsl fluid changes in induced convulsions were more like those of creniooerebral trsume than those found Regsrding the one show in. ilepsyu pstient in the series who thiled to either free ocetylcholine or e cholinesterese ratio reverssl in the spinal fluid, they wrote: that this patient was the only one "It is interesting of the six to show no _.,. �7‘ response to treatment." It is I probably that induced convulsions increase free acetylcholine and enhancing cerebral perniability altering fluids. in intereellular the appearance of cholinesterases. Free acetylcholine by JMAco repeated seizures. EEG hypersynchrony is one is maintained reflection of altered of other electrolytes. and altered permiebility of acetylcholine levels It is these changes in intercellulor electrolytes that provide behavioral changes the for substrate biochemical persistent the following induced convulsions. L/ (f) Cholineatersaes and the Classification of Pezchoses: These studies may also have autonomic reactivity and the Funkenstein and others ( application to the problem of classification of the psychoses. ) have demonstrated a relationship between the blood pressure response of patients -“.:')l\w - w—w - Fry-w M7.“ �rm, w.» v—v-v- ya—_ -7. -. v'*a‘ 1——.r an ad“): , v-u n.7,. y ~. 7' V .. - r—*yx:'\r‘~'7—‘ —..vwr rhw- revues—WWI: a-m-x) v aw. 'IIMIN'.WP1L _,.. wr—Mrn 'w .n-u- u ...- nun-mun—u-wwwsrx— I‘d 'fllr-nr-F-qlf r".:'m~ — - —» ~ to injected meoholyl and their clinical response to convulsive therapy. which induce! Neoholyl is e potent oholinergie agent Vlsodiletion, tachycardia, sweating, and It is inoreesed peristelsis. rapidly hydrolysed by cholinesterese-I and slowly by eholinestsrese-II. blood pressure or subjects tells etter injected The meeholyl end returns to the baseline in a variable length of time, 2‘2;, five to pressure returns to the hgaeline in as Groups Pstients more than an minutes. I. II, or III reactions: 5 whose blood minutes ere olessitied those whose blood pressure takes so or more minutes to return to baseline, as Group and VIII reactions. The Group I reactors here s 9% improvement reactors s rate with convulsive therepy, and the 35% recovery rate. In contrast, the reactors heve s 89% (Punkenstein 35 3;, 1952). petients In whom IInIII Group VI and the Group VII 3 9'71 recovery Patients in Funkenstein Groups I to III upon as Group VI may be rate looked the injected meeholyl 1s rqpidly ~ �. . ”(Inni- rwlv‘v -. v -hr ~r. ‘r Wﬂm‘r;vz.z ~~w~ ‘ vmvrmm-mwvnvmwurr . . . . -.n- . ~v-cv rwwmvrrw-r ’Hm . , . warm-n'ku-w—w-vwvu-r‘mwm ’W'I-W‘WW . , ., . ‘23.. Groups VII v1 and the while hydrolyzed; slow hydrolysis rste. we may patients have a. the therefore. that predict, would 1.1!! Groups of blood oholinestersse nativity levels be high; while the setivity of Groups A VI-u-VII would be low. central odds nervous be rsgsrding similsr analysis msy devsIOpeent of the in system levels or oholinsstersse~l EEG of soetyloholine. levels and fluid spinal hypersyndhrony In studies of EEG changes following indueed eonvulsions resolted in seizures subjects were identified in whom a few a great amount or slow save activity; while other subjects (Pink seizures and to frequent exhibited few changes to many and Kuhn. 1956). If electrogrsphio hypersynehrony is s that probable is refleetion of inoressed tree soetyloholine, it subjeets who rapidly (the usintain hypersynehrony end those in whom it differences be exhibiting hours) disappears nsy hydrolysis oholinestsrsseoseetyloholine the of in the kinetics systems. Persistent hypersynehreny may be seen to result from associated of soetyloholins. s decreased rate of hydrolysis with low or oholinestersse-I either oonomntrstions of z - w mv as ‘— e �nw—w—uurw—u-A ~ «wv-u . "Hp; v-r w: w-ws-u—mxw —» al’im'rw‘imﬂl'wnnmmﬁ.rww-‘wmm' cholinesterasemII. Conversely, in patients with hyperaynchrony. cholinestoruaoul and fluid may be a basin fbr :yutom 1110111 : unusually high). wwwvvnwa >vv'wwa-uww «VII-MWI—w-W short~IIth .1: in tissue and spinal Thus these speculations providn congruent hypothesis rognrdlng central norvnua ruaativity to electroshock, and parephoral ahelinergio 09‘. �‘‘ r— v» -v «'1: -w:. . ~v~wr 1.». —.vn.~n—u nvw .w is w,“ . V m .,._v you-um: v...“ .uw m...” w. i. (“Hwy . , . V . v—wr\wl~;r‘-V‘va"vwg . 7-..,emu.,_,._c w‘,_pwmi,,”.w.'w.ww rtr‘ ., 1”,.“ M y OOHGLUSIONI be to e neehsnisns appear Gentrel eholinergie The convulsive the therspy process. dignifiesnt teeter in induced that to indioste be date interpreted any published Leonvulsione ere ssseeisted with en increase in intereelluler be by destroyed than esn to levels greeter seetyleholine eholinestersseal activity. Vhsodilstion and increased oellulsr pernisbility is relieved by increased amounts of eholineetsreeeoII, other and electrolytes in inter- celluler fluids. It is these changes that ere reflected in the increased electrical hypersynehreny which is recorded in scalp electrodes, and which esn be modified by sntieholinergie drugs. as stropine, beneotysine, dietheeine, proeyelidine, etc. It in these changes. else. thst provide the change in biochemical milieu which to slter alters cellular ectivities eufﬂ.eient the behsvior of subjects. Fhilure to induce high and failure of aoetyicholine, concentrations and persistent ( . . 'W—vnww �- —-——--p~rm- ,v-vln’ .-. ‘w-m-w --v< w u-wv «m ”uru-ewmmw‘ vat—rm,“ W'WV -. - . wwwm mmnmnuw—wm "wrrm,w— "-1. Wm, chengpe, concomitant results in a failure to induce electrolyte to produce behavioral change. Difference: in the rate 0! development of cerebral chengee may on reflect differences in subjects in their reliance cholinergic mechaniene, or in their sensitivity to changes in acetylcholine levele. These differences provide the basic fer the claeeificcticn cf the menilly by my: and Kuhn (1960). 111 by Funkenetein and �.4 w . .._u~mv — \w"wxww ~ wlxmw-mwmmwwrlmmrrw IV: 6-6-65 CI‘DIINEmIC WISE, CWVULSIVE AND BBMVIOR W, Studies of cerebral changes associated with convulsive therapy have indicated that the development of early and persistent signs of altered coronal fmctim are prerequisite to oranges in behavior (Pink and Kern, 1956). In these studies, electroencephalographic slowing was the most sigmificent index of altered brain function. Th demonstratim that premedication with high doses of atropine and Johnson, (Ulett slow of mve the activity prevented appearance 1956) suggested a relation to cholinergio nechnisms. The role of eoetylcholine and ﬂu cholinestemses in convulsive therapy is amplified in the following review which smrizes the published data. The mle of acetylcholine in the tmsmis sion of nervous impulses has been studies extensively since the of Dale (19136) and Loewi (1921). Acetylcholine constituent of nervous tissue existing in a first descriptions is bound .21 normal fans which is �. -~»-.- cwlwx—Wm.m~mn mmmvwvx 'w'w-m‘ w'dnuev—Wn —-'-v.":'-v-yvl~<-wmv -‘-w'-W"’mnrm"u'm’mmp '«ai-lu'vwv'w»; umpnw-so w-wm'n It is liberated driving the excitatim process. W the specific action of ctnlimstemse and as rapidly recmstituted 19:59). mpidly hydrolyzed by the dwlimacetylase system (Richter 8 Welland, free ac etylcmline has been reported in normal No cemhmspinal ﬂuid despite the rapid breakdom of bound acetyl— choline during pariah of activity and excitement (Tower and HcEechem, muse). The cembmspinel fluid normlly has resemble chclinesteme activity, homver, principally of the "true" or mechclyl hydrolyzing type (Nectmensm and Rcthmberg, 19u5). In the absence of free acetyldxoline and under the cmditims described, electroencephalogram fail to shm: any mietent abmmelity. (1:) was fmmd Effect of Wiccambml Mm: Pme acetyldioline in the cerebrmpirml fluid within a experimtel heed tram varied between 2.7 and 9.0 dew after in cats and persisted for varying periods (Bernstein 19%). an hours to m related to few minutes gamma The qumtity of free acetylchclim percent, and the amount was of induced trmrne. -n way-a ---1-m'— «mu-w v;- �v ‘ .v-vuwv—‘uwuwaI—r'm mm ‘lh'une‘ “an”, . - 1W um van-mar ammw— mmmx($—‘Wv~ ~-;Www Ww-v' .wma a..- ‘nv‘w I'u Commitmt electmemephalogme Th records were first filhd with mmted patterned dwxges. high voltage fast activity, interpreted as evidmoe of m intense manual disclmze, mly to befollmdbyasrwrtperiodofﬂettmingofallmcomed electrical activity. 'Ihese planes were then followed by pmlmged periods of high amplitude sharp waves in the delta frequencies. The to the beheviml enemas were mutant of measured fme related to degree of acetylcmlim. tram and With higmer greater of acetylcholine, Bernstein reported degrees of abnormality and greater- changes in moiwmss. levels EEG In addition, spmtaneous poct~tmunatic seizures were also related to the mt of free eontylcholine appearing in the spinal fluid. aoetylcholine Bunstein later applied to expomd out cerebral cortex. mm the cmmtmtim of acetyldaoline was 1 gm pement orless, Mowemdhimmlitude sharpwavesoflwfmquencyin the electmenoephalm. When the concentration was inmd to w... wal‘r-vunu .,.. u ��min-u .41. - v... and :— » -1~—— “Va-x v,m..,».«n—n ww'Al'wr‘w'nx‘xa'r .. ”-p- vwrn 'iwrylvv.-ws“ «ﬁrm-mu». tr'r'r—I‘lumm$1~I'm’w-VWW-Iv‘rn'wwu .~ that the reversal of the dwlinestemse fractim sensitive indicator of cerebral BMW tram Jag-Anny... ”a.“ r‘np‘woyppﬂ" v—y- x w— v—w-1,msw»: v. was a more damage. were takan at varying intervals following in most of these subjects. me authors reported the relation homunmofﬁmahmmntymdtheappeammoffrm mtyldwlim in the w‘bmspinal fluid. Thu: AW my We and that a «the mount 05 (m acdytcholxiuc 5mm summing Weenebmdtﬂawm batman the mount 05 mayuuz Won W Memory, main wind In the Micheline, (1)) M indicate m dcgm and changes Effect of and typc 05 in AM mm on unﬁnisnmd 0.5-1.0 awomuphatogmmc bchawéoa. at-«mmtic nag/kg (an. atropine EEG and Behavior: pmtually after mmummdmmmmdbmmofmeme. behaviomland anatomic aims of tmuna. Atropine also blocked the clinical changes similar to head mum EEG md seen following the experi— mtal additim of intracisterml aoetyldnline. n-w �.r .nwm-nuw v m, 1‘ x—~.wwrv-—um—mw“n-«WW«-Waqm v Ward (1950) . mm dawn c." m xwwuv— m ‘- um ,r—m—xw applied thase observations to the treatment of hmm cases of closed head injury. In of a: patients with varying be administered atropine subcutaneously in doses tram, of 0.1 mg/kg. In 20 some cam he noted clinical immanent and in others a reversal of the electmphalogruphic effects of the tram. In a study of dietlmint. another antidmolimrgic dmg, Janknor and “dancer (1958) reported significant alterations in the post~trmmntic olectmenoephalogzm. dose in #0 slow single intravenom patients with ahmml electroencephalogram resulted in normalizing in The A 22 subjects and marked immvemnt in six others. sum elect of atropine in blocking the appearance of um activity convulsive following in subjects reported was 1956); (In a therapy (Ulett md Johnson, later study then authors failed to mplioate this study, suggesting that or population changes may have [Johnson 93.51., 1960]). dosage factors cmtributed to the different results .u-wmwm �"rm—W .7, . .\.—.~ v‘ u. w wr— w' w --=»—-.--«-v- 'w' nu.- "I 1- nun.“ mm-‘Ivm’lwuu‘twr "uvmq-WIWVWW. “HM-:rv‘lwr." 1— x—A 'i‘w'wwuvuwrwwn uvvmw": «rung-w unmoun- . aw awn:v-v—nnJ—m variety of experimta with a potent dzolinestomo inhibitor, A DI? (di—iaopmpyl ﬂmmophosphatc) fmqumcy EEG mutated hiya mpﬂttxde rapid éimilar pat-hams to status epilepticus. as well as dam status (Md: 5331.. of abnormality similar to that noted in pmt—trmtic looser m 1950). doses of mad 1950; W ﬁg, 19139; aid Won 95%, eleotmonoeptulomphic effects were blocked by small pmteral atropine. Chatﬂald md miml com»: with proatignine Way (19142) pmpamd and evoked electmmoamalo- graphic spike activity. The prior uninistmtion of atmpim blodmd this spiking, 'cuminatod by wif mat, the abnomlity could be mine. what to these findings, Banner md Harri.“ (19152), applied topical mimome in Momma of 2-1/2 to In 10% to tho awed cortex of cats, and noted no effect after intravmous WClm/kg)mﬂne1¢otmumphalommicdmges. 'Iho mtmtims of acetyldnlim in those experimts , mm, was significantly higher than the topical application: (1—1; gm meant) m "nm‘lV‘I-"WPX' mm» �.9— intmiﬁuml and the Bormtdn (19%). (0.2—1.0 W gm percent) injections of and Pbrz'itt, also made mate of elmwuhgrmic effects similar to aoetydxolim from ucholyl 1n (mummyldwline) commenting: dam. '33); m and dozyl (carbmayldloline) later than the acutyldnlim concentrau ”W th- inmmd offeetivomss of these momma. drum to their mitivity to animal lack of durum. FmavWa‘WandWaMu my I mama that Waupiwgwm «may mm by «wane, uau we. on a a mutt 0‘ mm. Magnum: with chaunutume blocked M (:3) We): Waxed bg We. Role mm away applied.- can be ‘ of Oanbmsgg ﬂuid @951me in Saizums: Amtyldzolim is normally present in mrvous tissm in an inactive bound fem. Daring periods of activity, free amtyld'aoline is ��. N...- ~mv nun-7‘ «mamwmw-nrwu-W-ww-m—mmw Yum—U" v2»: 'lwwvv Wx-uwww- vv'r‘wr-I w-ww ‘t‘I—L :\ mean-v1- avast-Lo— nary-row: .10... Inspimlﬂuidstudiesinm, (19%) and Tower md Warn Cone. TmrmndEadnm (mush) reported significant qumtitios of fun mtyldwlim in patients with epilepsy. 0f 56 cpilaptic patients, an (77%) demastmted ﬂammable free Michelin in quantities of 0.02 mm of 1.0 gm to 5.0 gm per cent with m per cunt. The acetylcholine 11.3ch. was dinctlymlaudmﬂmfmqmcyofaeizm, theemntof 0W0 dun-normality, and the minim oflthe It‘bom lagt seizure. tha to angling tingof no mmim to of Ila-dictum. type epilepsy or lewd of dwlimtemse activity. WW a W 61011110 Michelin: appearinginﬁn of the awn. is a (mm of the Madam arlwhetha-r the aim fluid is spinal W is pmblmtical. (mush) suggested that the in acety1~ Tower md' inmd acetyldwline mlat§d liberation is not due to the seizum itself but is to the process casing the seizum. In a study of the hypothesis that v w. �' “W "m’ W“"‘W*P"W‘ TW""-'“'M'rmz‘m-ww' : ~<I w'l-w' uzm-w-wwnw-rmr wrmnsa-mmrw “my; —nwu—n-»mrw—u-—r w-w w n—w- wan-m .mmw- n- -_w.—..——,aw—. mw'hmmrmw m «w -11. the accumulation of acctylcholine is basic to the seizure process, and animals metrazole convulsions induced in (1953) by Tcrda dctcrnined the level of aoetyldmlinc in bmin tissue befom and during convulsions. She noted that convulsions are pmocoded by tissue; of content that the content in the acotylcholinc a rise gradually falls during the convulsion; and that below certain lcvols, convulsions foilod to occur. fall in tissue acctyldholinc She suggested that the during a convulsion was due to inhibition of acctylcholinc synthesis by increased concentrations of notabolitcs such as alumniumicns. Tho passagp of electric current through brain substances induces a change in callular activity with an increase in free aoatylcholinc to lnvcls sufficient to induce a grand mal soizumc. Tho prosenco of free aoctylcholinc in the interocllular fluids is associated with electrical hyperoynchrcny, reflected the EEG as dolta slowing. (d) Effcct of Electroahock on Acctxlcholinc and Cholin~ saturates: Tower and McEachern (lShQa), in their study of cnanioocrcbnnl trauma, includcd obscrvations of six psychiatrin �, .— “7 hin""'-"""""’n w—xwwr‘W'wv-Wsmuwvw ”‘1.meer!. ., . A a .m "Jaw-«v 7 wmr- mm- vmm:wwwq~mw‘m¢7~w 1"‘3-0! w ~12-- patients attu- 3-7 Linda-going mmrulsive therapy} Studying the patients mam-atmﬂay upwind fm Micheline activity an.incseaae .ad rxuia in.two in in th. Spinal patients; dwlimsteWII rawnrsal a: a damase in and mum-I with a the ratio of cholinesteruses in five of the six obsewatims time has paints. W they concluded that'the spinal new; convuisions were 11kg those tunic ahansps in induced mm a! than those found in epilepsy. Ragarding the ma patimt in‘the series who failed to show 01th» I’m mtylolnline or a dwlirastemao ratio reversal in this intsmsting the spinal fluid, thoy smote: "It is that pstimtmﬂamlyaaoftrasistosmwnompameto mamt." WM than. a show: in «1mm, cons/Lamb“ augment about ﬂu. note 1,: 1.6 05 “chaste that 7W!- acaytchaune mwmgaammwmmuwsm <1“ch 4:.qu and Adm/Lu enhance. autyb Ls that «sorghum damnation, �“mu-w. v— vaw >W—Wrﬁww.vwam—.m .‘w'wwrr Mr“!!! wrwwumm'm WV - W9 augment wmm 1WW"WYI3"W'FVI'W‘VW wwmmww-zw (”wan-vim -13- Lawn. tww 05 “Midtown whiz: “up and auuthau wetytchauu puduocéou inc/mum about. (was. (2) Central Nervous Sygtem Cholinesterases: Cbneumitant with their observatims of W (1939) muasumnd spinal in acetycholine, Towor md Hcﬁadxem fluid cholinesterase activity. The types of'dholinostoruscs art normally found in the spinal fluid: momentum—I ("trm,” "specific," which has a <92" mdmolyl hydrolyzing) . big: specificity for amtylcholim; and duolinestemseoﬂ ("peeudo,” "um-specific,” or bonnoyldwlinc-hydmlyzing) . wands hydrolyze mtylmolim but have different Both rates of hydrolysis {bu-ulcholyl and banzaylcholine. This diffcrantial rate permits gamma distinctions. By ram-ting the cholimsternse activity as a ratio of the activity with macholyl bonaoyidaonm substrates two mama and with acetyldmbline an to- substrate ratios am fomd: momentum-Ilacetyldnlim md alwlimstcmeII/amtylmolim (with ratios normal CS? Ach/Aeh a 100) . omtains ostemses in the. ratio of cholimstcme—I to dmlincsteme-II. Thus, normal In such 33: 17 CS? for consist. �-.v rmvs 'mm l-F'W'WW wmmmm .mpr—w— rm . . may of "specific" caucuses with a small now-spedfic estemae coupon-mt. In pathmts with hand inmim of tho cm the fluid fraction of the spinal activity. dam the and 'mey also observed a of tha dwlhmstomse with ad mm Wm report and daclizmtomes with a simifioant increase in the “Wm-II Wanna-I mm Tower and of the W a decrease in relation batman with the severity of cummpmlogmpic mun. In patients with increased spinal fluid amtyldxolim as a multofspmm of Wm warm seizmu.‘hdnvor. or total dwlinestcmo activity in the made was found. metimmybomﬂomgamﬂngdmgeainmn mm activity. tha pemability as explaining the WWW-I m1 mm: syatcm is fomd 1n imam Wt in dulimstemse mnomtmtim in mile dwlixmtemesﬂ pmdmimtes in 0th:- tissuaa. especially blood scrum. With an increase in �,- xw- m-mmwm m anatylmolina lawla in intercollular cambml fluids following atimlatim, convulaima or tram, vasodilaticn md cellular pamability my be ﬁlmed pndictod, with a dogma of mmudaﬁm of vascular fluid: into the inter gallular spams mtmmmtmdamimofmvmodimm(mt g; g, 19%). Spiagal and Spiegal~Adolf mutated such pamabmty W 1953). marred inmaaad omchctivity of the tissues Thay associated with W than in mm reports (19%; 19u2, 1m, 19%. appaarmca of various ions as potassim and in the spinal fluid following electrically indumd commie». Thom was also a simificmt-imm in such nm-aloctrolytaa as manic-acid splitting anzymas. (images in of circumstance-11 (Tower and Wm lSth). _ �wwlv mun-am.- V‘r‘ww.\\.sm uwrvvu‘x' ..- me—wwmvmvwn .q-zwuwm pawn-w ., cannwmuw v-Mr-ru-m‘ovr WWWWW «um—a. -.--< www.mm -15.. The increase in dwlinsstsms activity should be associated Its persistence with the rapid dostmctim of free asstyldxolins. ' in spinal fluid after trauma and seizure of the amtyldxolins—dxolixnstsmsvl may be system related to the sensitivity to concentration relation- ships (Nsdmsnsm and Bothsnbsrg, 19%; Tower and 3mm and MscIntosh. 1955). At “physiologic" Wm, 19%; oonosntmtims, hydrolysis of aostyloholins is rapid (3-H mimosaoonds) but at higher and mosntmtims, the activity falls off quickly. In lomr W, the cl'nolimstsms-II-sestylohomm relationship is naiospscific and the rats of hydrolysis increases with concentration. usual levels of sootyldxolim stosll sambmms is specific activity of cimlinsstemss-I in Thus, the destroyed by the few milliseconds. Wm omosntmtion of soatyldioline in emsssivs excitation leads to an mm tissue, the mm of hydrolysis sxosedsd. com. The ssizm threshold may by cholinsstemss—I is be roamed and a seizure me dissociation in mstylduolinwdxolinestemseul relation- ship results in s psrsistsnos of aostyldaolﬁne. The seizure may �mm “a." "W.— .mﬂmpw txm mm Wm-mmwmm—mwm m "m . amtyldiolixn diffunes rapidly, affecting vascular md cellular pamability and and Wins catamaran-II W of in the concentrations of various ions CSP. The nativity of dwlinostamse—II, cfficimw md depuuhnt low on the oonomtmtim kinetics, mmmldnwninmetissmsinhwmtodaystolewls for the physiologic action of dwlinostemse-I. (I) mo md Classificatim of mmm, gmmm . mamas: Altemtion in the blood brain pemability barrier by the continuing actim of mtyldmolim may be the biomenﬁcal sub- strata for the post-3W hypemyndumy of the electro- mmpmom. Such mag, 1956 is possibility o mom in the report by Wmtingm 5.11m intha concentration of‘ miminbmintissmsmmdaysafteraserieaofuinduoed Gambian. this His dun 1m mlccmln, aim the change in momtmion of mutually absent in brain tissue to be ��mm. WV wwwm'wmmww’rr‘v m (memwmw“'m'ww .19- my be mama“ in the. mum nub/mug ad the. dwuuuthu— hypmymmuy Awwu. my mama Whom 1’th be. oﬁ acetyl— dummzd hyd/wtyau to as a mt: {m mm an Law ma mammom wowed mun, u Cthénutcmc-II. Comma (Ly, in and Wmmv! WW, my be muddy 06, mm ~11 ewwc with 5h0u~uv¢d in Mac, to the Wainwmmk Mammy. WW and spinal (laid high) . stat-ﬂea ’meae may also have application 3 chaunutmvr MM}: between the blood problem of )have pmsum mponse of patients to initiated médblyl and their (minim). response to I convulsive mm tram. which is cholinorgic a potent hamlyl amt vaodilatim. tachycardia, mating, axomestemeq hydrolyzed by is It midly astemo—II. "me blood and hemmed peristalsis. and slowly by moun- pmssm of subjects’fans after injgcted manlylmdmtmmtoﬁnbmeuminavariablplmgﬁmofﬁm, �-m. “...u. “v ,,.. ‘mw you ,,, d . ”are". ‘V‘ -- m, mus-www- I vm‘ five to W rm www.- w. m 1 ”3.... v- .-r'l w - way-vr—v- .m-MWWWW. “gnaw-why , Patients more than 20 minutos. Mums to the baseline in 5 an minutes ,,.mu(._“‘,_,m,“ . whose blood classified as present. Groups I, II,’ arm mmmmbaaoline, amHdeIImactions. MW]: or III mactima; ﬁnes mean blood rams hm a 9i Wt the aroup II~III reactors a 35% rate pmsm takes minutes 20 and convulsiva'thompy. with. unwary rate. In umtmst, the MHmmmmmaast'mddnGmupsvnath-wverymu (main 5; g, 1952). Patimtsinmﬂcmaminmltolnmaybelmdm as patimts in whiu the We may the injactgd mdaolyl is rapidly hydrolyzed; Group Hand VII predict, hvels of W when: Won, W H~Vii a slaw hydrolysis rate. that tha blood Esolimstemo activity -I~III would be him; whim the activity of ma be low. regarding the data for eatcmenl, in patina hm We recall hem a similarpmdictim mntmlm which the domiopumt syntax: levels of cholin— of early and sustaimd EEG lypamynclumy and elevated spinal fluid levels of aoetyldlolirm was minted to a low level of dwiineaterase activity. mus, w-n —. wu- �,-.n I ‘ -21- the data of paripiuml stimulation by dwlimrgic agents is wt to the hypothesis regarding mutual “activity to electroshodc. mm system m1? m'.mrrw-uww gum �CIDLINBMIC PECHANISIS IN WV}: m m M, NJ). From PM the Departunt of at the Missouri Institute of Paydziatry. Lhimity of ransom School of Medicine, 5WD Arsenal Stunt, St. Louis, Missouri 63139. Aided, in part, by usms grunts 1914-927, 11-1—2715, mmzus, and Iii-11380; and the Psychiatric Renard: Fomdation of Missouri . �VI: 7-17-65 GIOLINERGIC MICHANISI‘B IN CONVULSIVE W Despite extensive application and study, the mode of the oonwlaive therapy process “mains enigmatic. has been devoted to neurophysiological social ) aspects , ( Much study l, ( ), clinical psychologice1( . of action ), ( elucidating the present neuro- ). physiologioal-edeptive View of the process ( 'me wly development and persistence of signs of {motions were reported to be (Pink and m, activity es the The this and muisite to changes altered cerebral in behavior 1956), with electroencephalogramic slow wave most significant index of altered brain function. demtmtion that pmdicetim with atropine inhibited slow wave activity (Ulett and Johnson, 1957) and the report that mtidaolinergic «wounds reversed these clinical as well as electrogrephic menses (Fink, 1958) suggests that the biochemical basis for the mvulaive therapy process may be in the cholinergic mdmmisms of the central nervous system. This review discusses the available data mending acetyldxoline and �and the dualineetemsw in the convulsive therapy process . Acetylcmlim has been extensively studied w an active agent in the transmissim of nervous impulses since the deecziptiom of Dale (191») and Ioewi (1921). It is first a constituent of nervous tissue, existing in a bound form which is liberated during the excitation pmoess . It is rapidly hydrolyzed through the specific action of molimaterase and is rapidly reconstituted by the choline-acetylase system (Ricmer and Crosslend, 19%). In normal cerebmspinal fluid, free acetylcholine is not present despite the rapid breakdown of bcmd acetylmolim during periow of activity and excitement (Tower and Hailed-tern, wheel). The cerebmepinel dwiimnteme activity, however, medxclyl hylmlyzing type fluid does have maurnble principally of the "true" or (Madman md Rothenberg, 19%) . In the absence of free acetyldmline and under the conditions described, electmenceplumgm fail to show elmozmlity. �(a) Cholinemc Aspects of (kmiooembml Trams: Free eontylcholine was found in the oerebmspinsl fluid within a few minutes after experimental head tmuma in cats and persisted for varying periods up to “8 hours (Bernstein, 191:6). The quantity of gm free acetyldloline varied between 2.7 and 9.0 the wt was Wt related to the degree of induced electroencephalogram menses. The records were percent, and tram. demtmted pet-rm first filled with high voltage fast activity, interpreted as evidence of an intense neuronal disdurge, soon to short period of ﬂattening of all recorded he succeeded by e electrical activity. These phases were then followed by prolonged periods of high saplitude sharp waves in the delta frequencies . Ihe behavioral changes were related both to the degree of tum and to the want of measured free aoetyldwline. 9th higher- levels of aoetylcholine. Bernstein imported greater- degrees of EEG abnormality and greater damages in consciousness . �Spmtanccm post-traumatic seizures mm also related to the mmt of free acetylcholine appearing in the spinal fluid. Bernstein applied ccatylcholine to exposed cat cerebral cortex. M the cmccntmtim of acutyldrolinc WM 1 gm low frequency of waves unplitudc sharp high percent or loss, appeared in the electroencephalogram. men the cmcantmticn was Wed to 2 gm percent, the electroencephalogram: flattened in a fashim parallel to the pcatétmumatic records. Pmllel investigations in neurological patients by and Madam (191ml) Tower dammtmted free acctyldrcline in the ccmbmspiml fluid only in patients with meant head trauma, recent grmdoml seizures or after clactmconvulsivc therapy. Free acetylchclim varied from assaying spinal fluid 0 .2 to 100 gm percent. In drclimstemc activity, they noted a sharp rise in the nonopecific cholincsterasc fraction (benzoylcholimnsplitting) and a drop in the specific cholinestemse fraction (maholyl-splitting) in patients with head trauma and ﬁll-owing convulsive therapy. The cerebrcspinal fluid did not �exhibit such inversion, althougz lit command free acetyldxolim. after Spontaneous seams . that the lavel of They comluded two watylcholim varied directly with the dame of cerebral damage and that reversal of the dzolimsteme fructims a more sensitive indicator of mmbral dmaga. taken at varying intervals following mlntim batman the W EEG 935;, Ehcﬂmmaphalom, also indicated a abnormality and the of fme mtg/10mm in [Add 1 Kovach Thu dogma of mm. was ﬁne cerebmspiﬁal fluid. 1957] mmummmuummcam maumuuam WWWMdﬂwmo‘ (an Widow, the ham and. type. 0‘ WWch abmmutg, mmuummuuaappmu Mandated pm. �Fwy-.. W, .,- V l .7..— (wt‘ mm- M 1-... WWW“ 'mw .. :‘w ,v- a. , , m1. vv vv-uw-u-,o-vw-w.w.w ‘V'I-V-t.mNrIV-WI AntiohoMc (b) wry-urn "I“ wv-mvww—w-wuam—run-mnw—uu—wxw m and tram: ”myr—w—vm—wwwq wrivlwmwwr-wﬂw v: ,«w- me electmmphic, beluvioml md nemlogic Sign of trauma were blocked by the mutual ministration of 0. 5~1.0 ag/kg atropine (Bomatein, 19%). as were similar olinmel oranges occurring after the inmatemel additim of acetylcmline. Word (1950) applied these observations to the Moment of closed head injuries. In 20 patients with varying degrees of amine tram, ministered subcutaneously in done: of 0.1 ng/kg, mating clinical improvamt in some and a reversal of the electmenoepmlogmphic effeots in others. In a study of dictum, mm mticmlinergic drug, Jenkner and warmer (1955) mpwted electmmphalogxm. the postnmtmtic done he in forty patimts with A altemtims in single intmvemua em}. electroenceprulogrmne resulted in normalizing in twenty—m and muted imminent in six others. Similar observations have been reported by Denisenko (1965) using methylbmectyzim and ‘ meantin in poet-trumatic ﬂock and cerebral edem. animal experimts of ‘ . u—v. . .mmrrmm �- .v -'4In v'nvwr»vr Anew—Wt nv -V “war w rr v. I1wurwuu‘wv gm" w'twv‘z' 'or‘ Ila-3 », ~.,r-.mwm-w-—~ v.“ ,1,“ .‘ .v-y m twinw-vp "Ivy" .m.‘ war. .r my rnm ~; . "mam—q .74- ..w w. .... , Thee duet-mums wen eeueeed in the omwleive therapy process by Ulett and Jornem (1957). Then workers eduiniotemd doeegeaofatmpineupto the patients received that the was mt: mper'daydm‘ingthemeke «mm of slow wave therapy. They Wed activity produced in these patients significantly has then the omtrol m who had not mind the atropine ministration. (In a. later study these eutm failed to replicate this etuiy, suggesting that douse factors or populatim changes have Wed may to different results [Jomem 3:311; 1960]). These observations provided the basis otlur 1cm mtieMlinergic W for studies with (Fink. 1958, 1960). The intmmue injection of emerimentally active antiomlimrgid comma es diethedm, benectyzine. the piperidylbenziletes JB-318, JB-336 and JB—329 (Dim). and wan-2299 induced deemmmiution in psychiatric eubjects. These were associated with bernvioml ﬂirting, anxiety. EEG EEG clmges tram, illusions and hallminetima. In patients um had recently �,__.,,__,,.. . V... 7)... W- w -— ....,... . .V-r—w, .wx-7'Uwiwt ~s| '1‘ u u a...” ,.. w‘mmjwlm‘vwnmu‘m . "0...an ”mi—W- .thwuww. ‘ m.,.m-.-.,,, M_ "H". H," ., ,.. .w-.m.1, , a“, r .neqy..-mw—-; - .r» vr'." received eleotmoonwnoive therapy. the eduinietmtim of theseoomomdemeeaooietedwithemdmtioninslowmve activity and meme]. of euphoria, denial Atropine was also EEG emined in desmlumiutim WI m and tension. and confusion. low doses. and obeemd in these administratims, mind At higher superimposed beta tachycardia, We, hyper-8mm slow waves, followed by lower voltage, poorly activity with by activity mined delta “mind by progressive confueim and disorimtatim. Both in oenbral mm and indumd omvulsime, the ehotmﬁmphio clauses my be modified by the comm-rent administmtim of micmmemic drugs, thus Weed mt: of aoetyloholine or- mating that incmeeed cholimrgic receptivity is eeeooieted with the high voltage slou’ wave activity. (o) 13min mmnm and m! mmm : SimilarEBGohmgeemdthblookingthmfheshenobmmd following the direct application: of aoetyloholim to the centre). mam. - .rml... ww—wu-uuwy w— “WY—r! �'lho anninismticn of a chainsaw. inhibitor DP? (di-isopmpyl fluomphocptute) elicited high maplitudo rapid frequency W EEG patterns similar to status cpilcptiws, as well as similar to those of post~tzmmtic states amen 23%, 19%, 1950; and ma: gag, (W We 1950). effocts'wom blodcad by small doses of pmntaral atropine. mat was 91; 5}; EEG The inmaso in acetyldaoline after tetmrdxyl pymphosphate named indumd and routed to the toxic mmisfostatims (Wand 3m, PM: 1952; ('11???) and convulsims 1957;) Chatfiold and Dummy (19h?) pmpamd exposed animal cortex with Tho pmtimim and ma chmmlomic spike activity. prior administmtim of atmpino blodcod this spiking, or pment, the mutuality could he oliminatcd by if atropine. In contrast to those findings, Bram” and Merritt (19%) applied topics-.1 acctyloholim in to the expound cortex mania-ts of 2~1l2 to 10$ of cats. md mted no effect on the electroencephalographic changes after intravenous atmpim (1 Wits.) 'me concanmtims of acatyldnlim in ﬁxes: cxperimanta, �10 harem, wan higher than the topical applications and the inmoistomal (0.2-4.0 Bernstein (19%). Exam» and gm (1-14 gamma percent) pennant) injections of hwitt also made note of electro- m unholy]. onooplulogmphio effects similar to Midtown (nostylhotmﬁayloholine) and doryl (Wlmlinoﬁn mantmtims moh lowor than the acutyloholim oonoonmtiom. 'Ihoy ascribed tho imaged effoctivomos of look of sensitivity duolingio those drugs to thoir to oembml olnlimstemes. Thou data one conflicting and furthr study is masonry to qualify this issue . Gummyiml Fluid mglmlinc (o) of aoetyloholim mtabolism and inﬂates that it is Selma: found in One View mm tissuns in an inactivo band form, wring periods of activity, mtyloholim is liberated at the call midly mum, Mum it is deactiva‘ood by dzolimstomso. 'Iho mount of bomd mtyloboline is the resultant of tho oontinumas pmoosses of synthesis, liberation and broakcbm. It the level has been postulated that rim timing sleep and falls during activity. and Czomland, 19%; Elliott, (Richter Sam): and Hmdorson, 1950; Gianna: �,7... ,r‘ w .w..,» "gun-w WW, _ w w" Rpm. 1962). .1,‘ A. 4w- By ....- a. m brain mg. higher than 3005 tissue levels is mw. 1...,” wr'w".‘— wan mama basin .v—w tho love]. of during :- "w m:a..»=-v~<wmu «we» u-m—v .fr'um-g v.~'mrw-"n—u'w .r‘xm is high mtylcmlim (micro- munch and sleep to b- mm, mini-It. \‘w‘ , air quick freezing Minds. post-ulna! levels. (7 Thu diffm in as the msyntlnais mm for gm/m/ndnuta). Elliot $3; omfimd these observations. also toting that after nan-uncle aonwlaims spinal "Wu-1 tim) wotylcmm in rat (1950) , using liquid Richter and Cmoclmd per ‘v-‘w‘m fm acetylcmlim m «ﬂammable ﬂuidinmncmtmtimamtoagampermm. Pepeu (1962) fomd an qt central mm 11mm in mtylclnlim Wan depressants to in the mm caused by a group be roughly proportional totindamoofdepmasimoftheemmlmmusmummm‘ mdmtim in Prue mm activity. mtylcrolim m 'fluid in mportad in‘tha spinal patients with epilepsy (Cone, Tum“ md and mum. mmud 5.0 m 19149 b). or 56 fm amtylcmlim percent with McEncMm, 19%; epileptic patients, an (77%) in quantities of 0.02 to an average of 1.0 TM:- mm cont. �v— v w. «...v..v,v .-A—W. ,_.1,._,...V,. -v-.»-m—wv —-.~ ammm‘ «wwwm 'y'vvx'v u—wu.uw,n-w.-w.~:.wmw.1». mu '1 “a“. - .vwruw—Nv- l2 Maryldnlim levels wan related to the froqmncy of seizures, mmdcmmmhmiomlﬂy,mdtoﬁm 1b zinc. the lat column, but bore no mlation to medication, type of cpilopsy or level of Tadcr and Wm ($0th (Hugh) Vimd tbs increased acetyldmclim a lay-product of the Stwying the hypothuis that the inducod aim. m activity. (1953) 301m, and not causal. mum We! of acotylcholine the level of acatyldiolim inbmintissucmotmaoh convulsion. Stumtcdarisoinﬂae acetyldaolim content of brain, baton a sebum and a fall during tho convulsion. Below curtain levels of acetyldmolino, convulsion hind-to comm. She smeared that the fall in tissue can due acetylcholim during a cmvulsim acetylcmlim synthesis sue): on by Wed to inhibition of concentrations of natabolites amnim 10m. Wendhpoualsommdclmgosincenmlmm systcn acetylcholim follauins “rims stinulmts . Only after �13 SMDutyhthyIMimte was there a mcholyl and 3, W significant dam in the acutylcholim level. they noted a in association with inmost! omvulsions. drugs which may qumtifiad as atiwlmts 1:me maninaoetyldwlim impmniazid 4» and no W mind + 1309A) comma, them in mtyleholim lava]. muss these by convulsions. (The than WWW duspite int-mo excitation produced by those mu imam. (LSD. mpmma level. other With were diffemnms in observations mmmmmggmrmrmdmm may be related mutants. to the differences in fm‘ methods th: Lunar unwind of biochemical changes in spinal fluid nflcatingttnfmeaoetylmolim,whilnsiamamandhpeu‘ manna tatal Myldwlim in tissue uncaring bound fm form Thu: an and of acetyldmlim.) AW W Auggut ﬂux Apontaum by an u induced We 1mm in law (no. acotyzchouue �-, .4.‘ . rum- .1:.--—.-. -. ‘T r. .l ~,w ':.»"-rx\~\I--«-~-v~’ ‘mw"‘ m~.r...v.w—.m...~»-. . .«m-n vyr -. . 1-.“ , —;..- r...» ,.r;« “a v.—~ 1n tummy-1 La 5pc“: (mid. mmwe bound (on which my Wag dalmatian, “up and mduaﬁon immune mane (d) Oantml Nervous activity. (19%) also ‘mo Austen/ted 6mm «cavity and Aazuu mm:., m Wm be. tum . Sgt” mama enhance Mae. Lama masthead in the W 06 acetytdtoum (holimstomaa: Tour and spinal fluid diolimstema typas of duolimstarms we normally fund in thc spinal fluid: dmlimstume-I ("tr-m," “specific," or Molyl—hydmlyzing) , which has a high specificity for acetyldiolim; and daonmstemo-II <"imudo," "mspadfic," com or benzeyldxolim-hydmlyzing) . Both mtyloholim but rates of hydrolysis for have diffamnt hydrolym diffcmtial rate Molyl and bomoyldmolim . This qualitatiw distinctions. reporting the duolimstemse By permits activity as a ratio of the activity with a maholyl substrate with a bemoyldxolim aubstmtc mud and to a substrate of mtyldmolim, ten mtios are found: dualﬁnatemeJ/mtyldmlim �-- ~ :4: 7r>m\‘-Vrmwu~<hvuwrr. n >--'rw. aw, ww H'VJ’IW'W‘VCu-‘rm'"‘l ~w:wa-w-._,.rm unr— w .vumma .w. "- urﬁ ,. .... 0-» ‘wV.M-a>vﬁ “Tr-aw -r-.-~,:-. 1m.” ~ m 15 and Mm-II/mtyldmlim. comm fluid :30an censuses for “must-men! to In such ratios mall in tho ratio of 33:17 dawn . Inpatimtswithhadtmm.mrmmmmmd mimmimofﬂndnﬂmtmwiﬁ'minmeinm W41 Mum-I fraction of th- spinal fluid and a activity. ‘11:. W in what of tho cholimtomso Wmmuudmtmmtyofmmmdmm m at the In :13qu WW. mints with owned spinal fluid acetyldxolino m:mm,mvar,mm1nﬁnmioof dwlimtm or total mun-statue activity was fomd._ mmmannmmmymmmamm mumimmminanmpombiuty. WWW-Ii: antral mm system while Manama-II pmdminms 1’ththth in other tissue. specially blood scum. in mtyldmlim hula With an inmue in mnbml intcmauular fluids, up“ .7. 7" .- » -~ ..,_, , u �A , . ,_ =...V........ w...” ..l.._, nv'rvxw w." .7 "Myw-IlI-Irwwaur- ‘7 ""Fvwmm“ v raw-4‘7“-” ”Val n”,_~ -17 . "A «rum—u ﬂ,” "mum—.1,“ NW... , 16 vasodilation and Wei with a degree of umudatim of vascular fluids into the inter» cellular permeability cellular spaces varying with the extent vaaodﬂataticn (Kabat and their Wm 35. _a_1_, 19%). and may be pmdicted, dmtion of the 81313301, Spiegel—Adolf, (1981. 19%, 19%, 1938, 1953) WWed sud: permeability changes md maimed mndmtivity of the tissue associated with the appearance of various ions (as potassium and prosphate) in the epiml fluid {alluring electrically induoud convulsions . Such nucleicaoid splitting cellular permeability WWW of aims, may nm-elactmlytes, as also ixmaaed. Changes thus pmvida the basis for the high acetylde and the inmased mntratims of cholimsteme-II in induced animus or head tmuma and Wm 'Ihe in ' (Tamar- 1939c) . persistm of mtyldwlim in spinal fluid after head trauma and after aims daspita increased dwlinastemse activity related to the sensitivity of the aoetyldiolin'e- may be dwlimstarmd system to Wmtim relationships (Nadmansm �,wn‘ww’ ,.. i . ..-.. _‘ “a... n”. “ ‘,,_ .3», .1. m, .Vq‘r‘. am-rw , ~,--‘V~rwtrm—Ww ..~.-—-~—..-w wr".v\-4I"\9-rr"x““w-myrvwrmmwn'v .(-,.‘v.,..._..-..‘_w,,,,rn.—.y~.—_-.r~,- 3“ .~.-. 17 and Withers, 19'65; Towcr and Wm, HacIntosh, 1955) . At ”physiologic” 1909c; Burger: and comtmticns, hydrolysis of acatylcholinc is rapid (34 micxmocondn) but at higher and lower concentratims, the activity what, falls off quickly. In the dmlincatnmo-II acctyldmolim mlatimship is ad ﬁn mn-cpociic m 01’ hydrolysis cmccntmtioc. W witl': increased. anvimcfﬁnscmlatimhipc suggestsﬂmtwhilem usual commtrwticns of acetyldmoline t cell m: are dcstmyud by tbs specific activity of cholimsteme-J. in a fut micro-cm, an emaive concentration following cxcitaticn may exceed the rate of hydrolysis by cholimstemso-I. seizure mmmm the uixum may be mmd and a seizure itself adding to the mm: The induced, with of free amtylcmline. 1110 increased acetylcholinc diffuses rapidly, affacting vascular and cellular minty and increasing the various ism and circumstance-II in the of dialimtcmc-II , mums CSF. The of activity thaugh of low efficiency and depending on �the mien kimtics, mamas tho watyldxolim in the tissuns in hours to days to levols for the physiologic actim of dwlimstame-I... Chaumtemu «ppm is ﬂu. camamemmmm In The. am 5M cu a. gamma gum, mating 5m a“ when pmabuug “mined by imucd changu mm. Wed mm“ me put “the hmmtéc Wm “mucus the ants (n ma agate»: 05 Wu manually «mum. (a) Amgzleholine, Alumina in MW at cm EEG the. blood-brain Mum and Indumd Oomvulsiaw: pemnbility barrier winning action of mtyldwlim may be the by the biodmmioal substrate for tha poatwlectmahock hypemyndmy of the eloctmanmpinlom. 3% a possibility is evident in the Mommim of an immense in the concentration of cocaine in brain tissms thme a series of 12 induced convulsions (Aird army in concentration of this days after 5331., 1956). The 1m mlecmle, ordinarily absent �mnpr- rug—m.» r m «7 r.~L,-»---.--,V-...Ww.‘n - v v '.>T4wmw‘m .mw—z , ru71.,‘ mu mr‘m—D'J.lr>aw' yawn-vanquas,‘ ‘w. - p". yr. -., “wharf” . WV. ”us-apt..." 1.. .19- in brain tissue, was asaociatad with the appoarunoe of hyper» synchrony (delta bursts) We hIVD in the electroencephalogram. confirmed tbs many pruvious reports thut convulsive thaxapy induces olectnngnlphic hyporuynchrcny (Pink and Kahn. 1956; Pink 33.3;, 1961). Duspite a constant application of mmmmuammmty'mmtmo: appoarunnn, the duration and tho cxmnnx of the electrogruphic slow Haws by activity as wall as the sensitivity to modification alnrting, hyporvuntilatian and barbiturates in psychiatric (papulntians. Tho early appoarnnnn of high degxan hyper~ syndhmuny and its puraistnncn throughout a truatmant course has been dnscribod an pmuruqnisite M (Roth, 1951; Roth It is possible that EEG to £11., impruwument ﬁollcwing 1933; Pink md M111, 1956). the diffirnnces in tho degree of indncod hyporuynchrcnv may bc related to differances in the activity or auntrul cholinnrgic mechanisms. patients to davalop hyporsynahruny The may failure of certain thus be associatad precluding a clinical rlsponse to induced convulsions. Tbuer .. l . V , ”.17 v ,, n �w, ._‘_,._..._‘,|,,, r. Wm. ;.,,,,.__ m. ,. ~ "v.0... . (T W . r r, -_ "u . rw.par.-‘W-.~ .erz. .7.” , .1 . _ y . ., 4.1-. . -- n v-uvnwwwv-wm‘uv “wave-«W.www—ur-p—, w-n—w—w M-ru- "n" .,-v , . _ _ , ‘ v—av-um . . woun- 7 -w v-_. .- m 20 and Wm (19%.), in ﬂair study of W231 tmm, hcludcd observaﬁm of six psydtiatric patients mder'going omwlsive mampy. Studying the patients after 3-7 tiny upon“! {me spinal fluid and an inmm mutants Minimum in two patients; in mournstcmvn and a dam in .mvemal pith of the ratio of dxonmatorms a dwiimstame-I in five of the six patients. From mludad that the spinal fluid these obscwations ﬂwy We: in ma commlsiom mmﬁmmoofmioambmltmﬁmmof sputum epilepsy. WWMpntientinﬂwmﬂaawhofanedtom oither {no acetylomnm or a dmlimsteme ratio reversal in iﬁtemsting that this the spinal ﬂuid, tiny. wrote: "It is patimtwaaﬂnonlymafﬂnsixmshwmmsmoto Wt." ‘ at If alectmgraptdc hyporsyndmrmy increased free acetyldmolim, subjects who is a mﬂectim maintain hyper- syndmymdttmeinﬁmitdisappemmidlymybc waiting diffemnoas in the kinetim of the dmolimstemsw » , _ v—-— w . 7 v vamp-omen“ W . p ,. . V... , ‘ �22 “I (21011th 'mooo studios and the Classificatim of a : malochm applioatimtotmpmblanof atomic mootivity and the classification of the Mountain Po mm and ( ) mlatimhip boom the psychoses. how dumstmted blood possum response to injected ndxolyl and the clinical mpomo of psychiatric patients to convulsive ﬁxaapy. Homolyl which W is a percent cholinorgio agent vaoodilation, taduyoudia, sweating, and peristalsis. It is rapidly hydrolyzed dxonmotorm-II . slowly by The blood falls after injoctod Immolyl within five to more than 9mm and takes Group 20 Group VI and VII oholimstemeel md pussum of subjects mtums to the baseline minutes. Patients whose blood {within baseline the returns to classiﬁed as prawn 20 by W 5 ndnutes have been I, II, or III reactors; those whose blood ormminums tomtumto baseline, reactors. M I and thp III—III as mam �.. pr 7: . -r WW..." . . .r. . n .. 7.. .- -. mm». . 1 unw- u . “val ~ « - ....._. v .. wiv'r—z-v .?-'a‘.v~'uV.—T{=n‘)("\ﬁlr- - ,r., "saw-- wry-WW...» N. mv—ﬁ m—m ‘»-y-_I-sﬁ-vvvvx , 23 have a 9 and a 35% recovery and Grow VII mentors 91; gl__. 1952). patients in Group whom while Groups VI 89% rate, mspectivuly, while and 97‘ recovery I to III mactom the injected mornlyl Group VI rates (Funkeastein may he looked upon as is rapidly hydrolymd; md VII have a slow hydrolysis rate. We may pmdiot, thcmfore, that the blood dxolinesteme activity levels of Grow): I-III would Groups VI A uystcm - bu high; while the activity of VII would be low. similar analysis may be mad: regarding central nervous levels of dwlinectemse—I in the duvelownnt of EEG hypersynchrmy and spinal fluid levels of aoetylcholim, providing a basis for a omgment hypothesis regarding centml nervous syntax: reactivity to induced oonvulsims cholinergic agents. and to peripheral �- ~—-~vw=rr'u. . ~ . “,_ w-vvww (“vwxx mu, .- v*'ul""‘v‘“""w“1-c-»w‘mlh-rtr"'4<-Ia‘.—-vuz‘ --— (—1 m-wry_._ 7...," .V, 7 ,_, . ‘ my — . w". ,.c_..,.. .. u... w. Flaw—w. v3. ‘~.,..,,‘w,-." 2‘4 CONCUISION: Central cholinergic mechanism appear to be a significmt factor in the convulsive therapy process. may The published data interpreted to indicate that induced convulsion: are be associated with on increased- in intercellular acetylcholine to levels greater than can be destroyed activity. Vaeodilatim and increased by dmlimsterese—I cellular pemability are followed by increased ammte of clnlinestemee—II and other enzymes and electrolytes in intercellular fluids. These chmgea are hypemynclu'my which can be mdified by reflected in the increased electrical is recorded in scalp electrodes, and which mticholinergic drugs as atropine, benactyzine, and ydieﬁuazine. The changes in the cerebral biochemical milieu alter cellular activities sufficiently to be associated with altered behavior of subjects. Failure to induce high and persistent cmoentrttions of aoetylcmline and failure to induce concomitmt electrolyte changes results in a failure to produce behavioml change. n: M ...1,.“‘..w. “,4 _. ...... ._ �25 Differences in the rates of development of mm reflect differences in their lependance of cubjects mechanism- changes on chom'cergic or in their sensitivity to chmges in acetylcholine levels. mean differences provide the basis for the classification of the mentally ill by kaenstein and by Pink md Kuhn These observations provide the mode a Miami (1961). Mechanical basis for of action of indmed nmvcﬂsims in altering the behavior of psychotic subjects. These views are consistent with the more earlier general neurophysiclcgic-«iaptive theory expressed (Rink, 1957) . �" -v~1r'-W4'VY—,‘V.'Z"V‘."-‘ w "- ---'~-' REFERENCES Aim, R. 8., Strait, I... 1‘... Pace, J. W., Hmnofi', M. K. md S . C. Nemphysiclogic effects of electrically loaned deitch, convulsions. Aach. ucuxoz. Izyahtat. (catc.). 1956, 75: 37l~378. Pmmoe and actim of coetyldwline in oxporinnntal Box-cumin, M.D. brain trauma. 1. Nounaphga£o£., 1986, 9: 3%9-366. Brannon, C. and Merritt, H. H. Effect of certain choline derivatives on electrical activity of the cortex. Moh. Newt. Pageant. (ChicJ. 19H2, M8: 382-395. W, of amtylcholim. S. A. (Editors), V. and Hoolntcsh, F. C. ‘lhc physiological Biglificmoe In I. K. A. C. Elliot, C. C limos, ummag. H. Page and J. H. Quutcl Springfield, 111., 1955: 378-375. Omtfiald, P. O. and Dagny, E. W. Effects of proatigmine and acetylcholim on cortical potentials. Mn. 3. Phyaialu 1982, 135: 633-630. Wm, D. Acetylchclino and murmal Corn, w. V.,-'l'cwcr, D. B. and activity in cpilcpsy. J.A.M.A., lane. 73: 59-63. Dab, H. H. thoiz- The action of certain caters md others of choline, and nlctim to maxim. J. Hamel. Elliott, Exp. The)!" 19114, 6:187. C., Swank, R. L. and Henderson, N. Effects of mostlutico and cmvulamts on acetylcholine content of brain. MM. 1. 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A. and �'"WW.'I<-.~;—-- -, -‘—-'-a . .. r! _‘,',.."_'__m, ,- . ‘1).m. u ‘P. - ..~—.—.-a..nuu.~.~ . ‘~»~..ww*m‘m—. - v w W .-w-rvu.wm.m .w, ”mu “.3 w-w WW..."— xw-mv-vrv at K Ib‘mwv": “nun-ms?” u mmic mutt, of in mlation pmgnoatic system sigxifiomoa to test mm Maintain, D. H., 013011031106: truatmant. Payclwaom. “ad” 1952, lb: 3u7~362. .Giaman, N. J. wtyld‘tolim. H. and Solomon, R. C. ML, F., Md Pepau, G. W. 1. Drug—inclined changes in brain 1962, 19: 226-23“. A. and Hiwich, H. E. Macaulay, J., amen, Effects of diwinopmpyl flmmplmsm (DE?) on ahatmenoepbalognm and dwlimtama activity. methamph. can. ”Mphgunl., 1950, 2: “1-48. Basis, C. Wm, W,mm" H. 3.. Basia, C. In, J. I... Bales, P. D. and A. H. Effect of trimathadiono (Tridimo) and other drugs on mvulsims named by di~ioopmpyl fluorophosph'ata (DFP). 1950, 106: 816-820. mu. 1. Pﬁwidl, Jamar-r. F. L. and bachnar, H. The effect of Dipamol on the ehatmwmphalogminmmmlaubjcctminﬁmewith Gambia]. 7: um. 303‘3050 Ehctaouuph. can. Namephgalatu 1955, Jansen, L. C., Ulatt, G. A.. Johnson, 24., Smith, K. 31:! Sims, J. 0. thanpy (with md wiﬂmt atmpim); affact on alantrmioany Julyzad electroencephalogram. Malt. Gan. WWW! mm" 1960, 2: 323—336. 61mm, M. and Knaub, V. Quantitative estimation ofﬁnalbminandgmglnbulininnomlmdpaﬁmlogic cembmspinal fluid by imxmehamiml methods. Mu. J. Meet, Kabat, E. A... 1938, k (5): 653-862. Loud, 0. Fiber hwmrale {Ibertmgbarkait den Hennammiﬂnmg. Mali. 5. d. an. ”quiet" 1921, 189: 239~2u2. Wm, mm, spadficity mm in new on D. and Studies on dualinestame: tissue. J. Biol. (than, H. A. of 19%, 158: 653-666. Richter. D. and unwind. J. Vaziatim in acetyleholim content of the brain with physiological state. MM. 1 . Phyaiatu 19139, 189: 2157-455. W in the EEG mdar bubimmte Mmesia pmdwad by alactm-omvulsiva tumult and thair significance ECT of the action. Manuphguol.” can. Eumuuph. may to? 19 1, 3: 261-280. Roth, H. ‘ W mt. WW. Ruth. 14.. Kay, D. Pmtothal omwlsiva 1957, 9: 225-437. J. md amen, J. Prognosis and ahetmphalogmphic changes in electroW. K... Shae, can. Memphyauln Spiagel, E. A. and Spiagal-Adolf, H. Permability changes in the brain induced by mm). and insulin convulsions. J. New. Matt. v.3... 19M, 93: 750-755. �F ” rum" , ,7“... T9,“ wm.~n..wr.”“.,.,r,.w ..;._‘.,..,_,Vk,»,mqr,..r. 14."... _.-..,.4,. r...“ ‘. ”um-um..." :w-"CRIWJEFIMI-‘wf‘t . .,»;r-,W—;.—‘m'w"Ir-E'WAn-‘n-vu-I 1”“7(IAHV«——l ._ - n -.--~ 7»-v—-———~r-—-n~—w-v-—. -3Spicgol, E. A. and Spinal-Adolf, H. Physioochemiml effects of ohctrically 1mm oonvulsiam (oembxospinal fluid studies) . Tm. Mu. Haunt. AM” 19%, 70: 130-132. Spiogel, E. A. and Spinal-Molt, M. Physiological and physioochemioal mohanim in electroshock tmatmnt. Conga. Newt” 1953, 13: 38-63. Wm Spiegol, E. A., Spinal—Adolf, We dinning“. in the brain Tm. Mu. and Kenny, G. Haysiooodmﬁoal electrically indumd omvulsiw Nunez. AM" 19342, 68: M. m. Wt Spiegcl-Adolf. 21., Wilcox. P. H. and Spiegel, B. A. Oambmpinal fluid in elnctmehodc of psychoses. J. 19%, 10”: 697-706. chm W. 3ch” Stem, W. E. The min of acetyldxolim in bmin metabolism and ﬁmction. Man. J. ”13‘. “£41., 1957, 36: 222-455. Torda. C. Effect of omwlaion ﬂaming agents on the acetyldmlim content of the brain. J. Phyaiol., Amen. 1953, 173: 179—183. Tom, C. Effects of single injection of oortiootrvpin (ACE!) ion and acetyloholim content of brain. on I. “watch, 1953, 173: 175-178. mum W. and nauronal mtyldmline activity. I. Mr. Wm. Cholimterm patterns ma motyldwolim in the oambmspiml fluids of patients with Canad. J. Hum, 19mm, tram. 27 (Seat. E): 105-419. D. a. and Wm the omtmt md WMim of W323, in human cerebmcpinal fluids. Cam. 1. Tower, D. B. and cholimatcmes 191.9», 27 D. D. mm, (Seat. E): 132-435. Tower, D. B. and unis-clam, D. Mutyldxolima md mama]. activity. Motylcholine md daclimteme activity in the In”! osmbmspinal II. fluids of patients with epilepsy. Canal. J. 3.914%, 27 (Scat. E): 120-131. mm, Ulett, G. A. and Johnsm, H. w. Effect of atropine and soopolaminc upm chotmonoeptnhgmphic changes induced by electm—oonwlsive therapy. Eamomuph. can. Monophyunzn 1957, 9: 217—22u. Hard, A. A. Atropine in the tmatmnt of closed hand injury, J. Meano.ung., 1950,‘7: ass-noz. .V. .- - �(July 2, 1965) Jan. 3, 1958 EDIE 0!" ACTION OF TheCNS BIWCAL ms IN EHAVIOR indopendcntupmanmrofenzyne for systems proper mtabolism and functim, including cholimstemae- aoctylcholine, glucose-phosphatase, etc. The bahavior variety of is large, in either direction wt: that affect CNS ﬁmcticn and, thereby, since processes in equilibriun by increasing may be shifted or damaging the available quantity of a metabolite. A. For drug action, thanfom, tho following are cmsideraticns in potency: ‘ (a)mescdrngaffectmmzymsyste1nina reliable my? it (1:) Can (c) What get to CNS to affect the system? defenses does organism process to block or limit drug's actim mac in CNS? metabolism the affect directly amt of a specific system, to that extmt is the CNS dependent upon the system? Is the dafoct thm induced sigiificmt for the metabolism B. of CNS Secondly, while an may mderlying behavior? Rut Menace can body call into play when system has, is affected to substitute other may system? the variatim in drug effects in behavior depend upon: (a) Beluvior at onset; and pmdispositim (personality) to response; (b) mug dosage - availability to has on m mzym system; CNS and the effect it �W'wv‘mw n—m—.n-u.r:~wvmr .v 4-:- \I.’—:r~"!lwwmi‘ mama v; M'er‘ui'v-V-‘P 1‘2'.~vr1v-'wv— (c) Depmdence of war "-3;*..)I(7'4<~<'I‘R,IWT~’:~.~HV~’V~W ~, - an.» :uru.r-owr:< , .. mm? a. mum cvw V:""\ 1 < =- 1 w - -—-v. again on specific enzyme ommimic defenses (Le. substitutim for affected system). (d) Whether effect was gradual (allowing for system -— defenses, and ,r'ia Le. , enema metabolic system) or acute (not allowing defense). Individual differemes in meme may be due, thus, to differences in: (a) Dosage, ratio 8 mute of mainiatmtim (b) dependence on the affected system (c) adaptive ability to biochemical changes. To these changes, EEG is a me approximation and indicator, reflecting the homeostatic balance in various the CNS. enzyme systems of ��21 mtylcholim hydrolysis system. Persistent malt from a damned rate of hydrolysis of aoetylomlme. associated with low mmantmtim of either or Grantham-11 . livcd W, hypemyndmany my (immunised (Oonvamly. in patients with shortcircumstance—I md «II in tissue and spinal fluid my be mustang! high). Fmthuc obawa‘ioumwouldcsuaudetmmduud MW ”mam m «wanted We. and in cmbut pmabuoty 5m. Wag MW mm (at. EEG «the hypwymmny Wow nu 06 wumwmu. Mad a WW and 426 in 6m with as on. attend by amazon 9‘ WM W behauiuat dung“ the blockade“ 50M um 06 muted Mud bum. pubabLgtMtuu the“. dungu Lgtu that The We! men 06 ethyl. 05 campus“. ammummamm- mm 60!: the. attuned wavubiana. mam � 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 Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 3/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-003 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1968 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/023fc3470d6cfddf7614342c86456639.pdf b07bb6498b31f3e58fe2ba4d191c8c0f PDF Text Text l+/26/57 To: Dr. Max Fink From: Dr. H. Goldenberg are contemplating a change in our cholinesterase incubation system which would cause significant differences (5-15% increase) in the reported values for true and pseudocholinesterase. This is the primary reason we haven't fOrwarded your spinal fluid values as well as the more recent serum analyses. We cholinesterase method (like all methods) comprises 2 steps: (1) incubation of enzyme with substrate under fixed Our conditions , and (2) analysis of the reaction products, from which enzyme activity is calculated. The second step employs our new and efficient color procedure. Step 1 is essentially that of earlier workers. On reinvestigating step 1 we find objections to the large amount of salt used by others in their system and may eliminate this ingredient. an apparent As salt is inhibitory, this increase in enzyme would cause concentration. All our past analyses can be corrected for this change by using appropriate factors, but the ultimate decision whether we are to shift our medium will be about 10 days in the making. are naturally anxious to get some idea of the relative changes in spinal fluid values following EST, I will forward figures based on the original salt system on Tuesday. However, as you will start running benzoylcholine as well as the butyryl susbstrate to determine whether there are 2 pseudocholinesterases in spinal fluid. This should resolve our uncertainties on this point and just might possibly lead to new findings. Next Friday we �February u , 1966 Dr. Harvey Robinson WW thimsity of The Baltim, Bur Dr. Institute Maryland Maryland 21201 lbbimm: In mid-October. I submitted the muncript ”0101111132310 Marxism in vaulsiw 'mempy" for ymr mitigation for publication in thc Jam 05 Havana and Mental Dame. I Max MP : jmh Fink. NJ). Promoter of Payduatry �L45 SOL.‘NAL OF /" .Nervour and Mental Diyemc ‘ Harvey A. Robinson} Managing Edi'oy' f Psychiatric Instihne u iv r re “’ofM—u‘ Ia d The \ 82mm”, ,, M0250; OCtOber 19, 1965 "’"-”‘\.:;,_. n—~L"""”"W‘m“‘“'°-—ﬂ _ ..._.. of receipt your acknowledge to This is Mechanisms "Cholinergic entitled manuscript " in Convulsive Therapy. �Max Fink, M. D. Department of Psychiatry Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 �Wm' ~ - .m ﬂ 9 .. w w' ‘5w; Hug-«m- - ‘ nun—v- w-pr. W 4mm‘w-q-w—I-sm . . w wwwmvwmm w “a - . m . , , an(rum October 15, 1965 Dr. Harvey Robinam Psychiatric Institute adversity of Huylmd The Baltimn. Maryland 21901 Dear Dr. Robinson: mm Pbdwﬁm in Convulsiw at. publication in the two copios The Joanne 05 of the manuscript " "010111101310 for your midnmtim for mm and W Dame. style of ﬂu citations follow those of this imtitutim, we will aubdt copies following your stylc if the article mots your approval. While the mead Sincumly yours , MIX HF: jun Pink, M.D. Professor of Psychiatry .wW '- 7k "-7“. m."- �THE N JOURNAL 67/92/011 I OF 6111 d M611 ta l lcwrence DifEdje S. Kubie, Editor-in-Chief Harvey A. Robinson, Managing Editor Eugene B. Brody, Consulting Editor The Psychiatric Institute F 0 U N D E D | N 1 University of Maryland Baltimore, Md. 21201 3 7 4 February 10, 1966 Dr. Max Fink Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5400 Arsenal Street St. Louis, Missouri 63139 Dear Doctor Fink: I am very sorry to have to tell you that your manuscript is still under editorial consideration. I do hope to be able to be able to write to you about it very soon. Sincerely our 8, 9V 5 W H. A.‘ Robinson HAR/sa »' �’4 THE JOURNAL OF New/0m and Mei/Ital Diieme lawrence S. Kubie, ZZZ:23:3,”;3.327.315?" The Psychiatric F 0 U N D E D | N 1 8 7 4 Editor-in-Chief Institute University of Maryland Baltimore, Md. 21201 February 1 1, 1966 Dr. Max Fink Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Doctor Fink: The Editorial Board has carefully considered your manu" Convulsive in entitled Mechanisms "Cholinergic Therapy. script Subject to your willingness to meet a number of minor criticisms and to make some changes that have been suggested by our readers, we should be very pleased to publish this article. This, then, is in the nature of a provisional acceptance. This consideration of brain cholinergic mechanisms and their significance in convulsive therapy represents an interesting and valuable point of view. Of course, other chemical changes have been demonstrated after seizures and have been assigned equally as important roles as acetylcholine. However, this position is clearly dated, developed forcefully, and the argument is pertinently documented. We feel that the manuscript makes a definite contribution. Nonetheless the Editors are of the opinion that the report embodies some weaknesses which if dealt with would significantly improve the quality of the paper. No one doubts that acetylcholine is important in neural function and that changes in acetylcholine and cholinesterase occur with induced seizures. The assumption that the handling of acetylcholine is fundamentally related to the amount A of hypersynchrony of the EEG is, we feel, an oversimplification. Q) in}. The thesis that the results of treatment by induced convulsions is related to the sensitivity to changes in acetylcholine levels (pp. 18—19).] has no information to substantiate it. Although you describe a "rational biochemical theory" for the mode of action of induced con- �Dr. Max Fink February 11, 1966 2. vulsions, you state only what is already known, that acetylcholine decreases in the tissues and increases in the spinal fluid with induced seizure and that the slow waves can be modified by anticholinergic drugs. Although you cite your own work for the effects ”I of atropine in counteracting the acetylcholine effects of induced seizures, you do not give evidence that the use of atropine changes 1 the therapeutic results in any confirmed study. There is no con— w “7 of evidence in for differences the vincing reactivity or sensitivity (3) central nervous system between psychotics and normals to r" acetylcholine or cholinesterase. ‘ recommend that you consider the following ideas for inclusion in the summary: We There is as yet no consistent evidence for differences in anticholinesterase or acetylcholine senstivity or levels between the psychotic and the normal brain. 1) \/" as yet no reproducible evidence that anticholinesterases given before, during or after electroconvulsive therapy change the results of the treatment. 2) There is 3) Cholinesterase and acetylcholine levels change in response to electroconvulsive treatment and in response to trauma may be a result of other biochemical changes resulting in vasodilation and increased cellular permeability which affect the level of consciousness, EEG, and behavior as well as acetylcholine distribution. At a more superficial level, we should also recommend that the manuscript be carefully scrutinized so as to ensure consistency in drug terminology. We would recommend that the generic names be used throughout the manuscript and that the capitalized trade name be included in parentheses, e. g. , methacholine (Mecholyl). We have indicated a few of these changes on p. 7, p. 9, and p. 10. I regret to note that the references do not follow the style we prefer to use. I am enclosing an information sheet, which may be of some help. Please note that the references should be alphabetized, then numbered, and cited by number in parentheses in the y / �Dr. Max Fink February 11, 1966 3. text. Please note, too, that the references should be typed double-spaced. This enormously facilitates preparing copy for the printer. On the hopeful assumption that you will be of a mind to undertake the recommended changes, I am returning one COpy of the manuscript, and will retain the other for purposes of reference. Please let me know how you feel about all of this. Very sincerely, H. A. Robinson HAR/sa Enclosures �February 16, 1966 mwmmwm Mm Manny mm Dmﬂuvoybmum Psychiatric of mm. Maryland 21201 M 3:321th Myoum andingm W"ﬂwmﬂcmin0mwlsiwnunpyﬂ MWWWmmWW Ivdﬁuﬂacmaffwttompem mum-mm. including meanwmmmmmmnwd. ﬁndtatian following tin style: whidnmmmmud. mmmmmmumamymwimmw mks. 11'. Rabin-cm ’nunkyou formant-aim. Stanlyymm, ﬂux Pink. NJ). Professor of Paydﬁatry fokp �Harsh n, 1986 Hr. Haw-y A. Roux-won, Hanging Editor 1?. Journal a! Havana and Hmtal Dim Psychiatric Institute m Lhimdty of Maryland Baltim'e. Manama new it. Robina: 21201 My" "(2le Wthunofgmdcma,mdmdﬂiedmcitatima toftttlnstyloottmjoumu. than Follovdngymmuwsﬂmn,1hvomdmfmdpmdmsuof in Oanvulsiw hernia: apart Mmemmhth meunincludad,udngayomlmm. Ihawdmdﬂntiﬂewdnhmdmmtimaddoh wanemtmdiatm. Ihopethntthiadmft.michI11hnmmttor,m dthyumappzovnl. M you for your mu. Stanly yams, Fink, NJ). Manor of Psychiatry Max 31‘? �‘5: i THE N JiOURNAL or I 67.120“ 5‘ 3' Men ta ﬂyld lawrence 1 D1336“? Harvey A. Robinson, Managing Editor Eugene B. Brody, Consulting Editor The Psychiatric F O U N D E D | N 1 Editor-in-Chief S. Kubie, Institute University of Maryland Baltimore, Md. 21201 3 7 4 March 9, 1966 Dr. Max Fink Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Doctor Fink: revision of your manuscript, for which many thanks. This now looks perfectly fine in all respects, and we shall be pleased to schedule it for publication. We have the best guess is that this material should get to the printer in five weeks' time or so. Galley proof, then, should come to you some time late in April. My When you receive the galley proof, I hope you will be able to correct it and to return it to me promptly. Very sincerely, H. A. HAR/sa Robinson 02,9 8“! �THE JOURNAL OF NERVOUS AND MENTAL DISEASE Copyright © 1965 by The Williams & Wilkins Co. Vol. 140, No. 2 Printed in U.S.A. Information for Authors Manuscripts and correspondence pertaining thereto should be addressed to the Managing Editor: DR. H. A. ROBINSON, The Psychiatric Institute, University of Maryland, Baltimore, Maryland 21201. Manuscripts should be typed double spaced on one side only of 8% x original and one clearly legible carbon copy should be submitted. 11 paper. The It is helpful if the author supplies a short title for use as a running head. This should be typed on a separate sheet and be the ﬁrst page of manuscript. Type the complete title of the article on a second sheet, and the authors’ names and afﬁliations on a third sheet. Type double-spaced on separate sheets: tabular matter, case histories, quotations, formulas, and other subsidiary matter in the text, footnotes, bibliographies, and legends for illustrations. Legends must not be attached to or written on the illustration copy. Positions for tables and ﬁgures in the text should be indicated in the margin of the text page. Manuscripts should be accompanied by two copies of an abstract of 300 words or less. Illustrations should be drawn in India ink on white paper with clear lettering. Photographs should be glossy prints. The title Of the article, name of author, and number of the ﬁgure should be written with a soft pencil on the back of each illustration, and the top designated. References should be designated in the text by number in parentheses, e.g., (7). The list headed REFERENCES at the end of the paper should be arranged in alphabetical order and numbered. Abbreviations should follow the style of the Index Medicus. Examples: Book reference: 3. Critchley, M. The Parietal Lobes, pp. 171—181. Arnold, London, 1953. Journal reference: E., Mirsky, A. F. and Pribram, K. H. Inﬂuence of amygdalectomy on social behavior in monkeys. J. Comp. Physiol. Psychol., 47: 173—178, 1954. 11. Rosvold, H. Costs of author’s alterations of type or cuts, in excess of $1.00 per page, will be charged to the author. Corrections of printer’s errors are not charged to the author. Also the author will be charged with the cost of engravings in excess of $50.00. One invoice will be sent covering cost of reprints, alterations and engravings. The editorial ofﬁce should be notiﬁed promptly of any change of address. Galley proofs are sent to the author, and should be returned with manuscript to the editorial ofﬁce. A table of cost of reprints with an order slip. is sent with galley proof. �runs-“mm” w'u‘. \ q. WJ~F'WWWWMW'W rerI-Iw-um w-mrwmwwz—mr urn—rm—v- mmrﬂrvmuu (HOMO ASPECTS NIX 0? rim, mm W HJ). "mt—amt“: �....‘.;v- I-‘mm ..r.-- .. ... v t . .. .... -- . 71-17”W‘ m .wn -.-»r.-n---» 1'- ~ 1* ~- the Department of Psychiatry, Washingtm University School and the Dapummt of Psychiatry at the of [ﬂasmri Institute of Paydmiatry, University of Missouri Sdhool of Madicino, SHOO Arsenal St., St. Louis, Missouri 63139. mam Aidad, in by usms grants m—sm, m—2715, menus, and PEI-11380; and thc Psychiatric Ibsen-cm medatim of Missouri. Ix: 65-8 part, 2—25-66 Ravisod for the Iowa 05 Nuvoua and Mental Dame. �GiOLIhEIRGIC ASPECTS OF CONVULSIVE 'DiERAPY While the mode of action of convulsive therapies remains enigmatic, one theory holds that the early development and persistence of changes in brain function are rﬁquisite to change in behavior (17, 20, 22). A useful index of murophysioloﬁical changes is the appearance of high voltage electroencephalographic slow wave activity (22, 23). While the biochemistry of this activity is poorly understood, damstretims that it may be inhibited by atropine premedicaticn (3k,66) or blocked by anticholiner-gic coepomds (18, 19) suggest that crolinergic system may play an active part. 'lhe EEG patterns and the response to anticholinergic drugs issimilar-inexperdmntalmdclinicalheadtrmmamdtoa lesser extent, in spontaneous seizures to that seen with convulsive trerepy. 'Ihe activity and changes in concentration of cholinesterases in brain and spinal fluid in head trams, spontaneous seizures and convulsive therapy also slow many similarities . This review discusses these observations to provide the basis for a hypothesis of the role of oholinergic changes in the convulsive therapy process . Acetylcholine has been extensively studied as an agent in the trensmissim of nervous impulses since tion by Dale (12) and Load (38). in a bound form, acetylcholine process . It is A its early identifica— constituent of nervous tissue is liberated during the excitaticm rapidly hydrolyzed through the radiation of acetylcholnesterase and is rapidly reconstituted by the cholineacetylase systemMS) . Free acetylcholine has not been measurable �in normal oerebmspinal ﬂuid despite the rapid bound aoetylcholine during periods But breakdown of of activity and excitementms) . tl'e normal cerebrospinal fluid does have mamble oholimstemse activity, principally of the "tune" of mcholyl hydrolyzing type ChoLéuuch Mpew 05 Wombat Tum. Free acetylcholim was fomd in the oerebrospinal fluid of cats (I41) . within a few minutes after experimtal heed trauma and persisted forvaryingperiodsuptouam. 'Ihequantityoffree eostylomline varied between 2.7 and 9.0 game percent, and the mmt was related to the degree of indmed trams (6). Conctmnt electroencephalogram first denmstrated high voltage fest activity, interpreted as evidence of an intense mutualdismarge,whichwassomsumededbyasmmperiod of flattening of all recorded electrical activity. 'Ihese phases were followed by prolonged periods of high mlitude sharp waves in the delta mquencies. 'Ihe behavioral changes related to the degree of induced of manned free aoetylcholine . With to the aunt higher levels of acetylcholine, Bernstein reported greater degrees of EEG abmvrmlity and greater changes in mciousness. trams and Spontaneous post~trmnnetic seizures were also related to the emunt of free acetylcholim appearing in the oerebrospmal ﬂuid. �em the concentration of ccctylcholim Bomstcin applicd acetyloholinc to cortex. When out oercbrul m l gonna porcentcrlcss,hizhmlitudosharpwavosof1wfmqucn¢m appeared in tho doctmmceptulcgrm. was mm in flattened to 2 gm: When tho concontmtim percent, the cloctromcapmlogmm a fashion parallel to the post-mtic records . Investigatiom in neurological patients by Tower and in the free ccctylcholinc com-Wmtod Wm spinal fluid only in patients with meant head trauma, meant seizures or after olectroconvulsivc thwapy (63). Mal Fun acctylcholim varied from 0.2 to 100 gm pcrctmt. In assaying spinal fluid circumstance activity, they noted a rise in the mpccifio oholimstcmsc fructim (bcnzoyloholinc— splitting) and a drop in tin swcific circumstance {motion (unﬁmdnlim-splitting) in patimts with head tram and sharp following convulsive tmmpy. Artur spontmoms seizures, fluid did not exhibit such inversim contained free acctylcholim. They concluded that however. the ccmbmapiml although it with the varied of free directly acotyloholim m1 and that mammal of the oholinestcmse dome of cerebral functions was a more mitivc indicator of ocmbml damage. the W Bloctmencophalom. talent at varying intervals following also indicated a relation betwum the degree of EEG m. abmmlitymdtmappwmocoffmcmtyldnlincintm combmapinal fluid. �-7- 1......» um"... —— u r. mﬁ" 57—..- .. -- 1"...” y-w.-u~m-v»- vows-r r, wlma-«w- ”a: u . ...v - -. mmased aoetylolnlim in net brain after trumatic also reported by Kovach, activity was inhibited in was to the muscle preparation. 9:5}; m ., n '- e . 71‘ —_.... - "MW“, shock (36). This aoetylcholine by the adninistmtion of atropine eleotrogruphic, behavioral and mmrologic signs of head me trauma were blocked by the parenteral administrvatim of O.5-—1.0 tug/kg atmpins, asweresimilar'clinicaldmgesooomringaftertm inhmisterml additim of anetyloholine (6). observations to the mamnt of closed head Ward applied these injtmies (67) . In 20 patients with varying degrees of trauma, he administered atropine subcutamxsly in doses of 0.1 rug/kg, mting clinical inpmvemnt in scan and a reversal of the electrogrephic effects in others. ‘Ihe some oranges in the post-trumtic electroencephalogrm were mporhsdbyJemmerandDednmrinastmyofdieﬂnazim, another mtidmolinergic drug (33). A single intravenous dose in forty patients resulted in normalizing the abtmal electroencephalogram in twenty—two and marksdnpmvementin six others. of post-Wtic shock and Similarly, in Wm oembraledemainminals, Denisenkorepor'tedablodcingofme clinical changes and trunntin by such (13) . Thu, the mount Aptnat (no. mticholinergio ounpomds as mthylbenaltyzim 05 (up. acetytdwune my thymus 4'1: the mum and the amount as 5w (cumming Wombat “Layman, the dzgue and type abnalmauty, and changu in demomcephatoguphtc W mm“ Md behavtm appm pheuauena, which may be udueed by the «Mugs. 05 «A 05 antéchounugtc _, t , �Bmu'n eeetytchoune and Mahounugic dkugA . The effects of the direct application of acetylcmline to the central nervous systemmyalsobeblookedbymtidmlinergic drugs. The aaninietntion of the clmlineeteme hmibitor diuisopmpyl flmrophoaphate (DFP) elicited high amplitude mpid frequency EEG patterns similar to status epileptiws and ecu post-traumatic states (2!, 31, 32, 68). These EEG effects were blocked by small doses of parenteral atropine and sccpolamine. The great increase in acetylcholim after tetmethyl pyrophosphate ('13P?) was measumd and related to the toxic effects and the induced cmwlsions (29, 59). Wield and Denpsey prepared exposed animal cortex with pmstignﬁne and evoked electroencephalographic spike activity. prior ministration of atropine blocked the appeamoe of spiking, or if present. this electrical activity could be 'Ihe eliminated by atropine (9) . In contrast to these findings, Brenner and Merritt applied topical acetyloholirm in concentrations of exposed cortex of cats , and noted no encephalogmphic chmges The 2—1/3 to 10% to the effect an the electro- after intravemm atropine (1 tug/kg) (7). concentrations of coats/lemme in these experimnts, however, were higher than the topical applicatims (1-H gamma percent) and the intmcietemal (0.240 game percent) injections of Bernstein (6). Brenmr and Merritt also noted electroencePMJogr'aplﬁc effects similar to acetyloholine after meﬁuolnline (rbctwlyl) and car‘bmxyldlolim (Daryl) in concentrations mob lower than the acetylcholine cmcentmticns . They asmibed the increased �effectiveness of these choliner-gic drugs to their lack of sensitivity to cerebral cholinasterases . These data are conﬂicting and to qualify this issue. Cmbnaepémc Fluid View Mar study is necessary Amman of aoetyloholine mtsbolism finds and it Su'wuu. One in nervous tissues in an bustive and bomd form. wring periods of activity, sootyloholixnis libemtedattheoellmmbmwl'nmit is rapidly deactivated by dnlinestemses . The mom“: of bound acetyloholine is the resultant of the oontimnous processes of syntl'nsis, liberation and It has been postulated mm. that the level rises during sleep and falls during waking activity (15, 29, #5, 60). Tobias egg};mported increased free and total sootyldmoline after chloroform and nonbutal (ck) anesthesia in net and frog brinui but no changes after strychnine or piorotoxic oawulsims (60). Richter and levels in transient, however, as the msynthesis rate for aoetyloholim in rat brain is high (7 ganm/gm/minute) (as). mass observations were confirmed by Elliot 51:. 514. (15) and Ckossland and Merrick (ll). Giarm and Pepeu found the increase in acetylolwline following various depressants to be rwghtypr'oportimltomedogmeofdopmsimofthe central mus system mad the redaction in motor Rayner-t and Buck, activity (29). however, studying brain acetylcholine levels �during sedation cone-1m that some sedatives were associated with elevated bmin acetylcholine, but that no rigorous mletimships existed (39). In part, this may be related to the earlier observations of and Elliot that acetyldwline synthesis assured in rat brain slices is accelerated by low dosages of mm narcotic drugs, but irhibited by high dosages (140). Free acetyldaoline was reported in the spinal ﬂuid in patients with epilepsy (10, 63). 0f 56 epileptic patients , m; demxsmtod free acetyldlolinc in qumtiﬁes of 0.02 to 5.0 with an average of 1.0:bgannn percent. Acetyldaoline percent gm levels were related to the fmqmncy of seizms, the extent of electroencephalographic abtmmlity, and to the time since the last seizure, but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliot 9}; 114 also noted fme aoetylcholine in the spiral fluid in mundane up to 3 gm percent after pentylene tetremol (Mammal) convulsions (15) . Mechem vimd the increased acetyloholine as a by—pmchct of the seizure, and not came]. (63). Studying the hypothesis that seizures were imhced by the commution of mtyloholine, ’lbrde measured the level of acetylcholine in hm tissue after pontylenetetmzcl convulsions. She noted a Tower and �rise in the acetylcholina content of the conwlsion. failed . to occur. hash before and a fall during certain levels of aoetyldwline, convulsions suggested that the fall in tissue aoetylcholine Below She during a convulsim was due to the inhibitim of acetylcholine syntresie by increased concenmtions of metabolites such as ammonium ions (61, 62). GiummmdPepeualsomeasmdclmges incenmlnewous system acetylcholine following various after mﬂadmlﬂle stimlatts (29) . Only and 3, 5-dimthylbutylethyl-baxbitm'ete was there a significant changein the acetyldmolim level . They noted a decrease in association with induced convulsions . With other drugs which they classified as ipmniazid + stimnam ipmiazid, (LSD, hydrmcytryptophan, and iprcniazid + DOPA) there in acetylcholine level . they concluded that despite intense excitation produced by these conpomda, them were no changes in acetylcholine hols unless these were observations ('lhe in convulsions. differemes by awarded were no changes betwentheseobservemandOomgtglﬁimdlbmrmdeadmem related to the differences in mthods of biochemical masummnts, for the latter measured chmges mflecting free may be acetylcholine only, while Siam and Pepeu measured the total acetylcholim. including forms of These AW“ bound and m acetylcrmlineluol). suggest that spontaneous an induced mm 4;qu in 5m. acetylehoLéne an abound 5m m bound 50m which my be Reﬂected in the enhance and Auzuau Cmbxal acetylchoune (Laid. activity spud deemed“, teaming tum Levels 06 acexyzehoune, whue deep and anesthesia augment Wicca“ plwduduon taming tame Levels . accompanied by an inc/Lease �t ~ .wr, ~ also Two ,7 w“ in... gym. m.“ cm u , . .......w....w,,.,_ .7... , , .7 , ,...,. “ﬂu..." ......._ , ». __‘ -7, N-... .. n"... -..—.. - .u»...——..r.n Wm m -gNuvom 3mm Chounutwuu. m:- and Wm maid spiral fluid momesternae activity (63, types of dumnstemes 614, 65). whioh hydrolyze acetylcholine are mutually found in the spixml fluid: ctnlimstemse~1 ("trm," "amcific," or mom—hydrolyzing) which has a high specificiw for anatyldnlino; and cholinestemse—II ("pseudo," "mnapccific," or bamyldmolimahydmlyzing) . The diffemt rates of hydmlysis for nothao‘noline and benaoyloholim permits qualitative distimtiom . By reporting tho dwlinestemse activity as a ratio of the activity with mtrudloline and huuoyldmlim substrates empamd to an acetyldxolim substrate dnlimstomseJ/aoatylcholﬁxe and armlimstemse—II/ aoetyldnlim ratios are derived. Normal oembxospinal fluid contains estemses in the ratio of 33:17 for dnlixxestemsa-I to dmlimstemse-II . In patients with head mum. 'lbwer and McEac-Mm reported m inwnion of the oholhnstemses with an shamans in the okxolia‘IIstomean fraction of the spinal fluid and a decrease in dxolimstemao-I activity. 11» extent of the oholimstemse malwasmlttadtoﬂmsewrityofmmmdtothedagzu of the elootmumphalomphio abnormality. In patients with elevated spinal fluid aoetyloholim after ratio of dolineatemoes or total oknlixmstemse activity was fomd. spontaneous seizures, mwever, no chmge in the �Following the recent denmstratims that neurol stinmlation produces changes in brain weight and acetylcholinesterase (37, ), Pryor M9, induced swims in and Otis studied the activity effects of repeated Wistar rats ('43). After as little as u weeks, they observed increases in brain weight and in acetylcholinestemse activity, related to decrements in behavioral performance. in cholinestemse activity may be related to which was Changes changes in cell membrane permeability. Qualinesterese-I is found in highest concentration in the central nervous system while cholinestemse—II predominates in other tissues, especially cerebral acetylcholine, vesclilaticn blood serum. With immersed and increased cellular permeability may be predicted, with a vucﬂai‘}uitrgnswatim varying with the extent and duration degree of of the vasodilation (35). Spiegel, Spiegel-Adolf, and their coworkers demtrated such permeability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassimn and phosphate) in the spinal fluid following electrically induced convulsions (Bu-58) . Such non- electrolytes as nucleic—acid splitting enzymes also increased. Changes in cellular permeability may be the basis for the high concentrations of acetylcholine and increased concentrations of cholinesterase-II after induced seizures or head trauma (65). The persistence of acetylcholine in spinal fluid after trams and after seizures despite increased cholinestemse activity may be related to the sensitivity of the acetylcholine— head cholinesterase-l system to concentration relationships (8, #1, 85) . �.At "physiologic" concentrations , hydrolysis of acetylcholine is rapid (34+ microseconds) but at higher. and lower comentrations, the activity falls off quickly. In contrast, the cholinestemse-II acetylchcline relationship is non-specific and the rate of hydrolysis increases with increased concentratim. ' relationships are related to the induction of seizures. the usual concentrations of ecetylchcline at cell membranes These While are destroyed by the specific activity of clmlimsterese-I in a few microseconds, an excessive concentmtim following excitation may exceed the rate of hydrolysis by dualinesterase-I. is seizmre threshold seizure reached and a seizure induced, with the wt scetylcholine affects vascular itself adding to the increased The of free scetylcholine. and The cellular pemeebility, altering the concentrations of various ions, including dialinestemse-II, in tissues and in the derebrospinel fluid. The activity of dwlinestemse-II, though the low efficiency and depending on cmcentmtion kinetics, remces the acetylcholine in the tissues in hours to days to levels for the physiologic action of chcljnestemse-I. Chawutuase theta ins/wade in appeals. in the spinal (ﬂuid as a uéueaon 06 ﬂuids, mulling (Item chaugu in mm sea numb/tans pumeaway occasioned by teamed aeetylehoune. The teamed ehounutuasu Me paint 06 the homeostatic mechanism canWLung the Leveu 6M. nmuoub system 06 acetyzchaune at can mmbmu necessary datum. �-12.. t-!ypeluync/wny and Induced EC?! Canvuuiom. The significance activity for the convulsive therapy process has been repeatedly stated (22, 23, SO, 51). The early appearance of high degree hypersynchrony and its persisof the deVelopment of high voltage slow wave tence throughout a treatment course has been described as pre- requisite to inpmvennnt. Both the electrograﬁiic and the behavioral clunges of inde cmvulsions were transiently reversed by the acute aministmtion of experimntal anticholimx‘gic alnpomds (18, 19). The intmvernus injection of diethazine, benactyzine, the piperidylbenzilatea and WIN-2299 induced These EEG JB—318, JB-336 and JB-329 BBQ (Ditran), deayncruonizatim in psychiatric subjects. changes were associated with behavioral aka: alerting, anxiety, tremors, illusions , and railucinatims. In patients who had recently received electromnvulsive therapy, them was a reduction in slow wave activity and a reversal of euphoria, dnnial and oonfmion. Atropim in low doses was associated with EEG desynolmnizatim accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchrmws slow anes, followed by lower voltage, poorly organized delta activity with activity fusion and diswientatim. superimposed beta was associated with progressive con- effect of anticholinergic drugs on slow wave activity was also assessed in convulsive therapy by the chronic adminis— tration of atropine (5 mam per day) and scapalomine (1 - 3 mg) The of-WW during the weeks of tmatmmt. The �-13.. mm of group who alwing was significantly less than in a cmtrol had not moiived the amine adminietretim (66). EEG The sasnples were too small for clinictl correlation, but the date is maistent with a definite blocking of the clinical effect. Marked improvement was seen of 5 in 2 of '7 atropine treated, none scapolmnine treated and in four of the six waiving mmdified authors may have Ad who ECT. cmtmls this study we not replicated by the suggest that dosage factors or population changes contributed to the different results (34). in mam Mam, the demoguphic changed induced continuum my be modiﬁed by the 06 muchounugic 06 acctywzounz ad anou’ated 9W1. dlmgd, dugguzéng inc/Lead ed that WWO): anemia inc/Lead ed chaunctgic adaptivity the high wattage Mow wave 05 x16 activity. AcetyMaune and Induced Couvwionc. Despite a constant application of mm , however, there is a greet variability in the time of eppeardnce, the duration and the exxent of the electmgrephic slow ween activity as well as the sensitivity of to modification by alerting, hyperventilation and barbiturates in psychiatric populations(30). The differences in the demo. of induced EEG hypersyncmrcny may related to differences in central duelinergic activity. The failure of certain patients to develop hypersynchmny be may be associated with the absence of free acetylcholine and with minimal clmxges in cerebral function, thus precluding a clinical response to induced convulsions. Tower and HcEachem, �-33.. in their study of omniooerebml tram, included observations of six psychiatric patients undergoing convulsive therapy (63). after 3-? treatments they reported free spinal fluid acetylcholine in two patients; and an increase in clnlinestemseull and a decrease in cholinestemse-I with a reversal of the ratio of oholinestemses in five of the six Studying the patients patients. the one patient in the series who failed to show either free aoetyloholine or a oholinestemoe ratio reversal in the spinal fluid was described as: "It is interesting that this patient was tmtmt.“ From the only one of the six to show no response to these observations they omeluded that the spinal fluid changes in induced convulsions were more like those of cmniooerebml trams than those of spontaneous epilepsy. Other evidence of altemtimas in the pemability barrier seen in the damstmtions of an increased cmoentmtim ofoooaineinbmintissues threedays aftersseriesole induced omvulsions (l). The change in concentration of this large molecule, ordinarily absent in briin tissue, was associated may be with the appearance of hypersynohmny (delta btmsts) in the elect'oenoephslogram. Fm thus obsmvauam we would conducts that induced command, Like mucouebmﬁ Mama and spontaneoua balm/ms, an associated with an inc/Laue in ﬁne. acetyzchoune in am, mey enhancing the. «:2qu as chaunutmuu. The Level. 05 ﬁne Macadam sawing «mm and �a hypUuynchlwny a one mama 06 mend Leveu 05 magichouue maintained by upewted induced Aazwlu. acetytchaune and the. melted mey including chewable/(Mu. 05 The momma», changu in Lym, including acetytchoune (that Aubamue 504 the. pwutent EEG and 04‘.th Aubetancu, mmummm elect/w- H movide the behavioml. changu and EEG hypn- the. Maﬁa Aynchhong ﬁauomlng induced convulsions. An 05 application the medic/tan Medication 06 05 05 «than couoquonA 424 (men in the convuuive zhmpy aupome and the paychoeu (21.). Chounuteluuu and the Medication 05 Peychaeu. Funkenetein g_t_ g}: demnstr‘ated a relationship between the blood pressure response to methocholine, an active cholinergic agent, the and the clinical response to omvuleive therapy (25-27). Inmdiately after the injection of methaoholine, blood pressure falls, usually returning to the baseline within 5-20 minutes. A return within 5 minutes places in the patients in Groups I, II or III; while a return after 20 minutes places the patient in Groups VI and VII. Group I and Group II-III have a 9 and a 35% recovery 89% VI VII and while Group Group respectively, motors rate, and 97% recovery rates to induced convulsions (27). Group I to III reactors may be looked upon as patients in whom methecholine is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. (The response to injected epinephrine was suggested as a second criteria in the �-16.. While (H8). value of limited but discriminating is classificatim, we have no biochemical explanation of the differences metabolism of nethachcline in these psychiatric in the it M8, is possible that the blood and tissue cholinestemse activity levels of Groups I-III is high, while that of Groups VIJII is to genera psychiatric populations. differences in blood oholinestemse levels in normal and low ccnpared The ill subjects have been extensively titled studied. Despite differences in methods ('4, 5) , elevated cholinesterase levels mntally ccupared to normal populations have been reported for depressive subjects (W, #6, H7, 52), schizOphrenic subjects (1“, 28, 53) and a mixed psychiatric population (#2) . Alpem reported lowered cholinestemse levels in schizophrenic subjects (2). mile these studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater and frequently elevated in the mntally ill. Negative reports include the failure by Bllman and Callaway (16) to confirm Rubin's study; and Altschule's review of the data suggesting no abnormality of cholinesterase Conclusion. levels in the mentally ill (3). This review stunnerizes sane of the available data suggesting that cholinergic mechanism may be central to the convulsive therapy process. Induced convulsions are associated with vasodilation and increased cellular permeability, followed by the pppeamnce of increased amomts of enzymes and electrolytes in �intercellular and cerebrospinal fluids. Amng the changes are immase in intercellular acetylcholine to levels greater than can be destroyed by aoetylcholinestemse activity, and enhanced amounts of butyrylcholinestemse. The increase in an acetylcholine, vasodilation, and increased cellular permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes are associated with increased electrical hypersynohmny which is recorded as EEG slow wave activity in scalp electrodes, and which can be modified by acute and chronic ediﬁnistmtims of many anticholinergic dmgs, including atropine. benactyzine, diethazine, pmcyclidine and various piperidylbenzilatus. In these regards, induced convulsions are more similar to cerebral trauma. than to spontaneous seizures. in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes , including the concentration of acetyloholine, results in failure to produce The changes behavioral change. Thin! is, as yet , no consistent evidence for differences in the sensitivity or dependence of populations on cholinergic medianisms; the differences in the rate of development of cerebral changes to the same number and frequency of induced convulsions and the classification based on the blood pressure response to mthacholim suggest, however, that such differences may be important in the pathogenesis of different psychoses. ��E' U ‘6 :6 _J! U m 3: = g 0 D. YOUR :3 I) Ta. 41: E O ° 8 : z a £3 'u E as. WITH .- g o 5 .— ‘E 3 e “ n:<3 0? DESK £5 :a: “1’" = 0 0)|.um :3? 1:5a o ‘ﬂ :1: III z....a) co n— .I I) o- '. ”-0 c: :3 0 >~ 3: 5 ” 9 '23: :2 a - c: 1.: U an 3.. 0>§ E "E g0 " L D. a; 0w a0 £5 z13 (g i: (U .—l ._ \— 3 13 U! w e 13 U < .g 23 at- 3 0 o - ac il ,~ 3" :2 '3 E PRESENT ea " ‘- 2'5o AT o 5" a»5 °E n.—O mi 1:8 m “ Ex a Illa REGISTRATION “" ”'7 a: c c q, u:3 32:) «n- m '0 C m >‘ 3: Q h” o: a: 0< c E 5‘: h o55 ON Eucu 0 1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII|IIIIIIIIIIII|IIIIIIIIIIIIIIIIlllllIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 122nd ANNUAL MEETING AMERICAN PSYCHIATRIC ASSOCIATION ATLANTIC CITY, N. J.—MAY 9-13, 1966 HIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIL_ IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII First Name City state Last Name �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY Max Read M.D. at the May Now, Fink, l22nd ﬂeeting of the American Psychiatric Association, 12, 1966, Atlantic City. Proféssor of Psychiatry, 5-9-66. New York Medical College, New York City. �The mode of action of induced convulsions is still puzzling. Various theories have been proposed, including those best described as wholly psychological in scope, and those wholly biological or Neither extreme point of view is consistent organic - structural. with the available facts, and the neurophysiological - adaptive models — combining, as they do, both the biological data and the personality historical facts - are the most satisfactory today. One of the neurophysiological - adaptive theories suggests that persistent alterations in brain fUnction are a necessary condition fOr behavioral change and inprovement in the convulsive therapies. While many measures of altered brain function have been studied, similar relationship of change in measure to behavioral change, the appearance of high voltage slow wave and each has shown a activity in the scalp recorded electroencephalogram.has been the The induced delta activity most useful index in these studies. is readily observed, easily quantified and the amount, distribution over the scalp, amplitude and persistence are each directly related the frequency of the induced seizures and are independent of the mode of induction of the seizure. to the number and While the biochemical basis for these EEG changesgii=3 poorly understood, observations that the induced slow wave activity was inhibited by the intravenous administration of anticholinergic that cholinergic mechanisms may play an active part not only in the EEG activity but in the therapeutic compounds, suggested process as well. �patterns and the response to anticholinergic drugs M. in convulsive therapy were—seen to be similar to the EEG and The EEG behavioral changes in experimental and clinical head trauma and to a lesser extent, in spontaneous seizures. This was clearly reflected in measures of the cholinesterases in brain and spinal fluid in these conditions. These observations led to a review of the neurological and biochemical data in induced convulsions, head trauma and spontaneous seizures, to attempt to relate the available observations to the neurophysiological and therapeutic changes observed in the convulsive therapy process. The activity of acetylcholine in the transmission of nervous impulses has been extensively sutdied since the early descriptions by Dale and Loewi.in 1914 and 1921. A constituent of nervous tissue in a bound ﬁorm, acetylcholine is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by cholineacetylase. Free acetylcholine has not been measurable in normal breakdown of bound the fluid despite cerebrospinal rapid acetylcholine during periods of activity and excitement. But the normal cerebrospinal fluid does have measurable cholinesterase activity. �In_exparimenta&—trauma—ie—eaes, free acetylcholine was found in the cerebrospinal fluid within a few minutes after head trauma lk.(4T$ and persisted for varying periods up to #8 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 and the amount was gamma percent directly related to the degree of induced trauma - the greater the induced head trauma, the higher the amount of neasured acetylcholine. Concurrent electroencephalograms first demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was soon succeeded by short periods of flattening of all recorded electrical activity. were fbllowed by prolonged and These phases persistent periods of high amplitude sharp waves in the delta frequencies. The degree to which the animal's behavior was disorganized related both to the degree of induced trauma and to the amount of measured free acetylcholine. The higher the observed levels- was of acetylcholine, the greater the degree of EEG abnormality and the greater the changes in consciousness. The development and the persistence of spontaneous post—traumatic seizures were also related to the amount of free acetylcholine measured in the cerebrospinal fluid. In a parallel study, acetylcholine was applied directly to the exposed cat cerebral cortex. acetylcholine was 1 gamma When the concentration of percent or less, high amplitude sharp �waves of low frequency appeared in the electroencephalogram. the concentration was increased to 2 gamma When percent, the electro- encephalogram flattened in a fashion parallel to the post-traumatic a relationship between the EEG changes records, thus again showing and the concentration of free acetylcholine. Investigations in neurological patients by in 1948 demonstrated Tower and McEachern free acetylcholine in the cerebrospinal fluid only in patients with recent head trauma and recent grand-mal seizures, but also after electroconvulsive therapy. Free acetylcholine varied fron10.2 to 100 gamma percent. In parallel studies they measured the spinal fluid cholinesterase a sharp rise in the butyrylcholinesterase (non-specific) fraction and a fall in the acetylcholinesterase activity. They noted (specific) fraction both in the patients with head trauma and in those fbllowing convulsive therapy. After spontaneous seizures, however, the cerebrospinal of cholinesterases although fluid did not exhibit such it an inversion did contain free acetylcholine. They that the level of free acetylcholine varied directly with the degree of cerebral damage and that the reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. concluded Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �Continuing a review of head trauma, we note behavioral and neurologic signs of head trauma that the may be EEG, blocked by the parenteral administration of atropine. ward applied these observations to the treatment of closed head injuries. In 20 degrees with of trauma, the subcutaneous varying patients administration of atropine in some and was a reversal of the associated with clinical improvement EEG effects in others. The same changes in the post—traumatic electroencephalogram.were reported by Jenkner and Lechner cholinergic drug. A in a study of diethazine, another anti— single intravenous dose in forty patients resulted in normalizing the abnormal electroencephalogram in twenty-two and marked improvement in six others. That, the amount 06 ghee acetylchouhe may the/LeaAe tn the Aptnat ﬁhee Mia/Cd 5031.0th Wicca/Lewd Mama and the amount acetytchotthe, the deg/Lee and abrzolunaLity, ahd‘changeé type 05 etect/Loeneephaﬂog/Laphéc tn euntcat behautot phenomena, whtch may be ILeduced by the 05 appea/L a4 ammmmon 06 ate/mutated anti- ehotéhejtgtc d/mgb. 3W acetytchoune and antéehouhugtc d/LugA. While the data is not as clear, the effects of the direct application of acetylcholine to the central nervous system by anticholinergic drugs. The may also be blocked administration of cholinesterase inhibitor di-isopropyl fluorophysphate (DFP) elicits high amplitude �patterns similar to status epilepticus and posttraumatic states. These EEG effects have been blocked by small rapid frequency EEG doses of parenteral atropine and scopolamine. Chatfield and Dempsey prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. prior adndnistration of atropine blocked the appearance of spiking, or if present, thes electrical activity could be eliminated by atropine. The Bornstein also reported that the parenteral administration of atropine to modify the behavioral and neurological signs observed after the intracisternal addition of acetylcholine. seemed In contrast to these findings, Brenner and Merritt applied topical acetylcholine in concentrations of 2-1/2 to 10% to the exposed cortex of cats and noted no effect on the electro- after intravenous atropine. not deﬁthtte, the obeehvattone éuggebt that atnoptne encephalographic changes White may bzoch the behautotat and EEG eﬁﬁecté 06 ghee tntaoduced acetytchottne tn the Aptnat glutd. CehebhOAptnat Ftutd Acetytchotthe and Setzuheb. to free acetylcholine and spontaneous seizures ship. One view we of acetylcholine metabolism finds tissues in an inactive and bound fornn Turning again note a relation- it in nervous During periods of activity, �acetylcholine is said to be liberated at cell membranes where it is rapidly hydrolyzed The amount and deactivated by cholinesterases. of bound acetylcholine is thus the resultant of the continuous processes of synthesis, liberation and breakdown. It has been postulated falls during waking that the level rises during sleep and activity. Free ace: Icholine was reported in the spinal fluid in patients with epilepsy. Of 56 epileptic patients, HM denonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma percent with an average of 1.0 gamma percent. Acetylcholine levels were related to the frequency of siezures, the extent of electroencephalographic abnormality, and to the time since the last seizure but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliott at aﬁ. also noted free acetylcholine in the spinal fluid in concentrations up to 3 gamma percent after pentylenetetrazol (Metrazol) convulsions. the increased acetylcholine as a by-producifof the seizure and not causal. Studying Tower and MCEachern viewed the hypothesis that seizures were induced by the accumulation of acetylcholine, Torda noted a rise in the acetylcholine content of brain before and a fall during pentylenetetrazol convulsions. certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in tissue acetylcholine during a convulsion was due to the inhibition of acetylcholine Below synthesis by increased concentrations of metabolites such as ammonium ions. �that AponianeOuA on induced Aeizunei incneaie in inieiceiiuian ﬁnee aceiyichoiine Theee etudicb AuggeAi ane accompanied by an iibenaied 5iuid. gnom iii Ceaebnai bound 50am which may be neﬁiecied activity in the Apinai and Aeizuneé enhance aceiyichoiine deeinuciion, iowening iiAAue ieueiA 05 aceiyichoiine, whiie bicep and anebihebia augment aceiyichoiine pnoduciion incneaAing iibéue £evw . EEG Hypenbynchnong and Induced ConuuiAionA. of high voltage EEG slow wave The significance activity for the convulsive therapy process has been repeatedly described, with numerous observers indicating that increased slowing is associated with behavioral In the usual course of convulSive therapy, inter- improvement. treatment electroencephalogram record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment continues, delta activity appears in bursts and is the dominant activity in all leads. These changes eventually are directly related to the number and rate of induced convulsions, and is not specific ﬁor a method ofinduction. While some relationships to type of electrical current has been observed, all _ seizure inducing methods or inhalant —— —- exhibit the electrical, intravenous same type of EEG chemical pattern changes. �early appearance of high degree hypersynchrony and its persistence throughout a tre-tment course has—bean—éeuné4834xr The «Milan... prerequisite to inprovement. Both the electrographic and the betavioral changes ofincuced conVulsions are transiently reversed by the acute administration of experimental anticholinergic compounds. The intravenous injection of diethazine, benactyzine, the piperidylbenzilates JB—318,JB—336 and JB- 329 (Ditran), WIN-2299 These EEG induced EEG desynchronization in psychiatric subjects. changes were associated with behavioral alerting, anxiety, tremors, 'llusions and hallucinations. In patients had recently received electroconvulsive therapy there was a reduction in slow wave activity and a reversal of euphoria, who denial and constion. Adztpine, in low doses, was also associated with EEG desynchronization accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchronous slow waves followed by lower voltage, pooly organized delta activity with superimposed beta activity was accompanied by progressive constion and disorientation. effect of anticholinergic dimugs on the slow wave convulsive of activity therLapy was also assessed by the chronic administration of atropine (5 mgm per day) and scopolamine (1-3 The during the weeks of treatment. The amount of EEG slowing was significantly less than in a control group. The samples were too small fora dinical correlation but the data is consistent mg) �-10with blocking of the clinical effects of electroconvulsive therapy. treated, Marked improvement was none of 5 scopolamine-treated and in controls receiving unnodified replicated ECT. of 2 u atropine- 7 of the 6 This study was not that dosage factors have contributed to the different by the authors who suggest or population changes may results in a second study. A6 reported in tn eeaebaat thauma, the eteetnognaphtc changeb 05 thduced convutttont may be modtﬁted by the adhthtbthatton 06 anttchottnehgte dnugt buggeétthg that tncheabed 05 acetytehottne on amountb tncneated chottnehgte necepttvtty t4 abboctated with the htgh wattage atow wave aettuttg. Convutttonb. Aeetytchottne and INduced Despite a constant application of treatments, however, there is great variability in the time of appearance, the duration, amount, and sensitivity to modification by alerting, hyperventilation and barbiturates activity in psychiatric populations. we would suggest that these differences may relate to differences in central cholinergic activity. The failure of of the electrographic 81 w wave certain patients to develop hypersynchrony may be associated with the failure to liberate excessive amounts of free acetylcholine, and with the minimal changes in cerebral fUnction ��-11a clinical response to induced convulsions is precluded. in their study of patients with head trauma, included observations of six psychiatric patients undergoing Tower and MCEachern after to 7 treatments they reported free spinal fluid acetylcholine in two convulsive therapy. Studying the patients 3 patients; and a reversal of the ratio of cholinesterase ratio reversal in the spinal fluid, the authors stated: "It is interesting that this patient was the only one of the six to show no response to treatment." From these observations they concluded that the spinal fluid changes in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Fnom thete obtenvattont we woutd conctude that induced convutétont, tthe chantocenebnat tnauma and Apontaneout tetzuneé, ate attoctated wtth an tncneate tn ﬁnee acetytchottne tn tnten- cettutun gtutdb, attentng cehebnat penmeabttttg and enhanctng the appeanance 05 chottnettenateb. The tevet t4 matntatned by nepeated tnduced tetzunet. tA one ncétectton 05 attened penmeabtttty attened tevett 05 06 06 ghee EEG acetytchottne hypenégnchhony acetytchottne and the etectnotgtet and othen Aubttanceb; tnctudtng ehottnebtehabet. The changeé tn tntencettutan etectno- tyte4,'tnctudtng acetytchottne, ptoutde the btochemtcat Aubttnate ﬂat the penttbtent behautonat changeA and EEG hypeneynchhony ﬂottawtng induced convutetont. ��-12- CONCLUSIONS This review summarizes some of the available data suggesting that cholinergic central to the convulsive have observed that induced convulsions are mechanisms may be therapy process. We associated with cerebral vasodilation and increased cellular perneability, fbllowed of by the appearance of increased amounts electrolytes in intercellular and cerebrospinal increase in acetylcholine, vasodilation and increased enzymes and fluids. The permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased hypersynchrony which is recorded as EEG slow wave electrical activity in scalp electrodes and which can be modified by the acute and chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl- benzilates. In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures. The changes in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes, including the concentration of acetleholine, results in failure to produce behavioral change. �-13There is, as yet, no consistent evidence for differences in the sensitivity or dependence of the cerebral mechanisms underlying interpersonal behavior of populations on Cholinergic mechanisms. Differences in the rate of development of cerebral changes to the sane number and frequency of induced convulsions and of the mentally ill classifications based on the blodo pressure response to methacholine suggest, however, that such differences may exist and may be related to the pathogenesis of different types of psychoses, as well as the success or failure of our present varieties of biologiCal treatments . �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY max Read at the Now, Professor of Psychiatry, Fink, M.D. 122nd meeting of the American may 12, 1966, Atlantic City. 5—9~66. New York Psychiatric Association, Medical College, New York City. �of action of induced convulsions is still puzzling. Various theories have been proposed, including those best described The mode - as wholly psychological in scope, and those wholly biological or Neither organic - structural. extreme point of view is consistent with the available facts, and the neurophysiological models — — adaptive combining, as they do, both the biological data and the personality historical facts - are the most satisfactory today. One of the neurophysiological - adaptive theories suggests that persistent alterations in brain fUnction are a necessary condition fbr behavioral change and improvement in the convulsive therapies. While many measures of altered brain fUnction have been studied, and each has shown a similar relationship of change in measure to behavioral change, the appearance of high voltage slow wave activity in the scalp recorded electroencephalogram has been the useful index in these studies. delta activity is readily observed, easily quantified and the amount, distribution most The induced over the scalp, amplitude and persistence are each directly related to the number and the frequency of the induced seizures and are independent of the mode of induction of the seizure. While the biochemical basis for these EEG changes were poorly understood, observations that the induced slow wave activity was inhibited by the intravenous administration of anticholinergic that cholinergic mechanisms may play an active part not only in the EEG activity but in the therapeutic compounds, suggested process as well. �patterns and the response to anticholinergic drugs in convulsive therapy were seen to be similar to the EEG and The EEG behavioral changes in experimental and clinical head trauma and to a lesser extent, in spontaneous seizures. This was clearly reflected in measures of the cholinesterases in brain and spinal fluid in these conditions. These observations led to a review of the neurological and biochemical data in induced convulsions, head trauma and spontaneous seizures, to attempt to relate the available observations to the neurophysiological and therapeutic changes observed in the convulsive therapy process. The activity of acetylcholine in the transmission of nervous impulses has been extensively sutdied since the early descriptions by Dale and Loewi,in 191” and 1921. A constituent of nervous tissue in a bound form, acetylcholine is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by cholineacetylase. Free acetylcholine has not been measurable in normal breakdown fluid the of bound cerebrospinal despite rapid acetylcholine during periods of activity and excitement. But the normal cerebrospinal fluid does have measurable cholinesterase activity. �In experimental trauma in cats, free acetylcholine was found in the cerebrospinal fluid within a few minutes after head trauma persisted for varying periods up to H8 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 gamma percent and and the amount was directly related to the degree of induced trauma the greater the induced head trauma, the higher the amount of measured acetylcholine. Concurrent electroencephalograms first demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was soon succeeded by short periods of flattening of all recorded electrical activity. These phases were fbllowed by prolonged and persistent periods of high amplitude sharp waves in the delta frequencies. The degree to Which the animal's behavior was disorganized related both to the degree of induced trauma and to the amount of measured free acetylcholine. The higher the observed levels was of acetylcholine, the greater the degree of EEG abnormality and the greater the changes in consciousness. The development and the persistence of spontaneous post-traumatic seizures were also related to the amount of free acetyldholine measured in the cerebrospinal fluid. In a parallel study, acetylcholine was applied directly to the exposed cat cerebral cortex. acetylcholine was 1 gamma When the concentration of percent or less, high amplitude sharp �waves of low frequency appeared in the electroencephalogram. the concentration was increased to 2 gamma When percent, the electro- encephalogram flattened in a fashion records, thus again showing parallel to the post—traumatic a relationship between the EEG changes and the concentration of free acetylcholine. Investigations in neurological patients by in 19H8 Tower and MeEachern demonstrated free acetylcholine in the cerebrospinal fluid only in patients with recent head trauma and recent grand-mal seizures, but also after electroconvulsive therapy. Free acetylcholine varied from.0.2 to 100 gamma percent. In parallel studies they measured the spinal fluid cholinesterase activity. They noted a sharp (non—specific) fraction and a rise in the butyrylcholinesterase fall in the aeetyldholinesterase (specific) fraction both in the patients with head trauma and in those fellowing convulsive therapy. After spontaneous seizures, however, the cerebrospinal of cholinesterases although fluid did not exhibit such it an inversion did contain free acetylcholine. They that the level of free acetylcholine varied directly with the degree of cerebral damage and that the reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. concluded Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �Continuing a review of head trauma, we note that the behavioral and neurologic signs of head trauma may be EEG, blocked by the parenteral administration of atropine. ward applied these observations to the treatment of closed head injuries. In 20 patients with varying degrees of trauma, the subcutaneous administration of atropine was associated with clinical improvement in some and a reversal of the EEG effects in others. The sane changes in the post-traumatic electroencephalogram were reported by Jenkner and Lechner cholinergic drug. in a study of diethazine, another anti— single intravenous dose in fbrty patients resulted in normalizing the abnormal electroencephalogram in A twenty-two and marked improvement in six others. That, the amount 06 ﬁnee acetytchottne may tncneabe tn the Aptnat ﬁtutd ﬁottownng enatnoeenebaat thauma and the amount 06 ghee aeetytchottne, the degnee and type 06 eteetaoencephatogaaphte abnoamattty, and changeA tn cttnteat behavton appeah ab tnteanetated phenomena, which may be deduced by the athntAtnatton 06 anti- ehottnengte dnugb. Baatn acetytchottne and antichottnengtc daugA. While the data is not as clear, the effects of the direct application of acetylcholine to the central nervous system by anticholinergic drugs. The may also be blocked administration of cholinesterase inhibitor di-isopropyl fluorophysphate (DFP) elicits high amplitude �patterns similar to status epilepticus and post— traumatic states. These EEG effects have been blocked by small rapid frequency EEG doses of parenteral atropine and scopolamine. Chatfield and Dempsey prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. prior administration of atropine blocked the appearance of spiking, or if present, thes electrical activity could be The eliminated by atropine. Bornstein also reported that the parenteral administration of atropine seemed to modify the behavioral and neurological signs observed after the intracisternal addition of acetylcholine. In contrast to these findings, Brenner and Merritt applied topical acetylcholine in concentrations of 2-1/2 to 10% to the exposed cortex of cats and noted no effect on the electro— after intravenous atropine. not deﬁtntte, the obbchvat£0n4 tuggebt that ataoptne encephalographic changes White may btoch the behautoaat and EEG eﬁﬁeeté 06 ﬁaee tntaodueed aeetytehottne tn the Aptnat ﬁtutd. CeaebaaAptnat Ftuid Aeetytchottne and Setzuaea. Turning to free acetylcholine and spontaneous seizures we again note a relationship. One view of acetylcholine metabolism finds it in nervous tissues in an inactive and bound fbrnn During periods of activity, �acetylcholine is said to be liberated at cell membranes where it is rapidly hydrolyzed The amount and deactivated by cholinesterases. of bound acetylcholine is thus the resultant of the continuous processes of synthesis, liberation and breakdown. It that the level rises during sleep and falls during waking activity. Free acetylcholine was reported in the spinal fluid in has been postulated patients with epilepsy. epileptic patients, denonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma percent with an average of 1.0 gamma percent. Acetylcholine Of 56 HM levels were related to the frequency of siezures, the extent of electroencephalographic abnormality, and to the time since the last seizure but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliott et al. also noted free acetylcholine in the spinal fluid in concentra— tions up to 3 gamma percent after pentylenetetrazol (Metrazol) convulsions. Tower and MCEachern viewed the increased acetylcholine as a by-produce of the seizure and not causal. Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Tbrda noted a rise in the acetylcholine content of brain befbre and a fall during pentylenetetrazol convulsions. certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in tissue acetylcholine Below during a convulsion was due to the inhibition of acetylcholine synthesis by increased concentrations of metabolites such as anmonium ions. �ane accompanied by an tibenated ﬁiuid. that Apontaneoub an induced Aeizuneé incneaAe in intetceiiuian ﬁnee acetyichoiine Atudiei buggeét TheAe iib gnom Cenebnai in the Apinai bound 60km which may be neﬁiected activity and Aeizunei enhance acetyichoiine duuuctéon, tom/ting tame Lewis and aneatnebia augment acetytchome, white deep acetyichoiine pnoduction incneaeing tiibue 06 ieveii. EEG Hypenaynchnony and Induced Convuiiioni. of high voltage EEG slow wave The significance activity for the convulsive therapy process has been repeatedly described, with numerous observers indicating that increased slowing is associated with behavioral In the usual course of convulsive therapy, improvement. inter- treatment electroencephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment continues, delta activity appears in bursts and eventually is the dominant activity in all leads. These changes are directly related to the number and rate of induced convulsions, and is not specific fbr a method ofinduction. While some relation— ships to type of electrical current has been observed, seizure inducing methods or inhalant -— -— electrical, intravenous eXhibit the same type of EEG all chemical pattern changes. �early appearance of high degree hypersynchrony and The its persistence throughout a treatment course has been fbund to be prerequisite to inprovement. Both the electrographic and the behavioral changes of hduced convulsions are transiently reversed by the acute administration of experimental anticholinergic compounds. The intravenous injection of diethazine, benactyzine, the piperidylbenzilates JB-318, induced WIN—2299 These EEG EEG JB—336 and JB-329 (Ditran), and desynchronization in psychiatric subjects. changes were associated with behavioral anxiety, tremors, illusions and hallucinations. alerting, In patients who recently received electroconvulsive therapy there was a reduction in slow wave activity and a reversal of euphoria, had denial and confusion. Atropine, in low doses, with EEG was also associated desynchronization accompanied by tachycardia, nervous- ness and tension. At higher dosages, hypersynchronous slow waves fbllowed by lower voltage, poorly organized delta activity with superimposed beta activity was accompanied by progressive constion The and disorientation. effect of anticholinergic drugs activity of convulsive therapy administration of atropine (5 was mgm on the slow wave also assessed by the chronic per day) and scopolamine during the weeks of treatment. The amount of EEG (1—3 mg) slowing was significantly less than in a control group. The samples were too small fbr a clinical correlation but the data is consistent �-10with blocking of the clinical effects of electroconvulsive therapy. Marked improvement treated, none of 5 was of 2 scopolamine-treated and in controls receiving unmodified replicated reported in of the 6 This study was not ECT. by the authors who suggest or population changes u atropine- 7 that dosage factors contributed to the different may have results in a second study. A4 tn cehebhat thauma, the eteetnoghaphte changeb 06 tnduced eonkutows may be modiﬁed by the achntnatjwtéon 06 anttchottnehgtc 06 acetytchottne dhugA Auggebttng on tnmeazsed that tncneabed amountA choltnetgtc heceptéw’ty t6 aAAoctated with the htgh voltage Atow wave activity. Acetytchotthe and INduced Convutbtoné. Despite a constant application of treatuents, however, there is great variability in the time of appearance, the duration, amount, and sensitivity to modification by alerting, hyperventilation of the electrographic slow and barbiturates activity in psydhiatric populations. we would suggest that these differences may relate to differences in central cholinergic activity. The failure of certain patients to develop hypersynchrony may be associated with the failure to liberate excessive amounts of free wave acetyldholine, and with the minimal changes in cerebral function �-11a clinical response to induced convulsions is precluded. in their study of patients with head trauma, included observations of six psychiatric patients undergoing Tower and MCEachern convulsive therapy. Studying the patients after 3 to 7 treat- ments they reported free spinal fluid acetylcholine in two patients; and a reversal of the ratio of cholinesterase ratio reversal in the spinal fluid, the authors stated: "It is interesting that this patient was the only one of the six to show no response to treatnent." From these observations they concluded that the spinal fluid changes in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Fnom theée obAenvationA convuibionc, we wouid tihe cnaniocenebnai ane aAAociated with an inn/Lease eonctude that induced tnauma and Apontaneoui beizuneb, in ﬁnee acetytchotine in inten- cettuian ﬁtuidb, ditching cenebnat penmeubiiity and enhancing the appeanance 06 choiinebtenabei. The tevet 06 ﬁnee acetyichotine i2: maintained by nepeated induced bunt/(.66. i6 one neﬁiection 06 attened penmeabiiity ditched ieveté 05 06 EEG hypeuynchnony acetyichotine and the eiectnoiytea and othen iabAt‘ance/s, inciuding choiineAtenaAeA. The changeA in intencetiuian etectno- iyteb, inciuding acetyichoiine, pnouide the biochemicat bubbtnate 50h the penAiAtent behavionai changeé and EEG hypenaynchnony ﬁattowing induced canvutbionb. �-12- CONCLUSIONS This review summarizes some of the available data suggesting that cholinergic medhanisms may be central to the convulsive that induced convulsions are associated with cerebral vasodilation and increased cellular therapy process. we have observed perneability, followed of by the appearance of increased amounts electrolytes in intercellular and cerebrospinal increase in acetylcholine, vasodilation and increased enzymes and fluids. The permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased hypersynchrony which is recorded as EEG slow wave electrical activity in scalp electrodes and which can be modified by the acute and Chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl— benzilates. In these regards, induced convulsions are more sinilar to cerebral trauma than to spontaneous seizures. The changes in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes, including the concentration of acetylcholine, results in failure to produce behavioral change. �-13‘5 There is, as yet, no consistent evidence for differences in the sensitivity or dependence of the cerebral mechanisms underlying interpersonal behavior of populations on cholinergic mechanisms. Differences in the rate of development of cerebral Changes to the sane number and frequency of induced convulsions and of the mentally ill based on the classifications blodo pressure response to methacholine suggest, however, that such differences may exist and may be related to the pathogenesis of different types of psychoses, as well as the success or failure of our present varieties of biological treatnents. �CHOLINERGIC MECHANISMS IN CONVULSIVE THERAPY MAX FINK, M.D. DEPARTMENT OF PSYCHIATRY AT THE MISSOURI INSTITUTE OF PSYCHIATRY UNIVERSITY OF MISSOURI SCHOOL OF MEDICINE 54-00 Arsenal Street St. Louis, Missouri 63139 PSYCHIATRIC RESEARCH FOUNDATION OF MISSOURI Pulilicntion No. 65 - 8 �CHOLINERGIC MECHANISMS IN CONVULSIVE THERAPY Max Fink, M.D. Psychiatric Research Foundation Publication 65—8 September, 1965 �From the Department of Psychiatry, washington University School of Medicine and the Department of Psychiatry at the Missouri Institute of Psychiatry, university of Missouri School of Medicine, 5400 Arsenal Street, St. Louis, Missouri 63139 Aided, in part, by USPHS grants MEI—927, NIH-2715, MH-o72u9, and MH—ll380; and the Psychiatric Research Foundation of Missouri. VIII: 8/21/65 65-8 �CHOLINERGIC MECHANISMS IN CONVULSIVE THERAPY Despite extensive use, the mode of action of the convulsive therapy process remains enigmatic. The neurophysiologicalradaptive theory attempts an assimalation of neurophysiological, psychological, clinical, social aspects of the process (Fink, 1957, 1962)° In this View, the early development*and persistence of signs of altered cerebral function are and requisite to changes in behavior (Pink and Kahn, 1956), with electroc encephalographic slow wave activity as the most significant index of altered brain function, Demonstrations that premedication with atropine inhibited this slow activity (Ulett and Johnson, 1957) and that-anticholinergic compounds reversed clinical as well as electrographic changes (Fink, 1958) suggests that the biochemical basis fbr wave “the convulsive therapy process may be of the central nervous system. The in the cholinergic mechanisms role of acetylcholine and the cholinesterases in the convulsiVe therapy process is discussed in this review, Acetylcholine has been extensively studied as an active agent in the transmission of nervous impulses since the first descriptions by Dale (191%) and Loewi (1921); It is a constituent of nervous tissue. existing in a processa bound form Which It is rapidly is liberated during the excitation hydrolyzed through the specific action of cholinesterase and is rapidly reconstituted by the choline— acetylase system<Richter andessland. 191:9)w In normal. �cerebrospinal fluid, free aoetylcholine is not present despite the rapid breakdown of bound acetylcholine during periods of activity and excitement (Tower and McEachern, 19u9a)° The cerebrospinal fluid does have measurable cholinesterase activity, principally of the "true" or mecholyl hydrolyzing type (Nachmanson In the absence of free acetylcholine and Rothenberg, 19MB), under’resting conditions, electroencephalograms fail to (a) Cholinergic Aspects of Craniocerebral Trauma: acetylcholine was found after experimental up to H8 show and abnormality. Free in the cerebrospinal fluid within a few minutes head trauma in cats and persisted for varying periods hours (Bornstein, 1946)o varied between 2,7 and 9,0 gamma The quantity of free acetylcholine percent, and the amount was related to the degree of induced trauma, Concurrent electroencephalograms demonstrated records first filled with high voltage fast activity, interpreted as evidence of an intense neuronal discharge,which was soon succeeded by a short period of flattening of all recorded electrical activity, by prolonged periods These phases were then fOIlowed of high amplitude sharp waves in the delta frequencies, The behavioral changes were related both to the degree of trauma and to the amount of measured free acetylcholine, With higher of acetylcholine, Bornstein reported greater degrees of EEG levels abnormality greater changes in consciousness, Spontaneous post-traumatic seizures were also related to the amount of free acetylcholine and �appearing in the spinal fluid. Bornstein applied acetylcholine to exposed cat cerebral cortex, the concentration of acetylcholine When was 1 gamma percent or less, high amplitude sharp waves of low frequency appeared in the electroencephalogramo When the concentration increased to 2 gamma was percent, the electroencephalogram flattened in a fashion parallel to the post-traumatic records° Investigations in neurological patients McEachern (19M9a) demonstrated by Tower and free acetylcholine in the cerebro— spinal fluid only in patients with recent head trauma, recent grand—mal seizures or after electroconvulsive therapy° Free acetylcholine varied from 0,2 to 100 gamma percent, In assaying spinal fluid cholinesterase activity, they noted a sharp rise in the nonSpecific cholinesterase fraction (benzoylcholine—splitting) and a drop in the specific cholinesterase fraction (mecholyl—splitting) in patients with head trauma and following convulsive therapy. After spontaneous seizures, however, the cerebrospinal fluid did not exhibit such inversion although it contained free acetylcholine. that the level of free acetylcholine varied directly with the degree of cerebral damage and that reversal of the cholinesterase fractions was a more sensitive indicator of cerebral damage. ElectroThey concluded encephalograms, taken at varying intervals following trauma, also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �These observations were recently confirmed by Kovach, Who recorded increased acetylcholine in rat brain inhibition of this activity and an by gt_§l. (1957) after traumatic shock the administration of atropine to the muscle preparationo ThuA the amount 06 ﬁnee acetytchottne may tncneaAe tn the Aptnat ﬁtutd ﬂattening chantacehebnat tnauma and the amount 06 ﬁnee aeetytchottne, the degnee and type changed tn cttnteat behavton appean (b) 06 a4 eteetnaencephatognaphtc abnonmattty, and tntennetated Anticholinergic drugs and trauma: The phenomena° electrographic, behavioral and neurologic signs of head trauma were blocked by the parenteral administration of 095-100 mg/kg atropine (Bornstein, 19u6), as were similar clinical changes occurring after the intracisternal addition of acetylcholine. Ward (1950) applied these observations to the treatment of closed head injurieso In 20 patients with varying degrees of trauma, he administered atropine subcutaneously in doses of 001 mg/kg, noting clinical improvement in some and a reversal of the electrographic effects in otherso Similar alterations in the post—traumatic electroencephalogram were reported by Jenkner and Lechner (1955) in a study of diethazine, another anticholinergic drugl A single intravenous dose in forty patients resulted in nornalizing the abnormal electroencephalogram in twenty~two and marked improvement in six otherso �Similar observations have been reported with methylbenactyzine and trasentin in animal experiments of post—traumatic shock cerebral The and edema (Denisenko, 1965), effect of atropine was assessed in the convulsive therapy process by Ulett and Johnson (1957), With the administration of to per day during the weeks the patients received electroshock therapy, the amount of slow wave activity atropine was up 5 mgm significantly less than in a control group received the atropine administration. who had not (These authors failed to replicate this study, suggesting that dosage factors or population changes may have contributed to different results [Johnson et_al., 1960])o Both the electrographic and the behavioral changes of induced convulsions were also reversed by the administration of experimental anticholinergic compounds (Fink, 1958, 1960), The intravenous injection of diethazine, benactyzine, the piperidylbenzilates JB-336 and JB-329 (Ditran), and in psychiatric subjects, These WIN—2299 EEG induced EEG JB—3l8, desynchronization changes were associated with behavioral alerting, anxiety, tremors, illusions, and hallucinations. recently received electroconvulsive therapy, a reduction in slow wave activity and a reversal of euphoria, In patients there was who had denial and confusion, Atropine in low doses, was associated with BEG desynchronization accompanied by tachycardia, nervousness and tension. �At higher dosages, hypersynchronous slow waves, followed by lower voltage, poorly organized delta activity with superimposed beta activity was associated with progressive confusion and disorientation, Both in eenebhat eteethoghaphte changeA 06 thauma and induced convutétOhA, the may be modtﬁted by the adhinttthatton anttchottnehgte dnugb, buggebtthg that tncheabed amountb aeetgtehottne on thcaeabed ehottnehgtc heeepttvtty t5 aMoctated with the high wattage stow wave aetéuttg, 06 Brain acetylcholine and anticholinergic drugs: (c) Similar EEG changes and similar blocking by anticholinergic drugs has been observed following the direct application of acetylcholine to the central nervous system, The administration of a cholinesterase inhibitor DFP (di-isopropyl fluorophosphate) elicited high amplitude patterns similar to status epilepticus, as well as changes similar to those of post—traumatic states (Freedman et_al., 19H93 rapid frequency EEG et_alf, EEG effects Himwich Hampson 1950; These were blocked by small doses of scopolamineo The 3:.Els’ 1950; and Wescoe et_al,, 1948). parenteral atropine and great increase in acetylcholine after tetraethyl pyrophosphate (TEPP) was measured and related to the toxic and convulsions induced (Giarman and Pepeu, 1952; Stone, 1957). Chatfield and Dempsey (1942) prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. The prior administration of atropine blocked this spiking, or the abnormality could be eliminated by atropine. if present, �In contrast to these findings, Brenner and Merritt (19u2) applied topical acetylcholine in concentrations of 2-1/2 to to the exposed cortex of cats, and noted no effect 10% on the electroencephalographic changes after intravenous atropine (l mg/kg)o The concentrations of acetylcholine in these experiments, however, were higher than the topical applications percent) and the intracisternal (002—10 gamma (l—M gamma percent) injections of Bornstein (19%)° Brenner and Merritt also made note of electroencephalographic effects similar to acetylcholine from mecholyl Cacetylbetamethylcholine) and doryl (carbamylcholine) in concentrations They much lower than the acetylcholine concentrations. ascribed the increased effectiveness of these cholinergic their lack of sensitivity to cerebral cholinesterases. These data are conflicting and further study is necessary to qualify this issue° drugs to (d) View Cerebrospinal Fluid Acetylcholine and Seizures: of acetylcholine metabolism indicates that nervous tissues in an inactive bound fornn it is One found in During periods of activity, acetylcholine is liberated at the cell membrane where it is rapidly deactivated by cholinesterasea The amount of bound acetylcholine is the resultant of the continuous processes of synthesis, liberation and breakdown. that the level rises during sleep (Tobias gt_al., 19u6; Richter and It has been postulated falls during activity. Crossland, 19u9; Elliot, Swankt and and Henderson, 1950; Giarman and Pepeu, 1962). Tobias et_al. found �8 increased free and total acetylcholine after chloroform and nembutal anesthesia in rat and frog brain, but no significant changes after strychnine or picrotoxin convulsions. Richter and Crossland measured the level of acetylcholine (micro-gamma per anesthesia and sleep in rat brain to be seizure levels, The brain tissue) during higher than postdifference in tissue levels is transient, however, as the resynthesis high (7 gamma/gm/minute)o Elliot et_§1f mg, 300% rate for acetylcholine in rat brain is These observations were confirmed by (1950) and Crossland and Merrick (195M). Pepeu (1962) found the increase Giarman and in acetylcholine following various depressants to be roughly proportional to the degree of depression of the central nervous system and the reduction in motor activity. Maynert and Buck (196”), however, studying brain acetylcholine and sedation concluded that some levels sedating agents are associated with elevated brain acetylcholine, but that no rigorous relationships existed. In part, this may be related to the earlier observations of Melennan and Elliot (1951) that acetylcholine synthesis measured in rat brain slices is accelerated by low dosages of narcotic drugs, but inhibited by high dosageso Free acetylcholine was reported in the spinal patients with epilepsy (Cone, fluid in Tower and McEachern, 19MB; Tower epileptic patinets, nu demonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma percent with and McEachern, 19u9b), an average of 1,0 gamma Of 56 percent. Acetylcholine levels were related �to the frequency of seizures, the extent of electroencephalographic abnormality, and to the time since the last seizure, but bore no relation to medication, type of epilepsy or level of cholinesterase activityo Elliot §t_al3 (1950) also noted free acetylcholine in the spinal fluid in concentrations up to 3 gamma percent after metrazole convulsions, Tower and McEachern (19u9b) viewed the increased acetylcholine as a by—produce of the seizure, and not causal, Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Torda (1953) measured the level of acetylcholine in brain tissue after metrazole convulsions, She noted a rise in the acetylcholine content of brain befbre a seizure and a fall during the convulsion° Below certain levels of acetylcholine, convulsions failed to occur° that the fall in tissue acetylcholine to inhibition of acetylcholine synthesis She suggested during a convulsion was due by increased concentrations of metabolites such as ammonium ions. Giarnen and Pepeu also measured changes in central nervous system acetylcholine following various stimulants. Only after mecholyl and 3, 5-dimethylbutylethyl-barbiturate was there a significant change in theacetylcholinelevel° They noted a decrease in association with induced convulsions. With other drugs which they iproniazid + classified as stimulants iproniazid, hydroxytryptoghan, and iproniazid + DOPA) there were no changes in acetylcholine level. (LSD, They concluded that �10 despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied differences in observations between these by convulsions, (The workers and Cone gt ale and Tower and McEachern may be related to the differences in methods of biodhemical measurements, for the latter measured changes reflecting free acetylcholine only, while total acetylcholine reflecting bound and free forms of acetylcholine, [McLennan and Elliot, 1951]). TheAe AiudieA Auggebi that Aponianeoui an induced beizuheb ane accompanied by an incheaAe in inienceiiuian ﬁnee aceiyichoiine iibenaied ﬁnom ii» bound 60am which may be neglected in the Apinai ﬁiuido Cehebnai aciiviiy and Aeizuneb enhance aceiyichoiine Giarman and Pepeu measured the debtnuction, iowehing iiAAue ieveii 06 acetyichoiine, whiie Aieep and aneéiheéia may augment aceiyichoiine pnoduciion incneaiing iiiéue ieueiie (e) Central Nervous System Cholinesterases: Tower and McEachern also measured spinal fluid cholinesterase activity. TWO types of cholinesterases are normally found in the spinal fluid: (19H9) cholinesterase—I ("true," "specific," 0r mecholyl-hydrolyzing), which has a high specificity for acetylcholine; and cholinesterase-II ("pseudo," "non—specific," or benzoyldholine—hydrolyzing)o compounds hydrolyze Both acetylcholine but have different rates of hydrolysis for mecholyl and benzoylcholine. This differential rate perndts qualitative distinctions. By reporting the cholinesterase �11 activity as a ratio of the activity with a mecholyl substrate and with a benzoylcholine substrate compared to a substrate of acetylcholine, two ratios are found: cholinesterase—I/acetylcholine and cholinesterase-IIlacetylcholineo In sudh ratios normal cerebrospinal fluid contains esterases in the ratio of 33:17 for cholinesterase-I to eholinesterase—IIo with In patients head trauma, Tower and McEachern reported an inversion of the cholinesterases with a increase in the cholinesterase-II fraction of the spinal fluid and a decrease in cholinesterase-I activity. The extent of the cholinesterase reversal was related to the severity of trauma and to the degree of the electroencephalographic abnormality. In patients with elevated spinal fluid acetylcholine spontaneous seizures, however, no change in the cholinesterases or total cholinesterase activity in cholinesterase activity after ratio of was found. related to changes in cell membrane perneability. Cholinesterase-I is found in highest concentration in the central nervous system while cholinesterase-II predominates in other tissues, especially The change may be blood serumo With an increase in acetylcholine levels in cerebral intercellular fluids, vasodilation cellular permeability may be predicted, with a degree of transudation of vascular fluids into the intercellular spaces varying with the extent and duration and increased of the vasodilation (Kabat et_alo, 19u8). Spiegel, Spiegel—Adolf, �12 and their co-workers (19u1, 19u2, lguu, 19H8, 1953) demonstrated such perneability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassium and phosphate) in the spinal fluid following convulsions° electrically induced Such non—electrolytes as nucleic—acid also increased, Changes in cellular perneability Splitting enzynes may thus provide the basis for the high concentrations of acetylcholine and the increased concentrations of cholinesterase-II in induced seizures or head trauma (Tower and MCEachern, 19H9c)o The persistance of acetylcholine in spinal fluid after head trauma and after seizures despite increased Cholinesterase activity may be related to the sensitivity of the acetylcholinecholinesterase-I system to concentration relationships (Nachmanson and Rothenberg, lQHS; Tower and McEachern, 19u90; Burgen and MacIntosh, 1955)o At "physiologic" is rapid concentrations, hydrolysis of acetylcholine (3-H microseconds) but the activity falls off quicklyc at higher and lower concentrations, In contrast, the cholinesterase—II acetylcholine relationship is non-specific and the rate of hydrolysis increases with increased concentration; These relationships are related to the induction of seizures. at cell membranes are destroyed by the specific activity of cholinesterase-I in a few microseconds, an excessive concentration following excitation While the usual concentrations of acetylcholine may exceed the rate of hydrolysis by cholinesterase-I. The seizure �13 threshold is reached and a seizure induced, with the seizure itself adding to the amount of free acetylcholine. The increased acetylcholine diffuses rapidly, affecting vascular and cellular perneability and increasing the concentrations of various ions, including cholinesterase—II, in tissues and in the cerebrospinal fluid, The activity of cholinesterase-II, though of low efficiency and depending on concentration the acetylcholine in the tissues in hours to days kinetics, reduces to levels fbr the physiologic action of cholinesterase—I. Chounutemu appeal: in the meme Maid Iheih anheaee in Lhzeheeﬂluiah ﬁﬁuidb, hebuﬁting in cell memblume The Una/Leaded a4 a heﬁKeetéon 05 ghom changee pumeabLU/ty oeeaAioned by incheaeed aeetyZehoLéne. emanate/wees connotahg the [evea 50h rte/wow byAtem 05 ahe pant 06 the homeozstauc mechahbsm acetyzehouhe at eeu membhahu heme/54mg activity, (f) Acetylcholine, EEG Hypersynchrony and Induced Convulsions: Alteration in the blood-brain perneability barrier by the continuing action of acetylcholine may be a biochemical substrate for the postelectroshock hypersyndhrony of the electroencephalogram, Such a possi- bility is evident in the demonstration of an increase in the concen- tration of cocaine in brain tissues threeidays after a series of 12 induced convulsions (Aird et_§lo, 1956)o The change in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynchrony(delta bursts) in the electroencephalogram° �11+ We have confirmed the many previous reports that convulsive thrapy induces electrographic hypersynchrony (Pink and Kahn, 1956; Fink 1951)° Despite a constant application of treatments there is §t_al., a great variability in the time of appearance, the duration and the extent of the electrographic slow wave activity as well as the sensitivity to modification by alerting, hyperventilation and barbiturates in psychiatric populations (Green, 1957). degree hypersynchrony and has been described as (Roth, 1951; Roth its persistence prerequisite to stain, in the degree of induced The early appearance of high throughout a treatment course improvement following electroshock 1957; Pink and Kahn, 1956)o EEG The differences hypersynchrony may be related to differences in central cholinergic activity, The failure of certain patients to develop hypersynchrony may be associated with the absence of free acetylcholine and with minimal changes in cerebral function, thus precluding a clinical response to induced convulsions° Tower and McEachern (19H9a), in their study of craniocerebral trauma, included observations of six psychiatric patients undergoing convulsive therapy. Studying the patients after 3—7 treatments they reported free Spinal fluid acetylcholine in two patients; and an increase in cholinesterase—II and a decrease in cholinesterase-I with a reversal of the ratio of cholinesterases in five of the six patients, The one patient in the series Who failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal fluid was described as: "It is interesting that this patient was the only one of the six to show no response to treatment." �15 From these observations they concluded that the spinal fluid changes in induced convulsions were more like those of creniocerebral trauma than those of spontaneous epilepsy° If electrographic hypersynchrony free acetylcholine, subjects whom it disappears rapidly who may be is a reflection of increased maintain hypersynchrony and those in exhibiting differences in the kinetics of the cholinesterase~acetylcholine hydrolysis systems. Persistent hypersynchrony may result from.a decreased rate of hydrolysis of acetylcholine, associated with low concentrations of either cholinesterase—I or cholinesterase—II. (Conversely, in patients with short—lived hypersynchrony, cholinesterase—I and in tissue and spinal fluid may be unusually higho) Fnom —II these obaehvationi uh uuuid conciude that induced convuiiionb ahe accociated with an incheaie in ghee acetyichotine in intehceiiuian ﬁiuidt, aitehing cehebhai pehmeabiiity enhancing the appeahance 05 choiinettehatei. The ieuei and 06 ﬁnee it maintained by nepeated induced beizuneb. EEG hypencynchhony it one heﬁiection 06 aiteaed ieveii 06 acetyichoiine acetyichoiine and attehed penmeabiiity 06 otheh eiectnoiyteb° that theAe changec It i4 phobabie in intenceiiuiah eiectnoigteb phovide the biochemicai Aubcthate ﬂan the penAiAtent behavionai changei ﬁoiiowing induced convuitionia �16 t.‘ Cg) wfi 0. as. oses= studies have application to the problem of autonomic reactivity and the classification of the psychoseso Funkenstein These between 1952) have demonstrated 1951, a relationship E£;,(19”89 g: the blood pressure response to injected methacholine (Mecholyl) and the clinical response of psychiatric patients to convulsive therapy. is a potent cholinergic agent which induces vasodilation, tachycardia9 sweating, and increased peristalsiso It is rapidly Methacholine hydrolyzed by cholinesterasedI and slowly by cholinesterase-IIo falls after injected blood pressure of subjects to the baseline within five to 20 minuteso returns to the baseline within 5 II, or III reactors; and Group have a VI and Group VII (Funkenstein EE.E£;9 1952)o upon as patients in while Groups VI Patients whom 9 and a reactors Group VI 89% 20 or and VII reactorso 35% pressure Group I, more Group I recovery rate, respectively, and 97% recovery rates I to III reactors mecholyl the injected may be looked is rapidly hydrolyzed; and VII have a slow hydrolysis rateo It is possible that the cholinesterase activity levels of Groups I-III is review, see Rose9 19620] whose blood classified as those whose blood pressure takes IIuIII reactors while Group mecholyl and returns minutes have been minutes to return to baseline, as Group The [For a recent blood and tissue high, while that of Groups VI-VII is low compared to general psychiatric populations° The mentally differences in blood cholinesterase levels in normal and ill subjects have been extensively studiedo Despite differences �17 in methods (Augustinsson, 1955, 1957) elevated cholinesterase levels compared to normal populations have been reported for depressive subjects (Richter and Lee, 1942; Rowntree e£_al;, 1950; Ravin and Altshule9 1952)? schizophrenic subjects (Early 33 Gal9 1963) and a mixed iii, psychiatric population (Plum, 1999; Rubin, 1958; 1960)o Alpern (1956) reported lowered cholinesterase levels in schizophrenic subjectso studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater While these and frequently elevated in the mentally illo Negative reports include the failure by Ellman and Callaway (1961) to confirm Rubin's study; and Altschule“s (1953) review of the data suggesting no abnormality of cholinesterase levels in the mentally illo A similar analysis may be made regarding the relation of central nervous system levels of cholinesterase in the development of EEG hyper- fluid levels of acetylcholine, thus providing a congruent hypothesis regarding central nervous system reactivity to induced convulsions and to peripheral cholinergic agents° synchrony and spinal �Dig- CONCLUSION: This review indicates that central cholinergic mechanisms are significant in the convulsive therapy processo Induced convulsions are associated with an increase in intercellular acetylcholine to levels greater than can be destroyed by acetylcholinesterase activityo Vasodilation and increased cellular permeability are followed by the appearance of increased amounts of butyrylcholinesterase and other enzymes and electrolytes in intercellular fluidso These biochemical changes are associated with increased hypersynchrony which is recorded as EEG electrodess and which can be modified by slow wave many electrical activity in scalp anticholinergic drugs, including atropine9 benactyzine, diethazine, procyclidine and piperidylbenzilateso In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures° in cerebral biochemistry alter cellular recovery and firing rates sufficiently to alter the behavior of subjectso Failure to induce high and persistent concentrations of acetylcholine These changes or failure to induce concomitant electrolyte changes.does not alter cerebral cellular activities and results in a failure to produce behavioral changeo Differences in the rate of development of cerebral changes to the same number and frequency of induced convulsions may reflect differences in the dependence of subjects on cholinergic mechanisms or �:19- in.their sensitivity to changes in acetylcholine levelso These differences provide the basis for the classifications of the mentally ill based on neurophysiological responsitivity by Funkenstein and by Pink and Kahno These data on cholinergic mechanisms provide a theory for the mode rational biochemical of action of induced convulsions in altering the behavior of psychotic subjects9 and are consistent with the more general neurophysiologicmadaptive theory of the convulsive therapy process expressed earliero �REFERENCES J W9, Hrenoff, M9 K9 and BowditchLS. 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Freedman, A Mo, Bales, P D, Willis, AG production of electrical major convulsive 117— 121% fIgﬁé'Jﬁ—J: “£11-“.V./ FUnkenstein,D and Himwich, Ho Ea J. ,Ameao patterns — Experimental,€$§£;7 PhgoLoLo, ,. , ”kw—.-Wn J Greenblatt, M and Solomon, H C Autonomic nervous Nehvo MenM 0L6 system changes following electric shock treatment :yatt77M Ho, [1988,L108: 1109422, FUnkenstein, DOH a, J Greenblatt, Solomon, M and paralleling psychologic changes in mentally 1 ill H C Autonomic changes patients 5:T Neav Mani.”’ﬁ . 1951. 011%“ 18,.I Funkenstein, DQH o, Greenblatt, Mo and Solomon, Ho Co Autonomic nervous system test of prognostic si ificance in relation to electroshock Made, {Pbychozsomo treatmento 13: 1952, 3u7—3629” {as 1__1___~u Gal, E0 M8 Cholinesterase activity of who blood from healthy and Sohizophrenic individuals° (Natune" 1963. 19821118-1119> WW (M) ) \9=*" , 5 6%-,“ V �and Pepeu, Go Drug-induced changes in brain acetylcholineo Jo Phanmac0£o," [meg/1&1: 226—2311, 5 Qiarman, (But, J M, o Signi ficance of individual variability in Home, :19574 ﬁg, 229-21104; electroshocko NJ, Green, A, MD Hampscn, w Jo wae " Essig, Co 1:1, ((muuw; and McCauley, f luorophosphate Himwich, A0 EEG response to Effects of H9 Ea electroencephalogram and cholinesterase asvivityo_(Ekectaoencepho Ciino Neuhophybio£0,f1950, g; ulgug> / div-isop‘ropyl (DFP) on Hinwich, Ho E0, Essig, Co Po, X-Iampson, Jo Lo, Bales, Po Do and Freedman, AU Mo Effect of trimetnadione (Tridione) and other drugs on convulsions caused by di—isopropyl fluorophosphate (DFP) Amen. J. R\“”” ““1950,‘1062 816-829) o * fM W . ” ”rm Lo and Lechner, Ho The effect of Diparcol on the electroencephalogram Jenkner, and in those with cerebral trauma, E£eot2wenceph. can. in the normal 1E"o ﬂax iwx subject /”Neun0phy4£o£o,{1955,LZE 303-6053 1M, Johnson, Ulett, Co, Lu J “3 '7 - A0, Johnson, Go Smith, MD, K0 and Sines, Jo Electroconvulsive therapy (with and without atropine); effect on electronically analyzed electroencephalogram Allah, Geno Pbychj. 1/ WM"' Kabat, E0 A0, Glusman, 0%., 0/ > and Knaub, V0 Quantitative estimation of the albumin and gamma globulin in normal and atholo ic cerebrospinal fluid by immunochemical methodso Wells 10 Mada, [194845;E 653—66253 ‘ “NW Mo / brain of the content Acetylcholine ’ Hung, if E53,: 13; 1—H >J 1;::11 t I44wéhjié. humorale Ubertragbarkeit der Herznervenwirkungo Fonyo, A0 and Halmagyi' in traumatic shocko (Aota Pkg/31.0 Kovach, A, Ga Bo , Mo ,1 ‘\ ’ ‘ _ , §’ Loewi, Anch, O.) 55 Maynert, Ube ﬁts, E0 W; Ho and Buck, 1319: 239-292, Effects of Eo Go onacetylcholine synthesﬁgofjo Phwumcoz, Nachmansohn, specificity Plum, (cum /. f; I, iﬂw 0‘ depressants on brain . convuls and narcotic drugd/ Expo ThULo, 1951, 103:_ 35,5433 { and Rothenberg, M, A, Studies on cholinesterase: on of enzymes in nerve tissueo (J. Mob Chmo,ffgu5.} _]_._5_8: 653—666“; Do Study of cholinesterase Chemo, 1960; pg: 332-390, Co Mo activity in nervous Serum cholinesterase activity in mental >M195 , } and mental disorders. R Ravin, H, A, and Altschule, Mo Do diseaseo /AItho Newwﬁc Pbychiaxo a CDNIOSO thacolagi£t,, 1961+, g; 191, and Elliott, K A 9C, Effects; "adetylcholineo Mcbennan, Phybiozo, 1921, . §§: 616-650) �1 Richter, D and Cmssland, J Variation in acetylcho ine content of the Phybioio, 19891159: 2887— 255 a, brain with physiological stateo /Ame8)L88 J 0 M Richter, D and Mo leeI 838 £882,188821 than yfI8828188 ,J’ "T“. <72: D and Lee, 1- Rose , MD 835~83gfj The , W. Ment. 306,8“, 0/1,” 0\ Serum choline esterase and depresmon. 13° Mani. Soc.) f“‘p‘. . 7, Punkenstein est-57K review of the &;8§dand P3ym ,j19625138 , o esterase and anxietyc J. Serum choline (,4 128—153, / ”W i literature. Aota ». in the EEG under barbiturate anaesthesia produced by electroa-convulsive treatment and their significance for the theory of Roth, M Changes C228. action fEZectaoenceph ECT Roth, Ma, Kay, D W Ko , Shaw, ) W28” NeuhophyéLOKO,[1951,[__w261—280 J J and Green, Prognosis and ﬁPentothal induced electroencephalographic changes in electroyzonvulsive treatment .. Eﬁemoenceph can NewzophyA/ZOLO, 8f‘1957.;___9: 225- 237 7’ A S [/80 ofd1d1opmpyl——° i and Wilson, A, The effects aﬂcorophosphonate in schizophrenic-1and manic depre sive psychosis. Newwz NQMOAU/tgo Paychiwto, 1950.313: 87-62, Romtree, D J Rubln, ° We, Nev1n, ° ° WW“ Acetylcholine hydrolysis in psychiatric patients Lo So /.1958,,Ll2___8258-25858) 7 7; /1881, ‘~‘ : 8 .x' )1 Spiegel, E A and Spiegel—Adolf, M Physioochemical effects of electrically induced convulsions (cerebrospinal fluid studies) K Titan/.5 Ame/r.° NewwL AM., 81888.70: 130132 @1111): Spiegel, E A and Spiegel-Adolf, M Physiological and physicochemical mechanisms in electroshock treatment Canéin Weuhoz [195’‘13, 38-63/ A changes Go M and Spiegel—Adolf, Spiegel, E Physicochemical Henry, in the brain accompanying electrically induced convulsive discharges W/TW Spiegel-Adolf, Arnuo ,____ Newwz MAM/Tmﬁﬁﬁ: 81783811 ,Wilcox, P H and Spiegel, E changes in electroshock treatment of psychoses 1988, gg_; 697 706); Stwone W E 90] Pkg/8 Amm M A. Cerebrospinal fluid Amen. J Paych/éaio, o role of acetylcholine in brain metabolism and functiom Med ,f19'7'; 3‘6: 222——255>/ The m._._ . ’1qu ,,,,, ~ '~'" - if! Suence, Spiegel, E A and Spiegel—Adolf, M Permeability changes in the brain induced by Metrazol and insulin convulsions (Jo NULU. Manx. 0125:, 83; 750 755 /0 %% . y“ ,2. ' �Lipton, Tobias, J and convulsants on brain acetylcholine contento *, Med“; ’7 (KS Me MW 0 1:. 51—515 and IJepinat, A, A0 A, Effect of anesthetics Phone Soco Expo BLO£./;~“ ' "I" 1 “t” "‘1’ r7 _ and McEachern, Do Acetylcholine and neuronal activity. I. Cholinesterase patterns and acetylcholine in the cerebrospinal fluids of— patients with craniocerebral traumao x/“Ctinado J Ru ea/Lch m cm 5,, Towem 7. {ﬁn/x”, ' CO ‘ Wm. _, Wk Effect of convulsion inducing a ents on the acetylcholine Ame/Lo Jo Pkg/Maze; 1953, ;l73: 179—183, brain; of the content (ACTH) on of Cc corticotropin Effects of single injection Torda, Jo PhyMLoL, braim,gj'ArrIe/Lo of content and ion acetylcholine ammonium 1953, ll}: 175—178j / Torda, - ,3- a Do Bo Q:W105=1195 W Towem Do Ba 191M313o 2],: and McEachern, molinesterases in jettg ) content and characterization of ., human Do The cerebrospinal fluidso (f'fCanado l32=~ll+53j a «QC/t; Ruea/Lch, J. é)' Do and neuronal and activity. II. Acetylcholine McEachem, B Acetylcholme and cholinesterase activity in the cerebrospinal fluids C’a‘nado p] of patients with epilepsy», \_’\ Tower, D; < 120~l3l> IVWL a Ruem&9?%27“m $0 ’5) and Wo M, of Effect scopolamine upon Johnson, atropine Ulett, electroencephalographic changes induced by electro-ccnvulsive therapy. Ezecthoencepm Cum Neu/Lophyaiozo,fI§S’7‘g"ig_: 217-221;} Go A, and ’/wt" 1 WardiAu AU, tropine (1950, E3 3984020) 1 ‘ in the treatment of closed head injuryoﬁJo Co, Green, RC _ V :1: r7?“ , . V___“,_,,_-..._. W0 1 Neu/LOAu/Lg., E0, McNamara, Bo Po and Krop, So The influence J. -7“~Phalmmroi. Exp. (”of atropine and scopolamine on the central effects of DFP°_ "»»».N..r lgu8'5‘_9_‘2;: 63-720 We‘oea ' /’ (“L-9““ The/Lo , �.l mI ,l I II, .I Al. _I ”I .l .I ,l 'l I JI I _l �SET DuPQCAaTE MAY 24 1966 (m (FINAL EG—J 68 HR �(mm (FINAL EG—J 68 EG—J 68 (CL oE-NMD-Mar 5-20-5D (COG 6131 MAX FINK MAX FINK MAX FINK MAX FINK MAX FINK (READ 660 BY PROVE!) MAX FINK THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF CHOLINERGIC ASPECTS MAX FINK, MD.1 �ﬁUPLECﬁzTE SILT MAY 24 1966 EG—J 71 W Ward-BMW Gal 2 %E-NMD-Mar 5/20-5Gx 6131 P. 15 5/19/66 722(3) 'E]li“l" 1Department of Psychiatry, ... . ’ - H' i I I .o E u - This study was aided, in part, by USPHS grants MH-927, MH—2715, MH-07249 and MH-11380; and by the Psychiatric Research Foundation of Missouri. While the mode of action of convulsive therapies remains enigmatic, one theory holds that the early development and persistence of changes in brain function are requisite to changes in behavior (18, 21, 22). A useful index of neurophysiological change is the appearance of high voltage electroencephalographic slow wave activ— ity (22, 23). While the biochemistry of this activity is poorly understood, demonstrations that it is inhibited by anticholinergic compounds (19, 20, 34, 66) suggest that cholinergic systems may play an active part. (m (FINAL The EEG patterns and the response to anticholinergic drugs in convulsive therapy are similar to experimental and clinical head trauma and, to a lesser extent, spontaneous seizures. Changes in concentration of cholinesterases in brain and spinal ﬂuid also show many similarities in these conditions. This review discusses these observations to provide a hypothesis for the role of cholinergic changes in convulsive therapy. The activity of acetylcholine in the transmission of nervous impulses has been extensively studied since the early descriptions by Dale (12) and Loewi (38). A constituent of nervous tissue in a bound form, acetylcholine, is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by the choline-acetylase system (45). Free ace— tylcholine has not been measurable in normal cerebrospinal ﬂuid despite the rapid breakdown of bound acetylcholine during periods of activity and excitement (63). ///"L.i//>{{ I "'4 1/. ,1/ :J Waéff?.__ �part. mm (FINAL (CL (GOG The EEG patterns and the response to anticholinergic drugs in convulsive therapy are similar to experimental and clinical head trauma and, to a lesser extent, spontaneous seizures. Changes in concentration of cholinesterases in brain and spinal ﬂuid also show many similarities in these conditions. This review discusses these observations to provide a hypothesis for the role of cholinergic changes in convulsive therapy. The activity of acetylcholine in the transmission of nervous impulses has been extensively studied since the early descriptions by Dale (12) and Loewi (38). A constituent of nervous tissue in a bound form, acetylcholine, is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by the choline-acetylase system (45). Free acetylcholine has not been measurable in normal cerebrospinal ﬂuid despite the rapid breakdown of bound acetylcholine during periods of activity and excitement (63). But the normal cerebrospinal ﬂuid does have measurable cholinesterase activity (41). CHOLINERGIC ASPECTS OF CRANIOCEREBRAL TRAUMA (READ 660 BY PROVE!) Free acetylcholine was found in the cerebrospinal ﬂuid of cats within a few minutes after experimental head trauma and persisted for varying periods up to 48 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 ga /100 cc, and the amount was related to t e degree of induced trauma (6). Concurrent electroencephalograms ﬁrst demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was succeeded by a short period of ﬂattening of all recorded electrical activity. These phases were followed by prolonged periods of �f.’u ”1: $3.: .gsi 1:..n‘1' 24 1955 EG—J 71 %E-NMD-Mar 5/20-5Fx 6131 P. 15 5/19/66 722(1) Gal 3 high amplitude sharp waves in the delta frequencies. The behavioral changes related to the degree of induced trauma and to the amount of measured free acetylcholine. With higher levels of acetylcholine, Bornstein (6) reported greater degrees of EEG abnormality and greater changes in consciousness. Spontaneous post-traumatic seizures were also related to the amount of free acetylcholine measured in the cerebrospinal ﬂuid. Bornstein applied acetylcholine to exposed cat cerebral cortex. When the concentration of acetylcholine was one gamma/100 cc or less, high amplitude sharp waves of low frequency appeared in the electroencephalogram. When the concentration was increased to two 100 gamma/ cc, the electroencephalogram ﬂattened in a fashion parallel to the post-traumatic records. by Tower and McEachern (63) demonstrated free acetylcholine in the cerebrospinal ﬂuid only in patients with recent head trauma, recent grand-mal seizures or after electroconvulsive therapy. Free acetylcholine varied from 0.2 to 100 gamma/ 100 cc. In assaying spinal ﬂuid cholinesterase activity, they noted a sharp rise in the butyrylcholinesterase fraction and a fall in the acetylcholinesterase fraction in patients with head trauma and following convulsive therapy. After spontaneous seizures, however, the cerebrospinal ﬂuid did not exhibit such inversion although it contained free acetylcholine. They concluded that the leve 0f free acetVlChnll‘np (FINAL ((1 �Bornstein applied acetylcholine to exposed cat cerebral cortex. When the concentration of acetylcholine was one gamma/100 cc or less, high amplitude sharp waves of low frequency appeared in the electroencephalogram. When the concentration was increased to two 100 gamma/ cc, the electroencephalogram ﬂattened in a fashion parallel to the post-traumatic records. Investigations in neurological patients by Tower and McEachern (63) demonstrated free acetylcholine in the cerebrospinal ﬂuid only in patients with recent head trauma, recent grand-mal seizures or after electroconvulsive therapy. Free acetylcholine varied from 0.2 to 100 gamma/ 100 cc. In assaying spinal ﬂuid cholinesterase activity, they noted a sharp rise in the butyrylcholinesterase fraction and a fall in the acetylcholinesterase fraction in patients with head trauma and following convulsive therapy. After spontaneous seizures, however, the cerebrospinal ﬂuid did not exhibit such inversion although it contained free acetylcholine. They concluded that the level of free acetylcholine varied directly with the degree of cerebral damage and that reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal ﬂuid. Increased acetylcholine in rat brain after traumatic shock was also reported by Kovach et al. (36). This acetylcholine activity was inhibited by the administration of atropine in vitro. The electrographic, behavioral and neurologic signs of head trauma were blocked by the parenteral administration of 0.5— 1.0 mg/kg atropine, as were similar clinical changes occurring after the intracisternal addition of acetylcholine (6). Ward applied these observations to the treatment of closed head injuries. In 20 patients with varying degrees of trauma, he administered atropine subcutaneously in doses of 0.1 mg/kg, noting clinical improvement in some and a reversal of the electrographic effects in others (67). The same changes in the post-traumatic electroencephalogram were reported by Jenkner and Lechner in a study of diethazine, another anticholinergic drug. A single intravenous dose in 40 patients resulted in normalizing the abnormal electroencephalogram in 22 and marked improvement in six others (33). (READ “660 mom �2' on I'-.-..AY 24 '“ 1965 EG—J 84 OE-NMD-Mar 5/20-5E GAL 4 6131 P. 18 5/19/66 722(1) Similarly, in experiments of post-trauma- tic shock and cerebral edema in animals, Denisenko (13) reported a blocking of the clinical changes by such anticholinergic compounds as methylbenactyzine and adiphenine (Trasentin). Thus, the amount of free acetylcholine ma increase in the spinal ﬂuid following craﬁicerebral trauma and the amount of free acetylcholine, the degree and type of electroencephalographic abnormality, and changes in clinical behavior appear as interrelated phenomena, which may be reduced by the administration of anticholinergic drugs. BRAIN ACETYLCHOLINE AND ANTICHOLINERGIC DRUGS (REV (FINAL (CL (00G (READ 660 BY PIOVID The effects of the direct application of acetylcholine to the central nervous system may also be blocked by anticholinergic drugs. The administration of the cholinesterase inhibitor di-isopropyl ﬂuoroph sphate (DFP) elicited high amplitude rapid frequency EEG patterns similar to status epilepticus and some post-traumatic states (24, 31, 32, 68). These EEG eﬂ'ects were blocked by small doses of parenteral atropine and scopolamine. The great increase in acetylcholine after tetraethyl pyrophosphate (TEPP) was measured and related to the toxic effects and the induced convulsions (29, 59). Chatﬁeld and Dempsey (9) prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. The prior administration of atropine blocked the appearance of spiking, or if present, this electrical activity could be eliminated by atropine. In contrast to these ﬁndings, Brenner and Merritt (7) applied topical acetylcholine in concentrations of two and onehalf to ten per cent to the exposed cortex of cats and noted no effect on the electroencephalographic changes after intravenous atropine (one mg/kg). The concentrations of acetylcholine in these experiments, however, were higher than the topical applications (one to four gamma/100 cc) and the intracisternal (0.2—10 gamma/100 cc) injections of Bornstein (6). Brenner and Merritt (7) also noted electroencephalographic effects similar to acetylcholine after methacholine (Mecholyl) and carbamylcholine (Doryl) in concentrations much lower than the acetylcholine concentrations. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral cholinesterases. These data are conﬂicting and further study is necessary to qualify this issue. , 0 �(FINA! (CL (COG (READ 660 BY PROVE!) atropine blocked the appearance of spiking, or if present, this electrical activity could be eliminated by atropine. In contrast to these ﬁndings, Brenner and Merritt (7) applied topical acetylcholine in concentrations of two and onehalf to ten per cent to the exposed cortex of cats and noted no effect on the electroencephalographic changes after intravenous atropine (one mg/kg). The concentrations of acetylcholine in these experiments, however, were higher than the topical applications (one to four gamma/100 cc) and the intracisternal (0.2—10 gamma/100 cc) injections of Bornstein (6). Brenner and Merritt (7) also noted electroenceph— alographic effects similar to acetylcholine after methacholine (Mecholyl) and carbamylcholine (Doryl) in concentrations much lower than the acetylcholine concentrations. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral ch0linesterases. These data are conﬂicting and further study is necessary to qualify this issue. CEREBROSPINAL FLUID ACETYLCHOLINE AND SEIZURES One View of acetylcholine metabolism ﬁnds it in nervous tissues in an inactive and bound form. During periods of activity, acetylcholine is liberated at the cell membrane where it is rapidly deactivated by cholinesterases. The amount of bound acetylcholine is the resultant of the continuous processes of synthesis, liberation and breakdown (15). It has been postulated that the level rises during sleep and falls during waking activity (16, 29, 45, 60). Tobias et al. (60) reported increased free and total acetylcholine after chloroform and pentobarbital anesthesia in rat and frog brain but no changes after strychnine or pictrotoxin convulsions. Richter and Crossland (45) measured the level of acetylcholine (microgamma per mg brain tis— sue) during anesthesia and sleep in rat brain to be 300 per cent higher than postseizure levels. The difference in tissue levels is transient, however, as the resynthesis rate for acetylcholine in rat brain is high (seven gamma/gm/minute). These observations were conﬁrmed by Elliott et al. (16) and Crossland and Merrick (11). Giarman and Pepeu reported the increase in acetylcholine following various depressants to be roughly proportional to the degree of depression of the central nervous system and the reduction in motor activity (29). Maynert and Buck, however, studying brain acetylcholine levels during sedation concluded that some sedatives were associated with elevated brain acetylcholine but that no rigorous relationships existed (39). In part, this may be related to the earlier observations of McLennan and Elliott (40) that acetylcholine synthesis measured in rat brain slices is accelerated by low dosages of narcotic drugs, but inhibited by high dosages. �£.;__1 -C£HTE rJdJl “‘ . 2-59—11! RAY 24 l966 EG—J 84 OE—NMD-Mar 5/20-5E 6131 P. 21 5/19/66 722(3) A) GAL 5 Free acetylcholine was reported in the spinal ﬂuid in patients with epilepsy (10, 63). Of 56 epileptic patients, 44 demonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma/ 100 cc with an average of 1.0 gamma/ 100 cc. Acetylcholine levels were related to the frequency of seizures, the extent of electoencephalographic abmality, and to the time since the last sféizlmre but bore no relation to medication, type of epilepsy or level of cholinesterase activity Elliott et al. (16) also noted free acetylcholine in the spinal ﬂuid in concentrations up to three gamma/100 cc after pentylenetetrazol (Metrazol) convulsions. Tower and McEachern (63) viewed the increased acetylcholine as a by-product of the seizure and not causal. Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Torda (61, 62) measured the level of acetylcholine in brain tissue after pentylenetetrazol convulsions. She noted a rise in the acetylcholine content of brain before and a fall during the convulsion. Below certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in tissue acetylcholine during a convulsion was due to the inhibition of acetylcholine synthesis by increased concentrations of metabolites such as ammonium ions. Giarman and Pepeu also measured changes in central nervous system acetylcholine following various stimulants (29). Only after methacholine and 3,5dimethylbutylethyl-barbiturate was there a signiﬁcant change in the acetylcholine level. They noted a decrease in association with induced convulsions. With other drugs which they classiﬁed as stimulants (LSD, iproniazid, iproniazid plus hydroxytryptophan, and iproniazid plus DOPA) there were no changes in the acetylcholine level. They concluded that despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied by convulsions. (The differences in observations between these observers and Gone et al. (10) and Tower and McEachern ( may be related to the differences in methods of biochemical measurements, for the latter measured changes reﬂecting free only, While Giarman and ) measured total acetylcholine Pepeu includin_ bound and free forms of acetyl- K ya .7; Mageline ”ﬁl- These studies suggest that spontaneous or induced seizures are accompanied by an increase in intercellular free acetyl choline liberated from its bound form which may be reﬂected in the spinal ﬂuid. Cerebral activity and seizures enhance acetylcholine destruction, lowering tissue levels of acetylcholine, while sleep and anesthesia augment acetylcholine production increasing tissue levels. (REV (FINAL 206((1 CENTRAL NERVOUS SYSTEM �bllUl‘U l/oi ’/—\, C/ were LlU Guanges 111 we acetylcnoune level. They concluded that despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied by convulsions. (The differences in observations between these observers and Cone et all. (10) and Tower and McEachern ( may be related to the differences in methods of biochemical measurements, for the latter measured changes reﬂecting free holine only, while Giarman and ce ) measured total acetylcholine includin bound and free forms of acetyl- K m “Tho («3 in). These studies suggest that spontaneous or induced seizures are accompanied by an increase in intercellular free acetyl choline liberated from its bound form which may be reﬂected in the spinal ﬂuid. Cerebral activity and seizures enhance acetylcholine destruction, lowering tissue levels of acetylcholine, while sleep and anesthesia augment acetylcholine production increasing tissue levels. (REV (FINAL (CL CENTRAL NERVOUS SYSTEM CHOLINESTERASES Tower and McEachern (63, 64, 65) also measured spinal ﬂuid cholinesterase activity. By reporting cholinesterase activity as a ratio of the rate of hydrolysis with two substrates compared to an acetylcholine substrate, acetylcholinesterase/acetylcholine and butyrylcholinesterase/acetylcholine ratios are derived. Normal cerebrospinal ﬂuid contains these esterases in the ratio of 33:17. In patients with head trauma, Tower and McEachern reported an inversion of the cholinesterases with an increase in the butyrylcholinesterase of the spinal ﬂuid and a decrease in acetylcholinesterase activity. The extent of the cholinesterase reversal was related to the severity of trauma and to the degree of EEG abnormality. A similar reversal was observed in patients undergoing convulsive therapy. In patients with elevated spinal ﬂuid acetylcholine after spontaneous seizures, however, no change in the ratio of cholinesterases or total cholinesterase activity was found. Changes in cholinesterase activity may be related to changes in cell membrane permeability. Acetylcholinesterase is found in highest concentration in the central nervous system. while butyrylcholinesterase predominates in other tissues, especially blood serum. With increased cerebral acetylcholine, vasodilation and increased cellular permeability may be predicted, with vascular ﬂuid transudation varying with the extent and duration of the vasodilation (35). Spiegel, Spiegel-Adolf and their coworkers (54—58) demonstrated such permeability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassium and phosphate) in the spinal ﬂuid following electrically induced convulsions. Such non-electrolytes as nucleic-acid splitting enzymes also increased. Changes in cellular permeability may be the basis for the high (ooc (nun 660 8! mom �..._.l!_ﬁ$ .0"de " ;CF;TE MAY 24 55-12%”? 1965 That changes in cholinesterases may be large and measurable is suggested by the acetylcholinesterase activity which was related to decrements in be havioral perform- ance. The persistance‘ of acetylcholine in spinal ﬂuid after head trauma and after seizures despite increased cholinesterase activity may be related to the sensitivity of the acetylcholine~acetylcholinesterase ip is non-speciﬁc, and (m the rate of hydrolysis increases with increased concentration. These relationships relate to theories of the induction of seizures. While the usual concentrations of acetylcholine at cell destroyed by the speciﬁc activity of acetylcholinesterase in a few microseconds, an excessive concentration following excitation may exceed its rate of hydrolysis. The seizure threshold may be (FINAL altering the concentr including butyrylcholinesterase in tissues and in the cerebrospinal ﬂuid. Through the activity of this esterase, though of low efﬁciency and depending on concentration kinetics, acetylchol' ' J (CL (GOG ”J (nun 660 BY mom acetylcholinesterase. Cholinesterases appear in the spinal ﬂuid as a reﬂection of their increase in intercellular ﬂuids resulting fr om changes in cell membrane permeabilit y accompanying increased acetylcholine. EEG HYPERSYN CHRON Y AND INDUCED CON VULSIONS onvulsive therapy process has been repeatedly described (22, 23, 50, 51). In the usual course of convulsive therapy, inter-treatment electro~ encephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment �(FINAL (CL (GOG (READ 660 BY PROVE!) Name wscu adding to the amount of free acetylcholine. Increased acetylcholine affects vascular and cellular permeability altering the concentrations of various ions, including butyrylcholinesterase in tissues and in the cerebrospinal ﬂuid. Through the activity of this esterase, though of low efﬁciency and depending on concentration kinetics, acetylcholine is reduced in tis- acetylcholinesterase. "" ”My Cholinesterases appear ﬂuid as a reﬂection of their ' tercellular ﬂuids resulting fr om changes in cell membrane permeabilit y accompanying increased acetylcholine. EEG HYPERSYN CHRON Y AND INDUCED CON VULSIONS onvulsive therapy process has been (22, 23, 50, 51). In the repeatedly described usual course of convulsive therapy, inter-treatment electroencephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatelta activity appears in methods~electrical, intravenous chemical or inhalant—exhibit the same type of EEG pattern changes (21, 22, 23, 30). The early appearance of high degree hypersynchrony and its persistence throughout a treatment course has been found to be prerequisite to improvement. Both the electrographic and th e behavioral changes of induced convulsio us are transiently reversed by the acute administration of experimental anticholinergic compounds 19 20). The intravenou injec ion 0 diethazine, benactyzine, t e piperidylbenzilates JB—318, JB—336 and JB—329 (Ditran), and WIN—2299 induced EEG desynchronization in psychiatric subjects. These EEG changes were associated with behavioral alerting, anxiety, tremors, illusions and hallucinations. In patients cently received electroconvu lsive therapy there was a reduction in slow and a reversal of ' euphoria, d fusion. Atropine, in low doses, was also associated with EEG desynchronization accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchronous slow waves followed by lower voltage, poorly organized delta activity with superimposed beta activity companied by progressive confusion and disorientation. The effect of anticholinergic drugs on the slow wave activity of convulsive therapy was also assessed by the chronic administration of atropine (ﬁve mgm per day) and scopolamine (one to three mg) during the Weeks of treatment. The amount of EEG slowing was signiﬁcantly less than S �J anaema WKY ,— 24 ("f “" -' 1965 EG—J 85 OE-NMD-Mar 5—20-5Fx Gal. 7 6131 P. 28 5/19/66 722(3) Marked improvement was reported in two of seven atropine-treated, norx of ﬁve scopolamine-treated and in four of the six controls receiving unmodiﬁed ECT. This study was not replicated by the authors who suggest that dosage factors or population changes may have contributed to the different results in a second study (34). As in cerebral trauma, the electrographic changes of induced convulsions be may modiﬁed by the administration of anticholinergic drugs suggesting that increased amounts of acetylcholine or increased cholinergic receptivity is associated with the high voltage slow wave activity. ACETYLC‘HOLINE AND INDUCED CON VULSIONS Despite a constant application of treatments, however, there is great variability in the time of appearance, the duration, amount, and sensitivity to modiﬁcation by alerting, hyperventilation and barbiturates of the electrographic slow wave activity in psychiatric populations (30). These differences relate to differences in central cholinergic activity. The failure of certain patients to develop hypersynchrony may be associated with the absence of free acetylcholine and with minimal changes in cerebral function, thus precluding a clinical response to induced convulsions. Tower and McEachern (63), in their study of craniocerebral trauma, included observations of six psychiatric patients undergoing convulsive therapy. Studying the patients after three to seven treatments they reported free spinal ﬂuid acetylcholine in two patients, and an increase in butyrylcholinesterase and a decrease in acetylcholinesterase with a reversal of the ratio of cholinesterases in ﬁve of the six patients. Only one patient in the series failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal ﬂui They concluded that the spinal ﬂuid anges in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Other evidence of alterations in the permeability barrier may be seen in the demonstrations of an increased concentration of cocaine in brain tissues three days after a series of 12 induced convulsions ( 1). The change in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynchrony (delta bursts) in the electroencephalogram. From these observations we would conclude that induced convulsions, like craniocerebral trauma and spontaneous seizures, are associated with an increase in free acetylcholine in intercellular ﬂuids, altering cerebral permeability and enhancing the ‘ (FINAL 06((1 �”renown; m cm; patients, and an increase in butyrylcholinesterase and a decrease in acetylcholinesterase with a reversal of the ratio of cholinesterases in ﬁve of the six patients. Only one patient in the series failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal ﬂui They concluded that the spinal ﬂuid anges in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Other evidence of alterations in the permeability barrier may be seen in the demonstrations of an increased concentration of cocaine in brain tissues three days after a series of 12 induced convulsions (1). The change in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynchrony (delta bursts) in the electroencephalogram. From these observations we would conclude that induced convulsions, like craniocerebral trauma and spontaneous seizures, are associated with an increase in free acetylcholine in intercellular ﬂuids, altering cerebral permeability and enhancing the appearance of cholinesterases. The level of free acetylcholine is maintained by repeated induced seizures. EEG hypersyn— chrony is one reﬂection of altered levels of acetylcholine and the altered permeability of electrolytes and other substances, including cholinesterases. The changes in intercellular electrolytes, including acetylcholine, provide the biochemical substrate for the persistent behavioral changes and EEG hypersynchrony following induced conv onsM. An application WM““WWWM‘MMMK of these conclusions is seen in the studies of the prediction of the convulsive therapy response and the claspsychoses. I ., / l \\ W CHOLINESTERASES AND THE CLASSIFICATION OF PSYCHOSES 69‘ / Funkenstein et al. (25—27) reported a relationship between the blood pressure response to methacholine and the clinical response to convulsive therapy. Immediately after the injection of methacholine the blood pressure falls, usually returning to the baseline within ﬁve to 20 minutes. A return within ﬁve minutes places the patients in Groups I, II or III; while a return after 20 minutes place the patients in roups VI and VII. Group I and Group II have a nine per cent and a 35 per ent recovery rate, respectively, while Group VI and Group VII subjects have 89 per cent and 97 per cent recovery rates to induced convulsions (27). Group I, II and III reactors may be looked upon as patients in whom methacholine is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. (The response to injected epinephrine was suggested as a second criteria in the classiﬁcation, but is of limited discriminating value [48].) While we have no biochemical explanation for the differences in the metabolism of methacholine in these psychiatric groups, it is possible that the blood and tissue choline— sterase activity levels of Groups I—III is I/ high while that of Groups VI—VII is low compared to general psychiatric populations. (m (FINAL (CL (COG �1»:er 24 1966 EG—K 5 %E-NMD-(March) 5/20-5FX 6131 P. 31 5/19/66 722(1) a» (mm /’ ' J (run. , (CL (GOG (READ 660 BY PROVE!) Gal. 8 The differences in blood cholinesterase levels in normal and mentally ill subjects have been extensively studied. Despite differences in methods (4, 5), elevated cholinesterase levels compared to normal populations have been reported for depressive subjects (44, 46, 47, 52), schizophrenic subjects (14, 28, 53) and a mixed psychiatric population (42). Alpern reported lowered cholinesterase levels in schizophrenic subjects (2). While these studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater and frequently elevated in the mentally ill. Negative reports include the failure by Ellman and Callaway (17) to conﬁrm Rubin’s study; and Altchule’s review of the data suggesting no abnormality of cholinesterase levels in the mentally ill (3). -. ..-_-- _ HeSe studies suggest that cholinergic measures may play a signiﬁcant role in the therapeutic response to convulsive therapy and in the pathogenesis of psychoses. ., ' , 7 CONCLUSION This review summarizes some of the available data suggesting that cholinergic mechanisms may be central to the convulsive therapy process. Induced convulsions are associated with cerebral vasodilation and increased cellular permeability, followed by the appearance of increased amounts of enzymes and electrolytes in intercellular and cerebrospinal ﬂuids. The increase in acetylcholine, vasodilation and increased permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased electrical hypersynchrony which is recorded as EEG slow wave activity in scalp electrodes and which can be modiﬁed by the acute and chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various DineridVI-hﬂnzilnqu �“lose stuures suggesr, that cholinergic measures may play a signiﬁcant role in / ( (CL ((IJG (READ 660 BY PROVE!) the therapeutic response to convulsive therapy and in the pathogenesis of psy- { choses. , ,- ' ’ CONCLUSION This review summarizes some of the available data suggesting that cholinergic mechanisms may be central to the convul— sive therapy process. Induced convulsions are associated with cerebral vasodilation and increased cellular permeability, followed by the appearance of increased amounts of enzymes and electrolytes in intercellular and cerebrospinal ﬂuids. The increase in acetylcholine, vasodilation and increased permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased electrical hypersynchrony which is recorded as EEG slow wave activity in scalp electrodes and which can be modiﬁed by the acute and chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl-benzilates. In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures. The changes in cerebral biochemistry alter cellular activity sufﬁciently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes, including the concentration of acetylcholine, results in failure to produce behavioral change. There is, as yet, no consistent evidence for differences in the sensitivity or dependence of populations on cholinergic mechanisms. Differences in the rate of develop— ment of cerebral changes to the same number and frequency of induced convulsions and classiﬁcations of the mentally ill based on the blood pressure response to methacholine suggest, however, that such differences may be signiﬁcant in the pathogenesis of different psychoses. 1. REFERENCES Aird, R. B., Strait, L. A., Pace, J. W., HrenoH, M. K. and Bowditch, S. C. Neurophysiological effect of electrically induced A.M.A. Arch. Neurol. Psychiat.,convulsions. 75: 371— 2. 378, 1956. Alpern, D. O. Aktivnost kholinesterasy i kho— linergicheskaya reaktsiya krovi pri shizofrenii. (Cholinesterase activity and choliner— gic reaction of the blood in schizophrenia.) Fiziol. Zh. (Kiev), 4: 87—90, 1956. 3. Altschule, M. D., Bodily Physiology in Mental and Emotional Disorders, pp. 169—172. Grune & Stratton, New York, 1953. 4. Augustinsson, K.-B. The normal variation of human blood cholinesterase activity. Acta Physiol. Scand., 35: 40—52, 1955. 5. Augustinsson, K.—B. Assay methods for cholinesterase. In Glick, D., ed. Methods Bioof Chemical Analysis, vol. 5, 1—63. Interpp. science Publishers, New York, 1957. 6. Bernstein, M. D. Presence and action of acetylcholine in experimental brain trauma. J. neurophysiol., 9: 349—366, 1946. 7. BFe'hner, C. and Merritt, H. H. Effect of certain choline derivatives on electrical of the cortex. A.M.A. Arch. Neurol. activity Psychiat., 48: 382—395, 1942. 8. Burgen, A. S. V. and MacIntosh, F. C. The physiological signiﬁcance of acetylcholine. In Elliot, K. A. C., Page, I. H. and Quastel, J. H., eds. Nem‘ochemistry, pp. 374—375. Thomas, Springﬁeld, Illinois, 1955. l l l | �SET aumscmi-Z MAY 24 1966 EG—K 5 %E-NMD-Mar 5/20-5Fx Gal 6131 p. 7 5-20-66 640 9. Chatﬂeld, P. O. 9 (4) and Dempsey, E. W. Effects of prostigmine and acetylcholine potentials. Amer. J. Physiol., 135:on cortical 633—640, 1942. 10. Cone, W. V., Tower, D. B. and Acetylcholine and neuronal McEachern, D. activity in epilepsy. J.A.M.A., 73: 59—63, 1948. 11. Crossland, J. and Merrick, A. J. The effect of anaesthesia on the acetylcholine content of the brain. J. Physiol. (London), 125: 56—66, 1954. 12. carine. J. Parmacol. Exp. Ther., 6: 147, 1914. Denisenko, P. P. Pharmacological blocking of central cholinoreactive systems and the possibilities of its therapeutic application. In 13. 14. Early, D. F., Hemphill, R. E., Reiss, M. and Brummel, Investigations into cholinesterase levels in serum and cerebrospinal ﬂuid of psychotic patients. Biochem. J 45: 552—556, . ., 1949. 15. Eccles, J. C. The Physiology Academic Press, New York, 1964.of Synapses. 16. Elliott, K. A. C., Swank, R. L. and Henderson, N. Effects of anesthetics and convulsants on acetylcholine content of brain. Amer. J. Physiol., 162: 469—474, 1950. 17. Ellman, G. L. and Callaway, E. Erythrocyte cholinesterase-levels in mental patients. Na- ture (London), 1.92: 1216, 1961. 18. Fink, M. A uniﬁed theory of the action of physiodynamic therapies. J. Hillside Hosp. (Glen Oaks), 6: 197—206, 1957. 19. Fink, M. Eﬁ‘ect of anticholinergic ethazine, on EEG and behavior: agent, diSigniﬁcance for theory of convulsive Arch. Neurol. Psychiat., 80:therapy. A.M.A. 380—387, 1958. 20. Fink, M. Effect of anticholinergic compounds on post convulsive electroencephalogram and behavior of psychiatric patients. Electroenceph. Clin. Neurophysiol., 12: 359—369, 1960. 21. Fink, M. The mode of action of convulsive therapy: The neurophysiologic-adaptive View. J. Neuropsychiat., 3: 231—233, 1962. 22. Fink, M. and Kahn, R. L. Quantitative studies of slow wave activity following electroshock. 23. 1956. ' ' i ’ Fink, M., Kahn, R. L., Karp, E., Pollack, M., Green, M. A., Alan, B. and Lefkowits, H. J. Inhalant-induced convulsions. Arch. Gen. Psychiat. (ChicagO), 4: 259—266, 1961. 24. Freedman, A. M., Bales, P. D., Willis, A. and Himwich, H. E. Experimental production of electrical major convulsive J. Physiol., 156‘: 117—124, 1949.patterns. Amer. 25. Funkenstein, D. H., Greenblatt, M. and Solo26. mon, H. C. Autonomic changes psychologic changes in mentally illparalleling J. Nerv. Ment. Dis, 114: 1—18, 1951. patients. 27. Funkenstein, D. H., Greenblatt, M. and Solomon, H. C. Autonomic nervous system test of prognostic signiﬁcance in relation to electroshock treatment. Psychosom. Med., 14: 347—362, 1952. 28. Gal, E. M. Cholinesterase blood from healthy and activity of whole schizophrenic individuals. Nature (London), 198: 29. 1963. 1118—1119, Giarman, M. J. and Pepeu, G. Drug-induced changes in brain acetylcholine. Brit. J. Pharmacol., 19: 226—234, 1962. 30. Green, M. A. Signiﬁcance of individual variability in EEG response to electroshock. J. Hillside Hosp. (Glen Oaks), 6‘: 229—240, 1957. 31. Hampson, J. L., Essig, C. F., McCauley, A. and Himwich, H. E. Effects of di-isopropyl ﬂuorophosphate (DFP) on electroencephalogram and cholinesterase activity. Electroenceph. Clin. Neurophysiol., 2: 41—48, 1950. 32. Himwich, H. E., Essig, C. F., Hampson, J. L., Bales, P. D. and Freedman, A. M. Effect of trimethadione (Tridinmn) A—--~— (REV (FINAL :OG(CL �“““““““ vuuvululULlS. Arch. Gen. Psychiat. (Chicago), 4: 259—266, 1961. 24. Freedman, A. M., Bales, P. D., Willis, A. and Himwich, H. E. Experimental production of electrical major convulsive J. Physiol., 156': 117—124, 1949.patterns. Amer. 25. Funkenstein, D. H., Greenblatt, M. and Solo— 347—362, 1952. 28. Gal, E. M. Cholinesterase blood from healthy and activity of whole schizophrenic individuals. Nature (London), 198: 29. 1118—1119, 1963. Giarman, M. J. and Pepeu, G. Drug-induced changes in brain acetylcholine. Brit. J. Pharmacol, 19: 226—234, 1962. 30. Green, M. A. Signiﬁcance of individual variability in EEG response to electroshock. J. Hillside Hosp. (Glen Oaks), 6: 229-240, 1957. 31. Hampson, J. L., Essig, C. F., McCauley, A. and Himwich, H. E. Effects of di-isopropyl ﬂuorophosphate (DFP) on electroencephalogram and cholinesterase activity. Electroenceph. Clin. Neurophysiol., 2: 41—48, 1950. 32. Himwich, H. E., Essig, C. F., Hampson, J. L., Bales, P. D. and Freedman, A. M. trimethadione (Tridione) and other Effect of convulsions caused by di-isopropyldrugs on ﬂuorophosphate (DFP). Amer. J. Psychiat, 106: 33. (mm (FINAL (CL (COG 816—820, 1950. Jenkner, F. L. and Lechner, H. The effect of Diparcol on the electroencephalogram in the normal subject and in those with cerebral trauma. Electroenceph. Clin. Neurophysiol., 7: 303—305, 1955. 34. Johnson, L. C., ilett, G. A., Johnson, M., 660 B! 35. 324—336, 1960. i ' ’ Kabat, E. A., Glusman, M. and V. Knaub, Quantitative estimation of the albumin and gamma globulin in normal and pathologic cerebrospinal ﬂuid by immunochemical methods. Amer. J. Med., 4: 653—662, 1948. 36. Kovach, A. G. B., Fonyo, A. and Halmagyi, M. Acetylcholine content of the brain in traumatic shock. Acta Physiol. Acad. Sci. Hung, 13: 1—4, 1957. 37. Krech, D., Rosenzweig, M. R. and Bennett, E. L. Effects of environmental and training on brain chemistry.complexity J. Comp. Physiol. Bsychol., 53: 5093519, 1960. 38. Loewi, O. Uber humorale Ubertragbarkeit der Herznervenwirkung. Pﬂueger Arch. Ges. Physiol., 189: 239—242, 1921. 39. Maynert, E. W. and Buck, E. G. Effects of CNS. depressants on brain acetylcholine. Pharmacologist, 6: 191, 1964. 40. McLennan, H. and Elliott, K. A. C. Effects of convulsant and narcotic drugs choline synthesis. J. Pharmacol. on acetylExp. Ther., 103.- 35—43, 1951. 41. N achmansohn, D. and Rothenberg, M. A. Studies on cholinesterase: On speciﬁcity of in enzymes nerve tissue. J. Biol. Chem., 158: 653—666, 1945. 42. Plum, C. M. Study of cholinesterase activity in nervous and mental disorders. Clin. Chem., 43. 6’: 332—340, 1960. Pryor, G. T. and Otis, L. S. Effects of chronic administration of electroconvulsive shock on behavior, brain weight and brain chemistry. Paper presented at the American Association for the Advancement of Science, Berkeley, 1965. 44. Ravin, H. A. and Altschule, M. D. Serum cholinesterase activity in mental disease. A.M.A. Arch. Neurol. Psychiat., 58: 645—650, 1952. 45. 46. Richter, D. and Crossland, J. Variation in acetylcholine content of the brain with physiological state. Amer. J. Physiol., 159: 247—255, 1949. Richter, D. and Lee, M. Serum choline esterase and anxiety. J. Ment. Sci. (London), 88: 428—434, 1942. PROVE!) �Dupucmr. MAY SET 241966 EG—K 6 EG~K 6 %E-NMD6131 p. 12 5-20-66 640 (4) 47.R h M. ee, Serum choline and depression. esterase J Ment. Sci. 435—439, 1942. (London), 88: extension. J. 429—437, 1962. 50. Roth M. , Changes in the EEG under barbiturate anaesthesia vulsive treatment pro duced by electro-conand their signiﬁcance the theory of ECT for a ction. Electroenceph. Clin. N 51. Roth, M.,europhysiol., 3: 261—280, 1951. K physiol., .9: 225—237, 195 . 52. R owntree, D. W., Nevin, :I‘he eifects 53. Rub' 54. (REV 55. Spiegel. E. (FINAL (CL �J. , .,Kay, ' .W.K SI 52. Rowntree, D. W., The effects of Nevin, S. and Wilson, A. in schizophreniadiisopropylﬂuorophosphonate and manic depressive chosis. J. Neurol. psyNeurosurg. 47—62, 1950. Psychiat., 13: 53. Rubin, . . . .. /W_g3, v logical and . Physio, physiocochemical mechanisms lectroshock treatment. in C . N ' 1953. 57. Spiegel, E. A., Spiegel-Adolf, M. and Henr G. Physicochemical Chan of psychoses. Amer. J. Psychiat., 104: 697—706, 1948. 59. Stone, W. .E' Th brain acetylcholine Biol. Med., 61: 51—54,content. Proc. Soc. Exp. 1946. 61. Torda, C. ' Effect of ' Amer. J. Physiol., 173: ontent of the brain. 179—183, 1953. 62. Torda, C. Effects of single injection of corticotropin (ACTH) on ammonium ion and acetylcholine content of Physiol., 173: 176—178, 1953. brain. Amer. J. 63. Tower, D. B. and McE achern, D. Acetylcholine and neuronal activit y. I. Cholinesterase terns and acetylcholin ' patﬂuid Canad. J. Res. Sect E, 64. Tower, D. B and McEachern, D. The content and characterization human cerebrospinal of cholinesterases in Sect. E, 97: 132—145, ﬂuids. Canad. J. Res. 1949. 65. Tower, D. B. and convulsive thera anges induced by electroNeurophysiol., .9: y. Electroenceph. Clin. 217—224, 1957. 67. Ward, A. A., Jr. Atropine in the treatment of closed head injury. J. Neurosurg., 7: 402, 1950. 398— v h I E a � 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 Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 4/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-004 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1969 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/511f4f0361d13255b6a58a7278a6c995.pdf aa5fa93900e4b745f3e573a0963c15cc PDF Text Text May 17, 2017 A Boy from the Bronx: A Recollection Max Fink, M.D. Arline Alda’s “Just Kids from the Bronx” enticed me to recollect the first 20 years of my life.1 The personal stories of her friends and those of her husband Alan Alda of childhoods spent in Bronx apartment houses and public schools described the rich lives of European immigrants first to the city and their spread to the outer borough of the Bronx with their farms and parks and unimproved acres. Her 19-year old brother Adolph came from New York to shepherd us across the Atlantic on the SS George Washington. We joined my mother’s families the Gottliebs and the Lowenthals in a cluster of apartment houses on Fifth Avenue just north of Central Park. The park, bicycle paths, lake and boat pond were our playgrounds. After my father received the New York State license to practice medicine, my parents travelled along the newly developed Pelham Bay Park elevated train line, along the southeast corridor of the Bronx, stopping at one exit after another, walking the streets near each station, seeking an apartment suitable for a doctor’s office. A five story apartment building at 1201 Elder Avenue just 50 yards from the elevated train station offered a six room ground floor apartment. The corner store was a pharmacy and soda fountain and a luncheonette with newspapers and magazines on the other side. 2 The dual track train stood on steel columns along Westchester Avenue, over trolley car tracks that offered a busy and noisy transportation hub. Multi-story brick houses with honey locust trees filled the avenue. PS 77 elementary school3 was two streets to the North and East on 172 Street and Ward Avenue, with the James Monroe High School just one street to the North. My parents joined the reformed synagogue on �Elder Avenue and 172 Street.4 This enclave became a vibrant Jewish community that sustained my father’s practice. Other practitioners settled in the neighboring streets and the need for hospital facilities led community physicians to establish the two-story Hunts Point Hospital and then a few years later a much larger Bronx Hospital, both offering facilities for practitioners to treat their patients.5 My mother’s brother Max Lowenthal established his office and home on Washington Avenue, a few streets from the Bronx Hospital. His home was on a large lot offering a playground for our family visits. His oldest son Charles was a Scoutmaster and both my brother and I were active Boy Scouts. In time my parents rented an apartment (#3) in the same building as our home. Melvin and Ruth Muroff, lifelong friends lived in Apartment #2. (Apartment #4 was the office of our dentist Dr. Heyman.) In 1928, my father’s mother Dvora Grunwerg migrated and was established in Apartment #5. She occupied the first two rooms leaving the large living room with windows facing the elevated railroad as a play area for my brother Sidney and myself. We adapted to the screeching brakes of train halts and noises of the doors and motors every few minutes, day and night. The living room was our playground, with Lionel electric trains on the floor, chemical experiments, chess and marble games on tables. My grandmother adhered to orthodox Jewish practices and tolerated our noises and arguments. My father’s office windows faced the street. Although Elder Avenue was lightly travelled, my friends and I were admonished to keep the noise levels low. My father parked his car in front of the building entrance, a notice that he was in his office. His open “office hours” �were 12 to 1 and 6 to 8 each day. My brother and I were expected to join him for dinner each day at 5:30. The office telephone was monitored at all times so early in my life I learned to answer the ring with ”Dr. Fink’s office” and record the messages. When my father went to a movie house or a play or opera in the city, he sought an aisle seat after notifying the usher that he was available for calls. I had a mutt dog called Pal. He developed seizures, often vomited, and more often whimpered and cried for long periods. My father had various medications in his office and I soon learned that the pink capsule (secobarbital, Seconal) would quiet Pal nicely. One night, when my parents were at a movie house, Pal was very upset. I fed him two capsules and went back to reading and listening to radio music. Not hearing from Pal, I found him under the dining room table, unconscious and not responding. Panicked, I called my father and blurted that he should come home quickly for an emergency. After a hurried drive through the broad streets of Southern Boulevard, over the trolley tracks, he rushed in and when I showed him the “dead” dog, he listened and examined and opined that the dog would soon recover. My chagrin was an early lesson in the need for examination before ringing a panic button. During the financial depression of the 1930s a barter system was in place. I was often sent to the grocer, butcher and fish shops, pharmacy and laundry, bringing home packages after my mother had called. I rarely needed cash money except to use the train or trolley systems. By 1936 the developing Spanish Civil War and the anti-Jewish restrictions in Germany became daily family concerns as my parents sought to bring Jewish relatives and school classmates to America. To obtain a visa the immigrants needed evidence that they would not �become wards of the government. My parents established bank accounts in the names of each of the relatives with a joint owner, often using me as the citizen.6 PS 77 and the James Monroe High School were well regulated. Boys wore white shirts and dark shorts or knickerbocker pants (knickers) clustered just below the knee; girls wore white midi-blouses and dark skirts. While the halls were noisy between classes, hall “monitors” maintained order. Being a “monitor” was an “honor” and despite my small size, I was an active hall monitor. Desks bound to the floor filled classrooms. I was short and usually sat up front and did not realize until I took eye tests for a driver’s license at age 16 that I was near-sighted. My first pair of glasses were a revelation. I surely was a “nerd” and in the practice of the time I skipped grades four times, graduating from elementary school at age 12. I qualified for the prestigious Manhattan high schools, but my parents refused permission saying that the James Monroe High School was just four streets away and required no travel. The school had four program “tracks” and I was soon established as college bound on the academic track. I studied German to meet the language requirement and became an editor of the monthly Plaudermäulchen (“chatterbox”) and wrote each issue’s crossword puzzle. I was favored by Ms. Sweet, teacher of English literature and head of the Arista, the honorary academic society. Tall and lean, always well dressed, she was an enthusiastic reader of murder mysteries, sharing them with students. When she learned that I wanted to go to medical school, she sent me to the coach of the football team, Mr. Wiedman who offered me a position as a “team manager.” I kept records of the games, team equipment, medical supplies, and monitored travel arrangements for off-site games. At the end of the game season I arranged a team dinner, �once at a New York City retaurant on Times Square. At the school graduation I was awarded an athletic letter M, a note in my college application that may have supported my college admission as a “well rounded student.” I graduated high school in January 1939 at age 16 and enrolled in New York University’s College at its Bronx campus for its Feb-Sep program.7 I lived at home and used the trolley line to come to school. By the second year I established myself as a library assistant in the Gould Memorial Library and a research fellow in the biology programs under Carl Sandstrom and Horace W. Stunkard.8 I soon found niches in the Library and Biology Buildings in which I could leave a cot and some clothes and I often remained on campus for days on end. As an editor of the Heights Daily News, the college’s 4 to 8 page newspaper, I spent a night each week at the printshop in Fort Lee, New Jersey, editing page proofs and setting type for headlines. I wrote stories of campus events and visiting lectures. The aroma of print ink settled in my clothes and led me to work from time to time in the art book multi-color print shop of Martin Jahoda. Martin was émigré relative of my father’s medical school classmate Julius Halpern who fled Vienna with his wife Frieda and daughter Eva on March 12, 1938 (the day that Hitler was welcomed into Vienna). The family lived nearby on Elder Avenue as he studied for the New York State medical licensing examinations. I coached him in English and as a gift he gave me a Leica camera that was compact and easily fit my trouser’s pocket. I used it throughout my medical school career. My parents moved their home to Pelham Manor at 528 Manor Ridge Road before WW II. I did not live at that home. My parents had supported the Elder Avenue Synagogue and they led the organization of the Pelham Jewish Center in their village. It took many years of effort to overcome the community’s restrictive covenants against Jews and blacks, the prevailing Nimby �attitude of Westchester County communities at the time. The Center and Synagogue opened on the Esplanade in 1953. My brother Sidney was born in 1927. He followed the same trajectory in the same public schools that I attended. He graduated Columbia College in 1948 and Columbia’s College of Physicians and Surgeons for his medical degree in 1952. His residency training in medicine at Montefiore Hospital was followed by years of research as a Damon Runyon Fellow. He specialized in gastroenterology and by 1959 he left the Bronx for a career in community practice.9 I recall our Victrola, a large mahogany box that played 10- and 12-inch vinyl records. My parents and then I collected records, mostly symphonic and operatic. My parents had been well versed in opera during their education in Vienna. Radio music dominated our living room as we avidly followed the news, hours of symphonic and operatic music, and the stories of Manchu the Magician, the Lone Ranger and Jack Armstrong, the All-American Boy and other “soap operas” for boys. What else do I recall of my experience in the Bronx? During childhood, cars and trucks were few, much if not most traffic was horse-drawn wagons, leaving manure on the streets. White-clothed Sanitation sweepers kept the streets clean; but we were accustomed to playing ball in littered streets. The Bronx River flowed three streets west of Elder Avenue. “The mud flats” of its banks, the Morrisania Farms with milk cows and chickens just to the north. The Bronx Zoological and Botanical Parks a quarter mile north, well within walking distances, were our playgrounds. We played stickball, practiced skills with marbles (immies, steelies, aggies), tossed and collected Goudey Indian and World War I Air Ace Cards, and built carts using 4-wheel �roller skates. On week-end afternoons we took the train to New York City to visit the Museum of Natural History with its dioramas and Saturday afternoon films like Nanook of the North and the conquest of the North and South Poles by Admiral Peary and Roald Amundsen. I learned to swim at the Castle Hill pools and ride horses at Pelham Bay Park. Speaking of Indian cards, in 1990 my daughter Linda was teaching at Middlebury College. She and Martha went on a shopping trip leaving me to wander US Route 7 alone. A bookshop showcase contained Goudey Indian Cards of 1936 vintage. Nostalgia led me to buy three for $5. For the next decade I bought, bartered, and exchanged cards at ephemera shows until I had a full set of 216 cards in good to excellent condition. These have been a prize collection in my library and are now at the Oregon Museum of Science and Industry in Portland. I received my letter of admission to New York University Medical School on December 6, 1941 the day before the Japanese attack on Pearl Harbor. That summer I began my studies at Bellevue Hospital and was inducted into the Army Specialized Training Program (ASTP) for my medical school years. Because Bellevue faculty made up one of the Hospitals sent overseas, we were taught by a very junior faculty. I participated in many research protocols and was encouraged to undertake procedures as obtaining blood and spinal fluid, set fractures, deliver babies, and do minor surgery. On graduation in June 1945 I started an internship at Morrisania City Hospital in the Bronx. In April 1946 I went on active military duty, was trained in neuropsychiatry at the army School of Military Neuropsychiatry in San Antonio and served 20 months stateside. At age 24, I was suddenly discharged in November 1947 with the end of the war and troop demobilization. Having been in school continuously since childhood I elected to spend the next six months as a ship’s Surgeon on the Grace and American Export Lines. On a Grace Line cruise to South �America I met Bertie and Harry Gross of Great Neck, and met their daughter Martha when we returned at the end of the cruise to Pier 57 in NYC. We began our courtship and Martha and I married in September 11, 1949 after her graduation from Barnard College in June.10 Throughout medical school days I lived at Elder Avenue, often taking the subway to the school. My internship at Morrisania City Hospital from July 1945 to June 1946 and my residencies at Montefiore and Bellevue Hospitals kept me within the borough. On January 2, 1952 I joined the staff of Hillside Hospital on the eastern edge of Queens. I had already established a base at Martha’s parents home in Great Neck in 1949 and thereafter my connection to the Bronx was limited to visits to my father’s Elder Avenue office until his death in 1965 at age 67. My mother Bronia was my father’s assistant when he opened his office. After my brother and I spent our days in school my mother took part in community services, especially during the war years. She organized a storefront child care center on Elder Avenue, nurtured it to become an affiliate of the Federation of Jewish Philanthropies. She developed centers at Clason Point and then at Bronx River Housing. During the war years she was chairwoman of the local rationing board. She was a well known community leader. Bronia’s medical education was interrupted by my birth during her fourth year at the University of Vienna. After the war, when Sidney and I were well along in our schooling she sought to enroll in a New York City medical school to continue her medical education, but was refused admission. With her experience as a community leader, she turned to training in social work, graduating from the Columbia University School of Social Work in 1956. Thereafter she worked at the Lenox Hill Hospital until retired by age at 65 (1967); then at the Brandywine Nursing Home where she worked for an additional 12 years, �My uncle Max Lowenthal had three children. His daughter Irma was very close to my mother and after her children were grown, she too was active in Bronx projects. She married a physician Henry Fleck. She was born in Poland in 1919, emigrated in 1921, and died in 2004 at age 84. Her obituary describes her extensive efforts in enhancing Bronx culture.11 Our families were educated and nurtured in the Bronx. It was a happy environment with little to anticipate the riots and burnings and the white flight of the 1970s.12 During the years of the economic depression, a barter economy and volunteer community efforts encouraged child care and welfare for the poor. It was a nurturing community. 1 Alda, Arline. Just Kids from the Bronx. New York: Henry Holt & Co., 2015. 2 The luncheonette was managed by the Muroffs who were lived next door neighbors. Their son Melvin, 2 years older than I, became a lifelong close friend. A graduate of the Menninger Foundation Institute in Topeka, he later practiced clinical psychology in Scarsdale, New York. He and his wife Blanche were loyal friends and supporters of my research as members of the Board of the International Association for Psychiatric Research. 3 4 Now redesignated Public Schools 195 and 196, at the junction of Ward Avenue and 172 Street. My brother and I obtained our Jewish education and celebrated our Bar Mitzvahs at this center. 5 By 2015 neither hospital, nor the Morrisania City Hospital were still to be found. 6 My parents became citizens in 1928, and I was designated as a citizen at the same time. 7 For students who completed high school admission in February an intensive summer program allowed students to join the sophomore class in September. 8 My research problem was to study the impact of light and darkness on the mitosis diurnal cycle in the ependymal layer of the 48 to 72 hour chick. Others had studied th 24 to 48 and 72 to 96 hour cycles. We found no changes in mitosis rates. 9 After a period of research at Montefiore Sidney began a clinical practice in Paterson, New Jersey with a group headed by Irving Selikoff, an eminent researcher in pulmonary diseases,. He moved to an academi position in Chicago, then at the Veterans Hospital in Providence. He married Eleonor Engelman, a student at Barnard College. They had 3 children Michael (now in Chicago working for more than 25 years as an analyst at United Air Lines); Deena on the faculty in Mathematics and Computer Science at New York University’s Courant Institute; and Bert, a publicist for Rogers & Hammerstein Music studios. While in Providence Ellie died; Sidney joined the US Air Force as medical officer, where he met and married nurse Nesta Hignett, moved to the Veterans Hospital in Hampton VA. After her death he retired to Hampton community. �10 Martha died suddenly on March 31, 2016. Her ashes are under a Japanese Cherry tree on our lawn in Nissequogue. We had been happily married for 67 years. We have 3 children born between 1951 and 1958. Jonathan is Professor and VP for Research at Portland State University; Rachel is Professor of Biology at Mount Holyoke College, and Linda is Professor of Ecology at Sweet Briar College. Jon married Nina DeLange in Phoenix and they have a daughter Laurel and a son Andrew. Laurel graduated Arizona State University and obtained the Master’s degree at the University in Brisbane, Australia. Andrew is completing his sophomore year at University of British Columbia in Vancouver, Canada. Rachel married Tom Dennis, a Professor of Astronomy/Physics and has Rose Dennis who graduated Mt Holyoke College on May 15, 2016 and Hieu Dennis who is completing his 2 nd year at Union College. Linda married the Monarch Butterfly scientist Lincoln Brower who taught her during her career at Amherst College. They do not have children. 11 http://www.nytimes.com/2004/02/26/nyregion/irma-fleck-84-who-battled-decay-in-the-bronx-is-dead.html?_r=0; http://timesmachine.nytimes.com/timesmachine/1971/01/12/83198899.html?pageNumber=26; http://www.nytimes.com/1986/09/17/opinion/l-a-way-for-hay-fever-victims-to-fight-back-763486.html; http://www.nytimes.com/1989/06/07/opinion/l-violence-of-old-men-vs-the-idealism-of-youth-what-tocquevillesaid-279689.html 12 Mahler J. Ladies and Gentlemen, the Bronx Is Burning: 1977, Baseball, Politics, and the Battle for the Soul of a City. NY: Farrar, Straus, Giroux,2006. Appendix 2: The Forgotten Merits of Diagnostic Tests � 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 Biographical Files Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Boy from the Bronx: A Recollection Subject The topic of the resource <a title="Memoir" href="http://id.loc.gov/authorities/subjects/sh85010050" target="_blank">Memoir</a> Description An account of the resource A short, unpublished autobiography written by Dr. Max Fink, M.D. 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> 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). Date A point or period of time associated with an event in the lifecycle of the resource 2017-05-17 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> Relation A related resource The Max Fink Collection Type The nature or genre of the resource text Identifier An unambiguous reference to the resource within a given context mfp_aboyfromthebronx_20170517_dis 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 Biographical http://exhibits.library.stonybrook.edu/mfp/files/original/a1c70b872beb13c5b56dba9ecef3099b.pdf de32dee2acdbbfa2e67eb3cd0c31e52d PDF Text Text Simultaneous of Perception Tactile Stimuli in Normal Children Max Fin/z, M.D. and Morris B. Bender, M.D. Normal adults readily identify and localize tactile stimuli applied simultaneously to the face and the hand (the “face-hand test”).1 While half the subjects perceive stimuli incorrectly on the initial trial, all are accurate by the tenth trial of the test. Young children, however, ﬁnd the task of identiﬁcation and localization of two skin stimulations difﬁcult. They report only one of the two stimuli, or, if they report the two, frequently mislocalize one of them. The omission or mislocalization of stimuli is not haphazard but follows a consistent pattern in which stimuli to the face are readily appreciated (“most dominant”) while those to the hand are not (“least dominant”). In order to determine the pattern of “dominance” in children and the age at which such tactile perceptual tasks are correctly performed, a study of normal children was undertaken. The responses of children to the face-hand test and to simultaneous tactile tests of other body parts were ascertained. SUBJECTS AND METHOD Three hundred normal children between the ages of three and 15 were examined. They were from a neighborhood child care center, from the wards and clinics of Bellevue Hospital, and children of neighbors and friends. They were without manifest disorder of the nervous system. A few children at two and a half years of age were included in the three year age group, but younger children were generally not able to comprehend the test. The subjects were examined individually, but there were many who were examined in a day-room in full view of other children. The child was engaged in play and when toys were available they were used to gain his confidence and interest. At some time during play, the face-hand test was introduced. From the department of neurology and psychiatry, New York University College of Medicine and the Bellevue Hospital, New York City. This work was aided in part by a fellowship grant from the National Foundation for In- fantile Paralysis, and by a grant-in—aid from the Coordinating Council for Cerebral Palsy in New York City, Inc. Read at the fourth annual meeting of the American Academy of Neurology, Louisville, Kentucky, April 24, 1952. 27 Reprinted from NEUROLOGY, Minneapolis, January, 1953, Vol. 3, No. 1 �28 NE UROLOGY For the face—hand test, the child was told: “I (examiner) am going to touch you,” and he was to “touch the same place I touch.” He was asked to close his eyes. The examiner, with the ﬁngers, then touched simultaneously a cheek and the dorsum of the contralateral hand of the subject. The child was asked what he felt, and to point to the sites stimulated. After this response, the child was asked to close his eyes again, and now the opposite cheek and hand were similarly stimulated and the report recorded. If only one response was given to this trial, the child was asked if there had been another stimulus anywhere else. Following these two trials, the cheek and hand on the same side of the body were tested in a similar fashion. The ﬁfth and sixth trials were not of asymmetric body parts but simultaneous stimulation of both cheeks or both hands. The following various types of stimulation were used: heterologous stimula— tion of asymmetric body parts on opposite sides, as right cheek and left hand; homolateral stimulation of asymmetric body parts on the same side of the body, as right cheek and right hand; and homologous stimulation of symmetric body parts, as both cheeks or both hands. Such tests were repeated in each child until at least ten trials were recorded. Subsequent tests of other body parts, performed in a similar fashion, were introduced until at least 20 consecutive trials were observed in each subject. A number of modiﬁcations had to be introduced for young children. Many would not play the game with eyes closed, but insisted on keeping their eyes open. In such cases the tests were applied with eyes open. Also, a large number of three and four year old children insisted on pointing to the examiner’s hands and face on the initial trials. For these children, a few trials of single touch stimuli applied to the thigh, chest or hand were introduced, until they grasped the concept of pointing to their own bodies after the stimulation. These single trials were carried out with eyes open. After the series of double simultaneous stimulation tests were completed, single stimuli were applied to various body parts to exclude from the normal focal difﬁculties. with subjects any sensory group The children were asked what they had felt and to point to the places stimulated. Verbal reports of the locus of stimulation were not accepted. It was occasionally noted that children would correctly name the parts stimulated, i. e., the cheek and hand, but then point to both cheeks, or to two places on one cheek. It seemed as if naming the locus yielded more accurate responses than did pointing. These tactile tests were repeated on consecutive days, or subsequently after a lapse of a few days or weeks in some children. At such times, cutaneous stimuli other than light touch were added to the testing. These included repetitive touch (rubbing), single pin prick, and repetitive pin pricks. RESULTS Incidence of errors: Young children made many errors on face-hand tests. Eighty per cent of children under the age of six failed to localize both stimuli �PERCEPTION OF TACTILE STIMULI IN CHILDREN I00 m 2, E ,_ 9 II m p. k no: m at “J ,— uzJ u o: to u. 100 90 (“C9, ‘ 80 85 70 L2 so 2 | 4 5 6 7 8 9 IO I2 ll .‘N‘K ‘ . '\ x. _ __ “t“ c: In a. 3 '_ ‘~~. \._x_x_‘. - \K 3 0 \,\,. -----------.‘ I‘. E 20 ‘ \ LA— 30 ‘. .- 8 so c: 0 4o o 30 40 ‘- 60 o. 50 -------------- 70 Z 60 \ ' 90 r: ~-.. a . ,_\.-___..‘ 29 _ 3 ......... . YEARS 5 YEARS 7 YEA S .----I ~~~~~ o .......... 9 YEARS L345 NUMBER OF TRIAL AGE Graph 1. Graph 2. during the initial ten trials of the face—hand test; many of these even with eyes open. In the older children the number of failures fell sharply (graph 1) so that only 2 per cent of children in the 11 to 15 year age groups continued to make errors after the initial ten trials. Apparently the ability to identify two simultaneously applied tactile stimuli was directly related to the age of the child. This ability was also related to the number of previous trials of the face-hand test. In table 1 the trial of the test after which the child was consistently correct is recorded. The last column of the table includes all the subjects who made errors in the ﬁrst ten trials, and on many trials of the test beyond the tenth. Graph 2 illustrates this relation for selected age groups. Type of testing: In these studies homolateral and heterologous stimulations were carried out at random. Errors were made by subjects of all age groups in tests of either type. Homologous tests, such as both cheeks, or both hands, randomly interspersed in the testing after the fourth trial, elicited correct reof this served clue While all the older to in as a some cases. nearly sponses TABLE 1 NUMBER OF TRIALS OF THE FACE-HAND TEST NECESSARY FOR PERSISTENT CORRECT RESPONSES ( Age 3 4 5 6 7 8 9 10 ll 12 13—15 Total Number of Subjects 39 34 37 36 26 22 23 20 21 24 29 Touch Stimuli) 1 2 — — — — — 2 — —— l 4 2 2 6 8 6 2 6 8 3 7 4 10 Trial Correct 3 4 5 6 7 l l 1 l 6 3 4 5 2 4 6 — —— 3 2 2 — 5 4 l 6 4 l 8 9 — 2 1 — 2 — l — — —- — 2 2 5 4 — — 1 2 2 1 — 2 2 2 — 1 — — — — 1 — — — — l 2 1 — -- — — — l 2 l l — 1 — —— — 2 Errors Beyond 10 Trials 34 28 28 22 10 4 3 2 0 2 0 �30 NE UROLOGY children that two stimuli were being applied, it did not seem to alter the results in the younger children. In these subjects subsequent trials of the face-hand test were incorrectly reported, even though the responses to the symmetric stimuli had been correct. The perception of symmetric stimuli was much better than asymmetric stimuli. Subsequent testing: Of the total group of children studied, face—hand tests were repeated at varying intervals subsequent to the initial testing in 40 children. Of the children under the age of six, subsequent testing elicited the same difficulties with face—hand tests as was evident on the initial examination. In a few children over six years of age, who seemed to have grasped the concept of two stimulations in the initial testing, errors were manifest on subsequent days. It was as if many trials were necessary for successful learning of the task, and then, even though the task was successfully completed, the learning was temporary. These observations are in contrast to those made in normal adults, in whom subsequent testing did not elicit the errors of the initial test.1 Type and pattern of responses: The errors (table 1) made by children on repeated trials of the face-hand test were of six types: (a) a touch on the cheek only, implying no perception in the hand; (b) a touch on each cheek, implying a mislocalization of the stimulus applied to the hand; (0) a touch on the cheek, and a second touch on the shoulder, neck or elbow, implying a partial mislocalization of the stimulus applied to the hand; (d) a touch on the hand only, implying no perception in the cheek; (e) a touch on each hand implying a mislocalization of the cheek stimulus to the hand; and (f) one or two touches on the examiner’s body, implying a mislocalization away from the child’s body. Face dominance (responses (I, b, c) was apparent in all age groups. It was most manifest as extinction“ of the stimulus to the hand (response a), and was seen in 62 per cent of the errors. Mislocalization of the hand stimulus to the cheek (displacement) was observed in 31 per cent of the errors. While most of the displacements were observed in tests involving cheek and hand on opposite sides of the body, 7 per cent of the errors were displacements from the hand to the cheek in the simultaneous stimulation of homolateral body parts, e. g., right cheek and right hand. At such times the child pointed to the cheek once, saying “a touch here,” and then, moving his ﬁngers 2 to 3 centimeters lower on the cheek, saying “and here.” Other types of displacement were infrequent. There were partial displacements from the hand to the shoulder or neck. Mislocalization of a stimulus across the midline of the body, known as allesthesia,3 was occasionally apparent in the stimulus to the hand on heterologous testing. Furthermore, children *The failure to report one of two simultaneous stimulations has been called “extinction” of a stimulus? The mislocalization of a percept to the homologous body part of the second stimulus is called “displacement.” The mislocalization of a percept in the direction of the second stimulus is called “partial displacement.” In each instance, the stimulus which is correctly reported is said to be “dominant.” �PERCEPTION OF TACTILE STIMULI IN CHILDREN 31 under five years of age frequently mislocalized the initial stimulation away from their body to parts of the examiner’s body or into space (response 7‘). This phenomenon, known as exosomesthesia,4 persisted in some children despite repeated stimulations with the child’s eyes open, and despite the examiner’s insistence that it was the child who had been touched. Another phenomenon was seen during homolateral testing. The child reported only the stimulus applied to the cheek. If the examiner asked insistently, “Did you feel another touch anywhere else?”, a number of children hesitatingly pointed to the symmetrical point in the Cheek on the opposite side of the body. In order to determine whether this was a unique or a systematic phenomenon, tests of other body parts were carried out. In homolateral tests of foot and hand, shoulder and hand, and cheek and foot, the same phenomenon was observed. The child first reported only the foot, the shoulder or the cheek—and then, when the examiner insisted on a second locus, pointed to the opposite foot, shoulder or side of the face. Furthermore, in some young children the phenomenon appeared on single stimulation. Single stimuli applied to any body part were localized correctly. If the examiner then insisted that there had been a second stimulus, the child pointed hesitatingly to the symmetric part on the opposite side of the body. As already indicated, hand dominance (responses d and e) was infrequent. It was observed in 7 per cent of the errors on face-hand tests. In all subjects in whom it was apparent, subsequent trials of the face-hand test manifested the pattern of face dominance. Relation of hand and foot: In tests of parts of the body other than the face and hand, the hand was always least dominant and the cheek the most. Simultaneous tests of foot and hand, the foot-hand test, were introduced after the initial ten trials of the face-hand test in most children. In the foot-hand test, foot dominance was apparent in 51 per cent of the responses (see table 2). It was demonstrated by hand extinction, by displacement of hand stimuli to the foot, and by partial displacement to the thigh, knee and leg. TABLE 2 FOOT-HAND TEST ( Touch Stimulation Bilateral Ipsilateral Stimuli) Total Trials 53 48 Responses Correct 21 23 Foot 17 16 Hand 1 3 F oot— Foot 10 3 Partial F t.—F t. 2 3 HandHand 2 O Other stimuli: A small group of children who made errors in tests repeated at varying intervals were examined with other cutaneous stimuli. Extinction and displacement phenomena were present in face-hand tests using pin prick, repetitive pin prick and repetitive touch (rubbing) stimulations. While the number of errors with these stimuli were fewer than with touch stimuli, the �32 NE UROLOGY still extinction hand of and dominance face was apparent. pattern DISCUSSION The ability to identify and localize simultaneous stimuli separated from each other at some distance is a complex function which gradually develops during the ﬁrst decade of life. It is a relatively unstable ability, for many Focal discriminations. such disturb of the the in state can organism changes cerebral disease as in hemiplegia5 or parietal lobe lesions,2 spinal cord lesions,2 and diffuse brain diseases such as toxic states, senility and inﬂammatory conditions6 can so alter tactile discrimination that the phenomena of extinction and displacement become prominent. Errors in simultaneous tactile tests are the of the trials few initial the test—during adults normal in during apparent period of learning.1 Persons subjected to large doses of barbiturates,6 electroshock therapy6 or anesthesia7 also manifest such inability. A prominent feature in all groups is the uniformity of face dominance. When discrimination of simultaneous stimuli is interfered with, for whatever stimuli the in hand and the stimuli not the made to in the are errors reason, to the face. The corollary of “face dominance” is “hand extinction.” It, too, is apparent in all subjects and under the variety of conditions studied. Furthermore, in an “order of dominance” other body parts are between these two limits. Studies in patients with hemiplegia5 and patients with severe mental of dominance order revealed have disease6 of brain result an a as changes of face-shoulder—trunk-thigh-foot and hand. Insofar as these other body parts were studied in these children, a similar order was observed. Since dominance is evident in young children, it appears that the pattern of dominance is an inherent function of the organism. This childlike way of responding to simultaneous tactile stimuli is exposed and exaggerated in adults under a variety of pathologic conditions. these of dominance rostral to explain has Cohn a theory suggested Recently observations.8 Our observations are not in accord with such a theory. The dominance of the foot to the hand in children, as well as the dominance of with of series hand in the two foot and to patients large buttock, thigh penis, diffuse brain dysfunctionfv9 make such an explanation untenable. with in with children normal in ﬁndings patients of ﬁndings Comparison those with children in the On mental ﬁndings comparing syndrome: organic previously reported in patients with severe mental changes due to brain dysfunction,6 a close similarity in performance is observed. In both groups the ability to discriminate simultaneous stimuli is limited. On non-homologous tactile tests, such as the face—hand test, errors are made on initial and subdisis the of stimulus most While extinction frequent trials. error, a sequent with a and children both In errors is occur patients, common. placement done be stimuli. of Furthermore, frequently testing cutaneous may variety with eyes open, and in many instances with repeated verbal clues that there is of factor The not prommade. still and learning are stimuli, errors two are inent Since testing on subsequent days will elicit the previous patterned errors. �PERCEPTION OF TACTILE STIMULI IN CHILDREN 83 In Gestalt terms, patients with organic mental defects and children have difﬁ— culty in extracting a complex sensory “ﬁgure” from the “background” of the total sensory “ﬁeld.” Signiﬁcantly in each group there is no difﬁculty in identifying simultaneous stimuli if the stimuli are applied in symmetric regions of the body, such as each hand or both sides of the face. Here, each stimulus ﬁgure has a common background in terms of body image, namely the hand.10 Face dominance is apparent in both groups. It is manifest not only on tests of face and hand but also on tests of face and other body parts. Also, insofar as it was tested, the order of dominance for other body parts is similar. While extinction and displacement are the most frequent types of error, other phenomena are elicited in both children and patients. Partial displacements, e. g., the mislocalization of the percept from the hand to the shoulder or neck on the face-hand test, are occasionally observed. The phenomena of allesthesia and exosomesthesia are seen in the more severely affected patients and in the youngest children; both are frequently associated in the same subjects. In allesthesia, the subjects usually localize the cheek stimulus correctly but mislocalize the hand stimulus to the opposite hand or elbow, In exo— somesthesia, the stimuli are mislocalized either to space in front of the subject or to the examiner’s body. This phenomenon was frequent in the youngest children, and despite the examiner’s urging that the child point to its own body, the child persisted in such mislocalizations until a trial of the face-hand test was performed with eyes open. In addition to these phenomena which appear spontaneously, patients with organic mental syndrome also manifest another response to simultaneous stimulation ﬁrst noted in children, i. e., on homolateral testing only one stimulus (the cheek) is spontaneously reported; but when the examiner insists, the second is mislocalized to the opposite cheek. Since the patients show so many similarities to young children in their responses, it was predicted that they would also show this phenomenon. In a series of patients with severe mental changes, homolateral tests of the cheek, hand, foot, shoulder and thigh were applied. When only one stimulus was reported, the examiner asked for the locus of the second stimulus. Responses were obtained in 20 per cent of the patients, and in each one the second stimulus was mislocalized to the symmetric body part. Furthermore, in some subjects the same phenomenon was observed with single stimulation. This phenomenon appears to be similar to the completion phenomenon described in Gestalt literature as “closure” and “good continuation.” These are usually described for other sensory modalities. When a circle is tachistoscopically exposed in the visual ﬁeld so that half falls on a hemianopic ﬁeld, or if a cross is exposed so that the center falls in the blind spot, many subjects report a complete circle or cross. This “completion” occurs for “good” ﬁgures. In simultaneous tactile studies, symmetric ﬁgures appear to be the “good” or “strong” ﬁgures. �NE UROLOGY 34 CONCLUSIONS Ability to identify and localize asymmetric simultaneous tactile stimuli develops gradually during the ﬁrst decade of life, and is present in 80 per cent of normal children by the age of eight. Symmetric stimuli are more readily localized and this ability is well developed in normal three year old children. 2. The errors on asymmetric (bilateral and ipsilateral) stimulation involve either extinction (only one of the two stimuli is reported), or displacement (one or both stimuli are mislocalized). Whenever extinction and displacement occur, stimuli to the face tend to be correctly reported. This face dominance is found at all age levels tested. 8. One can conclude that extinction and displacement of tactile stimuli, as well as face dominance, constitute a normal and consistent pattern of rechilin these addition In children. observe, in to one can responses sponse dren under six years of age, the phenomena of allesthesia, exosomesthesia and partial displacement as normal reactions to simultaneous tactile stimulation. 4. The difficulties in recognition of simultaneous tactile stimuli, as shown by young children, reappear in the same fashion in adult patients With focal or diffuse dysfunction of the brain. The abilities of tactile discrimination acquired by the child during growth are lost by the adult who develops mental changes as a result of cerebral damage. 1. REFERENCES M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests 0f face and hand, Th Am. Neurol. A- 751 250, 1950; BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. 5‘ P sychiat. 661355, 195.12. BENDER, M. B.: Extinction and prec1p1tation of cutaneous sensations, Arch. Neurol. 8c Psychiat. 54:1, 1945; KOLB, L.: Observations on the somatic sensory extinction phenomenon and the bOdY sch—eme after unilateral resection of the posterior central gyrus, Tr. Am. Neurol. A' 75: 1950' 3- BENDER’ M' 3'; WORTH, 5' B" and CRAMER’ J“: Organic mental syndrome w‘th phenomena of extinction and allesthesia, Arch. Neurol. & Psychiat. 59:273, 1948. 4' SHAMRO’ M . F .'’ FINK’ M. ’ and B ENDER ’ M. B.: Exosomesthesra, or the phenomenon 1c e ment of sensation into extra p er o f di spa 8‘ Psychiat. 68:481’ Neurol. Arch. space, $109221 717, 1949. 1. BENDER, _ 5' _ _ M. F and Extinction phenomenon in FELL , A . W, .. hemiplegia, Arch. Neurol. 8c Psychiat. 62: BEND-ER M B . SHAPIRO SCHAP- M. 3,; The face-hand test as a diagnostic sign of organic mental syndrome, Neurology 2:46, 6. PINK, M_; GREEN, M" and BENDER, 1952, J” and M. B.: Perceptual patterns during recovery from general anesthesia, J_ Neurol., Neurosurg. & Psychiat. 14:316, 1951_ 8 . COHN, R., and RAJNES, G. N.: On certain aspects of the sensory organization of the human brain: A study in rostral dominance as determined by ipsilateral simultaneous stimulation Tr Am Neurol A '74'162 1949. COHN, R.: On certain aspects of the human brain: sensory organization of the . . .1 f A Ch‘d‘en’ II Neurolsggljylfllgastlrgsﬁommancem 7_ JAFFE, BENDER, 1 9. GREEN, M., FINK, M., and BENDER, M. B.: . . . Order 0 f dominance in cutaneous perception. Tr. Am. Neurol. A. In press. 10. JAFFE, J., and BENDER, M. B.: The factor of symmetry in the perception of two simultaneous cutaneous stimuli, Brain 75: part 2, 167-176’ 1952’ �All, [:w.,¢fﬂ (f P Aﬂu‘ f 1 \. 3/“5 ”a...” «w 0' V -—« ‘ "1“" ‘3'". :’ I ‘1 - momswammanual I! W swam new m cm h I“ m, I.B.*’ ' and MM! 3. Bind”. Id). mun-11:16:11.0. ’0 «mum»: 11» 3.11m mama, 1m: 1m: mum tar mama. 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Such mt- nu mm mad“. Bub-cam: «at. a: at»: W mu, portend in a 11-11” fauna”. mu 5.3::ch mu} at last 20 «mun cm).- were ovum 1:: «oh mun. A mm.- at modiﬁcation: and to tundra. um: an am with ma aloud, but imam men mu tho me: in". mind would not play the hoping m1:- Qm can. In “sacrum. he introduced ta:- yams Aloe. tMomhrotMandtmmem - �3. chum insist“ on pointing to m minor: ms: mm! m. an the mun mm . For than «mm. a ﬂu train a! 31min touch mama. mind to m- tm. «m: a: hand an mm“, W "man. rm. um. with an will km the the «can» of pointing to their own My gm: can-1d out with «you upon. mu emu. am is!» «mu or am» Immanuel twain tutu an «alarm. 31ml. um: In. ”and ta Mm but: mm to mime any ”5.106“ run run imam-y In Monti” m m mm). Th0 the ltro childrun plan “mum. an mt accepted. comet]; ml. the but than pom: to «and u 1: did pointing. m. that that hid {bit ‘ Iaknd Vorhnl ﬁnd to point ta mm: at the km. of ”melon It an «autumn; noted that child!» would MI “mum. 1..., ma. chock and m. chub. a- to We! also” on one «book. It the 1m- yxolm non «amt. mm“ than m m m. mun tutu are muted «was» an, or ’ on tub-mun: after a up» a? a um, «hum tn an or miss 1.11 um «mm. “1-311. other than light touch mm mm to the unsung. Th.“ manned tomb (rubbing), uncle pin puck. and mouth. pan prion. A: not: mum; m: may gunman“ gt; tutu. mun" Young «at cum I“: my mm on m or calm-on and» the or an $31106 to localllo both ntﬂlull during tho initial tﬁn trails of the {mum mt; any of rub 0n- opon. In the older of children. tho I) go that ton amply tutu-hand Mr not MC»: ham: (W �M muormmmmmumtormmeum: «manned to lake emu after the initial ten triﬂe . Aypemtly the ability to identify two Immemly applied mule ennui me directly related to the we of the «and. m- «mu» m the related tn the mm or previous mu of the face—head tent. fun. I, the tr“). 0: the teet after which the alum nee eminently cmeot 1e recorded. The net «Inn of the hue mama» en the etheote who nude emre 1a the nut ten mun; end on may triu- at the teet the tenth. Graph II 11130th thin vellum tar “looted use m etimlettm man; In Wme. em» In theee mute”). Ina heterolesm were carried out at random. Errata were slide by eubJeete at all ese in teete or either type. 95' me Wham teete. mt: ee both chem, or bath heme. maul: intenpereea in the teeting after the fourth mn. elicited can-eat renames in nearly e11 onee. Me true «reed u e clue to em or the older children that two etmn were being applied. it did not “an to alter the reenlte 1n the younger «mum. In the“ eubjeete “ohm teet mm amarmtu Warm, even though the reenmeee to the ”metric etinuu m been amt.perception of mute «m: an moi: better this: “metric “mu. “tenant MM‘ or the totel of ammo“ emu, m I'm-bend teete were «Noemi; tﬂele or the ‘l‘he A ’ . reputed at “mm tntemle eubeeemt to initial touting in to children. or the children under the ace an. mmumt tut-1m engage the em ditﬁaultiee emu teete over 6 um me etmutione the of “cum evident an the mute). examination. In e ten children or «use, who seemed to lave the concept or two in the auntie). tenths, emu were meanest on W �5._ lubiOQnﬂnt mooaum 43):. It III 1mm a; it'unay trials aura nooonuary tar of the tuk. and aim, mm though the tuk Inna-unrully aunplotod, tho laurntnz uni tauparlrw. than: abacrvutxonn are in central: to that: undo in nernnl Odnltl. in lawn tubaoqnant ﬂouting did not ultelt tho error! 0: Ch. initiil cost (1). $223,535,!Itt953lggbggggggggg; by mum, on Muted its arrow: m (Ethic I) and. mu. or m tum-Inna m: am at an typed: (n) u touoh on the chuck only. implying an pcrcoption in an. hand; (b) a touch on ouch chock. tnvlyins I Italoclllsntian of thc stinulna :pplicd to the bind: (a) a touch on thn dutch, and u aecend tuueh on the uh auldnr. neck or elbow, implying u partial tion or the act-ulna upleud to tan hand; (d) a touch on n13100¢11la~ tbs hand only, Ilplring no porodpttoa 1n thn chock; (a) n taucu on cash hand implying a niuloealisattan at the chuck stimulus to thn bind. and (f) on. or tun taught: on tut alaninor's body. implying a um W m- Illlocllillw the «Inw- body. Flea "dalinundo” (rtspanuoo a, £9 3) an: appurvnt 1n I11 as. grdupl. It nun Inst unnzthnt as c:t1nction* or the uttnulun to the hand (response 3). tad II! Icon in 6a! of thc errata. lialocnlizatton or the hand Itilnlut tn ch. chock (dtnplnoqnnnt) wt: obaorvod in 31! or en. 03:93.. ﬂail. Hunt at thy dinplaocnnutl var. obnorvud ‘03:: involving in abnok and hind an appetite class or the body. I! of tho aurora was: ddnpllaclauts tram the hand to tun shack in tho w I rm 1m ‘*vwr‘ Trt“7~ «*~ 1* urn 9 ?“ie' 4L1“ .r‘mr 3 "'1 anon dlzlod “untinatian' at a nut-alum. Iﬂl omnlilatton or x gore t to tho hdualasduu bod? part of thy nueand stdlmnnn tn dulled «up tomcat.” at a wept 1n the “mum of the ltdond act-min. 1:unlmnmum culled "partial In much instinct, tho ntzluznl which 1: corruotly rapewtuddiaplncunnut.” 1: said to be “dominant.“ . m w �6. sinnltunoans ntﬂnnlattua at hannzutavll body parts. 0.3. right ¢hsok and right hand. At auah tilt. the chilc Iould point to the catch once, saying ”a touch hit..” and than. raving his finger: 5-3 can. lint! an the aback, 3&7. ”and hurt.“ 0th.: typcn at «Laplaoa-nat Hurt turraquont. intro wort partial dimplaocnnntl frnn‘thn hand ta the nhauldcr or nook. llllocalisltian or .- anuzmu (3) t stinhlu: mat!!! the uidliuo of tho body, known m ”mama: imam in the «mm. to the touting. rurthoanuro, childrin under {Iva years or as. :rvqulntly'ninlooulssnd ta. Initial utiuulation away tram thair body to part: of tho nan-anor*a boar 9: into space (rampant. r). rhi- pupae-aaan. known a: iﬁoﬂHIOIihllil (u), per-11:06 in OHIO children despit- rupeutad lt1-n1a330an vita tn. child'- are: open. and despite tan ell-Lucr'u tastntcnat that 1: III the child hand an hutcralacoun that had beta tauahnd. A Anothor phannnnnoa III Inna during ho-mlatovnl touting. ihe child uuuld ropnrt only tn. ttxunlun applied to the check. It the uxtntnor askod insistinsly. ‘Bid yuu r001 anothnr touch anywhnro also?" alanine: at nhildrun quld hanttatingly point to the syn-etrlanl point‘ln tan ordor to chock on tho apposito side or the body. detomnxnp uhoﬁhar this vac a unigua or I Iritalntte phenanonon. In tout. or «that bed: parts var. carried out. In henolcternl tests or root and hand. showman: Ind hand. and about and rant. the It.» phanoInnan.ﬂla ohm-twee. in. «E114 txrnt reported only the feat, tho thauldor er ‘a. catch - and thou, whoa tho attains? inaxated a acoand locus. point-d to the appositu fact, guanine» an aids of thy rice. on Furthanlaro, in non. young «aileron, tho phnnulanou appeared on linslc :ttnulatiou. singlu atannli applied in any body part would bi correctly localixac. It tho ‘mlninor adv insisted that "tram , _,_, L¥=§ ‘&:‘-’ �7. churn had bcon a Iguana skinning. the child petntod hnl1tltznaly appease aid. e: um body. uni-ms pm on to m an 0.1mm indium. and 4mm“ (mpmu g and g) an tnnu-hnnd was intrnqunnt. It nus abnothd 1n 7’ of in. crrarl tents. In all tubdcatl 1n wasn't: an: appurunt, uuhuoqucnt a: tan ruao~hnnd tout unairnatnd can pn‘%crn at run. A. trial. dcnlnnnoo. other sun had: aggggggggg£,§ga§,gag;zgg§L, In taut. or part. or ulnar! 10¢It admin-at uhnn tho ran. and hand, tun hand It. loot. salultunooun tent: or 190$ and hand. tn. toot~annd tout. worn introdaaod after the initial ton 8:111! at tn. taco-hand tact 1n Inn: ohildrtn. In 8h. feat-hind tent. feet 11). dauinnnao In: taparont in 5x! at tho rcupanloa (In. that: and th. cup-k tho nanitoat by hand axttnottou; by dinning-nun: a: hand actual: and to uh. tout; and by par£111 displucullut to the this». knot, 1.3. who and. Irruru §§§55;5L,A 3-513 area» or childrou. It was with 0th.: in tents repentod at varrtns tutorVIJu warn nunltnod cutuusoun Itinnli. Izttnotian Qua allpllaulant phone-nan.unro prick prettnt 1n tacoohnad tent. Etta: pin pr1ok. rupotxtivc pin uuaxo tn. gumbo: at and rcpotitivo touoh (rubbing) attlulitionl. tuudh uttunzi.m orrorl with than. stimuli I‘l‘ town: than with of tuna dunialnoc and bind untiuotzon In: ntill laplrcnt. ~ W pattern ability to idontitr tad 100311£0 sepnruhod tron ouch 9th.» at nun» «titans. Th. ntnultanoonn lit-n11 LI 3 culplcx runntion 1: agenda of 1110. It grudullly dcvnlup: during tn. £12.: tho attic of tho a relatichy unltahlo ab1lity. tar Inn: china»: in otrobrnl alt-n:grannimn eta diutnrb tuna disarm-tnntlonn. focal which �8. in heeipiegie (5) er perietei lobe ieeione (a); epinei cord leeiane (23); end difruee brain dieeeeee ee taxie etetee, seniiity end inflammatory aenditiane (6) zen eo alter tactile dieerininetiaa that the phenunene of extinction and diepieeelent became pruninent. lrrere in simultaneoue teetiie teete ere apparent in aerial eduite ﬂaring the initiel tee trieie at the tent -- during the period or “learning” (1). Pereene eubaeotod to ierge doeee or barbituratee (6), electromehook therepy (6) or eneetheeie (7) eieo leniteet such en inability. ' pro-inent feature in all sreupe ie the unifornity of race dominance. when dieerieinetion or eieuiteneeue stimuli in interfered with, for thetever reeeon, the errors are made in the etmluli to the head and not in the etinnii to the tece. The cavalier: or “face delinenee” ie “hand extinction.“ it, too. is apperent in e11 etheete end under the variety or ccnditioue studied. further-ere, in en ”order or daninenee” other body peril ere A tee limite. Bennie: in petieute with helipiegie (5) end petiente with eevere mental chensee ee e reeuit or brain between theee dieeeee (6) here revealed an order at equinenee or teee~ehoui¢er~ trunkathixh-teot and bend. Ineorar ee theee other body parts were etudied in theee children, e eieiler order tee observed. Since dominance ie evident in young children, it eppeere that the pattern or dominenae in en inherent function or the arsenien. This chidiheed new of reeponding to einniueneaue tactile stimuli in expoeed end exaggerated in edulte ander e variety or pathological oonditione. Recently Cohn bee suggested a theory at reetrli dominance to explein theee obeervetione (8). Our oheervetione are not in accord with each a theory. The dominence of the-toot to the hand in �9. children, an wall I. the douinlnco of penis, buttock, that and thigh to the hand in two large aerial of patients with diffuae bruin artfunction (6, 9) Elk. such an explination untenable. a in lethal Childrun with Findiggu‘;g PM oclparins Eh. tinﬁinsu in ohildron with than. prawiounly roportod in patient. with .QVOTC Inuit: chtngos an. to hrnin dylrunetian (6), a clot. nililnriey in pariah-anon in obturvod; In both group: tn. ability to dilcrilihtti Silaltnntoul Itiluli in lilitod. 0n aon—hanolosous tactilu touch. Inah II the rte-«hand hatt, error: it. 0n and: on initial and suhncnunnt triulu. Hhilo astinntioa or a thinning 1! the unit Iroquant error. diaplhoalnnt 1! cannon. In both childvun and viii-nth, errors occur with a vurioty at cutnnoons Iii-n11. lurthnmnmrv. touting In: tritulntly h. done with 01': open, and in sin: ihntcnooa. with ropaatod Vtrhal ulna: that than. tr. ewe atiluli and still arr!!! Ito undo. 1h. {later or learning 1: not pro-inont niuoo touting on tableau-ht any: will olioit tho previous pattctnod errata. In Gottﬂlt tum-n. patient. with organic anneal dctocta and ohildron have dirtiauity in extracting a ao-piua non-cry ”right!” frun thy ”buneroani” of the total Ionlary "field.” Significantly in each group inure in no difficulty in idantitying. linultanoaua Iii-uli if thy stimuli are applied in syn-attic regions at tho body, Inch it each hind or both 3140. ot-thn than. 3390, each Itilnlun figure ha. a cal-an background in turns of body insgo, unholy, en. "mm." (in), In both groups. that dalinlnco it apparcnt. It in InnlfGIt not only on test. of tuna and hund but Illa on teats or that had othcr body part3. Alto, innotlr II it II! tostod, thn order of dunintnec for othcr body part. in lililnr. while extinction and displaculont are the halt frequent typco �10. or error, othcr annualanu are elicitcd in both children ind patinnta. Partial dinplusoamnta. 0.5. tan uislocalisation of thc pochpt tram tho hand to in. nhaulder or neck on the racowhnnd test, It. cool-ioually obnervod. Th. phcaonnnn or ”allouthnsia" Ina ”axe-anesthesia“ are seen in the more severely affictcd patiatn and an. raunxoat childrvn; bath are franunntly unlooiuted in the same subjeeta. In nllcpthoaia, tat uuhjootu usually localine tbs chock ltinmluu correctly but niuloauliuc the hand Itilulus to thc appetitt hand or clbav. In cxosaunathouia, the ttinnli are ninlocslizod either to Iptcc in front of th: subject er to the uxnnincr'i body. This phcuancnon was frequent in the youngest ohildrcn, Ind despit¢ the nan-ingr'a urging the child pdrnilted in web the cum to point to its on niuloellisationn until I trial of the flag-hand toot nus perfornnd m, with eye: open. nation to than phenomena mm- apantaneaualy, patient: with orgtaio umutul syndruno also naniront Iuother respaano In sauna to simultaneous stimulation rirut noted in children. 1.3., an honolnteral rice-hand testing only on. stimulus (the aback) in spontaneously reported; but yuan tho examintr insists. tbs second it ninlocnlixod ta thn apposite chuck. since the pationtl than IO Ian: niuiltritics in their reapoaacs to young children, it was prodiatod that they would ulna ahcu this phnnannnau. In I series a! patient. with tavern nautal chins... hamolateral taut: or the cheek, nine. (out, thouldor and thigh wart avplicd. ”bun uni: ant nth-alum III reported, the aI-inor Inked for the loan. at the scoond ntinulua. Runyon... varb obtained in 20% of thc patientl, and in each one tn. second utiuulus an: uinlcotlixod to thy ayunetric body part. Purthornarv, in none subjects tbs name phenomenan III observed with single utilnlntion. �11. This phone-soon sppssrs to ho sisilsr to tho cosplstiou phone-soon described iu dostslt litersturs ss 'closurs” sud ”good oontinnstion.” fhsss srs—usoslly describsd for othsr ssnsory Iodslitiss. Uhsn s circle is tschistoscopicslly sxpossd in tho visual risld so thst hslr fslls on s hssisnopic risld. or it s cross is exposed so thst tho contor tolls in tho blind spot, ssny subjects rsport s cosplsts circls or cross. This ”cosplsticn' occurs for “good” figurss. In sisnltsnsous tsctilc studios, syn-stric figurss spoosr to to tho "good“ or ”strong" figurss. W ’ l. shility to idshtiry sud locsliss ssyI-stric simultaneous tsctilc stisuli dsvslops grsduslly during ths first docsds of lits, using prsssnt in 80‘ or nornsl childrsn by tho sac of sight yssrs. Syn-stric stﬂ-uli soc smrs oosdily locslissd and this shility is ssll dsvolopsd in non-s1 three your old children. 2. the own on umtric (hilstsrsl sud ipsilstsrdl) sti-nlstion involvs sithor extinction (only cos of the two stisuli is rsportsd). or displscslsnt (cos or both stimuli srs nislocsliscd). Hhsnsvsr sxtihcticn and displscsssnt occur. stimuli to tho tscs tend to to corrsotly rspostsd. this "fscc dcsdnshcs' is found st sll sgs lsvsls tsstsd. 3. ans can concluds thst sstincticn sud displsoslsnt or tsetils stisnli. ss ssll ss rscs dosinshcs, oonstituts s now-s1 sud consistent pottsrn ct rsspohss in childrsn. In sddition to thsss rssponsss ons osn observe, in childrsn under six yssrs or age, tho phsncsons or sllssthssis, sacsosssthssis sad psrtisl displscsssnt ss nonssl resctions to silultsnsous tsctils sttlnlstion. h. rho difficulties in rscosnitioh ct silnltsasons tsctils stimuli, ss shown by young childrsn, rssppssr in tho sons rsshion �12. in adult patient! with focal or dittuuo dyutuaatian or the bwltn. The abilities or taettlc discrimination acquired by the child aura»; growth are lost by tbs adult who develop: Inntal change. an I rniulﬁ of cerebral Gianna. �13. ﬂlFMGE m, 1;; (a) 1. and mm, 11.: Pattern. in pox-owner! l. rm. tut. or no. and hand. Tram.An.umol.Auoc.l ILL, tn 31-111mm: 250-252, June, 1950. ' W, PINK. I. mm. 11.3.,tutu 8:) alumnae“: or no: and hand. §_6_g_ mm, unutionn. a. (3) ._ 309mb“, 1951. 11.: in perception Pattern: mh.nm1.tn Mutt" and pmlpttation of autumn ntmtien ”chasm-111.Iul'lzomnt.l 2.}. 1-9. July, 195. 11.3.; «11m extinction In: Observttionu on tho scuttle of thc unilaton'liinuction utter body and the phone-anon patent: central gym... $311.43.!mol.Auoc., 15}. June. 1950. 11.11.. mm, 3.3. and mm, 1.: tax-mun ”111111 amore“ mm, of extinction and ant-than. Amhgmﬂﬁﬂnhut. with (D) 3. 355.362, and um 1101.3, 9mm 11.3.: humane-u, or the I. or1.,dnpnocunt rm, I. andormm situation into exam-personal men. human 7111 preparation). 1. 31112130, 5. SHAPED. NJ. and SCEM’PILL, 1.3.: ntinntion I.B., mm, phone-anon 1n 11.111103“. mh.£om1.trnzah1ut.l Q. 7174'”, Decanter, 19kg. $3.1 m two-dune tent is tad m, m, stagnant“ sign or organic until Imam. umlm‘ g; It. I!” a 6. FIRE, 7. J. and mm, ILB. Parceptual ptttomu during maven um, IMIthOIiI. J. gurolquhzcmt.‘ .134. moral rm 316—321, 3951. 136.58, x ' (a) com, R. and RAM, 0.3.: 011Aeon-tun "peat. of the unnory organisation or the has»: but!" study in rental «drum. n «teamed by unilateral umltmomn stimulation. mm.m.nm1. """""""""""""'""'"""" 8. ”.00., It! 10. Mo 19%. or the union crewman at certain “poet: A dwinunoc 111 children. or 11. rantml Itudy the bum brain: (11) ' 169, com, Rd On ”union, 3;, 119-122 (nu-ch) 1951. 31., ”It, I. and mm. 11.3.: 0rd» of ammo. 1n tactile mm, perception. (in prepmtion). the are. tint: J. and mm II.B.: m tutor or ulna-ybe1n911111121106)? ””8, (to or two simultaneous 311th “1.1111. Min, �m; mm or May or the now-83M mt aw Comet Rupmurp. (Touch 1‘93- Nahum ' sex-nu) WAGorgoot manure. efﬂuent: 3 39 t 31» 5 37 ,6 36 7 26 8 22 9 23 10 20 11 21 12 an 13-1529 iggggglgg rump-mm all " 1025 ~-1_-11-.2 ~~1.22»1~ .21321--».‘, --125n~2. 1262~122~ £63-21-a- 28‘sal--26515-1--6821-1-21 3746 -3..n106#21~-2 33 ‘28 28 22 -_ 10 x 3 a 0 2 o �W Foot-Band iblt (Touch Stimuli) '8!IIBIITIUR"“TU!I£ IRIALS .0 00 O Foot n , Ft.~lt. Kind talatoral 53 21 17 1 10 2 2 Ipuilaturnl #8 23 16 3 3 3 0 �" FER CENTOF GROUP ,, I: \. 4’ PER CENT ERROR AFTER k O! 39V 8 N O (,J O 43 O U1 O ERRORS MAKTNG IO 63 O K TRIALS \l O 03 O «0 O OOI �THE MOUNT SINAI HOSPITAL NEW YORK CITY MONTHLX NEUROLOGICAL RESEARCH SEMINAR TUESDAY 27, NOVEMBER BOARD ROOM - 2nd 8:30 P. 1951 M. FLOOR ADMINISTRATION BUILDING EQGMM THE PERCEPTION OF MUETIPLE STIMULI Ia II. DR. MEX FINK AND DR. MARTIN GREENE: TACTILE D.D.S. DR. ROBERT L. KAHN AND DR. EDWIN A PATTERNS WEINSTEIN: OF RESPONSES ON (UNTITIED PAPER) DR. W. S. CHAIRMAN BATTERSBY �} r l x } um um. W“; % ﬂu—é“: 145m’ "I 5’44. 1’31“ _ 4L ‘ 3, ,. I Q ~ ‘ _n ‘ﬂu‘ I... A..— "-4 A4— ‘ﬂ‘ N11,, ’ .‘ “ ��Fluid Spinal Findings Following Cerebral Angiography Joseph M. Stein, M.D. and Max Fink, M.D. WITH increasing use of cerebral angiography, the problem arose as to whether the procedure, of itself, produced changes in the cerebrospinal ﬂuid. Fortyeight hours after angiography a spinal ﬂuid examination in a patient suspected of a brain tumor revealed a cloudy ﬂuid with 3,000 white blood cells per cu. mm. Prior to angiography the ﬂuid had been clear, colorless and without any cells. As no information concerning the relationship of pleocytosis to angiography was available, it was decided to study the changes in the spinal ﬂuid by the usual clinical methods. Spinal ﬂuids from 21 patients were examined prior to and following angiography. Lumbar punctures prior to angiography were done at various intervals, but all punctures following angiography were performed between 12 and 24 hours after the procedure. In each instance the spinal ﬂuid was exam— ined for color, cell count and total protein content. All angiograms were percutaneous, using 35 per cent Diodrast as the contrast medium. Maximal Diodrast volume was 70 ml. at one procedure. While the majority of patients were subjected to unilateral carotid punctures, bilateral punctures were done in four, and combined bilateral carotid and vertebral punctures in one patient. Either intravenous Pentothal (14 cases) or local procaine (seven cases) anesthesia was used. RESULTS Of the 21 subjects, signiﬁcant changes in the spinal ﬂuid following angiography were seen in only two cases. In one, a patient with a cerebral angiomatous malformation and multiple aneurysms, 5,000 red blood cells per cu. mm. were seen in a pink spinal ﬂuid. In the second, a patient with a chromophobe adenoma of the pituitary gland, the protein content of the spinal ﬂuid changed from 89 to 151 mg. per cent; also, seven lymphocytes per cu. mm. were recorded when previously there had been none. In all other subjects, changes in color, protein content and cell count were not signiﬁcant. Three subjects showed transient hemiparesis following anFrom the department of neurology and psychiatry, New York University College of Medi— cine and the neurologic service (third division) and psychiatric division, Bellevue Hos— pital, New York City. Reprinted from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, N0. 2 137 �NE UROLOGY 138 giography, and in none of these were there signiﬁcant changes in the spinal ﬂuid. Since Diodrast can cause changes in membrane permeability,1 and the spinal ﬂuid reﬂects such changes, it could be postulated that a relationship between complications following angiography and changes in the spinal ﬂuid might exist. Such changes were not demonstrated in the present cases. F urther investigations with more exacting techniques for protein determination and protein differentiation are indicated. CONCLUSIONS Neither a marked pleocytosis nor a marked increase in protein content of the spinal ﬂuid are usual concomitants of Diodrast angiography. It may be concluded that when such spinal ﬂuid changes are found they are unrelated to the procedure. REFERENCE 0.: Cerebral angiography: Tolerance for contrast media of diodrast type, 1. OLSSON, J. Neurol, Neurosurg., 1949. 6c Psych, 12:312, �afnuéwlc4’43hm 774449711 Min-1. KM spam: main ﬁndings mnmm mum: mug-play Alon/«4J7? 4.5;}2 zlr" 777': 137-? L/r—s g- If...” no 3"}! ”in. l“ Bax ﬂak $.13. inoronuiag II. or norohrul ungiogrlyhr up i!!! toot aoarruncoa with in. )robluu of uhothcr tho proaodurn.?ut itaolr. pruduaad dhnagoo in the earnbrospianl fluid. rawtyunéght hour: utter ungiegrnphg; a spinal fluid unanianttca int: yqtimut In.unme900%“ o: a and; 27mm with blood tall: pow cubic willltcr. ?tlew to unsiegruphy eh. {lama and without any any. ma how infant“ clan containing tan rolgtleaahlp or pluoaytouta to ungtuguuﬁny in. avgllablo. 1% Ian aoasdod to study ﬂu. dhanﬁog 1h tho spinal Wick m mu m. mum . a.“ am. ”mm. llnid by ﬁbe_unus1 01131931 nnﬁhndu. ‘ Spinal fluids tram tuouty-uno pationta wank $munincd print to and running mum-33mg. 1mm: pun-mm Mar to nag!“— phy tor. don. at various ia$¢rvnln._huk :11 pun-tuﬁcs rolluuinu Ina glogruphy uumo partarnma hoﬁuoonyln anﬂ SQ hear: ﬁitor in» procew tying: {tula can «hunlncd for 00109. 0011 gaunt ‘nd total protein ooatnnt. £11 angiogru-I Inn. pnruutaaonua. uniac;aiﬂ aladraut an Eh. «entrant Inﬁlllm Hand-:1 dioarunt doing. via 70'. a! an. atsa Isaac, “anal. Eh. aujoritx at pgticnta wort auh1oato¢ to unilateral anvctid puuttnruug hilnwurnl gunnturua vat. dam. in fan: putluntn darn. In Ogah {uncanno ch» 3 an! canbinoﬁ bilazqrul suretzd and v.:%.hrn1 in «at. Eiﬁhar intravunoun ponaothal (I! an...) a: local nrmuntun (v 0....) uaaaehnain van 3308. 3 �gggultgt or uh. twentybonp‘nnbjootl, signirionnt «nausea in the ”spinnl fluid thlloving-angiogruphy warn anon in only two out... In «an. a pttiunt with n acrobtul nugiountoua malformation and multiplo unnuryunu, 6000 rod blood «.11: pl? cubic millitor won. in a pinkidh colorod spinal fluid. In the uncond. u pationt with n ohrauophobo adonaln or the pituitary gland, thy pictoll content of tho lbinnl fluid oh‘ngod Iran 89 uilligrml por'uone ta 161 3111151.: par cant. Alto. lava: lynphonyton per aubio mils noon lilihor wort I And racowdod whoa prbviaunly thorn bud boon noun. In ‘11 nth.» nubjootu. chanson in 90102. praz-in aunt-n: call count war. no: significant. Ebro. subjects aurforod trsnn- in.noao wcro thnr. significant august. in tun apinul fluid. In two subjectl. ﬁne apinnl fluid romainod an» ohangod. In thy third. far aronntod :04 blood cell: and twa nymphooytoo per eubio nillilitor turn notod, what. non. had boon inacn prior to thy pron-aura. Binao diodrune can onus. ohungon in membran- perusubilsey (1}. ﬁnd tho spinal fluid reflect. august: in cm. manna... u my be paw-ha than a. rel-Mon menu ounplicntiann ﬁnd such change: axintn. audh changun Into not do- iont haniparonil. and nonntrntod hart. vurchsr inyuatigntioaa vith.noro oxnoting tooha bio: for protein dutorninntion and protein ditrurontiation are in» diontod. W . ploooytonin nor a ngrkad inoronno in protoiu content of an. [pinnl fluid urn uuuul oonoanituntu or aiodrn-t angiogruphy. it'nuy ho aonaluaod Shut ihon Inch apin;l fluid chanQOa urn found. thqy uri unrolatod to an: groundnut. llithnr : lurkod �HO! £3523 ' Angiogmphy: relax-ma. {for 01am. 0.: 00113an 01' Contact M1. Diner“: . o J. Roux-o]... Mum-m... a: hymns. 33:313—816. (am. i949. �x- "e" ' " "-’ - 1' ' I?“ .. J- A" J , ~ ~‘,"~’rnr -m. _.—»,-nn,v~..wni~ ~- 1-... . l“. 9,, .w. Presented at the Fourth Annual Meeting - American Academy Louisville of Neurology - April, 24, 1952 Dr. Costello, Members, and Guests of the Academy: In the course of sensory studies by the method of dou- learned that normal adults readily identify and localize the tow stimuli within the ini- ble simultaneous stimulation, we tial Young ten trials of the test. children, however, seemed could not identify both sti- to make persistent errors. They muli, or if identifying the tWO stimuli} they could not localize them. In order to study the responses and their relation to the age of the subjects, face-hand tests-~the prototype of simultaneous tactile tests—~were applied to 300 normal children ranging in ages from 5 to 15 years. The children were all without manifest disorder of the hervous system, and were from child care centers, hospital clinics and children of neighbors and friends. In the course of some nlay with each child, the examiner introduced the ﬁace-hané test. In this test, the child closes his eyes, and the examiner, with his fingers, simultaneously touches the subject's cheek and dorsum of his contralateral hand. The child is asked to point to the places where he per- the child is asked to close his eyes, and the test repeated-~with opposite cheek and hand stimulated. Subsequently cheek and hand on the same side of the body and simultaneous stimulation of both sides of the face, or both hands are included. At least ten consecutive trials of the face-hand test are recorded for ceived each tje child. stmmuli, and the report is recorded. Again �2. Eighty percent of children under six years of age failed to localize both stimuli correctly during the initial ten trials. The number of errors fell off sharply among the older children, so that only 2% of children in the 11-15 year age groups continued to make errors after the tenth trial.\ This is represented in the first graph--.. Apparently the ability to localize two simultaneously applied tactile stimuli is directly related to the ageof the subject. This same relationship is represented in the second graph. The percent of the subjents in each age group making errors on each trial of the test is compared for representative age groups. Ihe older children manifest an ability to learn from previous trials of the test while the younger chil- dren do not. incorrect responses of all children were of two types--failure to identify one dfithe two stimuli, called "extinction", hr, identifying two stimuli but mislocalizing The 'one of them termed "displacement". Extinction of hand stimuli observed in of the errors, while displacement was in 51%. The preponderance of errors were in the perception of the stimulus to the hand. The stimulus to the cheek was almost was 62% correctly reported. This ability to identify the cheek stimulus in preference to the stimulus to the hand was pre— viously observed in normal adults and termed "face dominance." always face dominance was uniformlylapparent in the children of all age groups in theseries. The errors were apparent in tests involving the cheek and hand on Opposite sides of the body as well as cheek and Such ! i �5. I ’ ‘ I" hand on the same side of the body. WhileverrorSawere frequent in tests of face and hand, chillren made no errors in identi- fying symmetric stimuli, as both cheeks. In the younger children, partial displacement from hand to homolateral shoulderder or neck, or displacements from a hand to the oppo- site hand(allesthesia), or even into snace in front of the child(exosomesthesia) were seen. The incidence of these dis-placements was less than 4%. Since these phenomena were so apparent in younger children and became less frequent with increasing age, it was concluded that extinction and the varieties I of displacement are normal phases in the degqlopment of the response to simultaneous tactile stimuli. In normal adults and older children, such phenomena are apparent during the initial trials only. From these studies it was concluded that the phenomena ’of extinction and displacement are normal phases in the dev elopment of the perception of simultaneous tactile stimuli. Face gew A Ar: 4,»- a. v12.w_ at all age level; and is an inherent pattern of organization of function. Ihe perception of simultaneous tactile stimuli is directly related to chronological dominance is observed age, being gradually develOped in the first decade of life, and being well developed in 80% of children by the age of 8 years. e MW. ._ L. �EBRUPHYSIOLUGY “¢ ,_ 4, .4. lAB'RATOT‘Y HILLSIDE HOSPITAL GLEN OAKS. N. Y. é 0......w...y -,..‘u.- ’. ”luau s..»—..._ Perception of Simultaneous Tactile Stimuli *in Normal Children wrvq Ira ‘ r , A» “WV-'1.......;.,...«-_'.... [Wax Kin/L, M.D. and Morris B. Bender, M.D. r 1w l . V» ~4M-I’an‘,‘ . “and” ...-...a_.~.......~.w:..c- Amman...» .. -_. .w Normal adults readily identify and localize tactile stimuli applied simul1 taneously to the face and the hand (the "fface--l1and test”). While half the subjects perceive stimuli incorrectly on the initial trial, all are accurate by the tLIItlI tIi Il oi the I:.est Young children, however, find the task of identiﬁcation and localization of two skin stimulations difficult. They report only one of the two stimuli, or, if they report the two, frequently mislocalize one of them. The omission or mislocalization of stimuli is not haphazard but follows a consistent pattem in which stimuli to the face are readily appreciated (" most dominant" ) while those to the hand are not (' least dominant” ). lII mdeI to determine the pattern of' dominance” in children and the age which such tactile peiceptual tasks are correctly performed, a study of at normal children was undeitaken. The responses of children to the face- hand test and to simultaneous tactile tests of other body parts were ascertained. SUBJECTS AND METHOD . ca...” .‘ﬁrw' -‘-—<-“-~»—« — ' \, Three hundred normal children between the ages of three and 15 were examined. They were from a neighborhood child care center, from the wards and clinics of Bellevue Hospital, and children of neighbors and friends. They were without manifest disorder of the nervous system. A few children at two and a half years of age were included in the three year age group, but younger children were generally not able to comprehend the test. The subjects were examined individually, but there were many who were examined in a day-room in full view of other children. The child was engaged in play and when toys were available they were used to gain his conﬁdence and interest. 'At some time during play, the face-hand test was introduced. From the department of neurology and psychiatry, New York University College of \icdicinc and the Bellevue Hospital, New York City. This work wIs aided in part by a fellowship grant from the National Foundation for In- fantile Paralysis, and by a grant-in-aid from the Coordinating Council for Cerebral Palsy in New York City, 'Inc. Read at the fourth annual meeting of the American Academy of Neurology, Louisville, Kentucky, April 24, 1952. 27 Reprinted from NEUROLOGY, Minneapolis, January, 1953, Vol. 3, No. 1 ,. ’ 4 I» J �’3 NEUROLOGY 28 ._»--.A:::’mwww Nu... .. P... I. . ,u.‘ w» 'm ....-w)»...._»:,..- .. “1'3““- :7 —y’u«~¢_-'”’(, . A a ""‘f-u-mmﬁr »« ...._,......> .I, . ww‘.MF—b—4w‘ For the face- hand test, the child was told: "I (examiner) am going to touch you, and he was to "touch the same place I touch." He Was asked to close his eyes. The examiner, with the fingers, then touched simultaneously a cheek and the (lorsum of the contralateral hand of the subject. The child was asked what he felt, and to point to the sites stimulated After this response. the child was asked to close his eyes again, and now the opposite (both and hand were similarly stimulated and the report recorded. If only one Itsponse was given to this trial, the child was asked if there had been another stimulus anywhere else. Following these two trials, the cheek and hand on the same side of the body were tested in a similar fashion. The fifth and sixth trials were not of asymmetric body parts but simultaneous stimulation of both cheeks or both hands. The following various types of stimulation were used: heterologous stimulation of asymmetric body parts on opposite sides, as right cheek and left hand; homolateral stimulation of asymmetric body parts on the same side of the body, as right cheek and right hand; and homologous stimulation of symmetric body parts, as both checks or both hands. Such tests were repeated in each child until at least ten trials were recorded. Subsequent tests of other body parts, performed in a similar fashion, were introduced until at least 20 consecutive trials were observed in each subject. A number of modifications had to be introduced for young children. Many would not play the game with eyes closed, but insisted on keeping their eyes open. III such cases the tests were applied with eyes open. Also, a large number of three and four year old children insisted on pointing to the examiner’s hands and face on the initial trials. For these children, a few trials of single touch stimuli applied to the thigh, chest or hand were introduced, until they grasped the concept of pointing to their own bodies after the stimulation. These single trials were carried out with eyes open. After the series 'of double simultaneous stimulation tests were completed, single stimuli were applied to various body parts to exclude from the normal group any subjectswith focal sensory difficulties. The children were asked what they had felt and to point to the places stimulated. Verbal Ieports of the locus of stimulatiOn were not accepted. It was occasionally noted that children would correctly name the parts stimulated, i. e., the cheek and hand, but then point to both cheeks, or to two places on one check. It seemed as if naming the locus yielded more accurate responses than did pointing. These tactile tests were repeated on consecutive days, or subsequently after a lapse of a few days or weeks in some children. At such times, cutaneous stimuli other than light touch were added to the testing. These included repetitive touch (rubbing), single pin prick, and repetitive pin pricks. _ . . . ~‘~- .mh—wwyﬂn NJ,“ e., .va RESULTS .....-..-~_.- «-~ - ' ’ children made many errors on face-hand tests. Eighty per cent of children under the age of six failed to localize both stimuli I ncidcnce‘of errors: Young , 2mm, �PERCEPTION OF TACTILE STIMULI IN CHILDREN 29 iooJ 90‘ 3 < 60 E .. 704 9 6° . '1 3 50a S ‘0 :2 i g a: 0: “‘ , _ . ~....._.. 1“ 90 5 \.\ 70‘ 3 5 ‘- 604 ‘ “\ \‘\ \ 10‘ \“ ‘~.‘ /\ . . 304 ’i H.“ . 3 2° ‘~. 5‘56739Dll12046 ‘ U ”M " “~- J vans -- -- s vans ' ‘04 3 x . so g . -\ . no x3 \s 30‘ ' \-\...-. ‘4‘. nuns ..... ' -~-- 9 , ‘K vans n '5J4ST709210MEG names Y CF TRIAL AGE Graph 1. , m~w-~m \‘x‘ ‘ it 6'20 2f IOO l g D- I: ~—«—-~-..‘..__;__....~_ x Graph 2. during the initial ten trials of the face-hand test; many of these even with eyes open: In the older children the number‘of failures fell sharply (graph 1) so that only 2 per cent of children in the 11 to 15 year age groups continued to make errors after the initial ten trials. Apparently the ability to identify two simultaneously applied tactile stimuli was directly related to the age of the child. This ability was also related to the number of previous trials of the face-hand test. In table 1 the trial of the test after which the child was consistently correct is recorded. The last column of the table includes all the subjects who made errors in the first ten trials, and on many trials of the test beyond the tenth. Graph 2 illustrates this relation for selected age groups. Type of testing: In these studies homolateral and heterologous stimulations were carried out at random. Errors were made by subjects of all age groups in tests of. either type. Homologous tests, such as both cheeks, or both hands, randomly interspersed in the testing after the fourth trial, elicited correct‘respouses in nearly all cases. While this served as a clue to some of the older .W....m~. TABLE . a . . t (Touch Stimuli) c . m-‘Wn Age ...._.-.m..;. 3 4 Total Number of Subjects 39 S4 37 36 26 5 6 7 8 9 10 WWM..W~«.».-.A_. 1 NULIBER OF TRIALS OF THE FACE-HAND TEST NECESSARY FOR PERSISTENT CORRECT RESPONSES 11 12 13—15 ‘22 - 23 20 21 24 29 2 1 3 Trial Correct 4 5 6 8 - — 1 2. 4 -- 1 6 6 3 2., 4 2 5 -2 1 — - -2 1 — — 1 — 1 -3 1 8 2 6 6 8 3 7 4 10 2 . 4 5 2 4 6 -— 5 4 I 6 4 1 1 2 2 2 2 - — l 2 1 1 1 1 — 1 — -1 — 2 2 9 2 ,- - — — 2 - - - 2 l - 2 — 1 — - - — Errors Beyond 10 Trials 34 ' 28 28 22 10 4 3 2 0 2 0 �NEUROLOGY p , it did not seem to alter the hildrcn that two stimuli were being applied, trials of the insults in the younger children. In these subjects subsequent the responses to the lee-hand test were incorrectly reported, even though stimuli was of mmetric stimuli had been correct. The perception symmetric ,iuch better than asymmetric stimuli. of children studied, face-hand Subsequent testing: Of the total group to the initial testing in fusts were repeated at varying intervals subsequent of six, subsequent testing elicited it) children. ()f the children under the age on the initial examhe same. difficulties with facc~hand tests as was evident seemed to have grasped who six years of age, ,nation. In a few children over manifest on were errors in the initial testing. ghc concept of two stimulations learnsuccessful for 3ubsequcnt days. It was as if many trials were necessary completed, successfully task was the ‘iig of the task, and then, even though These observations are in contrast to those made ‘gie learning was temporary. elicit the errors of the {i normal adults, in whom subsequent testing did not tidal ".4 I test.1 (table 1) made by children on Type and pattern of responses: The errors six of types: (a) a touch on the i'peated trials of the faCe-hand test were touch on each cheek, heck only, implying no perception in the hand; (b) a the hand; (0) a touch implying a mislocalization of the stimulus applied to neck or elbow, implying in the cheek, and a second touch on the shoulder, the hand; ((1) a touch on to stimulus applied partial mislocalization of the in the check; (6) a touch on each he hand only, implying no perception cheek stimulus to the hand; and (f) of land implying a mislocalization the examiner’s body, implying a mislocalization away pie-or two touches on the grom the child’s body. all age groups. ’It was Face dominance ( respbnses a, b, c) was apparent in hand the (response a), and host manifest as extinction“ of the stimulus to hand stimulus to of the Mislocalization .'as seen in 62 per cent of the errors. of the errors. While cent 31 observed in per he cheek (displacement)i was and hand cheek in tests involving observed {rest of the displacements were displacements of the were errors 7 in opposite sides of the body, per cent of homolateral stimulation simultaneous the in check the hand to tom the child pointed the times such At hand. ody parts, e. g., right cheek and right 2 to 3 his ﬁngers b the cheek once, saying 5‘a touch here,” and then, moving lentimeters lower on the cheek, saying “and here.” Other types of displacel‘nent were infrequent. There were partial displaceshoulder or neck. Mislocalization of a stimulus ;ients from the hand to the occasionally apparfeross the midline of the body, known as allesthesia,3 was children Furthermore, testing. hand heterologous the on to int in the stimulus p , - “ ,, simultaneous stimulations has been called "extinction” :The failure to report one of 'two of of the second a percept to the homologous body part 3i a stimulus.2 The mislocalization of the direction the in of mislocalization a percept iimulus is called "displacement." The the stimulus which is each " instance, In displacement.” artial is called lacond stimulus iorrectly reported is ‘said. to e "dominant." . i . . , l . �PERCEPTION OF TACTILE STIMULI IN CHILDREN 31 under ﬁve years of age frequently mislocalized the initial stimulation away from their body to parts of the examiner's body or into space (response f). This phenomenon, known as exosomesthcsia,‘ persisted in some children despite repeated stimulations with the child's eyes open, and despite the examiner's insistence that it was the child who had been touched. Another phenomenon was seen during homolateral testing. The child reported only the stimulus applied to the cheek. If the examiner asked insistently, “Did you feel another touch anywhere else?", a number of children hesitatingly pointed to the symmetrical point in the check on the opposite side of the body. In order to determine whether this was a unique or a systematic phenomenon, tests of other body parts were carried out. In homolateral tests of foot and hand, shoulder and hand, and cheek and foot, the same phenomenon was observed. The child ﬁrst reported only the foot, the shoulder or the cheek—and then, when the examiner insisted on second locus, pointed a to the opposite foot, shoulder or side of the face. ,Furthermore, in some young children the phenomenon appeared on single stimulation. Single stimuli applied to any body were localized correctly. part If the examiner then insisted that there had been a-seeond sti‘mulus,'the 'ch'ild— pointed hesitatingly to the symmetric part on the opposite side of the body. As already indicated, hand dominance (responses (1 and e) was infrequent. It was observed in 7 per cent of the errors on face-hand tests. In all subjects in whom it was apparent, subsequent trials of the face-hand test manifested the pattern of face dominance. Relation of hand and foot: In tests of parts of the body other than the face and hand, the hand was always least dominant and the cheek the most. Simultaneous tests of foot and hand, the foot-hand test, were introduced after the initial ten trials of the face-hand test in most children. In the foot~hand test, foot dominance was apparent in 51 per cent of the responses (see table 2). It was demonstrated by hand extinction, by displacement of hand stimuli to the foot, and by partial displacement to the thigh, knee and leg. - _‘ _ _ . .- _-~qu.-. ‘ 7 TABLE 2 FOOT-HAND TEST _W&-u.~.“.~w (Touch Stimuli) 5......“ Stimulation Total Trials .., -_._... is a- Bilateral Ipsilateral 53 48 Correct 21 23 Foot 17 16 Responses FootHand Foot 1 3 10 3 Partial Hand- 2 3 2 0 Ft.-Ft. Hand ”ma—”Ayug. .. . A .. r M»~..-.._—t_.. I Otlzcr stimuli: A small group of children who made errors in tests at varying intervals were examined with other cutaneous stimuli. repeated Extinction and displacement phenomena were present in face-hand tests using pin prick, repetitive pin prick and repetitive touch (rubbing) stimulations. \Vhile the number of errors with these stimuli were fewer than with touch stimuli, the i , ,_ ' �w“ o a. ‘NHJa-w ' 32 . NEUROLOGY I still apparent. pattern of face dominance and hand extinction was _ ._ f DISCUSSION __ NM... . ~‘ak ,..,~ .... -V~’W~¢-—/“A... -Mww ,rw ‘r f ,. ‘....-._..u-n-. v“\——»\‘ ‘. < r 3 The ability to identify and localize simultaneous stimuli separated from each other at some distance is a complex function which gradually develops for many during the first decade of life. It is a relatively unstable ability, Focal discriminations. such changes in the stateiof the organism can disturb lesions,2 cord lobe lesions,2 spinal cerebral disease as in hemiplegia" or parietal and diffuse brain diseases such as toxic States, senility and inflammatory conditions" can so alter tactile discrimination that the phenomena of extinction, and displacement become prominent. Errors in simultaneous tactile tests are of the test—«luring the apparent in normal adults during the initial few trials of doses barbiturates," electroperiod of learning.1 TPersons subjected to large such inability. shock therapy“ or anesthesia" also manifest A prominent feature in all groups is the uniformity of face dominance. When discrimination; of simultaneous stimuli is interfered with, for whatever in the stimuli reason, the errors are made in the stimuli to the hand and not It, too, extinction.” is "hand dominance" _to the face. The corollary of "face Furstudied. of conditions 'is apparent in all subjects and under the variety these two between thermore, in an "order of dominance" other body parts are mental with and severe patients limits. Studies in patients with hemiplegia“ of dominance order revealed have disease“ an of brain result a as changes other these body parts of face—shouldcr-trunk-thigh-foot and hand. Insofar as dominance Since observed. order similar was these children, in a studied were of dominance is an is evident in young children, it appears that the pattern inherent function of the organism. This childlike way of responding to simultaneous tactile'stimuli is exposed and exaggerated in adults under a variety of pathologic conditions. has suggested a theory of rostral dominance to explain these Recently observations." Our observations are not in accord with such a theory. The dominance of the foot to the hand in children, as well as the dominance of with penis, buttock, foot and thigh to the hand in two large series of patients untenable. such make explanation an diffuse brain dysfunction,“ Comparison of ﬁndings in normal children with ﬁndings in patients with organic mental syndrome: On comparing the findings in children with these previously reported in patients with severe mental changes due to brain dysfunction,6 a close similarity in performance is observed. In both groups the ability to'discriminate simultaneous stimuli is limited. On non-homologous tactile tests, such as the face-hand test, errors are made on initial and subdissequent trials.‘ While extinction of a stimulus is the most frequent error, with a placement is eommon. In both children and patients, errors» occur be done frequently Furthermore, stimuli. cutaneous testing may variety of with eyes open, and in many instances with repeated verbal clues that there of learning is not promare two stimuli, and still errors are made. The factor the elicit will patterned errors. previous days on subsequent inent since testing mgvﬁ . ; ' ' vb...“ .. ,r» ...- -,4‘-.;.,.va‘ . A. w, .. ~’M"|,.I vauy—as , " ' m-.. .... v -.... *qu...‘ {U thn A ' -....;..W" A... .‘- " " "‘W , A AA i. 1 1» 1 1 1 l i ‘ �PERCEPTION OF TACTILE STIMULI IN CHILDREN ‘ 3‘3 In Gestalt terms, patients with organic mental defects and children have difficulty in extracting a complex sensory "figure” from the "background" of the total sensory "field.” Significantly in each group there is no difficulty in identifying simultaneous stimuli if the stimuli are applied in symmetric regions of the body, such as each hand or both sides of the face. Here, each stimulus figure has a common background in tenns of body image. namely the hand.” Face dominance is apparent in both groups. It is manifest not only on tests of face and hand but also on tests of face and other body parts. Also, insofar as it was tested, the order of dominance for other body parts is similar. ' While extinction and displacement are the most frequent types of error, other phenomena are elicited in both children and patients. Partial displacements, e. g., the mislocalization of the percept from the hand to the shoulder or neck on the face-hand test, are occasionally observed. The phenomena of allesthesia and exosomesthesia are seen in the more severely affected patients and in the youngest children; both are frequently associated in the same subjeets. In allesthesia, the subjects ,usually localize the cheek stimulus correctly but mislocalize the hand stimulus to the opposite hand or elbow. In exo~somesthesia,—the stimuli are mislocalized either to space in front of the subject or to the examiner’s body. This phenomenon was frequent in the youngest children, and despite the examiner’s urging that the child point to its own body, the child persisted in such mislocalizations until a trial of the face-hand test was performed with eyes open. In addition to these phenomena which appear spontaneously, patients with rganie mental syndrome also manifest another response to simultaneous stim. ulation ﬁrst noted in children, i. e., on homolateral testing only one stimulus (the cheek) is spontaneously reported; but when the examiner insists, the second is mislocalized to the opposite cheek. Since the patients show so many similarities to young children in their responses, it was predicted that they would also show this phenomenon. In a series of patients with severe mental changes, homolateral tests of the cheek, hand, foot, shoulder and thigh were applied. When only one stimulus was reported, the examiner asked for the locus of the second stimulus. Responses were obtained in 20 per cent of the patients, and in each one the second stimulus was mislocalized to the symmetric body part. Furthemiore, in some subjects the same phenomenon was observed with single stimulation. This phenomenon appears to be similar to the completion phenomenon described in Gestalt literature as “closure" and “good continuation.” These are usually described for other sensory modalities. \Vhen a circle is taehistoscopically exposed in the visual field so that half falls on a hemianopic field. or if a cross is exposed so that the center falls in the blind spot, many subjects report a complete circle or cross. This “completion” occurs for “good" figures. In simultaneous tactile studies, symmetric figures appear to be the "good” or "strong" figures. R‘f. , » — “A... .......~-........1 ~ — - AI.- jar-rs: x ., r;'34 �l _‘ Amw— 9 , ..»—-w»4 ‘-‘*V—~.. » ._......-.-... Ms- 34 '1 CONCLUSIONS 1. Ability , NE U ROLOCY , to identify and localize asymmetric simultaneous tactile stimuli develops gradually during the first decade of life, and is present in 80 per cent of normal children by the age of eight. Symmetric stimuli are more readily localized and this ability is well developed in normal three year old children. 2. The errors on asymmetric (bilateral and ipsilateral) stimulation involve either extinction (only one of the two stimuli is reported), or displacement (one or both stimuli are mislocalizcd). Whenever extinction and displacement occur, stimuli to the face tend to be correctly reported. This face dom-’ inance is found at all age levels tested. 3. One can conclude that extinction and displacement of tactile stimuli, well as as face dominance, constitute a normal and consistent pattern of rein children. ,In addition to these responses one can observe, in chilsponse dren under six years of age, the phenomena of allesthesia, exosomesthesia and partial displacement as normal reactions to simultaneous tactile stimulation. 4. The difﬁculties in recognition of simultaneous tactile stimuli, as shown by young children, reappear in the same fashion in adult patients with focal or diiluse dysfunction of the brain. The abilities of tactile discrimination acquired by the child during growth are lost by the adult who develops mental changes as a result of cerebral damage. i . f . .. .-.-~vku-»~‘. .. , _ - - - . REF E1112. ’CES M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Tr. Am. Neurol. A. 75: 2'50, 1950; BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. & l’sychiat. 662355, 1951. BENDER, M. B.: Extinction and precipitation of cutaneous. sensations, Arch. Neurol. 61 Psychiat. 54:1, 1945; Kora, L.: Observations on the somatic sensory extinction phenomenon and‘ the body scheme after unilateral resection of the posterior central gyrus, Tr. Am. Neurol. A. 75: 1950. BISNDER, M. 13.; WOR'I‘IS, S. 8., and CRAMER, 1.: Organic mental syndrome with phenomena of extinction and allesthesia, Arch. Neurol. 8t Psychiat. 59:27}, 1948. SHAPIRO, M. F.; PINK, M., and BENDER, M. 13.: Exosomesthesia, or the phenomenon of displacement of sensation into extra-personal space, Arch. Neurol. 8t Psychiat. 68:481, 1.. BENDER, -<.»»N.-.~,.--~c¢-v--_.a . _ . .. .,.....-._..a..- . .. . . 1952. ’ M. 8.; SHAmno, M. F., and SCHAPPELL, A. W1: Extinction phenomenon in hemiplegia, Arch. Neurol. 61 Psychiat. 62: . BENDER, t l l e I lbs: - 3w 1?, M . Q33. (TFGJN'zX’UwAaQ , i l l 5...”... . . . . 717, 1949. FINK, M.; GREEN, M., and BENDER, M. 13.: The face-hand test as a diagnostic sign of organic mental syndrome, Neurology 2:46, . r 1952. JAFFE, J., and BENDER, M. B.: Perceptual patterns during recovery from general anesthesia, J. Neurol., Neurosurg. a Psychiat. 14:316,1951. COHN, R., and Rum-:5, G. N.: On certain aspects of the sensory organization of the human brain: A study in rostral dominance as determined by ipsilateral simultaneous stimulation. Tr. Am. Neurol. A. 74:162, 1949. COHN, R.: On certain aspects of the sensory organization of the human brain: II. A study of rostral dominance in children, Neurology 1:119, 1951. GREEN, M., FINK, M., and BENDER, M. 3.: Order of dominance in cutaneous perception. Tr. Am. Neurol. A. In press. JAFFB, 1., and BBNDER, M. 8.: The factor of symmetry in the perception of two simultaneous cutaneous stimuli, Brain 75: part 2, 167-176, 1952. , . l .. .- .-—-.... -~..—....- __.. ‘me—M . Mums—can 7—. . �PERCENT OF GROUP ERRORS MAKING 03 U" mo O _ m u ZCmeD A m OT: m ﬁnch? u m o........v..m.o . _i 2% (be; /C1{»c {ram 62' (2» , — x? "55"” 512/ p i M1144}; ZI“:.Y&A‘4 6A., 1M (.4: V7 “"' c / d4 A [7 5‘" r’,'. :e 7§~<1 593%“ 75/075 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Perception of simultaneous tactile stimuli in normal children. Neurology. 1953 Jan; 3(1): 27-34. And, Spinal Fluid Findings Following Cerebral Angiography. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-8-012 Date A point or period of time associated with an event in the lifecycle of the resource 1953 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>; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 8 items. 1: Reprint from NEUROLOGY, Minneapolis, January, 1953, Vol.3, No.1. Read at the fourth annual meeting of the American Academy of Neurology, Louis-ville, Kentucky, April 24. 2: [preprint] and graph. 3: Monthly Neurological Research Seminar, Nov. 27, 1951, Mount Sinai Hospital, New York City. 4: Report of Activities. 5: 2 items - Spinal Fluid Findings Following Cerebral Angiography; Reprint from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, N0. 2 AND [preprint]. 6: Presentation at the Fourth Annual Meeting - American Academy of Neurology - April 24, 1952, Lousiville; presented to Dr. Costello, members, and guests of the Academy. 7: Xerox of Perception of Simultaneous Tactile Stimuli in Normal Children. 8: graph. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/6428428b2e8c8dd8c101b89ff0bcc16f.pdf 0dca1e713671d6e32179b0a6fd1afba3 PDF Text Text Electroencqahalographic Correlates of the Electroshock Process Max Fink MJJ. and Martin A. Green 14.3). ‘ .. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., in part, by grant M—927, National Institutes of Mental Health, National Institutes of Health, U.S. Public Health Service. Aided, Read at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. V:3-l-58 New York, N.Y. �Electroencephalographic Correlates of the Electroshock Process During the past few years, renewed attention has been given to the relation between changes in measures of cerebral function, and the behavioral changes induced by electroshock (l, 2). Alteration in various aspects of the electroencephalogram has been emphasized by various observers (3, h) in cerebral function. In an initial study in this laboratory, a significant relationship between the degree and duration of induced delta activity and clinical evaluation of "improvement" was observed (6). Subsequent studies have focused on as a sensitive index of changes ' various parameters of the EEG changes including frequency of type of current, age of subject and pre-treatment record It is treatment,' characteristics. the purpose of this report to assess the relation of these aSpects of treatment to changes in the EEG and in clinical response; and to describe the role of serial electroencephalograms in the rational management and study of convulsive therapies. �-2- man: One hundred and seventy-three consecutive electroshock referrals have been studied. Electroencephalograms were taken before treatment, after treatment at weekly intervals during and following the course of therapy until the record had achieved its pre-treatment and on a day characteristics. Patients in whom demonstrated slow wave or spike All the EEG delta activity. the pre-treatment electroencephalogram activity were excluded from the series. records were quantitatively measured for the amount of On the basis of the per-cent time, slowest frequency, highest voltage and longest duration of bursts of slow waves, in selected lead combinations, the records were classified into "high," "moderate" and "low" degrees of delta activity, according to criteria previously published (6). Three convulsive techniques were employed: suprathreshold alternating current, threshold alternating current current methods. The and parathreshold unidirectional alternating current suprathreShold (7) and unidirect- ional parathreshold (8) treatments followed established techniques. In the threshold alternating current method, patients without prior sedation received small amounts of current (90 volts for 0.2 second), usually sufficient for a petit mal response. intervals voltage, and if necessary, duration.was increased until a grand mal convulsion was inAt 20 second voltage and duration necessary to induce a grand mal duced. The minimal was the threshold value. In addition, a convulsive-subconvulsive control study was instituted during a period of these observations. Randomly selected patients referred . �.3for electrotherapy received subconvulsive therapy instead of grand mal. In this technique, patients were given pentothal intravenously until asleep, and then either low voltage unidirectional current fbr 60 seconds alternating current of 80 to 120 volts for 0.2 second were administered for one to three applications, for a total of 2h to 36 petit mal (8) or responses. Of the 173 electrotherapy referrals, lh6 received grand threshold alternating current, 57 by current and 63 by 26 by suprathreshold mal therapy - alternating parathreshold unidirectional current methods. Twenty- seven subjects received a course of subconvulsive therapy. All treatments were given three times a week, for 12-20 treannents. failed to develop a significant behavioral or clinical response, or middle or high degrees of delta activity in the EEG, were subsequently Patients Who treated five to ten times per week. Evaluations of clinical reaponse were trist ment and resident therapists on two occasions. At the supervising psychia- the height of the treat- effect, the degree of behavioral change was scored as ”marked," "moderate," "minimal” orfhone." in behavior in interviews These made by after treatment was terminated. and were based on the ratings were estimates of the change and on the ward from the Ratings of "improvement" were also weeks made by pre-treatment patterns. these physicians two to three These ratings were value judgments four-fold classification of "recovered," "improved” and "unimproved or worse" (2, 6). "much improved," �RESULTS: 1. Variability in Delta Activity'with Convulsive Therapy: variability in the degree of induced delta activity reparted in the initial 2h patients {6) is confinned in these series of convulsive therapy referrals (Table I). While the number of high degree The wide records increases with treatment, fourth week, are still rated as 27% ”low" degrees of TABLE Degree of EEG in the third week, and 18% in the delta activity. I Delta Activity with Convulsive Therapy (Per-cent of Group) Treatment Period h 28 h6 60 Moderate Degree 12 21 27 22 Lou'Degree 68 h8 25 18 16 3 2 o High Degree No Delta Activity 2. Role of Convulsion in The EEG Response: significance of the convulsion per gg in the EEG and behavioral response was assessed in the convulsive-subconvulsive study. Of the h? subjects*'who received convulsive therapy in this study, 9 had * These included 28 subjects who received grand mal therapy on a random selection basis, plus 19 subconvulsive subjects referred for a "second course" of therapy. �-5high degree delta records in both second, third and fourth weeks of ment, 12 during two of the three weeks, and 13 during one of the periods. Thirteen of the h? subjects failed to show a treattest high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta activity records during any week of treatment. Low degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. In concurrent behavioral ratings, 25 of initial 28 subjects in the convulsive group showed marked behavioral change; while of the subconvulsive group, Of the 21; of the 27 showed Bdnimal or no behavioral changes (Table latter group, 19 were referred II). for a second course of therapy. In 1h of these, grand mal electroshock induced high degree delta activity all significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroShock, all and showed a showed middle degree records; and change. three of the five Showed a behavioral Thus, of the h? convulsive therapy subjects, h2 showed a behavioral change. significant �—6— II TABLE Ratings of Behavioral Change: Convulsive - Sdbconvulsive Therapies (Fburth-Fifth'weeks of Treatment), Moderate marked Minimal yggg i Convulsive Therapy (A?) 27 15 5 0 O 3 8 16 Subconvulsive Therapy (27) In evaluations of the degree of "improvement" 51% of the convulsive therapy group were rated as "recovered," and evaluated as sustaining the "improved," and only however, but 70% 11% III). as "improved" (Table 32% 7% were rated same weeks after treatment, "much improved" On discharge, degrees of improvement, while were ”unimproved." in the tWo first two were “unimproved," two weeks or 51% were h2% were 0f the subconvulsive group, categories, 19% after treatment. As in the "improved," these were re- ferred for a second course of therapy, hosPital discharge evaluations do not reflect the effects of subconvulsive therapy. TABLE III Ratings of Improvement: CoHVulsive-Subconvulsive Therapies (TWO Weeks After Last Treatment) Recovered Much Improved Improved Unimproved, worse Convulsive Therapy (h?) 9 15 15 8 Sdbconvulsive Therapy (27) 2 l 5 19 �Convulsive therapy induced and more favorable evaluations The significantly greater behavioral change of improvement than did subconvulsive therapy. clinical observations thus parallel the electroencephalographic data. Also, patients who showed.neither an convulsive therapy, EEG Showed both EEG and or a behavioral response to behavioral changes when Sub- placed on convulsive therapy. 3. Role of Type of Convulsive Therapy: In view of the variety of electroshock techniques employed, the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock on EEG delta activity undertaken. The results are graphically presented in Figures first figure relates and 1 and was 2. The the treatment type to the percentage of records demon- strating high degrees of EEG delta activity in each treatment group during the second, third and fburth weeks of treatment. In each period, treatnent with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unidirectional current and with alternating current at threshold strength was less effective than the supra- threshold alternating current technique in each period; the unidirectional current treatment being method only more effective than the threShold alternating current early in the course'of therapy.* Subconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same relationship by measuring the per cent of each treatment group showing no delta activity or only low degrees * The differences between suprathreshold and threShold treatment methods are significant at .05 by chi square in the h-é and 7-9 treatment periods, but not in 10-12 period. Parathreshold treatment methods are not significantly different free the other two methods during any treatment_period. �-8of such activity. Here, the subconvulsive group is 100% for each treatment period. Suprathreshold alternating current techniques the least number of such records in eaoh period, with threShold show and parathreshold techniques in between. h. Freguenqy of Treatment: Another factor is the frequency in the rate of development of delta activity of treatment. While three times a week, a number activity were treated were given more who all patients and In nine such patients, treatments in each instance middle or high degrees of delta activity were induced. Similar previously demonstrated by Pacella 5. Factor of In the initially treated failed to develop high degrees of delta intensively. daily or twice daily, were at 31. (9), correlates were EEG and Callaway (10). V Age: initial series of'patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta activity during the first and second weeks of treatment; while older subjects developed such activity to a significant degree during the third week. By the fourth week of treatment, age no longer between the groups. Combining the data from supports this observation. all differentiated convulsive therapies During the Second week, h3% of records are in patients under the age of no; but only 30% in patients from h0-60, and 18% in patients 61 and over. In the third measured high degree delta and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects have high degree delta records times per week. when treated 3 �.9TABLE Variation in Per IV Cent High Degree Delta EEG Records with Age * 9 Treatment Period Second week Third week Fourth'week in. is. 2:2 nee ho years (28) 15% 61% 69% ’41-50 Years (28) 29% h0% 56% 51-60 years (28) 32% 56% 55% Over 61 years (18) 18% 50% 80% es To ' 6. Pre-Treatnent Record Characteristics: Previous reports, summarized by Chusid and Pacella (3), noted a significant relationship between pre-treatmnt reca» rd character- istics and the degree of induced "abnonnality." Predominant alpha rhythm, “abnormal" (3) or “borderline abnormal" (11) records were more develop alterations in the EEG liable to than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment'record demonstrated diffuse slow wave activity, spike or spike wave activity were not included in the statistical analyses. Eight such subjects were «- difference in incidence of hig1 degree records is significant at .01 level of confidence between the second and fourth weeks and .05 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. The �-10.. treated with convulsive techniques, high degrees of delta activity however; and seven of them developed earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre-treatment alpha . and the degree of induced delta activity was undertaken. Rank order correlations of the preetreatment per cent time alpha in selected leads (anterior temporaldvertex) with the degree of delta activity during the third and fourth weeks of treatment of +.2h and +.3S reapectively. The in h3 patients demonstrated correlations relationship in the fourth week significant at the .05 level of confidence; while that in the third fails of significance, although the trend is indicated. is week �.11.. DISCUSSION: aspects of these studies warrant discussion: the significance of the convulsion in the electroshock process; and the role of serial electroTwo encephalograms in the rational management and’study of convulsive therapies. In the early studies of convulsive therapy numerous authors, including Kalinowsky 23 El. (12) and Pacella and electroencephalographic gt.§£. (9), emphasized both the clinical differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes Similarly, electroencephalograms in grand activity, while in petit mal therapy, no in less than 25% of subjects. mal therapy demonstrate delta delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, and focal convulsive techniques in each, in.turn,,discarded in routine therapy. Bergman §§.§l, (13), for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records at 15 such "seizures;“ while 70-75% had "abnormal” records after have been described, and Ulettgt El, (1h), in a careful convulsive-subconvulsive control study,reported a significant difference in the clinical response of grand mal seizures. patients receiving convulsive therapies convulsive (33%), or controls (38%). reSponse in the He (60-80%) and those noted two groups, and emphasized the for the therapeutic effect. ReCent ﬁne discrepancy in the EEG significance of the seizure additional reports based on a variety of data further emphasize receiving sub- ﬂue by various observers, significance of the convulsion �.12.. in the therapeutic response (h, 15, 16). convulsions per g2 are, or which thus indicates that reflect, the significant physiologic events are the basis for therapeutic efficacy of convulsive therapies. If the convulsion is the essential element both in the the behavioral response, does the any The evidence EEG and in induction of the seizure play mode of role in.this reSponse?. In the studies reported here, small differences in both the degree of EEG delta activity and the rate of its development different methods of induction of grand mal seizure. Ulett gt 3;, (1h) reported an improvement rate of 57% for the alternating current cenvulsive technique, and 76% for the photo-metrazol were observed between technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulsive photoametrazol technique. In a discussion of this report, Kalinowsky noted.that metrazol convulsions have impressed various workers as being more efficacious than induced convulsions. convulsant drug, PM More electrically recently, Edwalds, (17) describing a 1090, ascribed to it new clinical results slightly better than electroconvulsive techniques. further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance~ we have of clonic or tonic phase, apnea, 332. All grand mal seizures are seemingly not equivalent; and a seizure is not an "all or Different seizure patterns occur and these may none" phenomenon. reflect differences in the physiologic effect of different treatment methods. Further studies of this problem are in progress (18). �-13 .- While this variability in clinical results is reported, it is clear that with repeated canvulsions, rates no matter how induced, improvenent per cent are observed. The differences between various types of treatment are small, and, for the most part, may be readily obviated by of 60 to 80 the simple expedient of increasing the frequency or number of treatments. We may conclude way that convulsive therapy is nonpspecific with regard to the the convulsion is induced. The significant element is the brain change subsequent to the convulsion, and not the agent used in bringing about this brain change. In previous reports (6, 19, 20) convulsive therapy we have noted that is also non-Specific with regard to its application in mental illness, and in its clinical effects. and behavioral The present studies, amplify , therefore, the previous conclusion of the non-Specificity of convulsive we have therapies. applied methods of quantitative, serial studies reported here. EEG analyses in the clinical estimates of behavioral While change have yielded similar data, such evaluations are more dependent on the attitudes of the observer (21), and less amenable to quantification than the EEG. Application of EEG analyses to problemsin convulsive therapies provides a rational basis for the comparison of different treatment techniques. “we have previously noted clinical management patients who that EEG analyses may be applied in the of patients receiving convulsive therapy (6). In fail to show a significant behavioral response on treatnent regimens of three times per week, an electroencephalogram may serve as a �guide for further therapy. In those subjects in.whom high degree delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a more effective oonvulsant method, may result in the neurophysiologic changes. If the degree of delta activity is high and sustained for a number of weeks, other factors as personality (22) or environmental (19) may be assumed to preclude a satisfactory behavioral response, even when the neurophysiologic substrate and further convulsive therapy application has been suggested EEG may well be discontinued. by Roth (5) A is assured; similar for thiopental activated records. The successful application of quantitative convulsive therapies, has led to dynamic EEG techniques to their application to other physio- therapies. Recent reports from these laboratories note a similar application for the rational psychopharmacologic agents (20). management and understanding of �.15sunnru AND CONCLUSIONS: Serial quantitative analysis of the degree of induced activity in were made 173 consecutive EEG delta electrotherapy referrals. Patients were treated by three convulsive methods: suprathreShold alternating current, threshold alternating current and parathreshold unidirectional current. Random electrotherapy patients received a course of subcdnvulsive treatment instead of grand mal, in a convulsive-subconvulsive control study. 1. An induced grand mal convulsion is essential both for the electro- encephalographic and the behavioral changes ascribed to ”shock" therapy. 2. The rate (a) two The EEG delta activity of seizure induction: suprathreshold Mode techniques induce techniques. and degree of induced EEG changes earlier and is dependent upon: alternating current to a higher degree than threshold results of unidirectional current methods fall between these techniques. (b) Frequency of treatment: increasing frequency inereases degree of EEG delta activity. (c) Age of subject: Patients under delta activity earlier than older patients, but ment, differences are insignificant. (d) Pre-treatment record hS develop by the greater degrees of fourth week of treat- characteristics: Patients with dysrhythmic records or high per-cent time alpha activity develop greater degrees of delta activityearlier than patients with low per-cent time alpha activity. 3. It is suggested that serial quantitative electroencephalography provides a rational basis for the study and the clinical management of convulsive therapies. �REFERENCES l. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. 1.92: 22-26, 1952. Psychiat. 2. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobartital Test 3. Chusid, J.G. and Pacella, B.L.: The Electroencephalogram in the Electric Shock Therapies, J. Nerv. & Ment. Dis. 116: 95-107, 1952. h. Roth, 14.: Changes S. Roth, to Clinical Improvenent in Electroshock, AMA. Arch. Neurol. in the under Barbiturate Anaesthesia Produced by Treatment and Their Significance for the Electro-Convulsive ECT EEG Clin. Neurophysiol. 2: 261-280, 1951. Theory of Action, Kay, D.W.K., Shaw, J. and Green, J.: Prognosis and Pentethal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG Clin. Neurophysiol. _9_: 225—237, 1957. 7:41., ’ Fink, EEG M. and Kahn, R.L.: Relation of Electroencephalographic Delta A.M.A. Arch. Activity to Behavioral Beeponse in Electroshock, Neurol. and Psychiat. Z_8_: 516-525, 1957. 7. Kalinowsky, L. and Hoch, P.: ghock Treatments, Psychosurgegy and Other Somatic Treatments in Psychiatry, Grune and Stratton, N.Y. 1992. 8. Alexander, L.: Treatment of Mental Disorder, W.B. Saunders Co., Philadelphia, 1953. 9. Pacella, B.L., Barrera, E5. and Kalinowsky, L.: Variations in the Ele ctroencephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Paychiat. 367-38u, 19u2. g: 10. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Neurophysio . a: 157-162, 1950. ll. Kennard, M. and Willner, M.D.: Significance of Changes in the Electro— encephalogram which Results from Shock Therapy, Am. J. Psychiat. 1L2: : 12. 13. Olin. uo-us, 19m. Kalinowsky, L., Barrera, Reaponse l9LL2. EEG ms. in Electric and Horowitz, W.A.: The "Petit-Mal" Shock Therapy, Am.J. Psychiat. 28;: 708-711, " P.5., Impastato, D.J., Berg, S. and Feinstein, R...‘ Electroencephalographic Changes Following Electrically Induced Focal Bergman, Seizures, Conf. Neurol. 12: 271-277, .1953. �W K. and Gleser, 6.0.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, A31: Jo MChiat. 112: 79S~802, 19560 Ulett, GA” Smith, 15. weinstein, E. and Kahn, R.L.: Denial of Illness, 0.0. Thomas, Springfield, 1955. 16. Fleming, “13.0.: An Inquiry into the Mechanism of Action of Electric J. Nerv. & Ment. Dis. 121;: th-hSO, 1956. Shock. Treatments, 17. Edwalds, R.M.: Intravenous Administration of PM 1090: Clinical Elmerience with a New Convulsant Dmg. Read at FLY. Divisional Meeting A.P.A. 1957. 18. Green, M.A.: Significance ‘of Individual Variability in "EEG Respome to Electroshock, J. Hillside Hosp. é: 229-210, 1957. 19. Fink, M., Kahn, R.L. and Green, “.11.: Experimental Studies of the Electroshock Process, Dis. New. 835 . (in press). 20. Fink, M.: 21. Fink, A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside M. and Kahn, 9: 197-206, 1957. R.L.: Behavioral Patterns in Induced States of Hosp. Altered Brain Function. 1957. 22. Read at N.Y. Divisional Meeting A.P.A. Personality Factors in Behavioral Response to Electroshock Therapy, Coni‘. Neurol. (in press). Kahn, R.L. and Fink, 14.: �ELECTROENCEPHALOGRAPHIC CORRELATES OF THE ELECTROSHOCK PROCESS MAX FINK, M.D., and MARTIN A. GREEN, M.D. From the Department of Experimental Psychi: atry, Hillside Hospital, Glen Oaks, .N. Y. Pro blem : In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment; on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varial, including unidirectional and alternating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12-20 treatments. Patients who failed to develop a clinical response, or EEG changes of signiﬁcant degree, were subsequently treated at 5-10 times per week. The EEG records were classiﬁed for degree of delta activity into “high," “middle” and “low" degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest amplitude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. _ Results .' ~ .4]; 3, 54 I ._ 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was signiﬁcantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subCOnvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional but by the 4th week of treatment, the di' erences were eliminated. '4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. ”ﬁruments, ‘ Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. . 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient 3) Early. and sustained high degree electroencephalographic delta activity is a necessary,, though not sufﬁcient, pre-requisite for improvement in the electroshock process. ’4 ; Avf" �TRQIW m Subuuowluve Conoubwc \\ d, AC. and u“ .. ﬁYc-‘Hol‘b _ Paiszélﬁftfl’l _ A “ \t W: 0 2a 3! 4¢v 93¢ {I to 057:0 7‘ �. t‘, “i. I 3 “fatig- ‘ ﬂcrld;é J 1’ 3547.79 5‘ ”WW 55/ (7.?” Mfl m- a; V Ear ﬂ<.a..ma'" 7”,... 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The limited a arrimy or mass pmduru is probably due to �Electmaephalagnphio many ' ﬂax 1* From ﬂak, 11.9., comma at the Prone“ Robert L. the Department at Experimental M3. 3“ IMO; i Electmhook m and H. Green, 3.9. mummy, Hillside Hospital, 613:: ��.3 I “,— “A May .— - ,. Mu may or ﬂu mam-m M's-3., Mn A. «ma. 3.»... m mm. 2., an. an». hm mammmwuuauuudumbmm mama hm Wumm mm meta-W MM mam; many bun W- mu 411 m; tmmt «www.mtmmmmwmmwm mm m We! pun-Wt Wam- mum www.mmmmwnmmmzw mum-m Was um mama-1 Mum Me for In many mum-ca it Wm as g dry their 33m- mock, ma M W“ 1240 mm“. atmum‘mwwmaamm.umwu mam-m.mnmmmmmammmma mmmmWWtwmamuwwm WHWW'WWNMWMWIWMW: nut-m tho pm mu; mam-*4... mu I“ awn“, amt V‘ IMWWdWhmw.mm-WM,M m'mM§ msmumWMWqu-y,mzomm “mm; M 3-95 1997;: 2 ‘s g 1 1 -§ 5 ��Electroencephalographic Correlates of the Electroshock H Max Fink, 14.13., W Process MW 1. . *- 14‘1” P: Green, H.D./ 1/ 4.. W. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. =,\ �Problem: In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral reSponse has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalogram before on a day after a treatment” mg card» oﬁuntime intervals during, and following IKE/MA retheir pie-treatment characteristics. treatment at weekly . cords had achieved ‘ .“ -~ 7 1-..9- ~. WW . ~~~~~ . mm ' ~ ' ~ . ”will. . Treatment was stituted at three times per week for 12—20 treatments. West-of atients who failed to develop a clinical response, or EEG changes of significant de- WM m gree, were At ated The EEG 9"“ M" /{“" records were classified for degree of delta abnomality ﬁih records/gang the following indices: “high" "middle" and "low" the percent-time delta; highest percent-time delta :1 wave in the record; highest amplitude ivity. ng * 5"“ Results: M 1) A W‘ -Ax/1 74 ' gs «Ede:94‘»!wa by the supervising M M fxwvm/ positive correlation was slowest delta; and duration of burst act- Kiwi” W W WM i/fal law/Mm a: fin oi‘ .0 lead; any M psychiatrist 3f 1‘41. W dan— Mﬂmdgmmzé “ﬁmmmal? A}. established between the development of ram I’lZunfgy ��In)" l- .J, nmmwmmuwuuunmbmm ammmwmmwammmm 7mm mmwmmgmawmaw ummmvmrmmwmummumw mmmmnmmmm; Wt”.- W mum‘mmammmwmmru-mmm mommimmmﬁwmummum mmmumwuamm.umwu mummmmmam ' ”T” . «mﬁwwwumm,mwmm I EMA : I/r/rp ��(“7 ,. ' 9/“ ;\\ KM 4/ 44(ég/7’M4 4% 4%”‘49444.44.44 /4u44.. ﬁod—n—«a— A: 44.4.44. 14 m @ 4 4 4 L?! («I , I er!) ,1 rd 449-64 -wmm.mm.mnu4— Md ‘chZJ‘M- if éw/AMM -4444 (24 [44/2444] 444 743444.444. ~ 4444424444; (4472442444,) 44 444444 4245/44“ maﬁa-,4 ﬁwjj/WJZM 444444 W \WW’W ‘ 44.4 I 44444444444444 44- £441,148 ‘43 44.474444744- 44.4444/‘ WU) Ker-44444.4. 447444.544” MMW //-/v -n $4244 77 rte—“4.44.4 1/ 44444 45/4 4 ’4 (I) @)(3) 4045': ...44. 4..."... ..... ~ £44444 {Que/7 5:7 82444444 44,444 4 K M444 4244 5447 47,424,, 4244444 ,. �1: 2/1/58 EEG Correlates of Electroshock Process During the past few years, incnasing attention has been given to the ic relation between changes in the electroencephalogram and the behavioral change induced by electroshock. The initial application of EEG techniques to the electr0310ck problem in the period l9hO-l950, was summarized in an excellent review of treatments in 1952, that the who noted rather than the degree of induced neurophysiologic (reflected in the peutic by Chusid and Pacella outcome. EEG) These was the primary number change factor related to favorable thera- studies, largely based on descriptive analyses of pre and post-treatment records, were followed by serial quantitative analyses. In 1951 and 1952, Roth analyzed the in patients during a course of was related to the process ECT and of recovery. In 1953, in the laboratories EEG activated by this- He concluded that thiopental delta noted that induced detal activity at Hillside Hospital, we analysis of neurophysiologic bases of electroshock, based " undertook an on a hypothesis expressed by Weinstein and his coaworkere in which they related improvement in electroshock to persistent states of altered cerebral function. Our �-2... first did studies utilized the amobarbital test show a provement. relationShip and these, parenthetically, between changes in language and Our second index was the ratings of delta index of the electroencephalogram. In our original review of patients, recently reported, significant relationship between the degree delta activity It is and im— and we noted a duration of the induced clinical evaluation of behavioral change and "improvement." our purpose tonight to review these findings; to describe subsequent studies in which various aSpects of the treatment process were the degree of EEG delta activity; and to conclude with a related to summary of the present neurophysiologic adaptive view of convulsive therapy. One hundred and have been studied. a day forty-eight consecutive patien electroshock referrals Electroencephalograms were taken before treatment, on after a treatment at weekly intervals during, course of therapy, istics. until the record had achieved and following the its pre-treatment character- Various treatment procedures have been used, including alternating current threshold and suprathreshold electrodhock; parathreshold unidirectional current electroshock; and subconvulsive techniques with pentothal premedication. �-3- alternating current suprathreshold The K ) and unidirectional parathreshold (Reiter) teChniques are well described in the threshold alternating current patients, without prior sedation, received a methods, for 0.1 second, which was usually sufficient for a petit 20 second second. intervals, voltage increased by 10 volts 90 until a grand mal absence. At up to mal convulsion was induced. just necessary to induce a grand 1&0 volts, 0.1 mal was the threshold voltage and The value. In subconvulsive techniques, patients were given pentothal intravenously asleep, volts Voltage was then reduced to 100 volts x 0.2 second, and increased by 10 volt steps time was current, low and then either low voltage . current of or alternating unidirectional current for ”a 80 nvolts x until 60 seconds; . . 0.1 second were administered for one to three applications. All treatments were given three times a week treatments. Patients who failed to develop clinical reSponse, or EEG changes of treated 5-10 times per All EEG a initially, for 12-00 significant behavioral or significant degree, were subsequently week. records were quantitatively measured for the degree of delta activity. This index was determined by measuring the per cent time delta �.uin 180 seconds of each of three lead combinations, and both the average _and the highest index in any one lead were used; the slowest frequency and highest amplitude delta; Records in the and the initial series duration of the longest burst were placed those with the greatest changes in slow Degree Delta Activity." Delta Activity" and "Low Degree week of The specific limits of ratings of Low degree treatment. 3) Evaluations of changes in behavior were and "High were "Moderate Degree following three slides demonstrate a High-Middle and psychiatrist upper third - earlier report. (Figs. 1, 2, weeks thirds Delta Activity." record obtained during the fourth The The activity - were called wave The middle and lower each range are described in the The into sequence. . made by the supervising resident therapist at the height of the treatment effect. "improvement" were made by these physicians two to after treatment was terminated, and were based on the three four fold "much improved," "Improved" and "unimproved classification of "re00vered," or‘worse." In our initial reports ( , ) we noted that patients who developed �-5high degree delta sustained, activity early, and in whom such delta activity was were evaluated as "much improved" or "recovered" with a greater incidence than those patients who failed to demonstrate significantly delta such activity. These observations are portrayed in slide h. (Slide h; These patients had been treated with a unidirectional convulsive therapy. In a subsequent series of 5b ~ in Graph EST #1) which the degree of patients, a predictive study was undertaken delta activity induced during the second weeks of treatment was determined. 0f the subjects in whom and high degrees of delta activity were induced during both weeks, 67% were eventually much improved; while of those either week, only 30% who did rated as not have a high degree record in were so evaluated. treated with a unidiructional current; third and Of these patients, half were half with a suprathreshold alternating current technique. Slide 5 - (Table I, Exp. Studies) Results: 1. Role of Convulsion§:in Therapy. In the most recent series of patients, randomly selected subjects �-5received subconvulsive therapies instead of grand mal; and both alternating current Of and unidirectional current techniques were used. the subjects who received convulsive therapy, ______had high degree delta records in both second, third and fourth weeks of treatment; .____ during periods. two of the three weeks, and ____ during only one of the Only _____ subjects failed to show a single high record test on con- vulsive therapy. Of 27 the/subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. Low activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. Concurrent analyses of the behavioral ratings showed _____ of the con- vulsive group rated as showing marked behavioral change; while of the suboonvulsive group, 25 showed no behavioral changes. were referred for a second course of therapy. In 1h of electroshock induced high degree delta activity and behavioral change. activity Of the five who all Of these, nineteen these, grand mal showed a significant failed to demonstrate high degree delta on convulsive electroshock, all-showed middle degree records; �-7and two of the five 2. Factor of Type showed a behavioral change. of Therapy: In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock in EEG delta activity was undertaken. The results are graphically presented in Figures 7. The first related the percentage of records in each treatment group during the second, third and fourth weeks of treatment high degrees of EEG current techniques The gave a lower percentage of high degree unidirectional technique was also degree delta delta records. less effective'than the supra- all these periods. Although effective than threshold alternating current course of therapy. who demonstrated delta activity. In each period,threshold alternating threshold alternating current technique, in more 6 and methods early in the Note, that subconvulsive techniques yield no high activity records. In the next figure, the converse is demonstrated. The relationship between type of treatment, treatment period and percentage of treatment group showing no delta activity or only low degrees of such activity. �-3Here, the subconvulsive group is for each treatment period. Supra- 100% threshold alternating current techniques show the least number of Such records in each period. 3. Frequency of Treatment: Another factor on the rate of development of delta frequency treatment. While convulsive therapies were treated given daily or twice daily. activity were initially treated three failed to develop high degrees of delta activity times a week, a number who on all patients activity is the In all more sudh intensively. Treatments were instances high degrees of delta were induced. u. Factors of In the Age and Diagnosis: initial series of patients, it was noted that younger patients, under #5 years of age, developedlgreater degrees of delta the first such activity during and second weeks of treatment; while older subjects developed activity to a significant degree during the third week. week of treatment, age was no longer a By the fourth differentiating aSpect between the groups. With increasing series of patients, utilizing various treatment techniques, the differences between successive groups is largely a matter of treatment technique rather than age. �.9Similarly, conventional discharge diagnoses bear to the rate or degree of delta activity induced. in young schizophrenics, no The relation either delta activity induced older depressed, older schizophrenic paranoid, younger reactive depressed subjects are similar in indidence of high, middle and low degrees not, of itself, a at different stages of therapy. The diagnosis is significant neurophysiologic factor in electroshock. and �combining the data from all convulsive therapies supports this observa— tion. During the second week,h3% of records are high degree delta in patients ho; but only 30% in patients from uo-so, and 18% 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3 of the subjects have high degree when treated 3 delta records times per week. TABLE Variation in % High Degree Delta EEG Records with Age Treatment Pe riod To ho years hl-SO (28) (25) h3% 61% 69% 29% h0% 56% 51-60 (28) 32% 56% 55% 61+ (18) 18% 50% 80% S. Pre-Treatment Record Characteristibs: Previous reports, summarized by Chusid and Pacella; a ( ) rated significant relationship between pre-treatment records characteristics the degree of induced "abnormality? Escords with predominant alpha rhythm or "abnormal" (Chusid and Pacella) or "borderline abnonnal" and �.10- liable to developé alterations in the (Bagchi §£.El) records were more EEG than those with predominantly low voltage fast activity patterns. Rank order correlations of the pre-treahent per cent time alpha in selected leads (anterior temporal - vertex) with the degree of delta activity during the third and fourth patients demonstrated correlations of +.2h The weeks of treatment in h3 and +.35 reSpectively rehationship in the fourth week is significant at the .05 level of confidence; while that in the third week the trend fails of significance, although is apparently indicated. Discussion: Two aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and ﬁne role of electro- encephalography in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the initial studies of convulsive therapy numerous authors, Kalinowsky including Kalmaasky at al,(l9h2), and Pacella gt_§l:(l9h2) emphasized both the clinical and electroencephalographic differences and petit-mal responses. provement in 60 to 80% While grand mal between the grand-mal seizures induced clinical im- of cases, petit mal induced changes in less than �.1125% of subjects. Similarly, the electroencephalographic reSponse to grand mal is one of delta activity, and to petit mal, is delta activity. no In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been described, and each, in turn, discarded in routine therapy. Bergman gt_§l”( ) for example, in describing the electroencquh- eIographic effects of focal seizure techniques noted that patients had normal records "abnormal" records after after 15 such l0% "seizures;" while grand mal seizures. Ulett gt §l° 20 of the - 75% had ), in a ( careful control convulsive-subconvulsive amdy, reported the significant differences in the clinical changes between the convulsive therapies (60-80%) and subconvulsive (33%), and noted the discrepancy response in the two groups, and emphasized the in EEQ significance of the seizure for the therapeutic effect. These studies emphasize the significance of the grand mal convulsion, both for the clinical therapeutic effect and the electroencephalographic reaponse. Recent reports by various observers, and based on a variety of data, support this conclusion. If the convulsion is the essential element in the EEG and �-12behavioral reSponse in electrotherapy, does convulsion is the induced?. In the studies reported here, small differences in both the degree of were observed. it matter in what way EEG delta activity and the rate of the development Clinical evaluation demonstrated concomitant greater degrees of clinical efficacy for the suprathreshold alternating current method to the two other convulsive techniques. 'Other studies have also for various convulsive techniques. shown differences in clinical results Ulett gt_§l. ( ) noted similar differences in clinical results in a study of patients receiving alternating current5'and photic-metrazole convulsive and subconvulsive techniques. He reported improvement rate of Sl%,'76% and concluded, 33% respectively; that the convulsive photoshock technique clinical efficacy. Epstein and Wender (1955) compared unidirectional current techniques, and reported no results but that unidirectional techniques required more had the than alternating current methods. More a new convulsant drug,.Hﬂ 1090, ascribed to greater than electroconvulsive techniques. and greatest alternating and difference in clinical one to two treatments recently, Edwalds, describing it a clinical efficacy slightly �-13while some variability in clinical results is reported, is clear that with repeated convulsions, provement rates of 60 and for the most part, treatment. regard to have noted we may its 80% are induced; may be no matter how induced, imThe differences are small, obviated by increasing the frequency of conclude that convulsive therapy mode of tat - it is non-specific with induction. In previous reports convulsive therapy (EEG is non-specific with Theory) we regard to their application in mental illness, nor is their clinical or behavioral effects. The present studies amplify, therefore, the previous conclusion that convulsive therapies are non-Specific. 2. Role of Electroencephalography in Convulsive Therapy: we have applied methods of quantitative, serial in the studies reported here. change may give similar data, such evaluations are the attitudes of the observer of EEG ( analyses clinical estimates of behavioral While on EEG ) than the EEG. more closely dependent Further application Analyses to other problems in convulsive therapies may provide a rational basis for comparison of different treatment techniques. �We have previously noted in the clinical management of that EEG analyses may be applied patients receiving convulsive therapy. of In our experience, the early and sustained induction of high degreaydelta _ activity provides the physiologic basis for behavioral vulsive therapy. a An electroencephalogram in patients significant behavioral response per week may subjects in change who in fail on treatment regimens of high delta to show three times serve as a rational basis for clinical management. whom con— In those activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a thera- peutically more effective convulsant If the physiologic changes. be maintained may ( ) for a or environmental ( havioral response, even and degree of delta number of weeks, other ) may be assumed to when further convulsive therapy records. result in the neuro- activity is high; and it factors, as personality preclude s satisfactory be- the neurophysiologic substrate is assured; application has been suggested EEG method, may may welllae discontinued. by Roth ( ) A similar for thiopental activated �.1 5.. lhe successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these application for the rational management pharmacologic agents Summary and ( Conclusions: ). laboratories note a similar and understanding of psycho- �to“ Win the Natalya”. Watmﬁmmbun gim nation bum inﬂamed by It: omwgek. _ than olectmnuplaham In 1953. in the and behavioral mum at. dung" mud. Hospital, We“ of ashram-1019a: upon“ at olmtrouhook m mm. swim: ( champs in )1n were band on which may a. Win mm by Romain and his muted imprmmt 1n 01.6mm to tho a» mom” Mom: of paraiamat sum at altered mmbml function. mmmmmmw< Luminanctwnmtmuump how the damn am mum a: ﬁn 1mm den-a activity and mum «alum of huh-mm damp and “W.“ this report to "view than ﬁnding” to describe mum nmrophyuiolom to nuggut aspect: of u. Almanac-1m or maps-oat. of minimum: 3%! On. W bun swans. 3nd It 1. at W at mt Media in mini: m mun-at woo.” In. ”mud; MWmm in mud!“ and and sum). mom“. {Wﬁt acne-anti" «hammock Marni: a". um um baton taunts-ant, and an ammrttmtatmmquadummfmmw-mm �4-2. of therapy meal the noon: Md «mum. 45* M‘ Pntimts- mﬁpn-matnnt or significant . bum its pwtmhmt m dual-tramw- 31w m a; mum activity, mm are «eluded from tho curios. Fm tmww madman «playing 611nm 1) umg/aumam W at. “mm: 3) MW“ mm mpnthnuhold It) mbommlsiva tonhmqwu‘ with pantothnl Wt 813de m tall dumrlhod. 5%: ( 9 ma pmdicttion. Tm ( gunman; ) hummus damning current. method patients, Mind 1w “mats, mu sufficient tor a phi: 3:1 mm”. and, (Maugham); ummmm lawman! In the thrown!!! ﬁtment prior «mum. ~ W of “dam he.“ M915 smug a) nun-mung «mm at. 3* mm“; (90 Volt. M 20 for 0.1 sound), mad Manila, may, it mam-,7, duration: in” 1mm mm a and m]. whim m mama. mmmomd timmcuurytojutincmma gmdmlmtho, thruhold value. 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Wu ( g ) no The rating: mks utter dasﬁfiéum a! wind that patients me wanna �4‘" 1:131 damn 601%: activity . My, and in when m «1%: activity 1.! wow. wr- mlulud a “lunch Wmm or “uncured" with a grater muaow than than patient: activity. Thu. chomum who such delta m pawn-wed 1n and. h. (811* In Gnﬁ 511* s In the ta damn-tutu “mutant.” '1' M ”J (km. 1, nut wont. «run or puma“. ms Studio.) mm «new plum“ w tame m nmsmmmy mind .mmmvo thmpiu mm or mad Id; Ind both atom-$1M . W WW“ mt Man. RN and mod. at tho 1:? mm at: who mm mm ”mm haunt" than”. 9 hid high dome in both «ems, mm and fourth mks at truth-at] 1.2 wring hearth-thrum, mummly'motthlmtpoﬂm. thin-In “their? lubdwtlnuodto Muuuglchiwaogrudﬂumm convulnu thunpy. at tho 2? aubjootu who mum Wain mum, Wt, m �.5. dam-mud new or high down 4.11.: nativity mom or mutant. in! now of during both ﬂu my and: mu activity m not“ in than “hm new and third min at imam. and during the fourth elm-1n; in 8 ”Mo-ct: not. Conoumnbmlymatmbmmﬂungu mmwotthch'? a the mini” map rum u showing mud behavioral champ; or no bah":m1. of ”320mm" group, 25 at the 2? ma 101:1 mm. at the 1m» amp, 19 m Mum m- a mad um want.- m than ' “than”. Inlhotthou. activity and :11 kind mmmwkmmmmmmu mm a “Mimi Wharton]. W. in damn-at. 01' tho tin Ibo m dom- dolu nativity an convulsive deutmmwk, mam-a M61. diam records; and hoof this ﬂ“ mandahwiml W. mu, «multiv- thanpy Wad simian-um mam:- antics-:1 change! macaw mini-ll with 3m Moral mango, and W with” in km or mum placat- moving than-aw, 11de both it: MYI mm mud 8E0 «an inﬁnity. mum". «1m nativity, wan. auboomuluvo EEO ma rum“ to «mum mum-:3. «hang: m plan“ an mum �In via or ﬂu mow of unwock Mama» .uployod, And the mun-uni}: ham we «1%: activity mum at +4.2. «has a: typo a: 010%ka an max-nun. Th. gun“ The Won}. "upon”, and the mammal mmw m at gummy pmmtéd in man- 5 ma 6. first agar. ulna: in tub mutant this Walnut typo in 8W dating the unsung. EEG an. activity. mutant um: daunting «mat It mmknshald high.” mom: In each period, otnncth and with numung mt at thmshou oft-cu" thin tho lupnﬁhnlhad alumnus mnem- m tho ‘ ' the tau-angst; m 1m mm, in out mar-cum; curl-mt. tmtamt being not: «mm than the tux-«hold 11th Suboomumn #:00QO yield no high dam «in: activity neural. cum-at. uthod only curly 1n the Mum WWW“: treatment the am come of mumpwmng pox-«near wh/mpwoungno «Inactivity such trut- ”may of my: (low mu mom. What with Winch 1m). nun-mt ported; of the «new. third and fourth molt: of mt Whiting mm dam of » a: nativity. Kin, tho «boom!» in map is WW- than ' «01:1:de 1005‘ for «ch tram �.7. ponod. “puma-«hold uunbor of man alumina current handgun chow th- but. rcmd: in «a: period, nth tun-had ma mmm “chum. in how. f Tm 3. ts Author factor on the truancy at tmtmont. tins a cock, u mater on convulsive nu of mama: of delta activity in tho While :11 who patents wore initially treated thm fund to therapnn vor- dculop mu! demo- or :1qu nativity tmud' non mun-may. In aim Inch uncut-,- an 3110:: an); or win any, and in «eh instant» ﬁddle or my: damn of 601%: activity an mm. 8mm- ma comm won prenatally dumtntod by mu. ﬁg... ( ). m1 cumu( mnmuta k. W' In tho )_. mun unit. or patina“, 1%. was mind that. younger patients, Mr 16 your! at ago, dmlepod grater dam of delta nativity during thnrst. and poems! activity to of & tnatnnt, m at “about; 111111. older subjects. donlopod inch signiﬁcant dogma during the third weak. 3: the fourth not m was no 10:15:01- : dittounuatiug ”poet bottom the groups. �~8— Gcnhdnmg “I. data from an. During tho undo:- mom convulsiv- m. h)! a! mm m raw demo dam in mutant: the as. of hot but only patina“ 61 and. thonpuu supports this obumum. mm no longer present. and 305 in ptﬁmto rm 1:040, In the third and fourth ”aka, the and 183 in antenna» an “mantel: 2/3 of the lubjlctl but high degree «It: «and: uhon trotted 3 tin” par wok. mu Yunnan 1n 1 8131. Dog“ mu ma mm with La * m m mm we no M 51+ 0 m be as) has (as) m (as) (13) W 1:2 as M 691 he: saw 32: 5a 95:: 18: 50: M no durum in 1mm of high dome mom 1: significant u .013 andhurthtruaunnd .OSShomthoummtndthird mic: or tun-em in patient: «or 50 your: at nan) but is not uwimny manna“ 61:1on for the“ put-1m in groups and» 50 yum. �.9. mum "pom, mm by Gama and mu“ )mm . IWmt mktimhip batman pmmst. aunt heard Mauritian and m m W “nbmlity.” new nu: mm: at or 'abnoml' (Ohmic! and alpha mm M113) or “bomﬂino ulnar-t3! (Hum 91 9;.) Wanmmummnunmummmmmum may In than 1w may tut activity ”than. «an or imam“, abduct: who“ pm-vbrnmcnt domain-1m um um «hazy apn- or space an activity nah mam.» Eight A manic mimic or the mush pro-Manta“ ﬁnality. talcum ,mﬁk order tin am in «new land: m pro-smut“ ”mutton: of an} mutton. alpha and pu-mamnt (anterior Mignon). worm) with the 601m activity during the third and tour «the cf gaunt: dalmatﬂm man of than and «It: antivity «run, and for more mm «It: activity an mandala-n dam. of or are not nausea in an gunman. Won. that in puma“ without par aunt mm... er mama-ac «any. m tmtod with emu”. taotmiquu dmlopod high amoe- at palm of a more! or +31; and «35 tmﬁmt mpoctinlm in h3 �.10. m mumumrmmmuummtn the 4351.701“ Widen“; thl while that in. tho third ‘at dwiam. although W6 a mum. W: M «poet- at” than the not an. that”... mt dimuon; tho Winn“ of, whim 1n the 01.6%!“th pm“; and the r910 at «an nontra- W! mopbnlomph (1) 1n the In the including mama: and may or convulsive therapies. mud and“: of cumulus." therapy lawman whim-c. hum-kw the clinical Ind «Mom: ‘ ﬁg. (19%), and Plum 5;. (193:2) aphasia! bah 01¢“ch diatom bum the grim n.1, mpoutm “WM mammmm-Wamm 1mm"mntinwtomofmu. ptﬁtnlindwod Weamhlstmaﬁof mycu. mm. ﬂu chem-pulmyhle mm. to m a! mu ”Univ, and {no pout m1, 1: In subsequent. you-I, various no delta grand an in mum. W131“, has! CW, mﬂmtiml “hunting, mopohr unwitting. foul contain" techniquu have been �.11. thd in mum. than”. Barman 33 3;. mum, and nah, in turn, ) tar example, in mung an cloutWaganc «not: or ( focal "inure manna-u Mad that art-r a), 15 inch "maumr' m1- "isms. Matt 93 g. study, repel-Md a halving ( of patients had - 753 had “abnormal" ), in a ammo-at autumn mm mom _ max-d: utter grand «ram comm). «muywmbeomhin 1n «mm-:1 roman "a! panam- amid" that-apt“ (W) ma theta minus abnormal-1v. (331). or control: (381). no tho two 70 70% mp3, and new tho war-may 1n the 3m noon-- in mum the signification at ﬂu loam for tho thanpuutic strict. Mint additional upon-h 17 various ohsarvm, band an a «ﬂaw of (Rain-“1n and an, alpha“ th- awinmaa at tho ”amnion. m, Roth, mung). rpm, the mm. mnem- um minim par a, an a:- mu tho signiﬁcant physiologic mu mm m the has for thirty-nut: If an. convulsion «fancy or 'oamluva than-qua." I both it tho mud chant/1n mu m and in tho behavioral "903380, does m node of inﬂation at the role in um “spam-7. In the chads." ”ported ham. uny “mama Min-mm in both the dam- ot‘ “ism play any Oman Em hut-.2 sun-u- mu activity �.12. the and at» of 11:»: “mu m abut-"d bum Miami mod: of imitation or grind u). m. m an m. pmidu but: far the mama Mm't tint .mpnthxuhold m @0an album-ting current “chum m mt “tutu. m We cmuloiva than”. “the: India ban the sham moms cumulus.“ “Wu”. exam in clinical results for 813% g 51.. ( ) mud 31:11.11- mum. ms; in mm:- mdiu or Mum waiving atom-um mt mmlpin and mumml mvulnm m! mbmvukin tech.- 1i: amen niquu. no "ported Wat. m. at $73. 763 ad 331 yumﬁuln mam ﬂat the Wain Manhunt: Wm bud tho amt.“ clinical «tinny. non may, W, doom-thing n m «walnut: and drug, a: 1090, named to it a clinical mam; unghuy gmur um dawns." wanna“. w studios an have mm mm m «Wm mam-d by Mom Wm» hm! um manna” of latency, duration, prom-mac In of claim: or tonic ammt phi“, am, two. um; not :11 mind In}, From that. Sundial, it has Mm him: at. minimum; and that : �:31)’ W; m mm a not an an or w“ cum and than my unset dim-mt. taut-mt aimed. Dunn-mo mum panama dutannm in Mahala «rout. of tho Mar mm" 01' this probhn an 11: 9'08“”- thn this "unmey in clinical 1:3qu in ”period, it in clear ma, ups-mt. raw or - in chum-d. m dﬂhmu human var-1m W or mutant m 3.311, and, for ma most part, be mm w increasing the 1:qu ﬂnt with rap-wad comma”. no author he! 60 305 may com!” may: in nonwith mum to ﬁlm W tho minim in Mad. The simiﬂmt or amber at mutants. it. any Mic «mm that amt u the bran W Mum. ta the uranium, and not an mat mamas-1mm mama“... Inwim mm (3m, Theory) in we: noted that commits.” map? 1: l1” 1%. application in with mam maul, m: in its clinical and with Wticity of convulsive. ﬂan-pin. to I bender-1 «facts. no pron-at studs.» «3mm winters, the pram» at the ”and comm �U. have appliad ”mode or quantitative, serial me the m1: studies} mporud here. We in clinical estimates at behainnl change ‘ may give of tho xinihr data, obumr ( ' ) than an m. Us lava dependent an tho m a prawn/mum]. buns for Miami tmtmnt technique“ pmionlly noted that mm mm: my be applied in the clinical magnum. or patients receiving oonmlsivo therapy tin I um tad» Wr applicttion at m analyse: to other pmhlm in convulsive thumps.” compariaon of am such evaluations am @mnua ”ported here, the curly and ( )- In sustained induction at high dam,» a! do“: activity provides the phyaiolagic bait for behavioral in cumulative mmpy. «mango fail to thm char 3 mu. increasing a electroencephalogram in patients uwﬂmt Wen]. times per week aunt. In An w when mutant. tummy, Mummiaogic more big: delta activity has withholding effective «walnut. If changes. it my be 31an for tmtmt ”31mm of norm as a rational basis for clinical manage» mbaem in thonpeutiany aspen”. on who o. tho dome of nmbor of not. been induced, pmdimtien, 0r shifting to mum, my resuli in the mm activl ty is 11139 mks, nth» future, and a punctuality �~15— ( ) or mama}. ( behavioral response, and ) my be can when the «me! to panama. a utiatactory Wide-go mbctrato is assured; further eomhivo therapy my will tion has bum suggested by an Ruth ( moons-tn]. application of convulsive therapies, ) be discontinue. m gaunt: similar applica- for buoyant-.1 activated 330 record» quantum." ‘m tachniquu to bu led to their application to nth“ hemp-us. accent reports from than laboratories not. for A as MW“ similar applicatim mum-1 moment and man-Italians of paychephameolom ( ). �416~ gagglnnianus 1.‘ In aerial qynntitativn analysis of aetitity in degroe of induced EEG delta anhjocta receiving variant convnlaivo therapies, a poaitdvu relationship betuoon the digrea o! indueod delta activity and bath tbs dagroe oi'bohavioral ehnngo and ratings of impruvamsnt 2. and induced grand mﬂl convulaian An is reported. 1: elscntinl for both the EEG behlviaral change. 3. Th3 rate a. and dogrcc‘of induced Hbdo dalta activity is dependent upon: at soiturc inductian b. Fruqunncy at treatment a. Ag. 0! lnb3oct d. Pre¢treatmsnt h. It is pmuvidoa a recommended EEG record characteristics that aerial quantitative electroencephalography rational basis both for the study and clinical managenant or variaus paychodynlmie therapies. �II: 2-5-58. 0131/11.!" Correlates of the Electroshock Pincess EEG During the past feW'years, renewed attention has been given to the relation between changes in the electroencephalogram and behavioral changes induced by electroshock. In 1953, an analysis of neurophysiologic aspects of electroshock studies ( in the laboratories at Hillside Hospital, ) in was undertaken. were based on a hypothesis expressed by Weinstein and which they related improvement The his co-workers in.electro$hock to the development of persistent states of altered cerebral function. In thii initial EEG study ( ), we noted a significant relationship between the degree and duration of the induced delta activity evaluations of tIhI=HIIEIEIIEZl=E=IIi§"improvement." It is and clinical the purpose of this report to review these findings; to describe recent studies in which various neurophysiologic aSpects of the treatment process were assessed; and to suggest the application of electroencephalography in.studies and rational management of physiodynamic One hundred and been studied. a day therapies. forty-eight consecutive electroshock referrals have Electroencephalograms were taken before treatment, and on after a treatment at weekly intervals during and following the course �-2- until the record of therapy ﬂag»! Patientsbﬂwyhgug‘pre-treatment IN EEG - . eggpktfd’ef’d .,,.,;‘""ﬂWh . activity, an...“ M"M ﬁignificant asymmetry were MW’O‘Mmmws-‘W pre-treatment characteristics. demonstrated slogwgave or spike . WW its had achieved series. from the { ‘ {V .up-w‘ . Four treatmentt procedures employing g different types of stimuli have ' i V . 1) been used; /alternating current at-threshold strength; 2) alternating current at suprathreshold strength; unidirectional current (parathreshold); 3)- h) subconvulsive techniques with pentothal premedication. The alternating current suprathreshold are well described. ( ) and unidirectional parathreshold ( ) techniques In the threshold alternating current method patients, without prior sedation, received low currents, (90 volts for 0.1 second), usually Sufficient for a and, if petit mal response. At 20 second intervals, voltage ,_ thewmwmm necessary, duration! were increased until a grand mal convulsion was induced. In subconvulsive techniques, patients were given pentothal intravenously until asleep, and then either voltage unidirectional current for ); or alternating current of seconds ( administered treatments . low l 80 (30 to 120 volts x 0.1 second were for one to three applications, for a total of 2).; to 36 petit mal �All treatments were given three'times a week Patients treatments. clinical response, who initially, for 12-20 failed to develop a significant behavioral or or‘EEG changes of significant degree, were subsequently treated 5-10 times per week. All records were quantitatively measured for the degree of delta EEG Ml WM! We! MM‘AWW activity Masada—WW ‘ delta activity, "moderate" or "low" degreet . l‘ . . I i 5 3 . The 30W week of (Figs. 1, treatment. 2,3) Evaluations of changes in behavior were made by the supervising psychiatrist resident therapist at the heigat of the treatment effect. The of "improvement" were made by these physicians tw0 to three weeks treatment "high, " following three slides demonstrate a high, middle and low degree delta record: during the fourth and M was In our after terminated, and were based on the four fold classification of _ "recovered," ratings ”va ”much improved,"nand "unimproved initial reports (' , ') we noted or worse." that patients who developed �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta such activity. These observations are portrayed in slide h. (Slide u: Est #1) Graph Ecsults: The “W etweeni“! relation neurophysiologic 5" . . and behaVioral response W111 be assessed according to five aspects: 1) 0 2) Type of Convulsive Therapy 3) Frequency of Treatment h) Factor of 5) Pre-treatment Record Characteristics ’Of Age the uz’subgacts’WHo”retaived‘ccnvuISive‘tnerapy, 7 nan nigh delta records in both second, third two of the three weeks, of the u? subjects and fourth weeks of treatment; and 13 during only one of the failed to show a UEgIEE" 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta sudh activity. These observations are portrayed in slide h. (Slide u: Graph Est #1) WWW Results: 1. convulsive vs Subconvulsive Techniques: In the most recent series eizpahaaaih randomly selected patients re— ferred for electrotherapy received subconvulsive therapies instead of grand mal; and both alternating current and unidirectional current techniques were used. or the h? subjects who received convulsive therapy, delta records in both second, third two of the three weeks, and show a had high degree fourth weeks of treatment; and 13 during only one of the of the h? subjects failed to 9 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �.5demonstrated middle or high degree delta Y3...” of treatment.§ x Low ( / activity records during any week degrees of delta activity were notedhiﬁwthree subjects during both tgexsecond and third weeks of treatment, and I“ .,.,_,_.,.-‘ ”mud,” Y , “W", v V .V,. inAB subjects ,, ’dmﬁgthefourth Week alli'lll=l==I-I behavioral ratings Concurrent subjects in the convulsive group rated as shining showed hZ of the h? marked behavioral change; hat ‘ while of the subconvulsive group, , ioral changes. of therapy. the Of latter 25 of the minimal or no behav- 27 group, 19 were referred for a second course In 1h of these, grand mal electroshock induced high degree delta n...» . 4,7,.“ .;...-....‘..,r,, 9...“; .. n .mm ., 3., ,. .~-wms...mu m-.. _,. ”a”. .. activity "Walnut... all showed a V.-.~...,..,..~..,.u.ma..~m.—.~..._..Mn...._,.m.. m failed all 4 f. ./ ..,,,.A. . .- significant behavioral change.#fgf the five t. ' to demgnstrate high degreewdeita “if I/VFI' My" : ’ activity a” , Thus, convulsive therapy induced showing on five . Mm)“.- . showed a behaVioral ”n,mmwm .,wmlumwﬂun. significantly greater behavioral changes neither an EEG EEG delta activity. Furthermore, or behavioral response to subconvulsive therapy, showed both the-EEG and behavioral changes therapy. convulsive”2lectroshock, delta activity, while subconvulsive therapy induced minimal behavioral change, and minimal patients 51/ Who~~ I” “(my We“ EEG ,4 .2 shdwed middle degreeprecords; and two of the associated with """ ------—--- 5"“ , /,/r ,//'change.; a r and when placed on convulsive r. e r. a 7.“, �-b2. Role of Type of Convulsive Therapy: In view of the variety of electrOShock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock undertaken. The first The delta activity on EEG results are graphically presented in Figures 5 was and 6. figure relates the treatment type to the percentage of records in each treatment group during the second, third and fourth weeks of treat- delta activity. In each period, ment demonstrating high degrees of EEG treatment with alternating current at suprathreshbld strength gave the highest percentage of high degree delta records. ieeetment'uéth-unidirect- ional current and*lith alternating current at threshold strength was less effective than the suprathreshold alternating current technique, in each period; a the udtﬁiEgﬁgie;;%reurrent treatment being more effective than the threshold alternating current method only early in the course of therapy. Subconvulsive techniques yield no high degree delta The next figure demonstrates the same activity records. relationship by measuring the treatment per cent of each/group showing no delta activity or only low degrees of such activity. Here, the subconvulsive group is 100% for each treatment �-7period. Suprathreshold alternating current techniques number of such records in each period, with threshold show the least and parathreshold techniques in between. 3. Frequency of Treatment: factor Another dn the rate of development of delta activity is the frequency of treatment. While times aweek, a number who on convulsive therapies all patients were initially treated three failed to develop high degrees of delta activity were treated more In nine such patients, intensively. treatments were given daily or_twice daily, and in each instance middle or high degrees of delta activity were induced. previouSly demonstrated by Pacella gt El. h. Factor of In the ( Similar EEG ), and Callaway ( ). Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta first correlates were and second weeks cf activity during the treatnent; while older subjects developed such activity to a significant degree during of treatment, age was no longer a ﬁne third week. By the fourth week differentiating asPect between the groups. . �-8data from all convulsive therapies supports this observation. Combining the During the second week, under'the age of ho; h=t===:;.30% ' patients "www-W” 9,.0. .. 1M 1‘ . at . on.» . , of records are high degree h3% M 61 and over. In the n.-“5.”. m1”- A, “W third in patients from delta in patients WW WM M ‘4 treated 3 ~ ‘ , W. W"; A .W‘ andﬁdpproXimately 2/;xtf the subjects n:/}pﬁger present M” when cue-yaw and fourth weeks, the differences arep ~ «idelta records in hO-CO, and 18% timéé per W99§° ,ffﬂ have wwww‘t4m HM\“ " ”a“ “by" ‘ high degree W“”w" ‘f" Mama.W ”Q h/‘ WWW, Wn.ﬁ,,,,.,-r..m TABLE Variation in % High Degree Delta EEG Records with Age * Treatment Pariod 5g: ' in is. 2:2 are 61% 69% (28) m ul-so (28) 29% m 56% 51-60 (28) 432% 56% 55% 61+ (18) 18% 50% 80% To no years * The difference in incidence of high degree records is significant at .Ol% between the second and fourth weeks and .05% between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. �S. \ Pre-Treatment Record Characteristics: In earlier studies, a relationship between pre-treatment record characteristics, notably degree of abnormality or predominant alpha, the degree of induced "abnormality" was noted ( , ). and g In these series of patients, subjects whose pre-treatment record demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniques and seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertakenjémk order between pre-treatment alpha and correlations of the pre-treatment per cent time alpha ée—Ge-lMed-ﬁeds—éea-teWﬂ—aemﬁ-with the degree of delta 4. patients demonstrated correlation‘ of . 95’ M activity during the third-and four weeks of treatment in M/Wima . 4'“ M +.35’ if ' I43 f5” 4d” �-95. Pie-Treatment Record Characteristics: Previous reports, summarized by Chusid and Pacella,( ) noted a significant relationship between pre-treat ment record characteristics and the degree of induced "abnormality." Records with predominant alpha rhythn or "abnormal" (Chusid and Pacella) or "borderline abnormal" (Bagchi 33 13;.) records were more liable to develop alterations in the EEG than those with fast activity patterns. predominantly low voltage ,1 In these series of patients, subjects whose pre-treatment record~ demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniquesﬂand seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertaken'éxk. per cent time alpha degree of delta order activity during the third—and patients demonstrated correlation( of 05’ correlations of the pre-treatment WWWWith a, , between pre-treatment alpha and M/W/mu . M the four weeks of treatment in 4'“ W +35) [a ' 1.13 ”(tyne/l @4’” �gr.“ 3 r% \ -1¢¥“""‘MI‘CWEHi ‘ — n—fJ‘r‘mWﬁ“ is” w? \\\\- r" ”y, wwﬂ:;¢"‘”w {awr rth geeﬁ'is Significant at the IQ§hlével of . the relatidﬁship in The , .10- ,_ PMW’MW v . . . > I? if“? f e . . iﬁcénfidence; while thatﬂin the . ”His" ”419"“ M third . a"? "’1’ if.” . ﬁx ,q/J’WNW lynx-"”61 (”fl ”M" . . ' . the trend rewindicated. ’71" a/«am “Mmmmmwmm“minim“..m“, Discussion: aspects of these studies warrant discussion; the significance of Two the convulsion in the electroshock process; and the role of serial electroencephalogragh in the rational management and study of convulsive therapies. (1) Significance of Convulsions:’ In the initial studies of convulsive therapy numerous authors, including Kalinowsky gt_gl. (19h2), and Pacella gt ﬁl‘ (19h2) emphasized both clinical the and electroencephalographic ‘3' petit and , .. “7:4!“{ "5 “vﬁﬂu.. “2. ‘ ., r , mal responses. ',>~'(:.w ’ i differences idwmaewa‘huwmmmm. I'“.ﬁ:W’"amhma-~vmmm~a While Sa-‘iukw‘ﬂ-‘Ih-m‘yow'wwmmmww“ ‘ anthem," between the grand mal. k» " qut‘w' cal 'mal seizures inducedngﬂmd c 12 prove- gﬁetrﬁ‘w afﬁx), ‘ ducedﬁphaﬁges MW“ in less than 25% 0 4745“ M M one of delta activity:‘and to petit mal, is no delta activity. . WW 7 mm M In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been �.11described, and each, in turn, discarded in routine therapy. ( gt al. for example, in describing the electroencephalographic effects of ) focal seizure techniques noted that 70% I after mal Bergman 15 such of patients had normal records 4 "seizures;" while seizures. Ulett 23 El. 70 - 75% after had "abnormal" records grand ), in a careful control convulsive-subconvulsive ( study, reported a significant difference in clinical reSponse of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive w” as; 6L. (33%).{es—eontrele-438%92J He noted the discrepancy in the . . EEG response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. Recent additidnal reports on a by various observers, based variety of data,&emphasize the significance of the convulsion. (Weinstein and Kahn, Roth, Fleming). Thus, the evidence indicates that convulsions per se, are’or reflectlgthe significant physiologic events which are 0 the bases for therapeutic efficacy of "convulsive therapies." . both If the convulsion is the essential element/in the . . behavioral reponse, does the mode EEG and in the of induction of the seizure play role in this reSponse?. In the studies reported here, small but cally significant differences in both the degree of EEG any dLr statisti- delta activity �-12— and the rate of its ' development were observed between different methods of induction of grand mal seizure. Ulett gt al, ( ) reported an improvement rate of current convulsive technidue, but and concluded 76% 57% for alternating for the photic metrazol technique, that the convulsive photo-metrazol technique had a greater clinical efficacy. convulsant drug, PM More recently, Edwalds, describing a 1090, ascribed to it a new clinical efficacy slightly greater than electroconvulsive techniques. "we have further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance of clonic or tonic phase, apnea, seemingly not equivalent; and a etc. All grand mal seizures are �‘ .13seizure is not an "all or occur and these may none" phenomenon. Different; seizure patterns reflect the differences in physiologic effect of the different treatment method: Further studies of this problem are in progress. While that with repeated convulsions, of 60 - 80% are obServed. The or number of treatments. We Specific with regard to the differences is the brain may way is clear no matter how induced, improvement are small, and, for the most part, element it this variability in clinical results is reported, may be between various types of treatment obviated by increasing the frequency conclude‘that convulsive therapy the convulsion is induced. change subsequent rates to the convulsion, The and is non- significant not the agent ‘ \ . 92;}, \‘> �-1u- 2. Role of Electroencephalography in Convulsive Therapy: have applied methods of quantitative, We serial EEG analyses in the studies reported here. While clinical estimates of behavioral change may give similar data, such evaluations are more dependent on the attitudes Wé‘v M30 Further application of Wt. of the observer ( 3 than the EEG.‘ EEG analyses to a (5M basis rer'ZZ‘ other problems in convulsive therapies'mey providﬁérational \ MM41$;r’.11.~:a"3"‘“é-e?fof we have clinical different treatment techniques. previously noted that management of EEG analyses may be applied patients receiving convulsive therapy ( in the ). In the experiences reported here, the early and sustained induction of high degrees of delta activity provides the physiologic basis for behavioral change fail to in convulsive therapy. show a three times per ment. An electroencephalogram in patients significant behavioral response week may who on treatment regimens of serve as a rational basis for clinical manage- In those subjects in whom high delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a therapeutically more effective convulsant method, neurophysiologic changes. If the it may number of weeks, be maintained for a degree of delta may result in the activity is high; and other factors, as personality �-15( ) or environmental ( behavioral response, even and ) may when further convulsive therapy tion has been suggested by , _. *MM‘ ,nm4.~~-> ....~,..~v~m be assumed to preclude a satisfactory the neurophsyiologic substrate is assured; may well be discontinued. Roth ( ‘) A similar applica- for thiopental activated «AW‘~ EEG records. V . The successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational agents.( ). management and understanding of psychopharmacologic ..,. awuwlw'uuw... �-16Conclusions: 1. In serial quantitative analysis of degree of induced EEG delta activity in subjects receiving various convulsive therapies, a positive relationship between the degree of induced delta activity degree of behavioral change and ratings of improvement 2. An induced grand mal convulsion and both the is reported. is essential for both the EEG and behavioral change. 3. rate The a. and degree of induced Mode of delta activity is dependent upon: seizure induction b. Eiequency of treatment _ c. . 'h. It is Age of subject d. Pre-treatment recommended EEG record characteristics that serial quantitative electroencephalography provides a rational basis both for the study and clinical management of S various pix-Lodynamic therapies. �EASTERN PSYCHIATRIC RESEARCH ASSOCIATIQNHINC. OFFICERS 1957-1958 DR. DAVID J. IMPASTATO. SEC'Y-TREAS. 40 FIFTH AVENU’ETNEW YORK 11. N.Y. DR. LEO ALEXANDER. PRES. ‘33 DR. LAWRENCE H GAHAGAN, ASST. SEC'Y-TREAS. 164 EAST 74TH STREET NEW YORK 21. NHY " MARLBOROUGH ST.. BOSTON. MASS. i DR. THEODORE R. ROBIE. PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. DR. DR . DR. DR. DR DR. WILLIAM L. HOLT. JR. ‘IST VICE‘PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICEsPRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. Y. 0 0.0 COUNCIL JOSEPH EPSTEIN EMERICH FRIEDMAN WILLIAM FURST' "' PASQUALE LgorE‘sA'rA NICHOLAS Locngeio '* EVELYN‘IV'EY ' w O .0 TWELFTH SCIENTIFIC MEETING; THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SgHARP NEW YORK UNIVERSITY MEDICAL SCHOOL ALUMNIHALL-‘HALLH AII 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) o '0. “O o 0‘ PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing Completion Test (An Incisive Interpretation of the Unconscious) Ferruccio (Ii Cori, M. D. Discussant: Dr. David Wechsler 3. Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detail do you use in your examination of patients and the recording of your findings? ��EASTERN PSYCHIATRIC RESEARCH ASSOCIATION. INC. OFFICERS 1957-1958 DR. LEO ALEXANDER. PRES. 433 MARLBOROUGH 5.," BOSTON. _ MAss. DR. DAVID J. IMPASTATO. SEC Y-TREAs. 40 FIFTH AVENUE NEw YORK N. Y .f'W‘" 1“" AssT I-I SEC‘-Y TREAs. DR. LAWRENCE GAHAGAN 154 EAST 74TH STREET NEw YORK 21. N. v. II COUNCIL DR. THEODORE R. ROBIE, PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. JOSEPH EPSTEIN DR.’ EMERICH FRIEDMAN DR. WILLIAM FURST DR. PASQUALE LOTESTA DR. NICHOLAS LOCA'SCIo DR . EVELYN IVEY DR. WILLIAM L. HOLT. JR. IST VICE-PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICE-PRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. V. , 0 0.0 .0. I ' ‘ L I O 0.0 TWELFTH SCIENTIFIC MEETIN‘C THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SHARP NEW YORK UNIVERSITY MEDICAI_,,SCI:IQOL ALUMNI HALL— HALL "A" 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) O 0.. M 9 0.. PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing CompIetion Test (An Incisive Interpretation of the Unconscious) F erruccio di Cori, M. D. Discussant: 3. Dr. David WechsIer Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detaiI do you use in your examination of patients and the recording of your ﬁndings? �”mm: W A! W R433. mm, W 8mm. an. «mm W Main ~me7 WMMaotmm mm, mm mw mum at can a, m. mi» mm mm. 3.1. mum-«math-Wwwmnmaumﬂum, Wéym. ��to to m m (as) 29: ms (as) m m am (at) mm M «a (13) W «pork, m M m sea: M W mmwmama mm. ma: (.3) wanton-«arm “Manna mmmmmtm, “W“ (3) or “box-during my (11) mm: m not: 1m 1w to «:1an aluminum in tum than than with mew voltme- M nativity mtma 9”»th rum m nmm mt. «Wm mun WWW mmmmdmtho gamma. mum: mam-m Wﬂthmmutnmmmawoftmmmwm at Mt: «ﬂier, for “W pom, m mama In than not-1» at Fatima, subjects nativity, activity mad mm vim m Wham; Witty. m 01m awe may“. at mam anm mmmwmmmuwtmtymmm. mm A 4!- this a: my: damn words Miami. It mm awmmehonmdmdfmmam .WMMQMW Tha diffemm in 19 mathmmdmamthmmmmrﬁemufmymu mmmwmrmntmrthmmmmmmmm. ��‘ mm Ammqmuutmmmemmwuwm mm ”tamer mm mm W WW. momma 5.» tommmetthaméfwmafmuﬂumm.m 1. mwmmmuummmmm ,3" mtnuwdwatmwmu ”£2,“qu memumm. mm: WWW“ wwamm M Huh b. a. 1300th m1. um Mam” mum“. W:- & both for the. candy and mm Wm at ��Electroencephhlographic Correlates of the Electroshock Process MB): Fink MOD. and Martin A. Green PM). From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, in part, by grant M-927, National Institutes of Mental Health, National Institutes of Health, [1.8. Public Health Service. Aided, at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. Read E: 2- 15- :2 New York, N .Y. �EEG Correlates of the Electroshock Process During the past few years, renewed attention has been given b relation between changes in the electroencephalogram and behavioral changes induced by electroshock ( l-h ). Based on a hypothesis expressed ﬂie by weinstein and his coaworkers (5% in which they related improvement in electroshock to the development of persistent states of altered cerebral function, analysis of the neurophysiologic aSpects of electroshock an was undertaken in the laboratories at the Hillside Hospital in 1953. In fig initial EEG study,” a significant relationship between the degree and duration of the induced delta activity and clinical evaluations of behavioral change and "improvement" was reportedayeThis study was based on convulsions induced by a unidirectional current instrument '(Reiter). Subsequent eXperiences with alternating current techniques demonstrated differences in the rate and degree of development of delta activity. Age of subject and frequency of treatment were also factors in the EEG reSponse to convulsions. It is the purpose of this report to assess the role of treatment method, age of subject, frequency of treatment and pre-treatment EEG record Characteristics in the EEG and clinical re- sponse to convulsive therapy. Method: : hundred and £e££f3i=irt consecutive electroshock One been a day studied. Electroencephalograms after of therapy Patients wave ﬂ a treatment were taken before treatment, and on at weekly intervals during until the record referrals have had achieved its and following the course pre-treatment characteristics. in.whom the pre-treatment electroencephalogram demonstrated slow AsymmeM/ or Spike activity, or significant aaaynetcy; were excluded from the series. �M Wﬂnﬁ rig/L Wm MW W Jam ”WWW- ﬁght/M4 W M WWW W (W) Jam MM WMWWW/ WWWW2AW W; Jaww W ,asJ—u—m 4/— .49 «3'44» :L WWWWW.%II: WWWWWMMW W ﬂéﬁw‘jﬂ. W’ W .WM MAJJA MM Wag/d �-2employing different eatments proceo Four ‘ van-us of stimuli alte .‘. ‘. current at t-- old strengthf" al - ‘ a current at suprathreshold ‘directio: current ngth; 4 w (parathreshold); t) s unvulsive techniques with -ntothal premedication. have been used' , ~. _ _ nat' The ‘ - ‘ alternating current suprathreshold (7) km W ﬁatients, unidirectional parathreshold and MW b‘ currenté’ ., without prior sedation, received for? second), usually sufficient for a petit mal response. odes second 3", (90 volts At 20 W intewals‘voltage, and; if necessary, duration! ale-re increased . . , until a grand to "Nu“ In the threshold alternating current (8) techniQues aae‘ well described. method ‘ mal convulsion was induced. mwmnl- The “voltage and induce a grand mal was the threshold value. be necessary In subconvulsive techniques, patients were given pentothal intravenously gor (>0 until asleep, either seconds (8); or alternating were administered petit and then for one to three low voltage, currentoi' 80 unidirectional current to l20 voltsﬁrézsecond applications, for a total of 2b to 3.6 mal All treatments were given three times a treatments. Patients week initially, for 12-20 failed to develop a significant behavioral or m m 55;, Mew $3 :13; gm W, were subsequently who clinical reSponse, or Jo treats (1% times per week. All activity. EEG ‘ b records were quantitatively measured for the degree of delta The "records were evaluated as to whether they demonstrated "high," "moderate" or "low" degrees of delta activity, according; to criteria pre- viously published (6). Evaluations of changes in behavior were psychiatrist and made by the supervising resident therapist at the height of the treatment effect) �, WWW WM/Jéw A?%MWW%4 /¢(WWW’MW” JKWWM HQWWWi ' ‘ �-3... and were scored as "marked," "moderate,"'hdndmal" or "none.” "improvement" were made by these physicians two ratings of The to three weeks after treatment was terminated, and were based on the four fold classifica— tion of "recovered,” "much improved," and "unimproved or worse.“ (6) Results: 1. Convulsive vs Subconvulsive Techniques: W MW, ' WW therapgrfglhad the h? subjectstwho received convulsive high degree Of delta records in-both second, third two of the three weeks, and of the )4? 13 subjects failed to the 27 subjects who and during Show a convulsive therapy. Of 6";gr one “a Low weeks of treatment; 12 during of the test periods. Thirteen high degree delta record on received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. fourth activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. neahJ-l’ 21‘ ln concurrent behavioral ratings, hirof the.ﬁﬂ subjects in the ‘ convulsive group showed marked behavioral change; while of the subcdn- vulsive group, (Table I). therapy. *» Y‘aab éacbndldb ham, ‘ ﬂ Of 2h of the the or 27 showed minimal latter group, 19 were no behavioral changes. referred for a second course of In lb of these, grand mal electroshock induced high degree delta .RE niekagd: uan W‘LWM ,_ AAAAaaeut "W wthwﬁ W ynxuduvuax “Gunrﬂ nta. waT‘5~/::L¢Gﬁe , . I �.uactivity and all showed a significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroshock, all WW m Showed middle degree behaﬂoral change. m. L *3 3 hawk»: records; and two of the five 47 I TABIE Showed a W! 4‘ 9““..44 b ' Ratings of Behavioral Change; Convulsive—Subconvulsive Therapies (Tourth-Fifth'weeks of Treatment) Degree of Change Moderate Minimal 27 15 S O O 3 8 16 Marked ConvulSive Therapy (h?) Subconvulsive Therapy (27) None In evaluations two weeks after-treatment of the degree of "improveof the convulsive therapy grongj::ted as "much improved" or "recovered," and 32% as "improved."qag% discharge, 51% were evaluatedileZS ment," 51% sustaining the and only were were 7% same degrees of improvement, while were "unimproved." rated in the first Of "unimproved;"ﬁgﬁgeiggége§:§§:$§%§:red do were "improved," the subconvulsive group, however, two categorie51’19% hOSpital discharge evaluations h2% in the "improved,“ but for a 11% 70% second course of therapy, not reflect the effects of subconvulsive therapy. II TABLE Ratings of Improvement: Convulsive-Subconvulsive Therapies (Two'ﬂeeks After Last Treatment) Recovered Much Improved Improved Unimproved Worse Convulsive Therapy (h?) 9 15 15 8 Subconvulsive Therapy (27) 2 l S 19 �W. .r -5... din=;.€onvulsive therapyinduced signiiicantly greater behavioral MM“ whichchange and eva uations of improvement thangsubconvulsive therapy We The parallel the electroencephalogr . Also, patients -EEG clinical I observations“ ”A“! who showed neither showed both or a behavioral response to subconvulsive therapy, and behavioral changes when placed on convulsive an EEG therapy. 2.- Role of Type of Convulsive Therapy; In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analgrsis of the was undertaken. 2. The effect The oi‘ type of electroshock on EEG delta actvity results are graphically presented in Figures first figure relates 1 and the treatment type to the percentage of weeks record ‘n each treatment group during the second, third and fourth tre:Egentgggégggggating:high degrees of EEG delta actigggi) In each of period, treatment with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unicurrent and with alternating current at threshold strength was directional less efi'ective than the suprathreshold alternating current techniquef.in each period; the unidirectional current treatment being more effective than the threshold alternating current method only early in the course of therapy.* Vsubconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same the per cent of each treatment group showing 7“: relationship no by measuring delta activity or only low ncés ..-»_. :v-n suprathe a‘, ent perins, tre Eur, .l-i-o . an. etho’.'5 - thre o'd reatv t si " Can at .05 by chi 7—9 “-3 ou- in} vDi7”e~' ces b tw-z para --12 0-" 0d“; no ignifican ' dWL- ‘ j . hold met‘ods, and for each method �at Mt“ M74 @WWAEW �-6Here, the subconvulsive group degrees of such activity. is lOO%_for each treatment period. Suprathreshold alternating current techniques show the least number of such records in each period, with threshold and parathreshold techniques in between. 3. Frequengy of Treatment: Another factor in the rate of development of delta activity is the frequency of treatment. While all patients were initially treated three ltimes a week, a number who failed to develop high degrees cf delta activity on convulsive therapies were treated more intensively. In nine daily or twice daily, and in each instance middle or high degrees of delta activity were induced. Similar such patients, treatments were given correlates were previously demonstrated Callaway (10). EEG h. Factor of In the by Pacella gt'gl. (9), Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta the first such and second weeks of activity during treatment; while older subjects developed activity to a significant degree during the third week. fourth week of treatment, the groups. Combining observation. and By the differentiating aSpect between the data from.all convulsive therapies supports this age was no longer a IMring the second week, h3% of records are high degree delta in patients under the age of no; but only 30% in patients from uo—oo, and 18% in patients 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects degree delta records when treated 3 times per week. have high �-7TABLE Variation in % High Degree Delta Suwd To DO years (28) Records With Age M ﬁlm k2 29% ' W % Treatment Period $9.213 69% 61% h3% (28) Lil-50 EEG lit-.9. £211 £59. III W W ‘ 31-66 (28) 32% 56% 55% (18) 18% 50% 80% ‘ 61+ 5. Pre-Treatment Record Characteristics: * Previous reports, summarized by Chusid and Pacella, ($3 noted a significant relationship between pre—treatment record characteristics and the degree of induced "abnormality." Predominant alpha rhythm, "abnormal" (3» or "borderline abnormal" (11) records were more liable to develop alterations in the EEG than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment record demonstrated diffuse slow wave were not included activity, spike or spike wave activity in the statistical analyses. Eight such subjects were saven of them developed high degrees ”treated with convulsive technique? and of delta activity earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre—treatment alpha and the degree of induced delta activity was undertaken, Rank order * The difference in incidence of high degree records is significant at .0 between the second and fourth weeks and .051 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. WW WM *7 �-8correlations of the pre-treatment per cent time alpha in selected leads (anterior temporalavertex) with the degree of delta activity during the third and fourth weeks of treatment in _tions of +.2u and +.35 reSpectively. week is significant at third'week N£L0 Two h3 The patients demonstrated correlarelationship in the fourth the .05 level of confidence; while fails of significance, although the trend that in the is indicated. aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and the role of serial electroencephalograms in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the éﬁéggél studies of convulsive therapy numerous authors, including Kalinowsky 2:". g. (12), and Pacella §_t_ (9)7 emphasized 3;]: both the clinical and electroenCephalographic'differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes subjects. Similarly, electroencephalograms in grand delta activity, while in petit mal therapy, no in less than 25% of mal therapy demonstate delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, been described, and and focal convulsive tedhniques have in each, in turn, discarded in routine therapy. Bergman §t_al, (13b for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records 70-75% had "abnormal" records after grand after 15 such "seizures;”'while J �-9mal seizures. Ulett gt a;. (1h), in a careful control convulsive-sub- convulsive study, reported a significant difference in the clinical response of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive (33%), or controls (38%). EEG He noted the discrepancy in the response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. W Recent additional reports by various observers, based on a variety of data further emphasize the significance, of the convulsion in the therapeutiC'responSe (1, l5, 16).fﬁeinstein—end thus indicates that convulsions per; are, or reflect, the significant physiologic events which are the basis The evidence se_ fortherapeutic efficacy of convulsive therapies. If the convulsion is the essential the behavioral reSponse, does the any role in this reSponse?. in both the degree of EEG mode element both in the EEG and in of induction of the seizure play In the studies reported here, small differences delta activity and the rate of its development were observed between differentxnethods of induction of grand mal seizure.jh/§ Ulett gt a}: (11;) reportedan improvement rate of 57% for the alternating current convulsive technique, and 70% for the phodio-metrazol technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulSive photo-metrazol technique. this repert, Kalinowsky noted 'various workers as being vulsions. Eh More more that metrazol convulsions have impressed efficacious than electrically induced con- recently, Edualds, (l7) describing a 1090, ascribed to it In a discussion of new convulsant drug, a clinical results slightly better than electro- convulsive techniques. 'We have further noted that the convulsions induced by various tech- niques have varying characteristics of latency, duration, preponderance �.10of clonic or tonic phase, apnea, not equivalent; and etc. "All grand mal seizures are seemingly a seizure is not an "all or none" phenomenon. Different reflect the differences inhphysiologic effect of the different treatment methodfp Further studies of this problem seizure patterns occur and these ‘are in progress. While this variability in clinical results is reported, that with repeated convulsions, 'of 00 may - 80% are observed. The differences element is the brain may way rates between various types of treatment benobv1ated byzincreagang the frequency we may conclude specific with regard to the is clear no matter how induced, improvement are small, and, for the most part, or number of treatments. it that convulsive therapy is the convulsion is induced. The DOD? significant change subsequent to the convulsion, and not the agent in bringing about this brain change. In previous reports (6, 18, 19) we have noted that convulsive therapy is also non-specific with regard to its application in mental illness, and in its clinical and behavioral effects.used The present studies amplify, therefore, the previous conclusion of the non- Specificity of convulsive therapies. 2. Role of Electroencephalography in Oonvulsive Therapy: applied methods of quantitative, serial EEG analyses in the studies reported here. While clinical estimates of behavioral change have we have yielded similar data, such evaluations are more dependent on the attitudes of the observer (20), and less amenable to quantification than the EEG. Further application of EEG-analyses to other problems in convulsive therapies provide a rational basis for the comparison of different treatment techniques. we have clinical previously noted that management of EEG analysis may be applied in the patients receiving convulsive therapy (6). In patients �.11Who fail to significant behavioral response show a on treatment regimens of three times per week, an electroencephalogram may serve as a guide for further therapy. In thise subjects in whom high degree delta activity has not been induced, increasing treatment frequency, withholding pre- medication, or shifting to a more effective convulsant method, may result in the neurophysiologic changes. If the degree of delta‘activity is high and sustained for a or environment#(18) number of weeks, other may be assumed factora',as personality (21) to preclude a satisfactory behavioral reSponse, even when the neurophysiologic substrate convulsive therapy is assured; and further well be discontinued. A similar application has been suggested by Roth (3) for thiopental activated EEG records. The may successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational management and understanding of psychopharmacologic agents (19). ��3;; Zn, ~ 6w WMMWL, _ ~ 4; �(«My REFERENCES 1. Roth, 1.: Changes in the EEG Under Barbiturate Anaesthesia Produced by W.Q Electro-Convulsive Treatment and Their Significance for the . Theory of ECT Action, 3: 251-280, 1951. 33. £5 Clin. Neurophysiol. Roth, M., Kay, D. W.K., Shaw, J. and Green, J.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG “a..- Clin. Neurophy61ol. :2, Chusid, J. G. and Pacella, B. L.: Shock Therapies, h. Ulett, G. and ,1 MM Johnson, _ J. Nerv. m M. W.: 225-237, 1957. 2_: The Electroencephalogram in the Electric:;> &:Ment. Dis. 116: 95-107, 1952. m" "' any...MA... mm:-W M and Scopolamine Upon Efiect of Atropine Electroencephalographic Changes Induced w”,// 1. By Electroconvulsive . Therapy, EEG.,Clin. Neurophysiol. 2: 217-22h, 1957. S. ‘Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Its Relation to the Therapy: Psychiat. 6. Fink, M. of Shock Therapy, and Kahn, R.L.: Relation of Electroencephalographic Delta Neurol. & EBSponse in Electroshock, A.M.A. Arch. Psychiat. Z§: 51o5525, 1957. Kalinowsky, L. and Hoch, P.: Shock Treatments, Psychosurgery And Oﬂier Somatic Treatments in_Psyohiatry, Grune 8. éﬂ:_i; 192: 22-26, 1952. Activity to Behavioral 7. Theory & Stratton, N.Y., 1952. Alexander L.: Treatment of Mental Disorder, W.B. Saunders Co. fhiladelphia, 1953. 9. Pacella, B.L., Barrera, E.S. and Kalinowsky, L.: Variations in the Electro- encephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Psychiat. g1: 307-38u, 19h2. �10° 11 . Callaway, 3.: Slow wave Phenomena in Intensive E1ectroshock,«Elootpa. tag; ennaphalggrﬁk'Clin. Neurophysiol. a: 157-162, 1950. t K)~u~uu¢,nk‘04+&.LUéQQNUM’ antm 3‘ v~n£.aax+ueB ox BK 33,; swam: n 3,. H AW“ um “3' W i?! p 12. Kelinowsky, L., Barrera E.S. and Horowitz, WA“ in Electric Shock Therapy, Am. The J. Psychiat. .y. i'c I 4"?“ use... "Petit-Mal" Response 2Q: 708-711, l9h2. 13. Bergman, P.S., Impastato, D.J., Berg, S. and Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Fbcal Seizures, Conf. Neurol. 11: 271-277, 1953. 1h. Ulett, G.A., Smith, K. and Gleser, 0.0.: Evaluation of ConvulSive and Subconvulsive Shock Therapies Utilizing a Control Group, gm;_g, szchiat. 113: 795-802, 1956. 15. Wéinstein, E. and Kahn, R.L.: Denial of Illness, C.C. Thomas, Springfield, i 1955. 16. Fleming, T.C.: An Treatments l7. Edwalds, Inquiry into the Mechanism of Action of Electric Shock 'Jidbnuav'nﬁuatJWor ,WO-ASO , 1950 . K.M.: Intravenous Administration of with a New Convulsant Drug. Read at PM 1090: Clinical Experience N.Y. Divisional Meeting A.P.A. 1957. 18. Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the ElectroShock Process, Dis. Nerv. Sys. 19. Fink, M.: A Unified Theory of the ACtion of Physiod namic Therapies, J. Hillside 20. Fink, M. and Hosp .__(_3_§ 19 7-200, 1957 . Kahn, R.L.: Behavioral Patterns Brain Function. 21. (in press). Read Kahn, R.L. and Fink, M.: at in Induced States of Altered N.Y. Divisional Meeting A.P.A., 1957. Personality Factors in Behavioral Electroshock Therapy, Conf. Neurol. (in press). Response to �mmﬁmu mumm. in M minions: W manta, mm mm am mm mu, 3.1. a: mm mm, mam mm mum mm M Mia mu: m“. &, M. at mutmmmummmmwmumamrmxm. VIM ��m W a: moo nativity «many to: tho uwmmthomw Migration“ (Miamimdmthouoomw the «Mo Wvomwmmuﬁml) Withomotmm room: Woo with Moment, Magenﬂ MWm«on ntod u “MAW of data. muty. yW WW 1 4- .. 11111 . . mammumuwumamuwmw 25mm W» W t mm ”mm Wt? 'W 28 12“ 21 8'! a 66." h“ 35 13 16“ 3 2 a M K 60 t wowmammmmgmmmw stumpWM Wommmmmmmlﬁm at m woman” mind Wm t1»npy*1n this M. m: who 34? 9 .3, ommamae monmmmmmmmmywamm 19 ”loom mu, plat tofu-rod for t «W W“ of thong, ' Win . ﬂ UWJOOM ��m Mm Mm am m 1%- M 61 M 1:: (28) W (38) M M W (28) 311‘ 565 (18) W 30% , thmum mwmmammﬂva thmm Wsmﬂmt Wampum “W" (ﬂw‘W W“ (n)mmmmmw mmnwpum. mmmerpmmmwmmm~mam ‘- _'mmunwmmu%%wapm§uwmw mmmwmmamummwa. thmmm �“Nuthmmw Mgr: than m 3mm of A. ma W,mm,W. mama“mmWWW pom, mu nativity without. such M for mm wan-«mam» Mutiny. WM maym at the man hum put-mm awn mmarwu1ummuymmm. mum mumaunpmmmmmmamnmmm (wwwm)uwmmdmummwmm m gm was « tantalum w a: mum. mm mum m at Nﬂbwhﬁmmunlyo mmumpmm comma mm“ mw3mmsmmmmm Wmum am at mum, among: an m u Mam. . ��Reprinted from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958. Electroencephalographic Correlates of the Electroshock Process and MARTIN A. GREEN, M.D. In the course of an evaluation of the role of a1tered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re—assessed. MAX FINK, M.D., Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment, on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varied, including unidirectional and alter— nating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12 to 20 treatments. Patients who failed to develop a clinical response, or EEG changes of signiﬁcant degree, Were subsequently treated at 5 to 10 times per week. The EEG records were classiﬁed for degree of delta activity into “high,” “middle” and “low” degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest ampli— tude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the Read at the meeting of Eastern Psychiatric Research Association, Inc., held Feb. 6, 1958. electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. Results: 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was signiﬁcantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subconvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional instruments, but by the 4th week of treatment, the differences were eliminated. 4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient. 3) Early and sustained high degree electroencephalographic delta activity is a necessary, though not sufﬁcient, pre-requisite for improvement in the electroshock process. - �mmmmm Garnish” at the mammoak Mam Hawaii‘s WWW at Moan rawhiam, 35.11.3169 363331981, men Oaks, m... mamas a: mm mm mums. w grunt 16-927: 33.131th um, in wt, M. ”03¢ M116 English From the Mﬂtﬁﬂﬂ Band at 131-13 Halal, mm at the Eastern mum autumn ”Manama, ﬁat York, Pcbmary 6,. 1953. Whip-$8 Saran. 3.1. �WWMMW.WMMMMﬁmhm Wmmmmmmammmwmmmm WWW.1IW (1.1).. 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(1153de. similar applicatim has hm suggest“: m (5) far thiamm ”bland we} mrahar ha A by am mm. m ammm'vl maintain ma uwmqma ta mmhive W121“, but led to their diminution in amt Win-- Me alumina. W mec npplioatim 13$ Mt. “ports firm the” laboratories min a W mum amt! (26) ,; applieatien tar WM aid warming at ��11;. maids, 15‘; 310 3135 . W, 30. Gamay, An 1935.- ,1: am oxidation at mews 1956. a nu. 3m.: um Wan-awn at m 1090. mama. Inquiry into the sex-«mm, 3.3.: ' a: W. mm,Mariammm»: with a m ﬂew 9mg. am at 21:2. minim Hating LﬁPi‘J HA. I 19570 Signifimaa or mmm vmbili‘g in m magma Experimental stud-1W My Edi-m and am; 31*.“ My My; (in mm). 33m. 8 mun-9mm}: Rowan, W ‘ . 6f “13 o the Action or Physiodsmmia Therapies, m, 14,: 1 Unwed Thom a:197%.;195?‘ , 21. LG»: Shook m, 19a K; and “W,springtiad,m Rd“! W a! 16. 1?. 6:13.: Evaluatim at ma Mr, (3th 00mm}. ﬁr. gamma“ m1: Wraps.“ Winning a £34., Smith, 52* 3.1m Bahamian]. mum in Induced sung or M; n. ma Kuhn. Brain mum. Rand at NJ. 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Wu W. nativity that aw: 1w WWt ‘ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Electroencephalographic correlates of the electroshock process. Dis. Nerv.Syst., 19: 227, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-32-009 Date A point or period of time associated with an event in the lifecycle of the resource 1958 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>; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 12 items. 1: [preprint]. 2: Edit page. 3: Hand drawn graphs. 4: Handwritten notes. 5: Drafts. 6: Program for Eastern Psychiatric Research Association, Inc. Twelfth Scientific Meeting, February 6, 1958 (handwritten notes on back). 7: [preprint]. 8: Final copies. 9: Reprint from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958 (one page). 10: [preprint]. 11: Discussion - NY Neurological Society 3-11-58. 12: [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/cda4311bdad6b67d755b69d80816976c.pdf 2b63fbc4853cb463227378ec92424d29 PDF Text Text [Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 117, No. 1, Jan. 1953] PERCEPTION OF SIMULTANEOUS TACTILE STIMULI BY MENTALLY DEFECTIVE SUB]ECTS*1' MAX FINK, M.D.;t MARTIN A. GREEN, M.D.§ AND MORRIS B. BENDER, M.D. In studiesof the perception of two tactile stimuli applied simultaneously, it has been demonstrated that patients with diffuse brain dysfunction make errors. They persist in making errors either in re— porting only one of the stimuli (extinction) or in mislocalizing one or both stimuli (displacement). When errors are made in simultaneous stimulation of face and hand (the face—hand test) (I), the errors are in the recognition of the stimulus applied to the hand. The percept in the cheek is correctly reported. This “face-dominance” is apparent on initial test trials of normal adults. Similar results have been obtained in tests of young children. Children under the age of six years respond to simultaneous tactile tests almost with the same frequency of errors as do patients with dif— use brain dysfunction. With these facts before us, it soon became ap— parent that mental age was a factor in the perceptual response. There— fore, a study of the responses of mentally retarded adults with mental ages of young children was undertaken. Simultaneous tactile tests were applied to a group of mentally defective patients, and three aspects were studied: their responses to the tests; the order of dominance; and the relation, if any, to standard psychometric tests. SUBJECTS AND METHOD Fifty—seven mentally retarded adults from the wards of Letchworth Village, New York were examined. They ranged in chronological age from 13 to 41, and in mental age from two years, six months to nine ‘From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurologic Service of Bellevue and the Mount Sinai Hospital, New York. fRead before the Seventh Annual Convention and Scientiﬁc Program, Society of Biological Psychiatry, Atlantic City, May 11, 1952. IThis work aided in part by a Fellowship from the National Foundation for Infantile Paralysis. §Post—Doctorate Fellowship, United States Public Health Service. Work aided, in part, by a Grand—in—Aid #MH-139 from the United State Public Health Service, National Institutes of Health. [43] �Max Fink, Martin A. Green, and Morris B. Bender 44 years, eight months. The ﬁgures for mental ages were those recorded in hospital records reflecting performance on Stanford—Binet tests; and in each instance, the most recent estimate was used. RESPONSES TO SIMULTANEOUS TACTILE TESTS ON INITIAL AND SUBsEQUENT TRIALS FACE-HAND TEST 100 odul‘l’s wifh orqanic ------------ .. mental sqndrome 0O RESPONSES oO \l O DOMINANT 01 O a! O adult-mentally defective §O FACE PERCENT N0! 00 .. 0 0O 2 3 4 adult-normal 5 6 7 TRIAL NUMBER 8 9 10 showing responses to simultaneous tactile tests on initial and subsequent trials of the face-hand test in adults with organic mental syndrome, normal children of three to six years, mentally defective adults, and normal adults. FIG. I.—-Graph The subject was asked to close his eyes. Following this, he was simultaneously touched on the right cheek and the dorsum of the left hand. The examiner asked: “What did you feel?” If there was no response, the examiner said “Did you feel me touch you” and “Point to the place Where I touched you.” After this test the subject was again asked to close his eyes and the left cheek and left hand were stimu— lated, and the reports recorded. Subsequent tests included stimulation of left cheek and right hand, right cheek and hand, both cheeks, and both hands. This sequence of six trials was then repeated so that a total of 12 tests involving the cheek and hand combinations were carried out. Subsequently, tests of other body parts, as hand—foot, cheek—shoulder, thigh—foot, shoulder—thigh, cheek—foot, and shoulder—hand were intro— duced—four trials of each asymmetric combination and one trial each of the symmetric body parts. The entire sequence of tactile tests was completed with a repetition of trials of the face-hand test. �Perception of Tactile Stimuli by Mental Patient: 45 RESULTS On the initial trial, 98 percent of mentally retarded subjects reported the stimuli incorrectly. Eighty percent reported the face percept only, omitting the percept to the hand, a type of sensory extinctionﬁ“ The remainder localized the face percept correctly, but mislocalized the second percept to the opposite check, a type of sensory displace— ment. No subjects reported the stimulus to the hand alone or mislocalized the cheek stimulus to the hand. These responses are expressions of “face dominance.” Face dominance was also apparent on subsequent trials of the facehand test. Fifty percent of the subjects failed to localize the two stimuli correctly during the ﬁrst ten trials. They repeatedly failed to report the hand stimulus or repeatedly mislocalized it. The phenomenon of extinction was manifest in all subjects; while in 46 percent, displace— ment of percepts were also reported. A smaller number (38 percent) showed perseveration of responses, i.e., reported previous stimuli even though new stimuli had been applied to different parts of the body. The phenomenon of allesthesia (mislocalization of a stimulus across the midline to the opposite side of the body) (2) was occasionally observed. Only one patient demonstrated exosomesthesia (the displacement into extrapersonal space) (3). Half of the subjects succeeded in localizing and identifying the two stimuli during the initial ten trials. Their ability to localize the stimuli in the face—hand tests was carried over in the subsequent testing of other body parts. A few subjects, however, after correctly identifying the stimuli of the face-hand tests, made occasional errors during the testing of other body parts. These errors were almost exclusively in a failure to report one of the stimuli; neither displacement or perservera— tion was manifest. In all subjects simultaneous stimulation of homologous regions, e.g., cheek-cheek, or hand—hand, were interspersed throughout the testing. Errors were infrequent on such tests, even in those subjects who made persistent errors on stimulation of asymmetric regions, e.g., cheekhand. Such errors were observed in 15 subjects (26 percent) but only on occasions were the errors in a pattern as seen in a patient with a hemisensory syndrome due to a focal cerebral lesion. Relation to Mental Age—There was a deﬁnite relation between the incidence of persistent errors and the mental age of the subjects. Table I presents subjects grouped according to mental age (as determined by standard Stanford—Binet testing) and their responses to simultaneous tactile tests. It will be noted that there is a gradual fall *For convenience in writing we will call this type of response under conditions of double simultaneous stimulation extinction. �Max Fink, Martin A. Green, and Morris B. Bender 46 in the incidence of persistent errors on simultaneous tactile tests as mental age increases. TABLE Mental Age Group (year—month) I No. of Subjects Persistent Errors By 10 Trials 10 10 10 12 10 0 2-6 to 3—11 4—0 to 4—11 5—0 to 5—11 6—0 to 6—11 7—0 to 7—11 8—0 to 9-6 Correct 7 3 6 4 5 2 11 4 7 9 3 1 Relation of Body Parts—During the initial ten trials, face dominance was manifest in all subjects. In the subsequent tests of other body parts, additional patterns of “dominance” appeared. This was represented in the subject’s inability to identify and localize one of the stimuli or to mislocalize one percept in the direction of the second stimulus. As already intimated previously, the locus of the stimulus which is correctly reported is said to be “dominant.” In tests of cheek and shoulder, and cheek and foot, face dominance was observed (Table II). In tests of foot and hand, and shoulder and hand, both foot and shoulder are dominant over the hand. In the relationship of thigh and foot, and shoulder and thigh, both foot and shoulder are dominant over the thigh. TABLE II.——RESPONSES ON MULTIPLE SIMULTANEOUS TACTILE 57 MENTALLY DEFECTIVE SUBJECTS Total No. of Tests in All Patients TESTS IN .M Body Combination” FACE—hand FACE—foot 576 163 FACE-Shoulder 184 SHOULDER—thigh 170 SHOULDER-hand 151 FOOT—thigh 170 FOOT—hand 231 Incorrect Responses Correct Responses face or hand face and hand face or foot face and foot 315 36 face 64 9 9 or shoulder 15 252 128 face and shoulder 105 shoulder or thigh shoulder and thigh shoulder or hand shoulder and hand 45 12 63 3 foot 42 foot 58 or thigh 1 7 or hand 33 113 85 foot and thigh 11 1 foot and hand 140 *Capitalized letters (under Body Combination) indicate dominant part as manifest by t—test value of 5 percent or less. The differences in the incidence of errors in diﬂ’erent body combinations are largely due to the order of testing and the factor of learning. �Perception of Tactile Stimuli by Mental Patients 47 DISCUSSION These results when compared with those obtained in previous ex— periments show that there is a striking similarity in the performances of patients with organic mental syndrome due to diffuse cerebral disease or dysfunction (4a), to normal children below the age of seven years and to mental defective adults with a low mental age. The similarity lies in the types of responses, the persistence of errors, and in the order of dominance. Extinction and displacement phenomena are frequent in all three groups. The responses are apparent on the initial and on subsequent trials. In addition, allesthesia and exosomesthesia are occasionally ob; served. The subjects in each group manifest an inability to identify and localize asymmetric stimuli, that is, cheek and hand. Symmetric Stimuli, however, as stimuli applied to both hands, are well localized, even by the most mentally retarded subjects, by patients with severe brain dvsfunction, and by the youngest normal child. In every group the errors of localization persist through many trials of simultaneous tactile tests. The subjects are unable to localize the two Stimuli despite verbal clues offered by the examiner, such as asking whether there had been another Stimulus. The errors are present even when the subjects are tested with eyes open. The persistence of errors on repeated trials in the mentally deﬁcient adult, in the patients with mental changes, and in normal young children is in marked contrast to the ease with which normal adults correctly localize and identify the stimuli. The performances of these subjects are illustrated in the graph (Fig. I) which compares the percentage of errors during the initial ten trials of the face-hand test. It should be noted that the curve for the mentally defective adults includes 15 subjects who have a men— tal age of seven or more years (Table I). This will account for the curve being below that of normal children whose average mental age was rarely above seven years. Furthermore, the order of dominance observed in mentally re— tarded subjects is similar to that reported for patients with organic mental changes (4b). Face dominance is seen in all subjects, while the hand dominance is hardly manifest. The other body parts are between these limits. As in patients with organic mental changes or very young children one may be inclined to explain the inability of the retarded adults to localize the two Stimuli as due to “confusion” or “inattention.” Such an explanation is unwarranted because these subjects can perceive and localize symmetric Stimuli and the errors are not haphazard. The �48 Max Fink, Martin A. Green, and Morris B. Bender errors show in a pattern so that almost all errors are in stimuli to the hand and none in stimuli to the face. Furthermore, this pattern persists in tests of other body areas and is similar to patterns described for other groups of subjects (5). A comparison of the observations in normal young children and in the mentally retarded adults reveals a striking similarity in perform— ances when the mental ages of each group are compared. In both groups, there is a change in performance about the mental age of six years. It may be concluded that the face-hand test reﬂects the same performance ability as the Stanford—Binet test. The face—hand test has validity as a convenient approximation of performance above and below a mental age of seven years. SUMMARY The face—hand test and simultaneous tactile tests of other body parts were applied to 57 mentally defective adults. Their chronologic ages ranged from 13 to 41 years and their mental ages as determined by Stanford—Binet testing ranged from two years, six months to nine years, eight months. On the initial trial 98 percent failed to localize both stimuli and on subsequent trials 50 percent made persistent errors beyond the tenth trial. The errors were made in stimuli to the hand whereas stimuli to the face were correctly reported. Extinction, displacement, allesthesia, and exosomesthesia were observed. These performances of the mentally defective adult to the face-hand test are strikingly similar to the responses of patients with diffuse brain disease and of normal children of six years or less. Furthermore, there is a deﬁnite relation between the persistence of errors and the mental age of the subject. It is concluded that the face—hand test reﬂects the same performance as the Stanford—Binet and has validity as an approximation of performance above and below the mental age of seven years. REFERENCES Bender, M. B., Fink, M. and Green, M.: Patterns in perception on simultaneous tests of face and hand. Arch. Neural. &' P5ycl1iat., 66: 355, Sept. 1951. 2. Bender, M. B. and Nathanson, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena. Arch. Neural. 6' P5yc/zz'at., 64: 501, October, 1950. 3. Shapiro, M. F., Fink, M. and Bender, M. B.: Exosomesthesia or the phenomenon of displacement into extra—personal space. Arc/2. Neural. é‘r Psychiat. (in press). 4. (a) Pink, M., Green, M. and Bender, M. B.: The face—hand test as a diagnostic sign of organic mental syndrome. Neurology, 2: 46, Jan. 1952. 1. �Patients Mental Stimuli by Tactile of Perception 49 in cutaneous dominance of order The B.: M. and Bender, M. M., Fink, (b) Green, perception. Trans. Amer. Neural. Assam, 74: 1952. in Extinction phenomena W.: A. and Schappell, F. M. 5. Bender, M. B., Shapiro, hemiplegia. Arch. Neurol. 6' Psychiat., 62: 717, Dec., 1949. 1150 PARK AVE, NEW YORK 28, N. Y. �~ a!" hfmaulfﬁﬁg PIIOI?IIOI I! 0' SIIULRAIIOUB 3- _ «- $555!”? ‘ “my“, 1.; -A?» if} iﬂcllhl ITIIULI IIIIALEY 931301173 BUBJIB!£.* By In: vink, 3.»... Ina-tin A. Green. _ 8.3..” and ﬂorria B. Bondar, u.n. «mach-r r“ 3'" a” on Collegp or undicina and tho Neurolozze service of null-vac nouns Sinai Hospital, low York city. ‘. . 9*!h1u vnrk aidod a 1' in part for Infantilc Paralyuin. "M"; by a "‘"‘ " J, 73‘; "u f and tho Ftllauuhsp from the latiennl ronnunt1an . aﬁtPott-Dootortte Fellaunhip, Unitcd States Public ﬁbulth surviec. Hark aided, in part. by n Grantuinind #HH~139 from the United 3t&to Public ahalth Servico. National Inatitutas'ot ﬁnnlth. �1. In etudiee or the peroeption of two teetile stimuli applied eieoiteheoueiy, it hee been denohetreted that petiente with diffuee brain dysfunction Ink! errors. Qhey pereilt in liking. errore either in reporting only one or the etinnii (extihetioh) or in nielooeiieihc one or both etiwnii (diepleeeleht). when error: ere eede in ei-aiteneoue stimulation or face and head (the teoe~hend test) (1) the errore ere in the reoocnitidn or the etiluiue eppiied to the head. it. peroept in the cheek it correctly reported. This “reoe—deninanoe” ie eppereht on initial tent triele of aerial edulte. Siniier reeuite have been obteihed in teete or youn‘ children. children under the ene or six yeere reepond to ei-nlteheoue tactile teete eieoet with the eene treeuehoy or errore ee do patients with diffuhe brain dylfunotion. Uith thete flute before’ on, it eoon beoene apperent thet eentei esp wee e rector in the peroeptuei reepohee. Therefore. e study or the reeponeee or mentally retarded eduite with mental egee or young children wee underteken. aieoiteheoue teotiie teete were eppiied to e group or mentally detective petiente. end three eepeote were studied: their reepoheee to the tests; the order or doeinenee: end the reletion, it eny. to standard peyohdletrio teete. am no me neateily on! Pitty~eeven reterded eduite from the werde or Letohworth Viilege, lew York were examined. whey ranged in chronologioei ego from 13 to #1. end in wentei use from two yeereueix nonthe to nine veers-eight nohthe. The figuree tor'uehtei eaee were thoee recorded in hoeoitei record: reflecting pertoreenoe on stenrord~nihet teete; end ih.eeoh instance, themeoet recent eetinete “I “I'd e �its subsoot sss'ssksd to class his oyss. Following this ho sss sinultsnsously touched on tho right ohsok sod tho dorsal of tho loft hsno. rho oxsninor asked: ”tht did you tool?" If thsro uss no response. tho oxssinor sskod "Did you tool as touoh you'.snd-“?oint to the plans shore I touchsd you." Aftsr this tsst the subjsot sss sgsin sokod to class his syss sod tho lsrt ohssk.snd loft hsnd stisulotsd, sud tho rsports rooordsd. subssQusnt tssts inoludsd stmsulstion of lsrt ohssk and right hsno, right ohosk sud hsad, both chooks,snd both bonds. This ssquonoo or six trials sss than rspsstsd so thst a totsl or 12 tssts involving the chuck; Ind hand ounbinstions ssrs carried out. Subsequsntly, tosts or other body ports, on hsod~root, ohssk-shouldsr. thigh-toot, shouldsr-thigh. ohook~£oot, and shouldorvhsnd sore introduced ~ four trials or osoh ssyulstrio oosbinstion sad on: trisl esoh of tho symmetric body parts. tho ontirs musnos or mum tssts omlcm with s rspstition or trisls of the tsoo~hsnd test. m assault: 0n ths'initisl trisl, 98! of nontslly rotsrdod subjects roportsd tho stinuli inoorrsotly. light: psr osnt rsportsd tbs fsos porospt only, omitting the psroopt to ths hand, a typo or ssnsory sxtiuotion.’ so. rssnindor looslissd tbs tsos psrospt oorrsotly, but mislooslisod tho second poroopt to tbs opposits chock, s type of sensory displsosssnt. It subJsots roportsd tbs stimulus to tbs hand olom or nialoosliud musk stimulus to the Fla'Ior doﬁ§3nisnos in writing so will osll this typo or rssponso undsr conditions or double simultaneous stimulation as extinction. RID Pl; �3._ are unprbtnionn or “race dunintnoa." tact dulinnnn- an: also apparent on subuognlat triuln of rib: flacuhnnd tent. titty per cent at eh. handouts failed to lootliue the two stimuli oorrtetly during the firﬂt ten trillu. 1hr! rupoatediy thilod to vaport tn. hand atinulun or repoatedly nialoetlized it. 15h: phenomenan at extinction was manifest in all lubaoatsg while in forty~six per cont, displuocunnt or poroupta I've alto reportad. A smaller number (335) shorad perceverutien or runponlon; i.e.,_ri§;r§od previous stiuuli even though now stimuli had hc¢n~aapli¢d ta different part: of thn hady. The phenomenon of cilanthnniu (miulooalisntian of a stimulus across th. nialinn to the opposite 3140 at tho body) (3) was ooaaaiannlly obnorved. Only out phtiant dauonutrltod oxotaneutheuia (the dinplaooaonz into extra-pornonnl npaeo) (3). all! or the number or nubjoota uncooeaed in localising and identifying the two stimuli Grins the initial ton trinlu. Their nhility to 1033113. the Itimuli in tho thee—hand tents una carried over in thn auhnoquont testing or other body parts. A for Inbaoetn, amour, actor aomctly identifying m5. sen-mu at the hem-hand haiku. made oaacaiennl errata during the testing or other body parts. ihole errors ﬂute tlnmut again-ivoly in a failure to roport one ork‘ the stimuli . mum displacement of ”mat-tum Ion unite“. In all subject. sinultanoaul Itiunlation or hauologoun ii rngienl. 0.5. aher-ohnck, or hand*hnnd. wort intoruporled throughout the touting. 3mm mm infrequent on men tutu, «ms in those subject: who and. periisuont error. on neinulction at hand. Ehunu annponnou asymmetric regions, 0.3. chairman. fifteen subjects (26!) but only Mowers were chums! on occasions ware in thc error: in a �#. pattern as toga in t pttiont with n honiuoanory syndrnna dun ta 3 tonal cornbral Ionian. Relation to at." definite relation betunen thu 1nc1denoo or perintent 0mm and thc maul m or the subarea. run- I mount. .ubjootnerupod acaardins to nantul net (at dateruined by utcndard There wan a Stanfordwauant to:t1ns) and their respanaoa to ainultannaua tactile be noted that there in sauna; in the tutu.” It an insidonon or porozatcnt errors.on Innultnnaou: unul m 1mnnﬁn. mam. m am m; an tactilo test. an th- "$33“ $233.1. 1o 0 14: 7 3 93313:“ f (yrnrdnanthn) to 3-11 Mo to Mn 5-0 to 5~11 10 10 I 5 6.0 ta 6~11 1-0 to 7.41 12 5 7 11 a 9 8-0 to 9-6‘ I 1 3 2-»6 ‘ nolntion of 3352 Pitts! During the initinl ton trials, faae daninnan. was manifest in 311 lubjoata. In the subsequent tent: or ather body parka. ndditionnl pattcrnn of "dominance” appeared. This wt: ruprnutnzod 1n the aubjeot's inability to identity and localize on. of an. utiuuli or to niulooalitn on: poroept in an. dirlotion or thﬁ Ionand Itinulua.' As already intimated previoutly eh: Lyon: 0: the stimulus which in correctly reported 1: natd ta be ”daminanc". In tent: at check and shoulder. and cheek and fact, face dominance was �5’ obcurvod (Elblc II). In toot: both root and thauldcr at tnxgn It. to tho hand. in.tho rulatzonnh39 thigh. both too: and shoulder are dominant and shoulder and root, daninnnt to tho thigh. and or toot and hind. and shoulder and hand. ‘ BL! 11 alsronsna O! NHLEIPLE 81IULEARIGUS 2ACTILI TESTS BBFIGEIVI sunqsces retal £25: 6nnb1nnt10n' lumber of Toot. in Incorrect All Patient: lACI~hnnd 576 'Acl»foot 163 {AGE-shoulder 184 ‘ 8300LDIR~thigh 170 alonlﬂll¢hnnd 151 Factuthigh 170 toetuhnnd 231 I! 57 NBNEALLY Carroct Duo. 315 or Rand Rosaenaou Paco 1nd Band Fan. or loot taco and root Faee or Shouldor Rougonaol 36 252 9 128 9 Face and Shoulder 105 15 shoulder and Thigh shouldcr or ﬁnish Shouldcr or Hand 3 Shouldgg and 33nd #5 63 12 ‘ 113 Font or fhigh root and Thigh Foot ar Hand Foot and 81nd #2 » (under Body cambination) letterI/indtoatc dominant part *g;pltalilod 63‘ 10.3 17 33 111 1&0 as manxregt by t~toae va1ue of differenaei in tho incidence of errors in airfarent body combination: is largely duo to the order of talking and the factor or lcarning. Ema I ../ �6, amacuggxggg inane reunite when compared with thoae attained in previous experiments then that there in e striking similarity in the per- patient: with organic mental tn diffuee cerebral disease or dysfunction (23). normal children below the use of seven yeere end mental defective adults with e low mental age. The similarity lien in.the type: of reapeneee. the pernietenee 5: errors, and in the order of dominance. Extinction end diepleeenent phenanenn are frequent in all three groupe. Ibo responses are apparent on the initial end an Isabeeeuent triele. In addition, allettheeia and exonemeetheeie are formeneee of syndrome due I oeellioneily obeerved.. the eubJeote in each group unifeet an inability to identity Ind leeelile lay-nettle stimuli. thet is, cheek and hand. Symmetrie ntinnii. however, at etinuli applied to both hands, are well the most nanny named subjects. by patients with very severe brain dysfunction and by the younspnt annual child. In every group the errors or localizatien persist through many trial. of simultaneous teetiie tests. The subject: are unable ta lonelise the two Itinuli despite verbal clues uttered by the whether there had mu another etinuiuu. owner. each The errors are present even when the subjects are tented with eyes upon. The pertietenee of error: on repeated trial: in the mentally deficient eéuit, in the patient: with mental chance: and in annual young children it in marked contrast to the ease with which harnei adults correctly iooeiise and identify the stimuli. The per~ tornnneee or these tubaecte are illustrated in the graph which ieeeiised, even by u mam _ �7:. compare. their our cent error: during the initial ton trials of It Ihould be noted that the curve for the nontally deroctivo adult. includes 15-Iub1003! who have a mental age or 7 or more yuart, (see~!able I). rhia will account for, tho curve being below that or honnal children whose average mental tho race-hand tout. age was rarely above-7 yearn. Further-coo, tho order or conihahce observed in aoutally rotardcd subjects ia similar to that reported for pationta with organic nohtal chahuoa (at). Pace dominance in poem in all aubjeota, while thh hind dominance la hardly annifeat. The other body part. are tetuecn theaa linita. A: in patientc with organic tental chancea'or very young children one nay be inclined to explain the inability or the retarded adults to localine the two utiauli aa due to ”confusion” or "inattention." such an explanation in unnarranhcd hecanaa these subject. can perceive and localite Ion-atria Itinnli and the errata are not haphaaard. The errors shoe in a pattern to that clncut all emu are in stimuli to the hand and none in stimuli to the race. rurtheraore, this pattern per-iota in tecta or other body areaa la similar to patterns daaoribod for other group: of athects (2). A comparison of the ohcervaticna in normal young children and in tho mentally retarded adult. reveal: a striking ainilarity in perforntnoet than the mental age: or each group are oomparcd. In both groupa, there in a chahgc in pcrtor-ahcc about tho mental age or six soars. It may be concluded that the race-hand teat reflecta and the same performance ability an the stanrood~nihot tent. tho race~hahd tent has validity ac a convenient approxmuation at per» formance above and below a mental age of seven yearn. �8. tout and tinnitunnnu: tactila tact. or nth-r body part: unto Ipplioa to 57 noatnlly narcotivc adults. Qatar chronological asst runcpd from.13 to #1 start and taut: anntal yourn-é month. 1303 as dotcrldnld by stanrord~nanot touting rangpd Iran a The facauhnnd ,to 9 yearauﬁnonthlp Eris} 9&§.tlilod to 1903118. both act-“11 and an oubuogupne grin}: 50! and. persistent error. hoynnd can 0n tbs 131%151 trial. 1h. errors ﬂit! lid. in Itlluli to en. hind whovotl 'auumu so. the has am ”metal: "parka. ‘xxtmouon, dinpnomnt, touch . allalﬁhosia and oerquIthnuin wort obocrvod. ihnlo parrot-anac0: tbs Inntally detoetivo'aault to an; tacoohand tent at. utrakxngly similar tn the response: of puttcntn with dztruto brain agnonua and of normal children I59 :1: 13:23 or loan. rurthnmnaao, thorn in a dotinihn rclation botuoon tho p02— uittcnno of utter: and tbs anneal as. at tho aubJoot. It 1: con~ gludnd thnt tn. floc-hnnd touﬁ rotloots ch. sane pgttarllnno as tho senatord~31unt and has validity as tumgpprnximntion or performance V above and below tn. acntal an! or seven yours. �mung 9. ‘ 3.3., rm, I. and «am, Ila rue-m 1n nonunion mm. 1n nimltmeouo tent: or race and hand. ArchJomlJnnzohnt. 1. ﬁg, 355-352. 809%... 1951. 14., am, II. and mm, mm: The raeomand tut u an, a. diagnostic up) or organic mental undress. Inna-019g, g; ‘6“58; m, JW ll... um, I. 1952' and cutaneous perception. m, Mn..mx-.lourol.unoou H.3J The - order of in denim 195:. 7k: 11.3. and summon, HA utter-nu 1n alluthuu mm, than relation to diaerdor or body when and 0th» and unset-i 950. gs: 501615, October, SEAPIRO, ILL, 21m, 14. and mum, 14.8.: nouns-thou: or the plum-anon of dilpllomnt into ours—personal snot. phenomena. Atheurothghiut. , Archmoumhhrqrohut. (in m, ILL, .5. December, 1919. ) Vi crib ./ 7 {(12% 3!!“‘130, NJ. {aha-noun. 1:: 11031910311. ' pan) and WRAPPELL, AMA Minot“!!! Arch.murol.&Pazch1at.. ﬁg; 717-3724. �1% 1139:. 1. Graph gnawing runponnou tugs: ta ninultuniaua tantilo on in1t1a1 5nd subocquant trials of tho in adults with organic mental faoe‘hand test ‘ayndrunn. normal children. age 3~6 yonrt. mantally defective adults and normal adults. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Perception of simultaneous tactile stimuli by mentally defective subjects. J Nerv Ment Dis. 1953 Jan; 117(1): 43-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-9-013 Date A point or period of time associated with an event in the lifecycle of the resource 1953 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>; Green, Martin A.; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 117, No.1, Jan.1953 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/945d2769d3cde3d546dfd13ec8bc4c04.pdf 7b68d01261bda3dea9d45000fea060a8 PDF Text Text The F ace—Hand Test as a Diagnostic Sign of Organic Mental Syndrome Max Fin/c, M.D., Martin Green, [M.D. and [Morris B. Bender, M.D. In the course of sensory studies by the method of double simultaneous stimulation, it has been observed that patients with mental changes may show perceptual errors which are not demonstrable by routine single stimulation.1 When stimuli are simultaneously applied to the cheek and the hand (the face-hand testz) , patients frequently report only one of the two stimuli, or when reporting the two stimuli mislocalize one to another part of the body or even into space. These changes in perception are seen on repeated trials of the face-hand test and seem to form a con— sistent part of the syndrome usually labelled “organic mental syndrome” or “organic psychosis.” SUBJECTS Four hundred patients, who manifested cerebral dysfunction in the form of an organic mental syndrome due to a variety of causes, were studied on the wards of the Bellevue Psychiatric Hospital.* Each patient manifested, to some degree, the following mental changes: (1) impairment of memory, for both recent and remote events; (2) confusion and disorien— tation for time, space, situation and body image; (3) errors on calculation and general information tests; (4) distractibility, poor attention span, inability to handle more than one situation at a time, concreteness and *This number represents several series of patients in whom the method of double simultaneous stimulation were applied. It includes all tests of the face and hand by touch, pin prick and combinations of touch and pin prick stimuli, as well as tests of body areas other than the face and the hand. From the department of neurology and psychiatry, New York University College of Medi— cine, and the department of neurology and psychiatry, Bellevue Hospital, New York City. This work was aided in part by a Fellowship from the National Foundation for Infantile Paralysis, and by a research grant from the United States Public Health Service, National Institutes of Health. Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 46 �4'7 ORGANIC MENTAL SYNDROIVIE rigidity in thinking; (5) perseveration of speech and behavior; (6) emo— tional liability and readily elicited “catastrophic” reaction; (7) loss of initiative and interest in the environment and indecent exposure and soiling of the clothing. The clinical diagnoses were varied, including chronic alcoholism, post-traumatic encephalopathy, hypertensive cerebro-vascular disease, diffuse arteriosclerotic softening, syphilis of the central nervous system and degenerative diseases, such as Alzheimer’s disease, Hunting— ton’s chorea or senility. Observations on the face-hand test in patients with organic brain disease were compared with previously obtained results of similar examinations in normal adults and children and in adult patients with schizophrenia”. The normal adults and children, including students, associates and patients in clinics, were without manifest disorder of the nervous system. The schizophrenic adults were patients from the wards of the Bellevue Psychiatric Hospital. No effort was made to group the patients into the various clinical types of schizophrenia. JMETHOD The face—hand test was applied to each of these subjects. During routine physical examination the patient was asked to close his eyes. One cheek and the contralateral hand were simultaneously touched or stroked by the examiner’s ﬁngers. The patient was then asked what he had felt. The usual response was, “You touched me here,” while pointing to the cheek. After this initial application of the face-hand test, the patient was again asked to close his eyes and the contralateral cheek and hand were similarly stimulated. In the many instances when only one percept was reported, the patient was asked if he had felt anything else. Occasionally the second percept was reported after this question, but more often it was not. Thereafter the tests were applied to the face and hand and to other parts of the body. RESULTS In patients with the organic mental syndrome most responses to the initial and subsequent face-hand tests were of four types: (1) a touch on the cheek only, implying no sensation in the hand; (2) a touch on each cheek, implying a mislocalization or displacement of the percept evoked in the hand to the cheek; (3) a touch on the hand only, implying no sensation in the cheek; and (4) correct localization of the percepts evoked in the cheek and hand. Less frequently other responses were noted, as both percepts in the hand, or a percept in the cheek and homolateral hand implying a mislocalization from one hand to the opposite hand. In a few cases the �NE UROLOGY 4-8 percept in the hand was mislocalized to a part of the body upon which the hand was resting, out into space, or onto the examiner’s body. The following case illustrates the various responses of patients with an organic mental syndrome. Case admitted to the psychiatric hospital with a one year history of progressive difﬁculty in concentration, inability to continue work, mood disturbances, episodes of confusion, forgetfulness and occasional lapses into irrelevant speech. Later, following the death of his wife, he became depressed, cried frequently, and spent many hours talking to himself. The neurologic examination showed minimal right facial weakness and some gross tremors of the hands. On psychiatric examination the patient answered questions coherently and relevantly. He was euphoric and friendly. There was disorientation for time and place, his memory for both recent and remote events was poor, and confabulation was frequent. Calculation and general information tests were performed poorly. Judgment was poor and there was no insight into his difﬁculties. When left alone he carried on a conversation with himself, and when presented with a mirror he identiﬁed the image as that of his brother and conversed with the image, listening for replies and reporting them to the examiner. In addition, there were difﬁculties in expression, both verbal and written, with errors in reading, calculation and reporting numbers. He was able to carry out simple commands but made errors in imitating mouth and hand movements. He handled objects clumsily. There was right-left dis— orientation, and he made errors in naming body parts. Psychometric examination revealed a severe organic impairment with defects in memory, concentration, abstraction, and concrete verbalization. His performance on the Kohs block test was severely deﬁcient, exhibiting ability to complete only the ﬁrst two 1:——-A 60 year old man was ﬁgures. , 0n sensory examination by the method of single stimulation he could identify and localize pin prick and touch stimuli, except that stimuli applied to the left hand TABLE Stimulus Right cheek, left hand Left cheek, right hand Right cheek, right hand Left Cheek, left hand Right and left hand Right and left cheek Right cheek, left shoulder Left cheek, right shoulder Left foot, right hand Left hand, right foot Right and left hand Right cheek, right hand Left cheek, left hand Right and left cheek Right cheek, left hand Left cheek, right hand 1 Response Right and left cheek Right and left cheek Right cheek, right shoulder (P) Left cheek only Correct Correct Right and left cheek Left cheek, left shoulder Left foot, left hand Right and left foot Out into space* Two percepts right cheek Left cheek only Correct Right and left cheek Right and left cheek Type of Defect Displacement Displacement Displacement Extinction Displacement Displacement-allesthesia Displacement-allesthesia Displacement Exosomesthesia Displacement Extinction Displacement Displacement *Patient mislocalized these percepts into space, insisting that the stimulation had not been applied to his body. �49 ORG/1N1C .MENTAL SYNDROME were occasionally displaced to the shoulder or the face on the same side. There were no signiﬁcant differences in temperature, Vibration, position sense, and two-point discrimination tests on the two sides of the body. Stereognosis was intact. Examinations by the method of double simultaneous stimulation elicited many defects in cutaneous perception. These were manifest by extinction and displacement of percepts. The errors were persistent despite numerous examinations and over many weeks of study. Table 1 is an extract from the record of the patient’s responses to touch stimula- tion. Similar errors in localization of percepts were found when continuous and repetitive pin prick, tuning fork and temperature tube stimulations were used. 0n simultaneous stimulation of the cheek and any other region of the body, the patient correctly localized the percept in the face but seldom perceived correctly, or at all, the other stimulus. This was particularly evident when the cheek and hand were tested, especially a cheek and contralateral hand. A pneumoencephalogram revealed symmetrically dilated ventricles without displacement. A biopsy of brain tissue removed from the right cerebral hemisphere disclosed a prominence of senile plaques, Alzheimer cells and fatty pigmentation of neurons. COMMENT In this case there was no question as to the clinical diagnosis. The is of in defects not surprising. It is signiﬁcant that perception presence despite the severity of the mental dysfunction the alterations in perception were consistent and patterned. Even though the patient appeared confused he never made errors in perception and localization of stimuli on the face, whereas he frequently erred in the simultaneously stimulated hand. Extinction and displacements from the hand were frequent during many examinations. These perceptual errors were conspicuous by their consistency, orderliness and predictability against a background of apparent mental confusion. These changes can be considered a prominent sign in the organic mental syndrome. DISCUSSION Incidence of errors on the face-hand test: Of 156 patients with organic mental syndrome, 91 per cent made errors on the initial trial of the face-hand test using touch stimuli. Subsequent trials revealed a similar high incidence of errors. These errors were in a deﬁnite pattern, in which the face percepts were correctly localized, and the hand percepts either not perceived or mislocalized. Displacement of percepts from the hand to the cheek was a prominent feature during the initial few trials of the test. Errors were noted on both sides of the body and occurred on tests applied to cheek and hand on the same side of the body, or on opposite sides. In 87 per cent of the patients errors were apparent through the tenth trial of the test and persisted for many more trials. Repeated testing �NE UROLOGY 50 I 100 ~ ‘~_ 60 O RESPONSES 0*.\ Responses of normal children ages 3-6 DOMINANT Responses of schizophrenic patients FACE CENT PER 1 2 3 4 NUMBER FIG. 1. Responses on 5 6 or successnve '7 8 9 TRIALS gm multiple trials of the face—hand test to touch stimuli:. on subsequent days elicited similar errors. It must be emphasized that these patients were able to correctly identify and localize single stimuli applied to the face and hands. In signiﬁcant contrast to these observations on patients with organic mental syndrome are the observations on normal and schizophrenic adults.2 On the initial trial of the face- hand test to touch stimuli, '75 of normal and the adults cent per cent of the schizophrenic adults per failed to report one of the two stimuli. As the test was reapplied, the percentage of error rapidly declined until by the tenth trial of the facehand test less than 0.5 per cent of the normal adults and less than 3 per cent of the schizophrenic adults still showed omissions or mislocaliza— tions of percepts (ﬁgure 1). However, examination of children, age three to six years, with this method again showed a very high incidence of defects on face-hand tests. The curve of responses, as noted in ﬁgure 1, is parallel to the curve of responses of the patients with organic mental syndrome. The errors persisted for many trials and were observed in testing over many days. In older children, the curve of responses ap— proached that of the normal adult. A number of factors were found to inﬂuence these responses. Such elements as the type of stimulus, the conditions of the test, the part of �51 ()RGA N10 i1! ENTAL SYNDROME the body stimulated, “set” and “attention” of the patient, the type and severity of the mental changes, and the effect of drugs were considered. Timing and type of stimulus: In previous studies on normal and schizophrenic adults,2 simultaneity, similarity and equality in strength of stimuli were emphasized as essential for eliciting these responses. In the patients with mental changes, however, these factors were not as prominent since stimuli of unequal intensity or of different modalities still elicited errors in the tests. Dissimilar stimuli, as application of a touch stimulus to the cheek and a pin prick stimulus to the hand, or stimuli of unequal intensity, as a light touch to the cheek and forceful rubbing in the hand, elicited extinction and displacement of percepts. Similarly, errors in localization were elicited even if stimuli were not simultaneous, i.e. followed one another with a lapse of a moment or two. As previously reported, these errors on unequal, or dissimilar stimu— lation were not seen in the normal or schizophrenic controls. Application of the face—hand test using pin prick stimuli elicited the same pattern of responses as with touch stimuli. Eighty per cent of the patients made errors on the initial trial and such errors persisted in 60 of incidence is This defects trials. for than ten lower, cent more per however, than in the series with touch stimulations (table 2). In some of these patients it was possible to alternate touch and pin prick stimuli, and observe extinction and displacement of the touch percepts alternating with correct responses to pin prick stimuli. In a number of the more severely affected patients, extinction and displacement of percepts were also apparent on tests with temperature tubes, tuning forks and repetitive rubbing stimulations. TABLE 2 INITIAL TRIAL Organic Mental Syndrome Normal Adult Schizophrenic Adult Modality Touch Pin Prick Touch Pin Prick Touch Pin Prick Hand or Face Only Face-Face Hand-Hand Total Correct 156 50 160 68 15 10 122 35 7’7 75 15 45 ’72 50 51 24 36 13 14 5 3 3 2 2 1 2 0 1 5 0 This factor of the type of stimulus was more prominent in the normal and schizophrenic subjects. Less than 30 per cent of these made errors on the initial trial with pin prick stimuli, and the number of errors declined rapidly until by the tenth trial none of the normal subjects and only one of the schizophrenic subjects still showed errors. �NEUROLOGY of cutaneous stimuli between various body parts was apparent. lation of dissimilar body areas with the face as one locus, the the cheeks were well localized and identiﬁed, while stimuli were either not perceived or poorly localized. Combinations SQ On stimu— stimuli to elsewhere of stimuli to the face and trunk, face and foot, face and hand, etc., repeatedly showed face dominance. In contrast, in tests with the hand as one locus, the hand percept was always poorly perceived and poorly localized. This was observed in the initial trials in the normal and schizophrenic adults, but was more apparent in multiple trials in patients with organic mental changes. By repeatedly testing various combinations of other body areas, a gradient of the sensory relationships of these areas has been established. Because the face and hand regions represented the extremes in the pattern of responses, these two regions were selected as the basis of most of the tests. Therefore, this method of examination was named the face-hand test. The errors in these examinations were apparent in tests of both sides of the body without any manifest preference. In patients with hemiplegia of recent onset and associated mental changes, extinction and displacement of percepts were apparent bilaterally, but were more prominent and more persistent on the involved side of the body. In patients with long-standing hemiplegia in whom the mental syndrome was no longer apparent, the defects were limited to the involved half side of the body? The factor of mental set: The mental set or attitude often inﬂuenced the perceptual response. Once the normal adult was examined by the method of double simultaneous stimulation, subsequent tests failed to elicit a repetition of the errors which occurred on the initial face—hand test. It was as if these subjects had “learned” the set of “two-ness.” Moreover, when normal subjects were tested with face-face stimuli, the responses were correct, and then all subsequent face-hand tests were also correct. When face-face tests were interposed among trials of the face— hand test in the patients with mental changes, they continued to make errors on tests of face and hand, even though they were correct on the face-face trial. Such errors persisted for days. Evidently mental set and learning did not alter the pattern of response. The factoq' of attention: It is well known that attention can inﬂuence 4 perception.2' In a series of 30 normal adults who were told that two stimuli were to be applied, none made errors on the initial trial of the face-hand test. However, patients with severe mental changes, who were �53 ORGANIC MENTAL SYNDROME told either before the initial trial or on subsequent trials that there would be two stimuli, still showed extinction and displacement of percepts. It was possible to have the patient, with eyes open, observe the application of two stimuli and report them correctly. Then, with eyes closed, and the stimuli applied to the same or homologous areas, the patient would report the stimuli incorrectly. The effect of fatigue on the performance of the patient has already been mentioned. It is possible to increase the errors of the patient by administering the stimuli more frequently, or by making him aware of his errors and thereby increasing his anxiety. With mounting anxiety, errors increase until culminated by a catastrophic reaction and withdrawal from the examination. A similar effect of anxiety on performance was manifest in the normal subjects. The adults with manifest severe anxiety required more trials of the face—hand test to perceive the percepts correctly than adults without manifest anxiety. Degree of mental changes: We found a deﬁnite relationship between the severity of the mental changes and the frequency of errors in perception in the patients with an organic mental syndrome. The patients varied in their mental status from mild memory disturbances and alteration in intellectual ability, to severe psychomotor retardation, amnesia, aphasia and somnolence. The responses to the face-hand test varied from occasional extinction of percepts seen in the mild cases, to con— sistent, bilateral displacement of percepts to other parts of the body, the examiner’s body, or into space in the subjects more severely affected. In a number of patients with severe head trauma or following cerebral in mental functioning was acthe improvement progressive surgery, companied by a change in response to repeated trials of the face-hand test. The responses changed from bilateral displacement and allesthesia when damage was most severe, to extinction in decreasing frequency and ﬁnally consistently correct responses as the subject improved. Perceptual errors were greatest in subjects in whom nervous system dysfunction was acute in its course with rapid onset and short duration. Patients with severe head trauma, infections of the nervous system, vascular accidents and neoplasms were more likely to show extensive changes on double simultaneous stimulation than patients with chronic alcoholism or senility. It was in these last two groups that there were a number of subjects with organic mental changes who consistently per— ceived the two stimuli of the face—hand test correctly on the initial and on multiple trials. Type of mental defect: There was no obvious correlation of the freface—hand with of in of the the single test errors symptom any quency �NEUROLOGY 54 organic mental syndrome as in patterns of thinking, spatial or body orientation, memory or calculation. Errors in perception were most apparent when disturbances in function were most widespread. A good correlation existed, however, between the patient’s alertness and the responses on the face-hand test. In patients who were apathetic or lethargic, errors on double simultaneous stimulation were most promi— nent. This was apparent in many subjects who made errors occasionally during the initial trials of the face-hand test, but in Whom errors became more frequent and changed from extinction to displacement responses as the examination continued. Similarly, in testing patients with ﬂuctuating states of consciousness, there was a good correlation between the degree of alertness and the responses on multiple trials of the face— hand test. Some of the patients were unable to carry out tasks which had two different aspects. But despite this inability to do two things at once they were able to perceive the two stimuli applied to the sides of the face. Therefore, it could not be said that the inability to correctly perceive one of the two stimuli applied to the face and hand was due to a defect in the ability to perform a task with two different components. The factor of aphasia: Aphasia is sometimes considered a defect in mentation. Such a defect, Where severe or associated with mental changes characteristic of the organic mental syndrome, yields a picture of the pa— tient as confused. For instance, a patient with aphasia may also have a loss of memory and an inability to recall or recognize situations even after they are described to him. In order to determine whether aphasia per se will produce errors in the, face-hand test, aphasic patients, with or without such mental changes, were studied. Patients with aphasia but without mental changes did not make errors on the face—hand test, while patients with aphasia and mental changes made repeated and consistent errors on multiple trials of the test (ﬁgure 1) . Organic mental syndrome with normal responses on the face-hand test: As already noted, not all patients with an organic mental syndrome make errors in tests by the method of double simultaneous stimulation. In a series of 271 patients in whom various combinations of these tests were applied, there were 228 patients who made errors and 43 patients who gave correct responses on initial trials. Of these latter, however, there were 22 who made errors after the initial trial. The remaining 21 were correct throughout multiple trials. Of the 228 patients who made errors on the initial trial there were 28 who were subsequently correct and yielded responses similar to the normal as carried out in one series of tests. In of found 49 it the 271 patients with mental changes that was summary, �55 ORGANIC MENTAL SYNDROME yielded normal reactions. All of these 49 patients had an organic mental syndrome but in general the mental changes were not severe. lVIemory loss was spotty and the degree of orientation varied, Apathy was seldom marked. There were fluctuations in performances. At times there were long intervals, minutes to hours, during which the patient showed no apparent mental changes. Examinations during those symptom—free intervals showed the face—hand test to be normal. In several instances it was learned that the defects in memory or indifference in answering questions pertaining to orientation were‘due to an emotional depression or to a phlegmatic premorbid personality. Their organic mental syndrome was only apparent and not real. There were, however, 11 patients with severe mental changes who reported correct responses on repeated face—hand tests. Eﬂect of drugs: From the foregoing studies it is clear that patients with organic mental syndrome make errors in perception in double simul— taneous stimulation tests. Consequently it was thought that the mental changes induced by drugs should yield similar errors. To test this theory, normal adults were subjected to intravenous injections of 7 to 10 ml. of a 5 per cent solution of sodium Amytal administered slowly. This drug produced the usual nystagmus, dysarthric speech and drowsiness. In addi— tion, normal adults, who made no errors on the face—hand test prior to the injection, now made consistent bilateral errors. Within 5 minutes after the injection errors were apparent on many repeated trials of the test and these persisted during the period the drug action was effective. The more drowsy or intoxicated the subject became the greater the tend— ency to make errors in perception. At the onset, displacements of hand percepts were frequent, but as the drug effect diminished, displacements diminished and extinction of hand percepts became prominent—only to disappear as the subject became more alert. Similar effects have been observed in the patients with a mild mental syndrome. Where only extinction of hand percepts was apparent prior to the Amytal injection, displacement of percepts became frequent and persisted for the duration of the examination. The effect of the drug persisted for longer periods in patients with organic mental changes than in normal adults, so that displacement of percepts was manifest hours after the injection in the patient group. Similar observations on the effect of anesthetics on central nervous system function have been made in a study of normal adults subjected to varying periods of anesthesia.5 These subjects with no demonstrable disease of the brain, who made no errors on double simultaneous stimulation tests prior to anesthesia, manifested extinction and displacement of �NEUROLOGY 56 percepts in either hand on multiple trials of the face-hand test during recovery from anesthesia. When these subjects regained consciousness from a general anesthetic, they were disoriented and confused. There was a manifest correlation between the duration of the perceptual errors and the period of confusion, lethargy and apathy that followed the anes— thetic administration. Eﬂeet of convulsions: During post—convulsive states patients frequently show confusion and other symptoms of the organic mental syndrome. Since persistent errors on the face—hand test were found in patients with mental changes due to disease of the brain or due to drug intoxication, it was thought that any one who has an organic mental syndrome, of whatever cause, should show these errors. F or this reason, groups of patients were studied in whom convulsion were induced electrically for treatment of depressions. Patients who were given intravenous barbiturate prelimi— nary to electric stimulation were not included in this group. It was found that if the post-convulsive confusional state was severe, these patients showed a high incidence of errors on the face-hand test. As soon as the confusional state cleared, the incidence of errors in the facehand test decreased. Value of the face—hand test as a diagnostic sign: In order to determine the value of the face-hand test as a diagnostic sign of severe mental changes, a series of patients were examined in the admission ward of Bellevue Psychiatric Hospital. This examination was carried out by simultaneous stimulation of the face and hand. Each patient was given a series of 10 tests. N 0 history was taken nor were other clues used to make a diagnosis. Using this method it was found that in all cases in which the face—hand test showed errors on repeated trials, subsequent psychiatric examinations disclosed the presence of an organic mental syndrome. CONCLUSIONS From the foregoing observations it is apparent that subjects with the organic mental syndrome showed persistent errors on face—hand tests. It is signiﬁcant, however, that the same confused and disoriented patients did not err in a haphazard fashion. An analysis of their responses based on numerous tests showed that the errors were made in a predictable pattern. There were consistent errors in the hand percepts, whereas there were very few errors in response to the simultaneous stimulations applied to the face. Another signiﬁcant point is that this pattern was found not only in patients with cerebral dysfunction, whether it was due to structural or chemical changes in the brain, but also in normal children. This was found in children in whom the brain was not altered in any manner. The latter �57 , ORGANIC MENTAL SYNDROME observation indicates that this pattern is not the result of disease of the brain, and conversely, that it is inherently organized. Moreover, it indicates that this pattern is acquired early in life. N o explanation is offered as to why these patterns are so organized, namely, face dominance and hand “extinction.” The rostral dominance theory proposed by Cohn6 cannot be supported by these observations, inasmuch as it was found that the foot dominates over the hand. This fact automatically precludes the factor of rostral dominance. Moreover, the authors do not wish to agree or disagree with the well known theories proposed by Goldstein.7 Still another point is that reactions of the child are similar to those of the senile individual with mental changes. One might draw an analogy to the Babinski sign, which is considered normal in the developing infant and abnormal in the adult. From this analogy, it might be inferred that the presence of persistent errors on the face-hand test in the adult indicates a regression to the infantile level. However, we do not wish to convey the idea that we concur with such a theory. Finally, it might be concluded that what is seen in patients with dis— ease are normal patterns of function which appear to be grossly exag— gerated. As noted, repeated errors on face-hand tests may be found in the normal adult under certain conditions, particularly when there is altered brain function. Based on this hypothesis it is felt that a good deal of information about normal function can be obtained from patients with dysfunction as a result of altered structure. Aside from the theoretical considerations it must be concluded that the face—hand test has clinical value. It is a diagnostic sign of the organic mental syndrome. The persistence of errors on face-hand tests in an adult strongly suggest an organic mental syndrome. SUMMARY Patients with an organic mental syndrome make persistent errors in tests by double simultaneous stimulation of the face and hand. The errors are usually made in the hand. These errors are made on multiple trials of the face—hand test and on subsequent examinations on repeated days. The normal and the schizophrenic adults, however, do not make persistent errors. This difference in response between these groups is so striking as to have diagnostic value. Errors of extinction and / or displacement on multiple trials of the facehand test by touch stimulation are indicative of the organic mental syndrome. In a series of patients examined in the admitting room of the Bellevue Psychiatric Hospital, these tests were applied to patients as the �NEUROLOGY 58 ﬁrst questions of the interview. The diagnosis of an organic mental syn— drome was conﬁrmed by subsequent interview in every case. The significance of these ﬁndings is discussed. REFERENCES 1. (a) BENDER, M. B., and NATHANSON, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena, Arch. Neural. & Psychiat. 642501, 1950. (b) BENDE‘R, M. B., and WORTIS, S. B.; Patterns in perceptual, motor and intellectual functions in organic brain disease, Tr. Am. Neural. A. 72:31. 1947. (C) BENDER, M. B.; WORTIS, S. B., and CRAMER, J,: Organic mental syndrome with phenomena of extinction and allesthesia. Arch. Neural. & Psychiat. 59:273. 1948. (d) BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disorder of the body scheme, Tr. Am. Neural. A. 73:170, 1948. (e) SHAPIRO, M. F.; TEUBER, H. L., and BENDER. M. B.; Disturbance of body image and allesthesia. J. New. & illent. Dis. 108:253, 1948. (0 BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disturbance of the body scheme, Arch. Neural. 10 . . & Psychiat. 62:222. 1949. BENDER. M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Tr. Am. Neural. A. 75:250, 1950. (b) BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neural. &: Psychiat, 66:35.5, 1951. BENDER, M. B.; SHAPIRO. M. F., and SCHAPPELL, A. W.: Extinction phenomenon in hemiplegia, Arch. Neural. & Psychiat. 62:717. (a) 1949. The phenomenon of tactile inattention with special reference to parietal lesions, Brain 72:538. 1949. 5. JAFFE. J., and BENDER, M. B.; Perceptual patterns following general anesthesia. J. Neurol.. Neurosurg. & Psychiat.. in press. . COHN, K.: On certain aspects of the sensory organization of the human brain: 11. A study of rostral dominance in children, Neurology 1:119, 1951. GOLDSTEIN, K.: The Organism. New York, American Book Co., 1939. 4. CRITCHLEY, M.: In order to conceive a clear idea of the pathology, we have only to imagine the physiological phenomena, already noticed, assuming a pathological character. Now, the force of these phenomena may be augmented, diminished, or annihilated. In regard to the cerebral functions, we have, in the sentient nerves, pains or insensibility; in the cerebrum itself erroneous perceptions, judgments, and colitions, or delirium; or a total deﬁciency of these faculties, or come; in the motor nerves continual voluntary actions; or paralysis. Hall in Lectures on the Nervous System and Its Dis-eases, published in 1876. -——Marshall �The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome 31am Fink, M .D., 111a7'tin Green», M.D., and NI 0772's B. B ender, M.D. Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY �NEW YORK SOCIETY FOR CLINICAL PSYCHIATRY The 116th Regular Meeting oI the Society WILL BE HELD AT THE BELLEVUE PSYCHIATRIC HOSPITAL LEWIS I. SHARP. M.D.. Direcior 30”! STREET AND FIRST AVENUE THURSDAY, NOVEMBER 9th, 1950 AT 8:30 P.M. PROGRAMME I. TWELVE YEAR FOLLOW-UP STUDY ON METRAZOL TREATED CHILDREN AND ADOLESCENT SCHIZOPHRENICS . LAURETTA BENDER. MD. and S’raff 2. THE FACE-HAND TEST IN ORGANIC MENTAL DISEASE M. FINK, M.D.. MORRIS B. M. GREEN. MD. BENDER. and M.D. NOLAN D. C. LEWIS. M.D. MORRIS HERMAN. M.D. Prosideni Secrefary Staff invited — Dr. Herman �4/,q/, . 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' mm in: normal 0mm (x—é—x) at «W of an. 3.6 (0—0), mm m1:- (0+m0). ”mum“ uncut: (x—h—x) m magne- lulu ”mu name me mm mm (rm-I). * In. mama or W patzlcntl sun emu. ��i/‘l/B I STANDARBIQATION OF THE FACE-HAND TEST Introduction: In previous studies a simple perceptual test, the test, race-hand test was introduced and the responses to the of normal subjects and of patient with psychiatric disorders were described in detail (1~6). sists The test con- of applying touch or pinprick stimuli simultaneously to the face and hand while the subject's eyes are kept closed. The subject is then asked localize the percepts. occur. The two stimuli correctly or the subject and Two felt and to general types of response may be may what was perceived and localized perceive only one stimulus either not perceive the other (phenomena of extinction) or misloceliae the second stimulus (phencmens of displacement) (7). Most often the mislocslisstion or displacement occurs to another part or the subject's body but occasionally there is displacement into extrspersonsl space or onto the examiner (exosomesthesis) (8). Displacement of stimuli �2. across the mldllno of the body (alleatheala) is another form of displaoomont Normal adults initial trials orrots that may show of the among occur (9). errors in perception teat. characteristically of face dominance). all subjects correctly - be those is perceivod correctly As correct (phen- additional tests are tho errors disappear so that by the.tenth to on the oonaiot of extinction of the stimulus on the hnhd wheroao the face stimulus - may done trial noarly porcolvo both stimuli and continue 0o subsoQuent trials. has been tarmod a ”negatlvo faoe~hand This type of response test." lt oocura not only with normal gdulto but also in patients wito nohlzophronla, depression, or oovoro anxiety{ In contrast to the preceding groups, patient tith' an organic mental tyhoromo show extinction‘and diaplaoef want not only during the initial trials or the ‘tost but ’ after 10 total: of testing or as long on testing is continued. Such a rooponse is termed a ”positive taco—hand �3f test.” -by A normal "positite fees-hand test“ is also manifested ohildren, normal aged persons. fectives asvwell as syndrmhe. by patients with and mental de- an organic mental ~ Because of the differentiel_response or these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it hes been noted thst patients with an organic mental syndrone vary ' greatly in the type and frequency of peroeptuel errors. Also, subjects without organic brain disease ‘ occasionally manifest a positive faoefhend test. The questions thieh arose from these observations are: 1) Is it . poeeiole to classify or standardize the different types of errons ooeuring in subjects with e positive race-hand test? 3 2) Gen these different types of response he corb related with the several groups or subjects previously mentioned?; 3) In there e type of response which can be �llld to ooour absolutely only in notiente with eeyere 4 dieeeee of the brain? 'The present study ie an attempt to enerer these questions.‘ ~ “ ‘ . lethod end Resultez. We test reviewed our previous records of the face-hand done in almost syndrome, normal 1000 adulte, patients with organic mental and schizophrenia adults, as well an in lesser numbere~of normal children, normal aged persons, and subjects with mental defioienoy, depression or severe anxiety. Additional groups or some of theee subjects were aleoteeted in different types of stimuli. e systematic manner with The criteria ueed‘to form- ulate a standardization of the race-hand test were: 1) ‘type of perceptual errorx'a) frequency or the variOue type: or error: with different types of stimuli (touch, rubbing, scratching, or pinprick); quency of errors when 3) effect on the fre~ the Subject ere-witnesses the applio' cation of the stimuli (factor of attention). Fifteen to thirty trials ' or the test were usually done for each eubjeet. �5. Based on theoe criteria, it was possible to divide oeticnte showing a poeitive race-hand test into four groups. The oheracterietio reeponeee for each group are V ' in Teble I. summarized Qheee reeponeee with examples are described more fully in the following peregraphe. mm I Features of the Different Type: of Positive Face-Hand Test \ One-glue Extinction only with , a touch stimuli, Two-Blue Three—glue Extinction Extinction ~pinprick placement with touch, rubbing with touch, rubbing, and and deep ~ stimuli die- and pinprick ’stimull Four-Rina Same as three-plus with at least one or the following feeturoe: e) exosomeetheeie b) alleetheeie c) frequent pereervetion d) occurrence of errors while subject eye— witnesses the areas stim- ulated. One~Plue Face-ﬁend show These Test: errors only of extinction The subjecte in this gnoup~ and not of displacement. errors occur only with touch stimuli. When pinprick �6. in need, both stimuli are perceived correctly, although errors will again uppeer when touch stimuli are reintro- duoed. A 6h year old because of a 1% men with mild diabetes was admitted year history or difficulty in walking. For at leeet the same period of time the patient had been depressed, The elept and ate poorly. and wee impotent. only neurological finding was a elow, heeitent, shuffling gait. There vascular dieeaee. payohomotor was The peripheral patient appeared depressed. showed retardation, and cried readily. Senecrium intact. Spinal fluid, eere normal. The was no evidence of The EEG, and X—reya of the spine diagnoeie wee involutional psychosis. gait difficultiea were thought to be secondary to the depression. this patient hand test. A shoeed a onesplue response on the raoe~ sample of his response: rollove: �7. ' com stinging touch: right chcokolort hand' right cheek touch loft chock—right hand touch right check—right hand '“touch loft chockwlcft hand touch right check-loft chock touch right hand-loft hand touch right chock—loft hand touch lelt chock-right hand touch loft check-right hand ' left cheek right cheek left cheek T222 of Error extinction extinction oxtinction extinction correct correct right chock‘ extinction correct correct touch right check-right hand 'right cheek touch left chock—loft hand left cheek extinction extinction pinprick right chock—left hand correct pinprick loft chock-right hand oorncct pinprick right chook-right_hand correct pinprick loft chock-left hand corrcct touch right cheek-loft hand correct touch loft check~right hand loft chock extinction ' adamant: Although this type patients with cerebral disease, it Or response occurs in is not alwaya charac{'5 w (M . [cal/ca toriatic for this group. It is also seen in caciiihf defrlswod’ a; MAJ (as: t/(O‘ﬁli‘d 4"/ Mo, ﬁtter (a! amt/11:5 Skits} .(achizophrcnia, and, occasionalgy, in normal adults. �8. Two-Plus Paoe~ﬁand Test: In this group extinction ' occurs with pinpriok and rubbing stimuli as well as with These errors.may be touch stimuli. just as frequent with both types of etimhli or may be more conspicuous with touch than sith pinpriok is not present, but or rubbing. may ooour on an A.72 year old man had a 5 weeks and Displacement occasional trial. history of mental. behavioral changes. This. consisted of disorientation, confused behavior, and internittent autism. thero was an examination organic mental syndrome characterized by partial disorientation, defects in recent and oiroumlooutions illnoss, On in answering questions, denial of and pain asymbolia. logical disabilities. l-raye were normal. memory, evasione The A There were no other neuro~ spinal fluid, and EEG, pneumoenoephalogram showed skull diffuse ,oerebral atrophy. This patient's responses on the face-hand characterise the two-plus type or response. A test sample �of these responses followc: Stimulﬁs touch touch touch touch touch touch lett cheek~right hand right cheek-left hand left chock-left hand right cheek—right hand right chookéleft cheek right hund~1ert hand touch right cheek~left hand I . Roseanne ngo of Error left extinction extinction extinction extinction cheek right cheek left cheek right cheek correct correct right cheek pinpriok left cheek-right hand left cheek pinpriok right cheek-left hand oorrect’ pinprick loft cheek~lort hand left.choek pinpriok right cheek-right hand right cheek pinprick left cheek-right hand left cheek Gonncnt: extinction. extinction extinction , extinction extinction This roaponco occurs most often in patientcv with cerebral disease although patients with anxiety state, I depression or schizophrenia may also exhibit it. It is not seen in normal adults. Three-Plus Paco—Hand Test: This group is characterised by the Occurrence of displacement as well as with both touch and pinprick stimuli. The extinction frequency of �10; extinction and displaoomont may be aqual or unequal and, likewise, the number of errors with touch and pinprick otimuli will be variable. A 57 year old chronic alcoholic was found in the in a stuporous condition. Hia Itroot. breath had an alcoholic odor and there oas a laceration over his right foroooad. There here no hospitol focal neurological signs. During the doy the patient graduolly Spooch woo rambling and was was and skull had savoro memory defects There were no X~ru§a were ﬁalluoinationsti' nofonl. The diagnosis ocuto and chronic alcoholism with deterioration; A hand fluid And 35‘ expressed taranoid ideas aod was He hoatilo'hnd asaﬁultivo. ISpihal fully oooacioualgii. at timeo almost incoherent! oomplotoly‘diooriontod with confahulation. become first sample of this pationt'a toot, indicative of fallout: responooa on the race- a throe—plgo rooponao. in go ‘ �114‘ szg Rcaponso Stimulus of Error right chcck~left hand right chock-left hand displacement touch loft check~right hand right hand—left hand displacement touch right cheek-right hand right cheek extinction Touch touch touch loft loft cheokﬁloft hand Correct cheekoright hand. left chock extinction touch right chock-loft hand right check—left check diaplacomont touch right hand-left hand .correct pinprick right chock~1c£t hand‘ right-choek-lcft chock displccomcnt pinprikk loft chock-right hand loft chock-right cheek displacement ‘ pinprick right chock—right hand right cheek left check pinprlck left chock-loft hand FourvPlus Facc~Hand Test: extinction cxtincticn This group shows the. sovercat porcoptual errors. In addition to frequent extinction and displaccment ac scan group. one or . all in the threc~pluc of the following phononcna may be sccn' with touch andﬁlr pinprick stimuli: 1) oxoaomcsthesia; 2) allcsthosic; 3) frequent pcrservation of responses; h) the occurrence of perceptual errors even while the subject keeps his apes open and eye witnesses tho arcas' stimulated. �12. A 60 year old man had a oriéntation, torgetfulness, examination he ShOﬁBd a three year history of interest. and loan of On sovare organic mantal syndrome manifested by cemplete digorientation. marked -d6fect3, and inability to calculate. 'oodperativo. d18~ He was mamary alert There were no other neurological Spinal fluid and skull x-raya were normal. EEG and signs.' showed modernta, diffuse biaynohronoua slaving with slow alpha. A diffuse curcbral atrophy. pneumoogoephalograg disclosed A sample of the patient's roaponsee; 1ndlogt1ng a' fqur-plua face-hand tagt, is as fellows: Stimulus touch right cheek~ left hand touch left cheek» hand right aheek sonal spaco~ , v‘ right.oheok oxosomosthaaia extinction , _ oheek— lart left hand 10ft hand extinction , touch touch right hand- ‘ left-hhook-oxtrlporu , touch right cheekhand . , right right ‘, ‘ of Errér Tzﬁo Haazonse right cheek , oorrhot perseveration ' ' �13. touch right ohook- right chook~loft left hand touch left oheok¢ hand right pinpriok right hand loft ohook- loft right hand 'pinpriok right cheek- right right hand pinpriok loft ’lort hand loft chaok— pinpriok (eyes open) right cheek-left adamant: hand cheek—loft hand right ohook-lott left pinpriok loft chaak~ ohook ohook allosthosia displaoomont extinction _ cheek~oxtrnporaonnl apnoo displacement extinction cheek oxoaomeathosia right cheek—extrAporaonal oxosomosthoain space Throo~plua and four-plus responses invariably indicate disoaae of the brain. normal chock They are never found 1o adult: or in patients with psychiatric disorders. In oddition to tho difforont groups of subject: diaounsod above, the responses of normal children above fears 0! ago, normal hove ngod also been studiod. 3 persons, and montal defectives The distribution or the responses, or the children and aged poraooa are related moinly to age. The youngest children and the oldest adults show threo-plus and four—plus reopensoa. With changes in �age away from thine extremes, one-plus and two~plus re- spouses become more frequent. or the subjects with mentel deficiency, those with ﬁho lowest mental age have throe- plua and four—plus responses while one-plus and two-plus in subjects with higher mental 33035 'neoponses predominate Table II summarizes the distribution or the four different tfpes of responsesamong the various groups of subjects. ShOﬂ Only three-plus may be patients with and four-plus roséonses._ Such responses considered diagnostic of an organic mental syndrbme. TABLE ‘ an organic mental syndrome I; Frequency of One-Plus to Four~P1us Positive Pacerﬁend Test in Different Groups of Subjects Negative Ono~ F5H.test Pius organio nental Syndrome 10% 7% 1% Normal Adults (below 60’ 99% year: or age) “yachixophrenio Adults nearly noooae- Two~ Plan Patients with anxiety nearly occae~ states all ionelly Petients with paycho~ neerly genie depression all‘ Four~ Plus Plue_ 25% 335- o o ' 25% o _ ' ' all ionally Three» rare neVer never more never never �15;- Discussion: In answer to the questions raised in the intreduetlon, our results indicate that four general types of positibe Itsce-hsnd test occur and that these different types can be correlated with different groups of subjests (Table Our attentien there was a was ii). focused mainly on the question of whether type sf response which occurred only in pamienss with severe disease of the brain. All cases with a threeplus or foursplus response have organic brain disease. Suoh'responses are never seen in nermel adults or patients- Iith psychoaenic disorders, even theugh these groups occasionally show one~plus may or two-plus responses. Patients with oerehral disease manifesting s four~ plus response invsrihbly show vsneed foam or mental changes. the severest or most adOtherwise there is no correlations between the type.n! positive faoeahand test and the severity of she senserisl defense. Same good istients with severe mental changes may have only a twenplus �» response; In addition, 10% of patieoie with an ofganio mental syndrome hove a negative face~hand ereelized that the use of ‘fov the groups 16. teet.’ It is to four ~plus nomenclature a one implies an increasing degree of cerebral ‘. -dyafunntion. This nomenclature ‘ was used because of con(1 lenience and much an implication is not intended; . We? This classification of a positiieﬁface-haod should ‘ be useful clinically. In feeting neurological patients, the exect type of positive face-hand -corded, was will test should be re- rather than the deeignetion "the taceuhend test positive" as has been make it easier to of politiﬁe faoe«hand done until now; Judge whether the Such a prooeedure particular type test manifested; indieatee definite cerebral disease or whethef‘it may not be a mnnifestatioh of anxiety or depression.‘ The use or such a classification will also make it easier to compare the response of patients at different times during their illnees. In addition. . , it should be valuable in clinical experimental work,'euoh an the reopen-e or patients to drugs. eleetroehock trentmont; ate. �17o Ema 1“,? : .A stanﬁardization of the dittorgnt face-hand responses is prgsented. A ﬁypea of positive one-pins face—hand that consists of gxﬁinotion only with'touoh stimuli. Itwo~plus reapgnsg 1a charactﬁgixéd by A extinction with pinprick and rubbing gtimﬁix,‘gs.wéll as with touéh stim- uli? A three~plu3xfesponés consists cf extinction plus diapﬁacaﬁont with touch, rubbing, #nd pinprick stimuli. A four—plus rggpénso has all tha charactériatics of a ‘ é three-plus rgaponsa and in addition at least one of tbs following features: a) exo§bmeathesia; b)_allesthesia;. c) pérseveration of respongea;'d) occurrenoa of evbn while the errors subject aypeyitneéaas tha Aﬁﬁlication of fha stimuli. ‘Three—plﬁs éﬁdttour«plua responses invaritbly M-rindictte_¢1aeaaé of Fhé braig. One-plus and two~plua rdaponaea ocgur in patient; with brain disease but are alab maniteated by a hmélllﬁumber of normal alulta and . patients with psychogenic disorders. Pationts with a; r �183 four-plus response the Invarest mental changes but show otherwise there is no correlation betwoon-tho aovopgyy' of the montql changes and the . 7- test manifested. - . face-handV.‘ typo-of'politivo (J ’ " . , 'w L �19. REFERENCES 1. BENDER, u.a., PINK; 3. and GREEN, n. - Puttarnn 1n paﬁcegtiun on simultawawus ﬁesta a: face and hand. Arch.Neurol.&Pq1chiat., ﬁg: 355—362, September, 1951. 2. M.B., and PINK, M. ~ Tactile perceptual tests in the differential diagnosis or psychiatric disorders. J.Hillaido 3032., A: 21-31, Jlnunry, 1952. 3. FINK, M., GREEN, M., and BENDER, M.B. BENDER, tastNo.an dia'noatlo 1, ‘g: h'ar8, - The raoa4hand Sign or disease or the Jan~Feb., 1952. brain. Nburolo . FINE, H. and BENDER, M.B. - Dovelopmunt of perception 9f simultaneous tnctile'stimull in normal children. 2 27-3L, January, Neurolo 1953. JAFFE, J. and BENDER, M.B. ~ Barceptual patterns fol— lowing general anesthesia. J.Nouro.Neurosurg.&Psychiat., gg: 316-321, Hovombor, 1951. and BENDER, M.B. ~ Cutaneous perception in the aged. Aroh.Neurol.&ngphint. ﬁg: 577. 1953. g. BENDER, ﬂ.B. - The phenomenon of sensory displacement. GREEN, M.A. ,Armh.Neurol.&Pq;oh1at., 95: 607-621 May. 1951. 8. SHAPIRO,.M.F., PINK, m. and BENDER, v.3. ~ Exosomesthesia or displacement of cutaneous sensation into extruporsonnl space. Aroh.Rouvol.8:Psgchi-.at., 9. gag: 1.81-1.93, Oct. 1952. Patterns in allasthosia body scheme 3:: other g4: 501~515, Arch.Neurol.&Pa;chiat., aensorysphohamena. Oct. 19 2. BENDER, and M.B. and NATHANSON, H. — their relaticu ta disorder or 3 �3?}!DAMIM’1'IM 63‘ m FAW $33!? a, mu: 1. Green, 3. 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I mI Immu- mu mm a: mmmd‘ «gammy. adult?!» ‘Ia-I um: roux-III �13* ”I’m: slaw in mt. ”van“ yum ohms” ‘bat a» mum um. man 1: ma autumn” Miami: m “writ: the m: to“ Wand» autumn“ of thin that and of mm mm uni t1» tarp". an» 1. Italy at isthmus clinically Match or with. rut-had unnatural“: in magma-u work ��I 3"? ’ ﬂu-h'S-S.%F#M ___________Z;#__~__'——_ ��15 November 50 Dear Dr. Bender, of outline the studies in which Following is an I an participating under your supervision: a. Being prepared for presentation: i. Patterns in perception in simultaneous tests of the face and the hand 2. The Face-Hand test in the Organic Eental Syndrome 3. Patterns in perception in simultaneous tests of parts of the body other than the face and the hand 4. Caee report- Ethel Beckhorn Nos. 1-4 with‘Dr. Green. 5. Dyecheirie (with Dr. Shapiro) i" i‘b. Under study: 1. 08? changes following arteriography 2. Gomplicatione of arteriography; evaluation of the indications for the use of arteriogreﬁhy and the diagnostic value of the technic // Both of these studies with Dr. Stein. c. Proposed for study under grant by Rational Foundation > ~ for Infantile Paralysis: ',// n, , 1. Relation of sdaptation time, D. S. S. and threshold stimuli in hemiplegia 2. Patterns and factors in the responses of children to D.S.S.; comparison with patients with organic mental changes 5. Gen extinction and displacement be observed in normal subjects using threshold etimnli ? ��S.R. 5004-590M-701102(50) . Q.CITY OF 114 NEW YORK—DEPARTMENT OF HOSPITALS ....................................................................................HOSPITAL CaseNo..._....__.._____ PROGRESS RECORD Name...”...................................................................................... Admitted........................................................................ 19 .......... Ward ....................... Observations and Opinions of Visitings, Consultants and House Staﬁ. A Final Discharge Note Must Be Entered on This Sheet. Sign and Date Every Entry. .1 e . @an A ‘ I PM ‘ - "Wx. Ei‘f~ “. is _ \ [and V5“;- R‘- j "” r 4 iLIJJzJOU» SMCJE , A ' ""19“...“ '>. - Binding for Blank Leave _____________________———_———————-———————————— Continue Notes on Other Side �....................................... Division -_ ___.____________.____.______.~________. Name__________._____.____—____________ Admitted_____.______19___ Ward__.______ HISTORY Case No...........-.--..._.......... �Prev /‘ M. ‘ .‘2. ﬁr M/- > mmf‘ég: WW “W $79“me w /W Cm _ " '2) 05/- m [4 W.“ 4.xMWaﬂ- Y.‘ET>:0<I!WI.’:.6-m¢ 3. ‘ , m “V x-‘6 ' /MM 7 5% Wxép (a; £44, ﬂZZp/raa ‘ ' 414w" ' *W V » dpg, fast/aw. . ." ~ , ‘ ‘ ” WW w 44}, W ﬂm J‘ ' %¢ ./ Wugﬁéﬂy‘é {It/*4: ‘7' ' £4cﬂ/r/oﬂ / ‘ (a) c“: M 447‘ 014M; .— . W M¢W7 (a) ﬂﬂ ‘ lg‘ :11 I " 'I Cc) .A ”..th M 71 M 06‘,” f dams. M @5447 {a} )Lgpi ' ‘ CW “(:1 ‘ . I! 927'. / 2/41/57 I I .- . 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M Karo-4L _ ‘4 ...mo �.i M’m a??? MM Mpg mdM gm» 9' %%-Q zf/Zex/L "0 §. ‘ 7. 'C'meioo 0 - ,'. :_ ‘ , V I‘ f 2 w"ww-wrr‘rvmrg'm'rﬂ’wm .‘ ‘ va ~— 4”“) A.“ I —W"%*“W, .M'MJ’ %{d’ #Cnﬁwwﬁu '> -- iT do n- u ,7 ��' a: @729; :x/Ma. 0W Aw, I M» WWW; cm, ”MM” zz Aggy”: —G/2/m a. V'aéém , �Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION SEVENTY-FOURTH ANNUAL MEETING, JUNE 13-15, 1949 OBSERVATIONS ON THE EXTINCTION PHENOMENON IN HEMIPLEGIA MORRIS B. BENDER MORTIMER F. SHAPIRO AND A. W. SCHAPPELL NEW YORK Routine sensory examinations are usually carried out with the method of single stimulation. This method appears to be adequate, but it does not always disclose existing defects in sensibility. For example, in a patient with a right cerebral lesion the left side of the body may be sentient to a single stimulus. However, the sensation evoked at this very point may no longer be apparent as soon as another stimulation is made elsewhere, such as on the opposite side of the body. The same change in sensation may be elicited with the method of double simultaneous stimulation. This disappearance or extinction of a sensation is not always complete. At times the patient reports a dulling or obscuration rather than extinction. Extinction and obscuration have been found in tests of all types of sensation. They may be observed in patients with lesions implicating the sensory pathways of the brain or spinal cord. The object of this study was to determine: (a) the method which is most successful in eliciting the phenomenon of extinction, (b) the pattern in which extinction manifests itself on the paretic side in cases of cerebral hemiplegia and (C) the frequency with which extinction of cutaneous pin prick sensation occurs in patients with hemiplegia. Fifty patients with hemiplegia were selected at random from the medical and psychiatric wards of Bellevue Hospital. Patients with aphasia or psychosis were included in the series only when their responses in sensory tests were consistent in one respect or another. In this study the cutaneous sensory status of patients with hemiplegia were first estimated by the customary method of single stimulation with the prick of a pin. The patient was asked to report whether he felt a sharp or dull sensation. Various regions of the body were thus tested and compared for degree of sensibility. The same patient was then examined with the method of double simultaneous stimulation. Three variations of the method were employed: (A) simultaneous stimulation of points in homologous regions on the two sides of the body, such as the right and left hand, the right and left side of face, etc.; (B) simultaneous stimulation of points in non-homologous regions on the two sides 160 �Bender, et al.—Extinction Phenomenon in Hennplegia 161 of the body, such as the right face and left hand, the right shoulder and left face, etc.; (C) simultaneous stimulation of points in two different regions on the ipsilateral side of the body, such as the right face and right hand, the right hand and right foot. On each test the patient was asked to report the location and quality of sensations. When the patient reported only one sensation, he was asked if he felt another in any other region .of the body. If he felt two sensations evoked by the simultaneous method, he was asked to compare them. RESULTS The most effective technique for eliciting the phenomenon of extinction was found to be Method B, or the simultaneous stimulation of non-homologous regions on the two sides of the body, such as the face on the healthy side and the hand on the hemiplegic side. The next most effective was Method C, or the simultaneous stimulation of two regions on the hemiplegic side, as for example, the face and hand on the affected side. Method A, or the simultaneous stimulation of homologous areas on the two sides of the body, did not reveal sensory defects as frequently as did Methods B or C. Although we have been stressing the phenomenon of extinction or the disappearance or decrease of a sensation, we have not overlooked the other aspect of the situation obtained on double simultaneous stimulation, namely, the retention of a sensation. We shall refer to the sensation which is retained as “dominant” and the one which disappears as “extinct”. Examina— tions with the various methods of double simultaneous stimulation showed existence of gradients of sensibility throughout the body. One sensory region was dominant to another. Further studies showed that these gradients were patterned. The pattern on the hemiplegic side revealed sensory dominance greatest in the face and less in descending order in the following regions— face, thigh, shoulder, foot and hand. In other words, when the face and any other part of the body on the hemiplegic side were simultaneously tested, as a rule the sensation in the face was perceived while sensation in any other one part was reported as diminished or absent (extinct). A phenomenon which appeared directly related to sensory dominance was that of “displacement”. In some instances when non—homologous regions on both sides of the body were tested simultaneously, the patient reported he felt two sensations of equal intensity, there being no extinction. The sensation was localized correctly on the normal side. However, the sensation evoked by the stimulus applied to the affected side was incorrectly localized. There was an ipsilateral displacement of the sensation toward a region homologous to the point of stimulation on the normal side. The displacement was usually toward dominant sensory regions. Thus when the patient was pricked simultaneously on the face on the normal side and the hand on the hemiplegic side, he reported that both sides of the face had �162 Bender, et (LL—Extinction Phenomenon in H emiplegia been stimulated; or if the hand on the normal side and the face on the paretic side were simultaneously tested, he claimed that both hands had been pricked. In some cases of disease of the brain the displacement phe— nomenon was the earliest indication of sensory impairment. As the disease progressed, displacement was replaced by obscuration and eventually by extinction. One of the signiﬁcant ﬁndings of this study was the demonstration of sensory deﬁcits in patients with a severe psychosis or aphasia. Usually such patients are considered incapable of giving coherent or consistent answers in routine sensory examinations. The psychotic or aphasic individual has trouble in expressing comparisons between two successively induced sensa— tions. He has less trouble when the stimuli are applied simultaneously. With this technique the psychotic or aphasic patient usually responds by pointing to the sentient or “dominant” region and he repeatedly ignores the region which is apparently “extinct”. In summary, it was found that a sensation in one region of the body is readily inﬂuenced by a sensation evoked in another area. This inﬂuence is most apparent with the methods of double simultaneous stimulation. Using these methods in patients with hemiplegia it was found that extinction occurred in 44 of the 50 patients, whereas routine single stimulus examination ’disclosed defective sensation in only 29 cases. Furthermore in 28 of the latter 29 cases the sensory defects became more conspicuous with these techniques. ��.ﬂmwéﬂ nMMﬂL—{A‘ay /m4_g. fa/A/uc/WIZMM g/éé,‘M/£¢M ��, .p~.., ��' ‘D’Mwnrw hvﬂﬂ :- f/‘f/f’l a, am» , . MW Wm V“ ‘ “Mm ,¢__,-m..‘ w ngvm’regﬁww .5 w (V) (:3) gﬂ/hﬂﬂﬂh " M 7% rﬁi. ﬂé’i ﬂmw ’2 mm //M I.“ _ ‘ ‘ ‘ . ; . \n ��wifﬁmﬁ’ﬁ; ’ ��51$“ “<4 3 “it wﬁéu'wéi 3‘” van ��. hi illanh. ‘ , ‘ .A $1.1Hnawwlllflsfalz ”436,... 13.36 Tamrgwuau .-1...i1w.uiu.«ni.1> 53.53.», . �7,) 3“, Wu 3. ' * - “aim/ad. 4.54.wa 975‘; ‘au ) «,2; MMM) LC“ 962.7 ‘@ dﬂaﬁcﬁ . *3 SI ��5.9.50 Sensory Studies In a discussion with Dr Bender today he made the following suggestions: 1. That studies of the face— hand, face - penis as carried out in the normal could be extended in the pattern of shoulder - foot, hand - thigh etc. This will give an outline of a homonculus of sensory dominance in the normal-2. The studies of the reaction in the normal on the abnormal in the penis and breast tests two directions: the influence of amytal might on the normal response and the responses to the test in severe the test and initial be extended in anxiety states (hysterias . . .). 3. It would be an error at the present time to describe the testing as a definite aid in the diagnosis of the organic mental syndrome. With such a figure, the physiological implications of the testing would be pushed to the background. But that if the studies can be verified as valid in OMS, then it might later be described in that condition as another test like orientation, patterns be 4. A memory, etc. special study in normal children of these undertaken. 5. The problem of Beckhorn be presented as an example of a hemisensory syndrome that appears to D83 and SS upon proper stimulation; and the effect of intersensory testing. 6. In the writing of the definitive paper on the face - hand test, the following subjects must be covered: a discussion of the various theories behind dominance as the rostral idea, medial over lateral structures (concentric), importance of sexual symbols, skin sensitivity, etc.; the possibility that the disturbance is related to the state of consciousness and not the state of the reverbalization processes (aphasia, apraxia, etc.); order of dominance; 7. ﬂ“: 4 6) m—NMWYWKwh./Lu&m" “mu—~15 4/444./GLL; » (aﬂdiiaruiuiii7é«vl» «Ajfaa ��w' -——-- -—-\P,K.. -7. ”w“ , -..~ » ‘ . w... «kw, - , 2"” “av 7“,:'71,~',Izﬁivm"’">:_’r W."'etrwwgu—cvrw"'_nWWW'-W‘4~‘Xmu_t7$m,va'ﬁ«mv-JzT’n-VH—W-jw ��:5,“ .p �n. amm.m,mumaamfummmmm WWIIWWthﬂph man. «mmmmmmmmmmw sun-1m. mmﬂumuhmmmamtmmmw} “mummummummmmum. 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A and «rind "am. mo na- tartan an intact. him). mad, thotvmmmlom ma xnms at that ‘91:» mm,~pm31. m umu- in imam-v uma panama... damned typo. in» we annulus... an “to tho «ya-alum 69 In this 9131.!“ that«I I out-91m mum» on the {WW Ian." A awn»a! nu 'WOPW“ Yemen: a: , W ‘Wt I ' “wt touch an ' touch tumult tench Chow-loft hm right than! loft ma~n§z was ﬁght hm tough touch tough. ; . may“ Alma-10“. rum 13.31:! i maintain-ﬂ cum: right hum-Mu an Mi: mam: ma «Musician ,. unnatﬁn utimtion mot it“ in.“ 00m." animation ' com“ dwt Bulk-tilt; land ”at; . chm-k - «tintim � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The face-hand test as a diagnostic sign of organic mental syndrome. Neurology. 1952 Jan-Feb; 2(1): 46-58. And, Observations on the Extinction Phenomenon in Hemiplegia Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-3-005 Date A point or period of time associated with an event in the lifecycle of the resource 1952 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>; Green, Martin; Bender, Morris B.; Schappell, A. W. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 15 items, each with various amounts of pages. 1: Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 2: Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY. 3: New York Society for Clinical Psychiatry: The 116th Regular Meeting of the Society. 4: [Preprint]. 5: list of publications by Fink. 6 and 7: Drafts. 8: handwritten notes. 9: Letter to Dr. Bender from Fink. 10: handwritten note. 11: City of New York - Department of Hospitals/ Progress Record. 12: Handwritten notes. 13: Reprint from Transactions of the American Neurological Association 74th Annual Meeting, June 13-15, 1949; Observations on the Extinction Phenomenon in Hemiplegia (not written by Fink). 14: Handwritten notes. 15: typed pages. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/d22bf8e1eaccf5f9a01c426789665f0e.pdf 7c6234b95a1768fbfe1c37f8a9076215 PDF Text Text Reprinted from THE DYNAMICS OF PSYCHIATRIC DRUG THERAPY Edited by G. J. Sarwer-Foner, M.D. CHARLES C THOMAS ° PUBLISHER 0 Springﬁeld ' Illinois ' U.S.A. W DRUG INDUCED CHANGES IN INTERVIEW PATTERNS: LINGUISTIC AND NEUROPHYSIOLOGIC INDICES By MAX FINK, M.D., JOSEPH JAFFE, M.D., and ROBERT L. KAHN, PHD. In studies of the effects of newer psychopharmacologic agents on behavior, we are inclined to emphasize their effects on the patient. The newer compounds do, indeed, have specific physiologic effects, and we propose to review some of the induced neurophysiologic changes. But psychopharmacologic agents affect more than the patient alone—and it is the interactive effects that are the focus of this conference. I am reminded in this regard of the story told at a similar conference by Dr. David Rioch about a psychopharmacologic his that the On of earlier days an amphetamine. era, agent patients took amphetamine, Dr. Rioch reported, they seemed much better. However, on the day when he took the medication, the patients also were considerably improved! How can such changes in human interaction be measured? Of the many aspects of behavior that are altered by the new agents—and it is clear that all aspects of behavior, as perception, ideation, motor activity, mood and judgment are altered—verbal behavior has numerous attributes that make it suitable for the evaluation of changes in interpersonal relations. Verbal behavior is easily recorded, is readily quantified as it is already in units (words, phrases and sentences) and can be recorded and measured without the introduction of artificial sets, equipment, tests or instructions. Furthermore, speech is the core of psychotherreflect in of and measurement language changes may patterns apy changes in the ongoing relationship. For these reasons, we have Aided by Grants M-927 and MY-2092, National Institute of Mental Health, US. P.H.S., and Grant 56-151 of the Foundations’ Fund for Research in Psychiatry. 29 �The Dynamics of Psychiatric Drug Therapy 30 undertaken studies of language patterns—of the patient and of the therapist—as influenced by the newer psychopharmacologic agents. The groundwork for this report was laid in a study by R. L. Kahn of the language changes following convulsive therapy (1) . Under the conditions of the alteration in brain function induced by repeated convulsions, changes in syntactical aspects of language were observed which were related to the degree of cerebral dysfunction and to clinical ratings of improvement. Prior to treatment patients expressed their problems and their aspirations in the present tense and first person, without denial, evasion or cliche’s. During treatment, however, they increasingly utilized the past or future tense and the third person mode with qualification, evasion, denial, displacement, cliches and cryptic responses. Such language patterns on the part of the patient resulted in an alteration in the language patterns of the thera— pists. They, too, found interpretive statements in the present tense less communicative, and increasing use of the future tense, displacement, and minimization of symptoms as aspects of a reassuring attitude became prominent (2, 3). Syntactic analyses are essentially grammatic content analyses, and are dependent upon interpretations by the observer of the subject’s communication. More recently, the dyadic TTR, another measure of language change, has been applied to this problem by J. Jaffe (4, 5). The two person group, or dyad, comprising the interview is treated as a unitary system. The language measure involves the pooling of the verbal behavior of both participants—the patient and the therapist in psychotherapy. In these studies, the tape recorded interview is transcribed in temporal sequence without regard to the speaker of the words, and then divided into consecutive 25 word units of intereaction. TTR, or type-token-ratio, is an established psychological index of language diversity. The ratio reflects the number of different words (the types) to the total number of words (the tokens) in the sample. The TTR is calculated for each 25 word unit and the pattern of consecutive scores is studied. In patients undergoing convulsive therapy, there was a �The Dynamics of Psychiatric Drug Therapy 3] consistent decrease in the mean TTR and an increase in variability (standard deviation) about the mean. These changes reflect greater stereotypy and repetitiveness in the interaction. In a control group of subjects, without induced brain dysfunction, there was neither a change in mean TTR nor in the degree of variability, although there was a tendency for the variability to decrease (6). When these two language measures—one a grammatic content analysis and the second, a formal diversification score—were compared, a decrease in the mean and an increase in variability of the TTR patterns were observed in the subjects who evinced two or more syntactic language changes. Conversely, in those with less than two syntactic language changes, no significant difference in the mean or standard deviation of TTR was observed. These observations indicate that with increased syntactical language changes, there is also a decrease in language diversity with greater stereotypy and repetitiveness. Furthermore, when analyses of each language measure were made with the degree of induced neurophysiologic change, as reflected in the degree of delta activity in the electroencephalogram, significant differences were shown only by the subjects with high degrees of delta activity. In the earlier studies of convulsive therapy, a neurophysiologic-adaptive hypothesis of the mode of action of this form of therapy was expressed (7). In this hypothesis, the therapeutic process is ascribed to a persistent alteration in cerebral function, which provides the milieu for a change in interaction of the subject with his environment. Recently, this hypothesis has been applied to the newer tranquilizing agents (8) and validating studies are now in progress. The studies of verbal behavior are one part of the investigation. We would like to describe our present experimental techniques, report the data from the neurophysiologic and language studies for a number of compounds, and discuss the significance of language measures as indices of change in the ongoing interpersonal behavior of therapist and patient. �The Dynamics of Psychiatric Drug Therapy 32 METHODS At present, all observations are made in the EEG laboratory. Following a routine EEG recording, an unstructured psychiatric interview, with short periods of structured inquiry, is taperecorded. With EEG running, an intravenous injection is then given at a slow rate. When specific EEG or clinical changes are induced, EEG recording is stopped and the interview repeated. Periods of EEG recording and verbal interaction recording are alternated for the duration of the period of observation. The EEG is measured for changes in synchronization, shifts in dominant frequencies, and per cent time of slow wave (9) , alpha or beta frequencies. The tape recordings are transcribed and measured for the diversification of consecutive 25 word samples of dyadic speech (4, 5) and syntactical changes (1). The dyadic analyses have been described. In the syntactic analyses, the response to three standard questions is evaluated as to changes in grammar and content: “What is your main troubleP”; “Why did you come to this place?”; and “What do you wish for more than anything else?” Changes in syntactical use of person, alteration in tense, evasion (as answering a question with a question or “I don’t disof the the subjunctive, use as by know”), qualification, placement or verbal denial of symptoms, increased use of stereotyped expressions or clichés, cryptic responses or withdrawal and silence were scored as changes in the communication pattern. Consecutive patients referred for drug or convulsive therapies in a voluntary psychiatric hospital were seen prior to, and at various intervals during, treatment. To date, the following agents have been studied by these methods: amobarbital, benactyzine, chlorpromazine, diethazine, iproniazid, lysergic-acid diethylamide and Win-2299 (2-diethy1aminoethy1 cyclopentyl—Z-thienyl— glycolate) . �The Dynamics of Psychiatric Drug Therapy 33 OBSERVATIONS l. Electroencephalogram In a previous study (8), it was observed that agents that increase EEG synchronization or induce a shift in EEG frequencies to the slow range generally induce behavioral changes of sedation and tranquilization. Agents that desynchronize the record, however, or induce irregular fast activity, are associated with hallucinatory, excitatory or illusory activity. Of the first group of agents, we have tested amobarbital and chlorpromazine. Amobarbital regularly induces high voltage, well synchronized, fast activity, at 20-24 cps. The regularity of the appearance of this increased synchronized fast activity has become the basis for the “sedation threshold” (10). Chlorpromazine has a variety of effects, depending upon the pre-injection record. In subjects with well defined alpha activity, both alpha voltages and the percent time alpha activity increase (1 l) With poorly modulated, low voltage, fast records, the per cent time alpha increases. In patients with low degrees of slow wave activity, voltages of slow wave activity increase, and the per cent time of both delta and alpha increase. Diethazine, benactyzine, LSD, and Win-2299 are examples of the second group of compounds. In tests of diethazine (12), in subjects with well modulated high per cent time alpha records, there is a decrease in voltage and per cent time of alpha activity and irregular low voltage fast activity appears. In records with high voltage slow wave activity, decrease in voltage and per cent time of slow wave activity is prominent and is associated with irregular fast activity. Similar patterns have been observed for benactyzine, Win-2299 and LSD. . 2. Language Analyses Changes in language occur with these induced changes in brain function (Table I). With chlorpromazine and amobarbital (Class I) there is a decrease in the mean TTR and an increase in variability (standard deviations) of consecutive scores. These changes are similar to the changes noted earlier for elec— tro convulsive therapy (6) . In contrast, diethazine, benactyzine, �34 The Dynamics of Psychiatric Drug Therapy LSD and Win-2299 (Class II) induce an increase in mean and a decrease in variability. TTR TABLE I TTR Class I Class II CHANGE WITH DRUG ADMINISTRATION (N223) (N227) Difference Class Mean Standard Deviation —0.78 +0.44 +1.42* —l.00“ 220‘ 1.44“ I “ Class II Diethazine Benactyzine Amobarbital (l3) Chlorpromazine (10) LSD-25 Win-2299 p > .02 (9) (5) (3) (10) We have not, as yet, applied syntactic methods of analysis to these recordings. Syntactic analyses were done, however, in the earlier studies of the effects of amobarbital and diethazine in patients with varying amounts of slow wave activity after convulsive therapy. Amobarbital amplified, and diethazine reversed, the syntactic patterns produced by convulsive therapy. With amobarbital, denial, displacement, minimization, and use of third person and future and past tense increased significantly (1), while after diethazine, there was a significant decrease (l2) . DISCUSSION We have observed consistent relationships between the neurophysiologic effects of various drugs and changes in two measures of verbal interaction. We have not underscored, although we have consistently observed, that both the behavioral changes and the clinical ratings of improvement are dependent upon the induction of persistent neurophysiologic changes. We have sug— gested, therefore, that the language changes constitute an important segment of the cues upon which the evaluations of “improvement” are based (1) . These language measures provide an operational basis for studies of changes in interpersonal relations without resort to hypothetic energic or topographic constructs. �The Dynamics of Psychiatric Drug Therapy 35 Also important for our discussion is the demonstration that different patterns of verbal behavior may be related to the different neurophysiologic effects of various therapies. Language analyses provide another means of investigating and measuring neurophysiologic effects. Weinstein and Kahn’s (13) demonstrations that language patterns of orientation, confabulation and denial in structured interviews were valuable indices of brain disease, heralded such applications. The demonstration here of consistent changes in dyadic TTR scores suggests that unstructured verbal interviews may also be used successfully in neurophysiologic analyses. The measures described here are crude, and the data preliminary. The consistent nature of the findings as we have investigated each new agent has been striking. Other language measures have been suggested, including changes in rate of speech, tense, and relative amount of verbalization by each participant. Further analyses with other psychopharmacologic agents, and other measures of language analyses are in progress. How can we relate these observations to the problems of this conference? First, generalizations about the psychologic or psychodynamic effects of psychopharmacologic agents are probably untenable unless the varied neurophysiologic and language behavioral effects are encompassed in the hypothesis. While introspective analyses provide some measure of drug effects, more objective data are needed, and these may be provided by language analyses. For example, the successful use of chlorpromazine in the management of hallucinatory and excited states has been well-documented. In such states, high diversification of language, reflective of diffuse associative processes is prominent. This diversity clinically manifest in tangential, incoherent and neologistic speech, with rapidly shifting frames of reference (5) . With chlorpromazine therapy (and the induced alteration in brain function) there is a decrease in the diversification of the verbal interaction, with a decrease in the use of present tense and first person speech. These language patterns may provide the basis for the change in interaction between therapist and patient. Conversely, in apathetic, redundant, blocked or withdrawn pais �36 The Dynamics of Psychiatric Drug Therapy tients, the administration of LSD (14) or mescaline (15) have been suggested. These agents induce an increase in associative is reflecdiversification a increased which of language processes tion. These agents also increase the use of first person and of facilitate thus and tense speech survey may patterns, present the paﬁents premnn:atdtudes and feehngs “ﬁnch the therapbt is interested in exploring. In summary, we have indicated that concurrent neurophysiologic (EEG) and language behavior (syntactic and dyadic diversification) measures are techniques for the operational analyses of the effects of psychopharmacologic agents, in the two-person system of doctor and patient. Further exploration of language measures are suggested as a rational basis for the understanding of the psychologic effects of these new therapies. REFERENCES Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Hoch, P. and Zubin, J. eds. New York, Grune 8c Stratton, 1958, pp. 126—139. 2. Esecover, H., Jaffe, J., and Kahn, R. L.: Psychotherapeutic techniques with electroshock patients. J. Hillside Hosp, 7: 17-25, 1958. 3. Jaffe, J., Esecover, H., Kahn, R. L., and Fink, M.: Modification of psychotherapeutic and supervisory relationships by altered brain function. 1. In preparation. 4. Jaffe, J. An Objective Study of communication in psychiatric inter— views. ]. Hillside Hosp, 6:207-215, 1957. 5. Jaffe, J. Language of the Dyad. Psychiatry, 21:249-258, 1958. 6. Jaffe, J., Kahn, R. L., and Fink. M.: Communication patterns with altered brain function. Read at Eastern Psychologic Assoc, April 1958. 7. Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation between altered brain function and denial in electroshock therapy. A.M.A. Arch. Neurol. dy' Psychiat., 76:23-29, 1956. 8. Fink, M.: A unified theory of the action of physiodynamic therapies. ]. Hillside Hosp, 6:197—206, 1957. 9. Fink, M., and Kahn, R. L.: Relation of EEG delta activity to behavioral 63' Arch. A.M.A. Neurol. electroshock. in Psychiat., 78:516response 525, 1957. 10. Shagass, C.: The sedation threshold. A method for estimating tension in psychiatric patients. EEG Clin. Neurophysiol, 6:221-233, 1954. ��at 3:2» W mu mm. W WWW “a“ M I. 3., and mm mm mm and It 3.1%., April 12, mum, 11.: 8.1:»: at. 1958. mF?“ '1'? , immummdw mama» was: Wm, mmmumwuwam mu: m). 3,: ... 9 w_ gs 191.206. 1991. �Drug Indueod Ghana-l in Imam“ know: man ma Hwophylielogie XII Indiana ’m 11.9., Jawb- JII‘. xi)... ma Rabat In Kuhn PILD. mmm quoal' ﬁnd for Rani-eh in Fayehutry. PM the Ewart-mt a! Puemtry, Wain 3mm, Elan om, Jul. , 3.1. Aided by ﬁrm“ “2? and name, trident]. 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NWuammmmmumM) w‘nmmw3-MNMW' mmmamu _' Mumamwwammu‘ Mum mmmmmmaﬂmwm3 ‘ Mmmmm,mww:mmmam thwawmrwmmwunm MW hm,muwmmmmmm(m) MW¢W(WmmﬂMMWm �tum” for tho apex-gum]. may”: at the «feat: at mcmhac agents, in tho Mm mm a: “Mr a and patient. Further mention Imus: mm“ m :33ng u mum but: far the underﬂmdinc of the whim «that: 0: than an tharnpiu. at �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Drug induced changes in interview patterns: linguistic and neurophysiologic indices. In G.J. Sarwer-Foner (ed.), The Dynamics of Psychiatric Drug Therapy. C.C. Thomas, Springfield, IL, 1960: 29-44. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-45-011 Date A point or period of time associated with an event in the lifecycle of the resource 1960 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>; Jaffe, Joseph; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint, [preprint] and outline. Reprint from THE DYNAMICS OF PSYCHIATRIC DRUG THERAPY Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/83ab48a2c2deaa99207d2c9a9f5a4a5d.pdf 5d4afa38e2ad19bfcb3084fe8746be25 PDF Text Text 111: 9/55 Egbert I» Kuhn, mm. Hillside Raspiul, Glen Despite ”posted attomptn, wmlatiam am, my Ia‘rk between aim we activity dwed by «hammock and subsequent. therapeutic outcome haw ham Email, mrtain ahock therapy indum alterations in the sleetmncophalogm in all subjects. mamas voltage whim wmmuml. conclusions are wan-entree! Iran previous studies (1).- Electra:- Three pattema we generally dowribad: ‘1) slowing of tha 2) the in- may of mam, symtria awn {remiss} 51w wave activity, generality a: high appear as burnt nativity) and 3) didnu‘him cios in rate and amplitude. mm in din-act. a at beta rm;— relatim human 12m degree or Mg”, and the number and imam a! mama. In my subjoéts ”mum paint at change is daaeribod, which can be maintained by further those a. tmamnt, but which is apparently not increased. Such indueod oloatroenccpmlu ographic ehangaa are ﬂux-aims. to the pretreatment lswls is number, frequency and Another area than type m ate at“ return at the: cem’bml generally 1 to h weeks, dcpending mhﬁmﬁhip between dagraa of manifest and authors is the the ha}: of direct wry loss and aonfusim and the degree of electroencephalogmphie abmmlity. wry changes with few tmamants and without. Cases are demribed of 3mm significant olaetmncaphalogmphic mm without manifest clinical ﬂange; and also a: never: changes in cerebral emmnicn cf inpaimsnt. In these reports, ganic dimam an at tmtnen‘b. a! agreement ”mg the wry patterns it is? stated that Wim also correlates poorly with clinical results. Hammad at tbs Eastern me Society, Bethesda, September 30, 1955» mach or» ��Whﬁla and EEG these twa “mommy, atuéies dananatrute a ralatianship betwaen clininal ralult tho majority 91’ reports fail to do m. It 3.8 mt 11h]: that this diucrupanay is tha mosult a: diifarunt populatiana, but rather; tun dimer-macs in methods of evaluating Swami, than him at Matias; and diffexunaea in ontinnting change: in aarubrul runntian. In in» ﬁgurae at stuﬁias a! alﬁarnd twain tunetian indueed by at elsatma— in SW Yak, further data m the mkﬁiamhip betaaun EEG ahangea aaa clinical atfoeta of aluetrenhoek wars colleetcd. ’lhs genaral reaulta a: pruviaun investigatiena an the alteratienn in tho EEG with shank this 311137149 Hospital taro anniixnnd, but 313a, a ﬁatinite rmlatianahip betwaan.ﬁﬂﬁ effects and has clinical rasult was dnmnnstratod. Throa £661 are preaanted alaetmeshock today: (1) the m pattem mum electroshock and their “hum to in- pwavument. (2) The internorrelatianl at airfarant quantitieatians at ddlta acttvity. (3) m relation of these abaemtiam to a theary at abet whim. :'vzvﬁhgggggga§§§y Ihuntvmfaar aanaegutava patianta ratarrea for aleetre— 3 shock wart studied. Electruanczgu:.m¢~q us ' 5 warn nan: priar ta traatmant, at uaokly intsrvala ﬂaring traatment aha grist treatment. In 8 ehanns1_ﬂhdcra£t instrunsnt, uaodlo eloatrudus, and bipolar racording Hypervnntilaxdan was tha anly was unad. activatian tachnic utilixoé. truatnant, raaarda ware takna tbs day'attor; ganamully 25 to 31 hunts Datum: after traatmnnt. Th3 Baiter and the tmmnta wen administered by the staff paychia‘bris’m, 6 h? electrnatinulator. Treatment scheéulas namber of treatmants variad tram impruvemant, the 9 to 33. warm An thrae wing a. timma a'waek; patianta shaved alinical psychiatrist tended ta give raver treatments, and warn widely ��m5:- are mam of the diffieultiea in evaluating impmvmnm More might have «momma in the estimates of change in those patients. In any me, by E‘o wing this threefold clusifieatiem, the diffemooa between the groups will be distinct. 9E gag EVALUATIOX first and third W! A total. of 160 meow: were obtained in these who Following the suggestion of Strauss (h), the delta mm am determined for three: lead mmbinetiam (frontal—swam, anterior temporal - vertex, and lobe) for 180 ascends of Hoarding for not load. The delta index :13 on the pemont time woupiod by aerate. ”ﬂame mm of '3 ops- or slower. Tho avenge delta-dude: for the thm loads,.’md the highest delta may: in my load were the 1mm: and in the final tabulation. waves Sinateneouoly, the record me mad for the almost frequency 1am» tifiea at least twioe in my load; the highs» voltage of any delta may and the duration of the longest beret. cm the basis of those were placed 160 mores in It rank ﬁn indie” order from the of slow wave activity the meordu ngt abnormality to the lawn. The were then divided into 3 groups! a Met. upper thins? high degree abnormlﬂy, and lmat m were .. 1m demo mbmmlitm mum-*3: 1. 0m- nouns show a Mitim aomlntion human early out dugm m; okxomlity and improvement. Thane relationships are demonstrated 11: Slide 1. By utilising sleetroehock, we of troutmt is quantification of slow wave abnormality induced by conclude that snob EEG abnormality induced in the first 3 theme on “mental response. 2.. clinical mm minimums We, and than m clinical Mama for the short tom favorable mot bathroom met each of the eeeh other? indie”, first with the ‘ ��WWW £611.3ng ehetrashock mum is the mault of the emﬁm in the mtiant functim in winch new panama of adaptaum, part». Mae me “when amnamu 1mm thaw 6! dental, my be. of a inﬂame! brain as? WM. that: an. alts-rad milieu of eon-ohm}. a puma-equate for ~ 30W, :1: mmnt. mum as measured by delta abnormality is Ta @115 extent the first part. at the Mates».- ”WWI: many of quantitative far the duaidatian at ”Wm 51‘ 27mm mans studies paint. to the Em 5mm: �mm. 1.. than 39mm Lu Th0 Eleatmmeplulm in Thempim, J. Raw. 8: Kent. 131»... Egg 95.107, 3.9512. Jemph a. and Panelist, maetrie 311w]: 3., Harland, W... Kaufman, and Pincus, 6.: Changes in the 81qumaﬁmlegm and in the ke-mtion at 17 {shoutemida [teeming Enam- 3. shmk mommy af Agitated Mpmvam, Payuhoaom. Had... Qt mm, mm: own in the me Mr Barbiturau Anesthesia mma by Elw£mcanwlsin Mama’s and mm SiWicanee for the Timmy (31‘ E01 3.. m and Olin. Rummy“, g; 26l—280, 1951. mum, h. 8km“; Km: Clinical - at mm. madmaophalogmphie Studies a eomhtim Elwtmmawralegmphie and Anatomic Ganges in Gases with m: 14260, 191th. Hammin, Eel” and him, Rd": Mastic U“ a! Mbaﬁihl 3mm! (“Mm Sodium“) in Ma Brain 31m”, Am. J. Wat" m: 12, m, 6. Fink, 3., Am. J. Psychnti, ' 1953. m,Rental Bead», ﬂu H; and a! Qrmie 7. and Dimse, Org-mm Brain 5. Wﬁ; 19%. as n Diagnostia Sign Baum, at 246—58, 1952‘ W in now-y and Mauser, 3.: 33mm a: Impmmment in Wmhoak, cant. "euraloguu, 1‘? W6, mm, m, Fink, Lamina to Byndram, ﬁne Farm-Hand East u. and 1956. 8... www, EM” mumps“ Its my “~26, Kuhn, 8.1. and MM, 1.: Paychoais During mew-9mm Bushman he the Them? of 1952. 312302 Therapy, Am. 3» WM, ��MW“: ﬁwzww/Z WW! :: Var/7 . a; /W‘ / / MMﬁw l-I’M) /, VMW 5/ We W / ' - ’ / ri ' L 444:1” /~57:é'(/ *' . ' �/WW WQMW We. WDZM/JMD szd 4 ”Ma/Z7444444944“ M—IWM W43, g; ﬁw/ 444 W544.» MM ﬂWM AM MW ZIMMWQ L SCAMUE‘D % ”M W“ ”774/ W' AWQQ ”W47 ﬂaw/44¢;”jg Mix/«442 �ﬂ , V MW/a/é/WWM Mat/c9245.? M/W7M7Wa. MW/ZWa/d —%¢%7AQWW 2% H M AA/W/Wd4 Mama/21¢ #wdfm?/ WWWWX‘JP ﬂux/(‘5‘ WWW/LWMW/AW W%WW& ,MAW’ZmV/ %/laﬂ6¢r¢£Wﬂu~ WM 30%.... . �@: ’OZQJWWM %W M,:/éw€ £W7WW éwaf‘W Jazz/WW //~JW’{)W W / W,” make—4441M @ace WMA, W mg WWW—jfszd, éﬂfﬁé;e. I wmbéMW ﬂW; WWW MW @yagﬁa / mm V UZW‘ﬂm W4 M ﬂed/2W " �W cam/um aim W ,mmvwr‘MA/ﬂﬂ M Ma ://Z~M~/Z~;/ . .2. ‘ W ﬁWZW/LM/AM WYAMCMMWWM WW M562Qﬂﬁ7~fw W/QWWMW /¢éa¢d/W @ngaiu/é Mh/o/VW /MM*/WwWéAﬂ.—A 74%. MW/%Wé<~v ﬂms M—/k MM ﬂoWW/I ﬁ/ch/M ﬂWM,W/%9%Wﬂ- WK WW %W MMWMWWJ �3WWﬂw/y/QWW7/W /x£¢¢:W/ZW ~ ﬂ Mé/éex WA’8 75WW/iu7sﬁéw/A/AW/o ﬂmwMM éﬂyiw/(Wga ﬁ WQM/yr/x M. inAM. ﬂ/j/W/W/fgl/M ﬁﬁéz)’ aim/ah‘muzt V 4 UM a/“Z A/dxﬁAMMW -‘ ��;WW%AM a/A/W &M MmW%M;/A Adm/M' ”#7 Wet/«.4145 W%WZ;¢M¢MA w! W ﬁﬂéﬂﬁfdeWQMW' WWWW m km,MW7ML L' MM _ WI/Jﬁ W W . ' - �Q . MM W WWW WM‘“ ~AAAM/AAWM4’W AM‘v/Wzy’g A ' $4MM wz/Z’WWW/ AMAWW AWM �WWW “WMMW MM WW MMWMI "WK, MZMMMVMW ML, I'M/”MW W W ﬂbthxWM WWW /A%W/2Wg MM7 MW. V WM gifMMWﬂ/%M%‘7 4 MW MZM WM 7/134 (12%) Mc/Zzw/anéﬂff" Wm/m Mzgf �0%,. MAW/WW wWM Wr/WA/ZnaWk/ WWW—MW //6W7/» f/A/ay/MW/ W 9Z2WWA» ZaWZM' A: 4w/ W/ﬁ UV ngégfiﬂmm ”2% M”; j �“”1“ ”PM“ “was by ehetmeheek end euheequent um correlations batman elm traumatic eenelueiane from previous etudiee ere m «was; We Ge” cut-cone have been unsuccessful. «muted, 1 however. A11 pastime ﬁlth-A ~ seated to eleetroeheek thenpy nutter alteretione in the " electmneemme patterns. Three pltteme ere generally described as 1) the am ”3'“? am of high voltage which pregneeeee to burst activity; the 3) Mutation at but: 3 frequencies in rate and amplitude. There 1e e direct relation between the - of these changes, and the utmtien point of number and frequency ehmge 1e deeeriheé, which meat, but whieh, seemingly, frequeney and the type or is or treatments. In may an be maintained by eebjeeahe further ’6 ‘ treetmt, ship between degree of manifest M0113 memory the cited authors is lees and centueion maneephnlegnphio abnormality. Ceeee ere eited of severe the leek er and mm ‘ the degree of e memory We with significant electroencephalographic (ﬂange; and ﬂeece: aﬁWii..¢m”e in cerebral rhythm without. with“ clinical m Manet memory inpeimnt. In theee zeperte, aphasia in "month" he: on such organic ashram also earmletihg poorly we azmm rem! te , ., not inereeeed. Alec, such electmeneephalegmmw Another area of easement few treatments and without 6:3 7‘ g“3* �PM n2. awn”, homer. Two my be cited which mud n oomlatiem ham clinical improvemnt. Rowland, Halo mud, Kaufman and Peanut: in this 19% study of involutional woman ~( chums in the olectmncophalegm and in the accretion of 17 katostoroida new Electmncaphalognphic oranges wing alien-omen]: ens-251, 19M). and at agitated depreaeion, Paychoum. Hod. Q: a relation bunch changes in their clinical therapy roporbed activity as the disturbed be:havior boom now must, tho 13 cps activity incmaed. So treatment induced bohuviounl immanent, 13 ops activity diminished. with recurrent» of symptm, thorn m.- an increase in the 1 time 13 ops activity. rating scale and the per cent time manly, Mort Pmdnm by Theory of a Bath (changes Eloctroconmlaiw EGT action, we and ”no. of mums in which EEG 13 cps in the ma under Rumbas-ate Amsthaain and Their Significance for the hum cm. Hem-own. 1. 261-280, a relationship hottest: thiepontom manna We: and the recovery process “solicited. to inpmvomant. By that it Both noted that slow irregular in appuranm, could not be ntiatuctorily related mm antivity as new in a routine rcéord and be confirmed the reports 1951) described wan adminlltermg an intravenous aolutian of a barbituuto thmpentone, Roth elicited characteristic changes in the ma titer metroshock in mxy subjcct. Early than waé random irregular claw mu untidty, bilaterally which, with more treatment, increased to a highly We), synchronous, high amplitude delta runs and bursts. The” urn chiefly 2.3 cm, with voltages of 200.350 uv and cantlnuoua durations of 30.80 seconds. Winn the mating mcord cum“: rhythmic: Golta activity, umpontem increased its basic pm» its Imam. voltage and duration, spread Roth believed its urea, and decmuod that than chug" warn rehtod to the a! recovery, although, mo concluded: " Hanover, my development at a typical we cameo does slot ensure memory and 10 a! the 36 pntiontl who am men a mag. rams to me for longer m'tw wreaks. m M "Wu-v- 3‘ ' �~3¢ tmsicnt impmment in album). "lat-d. to tho EEG «mating EEG oondition mom to be pationto. .1: in are correct in W cm in thanmommue aﬂoat it would ammo: with tho seem, 31mg mat. tho of tho patients develop typical changes, that the physiological basis for in- provmnt is acquired by the majority or one»; it. «man in promoting recovery.“ w or' my not pm In the course of studiea of altered brain function induced by electron at this mums. Hospital in New York, further day. on the ”Intimaships betmn EEG chanson and :31ch effects of electroshock were collected. shock The general remain of mum innoMga’oiom on the alterations in the elontmhook mm omﬂmd, but. also, I doﬂnito relationship between on“ attacks and tho clinical remit «immtmted. Throo fooi are presented today: £30 with - m (1) Tho EEG patterns following electroshock and their relation to mpmmt. (2) mo intercormlationl of nativity. mama; qmtifioaumo or down " (3) The rolotion of those obaomtiona to a theory of electroshock I . SUBJECTS ‘ action. w W: prior to treatment. 1 Twentyofour common“ portion“ referred for ehctm» shook were awaited. An 8 and bipolar moording was Elootmnoephalogms channel Madonna instrument , and. Hypomtiution mdlo electrodes, m the only activation technio mod. During ornament. records wore taken on the day treatment, generally 25 to 31 hours after worn don. trauma“ after a. . ��In this group in mt chum amiable or who moan change was transient immanent. 3m amt. impa‘md. of chm ﬂuctuatians in behavior, at tins appearing. appeamd much as they did EV. diffsmd in tha third groups mmm or? 2 - Strauss (Clinical ham. Bruin that by tha and boron. Wu In w of the difficulties in evaluating impinmeﬁ'o. aa’oimataa of w H111 be A in than patients. change cam, by using this thmefald classiﬁmtim, firlt and sown pnuanu shaved only equivocal or But the ammo was not sua’oainod, no tm¢mnt, they We are “are might. have plum ware distinct. total at 160 thus 11001113 differences botmn the mm obtained in than manta. Following the maggostion or Dr. Rana me! mctmmphubgmc Studies Garrolations a! «.- Electmneophalogmphiu and Antonia chanson in Cases with Organic Dim. Al. J. Payout“... 3&1: hz—so. 19%); the delta ind»: :19th for thm lads (twahlupuriem. anterior tampon)... vortex. «comm of renaming for own land. The and puriﬁed-aunt love) for 180 don: mm is deﬁned an the ﬁgment. slmr. 1m m tin maupiod by waves or 7 tsp: daluninéex for the three loads, and the: highest in my 1nd ware ten mm: and in the final tabulntiom The average or c1011» Simultmebunly, tho ruéorci was scanned for the slowest freqmncy m imuﬁod M. lean twice wlta Have; ed, but ivity, m in my load; the highest voltage of my and. the ruration 01’ the longest burst. %er aspect: recordwe! in m final Malawian, worn m mgulamy of ham act.- aim of Alpha activity“ and um degm fraqmciu and amplitude of fast activitiea. “than indie” ‘14 net land study; Qua Inn «mm diam not. by thumb": to statistical meow. Fat amounts." mm identifiablo in all tho the clinical administration of barbiturates. A: thin ' ��07‘! Similar mm» or the relation at nah or the: Macs and minim mm mm mm. be tho group cum than boron. Slide 2 mmmmlaumormauummmmwmt. 1‘1»me result. the much upmd group Jump! to cut-1y lam-wad and unimpmvod group: mm: a by tho 10-12 10—80% A 52:: by tho 7-9 m 1123mm tmtmntz mm gnaw, alum - the #0 tmamm. ‘ similar out or our”: is demonstrated in 511603 for the man um delta 1:: am 1nd. In tho nut. slide the man ﬂaunt Imam in recorded, ma this ahm tho am aigniﬂunt nhﬂomhipl. Whiz. the mania imprond highest too ‘ pox-«em. patients than delta waves dam to 3 61:! or I.” by the «com! we]: or tmtmnt, th- at)»: two groups mm: man h 03:: by my fourth wok cf tutti-oat. and; The S and: improved group tho fourth the much new by show highar mm... by the not the elitism: Madly, slide 6 Vat «minim for tho mean highest amntndu chm the am are ”mam far :11 three groups. manta the mean aunties: of bursts. 111 (nu-ﬂint}. In than ml: of Hot noted long bun-at” treatment. Burnt: m no less ”mg. m. wave neural more than 7 {remnant in W m significantly 9119er hen, the is the fact” or “gummy of hm“. £91m!- rmthntly mm more maul“ in troqmcy “plum!” than in the other We groups; than studio: my be interpmud u demonstrating that manure: of slow and The patient: lbw longer hunts, winging 1W tho third unimprmd and modes-«uh inpmvod groups and and mm: mm: and by activity aria from the «wk 01‘ than am myuological pm”, m «imam in ablation to the diaturbmoos in earn-bun. function induhd by elactmahock. �3. ﬁnally, can these alterations in npoets of «tubal function mid: In tho» undies, the myriad. 1mm: current-d with own:but been altered by olectroshaok? mama af «tubal function were assayed- tut or Weinstoin and m um 01' double stimulation and tom text showed a W test thus EEG. 013110? any m we ho of tan. In than ation of intuvumu memory and mum” sodium until. racing. 0: than threw indies», only correlation with the subject simultaneous is interviewed 1.21th and can and’ qmatiom of orient- mm, the quantum an reputed errors in orientation, mnfabuhuan, dank). at 3.11am: and rsduplicauon are mud n 'poaitiw' myul tut, and are indicatiw of cerebral wilful-mum; Comet roman to than qmstim after and an a ‘mgatiw' W'm “at. In the wt click, #7. the pox-0mm positivc mm tom are 4 , m wanna. botmn tn. cmpund for meat. me much in titanium. of the m1. gmupa, with the number or weeks ovary patient much improm and at trut- m other tam gram . in the and: improved group had u positive mm by the third weak a! mama, m m abnomaiity panama; in tho unimproved swaps only me patimm had a positive as tram-£19m «opus command mam-m. In 311d. high degree 8. the an relation between, 1‘ EEG abnomlity shows a maul? The“ . ’ tinntmaus tactile tom inclines alarm). maxim and tho distinct carnation which in autism tinny signifiemt. Hint of tho an m1 and thin ahmd no won-elation with mama’s, it. can be concluded that tutu of wry and impromt. In an: and the than are axiom! typo. of mmbml dam- m cannot. speak in gm tom 9! g hrk a! comhum batman m m and 00me dyarnncum or organic payment, function tad taut �‘9. this point I should like us muss m findings and mass thoughts as to thsir significance for s theory or electmshoak mm. At. m moss is 11m. doubt that eloctmshwk m. It 3.: all upmsds to almr, symwio, We. induces delta nbnomnty 1:: tbs may frontal, but with Mmamrtmmm, With immune trusmt thaﬁsqmncios beam the smplitudu higher, tho bunt activity longer sad more regular. mile den: sbnomlity is pussnt in every mpord “ﬁr olsctmhock, its Roth‘s mum‘s mammg Manning emu .mmw «gm 9.: with bat-bum“ are Digniﬂmt 1n pmﬁmg the 11m” emu Mum by «wk. furthsr slntroahwk. In sans subjects sanity is not. induced despite atoms.” Our aux-relations of Guam 0!." test, um s meeasary chm-"u fail to wear in the tram. delta ammlity with 13pm srs «:1»th thorium. significant far tbs ”amiss: o: alteration in cox-ohm function as mm War, a high dogma «hits smorAn early, autumn mm by the EEG, and (and in the m1 taut), also by m. ' pmummﬁSiM for improvemt. when such EEG H u sign- nificmt clinical improvement V111 rail to wear in the patient' a hshs'dar. with wry loss, points Tbs rm. that than camlatiws mm not to the poasihiuty that. this is not a significant master in improvement. In conclusion, than studs.“ land uppers to s theory at E8? action moﬁntly unwanted by Gamma sud can at us (Kuhn). Thou “at ‘ authors postulstsd that wwwmt fanning olactroshoek is than malt of tbs amtion 1:: tbs patient 91' a min at altered brain function in much now puttéms or mputim, a-srtioulorly mm a! denial; my be main-- mm. mm m nudist Winn that :5 «land milieu of «avatar-J. museum u assured by mu abnormality is ,s pm~mu1s1u for improvisamt. ‘ro this extent the first. part. of ﬁns unseen-am Wall is ’“PPGTst �% m W, mm «was: m- studs.» punt to ﬂuaiﬁﬂﬁim of m “grammar of quantum" Wm at mum ' �Dr. Joseph S. A. Miller. To: From: Dr. Max Fink May I have your approval to submit this technical paper to the Eastern EEG Society for its October meeting in Bethesda ? ��mmmMmmwmtmmam mm m m mum as? (3) a» in mm. warm “at m m a: m mam a: mm mm: mwvm mmmmymmm mm,mzm �112:? My) Quantitative Studies 2;: Slow Wave I M 9/5"!» Activitz Following Electroshock Max Fink, HOD. Robert L. Kahn, PhoD. Hillside Hospital, Glen Oaks, New York Despite repeated attempts correlations between slow wave activity induced by electroshock and subsequent therapeutic outcasts have been unsuccessful. Howconclusions‘pfrom W; ”avg/a... rewart-m previous studies?“ "W Wm“ Ail—pam- over, certain mduuo are Electroshock therapy suffer alterations in the electroencephalogram«a»‘ﬁz 9%.- . 3m Three pattems are generally describedzu l) b slowing of the alpha frequen- cies; 2) the appearance of random, synmetxic slow wave activity, generally of; activity, and 3) diminution of beta frehigh voltage which Wﬁbwburst quencies in rate and amplitude. There is a direct relation between the degree of these changes, and the number and frequency of treatments. In many subjects a saturation point of change treatment, but the pretreatment levels mnnbe r, described, which can be maintained by further is which” are reversible. Qfﬂdeef Mir. not increased. The ographic changes the is «he, we!“ c,at!” 5mm electroencephal- rate of return of the cerebral patterns to is generally l to b, weeksxgﬂ’ipending directly ugh- on frequency and the type of treatment. cited authors is the lack of direct relationship between degree of manifest memory loss and confusion and the degree Another area of agreement among the of electroencephalographic abnormality. Cases are describedgevere memory changes with few treatments and without significant electroencephalographic change; and also of severe changes in cerebral or memory impairment. In these reports, Weclinical is correlatgug poorly With organicconfusion also Presented at the Eastern E E W rhytlmls without manifest 0 Society, Bethedda) -~-- clinical confusion > Md “HA0? 8 such gM’Y’EJ results. - Septembee 30, ”0...... «.~.—.._._,___...~—-— 4...“ ._.... 195? �Two studies, however, may be cited as noting a correlation between ectro- u: encephalographic changes and clinical improvement. Hoagland, Malamud, Kaufman rt- ﬁdand Pincus in their l9h6 study of involutional L’ women ‘1) - tonnage-MW: reported a =§W19§9+ relation between changes in their clinical rating scale and the per- cent time 4'40 W61 131, ‘ctivity. more than 3.2% activity increased. cw activity diminished. % A time 1301;: a More As treatment induced behaviojral improvement,—-B=eps tivity.C3,) Roth ﬂ" there was an MK, increase in the . Mow-W .--__ , WWW-WBW‘UI relationship msngmmeWeWw5M— the Mby. ~. the disturbed behavior became more manifest, the With recurrence of symptoms, e WA recently, As . 1 described a between thiopentone induced EEG changes and recovery process. Roth noted that slow wave activity as seen in a routine post-shock record was irregular in appearance, and he confirmed the reports that it could not be satisfactorily m , related to improvement. the However, by administering an intravenous thiopeﬁ‘tone, he elicited characteristic changes solution of in the EEG after electroshock in every subject. Early’there was random irregular slow wave act- ivity, whichyéith increased to a highly rhythmic, bilaterally more treatmen synchronous, high amplitude delta runs and M ILKoVol'PS bursts. These were with voltages of 200-350 is and continuous durations of 30-80 seconds. When its the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its believed that these changes were m F4» lemma; chiefly 2-3 area, and decreased its basic frequency. related to the process of recovery, and Both v �he concluded: “The development of a typical and 10 of the 36 patients who attained such a than two weeks. But transient improvement related to the ing the EEG EEG change does not ensure recovery failed torsmit for longer in clinical condition seemed tolae change in these patients. changes with the therapeutic effect it EEG change even If we are correct in connect- would seem, since most of the patients develop typical changes, that the physiological basis for improvement is acquired by the majority of cases; it may or may not prove effective in promoting recovery." Whileathesettwoﬁstudiessdemonstrate a relationship between clinical result and EEG abnormality, the majority of reports fail to do so. It is not likely that this discrepancy is the result of different populations, but rather, the differences in methods of evaluating improvement, the time of evaluation, and differences in estimating changes in cerebral function. In the course ofestudies of altered brain function induced by electroshock at the Hillside Hespital in further data on the relationship! be~ tween EEG changes and clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the EEG with New York, electroshock were confirmed, but also, a definite relationship between effects and the clinical result was demonstrated. Three EEG foci are presented today: (1) The EEG (2) The patterns following electroshock and their relation to improvement. intercorrelations of different quantifications of delta activity. (3) Athe relation of these observations to a theory of electroshock action. SUBJECTS AND METHOD: Twenty~four consecutive patients referred for electroshock were studied. Electroencephalograms were done treatment, at weekly intervals during treatment and after treatment. prior to An 8 channel �.5‘ but the dramatic in the change so evident patient continued to first group was not apparent. Each noticable disturbance such as obsessional think- show some ing, paranoid ideas, or somatic preoccupation. C. whom Minimalyy or Unimproved: In this group were placed seven patients in change was not clearly noticable or who showed only equivocal or improvement. improved. Some showed transient fluctuations in behavior, at times appearing But the changes were not sustained, so that somewhat by the end of treatment, they appeared.much as they did before. we are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, using this threefold classification, the differences between the third groups will be by first and distinct. EVALUATION OF EEG RECORDS: A total of jects. Following the suggestion of LJ.aPsychiatemgggnehZ-Sewwl9hhd, w 160 records were obtained in these subStrauss the delta index was determined for three lead (frontal-parietal, anterior temporal - vertex, and parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined combinations as the perbcent time occupied by waves of 7 cps or slower. The average for the three leads, and the highest delta index in any lead indices used in the final tabulation. index Simultaneously, the record was scanned delta- were the for the slowest frequency identified at least twice in any lead; the highest voltage of any delta wave; and the durb ation of the longest burst. (V) �Ch. Medcrart instrument, needle electrodes, and bipolar recording was used. Hyperb ventilation was the only activation technic utilized. During treatment,:records were taken the day after, generally 25 to 31 hours The treatments were administered by the C h? electrostimulator. number of treatments after treatment. staff psychiatrists, using a Reiter Treatment schedules were three times a week; and the varied from 9 to 33. As patients Showed clinical improve- ment, the There psychiatrist tended to give fewer treatments, and more widelyfspaced. were 15 women and 9 men in the series, and ages ranged from.2h to 68 with a median of h7. EVALUATION QE CLINICAL RESPONSE: All the patients eight were observed for at least after termination of therapy. determined on the basis of the res- weeks patient's reaponse to electroshock was ident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervisor in charge of electroshock. The patients were The divided into three groups A. Markeglz ggproved: ~ markedly improved, moderately improved and unimproved. The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer showed the which brought them symptoms into the hOSpital; their doctors felt they were better; and the nurses' notes confirmed such aspects as being able to sleep without medic- ation, better appetite, and improved capacity to get along with the other patients and participate in hospital activities. six patients in this group showed some improvebut continued to manifest indications of mental illness. These patients B. iModerately ggprove : The ment typically Showed symptomatic relief, i§,, acute depressive features might be gone, �On the basis of these five indices of slow wave activity the records placed in a rank order from the greatestabnormality to the lowest. cords were then divided into 3 groups - g uﬁbr were The 160 third - high degree EEG re- abnorm- ality) and lowest third =£w degree abnormality. RESULTS:1.0ur results show a positive correlation between early high degree EEG abnormality and improvement. These relationships are demonstrated in Slide I. utilizing these quantifications of slow wave abnormality induced by electroshock, we conclude that such EEG abnormality induced in the first 3 weeks of ‘By is treatment an essential pre-requisite for the short term favorable clinical response. 2. What relationships exist between each of the indices, clinical response, and then / amongst each first with the other? Similar analyses of the relation of each of the indices and clinical result identical curves to the group curve shown before. Slide 2 shows the relation of the delta index to improvement. The mean index in the much im- showed proved group jumps to 52% by the 7-9 treatment; while the moderately improved and unimproved groups show a gradual, slow increase to 10-20% by the 10-12 treatment. A similar set of curves id demonstrated in slide 3 for the mean highest percent time delta in one lead. In the next shows the show delta other two Slide same slide the slowest frequency is recorded, significant relationships. While the and this) tbo/ much improved patients to 3 cps or less by the second week of treatment, groups Sarely reach )4 cps by the fourth week of treatment. waves down 5 shows the same much improved group show week the mean correlations for the mean and- *{e highest amplitude, the higher voltages by the second week and by the fourth differences are persistent for all three groups. �Finally, slide 6 shows the duration of bursts. mean The records of the much Improved patients third treatment. Bursts are less frequent in the unimproved and week of show longer bursts, averaging more than 7 seconds by the mod- erately improved groups and are significantly shorter in duration. not noted here, however, is the factor of regularity of bursts. In the longer bursts, wave forms frequently were more regular in frequency and amplitude, than in the other two groups. These studies may be interpreted as demonstrating of slow wave activity arise from the same that each of these measures physiological process, and assume the significance in relation to the disturbances in cerebral function induced by electroshock. same I 3. Finally, can these alterations in the pects of cerebral function which EEG may have been be correlated with other ap- altered by electroshock? In these studies, three other indices of cerebral function were assayed - the amytal test of Weinstein and Kahg? tests of double simultaneous tactile stim- ulatioaj and tests of amytal test showed a memory and recalfz) Of these three indices, only the positive correlation with improvement and.with the EEG. results were presented recently at the American Psychiatric Association we will forgo a discussion at this time. ‘93 __,wle These and It.;::; suffice demonstrates the correlation berel éF, tween the amytal eating and the high degreerhEG abnormality. n—v_ this iigﬁgLshows ﬁb£ that the next slide, # 7 ' , distinct relationship between the two factors. At this point I should like to summarize our findings and express some thoughts as to their significance for a theory of electroshock action. There is little doubt that electroshock induces delta abnormality in the EEG. It is a symmetric, chiefly frontal, but with increasing treatment, spreads to all leads. With increasing treatment the frequencies became slower, the amplitudes higher, the burst activity longer and more regular. in every record after electroshock, its ‘While degree delta abnormality is present is variable. Roth's experiment's �~8- inducing increasing delta abnormality with barbiturate are significant in predicting the later changes induced by further electroshock. In some subjects however, a high degree delta abnormality is not induced despite extensive treatment. correlations of degree of delta abnormality with improvement are also significant for the theory of the mechanism of electroshock. An early, SusOur tained alteration in cerebral function as measured by the EEG, and also by the amytal test, appears to be a necessary pre-requisite for improvement. Where *- in the amytal test), the: the patient's behavior. €l%n ificant clinical improvement will fail to occur in fact that the correlations were not evident with memory loss, points to the possibility that this is not a significant factor in improvement. such changes fail to occur in the EEG (and The In conclusion, these studies lend support )to a theory of EST action recently (Kahn)(.r These authors postulated that enumerated by Weinstein and one of us improvement following electroshock is the result of a milieu of altered brain function in which of the creation in the patient new patterns of adaptation, part- icularly those of denial, may be maintained. These EEG studies demonstrate that an altered milieu of cerebral function as measured by delta abnormality is a pre-requisite for improvement. To this extent the first part of tbs Weinstein-Kahn hypothesis is supported. Secondly, these studies point to the validity or quantitative the elucidation of mechanisms of behavior. EEG studies for �1533 m a???" September 21, 1955 MEMORANDUM TO: FROM: Dr. Soseph S. A. Miller Dr. (1) Max Fink entitled "Quantitative Studies of Slow Wave Activity Following Electroshock" will be presented at the Eastem EEG meeting at Our paper Bethesda, Friday September 30th. (2) May I have permission for Dr. Kahn (the co-author) and myself to attend the sessions of the society? �(new? ' £5)“; saw» 21.. 1955 m! m1 Mamaahamr ”gum (1) our W amt-MM *mpmuu saw» a: 3m 1m Mtiviw (a) lily 1: MWMWﬂnbapWMWMMWmM at whim! is!» ma pammaa tear m». ”aim at the am m (m mama!) and W ta 357‘ �III: Quantitative Studies 2; Slow Wave 9/55 Activity Following'Electroshock Fink, Max MOD. Robert L. Kahn, Ph.D. Hillside Hospital, Glen Oaks, New York Despite repeated attempts, correlations between slow wave activity in- duced by electroshock and subsequent therapeutic outcome have been unsuccessful. However, certain conclusions are warranted from previous studies (1). Electro- shock therapy induces alterations in the electroencephalogram in all subjects. Three patterns are generally described: 1) slowing of the alpha frequencies; 2) the appearance of random, symmetric slow'wave voltage which cies in rate may activity, generally of high appear as burst activity; and 3) diminution of beta frequenThere and amplitude. is a direct relation between the degree of these changes, and the number and frequency of treatments. a saturation point of change is described, to the pretreatment levels The 1 to h weeks, depending directly on the treatment. relationship between degree of manifest memory degree of electroencephalographic abnormality. memory impairment. in cerebral loss and confusion of direct and the Cases are described of severe at the Eastern EEG rhythms without manifest In these reports, ganic confusion also correlates poorly with Evesented is the lack with few treatments and without significant electroencephalographic change; and also of severe changes confusion of further Such induced electroencephal- Another area of agreement among the cited authors memory changes subjects rate of return of the cerebral patterns is generally number, frequency and the type of many which can be maintained by treatment, but which is apparently not increaSed. ographic changes are reversible. In it is clinical stated that such or- clinical results. Society, Bethesda, September 30, 1955. �-2studies, however, Two cited as noting a correlation between may be electroencephalographic changes and clinical improvement. Hoagland, Malamud, in their l9h6 study of involutional Kaufman and Pincus women relation between changes in their clinical rating scale time more than 13 cycles per second activity. and the per-cent the disturbed behavior be- As manifest, the fast activity increased. came more (2) reported a treatment induced behavior- As al improvement, such fast activity diminished. With recurrence of there was an More induced increase in the Roth (3) described a recently, EEG time 13 cycles per second % provement. Roth noted it tone, he elicited characteristic changes in the was random irregular and bursts. w act- wave solution of the thicpen- EEG after electroshock in every slow wave activity, which increased bilaterally synchronous, high with mere treatment to a highly rhythmic, litude delta runs 51 was However, by administering an intravenous subject. Early, there that irregular in appearance, and could not be satisfactorily related to imr ivityas seen in a routine post-shock record reports that activity. relationship between thiopentone changes and the recovery process. he confirmed the symptoms, amp- chiefly 2-3 cycles per second, with These were voltages of 200-350 microvolts.and continuous durations of 30-80 seconds. the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its believed that these changes were patients than But two weeks. related to the ing the patients EEG EEG transient change even improvement change does not ensure recovery failed to remit for longer in clinical condition seemed to be change in these patients. If effect it we are correct in connect- would seem, since most of the typical changes, that the physiological basis for by the majority of cases; moting recove 1y." EEG attained such a changes with the therapeutic deveLOp is acquired who its area, and decreased its basic frequency. Roth related to the process of recovery, and he concluded: "The development of a typical and 10 of the 36 'When it may or may not prove improvement effective in pro- �.3While these two studies demonstrate a relationship between clinical result' and EEG abnormality, the majority of reports fail to do It is so. not likely that this discrepancy is the result of different populations, but rather, the differences in methods of evaluating improvement, the time of evaluation, and differences in estimating changes in cerebral function. In the course of studies of altered brain function induced by electro- at shock the Hillside Hospital in New York, further data on the relationship clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the EEG with between EEG changes and electroshock were confirmed, but also, a definite relationship between effects and the clinical result was EEG demonstrated. Three foci are presented today: (1) (The EEG patterns following electroshock and their relation to imp provement. (2) The (3) The SUBJECTS intercorrelations of different quantifications of delta activity. relation of these observations to a theory of electroshock acticn. AND METHOD: Twenty-four consecutive patients referred for electro- shock were studied. Electroencephalograms were done prior to treatment, at weekly intervals during treatment An 8 and after treatment. channel Medcraft instrument, needle electrodes, and bipolar recording was used. Hyperventilation was the only activation technic utilized. treatment, records were taken the day after, generally 25 to treatment. The Reiter C 31 hours During after treatments were administered by the staff psychiatrists, using a h? electrostimulator. Treatment schedules were three times a week; and the number of treatments varied from 9 to 33. improvement, the As patients psychiatrist tended to give fewer treatments, showed clinical and more widely �.u. There were 15 women and 9 men spaced. to 68 in the series, and ages ranged from 2h with a median of h7. g3 EVALUATION CLINICAL RESPONSE: All the patients were observed for at least eitht weeks after termination of therapy. patient‘s reSponse to electroshock'was determined on the basis of the resident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervisor in charge of electroshock. The patients The were divided into three groups - markedly improved, moderately improved and unimproved. A. Markedly Improved: The 11 cases in this group showing recovery or marked improvement. These symptoms which brought them into the beepital; patients were regarded as no longer showed the their doctor 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 B. improvement activities. six patients in this group showed some but continued to manifest indications of mental illness. These Moderately,lmproved: patients typically The showed symptomatic relief, i:g;, acute depressive features might be gone, but the dramatic change so evident in the apparent. Each patient continued to show some first group was not noticable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally g£_unimproved: In this group were placed seven patients in whom change was not clearly noticable or who showed only equivocal or transient improvement. Some showed fluctuations in behavior, at times appearing somewhat improved. But the changes were not treatment, they appeared much sustained, so that by the as they did before. end of �.5are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, by we using this threefold classification, the differences between the groups first and third will be distinct. 93 EVALUATION delta index EEG RECORDS: was A total of 160 records were obtained in these sub- jects. Following the suggestion of Strauss (h), the determined for three lead combinations (frontal-parietal, anterior temporal - vertex, and parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined as the per-cent time occupied by waves of 7 ops or slower. delta-index for the three leads, and the highest delta index in any lead were the indices used in the final tabulation. The average for the slowest frequency idenp tified at least twice in any lead; the highest voltage of any delta wave; and the duration of the longest burst. Simultaneously, the record 0n the was scanned basis of these five indices of slow wave activity the records were placed in a rank order from the greatest abnormality to the lowest. 160 records were then divided into groups abnormality, and lowest third = RESULTS: in Slide 3 - i;g=_upper third= The high degree EEG low degree abnormality. l. Our EEG abnormality and improvement. These relationships are demonstrated results show a positive correlation between early high degree I. utilizing these quantifications of slow wave abnormality induced electroshock, we conclude that such EEG abnormality induced in the first 3 By of treatment is an.essential pre-requisite for the short term favorable by weeks clinical response. 2. What relationships exist between each of the indices, clinical response, and then amongst each other? first with the �~6- Similar analyses of the relation of each of the indices and clinical result identical curves to the group curve shown before. Slide 2 shows the relation of the delta index to improvement. The mean index in the much improved showed group jumps to 52% by the 7-9 treatment; while the moderately improved and un- improved groups show a gradual, slow increase to 10720% by similar set of curves is demonstrated in slide A 3 the 10-12 for the mean treatment. highest percent time delta in one lead. In the next slide the shows the same delta show other two groups to the same much improved group show week h cps by the much improved While the much improved fourth correlations for the week of mean all three 6 shows the mean duration of patients this, too, patients treatment. highest amplitude, the higher voltages by the second week and by the fourth the differences are persistent for Finally, slide and cps or less by the second week of treatment, the 3 rarely readh 5 shows is recorded, slowest frequency significant relationships. waves down Slide mean show groups. bursts. The longer bursts, averaging more than records of the 7 seconds by the third week of treatment. Bursts are less frequent in the unimproved and moderately improved groups and are significantly shorter in duration. Not noted here, however, is the factor of regularity of bursts. In the longer bursts, forms frequently were more regular wave in frequency and amplitude, than in the other two groups. These ures of the studies may be interpreted as demonstrating that each of these meas- activity arise from the same physiological process, and assume significance in relation to the disturbances in cerebral function in- 31 w wave same duced by electroshock. 3. Finally, can these alterations in the pects of cerebral function which may have been EEG be correlated with other as- altered by electroshock? In these studies, three other indices of cerebral function were assayed - the amytal �-7- test of Weinstein and Kahn (5), (6), and tests of memory and tal test showed a positive correlation with tests of double simultaneous tactile stimulation recall (7). Of these three indices, only the amyimprovement and with the EEG. These results were presented recently at the American Psychiatric Association and we will forgo a discussion at this time. It may suffice that the next slide, # 7, demonstrates the correlation between the responses on amytal of abnormality. This graph EEG tests and the degree distinct relationship between the shows a two I factors. this point I should like to summarize our findings and express thoughts as to their significance for a theory of electroshock action. At is little doubt that electroshock induces delta abnormality in the symmetric, chiefly There It is EEG. frontal, but with increasing treatment, spreads to all leads. increasing treatment the frequencies With some became slower, the amplitudes the burst activity longer and more regular. While delta abnormality in every record after electroshock, its higher, is present is variable. Roth's experiment's degree inducing increasing delta abnormality with barbiturate are significant in predicting the later changes induced by further electroshock. In some subjects however, a high degree delta abnormality is not induced despite extensive treat- ment. Our correlations of degree of delta abnormality with significant for the theory of the mechanism of electroShock. tained alteration in cerebral function as measured amytal test, such changes clinical improvement are also An early, sus- by the EEG, and also by the appears to be a necessary pre-requisite for improvement. Where fail to occur in the improvement in the amytal test), then significant will fail to occur in the patient's behavior. The fact that EEG the correlations were not ivident with (and memory loss, points to the possibility that this is not a significant factor in improvement. In conclusion, these studies lend support to‘a theory of enumerated by Weinstein and one of us (Kahn) (8). EST These authors action recently postulated.that �-8improvement following electroshock of a milieu of is the result of the creation in the patient altered brain function in which new patterns of adaptation, part- icularly those of denial, may be maintained. These EEG studies demonstrate that an altered milieu of cerebral function as measured by delta abnormality is a pre-requisite for improvement. To this extent the first part of the weinsteinKahn hypothesis is supported. Secondly, these studies point to the . for the elucidation of validity of quantitative mechanisms of behavior. EEG studies �REFERENCES l. Chusid, Joseph G. and Pacella, Bernard L.: the Electric Shock Therapies, J. Nerv. The Electroencephalogram & Dis., 11g: 95-107, 1952. Ment. Hoagland, H., Malamud, W., Kaufman, and Pincus, 6.: encephalogram and in the Excretion of 17 in Changes in the Electro- Ketosteroids Accompanying Electro- shock Therapy of Agitated Depression, Psychosom. Med., §; 2&6-251, 19h6. 3. Roth, Martin: Changes in the EEG Under Barbiturate Anesthesia Produced Electroconvulsive Treatment and Their Significance for the Theory of Action, EEG by ECT and Olin. Neurophys., 2; 261-280, 1951. Strauss, Hans: Clinical and Electroencephalographic Studies ~ Correlations of Mental, Electroencephalographic and Anatomic Changes in Cases with Organic Brain Disease, So Am. J. Psychiat., 191: and Kahn, R.L.: weinstein, E.A., ("Amytal Sodium") Diagnostic hZ-SO, l9hh. Use of Amobarbital Sodium in Organic Brain Disease, Am. J. Psychiat., 192: 12, 889-89h: 1953. 6. Fink, M., Green, M. and Bender, M.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology, 2: h6-58, 1952. 7. Karin, H., Fink, M. and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conf. “eurologica, 1Q: 88-96, 1956. Weinstein, E.A., Kahn, R.L. and Linn, L.: Peychosis During Electroshock Therapy: 19.9.: Its Relation to the 22-26, 1952. Theony of Shock Therapy, Am. J. Psychiat., �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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Archives of Neurology (“7 Psychiatry November 1957, Vol. 78, pp. 516—525 Copyright 1957, by American Medical Association Relation of Electroencephalographic Delta Activity to Behavioral Response in Electroshoek Quantitative Serial Studies MAX FINK, M.D., and ROBERT L KAHN, Ph.D., Glen Oaks, N. Recent theories of'electroshock therapy 1'3 have emphasized the role of neurophysiologic changes as. the basis for the therapeutic ac— tion of electroshock. Consistent with these theories, we have observed a relation between changes in certain measures of brain function and behavioral response. We have noted that evaluations of clinical improvement fol— lowing electroshock are related to changes in orientation and confabulation after intra— venous amobarbital,4 learning and recall,5 and syntactical aspects of language.6 In view of these observations, it could be expected that electroencephalographic studies would show a similar relationship. Numerous observers have reported consistent changes in the electroencephalogram after electrically induced convulsions. There is diffuse slowing with increased voltage and dysrhythmic activity?"12 Fast activity decreases, both in voltage and in percent time}3 and in patients who are intensively treated there is a slowing of persistent alpha frequencies.14 The degree, duration, and extent of delta activity are directly related to the frequency and number of grand mal convulsions?"14 Such activity is usually symmetric and appears maximal in anterior leads, and the electroencephalog— Received for publication June 18, 1957. From the Department of Experimental Psychia— try, Hillside Hospital. Presented at a meeting of the Eastern Associa— tion of Electroencephalographers, Washington, D. C., September, 1955. Aided, in part, by Grant M—927, National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Dalian Foundation for Medical Research, New York. Y. raphic effects usually disappear in the four to eight weeks following the last treatmentfgi9 In contrast to the consistency of these observations, studies of the relationship between the electroencephalographic and the clinical changes show conﬂicting results. Chusid and Pacella,15 after an extensive review of the literature, concluded that the number of treatments rather than the degree of induced delta activity, was the primary factor related to a favorable therapeutic re— sponse. On the other hand, Hoagland et al.16 reported a relation between changes in the percent time fast activity (more than 13 cps) and independent clinical ratings of be— havioral change._ Roth2 similarly reported a relationship between changes in the clinical state and alterations in the delta response induced by intravenous thiopental sodium. The divergent observations reﬂect variations in methodology. The present study is an attempt to apply quantitative methods of analysis of serial electroencephalographic records to this problem. The purpose of this study is to determine (1) the relation of changes in electroencephalographic delta activity to the behavioral response in electro— shock, and (2) if a relationship does exist, the signiﬁcance it may have for an under-standing of the electroshock process. Subjects and Method 1. In the initial series, 24- consecutive patients referred for electroshock were studied. Electro— encephalograms were obtained prior to treatment and at weekly intervals during and after treatment, using an eight—channel Medcraft electroencephalograph and needle electrodes. Recording was bi— polar, and hyperventilation activation was utilized 516 ,. “(34.x �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE during each recording. During the treatment pe— riod, records were taken on the day following a treatment, generally 25 to 31 hours later. Grand mal electroshock therapy was administered by staff psychiatrists, using a Reiter C-47 electrostimulator. Treatment schedules were three times a week, and the number of treatments varied from 9 to 33. As patients showed a clinical response, the psychiatrist tended to give fewer and more widely spaced treatments. There were 15 women and 9 men in the series, and the ages ranged from 24 to 68, with a median of 47 years. Evaluation of EEG Records—A total of 160 records were obtained on these subjects. Following the suggestion of Strauss,17 the delta index was determined for three lead combinations (frontal— parietal, anterior temporal-vertex, and parietal-ear lobe) for 60 seconds of recording for each lead. The delta index is deﬁned as the percent time occupied by waves of 7 cps or slower. The run of each selected lead combination was scanned, and 180 cm. (60 seconds) of recording that was artifact-free was noted. An additive map measure was run along the base of all waves of 7 cps or slower, determining the number of centi— meters occupied by such slow activity. The ratio of this ﬁgure to 180 was the delta index of that combination. ’ After these measurements were made, the rec— ord was scanned for the slowest frequency clearly The total record was also scanned for burst activity. The duration of burst activity, the regularity (modulation) of the waves in the burst, and average voltage were noted. In the ﬁnal estimates of degree of delta activity, the average delta index for the three lead corn— binations, the highest delta index in any one lead, the slowest frequency, highest delta voltage, and duration of longest period of burst activity were listed for each record. The 160 records were ar— ranged in sequence for each index and the per— centile rank determined. The ranks were added and the records then arranged in rank order ac.— cording to this score. On the basis that the higher score reﬂected a greater degree of delta activity, the upper third of the records was classiﬁed as “high—degree delta”; the middle third, as “moderate-degree delta,” and the lowest third, as “lowdegree delta.” An example of each is shown in Figures 1, 2, and 3, respectively. High—degree delta records were characterized by an average delta index of at least 18%, a delta index of 21% or more in one of the three measured leads, a slowest frequency of less than 3% cps, a highest delta voltage of more than 100pv, and a burst duration of at least two and a half slow waves. LF-LO WWWAWWWNIWW WWW RF'RO LAT- LPT WWWVWWW RAT-RPT WWW/WWW PRE-EL seconds. Low-degree delta records were characterized by an average delta index of less than 2%, a highest delta index in one lead of 3% or less, frequencies no slower than 5% cps, voltages of less than 60pv, and burst duration of less than one—half second. W “WW W W identiﬁed at least twice in these selected lead combinations, and for the highest voltage of these R P‘E AMNVWWWNVW L F _ LO «wanjVMImWW-ﬂm WMWMWMMW RF- RO awmwwm WW LC-LMT LC-LMT RC-RMT “WW RC-RMT LP-E WWW WW RP-E RP‘E WWWNAMMMMMWMW WWW WWW LAT' L PT LAT-LPT RAT-RPT PRE- ELECTROSHOCK ISECOND , 24 HOURS AFTER EST Fig. 1.—Low-degree delta activity. Fink—Kuhn I50 M, it l2 5-17 . ‘ WWW RAT-RPT WWW PRE-ELEC .maﬁ-” _,__._---_., __..-_t r-.- 518 �vs WWWWﬁ ., .v. h A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY LF LO WMWWWWWW WWWWWWWW LC-LMT WWW RC-RMT LP-E KEN-W LAT- LPT WWWWWNWWNWMNA W WWW»! I RAT RPT VWVWWNWWWWWWNwWV‘WWW/wm PRE-ELECTROSHOCK 24 HOURS SECOND 1:5on AFTER EST 4* IO Fig. 2.—Moderate-degree delta activity. L F “ LO WWEJVANWWWJWWWMk/‘W‘mgfaNJWW‘AMW R F - RO JVWMWWWWAW WWW LC'LMT RC-RMT LP-E WWW-”WW . RP-E WWW“ LAT- L PT WWW RAT-RPT PRE-EL ECTROSHOCK WW ISOMV WWW/meﬂwx 24 HOURS AFTER EST 4* M Fig. 3.—High-degree delta activity. 518 Vol. 78, N07J., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE I Moderate-degree delta records were between these two groups, with an average delta index between 2% and 18%, a highest delta index in one lead of 3% to 20%, a slowest frequency of 4-5 cps, high— est amplitude of between 60yv and 90,uv, and burst duration of one-half to two seconds. 2. In a second series, of 54 consecutive, unselected electroshock patients, electroencephalo— graphic records were obtained prior to treatment. during the second and third weeks of treatment, and two weeks after treatment. These records were analyzed using measures identical with those in the initial series. Using the original cut-off points, these records were classiﬁed as high-, moderate—, and low—degree—delta records, and the initial observations were tested in a predictive study of therapeutic response. Evaluation of Clinical Response—All patients were observed for at least eight weeks after termination of therapy. The patient’s response to electroshock was determined on the basis of the resident psychiatrist’s impression, the staff opinion, the nurse’s notes, and the clinical evaluation of the supervisor in charge of electroshock. The patients were divided into three groups—much improved, moderately improved, and unimproved—according to the following criteria: A. Much Improved: The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer presented the symptoms which brought them 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 others and participate in hospital activities. B. Moderately Improved: The six patients in this group showed some improvement but continued to manifest symptoms of mental illness. These patients typically showed symptomatic relief; i. e., acute depressive features might be gone, but the dramatic change, so evident in the ﬁrst group, was not apparent. Each patient continued to show some noticeable disturbance, such as obsessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally or Unimproved: In this group were placed seven patients in whom change was not clearly noticeable, who showed equivocal or transient changes, or who became worse. They showed ﬂuctuations in behavior, at times appearing less ill. The changes were not sustained, however, so that by the end of treatment they appeared much as before. activity and clinical ratings demonstrated a signiﬁcant relationship between the early ap— pearance of high—degree delta activity and the “much-improved” clinical ratings. Of the records in patients who were rated as much improved, 80% were classiﬁed as high—de— gree delta in the second week, 91% in the third week, and 88% in the fourth week of treatment. Of the records in patients who were rated as unimproved, none showed high—degree delta in the second or third weeks of treatment, and only 20% were classiﬁed as high—degree delta in the fourth week. The data are expressed in Table 1 and graphically in Figure 4. TABLE 1.—Electroencephalographic Percentage of High-Degree Delta Records Degree of EEG Delta Activity and Clinical Ratings.——The initial analyses of the relation between the degree of induced delta F ink—Kahn 1. MUCH IMPRO +——Moo. IMPRO\ 50_ .---- UNIMPROVEI TIME A ‘13 A. 4‘“ PERCENT o: C? -.__~_ ,. m <.3 AVERAGE ...__.—_____.-._, c3 MEAN WAVES I50} .—- MUCH +——Moo. IMPROVI IMPROVI ---~ unmpnovso DELTA Treatment Period Much improved (11) OF 1-8 4—6 7—9 10—12 25 80 91 88 Moderately improved (6) 0 16 50 40 Unimproved (7) 0 O 0 20 IOOAv AMP(LITU)DE u- c.’ HIGHEST Indices and Clinical Ratings.——An analysis of the relation between each of the ﬁve indices used in the ﬁnal estimate of the degree of delta activity and the clinical ratings also show signiﬁcant correlations. In Figure 5A to E, each index is related to the number of convulsive treatments and the eventual therapeutic evaluation. The curves 2. Delta OOACTIVITY 90. 80- DELTA MUCH IMPROVED .—— M00. (III IMPROVE-10(6) ._-— UNIMPROVEDU) ‘ 70' 60‘ DEGREE 504 HIGH 40‘ 20I 0‘ o. O / '\. / 3O~ PERCENTAGE Results DELTA / I-3 / / ' / 4-6 __/' 7-9 NUMBER OF TREATMENTS MEAN L Fig. 5.—A-E, rt each index of delt: ' \\ /' / IO'IZ Fig. 4.—.Re1ation of clinical ratings to development of high—degree delta activity. 519 for the highest—am 5C) and the slow are most similar tc of delta activity ( The other three clearly differentia group from the p2 520 �/\ A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY f3 __J g . MUCH IMPROVEDUJ) IMPROVED (-6) 50_ pgmoo. o----UNIMPROVED(7) < 60’3 . w 2 40- E ,: PD 4 z as. 8 a: ling a: 30m a. aLu > ‘1 qz m 2 - lO- . _,e-’::.—// 0 "5' .V / U 3 :5 .J, Lu o a- //’ 53 a +— m u: I I9Z < g O 0 ________-_ . .......... _______ o 8 g 2 3 g 4§ E g. x «e —«' w D- W to 5 onZ I 4-6 ’ T 7-9 " IMPROVENS) .._.. UNIMPROVED(7) ' T IO-IZ ' -. ' —-—:—-—-"/ ,,«+ / / / {,x’ ”x” 5~ .t’ ----/’/ ,./ " /‘ ,xf “i3u Q (ll) MUCH IMPROVED o——MOD. Z 6-3 IL] +,.__._-,——‘ 0— 3- 6- a2 . 1—3 I 7-9 ----' C OK. 100- 50- ' 4—6 IO-‘IZ I50- ._Muc|-.1:|MPROVED(II) +——MOD. mpnovsom) ,_.- ummpaovso m 0 IL V" T I _. 7-9 A <>K //i1/ ------- °- -----MA’65... x 2 1m 5 NUMBER! OF TREATMENTS (I) . /// // i 2 . NUMBER OF TREATMENTS 4-6 1-3 3 ‘2 /+ ,, ........... ., -—-“"” ’4' , ‘ A -------2’ a: I l— // /" 20 o IMPROVED(II) 0--MO‘D. IMPROVED (6) °~--~U~NIMPROVED(7) LU p— {‘3 -— MUCH m D . o ‘‘‘‘‘ ———— -4ﬁ‘” 415 1-3 719 NUMBER OF TREATMENTS 7 r D I0--I2‘ NUMBER OF TREATMENTS B .9. g 7‘ 3a: 6‘ m n: lL , .9 ,r—e ' -— MUCH IMPROVED (u) +——MOD.IMPROVED(6) o----UN‘IMPROVEO(7) l0-l2 '\. I A .m 5.. 22 9 8 4— .— Fig. 5.—A-E, relation of clinical ratings to each index of delta activity. 33. 3: 3o V 3-. z a 2 2a l _ . I” +’/” //’ “““ ---------- o-""" .ﬁu‘idiﬁ“ , a _ O O ”_‘..—°V ° I ‘l ‘l l. l-3 4.96 7-9 IO‘IZ NUMBER OF TREATMENTS E for the highest—amplitudedelta activity (Fig. 5C) and the slowest frequency (Fig. 5D) are most similar to the curves for the degree of delta activity (Fig. 4). The other three indices (Fig. 5A, B, C) clearly differentiate the much improved group from the patients with the other two 520 ratings, but fail clearly to distinguish the moderate and unimproved groups. With in— creasing treatment, however, the separation of classes becomes clearer. Each index of delta activity, therefore, demonstrates a relation to the eventual short— term clinical rating which is much like that Val. 78, Nov., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE TABLE I i/ " . ” Average delta 2.—Interc0rrelati0ns of Individual I ndices and Degree of Delta Activity - - Average 63%qu Longest Dﬁﬁiéi‘é“ 350831153 +0.72 +0.67 +0.80 +0.72 +0.68 +0.84 —0.78 —0.47 -—0.90 Delta One Lead FkZVJSEEy Aﬁié’ﬁiie - +0.98 —0.79 _ Degree Highest delta in one lead +0.98 _ —0.67 Lowest frequency Highest amplitude —0.79 —0.67 __ +0.72 +0.72 —0.78 -- +0.57 +0.88 Longest duration bursts +0.67 +0.68 —0.47 +0.57 __ +0.63 Degree of delta activity +0.80 +0.84 —0.90 +0.88 +0.63 -- demonstrated for the combined index of de— gree of delta activity. The intercorrelations of each of these in— dices are shown in Table 2. All correlations are signiﬁcant at better than the 1% level of conﬁdence, although the highest correlations with the degree of delta activity are noted for the frequency and amplitude measures. The lowest correlations are noted for the duration} of burst activity. These observa— tions indiCater that in future studies or in clinical application frequency response and amplitude changes may serve as criteria for the degree of induced delta activity. 3. EEG Delta Activity as Index of Clinical Outcome—Following these observations, a study was undertaken to determine whether the degree of delta response was predictive of the short—term therapeutic outcome. On the basis of the observation that the much improved patients had developed high—degree delta activity early and had sustained such activity, electroencephalograms were obtained during the second and third weeks of treatment 011 54 consecutive electroshock patients. The records were scored as to whether high—degreedelta activity was achieved dur— ing both, one, or neither of the four—six and seven-nine treatment periods, and the data TABLE were Both high (18) 12 (67%) One high (16) 4 (25%) None high (20) 6 (30%) * (Table 3). Of the patients who manifested high—degree delta activity during the second and third weeks of treatment, 67% were rated as much improved, while only 30% of patients with- . 1 out high—degree delta activity were so rated. Thus, the early induction and persistence of high-degree delta activity are seen to be re— lated to the short—term clinical evaluation. Comment The present study demonstrates a con— sistent relationship between the degree and duration of induced electroencephalographic delta activity and clinical evaluation of behavioral change. While it is conceivable that the difference between our results and previous reports may be due to a variation in population, it is more likely that methodo— logical aspects are important factors. Serial records were obtained during the course of therapy, so that the sequence of electro encephalographic change was evident. The records were obtained at a constant time in— terval following a treatment. Finally, quantitative analyses of the records were made instead of relying on clinical impressions. Of other investigators of this problem, both Moderately Improved 2 (11%) 8 (50%) 4 (25%) 7 (35%) 7 T ship between ind havioral respor therefore, perm changes in the o attendant alterat the physiologic process.* A simil. by Roth 23 on the *The Unimproved 4 (22%) ac’tivity.18’21’22 we. biochemical received limited stu on acetylcholine-chi tion in blood—brain and protein equilibri without deﬁnitive C( (35%) Signiﬁcant at the 2% level of conﬁdence. Fink—Kuhn the induced neu1 behavioral respoi these observation of action of elect 1. Relation ofi Behavior.—Beha accompaniment function. Chang tude, judgment, and insight atten tion, from what extensively docu literature. In this study, e consistently to alt in a fashion whic with states of altc studies of Davis Strauss,19 Ostow have afﬁrmed the activity as an in< tion. Symmetric, has been interpre tion of midline centrencephalic s also indicative oi of consciousness being directly rel: tude, and freqi related to the clinical evaluations. Clinical Rating Much Improved 21 further elaboratii 3.—Patients with High-Delta Activity During Second and Third Weeks of Treatment* EEG Delta Roth 2 and Hoa out systematic E to demonstrate variables and be] Two aspects oi 521 522 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY Roth 2 and Hoagland et al.,16 who carried out systematic EEG analyses, were also able to demonstrate a relationship between EEG variables and behavioral changes. Two aspects of these observations warrant further elaboration: the relation and role of the induced neurophysiologic change to the behavioral response, and the signiﬁcance of these observations for a theory of the mode of action of electroshock therapy. 1. Relation of Neurophysiologic Change to Behavior.—Behavioral change is a consistent accompaniment of alteration in cerebral function. Changes in mood, language, atti— tude, judgment, thought process, perception, and insight attend changes in cerebral function, from whatever cause, and-- have been extensively documented in the neurologic literature. In this study, electroshock has been shown consistently to alter the electroencephalogram' in a fashion which we have come to associate with states of altered cerebral function. The studies of Davis and Davis,18 Ostow and Strauss,19 Ostow and Ostow,2‘0 and Jung 21 have afﬁrmed the signiﬁcance of diffuse delta activity as an index of altered brain func— tion. Symmetric, dysrhythmic delta activity has been interpreted as evidence of dysfunc— tion of midline hypothalamic centers—the centrencephalic system?9 Such activity is also indicative of an alteration in the state of consciousness, more marked alteration being directly related to the duration, ampli— tude, and frequency of the slow—wave activity.18'21’22 The demonstrated relation— ship between induced delta activity and beafter electroshock, havioral response the conclusion that therefore, permits in the centrencephalic system with changes attendant alteration in consciousness are the physiologic basis of the electroshock process."< A similar conclusion was presented by Roth 23 on the basis of his studies of the *The biochemical substrate of this process has received limited study. Emphasis, has been placed on acetylcho-line-cholinesterase change,”25 altera— tion in blood-brain barrier,8 and changes in ionic and protein equilibria 26"” by different investigators, without deﬁnitive conclusions. 522 effect of thiopental on electroencephalo— graphic delta activity. Another example of the relation of the electroencephalographic delta activity to be— havior is seen in reports of epileptic patients. Landolt 28,29 describes a young epileptic who was ordinarily pleasant, friendly, and cooperative for his clinic visits. At these times, records were consistently dsyrhythmic. On one occasion he was surly, irritable, and withdrawn, and his EEG was without delta activity. On the subsequent visit, the EEG was again dysrhythmic, and a behavioral “improvement” was noted. Similar observations have been reported by Brockman .et £11.30 and Fabing.31 In a previous study4 we had applied the amobarbital test for brain disease 32 in a serial fashion to this group of patients and reported a relationship between changes in this index of cerebral function and be— havioral change. Were other tests of cerebral function to be applied in a similar fashion, it is anticipated that these, too, would demon— strate consistent changes during treatment and a relation to behavioral response, within the limits of the sensitivity of the test to reﬂect changes in cerebral function. In this context, electroshock may be said to be a method of inducing a state of altered brain function for extended periods, in order to achieve changes in behavior. From this point of view, the development of a signiﬁcant degree of electroencephalo— graphic delta activity may be a readily determined guide in the rational management of electroshock therapy. In these studies we have examined various delta indices and/or the intercorrelations and have noted that the amplitude and the frequency of the induced slow waves are the best guide to the degree of delta'activity. In patients in whom the behavioral response to electroshock is inconsistent with the therapeutic expectation, examination of the electroencephalogram may provide a criterion for clariﬁcation. If the induced slow—wave activity is faster than 4 cps and lower than 100,u.v in anterior temporal—ear lobe or anterior temporal— frontal lead combinations, then there is Vol. 78, Nata; 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE presumptive evidence of inadequate electro— shock therapy. When frequencies less than 3% cps and voltages higher than lOOuv are maintained for a number of weeks, the assumption may be made that an adequate degree of altered brain function had been induced and that other factors (environ— mental, personality, pathophysiologic) were operating to preclude a favorable behavioral response to electroshock. A similar applica— tion can be made for amobarbital tests 4 or syntactic language after intravenous amobarbital.6 2. Theory of Electroshock Action—These studies of the electroshock process have demonstrated that alteration in brain func— tion is induced early and is sustained in patients in whom the greatest degree of behavioral change is noted. We have em— phasized high—degree EEG delta activity and positive amobarbital tests as indices of altered cerebral function, with the knowledge that other indices of altered brain function, applied in the same serial fashion, may also show signiﬁcant alterations and a relation to behavioral change. We have been impressed that the ratings of improvement are value judgments of the behavioral response. All patients in whom cerebral changes are induced by electroshock manifest changes in behavior. The range of behavioral patterns induced under these conditions is wide. Only certain patterns are evaluated as improved, however, while others are regarded as “unimproved.” “Improvement” is a special case of behavioral response, being a subjective evaluation on the part of the observer that the patient is “better.” Electroshock does not induce “improvement”; it induces a milieu of cerebral activity in which behavior is different than before electroshock. To the extent that the induced behavior in depressed patients is perceived as less complaining, depressed, agitated, or anxious, or in schizophrenic patients as less delusional, hallucinatory, or excited, the patient is evaluated as “im— proved.” When behavior, however, is per— ceived as anxious, agitated, paranoid, complaining, or withdrawn, it is evaluated Fink—Kahn as “unimproved.” The particular type of behavioral pattern induced by electroshock is dependent on a number of factors, such as personality.33 Another aspect of the rating of improvement is the environmental response to the induced behavior. The modiﬁcation of mutism, withdrawal, and negativism to excitement, overactivity, and irritability may be considered a positive movement by the therapist but a disorganization by the ward physician or family. The goals of the therapist and the family, and their expectations and tolerances, are signiﬁcant factors in the behavioral response of the patient to therapy, and, also, in the ratings of improve— ment. These same factors are signiﬁcant in the duration of the electroshock effect. The in— duced change in cerebral function persists for only two to eight weeks following even intensive courses of therapy. In many cases, the behavioral response is limited to this period of altered brain physiology. When in— duced changes in behavior are not adaptive in the milieu of the patient, the behavior reverts to pretreatment patterns. In other instances, the induced behavior is adaptive to the environment, and, we assume, sus— tained thereafter not by the initial change in brain function but by the newly developed interaction of ‘the subject with environment. That this is indeed true is seen by the fre— quent successful adaptation of the patient to the hospital milieu after electroshock, only to have a recurrence of symptoms when dis— charge planning is discussed or discharge is consummated. Altered brain function provides the physiologic milieu in which there is an altered interaction with the en— vironment—the doctor, family, or society. These observations lead to the conclusion that electroshock therapy is a nonspeciﬁc induction of persistent states of altered cerebral function. Such altered cerebral function provides the physiologic milieu for an alteration of the organism’s adaptive interpersonal behavior. Changes are in— duced in perception, language, mood, recall, and judgment which constitute a mode of 523 interaction with of behavior indu is dependent up subject, the envii action occurs, an of altered cerebrz A similar View was initially exp and Kahn,1 who tionship of neu: behavioral respor electroshock pr0( the observations Aird et al.3 The neurophys tion of electrosh( deﬁnition of the of further elabor: a hypothesis also standing of ther coma therapy, 1( agents. j Summary Serial electroe: weekly intervals referred for elect analyzed for the A signiﬁcant tween the degrec delta activity an( behavioral chang ﬁrmed in a predi 54 patients. Differences bi those obtained It terms of differen A neurophysi tion of the electrt It is concluded t] speciﬁc inductio: altered cerebral physiologic miliei tive interpersona Improvement as a special case c these conditions. by an observer factors, including 1 r' 524 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY interaction with the environment. The type of behavior induced under these conditions is dependent upon the personality of the subject, the environment in which the inter— action occurs, and the duration of the state of altered cerebral function. A similar view of the electroshock process was initially expressed by Weinstein, Linn, and Kahn,1 who emphasized the interrela— tionship of neurophysiologic changes and behavioral response. This description of the electroshock process is also consistent with the observations of Ulett et al.,34 Roth,2 and Aird et al.3 The neurophysiologic—adaptive interpreta— tion of electroshock provides an operational deﬁnition of the process, which has promise of further elaboration and observation. Such a hypothesis also has application to an under— standing of therapeutic process in insulin coma therapy, lobotomy, and tranquilizing agents. Summary and Conclusions Serial electroencephalograms obtained at weekly intervals in 24 consecutive patients referred for electroshock were quantitatively analyzed for the degree of delta activity. A signiﬁcant relationship was found be— tween the degree and duration of induced delta activity and the clinical evaluation of behavioral change. The results were conﬁrmed in a predictive study in an additional 54 patients. Differences between these results and those obtained by others are explained in terms of differences in methodology. A neurophysiologic-adaptive interpreta— tion of the electroshock process is presented. It is concluded that electroshock is the non— speciﬁc induction of persistent states of altered cerebral function, providing the physiologic milieu in which changes in adaptive interpersonal behavior occur. Improvement after electroshock is seen as a special case of behavioral response under these conditions. The rating is an evaluation by an observer depending on numerous factors, including the type of adaptation, the 524 and expectation of the observer (therapist, family, or administrator), and the setting in which the behavior occurs. goal Mrs. Helen Donovan, Miss Gayle Wankel, and Mrs. Hannah Mosquera gave technical assistance in this study. Hillside Hospital. REFERENCES l. Weinstein, E. A.; Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat. 109 :22-26, 1952. 2. Roth, M.: Changes in the EEG Under Bar— biturate Anaesthesia Produced by Electro—Coxnvulsive Treatment and Their Signiﬁcance for the Theory of ECT Action, Electroencephalog. & Clin. Neurophysiol 3 :2612-80, 1951. _ 3. Aird, R. B.; Strait, L. A.; Pace, A] W.; Hrenoff, M K. and Bowditch, S C.: Neurophysiologic Effects of Electrically Induced Con— vulsions, A. M. A. Arch Neurol. & Psychiatl- 75: 3371—3781956. 4. Kahn, R.L ; Fink, M., and Weinstein,,E. A.: Relation of Amobarbital Test to Clinical Improve— ment in Electroshock, A. M. A. Arch. Neurol. & Psychiat. 76 :23—29, 1956. 5. Korin, H.; Fink, M, and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conﬁnia neurol. 16: 88-96,1956. 6. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communications, edited by P. H. Hoch and I. Zubin, New York, Grune & Stratton, Inc., 1956. 7. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electro— shock, Electroencephalbgi&-Clin. Neurophysiol. 8: (abstract), 158 1956. Pacella, B. L.; Barrera, E. S., and Kalinowsky, L.: Variations in the'Electroencephalogram Associated with Electric Shock Therapy in Pa— tients with Mental Disorders, Arch. Neurol. & Psychiat. 47:367-384, 1942. 9. Proctor, L. D., and Goodwin, J. E.: Clinical and Electrophysiological Observations Following Electroshock, Am. J. Psychiat. 101:797-800, 1945. 10. Bagchi, B. K.; Howell, R. W., and Schmale, H. T.: The Electroencephalographic and Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders, Am. J. Psychiat. 8. 102 :49-61, 1945. Levy, N. A.; Serota, H. M., and Grinker, R.: Disturbances in Brain Function Following 11. R. Convulsive Shock Therapy, Arch. Neurol. & Psychiat. 47 :1009-1027, 1942. 12. Mosovich, A., and Katzenelbogen, S.: Elec— troshock Therapy, Clinical and ElectroencephaloVol. 78, N00,, 1957 ��mum m 3%: «u mmwgmwzum,mm muJ.MiMMﬁW3MhWW m if mwmum. “ w. Mr maummwmmmmmd W. mam. mm W. ‘ ��Wﬁmmmamhmmuwmmuw (mﬁmumlmwmmumwmm MQ}WW#WWWMWW W“Nmmmuwmﬁummxmwmmmmm Wan. 'meummmmm-umm m MW‘Mﬂqumemmuw-ua MW“ ' “- MWWW manna a) mxmmmmmmmwmm ��I ‘1“ A— �Wgwmmwmg MWMﬂmmmgw MWmmtmmum4h mwmm. wmmamm.mwm«mm* ��. v ,9 M» ﬂ..V 4%5.. ��..: 3 0%» .4 4L, “.4 .:‘ ».:4, J ��«ﬂit WWMM. m twmnmmmm ��.14. u J, wring >,R �‘ ’ ,. "M :jﬁ" W; Walt ��W W M“ WWW!» mu?Wmmm mm: at W mm: in. {1. a» a) mum at *1?" mm in W WW; W m m at ��77 was“W r I €25” 0551: (”n-hum or Inn-I 4 -5«-r.:.5“......”"55. {/7 m mu “$17115: to Word mm. in Whack: wants." Serum. Studies . "v a» 5, g an m HDandRoborbL ma. 3.5.5» I: M. ' ﬂ at mammal WW; Hillside Hospital, 01m Oaks, truths Want. lbw but. Aid-d, m m by gum. 14-927. mama mum. at Kent-.1 Health, mum). of ﬁnd/m, v.3. mm Health San-1a.; and the mm mem mum for Mad. Ragnar-9h, nWJa-rlcM mt: , of mammeephalcmphoro, Won, Present!!! aththe mum Duct, WWI} 1955. m: M57» ‘ ' . ' “mm .— ; �Relation 5?? -.._.. a: _ Meet w {Mari-ea m, Delta Activiw to More}. mm in Wanna: antiutive Serial Studies; a: electroshock therapy m ( 1, 2,. 3) have emphasized the rule of neurophysiologic changes as the basis for the therapeutic .1 . mutant with these ,L theories, we have observed auction of a mutual: bum changes a: new means of brain function and behavioral name. We have noted an... $73 WW 40 electmsheek/‘aﬁ- changes in orientation embarbital (2;), flaming and <6) . null and clinical hpmment following cmfabuletion after 111th (Shana syntactical aspects at ' 1% In view of these observations it. could be expected that. electroencephala ogrephie shudiee mld report-ad inﬂamed relationship. Nmaerous observers have eminent changes in the electmeneephelogm utter eleetzically Mime. rhyﬁMc em 1 similar utivity There 18 6.1.th9 slewing with increased voltage and dye. (7 ~ 12). Feet percent—tum (13), and utivity decreases, both in voltage and in in patients we are intensively trauma, there is e naming of persistent alpha frequmcies (1h). The degree, mum and extent or éelte amenity is directly rented to the r'nquemy and amber of grand ml I Wane (8 -- 11;). Such activity is usually swede, appears maximal effects usually disappear 1:1meme in anterior leads, and the in ma mks renewing the 1m treatment-,3. 9). In contrast to the comiateney or them observations, studies of the relationship between the elmtmmephelogrephie and the dilated conflicting menus. ohmic: and mean: (15). after an mag” show mun review of the literature, £9011ch that the amber er treatments rather then the degree of named delta. activity we: the primry factor pantie response. 011 the other hand, rented to a fwomble there- 21qu 93 g}; (16) :0pr a relation how changes in the percent time feet eetivity (more than 13 cps) and ��.4... In the rim]. estimates or degree of deli: activity, the average delta index for the 3 load oombimtiono, the highest 3011:: index in any one load, the ulwest frequency, Most delta. voltago and out-aunt: of longest period of burst activity was listed for each macro. The 160 noorda were mangod in aoquemo for one): index and the percentile ram: dotemined. The ranks wen oddod and the the ﬂoor!!! than Imnged in rank order awarding to this score. a: that the higher score refloctod a. grotto; agree of delta activity, the upper third of the mom were classified as “high dogma the middle mm 58 "mm. degree delta“ and the lowest third as ﬁlm dogmo‘ “main dolu:~, delta? . ohmotorizod by an ﬂange delta index delta 1mm of ‘2135 armors in one o! the three High degree «sum record- wore of at. least. 18%; a mound 1m; voltage mm second», w slam“ frequency of loss than m madman; m: a Inn-at. 3 3/1; ops; highest mu mum of u least 2 1/2 ‘ Low degree dorm noords was characterised by an loss than 2%; slower than S meat. delta 1m in one lead of 1/2 ops; volt-.93 loss than 60 loss than 1/2 nomad. ’Hodornto degree delta groups with an 60-80 20%; Mormons; and 31m“ from Inn-at indoor or or 1am mquanom no naming and burst duration 3% room-do won Minoan ”lose two mugs delta index between 2% and 18%; no load of 3 to mugo delta ‘ mm ﬁnite 3mm in of h-S cpl; highest amplimdo bemoan duration of 1/2 to 2 seconds. fiftyafour omomtivo, unselected electroshock patients, oloctmonooplulogmphic records worn obtained prior to trustmne, during the We! and third weeks of treatment, and tam weeks after 13) In a. second aortas of mama‘s. mesa rooonin were mlyud using: the identical moms as in the initial ��W degree the” %%Ru.® was WW3 to datamine whether the at delta response was Mauve of the short bum theramutic cum. m the baéis of thﬁ observation that the much improved panama had dweloped high dtgrae delta #ctivity unﬁt-1y and had. sustained such activity, chew mamalogms ware obtained tinting; the second and third weak: of mutant in pltiants. The records- were Scored as ta whether high degree dolta actiut‘y was acldwed timing; both, on: or with: of the h—é and 7.9 treatmnt pariah, the data was muted to the clinical evaluatimm (Table III). Sh eonsecutiva electroshock and mm III ' ‘ EEG man Delta. _ (18) Both High One mgr; .. “Home High (16) (20) f who pntienta without. mm W 2 (113) 12 (67%) h (225‘) u (292:) a (sex) h (25;) 6 (30%) 7 (35%) 7 (355) // anwx‘uaummm,m M down delta activity?» rated. M, the surly 1n- ducbion and persisteme of mg; dogma delta the short mm. clinical 4» Moderatelx manifest high degree delta activity during tha second and onlgrBOSof attainment. or the patients 'mm - ma activity is seen to be related multim Meant at the m1 of cmm. 2% to_ ��J We “WWW“ 1111111111: delta activity has m integrate as evidence of dysfunction at manna centers {mtmmphmc systoml (19) . mpothalandc and Such activity is also indicatim of an alteratim in the cuts of consciousness, with more marked alteration being directly related to this duration, mum. activity (If, 21, 22). me dmstmted roala‘bianchip between induced delta activity and behavioral response after electric and tmquency of the slow wave hint- conclucion that. changes shock, themfom , permits the cephnlic 3513mm with attondant. alteration in conscimmnesa basis of the electroshock pmccas. m the basic cf his stwiea of the Another example of the behavior is tut-h seen £81 ~11 A ‘ 11.:1‘rect . M of me b visits. cooperativefar hie 01.111111 MW”. occaa11m be was 1153110111; mic 9.1213 :1 ported by we delta activity, belmvioral On At. an WW $133114. (23) '1'?—“1/1'54"? W 55130) reports of epileptic patients. Landon ordimrlly pleasant, fﬁendly and them times, records the subsequent and 118 warn mimuy unit, Similar was mated. ram 111111 the EEG was again ﬁgsrhyth- obaomtionaﬁ ﬁre?” (31). applied the Maximal test 101» brain h nthembml serial fashian to this group of patients, and reporwd a mlatiomhip between changes in this index fwtion and behavioral changci. Herc Other tests of ccmbml {metion to be applied in a disease (32) an a 31:13:: 331131 fashion, 11'. is anticipated that thou, tab, would demonstrate bicchmcal substrate of this process has received 11mm: cm placed 011 acctyldlommholineatemse changes (2 ) (25), W818 has1nbean blooMrain barrier (3) and chasm in ionic and pmtoin nautical (£6) (2{) diffcmnt by aquilibria investigators, witho 1t definitive: con- it The 13111810113 . m surly, inﬂame and withdrawn, and his 1% ”13111101791331” In a prcvionl atudy (h) wwé‘gm relation Iof clactmcnceﬁulograpmc delta to (28) (29) describes a young synaptic: who was 011 the Gem-im- % the pigsiclcgic mansion similar 3.11 ��«18‘ {gnawing mu intents.“ name is courses of therapy. In limited to this 40f ,peziari many cases, the behavioral altemé! brain phys‘iolégz'f. When induued in behavior are net. aﬁaptive in ﬁhe mien of the patient, £16: behavior be pwmamm patterns. In cther instances, the induced behavior is Idaptive to the environment, and, we assume, sustained thereaﬁer not. by the changes" mm in brain function, but by the newly dmleed interaction at M2 subject with envirmmnt. Theft. miss is indeed true is sea: by the fremwnt suscaasm adamuon at the patient to we hospital milieu after electroshock. initial only change to We a marten-ea of symptoms when discharge planning is discussed or is mummied. Altered brag». function provides the Manage Mm: in which there is an altered hibernation with the environment -- the diIcharge doctor, famﬁly er society. I These ’ obm’cim lead to the canclusion that electroahack tirxerapy ﬂﬁmum Such Wyenﬁfic induction of persistent states of altered altemd mm; hid. rum um provides the physiologic milieu for m: altera- a -' tion of the organism‘: adaptygtexfgersoml behavior. in pemwp’oion. “a Changes WW3,W, mé‘m, and MW: which Max-scum with the ‘mirmn‘o. Mead ms:- than oonditim is deg-3mm I is The type of upon are induced m constitute 31 new behavior the personality of the 813123“, the environment in which the interaction occurs, and the duration of the stat. cf altered cerebral function. A similar View of the electroahock pmeesa ﬁas initiélly expressed by rm and Kuhn Heimtein, Minibar: (1), who mﬁmaized the interrelationship of changes and behavioral msponse. This doseription of ma shock pmoess is also consistent with the observatians of Ulett Roth (2) and Aird (3). 533 new electro- $3; (31:): gig}. Th5 meioloMptim Mode. interpretation of electmmock pmviaiea m mutational definition of the pmaaa uhie‘n has promiaa of further 3mm ' 49’ �“on and wax-mum. _ Such a. a; Wilma ‘ standing of therapeutic procesa in quillizing agents. . also has appliuticn to 1mm coma therapy, lobobono' an man». ané tran- �«is. J ‘ , ‘ 1. Serial aloutmmoyhnlogmma Waive W ohm!“ at many intervals in patients Mama! for electroshock were quantitatively for the degree of delta activity. ’ 2. 215 W aimifioant relationahip was found between the degree and aux-aﬂoat of induced delta activity and clinical ”elation of behavioral change. The results wen: confirmed in a meditative study in an additional 51: patients. A 3. Diffemnooa between them results and mono obtain-d by others are explained in toms of differences in m'modolow. h. A mmphyeiologic use is presented. It is duction - adaptive interpretation: of the elootmshock pro» concluded that electroshock is the non-Specific in- pomatantvatatea of altereri cerebral function, providing the ogic 31113:; in inch changes in adaptive interpersonal batman: occur. oi". 3. laymen)“. maponz—ze afar abotroshoch is under those conditions. " The seen u at 81300131 case of #133191“ botanical rating in an evolution by an observer (lemming on numerous faahora, including the type of adaptation. the goal and expectation of the observer (therapist, family or sminiatrator), ting in which the behavior mm. and the set- �4-43.6- Acknﬂedgemnt : We wish to Ranks]. and m. 31pm: our asppreciation to Mrs. Hahn Ewan, Miss Gayle Hannah fer their mammal assistance in this study. Wm �~17».- 1. Weimtein, E.A., Ling max-spy: Psychiat., z. MW 13., and Kuhn, R. .2 Psychosis During Its Rahtion ta the Log: 22.26, 1952. "zeory of Elan-maxed: J. Shank Thempy, Am. ‘ ' Bui‘biturato Anesthesia Produced by Changes in the m:m, wmm: Electra-convulsive Wmt and Their Significamo for the Theory EEG » act Action, Em. (315.11. Neurophys" 33 261-280, 1951. 3. Aim, R.B., Strait, LA" Pace, Jﬁ'q Hemoff, 14.x. ind Witch, 5.0.: of ﬁe‘grophysialmc Effec'ta of Electrically Induced Gomulsions, Adidmam. a: Paychiat” 15.: 371-678, 1956. Arch. a; 3.5.: Relation a: mom-banal Test to Clinical Imgmemnt in mctmmack, AJLA. Arch. Neurol. Kahn, 3.1,... Pink, 5:. and Heinatein, 2;; chum... 163 23.29, 1956. S. Hg Fink, aR'Z'Efrim, M. to Legging 19 1o 6. Kahn, 3.1.. and Fink Wt and Fur-- 8.: Relation of Changes in Mmery and Nasser, in Electmahmk, Cont. Mauro]... ya: rm; Changes in 8M6, Language During Electmshoek Therapy, in “PSy‘chopathangy of Cmmication," Trumaaticns Amr. Psychopaﬂml. Lame” 1955, Gram: Stmttan, Raw York. 7. an», m. ané Hahn, Ram Quantimm Studies of Slaw wave Activity Faun£2 Elactmshock, 8. 1236.. 63.111. Haumpkys" Q: 1538 (Ethan), 1956. 13.1." Barrera, 31.8. ant-3 Kalinowslgr, 2...: Variations in the Elect» encephalogm Maociateé with Electric: Shack Theta: in Patients with ﬁen’oal Eiisordern, Arch. neural. {é Psychiat” :1: 367-681;, 192:2. 9. Metar, Id)... and Goodwin, J.E.: Clinicnl and EleuhroMiologioal Observation! Following mammhmk, Am. J. Psychiat., 391.: $7.800, 1925.. 33336113., ' 3-“ 10. Bagahi, ' '11. My, 3.211., Ewell, 3.33., and Somalia, 8.1.: The Electreencepmlegrarphia Clinical Effecta of Elegtrically Induaegi Comnlsicms in the reament of Mental Disorders, Am. J. Paychiam, gag: 1&9~é1, 1915. HA... Beret... Km” and Grinker, R. Ru Disturbances in 3min Function I“ ComlsiVe Shock ’Faerapj. Arch. fieurol. Pay1914-2a MI 10094027, plain.” cum 12. Hamish A" and Katzenelbgen; 3.: Electmshock themm, 51mm. and 517'éacti‘oﬁgcehhalogmphic isms-Ems) J. Harv. ‘I Mani... Dis... 39, 9 we» m: ‘ 13. 24A. and “111mm 3.13.: Significance of Changes in Elect. mm, alogram Zhsults from Shock "therapy. J. chiat" 105 ,' 'va'hicit: 11045, 19%. Am. PB ��’19.. 29.’ Landau, Ru Uber )9 undw Vemer-‘mm W:- fur zguatwdsbilder be: PW3hmm$g 1?} 313‘331’ a 1mm,I' 19%50 schizophmxe Neurologio mu! Goo. 918178, W”, Related Type of TrutG.A.: to Thaw ‘3erE} 97-10%a1956. mnt, Confinia neurologica, 30» Bm:m,.ﬁoJo Bmcm, 31.. Ming, IL: Personal cmmication, .3:»:. Veins’oein, ‘EJ... Kuhn, 1m... Sugaxman, Ink. and 1mm; 1“: The Diagmstic Use of murbital "Sedan (”Am-tel sodium“) in Brain Disease, Am. J. Psychiat" ngﬁsws’h, 1953. ngaa 1n JOC.’ Jaebbsm’ 1956. $16: U... ' Pemmuty raetor‘a 1n mum: Psapmae to m,a.s hilactroahock Tharapy, Gent. Kennel. (in prose). Kahn, R.L. and 833%, 8A., Smith, K. and thconvulsive 6 ham, (3.6.: Evaluation of Convulsive and Shock Therapies W‘.’ at 79m, 1956. Utiliniqg 2., Control. Group, Am. J. �~20- 136mm m 1. Lou Dogma Delta Activity . m Figure 1.1. Moderate Dogma Delta Activity “M 3.11. High Degree Delta Activity Figum 1?. Relation of Clinical Ratings to Development of High Degree Delta Activity. Figure v.0. - 6) Ralation Clinical Ratings to Delta Activity. (11' ill-Ia EAL-k M Index of �12.5553" ’53?! $3.4 vii. ‘ '3 �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263m: STREET GLEN OAKS. N. Y. Flaws-ran: 3-7800 s. A. MILLER. M. D. MEDICAL DIRECTOR JOSEPH MAURICE BAC‘HRIACH ADMINISTRATOR SHRON KWALWASSER- M. D. ASSOC. MEDICAL DIR. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �, v—v—v ﬂu ; {'ZﬂA/C’ , — S’s/"- 4—'-J-{/ , -:v»- mm- -- -< - - .» ,. - —~ :~- -~--7— «— u « , v-«wy— —— v~vn~~m~——.W»,M—->w— yw—W “H's—WW £46 4/? /7¢3 far]Flaw/t M(",qu ”may Webcw~aa M4£27%01;“, 6W f5 Wm awe/W m Moxie/M M W ¢m MJM WM W ’@.A.:f;4m «4% dw.;&%-m/: Midang/fvaf mam ”I‘M/MM 2/49“”{24414 WMMMWJW M41; {W MWMM W. I, r �“qua-7 r.l_~- ".w. v "/ﬂ/Wd' Q/a 7 _.,;m,‘_<,,,,,..ﬁ_ .mm. uvr...“ 4 ¥ 77“.. ,, Va- .._ , "W, ,V _._ .—-.~ .,. V .7 .,,.‘ ;....- . , .:__,<W dag ,u/ W WM W M ‘ _ ,_.,. . . , qr, .._.; x7443 A4414M4M 7’7 ’ “ 74' m WW/M .W We! l..— my MAJ WM W M :W mm _ . (NV, Aux-5&2; 7 ﬂ £;W Jar/tamed 4 Ztaw a M..WA 2/ M44." 64;“..“4 92%] ”(“44ng l/amﬂv, (I , �. _. ~...v.;., , r“...— E , . V ~,~~—~ , »- . “-‘"‘ «(y—av“ .v. .r- . 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A WWW AW/MW“ mWngsUﬁat/Lg, ‘4 M M MlefWWﬂ/L‘XW W Wséaz W M» Md WW +2637 '- AAA/M4 M-M.é"/.2£ Wot/(WA (WM mam. �(16) 3 5 ﬂth, % Wk. MW ' - . 3 @3W Mr WM gge ,7 4% W A“ % W twé WK 77'W754’WW J calm/(P6,, (ii) Wot/7! MA: an 32AM“ a (6} W30 W A; 1 ¥ ‘— 6&3,“ A [ﬂ/t “M” C, “5&7: I �LW 23m W (“’W 21%;.“ 2 W15— a. éd// /7// I . $5 (0) /4,' ﬂair!“ M (W ‘-" (Axle—26‘) W/Wr d/ﬂmﬁ/Wﬂwxw‘ W4”- (f) kn/WK A [OJ-W [6} gt/M W (4717 (02/2 @WV4 =1 loo-WM W2a.. 23% 26/? VFW A" ,2 Amt“ E �jW/MM/ r_ QawaQ/ducfﬁ @ﬂ )4) 1/) , 3) i W mgW W551” :M / H MM? ge/fsf? )krqu. ﬁfth ﬂaw“ AﬁéﬂQ—m Mﬂe 2:. / M . - 5/3; ”a“, mgwk /W&”’V : �Bambi, B. It, Emil, R. m, and Schmidt, 3.13.8 inﬂated convulsions 1n the treatment of triaaﬁly_1 1023‘ 1]7 9 ”The alwtroancaphalogmphia effects mad 3111113511 1:1li an! aim disordem.“ém. J. Pqnhigt. ' Barrera, St American J. Egg and P866118, B: In: “EEG finding! ”‘001amd With 31Wtﬂ¢ therapy in patients with mental 333.: 206119ﬂ3. 3118.559}... GOldtarb, W" Laughlin, J3 Ma; 8336. Kiwﬁ’ H. Ea: ”P19163336. 1113111111 $193k dimm.“ Shaﬁkdu VMO Gottlieb, J.S., Ashby, PLO", and Kimble; L.L.:'mamamlogi¢ study of schimphn min and depressim. IV. Ina fluence of electriu cenmlaiva them on, the aodium mm]. reapmua of the saleabmencephalcgrm.‘ Am. J. Psychiat. 10 : 6869696§ 1958:: » Harris, Roma, W.A.:"ﬁsa of cur-are in mtraxol mnmlaant timer: with 15 3 5376 £1 19111“ observations.” maniatric Land 2mm, and Panama, E. Wt electmencephalograﬁxiu England, Hr, whim, Mum, and Cinema, D.E.: " me electroencephalogram hypoglycemia and recovery." 7 J" Wigton, Hughes, Arena Neural. Ward, Am. 13., and at 13816111312. 14.11., and Rims, Jardon, F.:“Electmencephalogmphie studies on patimam meshing electm~shoek mamnt.” 19141. “SWiamm of L.F.: «hmgas in thy alecmenecphu ﬂagram whichmsult from Each, ‘1'. 0., and autumn, Ed 251.13.. Arch. Neural. MO “The other effact of benmdrine and @2th ant: upon the (21mm Shank) EEGJIi'amatiun Pmc. 5:62“ 12%,. 8mm, mm, and Grinkar, 12.3.: Diaturbanaea in brain pastconvulsiw Levy, therapy." 53: shew}: W. ehiatu 50f 53§¥537g 12h3 8: 1mm, mm, 1' Payehnt. & m; J; Haul, B; H0; of schizophrenics curing insulin 1202 559‘5791 3.9;}; Gottlieb, J.S.: ”Chang” in. the eleetmeneephalogrm renewing insulin shack therapy." Neural. and Page and «1.12., J. $1131.01. as: ﬁgumg _ Jg.P§Fdhiﬂta 105‘,h0*h53 19h5v Knott, , mum reﬂuxing wnmlsiw shack mummy.” 1:7: 1009402“: 192:2. Go»; Wu, { G; Rn, Pma‘bor, IN Dr; and 600%, J“ E03 "Parallel psychologisal, psychiatria and Whalesinn). findings: in sahimphmnie patieats undar insulin ahcmk treatment." Am. J... Psychiatr.» 933 1422-4129. 121:1... lbriaﬁy, LB... and Siam, 573 112*.»718‘ 1913!. maevich, A" nut. and, shoal: therapy.” Arch. Neural. g mint. 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Jﬂm '2 ’1 wri-ryn 334/ m ; "‘ “ :~ <- W V 3K3»: -;M " HJWAM �Levy, N.A. and Grinker, and 8.3., ”Electroencephalogranhic and ElectriC9llylln- Clinical Studies Following Metrazol . duced Convulsime herany of Affective Disorders", Archives of Neurology and Psychiatryh7, 19h2. 1009-1099. L., "Variations Pacella, g. L., Barrera,.3. E,, and Kalinowsky, Electroshock Therany with Associated ~in El’ectroencenhaloggram Archives of Neurology Disorders." Mental of Patients with and Psychiatry A7, 19h2, pp. 367-38hk Sﬂnon, A., Yeager, C.L., and Bowman, K. 5., "Studies in Electronarcosis Therapy IV EEG Investigationsﬂ' J. Nerv.and Mental' Dis., 118, on. 131-1M33 "Clinical and Electrophvsiological 3.. Following ileotroshock". Am. J. Psych. 101, Proctor, D., and Goodwind, Observations laué, pp. 7a7-8a0. of Electricéghock TreatKarliner, W.,A "Neurolowic Comnlications review." J. of Nerv. and Mental Dis. 107, on. 1-10. ments: Rosen, A. R,, Secunda, L., and Finley, K. H., "Conservative In— Mental ' of Shock Therapy in Illness, Tracings Before, Electroenoenhalographic of cluding Study Therapy". Quarterly r"sychiatric and After ghack , During Approach 17, 19h3, to Use pp.6l7-6hl. Turner, W.J., Lowinger, Lg, and_Huddleson, J. 3., "The Correlation of Pro Electroshock Electroencephalogram and Theraneutic Results in Schizonhrenics? Amer. J. of Psych. 102, lghg, I ﬁa+41?1 r8}+d*uw~ CZ-2§ (hﬁwt lqﬁi ; :ryfugzo a9m~ﬂ¢3 _ _ ”—4“; «-4 �’5? [Evy—q“ .. x“. 7v , “aw—.77“ . ...,-._:$.. .1 , . fa?" Em: E». \‘a H :1 . .7 . , . . 1 ”way"- ,7 m ”V. '55: A“: - . Pup-<12: ‘ F.» 7“" ,s-n , Bagchi, B. K., Howell, R. W., and Schmale, H.T.: "The electroencephalographic clinical effects of elecmental disorders."Am. J. Psychiat. of treatment trically induced convulsions in the and 102: A9-61, 19A5. Barrera, S. E., and Pacella, B. L.: findings associated.with electric Shock therapy in patients with mental disorders." "EEG J. Physiol. 133.: 206,71951. Goldfarb, W., Laughlin, J. M., and Kiene, American H. E.:."Prolonged.insulin shock." Am. J. Psychiat. 101: 827, l9h5. Ashby, M.C., and Kinble, L.L.:"Pharmaoologic study of schizophrenia and depression. IV. Insodium the amytal response of the electfluence of electric convulsive therapy on 10h: l9h8. Am. 686-696, J. Psychiat. roencephalogram." Gottlieb, J.b., of curare in metrazol convulsant théerapy with electroencephalographic observations." Psychiatric Quart. 15: 537—5h3, 19h1. Hoagland, H., Rubin, M.A., and Cameron, D.E.: ” The electroencephalograms of schizophrenics during insulin 120: 559-570, 1937. Am. J. Physiol. hypoglycemia and recovery." Harris, M.M., and B. L.and Horwitz,‘w.A.:"Hse Pacella, 7 ‘ Wigton, R., and Jardon, F.:"Electroencephalographic studies on pat— J., Hughes, Arch. Neurol.& Psychiat. us: _ 7h8—7h9, ients receiving electro-shock treatment." l9hl. Kennard, M.A., and Nims, L.F.: "Significance of changes in the electroenceph- J. Psychiat. l9h8. 105: Ao—AS, alogram whichresult from.shock therapy." "'Am.“ Knott, J.R., and Gottlieb, J.S.: "Changes in the electroencephalogram following insulin shock therapy." Arch. Neurol. and P532 chiat. 50: 535-537, l9h3 a. Lennox, M.A., Ruch, T. C., and Guterman, B.: "The effect of benzedrine and Other chemical agents upon the postconvulsive (Electric Shock) EEG."Feraration Proc. 5:62, l9h6. Levy, N.A., Serota, H.M., and Grinker, R.R.: ‘Arch. Neurol. & Psychiat. D7: Disturbances in brain function following convulsive shock therapy." " 1009-1027, 19h2. Neel, B. H., Dswan, J. G., Myers, C. R., Proctor, L. D., and Goodwin, J- E.: "Parallel psychological, psychiatric and physiolog— ical findings in schizophrenic patients under insulin shock treatment." Am. J. Mo _ Psychiatr. 98: h22—h29, l9hl. Moriarty, J.D., and Siemens, J. 0.: "Electroencephalographic study &of electric shock therapy." Arch. Neurol. Psychiat. 57:712-718, l9h7. Nbsovich, A., and Katzenelogen, Dist. 107: 517-530, l9h8. 8.: "Electroshock therapy, clinical and &electroencephalographic studies. J. Nerv. lent. V �-2Pacella, B. L., Barrena, S. W., and Kalinowsky, L.: " Variations in the electro- encephalogram assbciated with electric shock therapy of patients with mental disorders. Arch. Neurol. & Psychiatric. h? 367-38h, (March) 19u2. Proctor, L.D., and Goodwin, J. E.: using raw 60 cycle alternating Egychiat. 99:525-530, 19h3. and Comparative electroencephalographic ob- serVations following electroshock therapy unidirectional fluctuating current. J. “““‘ Am. observaProctor, L.D. and Goodwin, J.E.: Clinical and electro-physiological Am. J. Psychiat. tions following electroshock. 101: 797—809, 19h51 Rosen, S. R., Secunda, L., and Finley, K.H.: conservative approach to the use of shock therapy in mental The illness. Psydhiatric Quart. 17: 617-6u1, 19h3. Sutherland, G. F.: experience with electric consideration of shock treatment in mental diSeases, withspecial regard to various psychosomatic phenomena and to certain electrotechnical factors." Am. J. Psychiat. 99: Sulzbach, W., Tillotson, K. J., " A Gullemin, V., and Jr.,some 519-52h, 19h3. Taylor, R. M., and Pacella, B. L.: . J. Nerv. _> & 1VLent. significance of abnormal electroencephalograms prior to electroconvulsive therapy. The Dis. 107: 220, l9h8. Lowinger, L., and Huddleson, J. H.: The correlation of pre-electro— shock electroencephalogram and therapeutic result in schizophrenia. .Am. J. Psychiat. 102: 299, l9h5. Turner, Neil, l9h7. W. J., A. A., Brinegar, W. 0.: "Electroencephalographic studies following electric Arch. Neurol. & Psychiat. 57: 719, shock therapy. �286.lﬂ§elation EEG Number Delta of Manuscript re: Activity ..." by Fink and Kahn Dear Doctor Fink: I am very pleased to inform you that your paper has been accepted by the Editorial Board for publica- NEUROLOGY AND PSYCHIATRY. tion in the of issue in an early article It is planned to use your A.M.A. ARCHIVES OF the ARCHIVES. Yours very truly, ROY R. GRINKER, M.D. Editor-in-Chief for Psychiatry P.S. It is necessary for publication that you forward an additional copy of your paper directly to Mr. G.S.Cooper, Managing Editor, A.M.A. Specialty Journals, 535 North Dearborn St., Thank you. Chicago 10, Illinois, as soon as possible. �L___E,, _, WW--. , , , , R. GRIEKEE, . DIRECTOR, P. a BOY MICHAEL REESE". 29th SIREET CHICAGO AND ,. pgmg's 2mg; E 16. ILLIIS|957 in %£;"3 Max Fink, Department M. DEdeEimental °f Hillside HOSPigg; 75 263rd Stfeéi “ ‘ Glen Oak§,3 c‘. NEWTYGRKE . -“ i V. - . I J .' --E EVE I ; . 3 i...' -_ .*-« . n a" Psychiatry l, ‘pja.'ff~xﬁE=b . .4 -' . ', 3‘, . 2“” ﬂ �C ' o Please return to r;’ MD Publications Inc., 30 East 60th St., New York, 22, by Jan. 2 1958. Relation of Electroencephalographic BeltavActiviiy to Behavioral Response in . Electroshock, Quantitative Serial Studies. EAX FENK Ali RDbnﬁT L. AAHN. AMA-Archives of. e rology & Pegcniatry 78: 516-525, November, 1957 - I In a study of the neurophysioloch correlates of convulsive more”, serial electroencephalogram were obtained at weekly intervals in an consecutive patients referred for electrodzock. no records were quantitatively analysed for the degree of delta activity by moments of the per cent. tine delta, latest frequency and highest amplitude delta in the record, and daemon of burst activity. signiﬁcant relationship was found batsmen the degree and duration of induced delta activity and clinical evaluation of behavioral change. The results were conﬁned in a predictive study in m additional 9; patients. A Differences between these results and those obtained by others are ex’ plained in tonne of differences in methodology. A presented. It - adaptive interpretation or convulsive the repy is is concluded that convulsive therapy is the nonspeciﬁc induction neurophysiologic of persistent states of altered cerebral function, providing the physiologic milieu in which changes in sdaptive intezpersonel behavior occur. Ilprosrenen’c steer electrooonvulsive therapy . is seen es :1 special. case of behavioral response under these conditions. the rating is an evalmtion by an observer depending on annex-one teeters, including the type of adaptation, the goal and expectetim of the observer (therapist, family or adainistrstor), and the setting in which the behavior occurs. �In a-study of the neurophysiologic correlates of convulsive therapy, serial electroencephalograms were obtained at weekly intervals in 2h conseCutive patients referred for electroshock. The records were quantita- tively analyzed for the degree of delta activity by measurements of the per cent time delta, lowest frequency and highest amplitude delta in the record, and duration or burst activity. significant relationship was found between the degree and duration of induced delta activity and clinical evaluation of behavioral change. A The results were confirmed in a predictive study in an additional Sh patients. Differences between these results and those obtained by others are explained in terms of differences in methodology. A therapy ‘ neurophysiologic - adaptive interprdation of the-ele- convulsive is presented. It is concluded thataai-lil-convulsive therapy is the nonspecific induction of persistent states of altered cerebral function, providing the physiologic milieu in which changes in adaptive interpersonal behavior occur. Improvement after eledtrégggzﬁﬂiz’gfezwzz a special case of behavioral response under these conditions. The rating is factors, including the type of adaptation, the goal expectation of the observer (therapist, family or administrator), and depending on numerous and an evaluation by an observer the setting in which the behavior occurs. �v w a, z. K . .3 2.» w\ A Y; . 369 .36 N = W. ��EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE graphic Studies, J. Nerv. & Ment. Dis. 107 :517—530. 1948. 13. Kennard, M. A., and Willner, M. D.: Signiﬁcance of Changes in Electroencephalogram Which Result from Shock Therapy, Am. J. Psychiat. 105:40—45, 1948. 14. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Electroencephalog. & Clin. Neurophysiol. 2 :157-162, 1950. 15. Chusid, J. G., and Pacella, B. L.: The Electroencephalogram in the Electric Shock Therapies, J. Nerv. & Ment. Dis. 116:95-107, 1952. 16. Hoagland, H.; Malamud, W.; Kaufman, I. C., and Pincus, G.: Changes in Electroencephalogram and in the Excretion of 17—Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. 8:246-251, 1946. 17. Strauss, H.: Clinical and Electroencephalo— graphic Studies: Correlations of Mental, Electro— encephalographic and Anatomic Changes in Cases with Organic Brain Disease, Am. J. Psychiat. 101: . 42-50, 1944. 18. Davis, H., and Davis, P. A.: The Electrical Activity of the Brain: Its Relation to Physiological States of Impaired Consciousness, A. Res. Nerv. & Ment. Dis, Proc. (1938) 19:50-80, 1939. 19. Ostow, M., and Strauss, H.: The Signiﬁcance of Bilateral Abnormality in the Electroencephalogram, J. Mt. Sinai Hosp. 20:173-193, 1953. 20. Ostow, M., and Ostow, M.: Bilaterally Synchronous Paroxysmal Slow Activity in the Electroencephalograms of Non-Epileptics, J. Nerv. & Ment. Dis. 103 :346-358, 1946. 21. Jung, R.: Correlations of Bioelectrical and Autonomic Phenomena with Alterations of Con— sciousness and Arousal in Man, in Brain Mecha— nisms and Consciousness, edited by J. F. Delafresnaye, Springﬁeld, 111., Charles C Thomas, Publisher, 1954, pp. 310-344. 22. Strauss, H.; Ostow, M., and Greenstein, L.: Diagnostic Electroencephalography, New York, Grune & Stratton, Inc., 1952. Fink—Kuhn 23. Roth, M.: A Theory of ECT Action and Its Bearing on the Biological Signiﬁcance of Epilepsy, J. Ment. Sc. 98 244—59, 1952. 24. Bornstein, M. B.: Presence and Action of Acetylcholine in Experimental Brain Trauma, J. Neurophysiol. 9:349—366, 1946. 25. Tower,‘ D., and McEachern, D.: The Content and Characterization of Cholinesterases in Human Cerebrospinal Fluids, Canad. J. Research, Sect. E. 27:132-145, 1949. 26. Spiegel—Adolf, M.; Wilcox, P. H., and Spiegel, E. A.: Cerebrospinal Fluid Changes in Electroshock Treatment in Psychosis, Am. J. Psychiat. 104:697—706, 1948. and Spiegel-Adolf, M.: Physiological and Physiochemical Mechanisms in Electroshock Treatment, Conﬁnia neurol. 13:38—63, 27. Spiegel, E. A., 1953. 28. Landolt, H.: Das EEG bei epileptischen Psychosen und schizophrenen Schiiben, Personal communication to the authors. 29. Landolt, H.: Uber Verstimmungen, Dam— merzustande und schizophrene Zustandsbilder bei Epilepsie, Schvveiz. Arch. Neurol. u. Psychiat. 76 1313—321, 1955. 30. Brockman, R. J.; Brockman, J. C.: Jacobsohn, U.; Gleser, G. C., and Ulett, G. A.: Changes in Convulsive Threshold as Related to Type of Treatment, Conﬁnia neurol. 16:97—104, 1956. 31. Fabing, H.: Personal communication to the authors, 1956. 32. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: The Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Brain Disease, Am. J. Psychiat. 109:889—894, 1953. 33. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, Conﬁnia neurol, to be published. 34. Ulett, G. A.; Smith, K., and Gleser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, Am. J. Psychiat. 112:795-802, 1956. Printed and Published in the United States of America 525 as �/ 4 I Tax A “ﬁn? .A g. _ MW.» .15. __ O \Q « A A" 33 9% ~ ,. \a E , +3? “a . § mm“ ‘ g... .496 = a «a. .«F N . . my 3s \AVUFQV. . a SEN z «Kay pm“ Aw ‘ . ﬁ 0. 3 qu$v g c. . E «7} Vi __ ramﬂjﬂaj~ a = Arsﬁv xaxwrwmﬂu f» r «UN: :15. _ .n A an é it MW: a. N» “.3 M‘\ «R . R.“ A Mi 31.. A} _ “$me _ 3J3 .. mamme . .rrn: = h J H mﬁuMMc «s V 4. NAQV � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of electroencephalographic delta activity to behavioral response in electroshock; quantitative serial studies. AMA Arch Neurol Psychiatry. 1957 Nov; 78(5):516-25. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-21b-026 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 7 items. 1: Reprint from the A.M.A. Archives of Neurology and Psychiatry November 1957, Vol.78, pp. 516—525. 2: Two final draft copies. 3: Several pages of handwritten notes. 4: Reference list (mix of typed and handwritten). 5: Postcard from Roy R. Grinker to Fink. 6: Copy of same page. 7: Scans of missing pages fromthe items listed above. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/12764b529d79f1eb96174bc90f2534b6.pdf ca3411637648ce13d529a98dea9e5b2f PDF Text Text Behavioral Patterns in Convulsive Therapy MAX FINK. MD. AND ROBERT L. KAHN. Ph.D. GLEN OAKS. L. |.. N. Y. �Reprinted flow the Archives of General Psychiatry July 1961, Vol 5, [71). 30— 36 Copyright 1961,]1y Agzeiican Zl/[edical Association Individual differences in the behavioral response to convulsive therapy are marked. In psychiatric practice, patients with similar psychopathologic syndromes, and of similar sex and age, show a variety of clinical responses: Some improve and sustain such change; some improve, only to relapse quickly; and some fail to improve. These differences have been related to the degree and duration of induced neurophysiological change?“6 premorbid patterns of personal— ity,""11'15 sociopsychological characteristics,13' 15 and psychotherapeutic approaches.1 While these studies have emphasized ratings of improvement, the derivative nature of this evaluation and its dependence on staff attitudes, expectations, and family tolerance have been stressed.2""5'8 The manifest behavioral patterns provide the basis for the evaluations of clinical response. It is the purpose of this report to describe behavioral patterns in patients undergoing convulsive therapy and to relate these to problems of the evaluation of improvement and to an understanding of the convulsive therapy process. Behavioral Patterns in Convulsive Therapy Of consecutive patients referred for electroshock therapy during 1956-1957, seventy-three patients were subjects of the analyses described here. The patients were selected for treatment by the resident therapist and the supervising psychiatrist -——the investigators playing no role in their selection. These observations were made during a lllll|llllll|Illllllllllllllllllllllll|lllllllllllllllllllllllllllll|lllllllllllllllllllllllllllllllllllllllllllIlllllllllllllllllllllllll|lllllllllllilllllllllllllllllllllllllllllllllllllllllll MAX FINK, MD. AND ROBERT L. KAHN, Ph.D. GLEN OAKS, L.I., N.Y. convulsive-subconvulsive electroshock study in which subjects referred for therapy were randomly assigned to courses of subconvulsive or con— vulsive treatments. Electroshock was administered 3 times weekly under thiopental sodium (Pentothal) premedica— tion, using either a Reiter unidirectional or a Medcraft alternating current instrument. Grand mal or subconvulsive treatments were administered by altering the strength of current. Neither Submitted for publication Jan.6, 1961. From the Department of Experimental Psy— chiatry, Hillside Hospital. Present Address: Division of Psychiatry, Monteﬁore Hospital, Bronx, N. Y. (Dr. Kahn). Read in part, at the New York Divisional Meet— ing, American Psychiatric Association, November, 1957. Aided by Grant M- 927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service 52 �CONVULSIVE THERAPY 31 ﬂecting the patient’s adaptation 2 to 4 weeks fol~ lowing the last treatment. patient, therapist, nor evaluating physicians was aware which course of therapy each patient received until after the evaluation period. Changes in brain function were measured at weekly intervals by tests of language patterns both clinically and after amobarbital and by the degree of slow-wave activity in electroencephalograms. The intercorrelation of these indices and their relation to behavioral changes have been reported previously?” The manifest symptom patterns of the referred patients were variable and included suicidal preoccupation, retardation, disturbances of mood and affect, excitement, agitation, panic and tension, delusions, ideas of reference, negativism, withdrawal, and somatic complaints. The clinical diagnoses were depressive psychoses of manic-depressive, involutional and reactive varieties, and schizophrenic psychoses of paranoid, mixed, catatonic, and pseudoneurotic types. Clinical behavior was assessed in weekly psychi— atric interviews, structured perceptual task situa— tions,“'15 and by conferences with the patient’s therapist. In these observations, the evaluation of improvement along the continuum of “recoveredunimproved” appeared inadequate and was supplemented by a rating of the degree of behavioral change. The degree of change in clinical and ward behavior was rated on a 4-point scale of “marked,” “moderate,” “minimal,” or “no change. H These evaluations were not value judgments as to the quality of the change, but rather quantitative es— timates of differences in behavioral patterns under similar conditions of observation. The assigned rating was based on changes observed during the treatment period and for 2 weeks post treatment. Evaluations of improvement response were made on the 4—point scale of “recovered,” “much im— proved,” “improved,” and “unimproved or worse.” These evaluations were value judgments, based upon the behavior of the patient, the therapist’s expectations, the tolerance by therapist and patient of those aspects of behavior often called “side— elfects of the treatment,” and the therapist’s judg— ment as to the family’s attitudes to the patient’s behavior. These evaluations were short—term, re- Observations A. Behavioral Change and Improvement. A comparison of the behavioral ratings and the improvement evaluations is presented in Table 1. That ratings of recovered and much improved were associated with high or moderate degrees of behavioral change is an expected observation. Similarly, that patients with minimal or no change in behavior were evaluated as unimproved or improved, is also expected. The signiﬁcant relationship, however, lies in the patients showing high and moderate degrees of behavioral change and still rated as showing a poor clinical response. Of the 30 patients observed with high degrees of behavioral change, 17 were evaluated as recovered and much improved, and 13 as improved or un— improved. B. Modes of Adaptation—Analyses of the behavioral patterns of the subjects during and following treatment permitted the description of various modes of adaptation. For illustrative purposes we have described 4 behavioral patterns under the titles of euphoric—hypomanic, somatization, paranoidvuithdrawal, and panic modes. Euphoric-Hypomanic Mode: These subj ects appeared pleasant, affable, and friendly. They dressed neatly, spoke quietly, and participated in ward activities with increased interest. Occasionally they dressed gaudily and smiled and giggled excessively. Pretreatment symptoms were not manifest, and premorbid attitudes and behavior were again prominent. 0f Evaluations of Behavioral Change and Clinical Improvement (Convulsive and Subconvulsive Therapies) TABLE l.——C0mparison Improvement Rating Ichavioral Change High degree change Moderate degree change Minimal degree change No change F ink—K ahn Recovered (30) (17) (10) (16) Much Improved 9 6 0 0 8 3 0 L? 53 Improved Unimproved and Worse 8 6 2 5 5 1 15 5 �32 - In their psychotherapeutic interviews they described their illness in a detached manner, emphasizing “it” (illness) as having “dis— appeared.” They denied having been ill and facetiously suggested they were at the hos— pital for a rest, or that the institution was not a hospital, but a resort or a school. Symptoms were described in the past tense, and the quality of having been a different person during the illness was reiterated. Speech was marked by denial, displacement, evasion, qualiﬁcation, and cliches.“ The third person mode was frequently used, as in such statements “the doctor says I am ill” or “my wife should have come here.” Gross changes in memory were either not apparent, or were described for the treat— ment period only. The patients expected and accepted these deﬁcits, and neither connection with treatment nor apprehension was expressed. They looked forward to home visits and made realistic discharge plans. While conﬂicts with family members were described, these were minimized and expressed mainly in the past tense. Referential questions were answered in a referential manner and with— out an arousal of affect. For the more hypo— manic subjects, questions about home planning were responded to nonreferentially, with marked use of inappropriate clichés. When pressed with referential inquiries, they quickly exhibited anxiety and discom— fort, minimized their feelings, and changed the focus of the session. Such adaptations were sustained throughout the discharge planning period. The more hypomanic features were rarely sustained and within a few weeks were replaced by a more stable euphoric or somatization type of adaptation. Somatization Mode: In these subjects, in— cessant complaints about bodily symptoms and loss of memory, demands for reassur— ance and relief, and preoccupation with feel— ings of unreality and confusion dominated behavior. They remained unkempt and their rooms were untidy. When such an adapta— tion appeared early in therapy, further treatment was refused. ARCHIVES OF GENERAL PSYCHIATRY Speech was principally in the present tense and in the ﬁrst person, with few third person references and a minimal use of clichés, denial, or qualiﬁcations. In psycho— therapy sessions, they were demanding and hostile, reporting their problems in terms similar to those used prior to therapy. They complained that the treatment caused addi— tional and more incapacitating difﬁculties. To referential questions, answers were gen— eraly correct, but associated with complaints of memory impairment. They described their family relations in pretreatment terms, with an occasional “I don’t remember” in response to experiential inquiries. Discharge planning was difﬁcult, since they insisted that their new symptoms prevented any home adaptation. On the ward, their hostile demands for attention and relief of symptoms increased with treatment. Participation in group ac— tivities increased, however, for those sub— jects who had previously been withdrawn and seclusive. Memory complaints were preeminent. Pa— tients demanded reassurance that their memory would return and repeatedly asked if treatment would be harmful. They de— scribed feelings of derealization and con— fusion. Events, bodily feelings, and relations to friends and relatives seemed strange, fuzzy, unclear, and out of focus. While they complained chieﬂy of memory impairment, they also complained of back pain, headache, tingling of ﬁngers and toes, nausea and weakness, and ascribed these to the treatment. At the end of treatment, the symptoms for which hospitalization had occurred were no longer present, and although complaints were many, their relation to the treatment and their transience was so universally ac— cepted by both the staff and the patients, that the results were evaluated as beneﬁcial. This adaptive mode was sustained into the postdischarge period. Paranoid and Withdrawal Mode: Another pattern was the appearance of paranoid ideation, suspiciousness, hostility, ideas of reference, and delusions. These patients Vol. 5, July, 1961 �CONVULSIVE THERAPY failed to care for themselves and remained unkempt in their dress. Their rooms, in which they remained much of the day, were untidy. Speech was sparse and not spontane— ous. When questioned about their illness, they were hostile and demanded to know why they were questioned. They refused to answer inquiries or categorically denied or agreed to all speciﬁc questions. Experi— ential questions were answered referentially. When inquiry was insistent, they denied illness and minimized the symptoms which had resulted in their admission. They refused or avoided sessions with their therapist and insisted convulsive ther— apy be ended because it was harming them. When treatments were continued, they demanded release from the hospital, or pre— cipitated discharge by elopement, suicide attempts, or aggressive and destructive out— bursts. They were unable to discuss their relations with family or friends and focused on demands for either release or relief from somatic symptoms. Hostility was overt and engendered a fearfulness in the staff. On the ward, when coaxed out of seclusion, they were loud, aggressive, and demanding. They were suspicious of attempts at friendliness and expressed thoughts that others wished to harm them or talked about them. While insisting on discharge, no realistic discharge planning was achieved. Their View of the environment was grossly distorted and self—centered, preventing adequate care. In testing, they were uncooperative, and voiced angry suggestions of being experi— mented upon or abused. Complaints of memory impairment were infrequent and occasionally denied even when clinically manifest. On such occasions, they were en— raged at the implied deﬁcit. Panic Mode: These patients became increasingly anxious, agitated, restless, sleep— less, and anorexic. In their dress, they were neat and cared for themselves. Speech pat— terns were unchanged and continued with emphasis on ﬁrst person and present tense modes. Symptoms were distressing and prominently voiced. When asked about pre— treatment symptoms, these were expressed . Fink—Kuhn 33 in the same terms as those used earlier, with the complaint that treatment had made everything worse. Patients feared treatment and hid on treatment days, or pleaded with the staff to forego further applications. They threatened elopement and if this failed, submitted administrative requests for discharge. On the ward, they continued their pretreatment patterns of minimal participation. On treatment days, they were withdrawn, sullen, and negativistic, and cooperation was poor. They demanded to see their therapists and on such occasions insisted that treatment be discontinued. They were unable to discuss family situations or their attitudes to others, being preoccupied with their feelings of fear. In discussing their home, they insisted on immediate discharge, while stating they were severely frightened, anxious, depressed, and unwell. Ideation was unchanged with fearfulness as the principal affect. Fears of damage to the brain or mind was expressed, accompanied by the awareness that memory impairment may be a Sign of such damage. Complaints of memory impairment were infrequent and when present, were ex— pressed as a speciﬁc reason for discontinuation of treatment. Patients were uncooperative and fearful of testing and participated only if encour— aged that such tests may be helpful in the therapist’s decision about further treatment. Occasionally, when treatment was discon~ tinued, a more stable adaptation of relief, acquiescence, and denial appeared. C. Adaptive Mode and Improvement Ratings—Thus, for the various adaptive behavioral patterns, a range of short—term evaluations was observed. Those subjects who developed and sustained the euphoric— hypomanic modes were generally rated as recovered or much improved. Patients with somatization and panic modes were oc— casionally rated as improved, although unimproved ratings were frequent. The paranoid—withdrawal mode was evaluated as unimproved or worse, as were patients exhibiting the panic modes. The relation be— �34 ARCHIVES OF GENERAL PSYCHIATRY TABLE 2.—Adapti7/e Mode and Improvement Improvement Rating Modes Euphoric-Hypomanic Somatlzatlon Paranoid-Withdrawal Panic No adaptive change‘ ‘ Includes subconvulsive (36) (10) 7) ( 7) (13) ( Recovered Much Improved 11 14 0 0 0 0 l 10 5 0 0 0 2 2 l Improved Unimproved, Worse l 4 5 5 12 treated subjects Without second course of ECT. tween adaptive modes and ratings improvement is summarized in Table 2. of Studies relating physiological or psychological aspects of convulsive therapy to clinical outcome have reported inconsistent results}6 Thus, it has been reported that depressed patients respond favorably to convulsive therapy while schizophrenic or neu— rotic subjects do not; while other observers indicate that neurotic depressive patients re— spond badly, and that some schizophrenic subjects do have favorable outcomes. Vari— ous measures have been suggested as predic— tors of improvement, only to fail on more extensive testing. In such instances, the differences in results and discrepancies in convulsion can be related to the utilization of a variety of global estimates of improve— ment as the criterion of behavioral change, without adequate speciﬁcation of the standards used in the evaluation. Such standards differ widely, depending on institutional populations and staff attitudinal factors. Varying attitudes toward “side-effects,” the use of global rating scales, and varying psychosocial attitudes affecting goals of treatment have each served to make results from different laboratories incom— patible. Thus, in our evaluations of con— vulsive therapy, the development of changes in memory, recall, and orientation have been considered as temporary manifestations of therapy and disregarded in the clinical eval— uations.3'19 Patients developing the euphoric or hypomanic modes, despite concomitant memory loss, have been rated as much im— proved. In a comparable study by Johnson et al.,10 the Lorr global ratings of behavioral change were utilized. In this type of evaluation the changes in memory and orientation are in— Comment These observations emphasize the variety of behavioral adaptations that occur during convulsive therapy and relate short—term evaluations of improvement to the type of behavioral change. Earlier observers of con— vulsive therapy have described a range of behavioral patterns, ascribing the changes to ego adaptive responses, to the trauma of the treatment, organic brain changes, or psychologic signiﬁcance of the treatment.7' 9'21 These observations that subjects with similar psychopathologic syndromes receiv— ing similar treatment may exhibit discordant behavioral adaptations and be variously rated as recovered or unimproved, are of signiﬁcance for an understanding of the convulsive therapy process. In earlier studies, the conclusion was reached that persistent alterations in brain function were a necessary condition for behavioral change in convulsive ther:«ipy.2""6 With changes in brain function, all aspects of behavior undergo modiﬁcation. Percep— tion, mood, affect, judgment, attitude, mem— ory and recall are altered, and with these, the subject’s adaptation in the environment. Not all behavioral changes are viewed as improvement, however. Improvement ap— pears to be a special type of behavioral response, being the subjective estimate by an observer that the patient is “better.” It is based, not only on the patient’s behavior, but also on such nonspeciﬁc aspects as the observer’s expectations, and tolerances, and those of the family and environment. 56 Vol. 5, lily, 1961 �CONVULSIVE THERAPY cluded as negative scores in the improvement scoring, so that a high number of subjects were reported as “unimproved or worse.” Besides population differences, this single factor is sufﬁciently potent to alter the rela— tionships between the 2 studies and justiﬁes the discrepant observations. The use of global estimates of behavioral change in evaluating therapy has other signiﬁcant deﬁciencies. Psychiatric therapies are rarely focused, or effective in modifying a single symptom. The induced changes affect a spectrum of behaviors, with varying rates of change for different aspects. Global estimates tend to lose differences in individual elements within the medial designations necessary to deﬁne the whole response. In such situations changes in behavior which may be prominent, though not pervasive nor enduring, may dominate the evaluation as to overshadow other, potentially more signif— icant changes. Thus, alterations in memory and recall, or increased somatization or in— creasing withdrawal may dominate unim— proved evaluations; while explicit verbal denial, clichés, and euphoria may lead to recovered or much improved designations. The use of improvement ratings may be empirically justiﬁed as an early approxima— tion in studies of a new therapeutic meas— ure, but further analyses of the behavioral ‘ observations are required for understanding and adequately applying the treatment. The typologies described in this report are one approach—one that has been helpful in our understanding of the convulsive therapy process and one that is now being tested in studies of psychopharmacologic agents. In addition to the differences in improve— ment evaluations occasioned by attitudes to “side—effects” and the use of global ratings, there are differences due to the attitudes of therapists toward various sociocultural pop— ulations. The adaptation of explicit verbal denial in a lower class patient in a community institution is welcomed by therapists and family, but the same adaptation in an upper class professional in a psychothera— peutic hospital is considered poor or psy— chotic. The display of rationalization. Fin k—K01m 35 minimization and displacement, even when accompanied by a return to premorbid work levels, is considered marked improvement in one setting, but is viewed as a lack of improvement in another if goals of insight had been set by the therapist. Interference with memory and recall may be disregarded by therapists for one sociocultural group, but arouse empathic solicitude for patients of another social class. Such factors affect not only institutional attitudes, but within an institution, therapists of different thera— peutic orientations may have differing atti— tudes towards evaluations and therapies. The many recent sociocultural studies of thera— pists, and their attitudes towards selection of therapies, are indicative of these attitudinal differences.13'17-18'20'22 It is our impression, therefore, that im— provement ratings are no longer useful devices in evaluating psychiatric therapies. For the symptomatic therapies extant today, which are seemingly not directed toward the alteration of an etiologic factor, typologic descriptions have a greater applicability and empiric justiﬁcation. Typologies based on concepts of diagnosis, target symptoms, or on dynamic—structural formulations have attempted to structure the pretreatment clusters in which therapies may be effective. Treatment and post—treatment symptom improvement scales have been used with utility. These are limited approximations, however, and there is a need for a broader approach to both the pretreatment and the treatment behavior, and a phenotypic, adaptive be— havioral typology, using multivariate tech— niques of data analysis, seems worthy of assessment. Summary An analysis of the variety of behavioral adaptations of 73 voluntary psychiatric pa— tients undergoing convulsive therapy resulted in the description of 4 major patterns. These are described as euphoric-hypomanic, somatization, paranoid—withdrawal, and pan— ic modes. The relation of these modes to clinical ratings of improvement is described. The �36 ARCHIVES OF GENERAL PSYCHIATRY derivative and generally nonoperational nature of improvement ratings is empha— sized. The difﬁculties in a communicative deﬁnition of this variable is seen as a major factor in the discrepant studies of indices predictive of improvement in convulsive therapy and in understanding the processes of somatic therapies in psychiatry. Therapy (With and W'ithout Atropine), Arch. Gen. Psychiat. 2:324-336, 1960. 11. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, edited by P. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126-139. 12. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Psychiat. 76 :23-29, 1956. 13. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings, and Diagnosis, A.M.A. Arch. Gen. Psychiat. 1:565-574, Max Fink, M.D., Department of Experimental Psychiatry, Hillside Hospital, 75—59 263rd St., Glen Oaks, L.I., N.Y. REFERENCES H Esecover, H.; Jaﬁe, J., and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients, J. Hillside Hosp. 7:17-25, 1958. 2. Fink, M.: A Uniﬁed Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp. 6: 1. 1959. 14. Kahn, R. L.; Pollack, M., and Fink, M.: F igure-Ground Discrimination After Induced Altered Brain Function, A.M.A. Arch. Neurol. 2:547-551, 1960. 15. Kahn, R. L.; Pollack, M., and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. Ment. Dis. 130:187—192, 197-206, 1957. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electro— shock: Quantitative Serial Studies, A.M.A. Arch. Neurol. Psychiat. 78:516-525, 1957. 4. Fink, M.; Kahn, R. L., and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. Syst. 19:113~118, 1958. 5. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Aﬂ'ecting Individual Differences in Behavioral Response to Convulsive Therapy, J. Nerv. Ment. Dis. 128 :243-248, 1959. 6. Fink, M.; Kahn, R. L.; Karp, E.; Pollack, M.; Green, M.; Alan, B., and Lef‘kowits, H. J.: Signiﬁcance of Inhalant Induced Convulsions for the Theory of the Convulsive Therapy Process, Arch. Gen. Psychiat. 4:259-266, 1961. 7. Frosch, J., and Impastat, D.: The Effects of Shock Treatment on the Ego, Psychoanal. Quart. 3. 1960. 16. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and other Somatic Treatments in Psychiatry, New York, Grune & Stratton, Inc., 1952. 17. Kaplan, A. 1., and Lefkowits, H. J.: Inﬂu— ence of Staff Attitudes and Environmental Factors on Treatment Selection, J. Hillside Hosp. 1961, to be published. 18. Klerman, G. L.; Sharaf, M.; Holzman, M., and Levinson, D. J.: Sociopsychological Charac- teristics of Resident Psychiatrists and their Use of Drug Therapy, Amer. J. Psychiat. 117:111-117, 1960. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conﬁn. Neurol. 16: 19.. 88-96, 1956. 20. McIver, J. and Redlich, F. C.: 17:226-239, 1948. 8. Frosch, J.; Impastato, D.; Ottenheimer, L., and Wortis, S. B.: Some Reactions Seen After Electric Shock Treatment, Amer. J. Psychiat. 102 Patterns of Psychiatric Practice, Amer. J. Psychiat. 115:692- 311—315, 1945. 697, 1959. 21. Millet, J. A. Glueck, B. C.: Psychopathologic Reactions and Electric-Shock Therapy, New York J. Med. 42:1553-1557, 1942. 10. Johnson, L. C.; Ulett, G. A.; Johnson, M.; Smith, K., and Sines, J. 0.: Electroconvulsive Psychosom. Med. 6:226-237, 1944. 22. Pasamanick, B.; Dinitz, S., and Lefton, M.: Psychiatric Orientation and Its Relation to Diag— nosis and Treatment in a Mental Hospital, Amer. J. Psychiat. 116:127-132, 1959. : P., and Morse, E.: On Certain Psychological Aspects of Electroshock Therapy, 9. 58 Printed and Published in the United States of America ��Putt-ran at Bohgvioral chant. and Inprorcnnnt 1n canvullivo rhcrapy In: Pink, x.n. and nobcrt L. Kuhn, Ph.D.* from the Dapartncnt or Expnrinontnl Psychiatry, ulna oakn, L.I., n.x. Hillside noupitsl, gratt K~927 of tho lattcnal Initituta a: nontal noulth, lutional Institutua a: Hatlth, United Status Puhlie Hualth survzoo. Reta in part, gt th.".!. 91'1319311 looting, American Payehintric Aidod by Association Northbor, 1951. : Btvﬂiomit o: Psych-try. Mutation 30-91%“. *Pruont Bronx, 1.1. VII: 1/61 “an" �Individuol ﬂittoroncoo in tho bohoviorol roopouoo to oonvoloivo thoropy oro oorkod. In poyohiotric proctico, potionto with oanslor poyohopotholoxtc oyudroaoo, one or oililor varioty or olinieol rosponooo: oooo toprovo old ouotoin ouch chongo; oooo 1-provo, only to rolopoo quickly; ond oooo toil to taprovo. rhooo dittorooeoo hovo boon rolotod to tho dogroo ond duration or indoood nourophyoiolociool ehongo (3,6) prooorbtd pottorno or poroonoltty (5,11,15), ooulopoyeholoctool chorootoriotioo (13,15) and porehothoropontto opprooehoo (1). Vh11o thooo otudioo hovo onphooiood voting: 0: taprovooont, tho dorivotivo unturo or thin ovoluotion ond 1t: dopondonco on otort ottttudoo, oxpoctotiono ond tooily toloronco oox ond ago, ohow o has boon strooood (2,h,5,8). rho oonttoot bohoviorol pottorno provido tho boots tor tho ovo$uot1ono of clinical rooponoo. It 1o tho purpooo o: thto roport to doocriborbohovtorol pottorno 1n pottonto nndoraoinz oonvolsivo thoropy, ond to roloto tho-o to problooo of tho ovolootioo of taprovooont and to on ondorotondinx o2 tho coo- vuloivo thoronyIProcooo. �gethod: or consecutive pe$$en$e reterred for electreehoek therepy 63:13; 1956—57. teveatybthree pettente were subjecte e: the eaelyeee eeeeribed here. the patients were selected tor treeto sent by the reeident therepiet end the aupervteiuc peyohietrteﬁ - the inveetzceterp playing no role in their selection. These convulsive—euhcenvulaSve electroc 3 during were III. obeervettene eheok study a; whieh subject. referred tar enereyy were rendenly unsigned to entrees e: cuboenvuletve er convulsive treetnente. Electroeheek wee edginietered three tines weekly under pentethel preunedieetiea, using either e letter unidirectional er e xederett alternating entrent inattenent. arena eel or enbeenvnleive treetnente were eduin1utered by titering the etrongth of current. leither patient, therapist not eveluetinx phyeiaiene tee evere which entree e1 therapy each pétient received until titer the evaluation period. weeiiy intervals cheese: in urea: tunetion were neeeered at by test: of leagues. petterne both 011336.11: eta etter eneberbitel, and by the degree e: 310: were activity in electroencephelegrene. 2he interoerreletien e: theee indieee 3 �.3cooplointl. rho alinicol dioxnoooo woro doproootvo of nonio—doproooivo, involutioaol ond rooetivo and ooaotic poyuhoooo voriotioo; one oohioophrontc poyehoooo or poronoid, aixod, oototonto and pooudonourotie typoo. clinical bohovior woo oooooood in vookly poyuhiotric intorviovo, otrootorod porooptuol took oituotiono (1h,15) and with contorouooo tho potiont'o thoropiot. II thooo ohoorvo~ by tiono, tho ovolootion of :Iprovouont along tho continual of 'rooovorod-untnprovod' oppooroa inoaoquoto, and woo topplonontod by o roting of tho dogroo of bohoviorol ohongo. rho dogroo of chonzo 1n olinieol tad word hohovior woo totod on o four point ocolo or 'norkod', “nodoroto', 'nininol' or'ho chango'. Thooo ovoluotiono woro not voluo Judznonto no to tho quality of tho ohonxo, but rothor, quontitotivo ootinotoo o: ditforouooo in hohoriorol pottorno undo: oinilor condition: at otoorvotion. rho oooigood voting woo hoood on ohongoo oboorvod during tho trootnont poriod and for too vooko poot~ trootaont. lvolootiono or ingrovonont roopoaoo woro undo on tho four point ocolo or 'rocovorod', 'nuoh taprovod', ﬁtnprovod', and “nailprovod or onroo'. rhooo ovolootaono ooro voluo Judgnouto, hoood upon tho bohovior of tho patient, tho thoroptot'o oxpoctotiono, tho toloronoo by thoropiot and potiont of thooo oopoeto of bohovior otton oollod *oido-orroeto of tho trootnont’, and tho thoropiot'o Judgnont on to tho tonily'o ottitudoo to the potioat'o hohovtor. fhooo ovolnotiono ooro abort-torn, rotlocting tho potiont'o odoptotion two to tour wool“ following the lost troutnOHto �gbaorvationo: (a) Donatioral chango and Ingrovonont coaparioon at tho bahavioral ratingo and tho iaprovoaont ovaluationo 1o proooatod in tabla I. that ratings at rocovorod and nuch iaptovod woro aaaociatod with high or moderate dogrooa at bohavioral change it an oxpoctod obaorvation. similarly, that patioato with ainiaal or no chango in behavior taro avalaotod ao uni-proved or iaprovod, io aloe oxpootod. tho aixaitioant rolatianahip, hovovor, lioa in tho patianta ohooing high and oodorato dogrooo or bohavioral ohoazo and atill ratod ao ohaoiaz a poor oliniaal roopoaao. at tho thirty patioato obaorvad with high dogrooa or hohaviaral ohango, aovontoon voro ovaluatod aa raeavorod and much iaprovod, and thirtoon ao inprovod or aainprovod. l .. --.. . ZLBLI (b) undo: at Adaptation I -“ﬂ--. o: the bohavioral pattorna at tho oobaocto daring and tailoring traataont poraittod tho description or variauo today of adaptation. For illoatrativo purpoooa vo havo doaoribod tour bohoriorol pattorna undo: tho titloa a: oaghorie-hzgoaanio, oaaatiaation. garanoid-withdraoa; and Analyooo Rania nodoo. Bughorio-lzzoaanie Roda: Thooo oubjocta appoarod plaaaant, atrablo and friaudly. they are-sod neatly, opako quiotly, and participated in word activitioo with ineroaaod �Zlﬂﬁﬁ I atnpgrtann 0t Evaluationl Qt nohavttrnl change and clinical Inpruvcnont (c0uvu1317c and subconvnlutru 1h0r&pico) ﬁtting XIErOVOIORt locovorod » _ Itch Inprdvod ﬁninpruvod and Ingrovod 39:30 Bahaviorll Ghangc nigh dogroo change (39) ﬁ lodorato (17) 8 9 8 5 3 6 6 2 Juana (‘10) o a 5 S (16) o 0 1 15 I. change ' ' I' �. ~5-. interest. 'oeeeeieeelly they dreeeed aeadily, end exiled end giggled excessively. Pre-treeteent eyepteee were net eenifeet end preeerbid ettitudee end hehevier were egeie prenieeet. In their peyohetherepeetie interviews they deecrihed their illueee in e deteched leaner, eepheeieieg ”it“ (illneee) ee they denied having-been ill end feeetieeely eeggeeted they were et the heepitel fer e reet; er thet the inetitutiee wee net e heepitel, but e reeert er e eeheel. Syeyteee were deeeribed in the pert teeee, end the geelity of keying been e different pereen during the illeeee hevins “dieeppeered’. reitereted. Speeeh wee eerked by deeiel,.diepleeeeeet, ereeiee, quelitieetiee end eliehee (11). the third pereen wee ' eede wee frequently need, ee in eeeh eteteeeete the doctor eeye 1 en 111' er *ey wife eheeld here eeee here.II Greee ehenzee in neeery were either not eppereat, or were deeeribed fer the treeteeet period only. the petieete expected end eeeepted theee defieite, end neither eeeeectiee with treeteeet her eppreheneien were expreeeed. they looked forward te here wieite end eede reelietie dieeherge pleee. While conflicts with feeily eenbere were deeeribed, theee were eieieieed end expreeeed neiely in the peet tenee. heferentiel qeeetieee were eeewered in e referential nearer end without en ereeeel of effect. for the mere hypeeeeie eebaeete, queetiene eheet here planning were reepended te nearefereetielly, with marked nee of inepprepriete eliehee. When preeeed with referentiel inquiries, they quickly exhibited �.5anxiety and dieeeatort, aiuiaieed their feelings and changed the teeua.e£ the eeeeien. Seek adaptatiene were euetained throughout the discharge planning period. The mere hypeaaaie features were rarely suetained, and within a for weeks were replaced by a mere etable euphoric er aenatizatien types of adaptation. ,8enatizetien Hades In theee_enbdeete, incessant eeaplainte about bodily eyaptene and lees e: eatery, deaands fer reaeeurenee and relief; and preoccupation with feelings of nnreality and eeeteeion doainated behavior. Ehey retained unkempt and their When each an adaptatien appeared early in were untidy. reels therapy, further treatment wee refused. speech nae printiptlly in the present teaee and in the first pereen, eith fee third peraen references and a ainiaai use at clichea, denial er qualifications. In peyohetherapy eeeeiene, they vere-deaandies and hostile, repertihg their prehieae in terae eiailar to these need prier to therapy. !hey eeaplained that the treatment eaaeed additieeel and mere incapacitating difficulties. re referential queatiens, answers were generally correct, but associated with eenplainte of aeaery inpairaent. they deeeribed their taaily relations in yreotreatneet terns, with en oecaaional '1 den't reaenber' in reepenee to experiential inquiriee. Discharge planning eaa dittiealt, as they insisted that their new eynptene prevented any home adaptation. their heetile demands for attentien and relief at eyupteas increased with treetaent. Participation in creep activities inereaaed, however, tar these eabaeete who had an the ward, �-7. previeaely been withdrawn and eeoleeive. Heaory eeaplainte were pre-eaiuent. ratioate deaanded reaaaaranee that their aeaery would return, and repeatedly asked if treatment would he hararul. they deeoribod feelinge of derealiaation and confusion. Erenta, bodily feelinge and relatiena to friends and relativee eeeaed etrange, teeny, unclear, and out of :oeue. While they oonplained ehietly e: book of alao ceaplained pain, headache, they iarairnent, aeaory tingling o: tinsera and teee, aaaaea and roakaoee, and aeorihed there to the troetaent. which end symptom: the for the at treatment, heepitalit iaatioa had occurred were no longer present, and although and to the treatment were relation their their aany, eoaploiate transieaoe eae eo univoreally aeeepted by both the start and the patients, that the rooalte rare evaluated or beneficial. !hie adaptive node wee eeetained into the peat-dieoharge period. Paranoid and Withdrawal lode: Another pattern tea the appearance or paranoid ideation, euepicieuaneea, hostility, ideae of reference and deleaiene. These patients failed to care for theaaolvee, and roaained unkeapt in their dress. Their reeaq.in which they reaained each or the day, were untidy. Speech eaa eparee and not epontaneeaa. when questioned about their illneae, they were hostile and demanded to know why they were queetiened. they retaeed to anewer inquiriee er categorieally denied or agreed to all epecixio queetiene. Experiential caeetiena were anewerod roterantially. When inquiry was ioeietoat, they doeidd illneea and ainiaieed tho ayaptena which �~8- resulted 3: their ednieeien. they retueed er eveided eeeeieee with their therepiet, end ineieted eenvuledve therepy he ended beeeeee iteee herningy then. When treeteente rere continued, they demanded releeee free the_hoepite1, or precipiteted dieeherge by elepeneut, euietde ettelpte er eczreeeive end deetreetdve outberete. They were uneble to diecuee their reletiens with relily or triende, and teeeeed either en deaende fer releeee or relief tree resette eynptoee. Ieettlity wee overt, end engendered e teertelneee 1n the etett. an the nerd, rhea eeexed out of see» Ineien, they were lend, eggreeetve end deeend1ng. They were eeepieieee e: etteepte at friendlteeee, end expreeeed theeghte thet other: edehed to here the: or talked ebeﬁt then. while ineieting en dteeherge, no reelietie dieeherge pleating wee eehseved. their View er the envirtneent wee creeely distorted end eelreeeutered, preventing'edeqnete care. In testing, they were uneeeperetive, end rained angry eeggeetiene a! being experirented ugen or ebueed. Complaints at nenery impairment were intrequent, and occeeienelly denied when even clinicelly meniteet. on such occasione, they were eareged et the inplied deficit. Peale Bede: Theee'pettﬂate beeene increeeingly enzione, eglteted, reetleee, eleepleee end enorexie. In their dreee, they were neet end eered ror themselves. Speech patterns hed were unehegged end eontinued with eepheeie on tiret pereon and preeent tenee nodes. .synpteme were dietreee1ng end prentuentiy voiced. When asked about preetreetment eynptore, �.9. theee were expreeaed in the aaae terae ae theee need earlier, with the eaaplaint that treataent had aade everything weree. Patienta reared treat-eat and hid an treataent daye, er pleaded with the etatt to forage farther applications. they threatened elepeaent and it thie tailed, enhaitted administrative reqaeata fer discharge. an the ward, they continued their preatreataent patterns at participatien. 0n treataent daye, they were withdrawn, aalien and negativietie, and cooperation wae peer. they deaanded te aee their therapiete and on each eceeeiene ineieted that treataant be discontinued. they were unable to diecnee {anily eitaatiene er their attitudee to ethere, being preo eeeayied with their feeling: at tear. In dieeaeaieg their minimal heaa, they inaiated en iaaediate dieeharge, while atating they were aewerely trightened, anxieaa, depreeeed and unwell. ’Ideatien was unchanged with tearfulneae ae the principal . affect. reare te the brain er aied wae expreeeed, aeeeapaaied by the awareaeee that aeaory iapairaeet may be a sign at each damage. ceaplainta at aeaery inpairaent were in~ ex daaage frequent and when present, were expressed ae a apeeitie reason (or dieeeatinaatiea of treatment. Patiente were uncooperative and fearful at testing, and participated only it encouraged that such decision about further tests may be helpful treataent. occasion. in the therapist's ally, when treatment wae diacentinued, a more stable adaptation of relier, aeqaieeeenee and denial appeared. �' (3) 29:9" tivo H96. and rovunoat n;¢1 3 Thus, fo:_th¢ var1oua_gdaptivq bohnvitrnl ptttornl, a runs; or ihort term evaluations were obsorvad. thus: subjects aha devolaped and sustained the euphoric-hyponanie nodou were generally ratoﬁ us rocaverod or nueh inpravod. Patients uith ponatizatian gnd panic modes were ocgusiantlly rated as improved, nithgugh uninprevod ratings were frequent. The paranoid-with. ﬁgural node was evaluated as unimprGVad or worse, as were model. The relation batucon the panic pn§;ontl czhibiting adaptive node and ratings or improvonent are Ialnnrilod in ' d‘ fable 1!. 1133! II -‘C- “CC- �tivo.ﬂndc 3nd Ada rovonoat Ingrovcnont Rating Rtoovered 3.4.. anh Improved Inprovcd ﬁninpravod, Horn. Euphoricvﬂyponanic (36) 11 1h 10 1 Selatinttion tiranotdniithdrauul (10) o 1 5 h ( 7) 0 o 2 5 Psntc ( 7) o o 2 5 ndaptivo ohtngoi (13) 0 0 1 12 I. alnoludas snbcenvulsivo trcntod unbaoctu without cocond course 01 not, �Bieeoeeien: fheee ebeervatiene eaphaeiee the variety of behavioral adaptatiene that-occur daring eonvaleive therapy, and relate abort tern evaluatieee or iapreveaeot to the type of behavioral change. larlier obeervere at oooveleive therapy have deeoribed a range of behavioral patterns, aeoribing the ehaogee to age adaptive reepenaee,to the traaaa of the treataent, organio brain changes, or peyehologio oigoifioanoe of the treataeot (7,8,9,21). These ebeervatione that subjects with eiailar peyohopethelegio eyndreaee receiving aiailar treatment aay exhibit dieoordaot behavioral adaptatiene, and be varioaely rated aa recovered or aaiaproved, ie o! eigoirieanoe for an onderetahding e: the eonvnlaive therapy prooeee. In earlier studies, the ooholoaioo val reached that pereietené alteratioea in brain tanotioo were a neoeeeary eonditieo to; behavioral change in oonvaloive therapy (2,h,6). With changes it brain tuaotioo, all aepeote of behavior undergo modification. Perception, need, affect, Jadgaent, attitude, aeaery and recall are altered, and with theee, the eabaeot'e adaptation in the environment. let all behavioral ebaegee are viewed aa iapreveaeot, however. Improvement appeare to be a special type oi behavioral reepooee, being the eobjeotive eetiaate by an obeorver that the patient ie 'hotter’. It ie baled, not only on the patieot'e behavior, but also on each oeo-apeoitie aepeeta aa the obeerver'a expeotatione, and toleraooee, and these at the taaily and eovirenaent. Studies relating physiological or peyehologioal aepeote �-12or oonvnloivo therapy to clinical inreported that deproeeed ontoone have reported been hae Thne, (16). it ooneietont roanlte eohiaowhile oonvnleivo therapy to patients reopond favorably oheorvore other while do not; oabjoota nonrotio phrenio or and badly, reepond patiente dopreeeive neurotic that indioate ontooaoe. do favorable have enhaeota that ooae aohiaophronio of inprovoaa predictora been enggeeted have Various noaanroe each inetanoea, In extensive tootinx. on aoro to lent, only tail can eonolneion in and diaoropanoioo in results the dittorenooe or oetiaatoe of global of a variety be related to the utilization vithoot behavioral change, of the criterion ilproveaent an evaluation. the need in etandarde of the adequate epooitioation Snoh etandarde differ videly, depending on institutional atatt attitadinal taotore. Varying attitudeand eoaloe of rating global the nae toaard 'aide-otteota', popelatione and o: treataent goale afteoting attitndee varying peyohoeooial have baoh eorved to lake reenlte tron different laboratorioe oonvnloivo therapy, o: ovalaationa in our fhne, inooapatiblo. and orientation recall in ohangee neaozy o: devolepaont the , and of therapy aanitoetatione have been considered ae teaperary dieregardod in the olinioal ovalaatione (3,19). Patients oonoonitant doepito aodea, hypeaanio the euphoric or developing anon been on ieproved. have rated neaory loee, In a ooaparable etndy by John-on gngg, (lo), the Lorr global of In type thie utilized.“ were change rating! of behavioral inolndod and orientation are in ohanxee the neaory evaluation �-13- negative oeoroa in the inprovenent nearing, no that a high nnaher or enhaooto were reported an 'aninproved or nerao.‘ Booidoe population ditterenoee, thia einglo factor in eattioiently potent to alter the relationehipe between the two etadios, and Justitieo the diooropant eboervationa. the nae or global eetinatea or behavioral change in evaluating therapy hae other significant detieieneiee. Psychiatric therapiea are rarely toenaed, or effective in modifying a single eyaptea. the induced ohanxoo affect a opeetrna oi hehaviera, with varying ratoa of change for ditterent aepoote. Global aetinateo tend to loae differenooe in individual ole-onto within the nedial deoignatione neeoeaany to define the whole reeponee. In oneh oitnationa ohangee in hehavier which nay he preninont, though not pervaaive nor enduring nay doninate the evaluation an to overehadoe other, potentially nore aignitioant ehanzee. than, alterationo in aenory and recall, or increaeed eonatination or inereaaing tithdrawal nay daninato nninproved evaluations; while explicit verbal denial, olieheo and euphoria nay lead to recovered or each iaproved designations. the nae o: inprevenent ratings nay he enpirioelly Jaatiried an an early approxiaation in studies of a new thorapeutio aoaonre, but inrthor analyoea o: the behavioral eboorva~ tiona are required for anderatanding and adequately applying the treatnent. rho typologiea deooribod in this report are one approaeh - one that hoe heon helptal in our nnderatanding or the oonvaloive therapy prooeea, and one that in non being teatod in etadiee o: payohepharaaeoloxie agento. on �ulhIn sddltlen to the differences in leprevesent evelestlens eeessieeed by attitudes to 'elde-effeets' end the use ef glebel due to the ettitedes ef thereplsts differences there ere retinls, tersrd rsrlees seeleesltsrsl peeeletiens. The edeptetien of explicit verbsl denial in s lever clues pstient in e eennenlty lestitntlee is welcomed by therspiste and really, but the seas sdsptstleu in en upper elese professional in e peyehethsrspeetle The displsy ef or psychotic. is hospital considered peer when and even nintnisstlen displscenent, retlensllsstien, eeeenpenied by s return to preeerbid work levels, is eensidered nsrked leprevenent in ens setting, but is viewed as e leek ef inpreveneet is enether if ceels of insight hsd been set by the thersplet. Interference with memory end reeell say he disregsrded by therspists fer ene seeieeeltnrel group, but sreese espethle eeliettede fer petlente ef endkher seeiel eless. Seek feetere effect not enly institutienel,%tt1tedee, but riteln en 1nst1ts~ tion, therapists of different therepeutie erlestétlees sey here evglestieae nsny thersples. towards sad the differing ettltedee recent seeiecnlterel studies ef therspists, end their sttitedes tevsrds eelsetion ef thersples, sre indiestive of these sttitndinsl differences (13,17,18,2o.22). It is our impression, therefore, thet inprevenent rstlngs are no longer useful devices in evslusting psyrhietrie therepies. For the eynptometie therapies extent today, which ere seemingly net direeted tewerd the slteretien ef en etiologic fecter, typelegte deecriptiens have s greeter spplleebility sud enpirie �-15. Justification. typologies haaad on concepts at diaxaaaia, targat aynpaaaa or on dyaaaio-atractaral formulations harattaaptad to atructara tho pra-traataaat clusters in witch thoraptaa nay be attaativa. fraatnant and paat—troatnant ayaytan impravaaant acalaa have haan used with utility. Thaao ara linitad approxinatiaaa, howavar, and thara 1a a naad far a broader approach to bath tho pra-traataant and traatnant bahaviara, and a phanotypio, adaptiva bahaviaral typolacy, aaing aaltivariata taohniqnaa at data analysis, aoana worthy a: aaaaaaaant. �w in enelyeie_er the veriety e1 beheviorelvudeptetiene or 73 velnntery peychietric petiente undergoing convulsive therepy reeulted in the description er tear nejor patterne. These are deecribed ee eupheric-hypenenic, eenetizetien, paranoid-withdrawal end penie nedee. the reletien er the-e nedee te clinical retinge e: ieprevenelt ie deecribed. the derivative end generally neu-eperetienel unture e: ieyrevenent retinge in enpheeieed. the difficulties in e cennunieetive detinitien e: thie veriehle ie eeen ee_e nejer teeter in the dieerepent etudiee et indieee predictive e: inprevenelt in cenveleive therapy, end in underetendinc the preeeeeee e: ee-etic therepiee in peywhietry. �-17- W' 1. Ieeeever, 1., latte, J. and Iain, R.L.: Peyehetherepeetie rechaiqaee with lieetreeheek Patiente. J. lilieide .3332..1; 17~2§, 1958. link, 1.: i ﬁaified theory of the ietiea e: Phyeiedyuanie rherapiee. J. lilleide legg. é; 197-206, 1957. BIG and of Delta Activity te telatien 1.5.: lake, link, I. lehavierel leepenee in lleetreeheek: Quantitative serial Stadiee. A.!.i. ireh. laurel. & Pezdhiat. 19: 516-525, 1257. n.: prerinental Studiee or «a. lleetreeheek Preeeee. Die. lerv. slat. 11: 113-119, and 3.1. Pellaek, a.a Payehelegieal rector. take, 3., tier, rant,§a.. lane, 1.1. and Green, 1958. Affecting Individual Differences in Behavioral Reapenee to canvaleive Therapy. J.l,!.B. 13g. 2k3-2h8, 1959. 6. Fiat, u., Kenn, 3.5., tarp, 3., Pollack, 1., Green, H., Alan, B. and Lei‘kewite, LL: Significance of Inhalant Induced neural-ion: tor the Theory er the convulsive Therapy Preeeee. L.H.i. Arch. Gen. Pezehiat. (in press). Preach, J. and Iepaetate, 9.: the Effects of shock Treataent on the 3:0. Pezgheenal. Quart. l1: 226-239, 19h8. Ireeeh, 6., Inpaeteto, 9., attenheiner, L. and Wartie, 8.3.: Some Reactions Seen After Electric Sheet Treatment. Amer. J. Pezghiat. 1021 311-315, 19h5. �.13- 3.0.: reyehepethelegie Reactiene end Bleetrie-Sheek Therapy.‘ 1.1: State J. led. g3. 1553-1557. 19h2. 10. Jehneen, L.c., Ulett, G.L., Jehneen, H., Snith, I. end Sines, 3.6.: Electreoeavuleive therapy (with end 9. alueek, Hithaut Atropine). Arch. Gen. Pazghie . g; 32h-336, 1966. 11. Kenn, 1.1. end Pink, l.c change: in Language Bering Elactroahock therapy. re ehe‘ethelo er colnunioetien, Ed. Roch, P. and Zubin, 3., Stuns e Stratten 126-139, 1958. 12. R.L., link, x. end Weinetetn, B.A.i Reletien of tnoberbitel rest to Clinical Inprevenent in Electroehock. Arch. neural. e rezehiet. lg: 23-29,'1956. 13. Kuhn, R.L., Pollack, H. end flag, 3.: Seeiepeyeheloxie Aspect; a: Peyehiatric Ireetnent in A Velentery Mental Hospital: Duretien or Hoepitelixetiea, Discharge hating: end Biegaeeie. 1.x.1. Arch. Gen. Pezehiet. ;} Kehn, 565-57h, 1959. 1k. Iehn, R.L., rolleck, H. end rink, H.a Figure-around Discriminetien After Induced Altered Brein Functien. A.H.L. Arch. lea-oi. g: 5&7-551, 1966. 15. Kuhn, R.L., Pollack, I. end tint, H.c Sociel Attitude (alliternie W ? Scale) end Convulaive Therepy. gig: 187~192, 1960. J.I.H.D. 16. lelileweky, L. and Heck, 2.: Shack trout-eats, Peychoeurgery end eﬁher Betetie Ireetnente 1n Peyehintry. Grtne end ___________._________________________.____ strn‘t.n. 3.1. , 1952e �lethed: 9t eeneecetire petiente referred fer eleetreeheek therepy during 1956-57, eeveety-three petiente were eebjeete of the ehelyeee deeerihed here. the pettente were selected fer treetnent by the reetdeut therepiet end the eupervieies peyehietriet the inveettsetere pleying he rele in their eeleetten. theee eheervetieee were nede during e eeeveletve-eeheeevuletve eleetreeheek etedy in which euhaeete referred for therepy were rendeely eeeirned to eeereee e1 eeheenveletre er eenreletve treeteente. Bleetreeheek eee edeiaietered three tinee weekly under pentethel pre-nedteetien, eeing either e letter unidireetienel or e heeerett elternetieg eerrent instreeeet. Greed eel or enheenvuleive treeteente were edninietered by eltering the etreexth a: current. [either petieht, therepiet her evelueting phyeieiene tee ewere which eeeree e: therepy eeeh pitieet received until etter the ewelnetiee period. eheugee in hreie tenetiee were neeeered et weekly intervele by teete e: leexeece petteree heth alerteelly end etter eeeberhttel, end by the degree e: elew eewe eetivity in electroencephelexrene. the intereerreletien e: theee indieee end their reletien te heherterel eheagee here been reperted prewieeely (3,1g). the senateet eyeptee petteree e: the referred pttiente were reriehle, end included euteidel preeeeepetien, reterdetieu, dieterheneee e: need end erreet, exeiteneat, egitetien, penie end teneaen, deleeiene, ideee et reference, hegettrien, rithdrewel 1 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Behavioral patterns in convulsive therapy. Arch Gen Psychiat. 1961 Jul; 5:30-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-53-019 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the Archives of General Psychiatry July 1961, Vol 5, pp. 30—36. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/97daec70fcaf9223c3cc93bef9185f48.pdf ea0a277a541fba43d45012096746cae2 PDF Text Text W, ;_ . » _ . ‘g wA .73.- ..g c 7... ._.‘ .v —.—‘.n, we“--- , V ,_ m- V ,7 , v.‘ -,v V. - , — xv- .r f.»--,—- ,.v—.-“.....:v«u..w,amw . .mmng—W (tr/33‘; «waver—u... .Mwm—V w... _ - . Electroshock and in Improvement Charges of Electroencephalographic Relation Therapy * Max Fink, M.D. Robert L. Kahn, Ph. D. This study was undertaken as part of an investigation of the relationship between V ”0.4",“ ., altered brain function to electroshock therapy. Twentyb prior to and at weekly intervals duringanki following the course of treatment. The total of four consecutive patients referred for A. awn-wmw and response 160 records so obtained were age percent time time delta at EST were given EEG'S classified according to five criteria: the aver- delta for three given lead combinations, the highest percent any one lead combination, the slowest delta frequency, the durb ation of the longest bursts and the highest delta amplitude. On the basis of the percentile scores obtained for each factor, the relative position of each record was determined. in the upper third of the distribution were Those considered to have high degree abnormality, while those on the lower third were low degree abnormality. By this method found between improvement and the EEG showed a high degree abnormality after weeks and over 90% after three weeks. of analysis a definite correlation was rating. Of one week of first three had such a record by the fourth week of treatment. for each of the EEG treatment, 80% A factors analyzed separately. week two weeks and only one similar relationship The was findings were con- firmed in a subsequent investigation of 30‘patients in which the tained in the second and third after 25% In the unimproved patients, however, none had a high abnormality record during the found the improved patients, EEG data ob- of treatment were used to prognosticate �nﬁi m\ improvement. It is as determined by concluded that early and persistent altered.brain function, this method, is a necessary prerequisite for improvement after electroshock therapy. * From the Research Service, Hillside HoSpital, Glen Oaks, New York. �sawmm MMW§WM w, VJ'IWWVWMM-ﬂmmﬁmm hula-«ﬁght ﬁwﬁymgmrmwt mm“ Wmmunmwm; W mmummawmmmwwmmm W - ’3 mmmmmmmammmm mummmmmmummm» "$01:me ‘-;:wamaf w*:.mmuumwmm_ m h zwm .»,wmawmmmuwwwm m Eegmuﬂ) , W3¢MW.M: ��WMWWnMﬂmmemW-,' W mmmmwmummwt tmmttnwWmhmhmz-Mnnmhmumtnmw thatmatmm WM” mmmmmt Wanm mummm Mahatma: Wmmmm “ mmmm mum mammmmmm manpmuummmmm,mmmmmm mwmmhm «mmmmmmm mmmwmm ammumthlm mm Wrmmiarmm Wthanntht mmnmm% my were” mmww Mmgmhhu hmwwmm mwmmmmmmwmmmwm WWWmtmrm-rammwww Wag“ mm hm mamwmmmmmmmmmmwm - , - pa. �Relatidn of Electroencephalographic Changes and Improvement in Electroshock Therapy ( 3 M , 7' W41] Fink M .D Robert L: Kahn, Ph.D. Max fir/V v, , .y This' study was undertaken as part of an investigation of the relationship 41/4er between altered brain function and reaponse to I/mt—wju? Twenty-four consecutive ’P—EII‘P patients referred for were given EEG-'5 EST prior to during and following the course of treatment. The .« and at weekly intervals total of . 100 records‘ were classified according to five criteria: the average percent If time delta for 'Mbmﬂavv I three given lead, the highest percent time delta at any one lead; the slowest WM frequency; amplitude, w“ H, mm. W the tame- of the longest On the basis of )‘n. MAJ bursts and the highest 601/9“— percentile scores ob- samba-med ' tained for each factor, the relative position of each record was determineg gose in the upper third of the destribution were considered to have 1 high degree A W MW W“ correlation tau/inc. Ml‘tW/‘au‘ abnormality, By this method of analysis improvement and the FE . after ‘ 1gh’abnorma11ty was found between _ 6f the oniy‘one week of treatment, 80 a er two weeks and over ' g . , A weeks. In the 'mimproved patients, during the A w a marked first c'atrately. The I I was found I I I I loe-ether-kand, g three weeks and only one similar relationship 313 ‘ had. such a each of the $in yw EEG 90% 4’ improved patients after three none had high abnormality record b% the fourth factors as . . 30 ‘ were usedﬁ progn altered bain EEG data obtained in the second and third week of treatment concluded that early and persistent W1 W im«Lu function, as determined by this method, is a necessaryﬂfor provement after electroshock therapy. W MM”- week?” analyzed findings were confined in a subsequent investigation of patients in which the 24’? " � 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 of Electroencephalographic Changes and Improvement in Electroshock Therapy (research) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-4-004 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource <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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/130db8be85bd0b48cc58aa475a58b045.pdf bc509f8c91b02a75587679edc6e65f4e PDF Text Text J4» M 4‘ \ G: 3/22/57/ s ' Electroencephalogram in Electroshock: Role of Delta Change in Behavioral RBSponse Following the original x observations that electroshock induces changes in the electroencephalogram, clinical studies correlating snob changes with numerous In an exhaustive review of these improvement were undertaken. studies, Chusid and Pacella (1952) conclude their survey with "in our opinion, the slow wave formations after electric shock treatment bear no direct relation- ship to clinical improvement. favorable therapeutic response depends The primarily upon the administration of a certain number of treatments in each particular case,and since patients vary considerably in the degree of abnormality noted with the relationship between changes and EEG it of treatments, same number follows that any clinical recovery is largely coincidentalai. A}; A (. if‘kt" if: I /(/.fr ~”/ his/((9 F ,7 .6- , 221 [ff & \ ('1 F621,!” if , CWA/Ll’ﬁi/I {‘QJ/QJ { (44.1. l '41 [L .6 o ’ f l! if; ,0 a’,,.€"5.,‘ \ 2x )4,er 1. '7 1‘ L-ﬁ ! :13 > I" Bdké’vttfi’ , ”1’ ‘ ‘ ﬂit)"; I , , , .. f, \ Mix/4.x. U ' R.» '4‘) ‘ 1/6, , I. 1| EEG (MA gr,“ I, , p. in 7,1,, V” ‘ 5 .9 4,, (3., "M /QM{ ﬂ’szf/lff’ ,' {.4 L J“ \ (’2‘: / f’ :3 «m 1‘; .- in" O v’ w.» 1 ,2”, 41 ” A £146.11” kg,” (1 r14; 1 Q41 47‘4”! "4 1.0 7’ (nt/Z/ﬂ/f 'I"l.-',v rr c F x9 if; 'A-b- :t {f I , x a ’, A; 5’, ﬂ I”? (11"! ! /‘) "(Wk , /‘ (1.. 1 f) ,- $.44 , a ,c r ., ,7 ‘a K 1 �‘ -' J ’13]? .f‘ 5‘ V In an early report, Hoagland . §§L§;;(l9h6) noted a correlation between changes in the per cent time of more j disturbed behavior tr I /J"‘Z3’fa,t~x V than 13 cps activity and independent clinical ratings became more As -. T} ‘ manifest‘I, the fast activity increased. With treatment induced behavioral improvement, this activity diminished; only to reappear with a ,_‘ if '9‘!“ ‘AlerA ‘ 1“ A 3:419:4{F’ﬁnf reéitumu-ne of symptoms. ~35; ('1 I a! ‘ I .~ ‘ " v I f A“ delta response an activated by intravenous thiopentone, elicited characteristic in the treatment course, there EEG was random changes in every subject. Early irregular slow wave . A... "‘--"'-~—.. tre;;;;;E“‘EQE;eaee3¢%o <§¥¥§:nore a highly rhythmic, amplitude f £41 "I, clinical correlation. Roth (1951), reporting the high I . / Similar observationsﬁwere reported by Kennard and Wilner (l9h8),without a V .v‘ 1/1 4 runs and bursts. These were chiefly activity whicht bilaterally 2 up to 200-350 microvolts and continuous duration of 30 to to synchronous cps, with voltages 3 80 seconds. When the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its area and decreased its basic its frequency. Ebth believed that these changes were related to the process of recovery, and concluded: "the development of a typical 10 of the 36 patients two weeks. But who transient EEG change does not insure recovery and obtained such change failed to remit for longer than improvement in clinical condition seemed to be related l,‘.' , . , I �to the the EEG EEG change even in these patients. If changes with the therapeutic effect, are correct in connecting we it would seem.since most of the patients developed typical changes, that the physiological basis for improvement is acquired effective in promoting recovery." «amen-«AW... mzu/vx-W it may or may not prove by the majority of cases; ( urn ) y‘a—wnup-H‘QOMﬂh-MIAN-mwﬂmhﬁia m m «WiniWW.iwm~mm , ., 7_ _, W_ni__u..aw»r Iz=tsagillunily agreed'that electroshock induces diffuse slowing and Meade,” (iég increased voltages in the electroencephalogram. There is 1iII some inW dam/a w dication that fast activity’, both in voltage and in per cent timel'aasae dice! dell-Ilia; enlistiées in nlxlxli; patients 2” are intensively treated, -CL¢€- who a slowing of the persistent alpha frequencies. degree, duration and The extent of the delta activity is directly related to the frequency and the number of grand mal convulsions. bInch activity is usually symmetric, and with anterior placed electrodes, appears maximal in anterior electroenceph- alographic leads. In patients received twelve to twenty treatments who have d‘xuet on a twice a week schedule, the electroencephalographic effects usually “WNJw‘A ; “ﬂmwui_w-i «- -‘ disappear in h -8 weeks following the last treatment.§ Studies of the prep it»? p treatment \ EEG 7 characteristics failed to demonstrate any relat’ ship with " _ po;t\seizure the electro cephalogram or clinical \ onse. Similarily, there ,2,. tax: has been n report of \ r C/ﬂu 1 L/{L-"Ligﬂa :14 SM K rum—i If /“ .\ a relation betwe K/ fat 6 Leg/2x,” ﬂu”? K) J M. f.” ( thexpost treatment record x” A v, f a [If ‘ ’ _ .- V: t . �Both of these. reports emphasize a. W relation between the degree of electro- encpphalographic change and current behatioral response. Mﬁﬂferent aSpects are emphasized, namely delta response to barbiturate activation and the beta response .2 m —‘ m-...-‘.......—...7...—....- Had other‘swlstematic studies been done, ha been that n correlation etween elec oencephalographic changes and M f: ”tax-:74“ 5": W” Cu X4,4! .z/f, behavioral response of electroshock exists. / Lack of such if indeed 6W .--, ‘ 5 r \‘p/‘ a relationship arm W Wei “)2” 40 /W does exist, may W # behavioral change, , -.’, ‘K" A_Iff measures of I, — 72:! r.«L.1/€ALI':" elm/7 ”r: ﬂ-the relationship between EEG "’-/ g EEG Chaﬂ geg “(W:tﬂ/f a” kg"; I?! or time or c) methods/of evaluating behavioral response, Whiéfux elucidatgun to reflect ' ' M/E‘C {if (vise/ZZ‘K; response and 44. . "M ‘ ��“NM messwnaithink' human” change was not clearly noticable or who showed only equivocal or transient improvement. Some showed fluctuations in behavior, at times appearing somewhat whom / improved. #1 But the changes were not sustained, so they appeared much that by the end of treatment, as they did before. are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, by We MW.— using this threefold classification, the differences between the groups will be distinct.“ M‘ﬁe ‘i first . ,, third subjects. these4“me ,w mgﬂﬁﬁwgﬂhuﬁgyé‘wﬂewww“L»?«up,she?w M. and WA“ s...,. 3...... suggestion of Dr. Hans Strauss (Clinical ; cou‘oinﬂtidﬁb three lead or (fnontal. '2’90' 0:" *NWt‘M *0-gis?¢ﬂm av .J,v pgg‘gggja;“1%ngformléqﬁesmefEMMMSMAa‘EE.3.9“‘3' '5" lW-s‘i «#33253 AIWJrrrw-sv‘am . ' ‘ _ ' "‘c~"‘"“M:= 5.»... ,V :4. , �. V .‘4 ,2 C. Minimallzfor Unimproved: In this group were placed seven patients was not cleanLy noticable or who showed only equivocal or change transient improvement. Some showed fluctuations in times appearing in whom behavior, at somewhat improved. But the change was not sustained, so of treatment, they appeared much as they did before. ,\‘\ that by the end are aware of the difficulties in.evaluating improvement Others J» might have differed in the estimates of change in these patients. In any case, by using this threefOld classification, the differences between the we 1 first and third groups will «*K‘EVALUATION OF EEG RECORDS: C ) be A distinct.” 1_”, 1.4 “MW, ”1, total of 160 records were obtained in these subjects. Fbllowing the suggestion ofillluills determined for three lead! and (frontal-parietal, anterior temporal;:vertex, parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined as the per-cent time occupied by waves of 7 CpS /°ebdéﬂbb or slew-n. The average delta-index for the three leads, and the highest delta index in any lead were'éég'indices used in the final tabulation. Simultaneously, the record was scanned for the slowest frequency inn identified at least twice in any lead; the highest voltage of any delta wave; and the dhration of the longest burst. Uther aSpects recorded, but not used in the final e/aluation, were the regularity of burst act- ivity, slowing of alpha activity; and.the degree frequencies d'amplitude of fast act1v1t1es. These indices did not lend themselves to s atistical study; and were not identifiable in all the recordsp.’ Fast activit'es were �.u- 7 j. ,2; pézfzn Air. {in //e 4/4; xiv-sea administered by the staff psychiatrists, using electrostimulator. Treatment schedules were three times a 52/ As 9-to showed from number and of 33. varied the treatments week; patients a Reiter h? C greaémae’b clinical fewer tended the to give treatments, psychiatrist , spaced. There were 15 women and 9 men in the series, and and more __,_____.__ 49/ the ages ranged from 2h to 68 with a median of h7. EVALUATION 93 CLINICAL RESPONSE: All the patients were observed for at least eight weeks after termination of ﬁiéemé; the basis therapy. The patient's response to electroshock was of the resident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervi§gaidxlcharge of electroshock. The patients were<ilvided into three groups - markedly improved, moderately improved and unimprovedJﬂaeduaa3lﬁ§EEEEEEZEEEEJEEEEiBnIhs) response—tejeieetreshock:§ [3 A. Markedly Improved: The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer showed the symptoms which brought them into the hospital; their doctors were better; felt they 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. some improvement These six patients in this group showed but continued to manifest indications of mental illness. Moderately Improved: patients typically The showed symptomatic relief, 33;, acute depressive features might be gone, but the dramatic change so evident in the group was not apparent. Each patient continued to show some first noticable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation. �medication could not be; controlled our evaluations of fast activity follow- 1", ing electroshe’cié are not satisfactory, and the results of Hoagland W’“‘"‘“W .m M ~ v 7,; ,,._,_.,.r..:.:..-.eew.u ttaal, ”Mina-x... .. On the basis of tho the records were placed in a rank order from the greatest abnormality to the lowest. The 160 records were then divided into third = 3 abnomality and lowest third high degree EEG m positive correlation groups = Low - i__e."upper degree abnormal- ity . , ,,,. Wﬂm.wrmnp~4ohm»wz 1..“ cheek? max .. __I . __' and improvement “Wm h. ,.wu...—.mmM ' om muc high een early ahno eA dc of tre tment. Tlie reco ds of the I :psyThese ) Mr"."W“, BydtiliZing these quanfications of slow wave abnormality in\ \ such EEG we be electroshock, abnormalitydnduc d duced conclude that { the in first 3 weeks ,r'response. 2. What M fur“ of treatment is essential for t ﬂea; "3 e short term” clinical k exist between the clinical reaponse»; and then amongeach '1 1. ach of the indices, 0 er? fi\st with ity �//' I, -w _‘ Quantitative Studies of Slow Wave Activity Follgging Electroshock Despite repeated attempts: correlations between slow wave activity induced by electroshock and subsequent therapeutic outcome have been unsuccessful. tain conclusions from previous studies are warrented,.heue¥sih All Cer- patients sub- electroencephalogra‘z;b electroshock the therapy suffer alterations in jected to pliilllﬁ. Three patterns are generally described as 1) the slowing of the alpha frequencies; 2) the appearance of random, symmetric SIOW'wave activity, generally activitygcigiNB) diminution of beta which of high voltage progresses to burst frequencies in rate and amplitude. There is a direct relation between the degree of these changes, and the number and frequency of treatments. saturation point of change is described, which can is not increased. ment, but which, seemingly, changes are reversible. The In many be maintained by subjects a further treat- Also, such electroencephalographic rate of return of the cerebral patterns to the pre- treatment levels is generally 1 to h weeks, depending directly again on the number, frequency and the type of treatment. Another area of agreement among the cited authors ship between degree of manifest roencephalographic abnormality. few treatments and without memory is the lack of direct relation- loss and confusion and the degree of elect- Mamba» cited-of severe Cases are memory changes significant electroencephalographic change; and also of severe changes in cerebral rhythms without manifest clinical confusion or laid memory on such impairment. O Mam! 6f 5. £257 In these reports, emphasis isfrequently organic confusion also correlating poorly with clinical results 0 ,Euﬁada, with �studies, however, Two cited may be 6L0 71t7¥éodf which—noted a correlation between Electroencephalographic changes and clinical improvement. amud, Kaufman and Péagcus Hoagland, Mal- +1924)» in this 19h6 study of involutional in the electroencephalogram and in the excretion of -(changes women ketosteroids 17 accomp panying electroshock therapy of agitated depression, Psychosom. Med. 8' 2h6-251,19h6lg, reported a relation between changes in their clinical me, rating scale and the per cent timeJlB cps activity;AL the bediszirbed havior became more manifest, the 13 cps activity increasedi Sivtreatmeht W induced behavioural improvement, 13 cps activity diminished. of symptoms, there was an increase in the More recently, Roth (6hanges in the % time 13 cps EEG With recurrence activity. under Barbiturate Anesthesia Produced by Electroconvulsive Treatment and Their Significance Theory of action, ECT EEG for the and Clin. Neurophys. 2: 261-280, 1951) described ekseTies-e£.sindies_in_nhieh a relationship between thiopentone induced EEG changes and the recovery process. was—elicited. Roth noted that slow Pod“ $12.94!. wave activity as seen in a routinenrecord was irregular in appearance, and he confirmed the reports that it could not be satisfactorily related to improvement. ; By administering an intravenous solution of‘;fbarbiturate thdoperitone, Beth elicited characteristic changes in the shock in every subject. Early there was random EEG irregular slow after electro- activity, which, with more treatment, increased to a highly rhythmic, bilaterally synchronous, high amplitude delta runs and bursts. These were chiefly wave 2-3 cps, with voltages of 200-350 uv and continuous durations of 30-80 seconds. pentone th: resting record increased its voltage and its basic When W duration, spread activity, thén- its area, and decreased frequency. Roth believed that these changes were related to the process of recovery,‘§i$haagh,;the a typical evinced rhythmic delta EEG ‘4” concluded: “’Enuaner, the development of change does not ensure recovery and 10 of the 36 attained such a change failed to remit for longer than patients two weeks. But who �Similar analyses of the relation of each of the indices and clinical result showed identical curves to the group curve shown before. Slide 2 shows the the relation of the delta index to improvement. to much improved group jumps index in by the 7-9 treatment; while the mod- 52% erately improved and unimproved groups 10-20% by The mean show a gradual, slow increase to the 10-12 treatment. similar set of curves is demonstrated in slide highest percent time delta in one lead. A In the next slide the mean slowest frequency 3 for‘the is recorded, mean and this too shows the same significant relationships. While the much improved patients show delta waves down to 3 cps or less by the second week of treatment, the other two groups barely reach h cps by the fourth week of treatment. Slide the 5 shows correlations for the same The much improved group show mean higher voltages by the second the fourth week the differences are perseatent for Finally, slide 6 shows highest amplitude the mean all three duration of bursts. week and by groups. The records of the much improved patients show longer bursts, averaging more than 7_ seconds by the third week of treatment. Bursts are less frequent in the unimproved and moderately improved groups and are significantly shorter here:€E:::¢::Mthe in duration. Not noted factor oﬁaregulgzgity of bursts. In the lonéﬁbursts, wave forms frequently were more regular in frequency and amplitude, than in the other two groupsl These studies may be measures of slow wave interpreted as demonstrating that each of these activity arise from the same physiological process, and assuﬂe the same significance function induﬁed by electroshock. in relation to the disturbances in cerebral �3. Finally, can these alterations in the aSpects of cerebral function which may EEG have been be correlated with other altered by electroshock? In these studies, three other indices of cerebral function were assayed! the amytal test of Weinstein and Kahn) tests of double simultaneous tactile g?) Si) stimulation/and tests of memory and recall. of these three indices, only “gigpﬁﬁt' V/ the amytal test showed a positive correlation withimprovement and with A); stoma; WW may.4, 41:2th Julia“ We 0’ is this test, the subject is interViewedm uestions o Ahbbld atdkhuus nae: alas/d autbaeaawae cafhﬂa ation of int venou sodium amytal, the stions are repeated errors in thQ/I-vm . e orientation, coniabulation, denial as "POSitive" amytal t:‘t, and illness and reduplicatioh are scored are indicative of cerebral dysfunction. “Ms”r Ab tal test. 9"” ,, .1, #ﬂwwf yyyﬁr” \ In the next,slide, #7, the pe centage positive amytalthSts are if“ if“? compared for edéh of the three groups, «hf weeks of treat- ‘3 - , jge’difference between the much impror -i the other two groups is strfiing. While every patient in the mu_;‘; oved group had a positive gonna al by the third week of treatment, the abno \ity persistedgF ment. M was it W#7 ation with improvement. In this that there are various types of cerebralﬂgyeﬁ function and that”g;:ﬂcannot speak in gross terms of a ”Absfgeeﬂ'thew 0“,.“ n .rvn w..,,«wm.~~m—we rm«Antw-12mm gﬂMéorrelat1on lath and cerebral dysfunction or organighpsychoses. muv maxim» we. \\I ‘\ \ 111; {ZENWWf’IﬂWW showed no can be concl EEG ‘\ ‘15 um! recall? These indices respect, \ \f transient despite continue. treatment. ‘ WW“ Rh “met”. WWW”, ‘ "New“ ewes V4799» “new“.y‘d ”fI M 51““? ﬂag“ ”Why �* Semen, these ethe:ee pemttethe �5M5? Vt m WWM in mamm: Relating at Induced Mu nativity to WMum, Roam Dunno midonblo study and shock mom Wind ahcck 1: menu. the man at Recent tho m enema (9.6mm, at wow-1cm «that. In Mm own... chanson u a, the basin no have: obnexwd n mum at chasm of am. And) hm tor tho 01mm- rolnucn comm chum inmaumdhmmncMmaadthamquRw. hmmmm hum batman clinical Wt 1'ch emanation taunting orientation and olcctmahock nit-h changes in Mam whnrbi’cal ( mummmhngmgcf ).ondmxyandmu1( “My in 1mm: an mluaticn of ”mm mums change: function, and behavioral M, '11: our no mama 1::th mm. 0mm nan and Panama (1952) minim, up direct an an incur W. the observation b y various observers that clontrcmm change: in the olentmencoptulogm, with clinical syn-- ). Thoprcmt in thc thmnnoophalnsx-nm, a» ), slow alumni}: ta Imma- «mung In an exhaustive amm their may W mm c: than nth-tho sum nan fez-mum arm clam-la shod: mm Wmt. such a! Watt tmmt but the favorable therapeutic mmmmmmmommwnmmrﬁ �tmm in tha dame of tone» Wt Maul” each m can, we we abnormality noted with the hem my rahtionuhip patient: vary comidenbly in am number of hmmts, it Em mango: and is War anneal largely wincidental or maul-11y mini-ad to othrrr factors.” Yet, the alwtmcephalognphie chmgu mmnt. and Most new Wen wltagt 611:8.an that fast. tin; and in tho who activity is dimuy mum mnﬂsm ( Bach L» law. ﬂuent: wha have intensively In View electromock, or the it dam, ), The to than {W appears than is a duration and mummy m W ind» in percent slowing at tho meat of delta Mar afar-and m1 and tho and with mtarlor mind in anterior aleetmmeﬁmomphic received twelve to wimpy ramming my be 1:: voltage and W. ( of wires treatments per wok, the diuppear in us new uWhock are con:- The” in considerable nativity in mud]: ”metric, plum mutant. «hatred», In dootrowophﬂm. no Imam. by mart that elactmshock Mm mm» ) ( accrual» ), bath wtivity in paint“ persistent alpha ( Maud mutants dammiognphic a» last mama; ctr tho ( mum: am mu bum max-meme and humeral a. schedub effects usually ). olcotmmephalumphic to an weapons. to that a mktionahip dam changes. Tia swan �.3... do ”human. indicate we}: a Mod a relation human ﬂung» in than :3 spa) and WW MW MW“, behavioral Wm: pentam, elicited characteristic of tmﬁwmt tandem thin xeuuiy EEG Vchanges ungular to m 209—350 m! mum, ”than and. continua-nu m banana that thaw eluded: want-d by 113sz men buﬁenlly m mum its mm changes were (39th of and to 3 which in» Mm, high cps. with voltages up 30 $9 60 seem. when the its thiopsntono increased «creased mum ta typical a. 2 at activity, mu We spread “ﬂy in the ”sunny appomd, slam warm harm. than. mm unravel“ resting more! mm and tmta only to ran in every subject. continued treatment. with to Winnie, cmsgd «puma. Whoa; an. ‘ mapma del‘hn' Wang... A: fem. nativity inerumdu with W” of (3.91:6) w ”want #130 tut activity (mu 9mm, aw; (1951), reporting the cm apart. Renal-ad 33 9; Momdont clinical mung; atbomionl behavior beam man: with 3 m Iﬁ an m its bum tummy... the games: at Waxy, and cam m change does not insure mmzy mmﬂmﬁpmtnmoewmmfailadtaréxd‘bfwlongw h * i’mﬁ and 1mm G (1'9 H u ”I ) won-m “a “mm the behaviaml comﬁtim. ‘ ‘ " :51, 9" L‘lig Yr ' II": .,,i‘3l’ ‘ V �4‘. he than tmiunf. wants; ﬁat ulaudtothcmmnge 1:33 the EEG mm militia“ patient» clung“ with ﬂat therapeutic effect, tin patianta dueloped typical dung”, pmt in 0.1mm audition sound is W by tho lager-1w cf 1.9 b- «mammotof «on, we Ifmara it most» 10111:! that. the physiological hula far in. W311: any or my not pm affective in mixing waver-y." Bow thee» mmmogmphie are Mixed, ”pom «pm-m 1 solution batman the dams of elect“? change Ind cement-mt behavioral suspense. Different aspect: namely delta mm to barbiturate activation and beta. not. ivity. In tho present impetigation, quantitative aerial studio! of the dart: anyone. were undertaken to timer the following quuuonls (1.) What. in tho "lama! of the elomcophalqmphie mama to be- havioral responu 1n electroshock? (2) I: a "hummus: «mm, :1an aubgocta 931; what signification my W’ at prior ta a) In the tmtmt, 8 chums). ﬁnder-It. bipolar, hm tor an under. of tho process of electromoek therapy? 1mm semi, tmnty-four Maw wa- ianta referred for chetmhoek were studied. do!» 11-. mammalogrm an tad at. weekly intervals during and after treatment. wing destromcwphnlognph and noodle and hyperventilation chem. bonding in mmum m mum emu each molding. �' mm Commuting, the at least .6. was scanned for the slowest frequency identified twice in any land; the highest voltage of any delta wave; and. , the dur- atian of the longest period or delta bum activity. mm basis or these five indicate! eleven” nativiwma racom were phoeduinnnkordar,tmthomtmmto£dauwmﬂtytotho lowest. recordanudividod into The 160 3 mu m- m thirdm classiﬁed as “high degree deli: a records"; the middle third, as fmdemto dag-no Fignm delta a records”; I, II, and and than lowest min! as now degree delta III portray pin-mm mama.- and treatment records taken am- inguwlwtmatmntpomodtoemlitythethm rangeaofdel’aamtiuty indwed‘hy electmahock. b) In a second shock some at raw-tour mun, patients, ehctmncopmlogmpluc moon!- lent. ,Mﬂng tin treatment. second and third 531133 records, the wore obtained mks of try-stunt, initial observations were tested in weeks x after «comm W m: mum on A11 of max-aw. after first eerie: of 160 I predictive haw ofthemu patients were The prior to treat-- and two ween the named of analysis developed in the pantie response. mmmxg unselected electro- W m- at 1am «at. patient“ mupomo to the bani: at the resident “psychiatrist’u 15leth m mm, the nut: > �.7... opinion, the man's not» apex-visa in and the 61111130. evaluation of tho charge of elwbroahock. The pntients were dived-d into three groups a mob academia]: uprated and mama, A. WM! mama which «an aim: themaa‘lmtu «coming to the following criteria; :3,an These punts no longer shmd the mm Th. 11 or Inn-had immanent. hmgIt than into mm .. group were mended the 116mm; their doctors folt they warn mum and ﬁleepuithoutmdscant-ad mkupactaasbomgamn to nation, better appetite, an! capmw to gut along with others improved and ‘ participate in B. mm Mimi pmmnt but cmtimed to try'picany shared gm, Each activities. but the The units” mm mun amt!» 01111130 K. idea, or We: m when than; a , m less 111. The a» haunt! teatum night he evident in tho first. group val not apparent . no m noticablo disturbance such an obsession). somatic pmccupauon. raved: mum not clearly noticablo, mo or who beam worse. may showed tons é! loam illness. mane 1.1191, 3&2.” mute dopresiive patinnt conﬂwd to thaw thinking, paranoid lb: patients in thisgmp showed change: were not mmn placed showed equivocal new patient-in or transient changes, ﬂuctuations in bshnvior, at sum, treatment, they appeared Inch as before; however, no that times- appearing by the and of �Mesa the analyses of the mlatian batman the delta activity and clinical ratings, denominated between the proved" early appunnce of high @3290 delta nativity and the classified 861 were in the third week in patients and 88$ who were or third in m who ”lunch won rated 13. u nah high degree 691%! in the second week; 91% mutant. 0: the raced: fourth week of rated as migrated, none wan high degree delta in the weeks at tmtmnt, aim ‘1: The and 20% tare high degree delta 21 the mnsudin mu 1, ma graphical; in ﬂgun h. can fourth week. a induced significant relationship clinical rating» 0! the meow in mucus. mmved, second 1 acme or m a i m 99am Delta mom m Indian W (7) Wed Imam-d 85:113.:- measured Mam: k} (u) 6. ( analyses mm indies: 91‘ of bursts, highest Men M 25 an 91 as o 3.6 50 M o o a an for the rolation hem-n each of mm (avenge S-Mm delta, mm, M. 133 and slowest highest 5mm an... they duration frequmy.) me the clinical rating!- In each instance, the relationship or degree or induced delta index and the clinical rating was sustained. This data will be pramud in detail in a �submmt ”port. taunIndaxotnu- 2. Em mmﬂmtaﬁm, contubulation art! dmial ion: 1' B of. 11111033 in a ”matured latex-via after the: administration or intravenous mobsrbital in patients ﬁrm brain lacuna have ham sum-mm as signs of 13mm arm noted such patterns to ba illness, unless than. was evidence «and probable, themfora, that persistently tum mum or new” cerebral 11' mot subjects, ). ( We had m- m putientl hospitaliud with mm. mum elsutmahock indmed patina nmbarbim tam Wild «ﬁbril be produced. mmmmmu ( ). It dysfunction, This was indeed mp0M< ). 1n ma, mm (58%) and 10-42 fourteen an 7-9 the m period, an am mum that um; report, nu mm cerebral dysfunction (671') at the 2h subjects, had positive period. In than Maw—four subjeotl, than new ninety-one to". sessions during the mac ital tests of therapy for which smear-rem; chumphalogrm and ambush- are availnble. Pro and poet mutant. records are not. mcludod. mmmmnmuummummamdmmmumuw sham a high relationship, both ratings of immt delta wﬁviw a for the tests to each other, during therapy. In Tabla W II, as. and to clinical degree of induced with the results a: the concurrent mbarbihl mu. �W TABLE KEG II 22m .. An___%mm W rat. at Hicidle 313x Low Positive (25) 29 a 8 Negative (us) 10 15 20 Watan relation between the test data and clinical ntings of am also simiﬁmt. In Tabla II, the ma and uobubital tout. results The me'dingtothoevomnl mmmmedgmp 27%,(5 m had n umber of with. gamma test mctm; sad” that tho cluster at with. nomad, high Em delta activity and mummy in» clinical rating. W Vi M proved rating 3.: 3 negative mm Wits). mung a: om. Email: alluifieant in the cluster at test, 19' 1nd Mo me an: activity and clued. Wand. Rat /m m\ rod ma Hunk High Dam and roman Amebazbital (29) Either Positive 33' Dam or obaz‘bital (26) hither High Dalta not Positive Amobarbital (35) Iv Immed r. M W Result! an Moderately Impmvcd 25 3 10 11 s S 1.0 21 3. Thedatain'kbluEmmnhumtommorotabmmtimdum n Simiicant by elm-aqua :t hotter than 2! 1m). of conﬁdence. �the course of therapy in the any are rater} uriy m the It and at We initial twenty-atom petimte. ra’cdsrxzvttl who me): improved tend to develop high degree a: treatmnt, Table 1) similar and sustain ohnmtionl, it throughout mde for the are gnphically portrayed in figure 5. A EEG delta. activity the period. (ﬁgure murbitel test result” Waite of figures it and 5 presented in figme 6, which chm e mmrkable eongmm of the two 3. am to 0n» ‘ » Following the observation: event? is test date. 2 in this group, that the mch :1de patients had developed a high degree delta neurity earl: end had untamed such activity, electroememalogrm were obtained during the week: of treat-ant in undertaken Sh second and lelectmdxock consecutive patients. This study to detenine whether or net the demo «at-delta response in third in pro— dictive of the wort-eta“ thermontic outcome The recent: were sound hand during both, one a to whether h1g1 degree delte activity was who or neither of the h~6 and 7-9 treatment periods, and the data was related to the clinical «elation TABLE I? (Table IV). �Ono "W, um (16) 20 um High (1:) h (25$) a (50%) h (25$) 6 (30%) 7 (35$) 7 (35$) . Total (9‘) "' ' m 31mm 22 at the 2% 19 level of confidence; 13 �«42:» or the 131518!” the Mint 111$ delta ”tawny during tho ”00nd and third mksoftmtnant, éﬂmmuduuwhimmd,mhmly3motp:mu diluent high delta are so mud. The sum inﬂation and dome delta activity in rebut! to the Short ton The arbitrary solution of ma second based upon an 12.15 6100ka trauma. mtotmm Further sax-ion and in which the W delta beauty, persistence of 6113100. mlmtim. third week: of tmmnt was mags tmtaont of this data Wul 1&1“th m course m that the div-lop» 1211le fort. at mm:- of weeks, in round to mum: at of immanent regardlesa of tho tine in the course of thump: II continua: treatment in after 15-20 am trauma, m delta mhngea no first. manifest. subjects resulting in high is associated with 9. MM this later period. Patients given many m dolta activity Won]. msponm at mama n the at. per weak, without the mention of high dogma delta activity, a United behavioral responu an - one that is M mwm mt 5.10 placebo responu ( Diﬁuaaig g of three tines Wm“ significantly different than ). Intansiw uranium. at a. fmqmoy of relultant induction or high dogma dam act- was: per ivity, will damn-cu not. Thu, :1 aignifimnt behavioral name. mesa studies duonstmte a consistent missionship batman the degree and duration or induced uhctrooneephalognphie delta utivity and clinical �‘13- enlmtim at behavioral change. 3ymetr1o 1m been and automated» We at tho evidence of dysfunction (mama; centers and dyerhythuo delta system) mam (own nativity WW Strata»)... and Such indioative of an alteration in the state of consciousness, also activity is new alteration bang unouy related to the aunt-10h, mum with more and frequency and (Strauss slow Bid] wane June, et the :1, of aotivity Brit). and behavioral between Muted one. rolationohip county We m the further electroshock permit: after aspen” on. mmepmm mm no: attendmt pluliologio basis of tho electroshock shock process thus physiologic “mat We conclusion that ohangee in aunties: prom. in consciousness an 1L o No upset: of the electro- elaboration: the mention of the to the behavioral response mm neuro- .. and the eigniﬂoanoe of these observations for a theory of the node, of action of electroshock tangy. (a) Role Won]. cerebral 2mm. change Changes and perception, prone”, whatever cause, ore In this dependent 9%. \mieteot 1: a moo-pennant in mm, Mt extmively mm, I of alteratim in ltti‘budl, judgent,thooght attending changes in cerebral Motion, documented rm liter-store. in the noumlogic electmahook has hem mum to consistently teat emanation, in a {whim Mob we alter two in- have con- to associate with �431). i has biochmm substrate or this mu- away. mm mm has hem placed an tho noctylchonm—ohonmstomso changes a (ﬁnest-in, KeEwhun), tho “Iteration 1n blood-brain burner (Aird), chug» Tower and in ionic prance” has and promnqunbm [9’99 “/fsrué /'(ﬂ’ I‘M? 7 ,r‘ L. j 44“! [Z (3916301 and 31113391 x w A“? 5 1:34: ; I; ' ‘ 3 g a f ff V M v 1 .-‘ - mm), L; z r g» ﬁggéfiten/ �orient-p with extensive In impatience an function. cerebral of altered states am after wherbitel, tests” mama ( Wemauin and his ) ( J ( o be” dmnetmted the pmdictiw mm of this test for arsenic cerebral Winn. Davie workers by ee extensive met-cue experience likewise, Oawendom( )and-ng ).( ), Oatmmdstnnae( ). mum“ ()huefﬂmdthe altered in e hm Matias. W ‘smu signiﬁcancecfdiffuee other tests of unbral mm been applied seriel reunion, it. is anticipated that than, too, mule! dum- mum sponse, within the in cerebral 30.6 delhectivityueninduet chengee W tmtmt salmon to vacuum re- and e units a! the sensitivity of the test. to reflect change! mum. lame mam, elmmwbeuidtcbeenthcdormmge muctﬂundMiantoerMMOmrwachime behevicral respcnae. «diam The mac of belmvioral patterns induced under these is wide. 'Inprcvemnt' being a subjective evaluation On 1e 3 special one at behavionl the part. cf the name, charter that the patient 1: ‘bottor.’ Electrcehcck due not induce “immanent“; diffemt than it indwcs a mum of cmbml activity in men behavicr To the extent that. the induced behavior in deprecaed permeate is perceived as lose whining, depressed, mane 18 or move, before electroshock. or in achnophrenic patients, �.1;- 1m maximal, proved". behavior, Wham complaining, or typo 9! “an. evaluated to. as is patient mm, wmmry or harm, am, 1+. 1.. in pamuivod a: mom, mum, «ammo a; 'milprovld.‘ The paranoid, woman- Warm. pattern induced by electroshock, is «pendent on a m mm, «mammumauyam-mmtt )ummotpmm. lumbar cramp]: o! the relation be to is laﬂw dolt( ) ( Meow m on the of. electroencephalographic mural mom me: to be- of epileptic patients. ban» )deaeribuoymgapﬂspucmm ordinarilypleaant, and cooperative for his clinic visits. consistently dyarhytmc. drnm, and his 1336 0:: on. occasion he 12. than. no: cum}, an ‘1th delta activity. on the that, records m unable and 31th- mbaoqmt visit, tho m was again dynamo-ac and o a behavioral 'zhtpromnt' nu ma. 51:11::- obumtionawm roporwdbyﬂntt( )mdnnnndor( ). (b) Theo Our , of Electron a . 7 _ studies of the electroshock procesn have demonstrated tho ing. ntemtion in brain function in induced only in whom the greatest degrees of behavioral change max deem delta. activity in the taste as indiceu or altered indioea and sustained as noted. Wannalogm and follow— in patimtl is have mailed positive mobarbitll «:0an function, with the knowledge that other at altered brain Motion, applied in the m sex-1&1 fashion, my �‘16-'- alee show We 3mm alteration and a relation to behavioral change. have been mmeeed that the rating: pf impmvemt are value Judg- ment- of the behavioral response. L11 patient-e induced by electroshock in when cerebral wrest changes in behavior. changes are My certain patterns ere evaluated ee immved, believer. while other! are regerded u "unmoved” Immutiaeeenuespeemeeeeefthebehaviorﬂ. mammoftheeuba of the conditions brain altered function. We Jest recent etudiee have netted a relation of the indueed botanical Our Home was to epeeific peremlity aspecteC ).. Patten“ the neat close]: apprm-mte the “explicit verbal denial" personality greater degrees of denial, dieplem, mu ), ( euphoria and Indie beim'ior (tuning electrosheck therapy. and: edeptetime are frequently rated alarmed", and no clinical my mum at! ”m that the reletieaehip between nationality, behavioral response mm is met clear. to the behavioral reepenee The mutton of other upeete of an new ﬁnder investigation. bother new in the nun: of taproment to the induced W103. 1a the environmental w new endeegativill ledificetim Tb of inﬁll, withdmel to excitement, overactivitw and irritebility my be considered e positive movement by may. The the met-cps.“ but a disorganization by the and maiden or goals of the therapist and the family, and their meantime �4.7 bSnoh phyeiologic milieu for an ultomtion the altered cerebral tmotion provides of the organin‘e edeptive interpersmol behavior. Changes are induced in percep- tion, language, mod. recall, and Judaism mick ponit adaptive intonation: new with the omirmmont to unfold. the type of adaptive behavior induced under these conditions which the is dependent upon the pereondity of the subject; the environment in intonation occurs; and the duration or the state or altered cerebral Man. i similar view of the electroshock process m initially expressed by Weinstun, Kuhn ( Linn and chungoe and behavioral ). who mailed the interrelationship or neurOphyeiologic room”. These etudies amplify clude anothar index or oltered broil: function and «e their obeorvotione to in- the eiootrooneuphlograme delte also broaden their initiol empheeie on the denial pmcoeo fol edeptative response, to include no the only cameo. 0. wide variety of indtcod behavioro under the conditions of altered brain faction. The description of the electroshock procese is also comietent with the observations of more 335;( ), Roth ( .) and Lire 59,5 ). This neurophysiologc-edeptive interpretation of electroshock pronides on operational definilan o! the process which has procaine or further elaboration and obeemtiono. Such an hypothesis also hoe application to an understanding of therapeutic process in insulin com. therapy ( ), lobotav and tronquillieing agents ( )e �.3transient in clinical condition improvement seemed to be related to the in these patients. If we are correct in connecting the EEG changes with the therapeutic effect it would seem, since most of the patients develop typical changes, that the physiological basis for imp EEG change even provement is acquired by the it may or majority of cases; may not prove I effective in promotingxrecovery." In the course of studies of‘g§:ered function brain induced by electro- at the Hillside Hospital\in New York, further data on the relationships between EEG changes and clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the shock EEG with electroshock were confirmed, but between EEu effects and the ailgs‘ca,~ clinical result a demonstrated. was \ I are presented today: (l) The definite relationship . Three foci \\ Engpatterns following electroshock and thein\re1ation to K improvement. (2) yThe intercorrelations of different quantifications of delta activity. (3) The relation of these observations to /////X ”WM SUBJECTS aﬁcijLQn.1 "ﬁ-"MW‘ _ i.-..mwm_w~w T /{1 Ionic ﬂ _ merm”wwww‘wmmm,._V.-c.-»...«——v—~~-"'” aim,” Twenty-four consecutive patients U” §§2_MEEHOD:Z§ _ -m “ﬁlm“-..— a theory of electroshock shock were studi d. "“‘m'w-"MW referred for electro- m4 Electroencephalo rams were done "511* few} 1/4?! Lot/W a“: channel Medcraft instrument , needle electrodes, prior to_treatment? “Ki 8 and bipolar recording was used. Hyperventilation wea-the-ealy-activation 6034’ (L. WLALF Q44. a, ‘ technic g treatment, records were taken earths day'aitasrar?;ézﬁé'"v*ﬁ‘ gurum fitter treatment. generally 25 to 31 hours MLWe 0%, 3» 1'9 CL �this point I should like to summarize our findings and express some thoughts as to their significance for a theory of electroshock action. There is little doubt that electroshock induces delta abnormality in the EEG. It is symmetric, chiefly frontal, but with increasingrtreatment, the'gequencies With became treatment leads. to spreads increasing all At slower, the amplitudes higher, the burst activity longer and more regular. While delta abnormality is present in every repord after electroshock, its degree is variable. Roth's experiment's inducing increasing delta abnormality with barbiturate are significant in predﬁting the later changes induced by further electroshock. In mality some subjects however, a high degree delta abnor- is not induced despite extensive treatment. Our correlations of degree of delta abnonuality with improvement are fgggziéam:ch ism of electroshock.therapy. significant An alterationm cerebral“function and also by the ' as measured by the magma as, amytal test,* ,t'necessary pre-requisite for improvement. EEG, zaﬂkﬂ early, sustained Where such 232:::: (and in the amytal test), chan es fail to occur in the a significant clinical improvement will fail to occur in the patient's behavior. not4ﬁghent The fact that the correlations were with memory loss, points to the possibility that this is not a significant factor in improvement. EEG In conclusion, these studies lend lapport tp a theory of EST enumerated action recently by Weinstein and one of us (Kahn). These authors postulated that improvement following electroshock is the result of the creation in the patient of a milieu of altered brain function in patterns of adaptation, particularly those of denial, may be maintained. Theib EEG studies demonstrate that an altered milieu of cerebral which new function as measured by delta abnormality is a pre-requisite for improvement. To supported. this extent the first part of the Heinstein-Kahn hypothesis is 4M.-. .1 �~5During the tram generally 25 be 31 11611113131381an ( the ) was period. words not. noun lam. Emu-mm, We... may“! Wu on a» ﬂy, following a trauma, all Wit”. test 101' at many intervals, berm, during ”mat “him the Wmtnont WI. manly been mported pntieats organic brain and study mm hi" ). ( thaw-ml electromook tharapy m manicured w the mt: manhunt“, tins using a Bauer 0 h? eleabmatdnulator. Treatment schedules. war. three a week; and the number of ,, Won arm- thorapy, reﬁll“ at this The all!!! wore studied by matmnu varied from to 33. 9 As patients show-d a clinical response, the psychiatrist tended to give fiver and more widely spaced treatments. Thorn are 15 women and 9 man in the can“, and the ages authaudiuoth'h mezhto EVALUATIOE 93‘. ject... 33 3'0nt for three lead “natal-ear W: total at 3.60 records were obtained in muse sub- Stmﬁss ( ) the delta index was the suggestion of minnow 10210) A 69%:de (frontal-parietal, anteriar “moral .. vertex, for 180 seconds of recording for each lead. 1: defined as the per-cont tine occupied by waves at 7 0:16 The delta or SWCI'. and 1W The <36;th and load the highsat kit: for, three the combinations, average 1mm in any om lead combination mm the indim used in ma fin-1 inasmuch. �«17end tolermm', are significant factors in the behavioral nepense of the petieet to therapy, am also, in the rating! a! mane effect. sue teeters an signiﬁcant in the The induced changes improvement. duration of the electroshock in cerebral function persist for 24: weeks only following even intensive courses of ti‘xerepy. In respenee ‘ W eases, the behavioral tenatedtemepeﬂodotalmmmmniologyo patterns of behavior we not adaptive in the mum Thackunged of the patient, and the behavior 'regreeees' to pun-treatise“ patterns. In other instance, the induced behavior in adaptive to the envirement. end, we assume, sustained therett‘ter not by the initial change in brain Noam, developedintencﬁenof subjectuithenﬂmmt. is seen by the milieu is may embd. linen in which 13 cheereetm have doctor, have, and peanut. stem a 1:1in or many. led to the conclusion that electroshock a non-specific induction or pernietent discharge mptive (pemnlihy) utilize devices not otherwise available ta - the mm when Altered cerebral fmetion the subaeeb’e different interaction with the envimmenﬁ These matmiswm only to have a mazrrence of disgusted or discharge in prelude: the pbyeiologic preceesea the newly fmeent mememl adaptation of the patient to the hospital after electroshock, planning but. b y of altered cerebral than” mm. � 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 of Electroencephalographic Changes and Improvement in Electroshock Therapy (research) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-7-007 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource <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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/b574305356446714449f347eaa71e515.pdf 4bf163bfe85fee82b5e7d9be3ad5c243 PDF Text Text Experimental Studies of the Electroshock Process MAX FINK, M.D., ROBERT L. KAHN, In the last seven years, increasing study by various authors“5 of the neurophysiologic alterations occurring in electroshock has resulted in a re-assessment of the mode of action of this form of therapy. The present neurophysiologic-adaptive hypothesisly2 states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in the continuing evaluation of the electroshock process in this laboratory. These include: The relation of changes in neurophysiolog‘ic indices to behavioral change; 2. Types of psychologic response expressed and factors in the evaluation of “improvement;” 1. 3. and The role of personality in the behavioral response. and Method: The studies have been carried out in groups of consecutive, unselected electroshock referrals. The subjects are voluntary patients in an open ward psychiatric hospital. All patients are treated by resident psychiatrists, who make the referral to the elec— troshock therapy unit. The duration and type of therapy, however, are determined by the supervising psychiatrists in charge of the treatment unit. Patients varied in age from 20 to 66, and have been diagnosed as suffering from depressive and schiz0phrenic I. Subjects illnesses. (a) Tests of Brain Function: Two indices of cerebral function have been stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,6 and changes in orientation and aware— ness of illness after amobarbital sodium.7 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided, in part, by grant M-927, National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Read at the Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N. J ., June, 1957. PH.D., and MARTIN A. GREEN, M.D. 1) EEG: Electroencephalograms were done weekly prior to treatment, and on a day following a treatment. Bipolar recording was used, and selected leads were measured fOr the degree of delta activity. The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and slowest frequency of delta, and, the longest duration of bursts were the measures utilized in the classiﬁcation of the recOrds into “high degree]? "‘mod— erate degree” and “low degree delta activity.”6 Amobarbital Test: This is a structured interview, in which the patient is asked a standard set of questions pertaining to ori— entation and awareness of illness. Amobarbital is then administered intravenously, in a concentration based upon body weight, at a rate of 1 cc to every 40 seconds, until nystagmus and slurred speech are induced. In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold} the procedure was modiﬁed to allow for weight differences of subjects. The same questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called “positive” and are indicative of states of altered cerebral function.7 Tests were carried out before electroshock, and at weekly intervals during elestroshock on the day following treatment. (b) Evaluation of Behavior: In addition to the notes of the patient’s therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and 2-4 weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these descriptions. Ratings of improvement 'Were based on the behavioral response two to three weeks after the last treatment, and reﬂect a short term clinical rating. The patients were divided into three groups: much improved, moderately improved and unimproved, based on criteria 2)_ described.2 Reprinted from Diseases of the Nervous System, Vol. XIX, No. 3, March 1958. �(0) Evaluation of Personality .' The initial method of personality assessment employed has been a structured family interview. In their original observations, Weinstein and Kahn described the characteristics of the maintenance of high degree delta activity and short term clinical ratings.6 Of the pa— tients who were rated much improved, 90% had high degree delta EEG records in the 3rd and 4th weeks of treatment, While of the unimproved patients, only 20% had such records. The relationship between delta activity and clinical ratings is seen in Figure 1. “explicit verbal denial personality.”9 To determine the signiﬁcance of this personality type for behavioral response, a structured questionnaire was developed. In interviews OO .— MUCH IMPROVED (u) with two members of the family, the patient’s usual attitudes and interests in 15 90 .-—— moo. IMPROVENG) UNIMPROVEDW) .-.— characEach speciﬁc areas were explored. 80 teristic was rated as being absent, moderately present or markedly present. Scores 7O of 0, 1 and 2, respectively, were assigned, '60 and added—the resulting score being termed 50 the “denial personality score.”1° (d) Treatment: Electroshock was admin- 4o istered on a schedule of three treatments 3. 30 12 week. A minimum of treatments was given, except in a few cases where a. severe 20 confusional state appeared earlier. The course of treatment was determined by the supervising psychiatrist in charge of the lO-lZ electroshock unit, based upon clinical criteria. Treatments were grand mal, using either a Medcraft alternating current instruobservations In these series, subsequent ment or a Reiter C-47 electrostimulator. Pain Based extended predictive were study. a tients were generally premedicated with inthe earlier it on was suggested observations, travenous Pentothal prior to the treatment. those the much that were improved patients In the past year, a subconvulsive therapy been in had whom delta high activity degree group was instituted. Randomly selected induced in and the of treatment course early electroshock referrals received 12-42 suband Records second sustained. the during convulsive treatments, under Pentothal preweeks of third treatment, therefore, were medication. These patients were subjected in 54 consecutive The results assessed. pato the same test procedures and the same bein Table Of I. the noted tients patients are therevaluations mal havioral as the grand delta who degree developed activity high makthe Neither psychiatrist apy subjects. weeks of third second the and treatduring ing the evaluation, the patient’s therapist, while much rated 67% improved, were ment, nor the patient was cognizant of which pawithout the such of 30% aconly patients tients received which form of therapy. The rated. so were tivity data for this series of patients is now being evaluated, and reference will be made only TABLE I to the general observations. Patients With High Delta Activity During II. Observations: Second, Third Weeks of Treatment RATING CLINICAL in Cerebral Role Function of Altered (a) '8 >. Behavior: i’ 75w: a: Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and a 1. .c: EEG Delta Both High (18) One High (16) None High (20) S E to. E 5 8 a 5 12 (67%) 4 (25%) 6 (30%) a; 8 ’5‘ Q sE (22%) 8 (50%) 7 (35%) 4 a D 2 4 7 (11%) (25%) (35%) . �Amobarbital Test In the initial series of 24 patients, ‘previ: ously reported,‘-’ eleven patients were rated as much improved,,andall had positive aniobarbital test reactions after 7 to 9 treatments and sustained this response. Of the unimproved patients, 15% had positive amobarbital responses in the third week and 28% in the fourth week, but these were not Sustained. A comparison of both the EEG observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. In 77 patients tested to date, observations during the second and third weeks of treatment were examined for the presence of high degree delta activity and positive amobarbital test results. Of the much improved patients, 75% had both positive amobarbital tests and high EEG delta activity during this period. Of the unimproved patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a signiﬁcant one; and equally signiﬁcant is the cluster of negative amobarbital tests, low and moderate EEG delta activity and clinical rating of unimproved. TABLE II EEG and Amobarbital Test Results During Second, Third Weeks of Treatmenﬁt 2. :, .c: 8 2 8 Total .................................................... 33 .01 E 3 8 E e s E Both Positive Amobarbital and High EEG Delta Activity ........................ 25 Either Positive Amobarbital or High EEG Delta Activity .......................... 8 Neither Positive Amobarbital nor High EEG Delta Activity .............. O *Significant at better than 2 2 Q E sD 10 3 12 5 3 11 25 19 level of confidence. (b) Clinical Patterns of Behavior: In these patients, we have observed varied responses to electroshock including the absence of noticeable symptoms with a return of pre-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic com.plaints and pre-occupations, states of in— creased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of’behavioral change is seen to be related to the degree of alter'a} tion in the neurophysiologic indices. During electroshock, with the gradual induction of states of altered brain function, and their restitution in the weeks following cessation of therapy, behavior shows characteristic patterns. The following are but a few of the gross patterns that are observed during the period of increasing and waning states of altered brain function. An early change in behavior in retarded subjects, for example, may be a change in the degree of participation in ward activities and increased neatness and interest in personal care. This is succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial of illness, and insistence upon going home. At this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest in the future becomes prominent. Premorbid patterns of behavior are in evidence, and the EEG returns to normal and the amobarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed during treatment, withdraw from participation in hospital activities, and complain increasingly of memory loss, physical distress and insomnia. Amobarbital tests and electroencephalograms may show the same degree of change as in the ﬁrst group. With cessation of treatment, there is either a return to the depressed state, or a persistent emphasis on the memory loss and physical complaints of the treatment. Another pattern, seen in hostile, negativistic and withdrawn patients, is the development of hyperactive, hypomanic, and impulsive behavior. Memory loss is marked, and clinical disorientation and confusion may be noted at the height of neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional for.3 �mation become prominent, to be followed by withdrawal and mutism. (c) Eﬁect of Subconvulsive Therapy: The interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by obser— vations in the subconvulsive group. TWentyseven subjects received subconvulsive therapy instead of grand mal. Minimal changes in the electroencephalogram and in amobarbital tests were induced, and the changes in clinical behavior were limited. The electroencephalograms demonstrated either no delta or a minimal amount of such activity. In no patient were moderate or high degree delta activity records observed. In the amobarbital tests, only three patients had positive tests during treatment, and in each instance it occurred only once. No change in symptoms or behavior was noted in twenty—three. Nineteen were referred for a second course of treatment. Grand mal electroshock in— duced changes in brain function of high de— gree delta activity and/or repeated positive amobarbital tests in fourteen of these. All fourteen showed signiﬁcant changes in behavior; While of the ﬁve patients in whom the physiologic indices showed only minor changes, only two patients showed a deﬁnite behavioral change. (d) Role of Personality in the Adaptive Respouse: Another variable in the adaptive response of the patients is the personality—the habitual attitudes, patterns of perception and behavior and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients showing denial mechanisms to the clinical result. The relatives of 47 patients were interviewed, and denial personality scores assessed. Scores ranged from 0 to 25, with a median of 11. The scores were divided into two groups: scores from 11 to 25 were classed as the “high denial group” and those from 0-10 as the “low denial group.” Of the patients with high denial personality scores (Table III), 58% were in the much improved group, and only one patient (4%) was in the unimproved group. The ratings of improvement for the patients with low denial personality scores were random—'4 about one third appearing in each rating category. TABLE III Relation of Denial Personality Scores to Clinical Response to Electroshock Personality Score 11-25 0-10 Total Much Improved 14 Moderately Unimproved Improved 7 9 9 1 7 21 18 8 Total 24 23 47 The difference in the denial scores between the much or the moderately improved patients, when compared to the unimproved patients, is statistically signiﬁcant. That the personality ratings were indeed reﬂective of the patients’ adaptive response under the conditions of altered brain function is noted in the correlation of these scores with actual changes in language patterns which had been described11 as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classiﬁed according to whether he showed three or more explicit language changes. The group of patients With high denial personality scores showed a signiﬁcantly greater number of language changes than patients with low personality scores. The coefﬁcient of correlation is +.71, which is signiﬁcant at better than the 1% level of conﬁdence. Discussion: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn,1 and again by Kahn, Fink and Weinstein,2 and the observations of Roth,3 Aird,4 and Ulett.5av Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. We have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital as indices of altered brain function. Other measures, applied in the same serial fashion, will, we believe, demonstrate the same relation to changes in behavior or alteration in brain function. Under the conditions of the induced 111. ‘0 �change in brain function, altered patterns of adaptation are expressed.» The type of adaptation varies, apparently dependent upon the personality organization. In these studies we have noted the relationship of an “explicit verbal denial” personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews.11 We have observed that patients with high denial scores are those who are more likely to be evaluated as “much improved” (Table III). The type of adaptation is varied, however, as we have described here. In this context, therefore, the conclusion is afﬁrmed that electroshock is a means of inducing change in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. We have emphasized “change in behavior” in this report. In previous studies, we related our observation to “improvement.” “Improvement” is a derivative evaluation of the induced behavioral change, which is dependent upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, who had been withdrawn, crying, and had expressed suicidal thoughts, no longer is seclusive, and is jovial, friendly and euphoric, denies his prob— lems and sees his previous thoughts of suicide as “silly,” a rating of “much improved” is made. To the extent that a schizophrenic patient is perceived as less delusional, less excited, and less Withdrawn, he is rated as “improved.” When, however, the induced behavior is one of increased anxiety and fear— fulness, or persistent complaints about memory loss, pain or other physical symptoms, or excitement and delusional thoughts, a rating of “unimproved” will be made. These studies amplify the present neurophysiologic-adaptive hypothesis of electroshock action. Further studies, deﬁning the signiﬁcant aspects of personality and of the expectations of the environment on the patterns of behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquilizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. IV. Summary and Conclusions: 1. This report summarizes continuing experimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an alteration in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The pattern of behavioral alteration is shown to vary markedly, depending upon the degree of induced cerebral dysfunction, the personality of the subject and the environmental situation. 4. “Improvement” ratings are seen as a special case of behavioral change dependent upon the type of adaptation elicited, the expectation of the therapist, administrator and family, and the tolerance of the milieu. 5. The extension of this neurophysiologicadaptive hypothesis of electroshock action to other forms of somatic therapies is suggested. 1. REFERENCES Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat, 109: 22-26, 1952. 2. Kahn, R. L., Fink, M., and Weinstein, E. A.: Re- lation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. and Psychiat., 76: 23-29, 1956. 3. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive Treatment and Their Signiﬁcance for the Theory of EST Action. EEG 01m. Neurophysiol., 3: 261-280, 1951. 4. Aird, R. N., Strait, L. A., Pace, J. W., Hernoff, M. K., and Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. Arch. Neurol. and Psychiat, 75: 371-378, 1956. 5 a. Ulett, G. A., Smith, K., and Glesser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group. Am. J. Psychiat, 112: 795-802, 1956. 5 b. Ulett, G. A., Glesser, G. C., Caldwell, B. M., and Smith, K.: The Use of Matched Groups in the Evaluation of Convulsive and Subconvulsive Photoshock. Bull. Merm. Olin, 18: 138-146, 1954. 6 a. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Olin. Neurophysiol., 8: 158 (Abst.) 1956. �6’ b. . . Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. Arch. Neurol. and P31chiat, 78: 516-525, 1957. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112: 889-894, 1953. Shagass, C.: The Sedation Threshold. A Method for Estimating Tension in Psychiatric Patients. EEG Clin. Neurophysiol., 6: 221-233, 1954. : . Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol.» and Psychiat, 69: 355-367, 1953. . Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock. Therapy. Conf. Neural. (In Press.) 11. Kahn, ;R. L., "and Fink, M.: Changes in Language During Electroshock Therapy in Psycho~ pathology of Communication (Hoch, P., and Zubin, J ., Eds.). Grune and Stratton, N. Y., 1957. (In press.) 10. _ ��.thv- AyiAuu. .gypZZILu Experimental Studies of the Electrcshock Process Max Fink, 14.13., Robert L. Kahn, 31.1). and Martin A. Green, M.D. From the Department of Experimental Psychiatry, Hillside HOSpital, Glen Oaks, N.Yo of Mental Health, part, by grant M—927, National Institute Service. Health Public U.S. of Health, National Institutes Aided, in Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N.J., June, 1957. Read Vo at the 6‘27-S7 �-2Experimental Studies of the Electroshock Process In the last seven years, increasing study by various authors (1-5) of the neurophysiologic alterations occurring in electroshock has re- sulted in a re-assessment of the The mode of action of this fcnm of therapy. present neurophysiologic-adaptive hypothesis (1,2) states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in this laboratory. in the continuing evaluation of the electroshock process These include: relation of changes in neurophysiologic indices in behavioral change; 1) The 2) types of psychologic response expressed and evaluation of "improvement;" and 3) the role of personality factors in the in the behavioral response. �II. -3“ Subjects and Method: studies have been carried out in groups of consecutive, unselected The electroshock referrals. ward subjects are voluntary patients in an The open psychiatric hospital. All patients are treated. by resident psychiatrists, who make the referral to the electroshock therapy unit. type of therapy, however, are determined by the supervising unit. Patients varied in age from charge of the treatment have been diagnosed as sufferina from depressive (a) Tests of Brain Function: have been Two duration and The psychiatrist in 20 to 66, and and schizophrenic illnesses. indices of the cerebral function stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,(6) and changes in orientation awareness of illness after amobarbital sodium (7). 1) Egg: Electroencephalograms were done.weekly ment, and on a day following a treatment. selected leads were measured and prior to treat- Bipolar recording was for the degree of delta activity. used, and The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and Slowest frequency of delta, and the longest duration of bursts were the measares utilized in the class- ification of the records into "high degree," "moderate degree" and "low degree delta activity" (7). 2) Amobarbital Test: This the patient is and awareness asked a standard set of questions pertaining to orientation of illness. Amobarbital is then administered intravenously, in a concentration based seconds,% is a structured interview, in which upon body weight, until nystagmus and at a rate of 1 cc slurred speech are induced. to every ho The same 1"“.% In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold (8), the procedure was modified to allow for weight differences of subjects. �~12.- questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called "positive" and are indicative of states of altered cerebral ftnction (7). Tests were carried at weekly intervals during.electroshock out before electrodiock, and day on a after a treatment. (b) Evaluation of Behavior: In addition to the notes of the patient's therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and Z-h weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these on descriptions. Ratings of the behavioral response reflect a short term groups: much improved, described ( two to three clinical rating. weeks The improvement were based after the last treatment, patients were divided and into three moderately improved and unimproved, based on criteria ). (c) Evaluation of Personality: The initial method of personality assessnent employed has been a structured family interview. In their orig- inal observations, Weinstein and Kahn described the characteristics of the "explicit verbal denial personality" (9). To determine the significance of this personality type for behavioral reSponse, a structured questionnaire was developed. In interviews with two members of the family, the patient’s usual attitudes and interests in 15 Specific areas were explored. Each characteristic was rated as being absent, moderately present or markedly present. Scores of 0, l and 2, reapectively, were assigned, and added - the resulting score being termed the "denial personality score" (10). (d) Treatment: Electroshock was administered on a schedule of three treatments a week. A minimum of 12 treatments was given, except in a few �cases where a severe confusional state appeared ment was determined by earlier. The course of treat- the supervising psychiatrist in charge of the electro- unit, based upon clinical criteria. Treatments were grandznal, using either a Medcraft alternating current instrument or a Reiter C-h? electro- shock stimulator. Patients were generally premedicated with.intravenous pentothal prior to the treatment. In the past year, a subconvulsive therapy group was instituted. Randemxy selected electroshock referrals received 12-h2 subconvulsive treatthe ments, under pentothal premedication. These patients were subjected to same test procedures and the same behavioral evaluations as the grand mal therapy subjects. Neither the psychiatrist making the evaluation, the patient's therapist, nor the patient was cognizant of which patients received which.form of therapy. The data for this series of‘patients being evaluated, and reference will be made only is now to the general observations. �III. Observations: A. Role of Altered Cerebral Function in Behavior: 1. Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and maintenance of high degree delta activity much and short term clinical ratings (6). or the patients who were rated weeks of improved, 90$ had high degree delta EEG records in the 3rd and hth treatment, while of the unimproved patients, only relationship between delta activity and 20% had such records. The clinical ratings is seen in Figure 1. In subsequent series, these observations were extended in a predictive much study. Based on the earlier Observations, it was suggested that the improved patients were those in high degree whom delta activity had been in the course of treatment and sustained. Records during the ant third weeks of treatment, therefore, were assessed. The results induced early second in Sh consecutive patients are noted in Table 1. veloped high degree delta ment, such 67% rated were activity were activity during the second much improved, so while only EEG High Delta and who de- third weeks of treat- of the patients without I Activity During Second, Third‘weeks of Treatment. Clinical Rating Much Imgroved Delta 30% the patients rated. TABLE Patients with Of Mbderately'lrunnved Unimproved (11%) Both High (18) 12 (67%) h (22%) 2 (16) u (25%) 8 (50%) h (25% None High (20) 6 (30%) 7 (35%) 7 One High (35%) �a7; 2. AmObarbital Test: In the of 2h patients, preViouSly reported (2), initial series eleven patients were rated as testreactions after 7 to much improved, and all 9 treatments and sustained had positive amObarbital this response. 0f the positive amobarbital reaponses in the third week and 28% in the fourth week, but these were not sustained. A comparison of'both the EEG Observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. unimproved In 77 patients, 15% had patients tested to date, observations during the second weeks of treatment were examined activity 75% and had both and third for the presence of high degree delta positive amobarbital test results. positive amobarbital tests Of the much improved and high EEG patients, delta activity during patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a significant one; and equally significant is this period. Of the unimproved the cluster of negative amobarbital activity and tests, low and moderate EEG clinical rating of unimproved. delta �9 ..—-- m TABLE EEG II and Amobarbital Test Results During Second, Third Weeks of Treatment.* Much Mbderately Improved gnimprovsd Improved Both Pbsitive Amobarbital and High EEG Delta Activity 25 10 3 Either Positive Amcbarbital or High EEG Delta Activity 8 12 5 _£L_ L (25) Neither Positive Amdbarbital nor High EEG Delta Activity (33) (Total) B. 1.1 (19) Clinical Patterns of Behavior: In these patients, we have observed including the absence of noticeable varied responses to electroshock symptoms with a return of yrs-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic complaints and preoccupations, states of increased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of behavioral change is seen to alteration in the neurophysiologic indices. brain During electroshock, with the gradual induction of states of altered function, and their restitution in the weeks following cessation of therapy, be related to the degree of behavior Shows characteristic patterns. The following are but a few of the are observed during the period of increasing and waning gross patterns that states of altered brain.function. Anearly change in behavior in retarded subjects, for example, rO-‘ﬁ’lt. * Significant at hotter than .01 level of confidence. x»,-~-n---.' ~rmw-n. may it...“ �be a change in the degree of neatness and participation in interest in personal care. This ward is activities and increased succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest of illness, and in the future insistence upon going home. becomes prominent. Pre-morbid evidence, and the EEG returns to normal At patterns of behavior are in and the amdbarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed and during treatment, withdraw from.participation in heapital activities, Amocomplain increasingly oi memory loss, physical distress and insomnia. barbital tests and electroencephalograms may show the same degree of change as in the first group. with cessation of treatment, there is either a return to the depressed state, or a persistent emphasis physical complaints of the treatment. Another pattern, seen is the loss is on the memory loss and in hostile, negativistic and withdrawn patients, development of hyperactive, hypomanic, and impulsive behavior. Memory marked, and clinical disorientation and confusion may be noted at thelieight o£1neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional formation become prominent, to be followed by withdrawal and mutism. C. Effect of Subconvulsive Therapy: interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by observations in the subconvulsive group. Twenty-seven subjects received subconvulsive The �~10; electroencephalogram therapy instead of grand mal. Minimal changes in the behavior and in smobarbital tests were induced, and the changes in clinical limited. The electroencephalograms demonstrated either no delta or were a minimal amount of such activity. In patient no were moderate or high activity records observed. In the amobarbital tests, only each instance three patients had positive tests during, treatment, and in it occurred only once . No change in symptoms or behavior was noted in degree delta treatment. twenty-times. Nineteen were referred for a second course of degree Grand mal electroshock induced changes in brain function of high delta activity and/or repeated positive amobarbital tests in fourteen of while of the these. All fourteen showed significant changes in behavior; five patients in whom the physiologic indices showed only minor changes, only two patients showed a definite behavioral change. of Personalitywin the Adaptiverg‘e‘spggg: the Another variable in the adaptive response of the patient is and behavior - the habitual attitudes, patterns of perception 1). Role personalitw and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients mechanisms to the clinical result. The showing denial relatives of h? patients were inter- Scores ranged from viewed, and denial, personality scores assessed. O to 25, scores were divided into two groups: scores from and those from O - 10 as 11 to 25 were classes as the "high denial group" with a median of 11. the “low denial The gar-mp." 0f the ,.latients with high denial personality scores (Table 58%; were in the much improved group, and. only one patient (1%) was III), in �911- the unimproved group. The ratings of for the patients with - about one third appearing in improvement low denial personality scores were random i each rating category. lean; Relation of Denial Personality Scores to Clinical Response to Electroshock Much Improved Moderately Improved Unimpmved Total M9&1}EI., §9ar£ 11 — 25 1h 9 1 2h 0 - 10 7 9 7 23 21 18 8 h? Total The difference in the denial scores between the improved patients, when compared to the unimproved much or the moderately patients, is statistically significant. That the personality ratings were indeed reflective of the patients' adaptive reaponse under the conditions of altered. brain function is noted. in the correlation of these scores with actual changes in language patterns which had *een described (11) as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classified according to whether or not he shone 6. three or more explicit language changes . The group of patients with high denial personality scores showed a significantly greater number of language changes than patients with low personality scores. The co- efficient of correlation is +.7l, which is significant at better than the 1% level of confidence. �IV. Discussign: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn (l) , and again by Kahn, (3), Aird (’4), and Ulett (5a, b). Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. He have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital Fink and 'E-i‘einstein (2), and the observations of Roth as indices of altered brain function. Other measures, applied in the serial fashion, will, we believe, demonstrate the in behavior or alteration in brain function. Under the conditions of the induced change same same relation to changes in brain function, The type of adaptation altered patterns of adaptation are expressed. these varies, apparently dependent upon the personality organization. In studies we have noted the relationship of an "explicit verbal denial" personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews (11) . We have observed that patients with high denial scores are those are more likely to who The type of adaptation be evaluated as is varied, "much improved" (Table III). however, as we have described here. In this context, therefore, the conclusion is affirmed that electroshock is a in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. means of inducing: change We have emphasized " change in behavior" vious studies, we in this report. In pre- related our observation to "improvement." "Improvement" �:13- derivitive evaluation of the induced behavioral change, which is dependend upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, is a who had been withdrawn, is seclusive, and crying, and had expressed suicidal thoughts, no longer is jovial, frienc‘ly and euphoric, denies his problems and sees his previous thoughts of suicide as is made. To "silly," a rating of "Inuch improved" the extent that a schizophrenic patient delusional, less excited, and less however, the induced behavior one is perceived as less rated as "improved." When, of increased anxiety and fearmlness, or loss, pain or other physical symptoms, or delusional thoughts, a rating of "unimproved" will be made. persistent complaints about excitement and is t-Iithdrawn, he is memory studies amplify the present neumphysiologic-adaptive hypothesis of electroshock action. Further studies, defining the significant aspects of personality and of the expectations of the environment on the patterns of These behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquillizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. �V. gunnery and. Conclusions: 1. This report sumarizes continuing esperimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an altera- tion in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The depending upon the subject 1;. pattern of behavioral alteration is shown to vary markedly, the degree of induced cerebral dysfunction, the personality of and. the environmental situation. "Improvement" ratings are seen as a Special case of behavioral the type of adantation elicited, the expectation of the therapist , adninistrator and family, and the tolerance of the milieu. change dependent upon this neurophysiologic-adaptive hypothesis of electmshocl: action to other forms of somatic therapies is suggested. S. The extension of �m REFEIUQI‘ICES l. Juno‘s—t Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its relation to the Theory of Shock Therapy, Am. J. Psychiat” 109: 22-26, 1952. of Amobarbital 1. and Weinstein, E.A.: RelationA.I—-I.A. Arch. Neurol. Electroshock, in Test to Clinical Improvement 1956. and Psychiat., IQ: 23-29, Roth, 1-1.: Changes in the EEG under Barbiturate Anesthesia Proclucec‘v by Electro-Convulsive Treatment and their Significance for the Theory of EST Action, EEG. Clin. Neurophysiol., _3.: 261-280, 1951. Kahn, R.L., Fink, 3. h. Pace, J.EI., Hernaff, M.K. and Bowditch, 5.0.: Neurophysiologic Effects of lectrically Induced Convulsions, A.:-I.A. Arch. Neurol. and Psychiat., 15: 371-378, 1956. Aird, Ran, Strait, L.A., . G.A., Smith, K. 5a. Ulett, Subconvulsive Shock and Gleeser, G.C.: Evaluation of Convulsive and Therapies Utilizing a Control Group, Am. J. Psychiat., 112: 795-802, 1956. 5b. Glasser, G.C., Caldtrell, B.M., and Smith, K.: The Use of I'iatched Groups in the Evaluation of Convulsive and Subcommlsive Biotoshock, Bull. Mann. 015.11., 6a. 6b. _1__8_: 138-1h6, 1951.. H. and Kahn, R.L.: Quantitative Studies of Slow Wave Followi.n:_; Electroshock, EEG Clin. Neurophysiol” _8_: 158 Fink, Activity (Abst.) 1956. EEG Delta Activity to Behavioral and ___: Relation of Response in hilactroshock: Quantitative Serial Studies, A.itI.A. Arch. Eleurol. and Psychiat. (in press). 7. E-Jeinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.:Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic Brain F‘lisease, Am. J. Psychiatu .133: 889-89h, 1953. 8. Shagass, C. : The Sedation Threshold. 9. Weinstein, E.A. and Kahn, R.L.: Personality Factors in Denial of illness, in Psychiatric Patients, A.1-I.A. Arch. Neurol. and EEG A Method for Estimating Tension Clin. Neurophysiol., Psychiat., _6_: 221-233, 1951;. 99;: 355-367, 1953. Parsonality Factors in Behavioral to Electroshock Therapy, Coni‘. Neurol., (in press) Response 10 . Kahn, R.L. and Fink, 14.: 11. Kahn, R.L. and Fink, 141.: Changes in languAge During Té‘lectroshock Therapy, in P cho tholo g; Comunication (Hoch, P. and Zubin, J., 13623.), Grune and tratton, N.Y., 1957. (in press). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental studies of the electroshock process. Dis Nerv Syst. 1958 Mar;19(3):113-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-30-007 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and reprint. Reprint from Diseases of the Nervous System, Vol.XIX, No.3, March 1958 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/549693df019a0cabd2aa7cfa90ad3ced.pdf 62db1d0b502fce82996214e0276f034a PDF Text Text ’i' WM 3mm; lacunae Whammy mum. a: convulsive ma Ems in 1:33,“;ant W Mhim Fth mm m 1-. 0-. A. 3.1% of mmm mmm, m the mam. mm m, 34.1., $1”. W Hakim}. W? of the Unﬁml Wﬁm%_ a! Manta Insti‘MkaWWith, mm ﬁﬂm mm: mm 80m“. He: 33.113169 -' Aldus! 3.33.1513, 01' a Se Wolagiaal W an arm mmg, Howof1m 3mmandm- ammal Psychiatry, Kw Yam assuming mum may, of 10-613mm, ﬂu: Kerk, 13., 1953:. Promtud a mama: . » ‘ 5.. #- sky and Mb �II: 3-1148 Experiment-3. 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Drug: a hammme, dict-hum am! ”mains, Wars: mm and illusory Momma. mamlihathat WW“: and «9:9me sedation and trwquinsaﬁm, but that man“ we avmahmnuaticm, with than; of mam mooted by manna-d and in 11191 dosage inch-1m maisty, obnmtians are clarity maniatent when awclw in him mam of marginal: and . . raga-Glen of the mm“ a: am am amum, shifts in tha pattern a: m alwtrmaephalogrm in thy dimtim of domchmiumm new in “mam um Maw, >ha11ueimtiom, fantasies, illusions or tremors, and in with mgriu, mlmtian 801: alum and Mammal of mahmniuuam ‘meﬁ pursuant clung” in mabrai imam “feat behavior mm mm»:- m with an ﬂ'heﬂtiﬁn in tbs in. 91' than we; *memd' or 'abutomtéd.‘ antral mam mm mum, thaw an upon“ a: mam:- including .mpmn, ma, arm, attitudo. mo aéaptive :11 not Rather, is an alarmist: mam-Wt. We mdar an“ conditimn in variable �.43.. fer eeeh eebJeet end is Gee-Wt mm. W puma-3.1m and the duration of the dieeueeed in behavior are “Wamhtﬂ matteetere es the type at teierenee, nether abut-term with; . ehenge 1d net "do eve-Tented by the The” rating; “may hem no value psychiatrist as 3W, mentions. a. . «2qu In this meta-e3" the Mamie men”, they men in «relented ale inpmtehent. Ahmed the Wed behavioral name, Mm temwmnw The induce a hehmveral alteratim or eerehrel Imam themem net I ‘cmlieetien' or [In *entemw «new but the chaired goal ef these fame of during the peat the therapy . Mum. u automate w the individual hehevierel new. to the degree of upon and alteration in brain renewal: have The inﬂated ehe’epe e W “mm mm mmmm and mix-Wm on harem. er the may tine-guest therapies intmchxeeé thirty rem, me eppehenﬂye has been a. epeeitie agent fer a: psycho»: (in the tense mat penieil‘lin 1e emeiﬂe Tar WW! and nieetmic mid for pellegm émntia) , but rather with greater or lesser degrees of epplieehmty behavior by altering the hombre}. when. and mm etiieaey in altering �, in m, we hm: mm the nmmsiologie upsets at, mm WW3 woman, and hm «minded am; the therapeutic pram of ammonia, insulin can, mtw and trmqnilimrs my Mutant Ilka-mum in «new in uhptaticm at ﬁn mama. mm; pmm the silica a» s. be 3.36de to tha inductian at .J‘mbsactb his 1- , a em Wt. the «ﬂaw at web mutant. mthod in mm to its mmw w W a pursuant. «hung: in! mmbml functim, of mm m «It: shift in the m 'speom with Wad mum“ may but a, amuimt W. management of Such a ' a» bu appliabﬂity in m m at those thumping to the scram of m payohophﬁmuolngia agents. and as 3 arms of mnmﬁzysioﬁmwu atom m further new of Matter and" � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental studies of convulsive and drug therapies in psychiatry: theoretical implications. Arch. Neurol. Psychiat. (Chic.), 80:733-734, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-33a-010 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0a85dc880c126770a2f4471ab91c4072.pdf 44a73db773213930685e535c3d7c50a0 PDF Text Text Inhalant—lnduced Convulsions MAX FINK, M.D.: ROBERT L. KAHN. Ph.D.: ERIC KARP. B.A. MAX POLLACK. Ph.D.; MARTIN A. GREEN. M.D.: BARRE ALAN, MD. AND HENRY J. LEFKOWITS. M.D. GLEN OAKS. LONG ISLAND, N.Y. �Reprinted from the Archives of General Psychiatry March 1961, Vol. 4, pp. 259— 266 Copyright 1961, by American Medical Association llHllllllll|llllllllllllllllll||llllllllll||llllllllllllllllllllllllllllll MAX FINK, M.D. ROBERT L. KAHN, Ph.D. Inhalant—Induced Convulsions Signiﬁcance for the Theory of the C onvulsive Therapy Process Despite many years of investigation of the convulsive therapy process, there is still much controversy concerning the importance of the seizure itself. Most studies have concluded that the convulsion is a necessary index of cerebral change essential to clinical behavioral change.9'1°'1‘53?"39 Some investigators, nevertheless, have assigned signiﬁcance not to the seizure but to such factors as the psychological meaning of the treatment to the patient, feelings of fear, and the repeated loss of consciousness.3'4'28 The early studies of Kalinowsky et a1.24 and Pacella et al.,3‘0 demonstrating both clinical and electrographic differences be— Submitted for publication Aug. 26, 1960. From the Department of Experimental Psy— chiatry, Hillside Hospital. Aided by grants MY-2092 and M—927 of the National Institute of Mental Health, US. Public Health Service. g ERIC KARP, B.A. MAX POLLACK, Ph.D. MARTIN A. GREEN, M.D. BARRE ALAN, M.D. AND HENRY J. LEFKOWITS, M.D. GLEN OAKS, LONG ISLAND, N.Y tween grand mal and petit mal treatments indicated the signiﬁcant role of the seizure. The various studies comparing convulsive with subconvulsive treatment demonstrated that techniques culminating in a convulsion were uniformly associated with measurable degrees of neurophysiologic and behavioral change, while subconvulsive techniques were not.1‘5'1’7"°’3‘40 In recent studies from this laboratory, similar differences in the 2 treatment types were observed for such aspects of behavior as EEG slow-wave ac— tivity,8’10 language changes after amobar— bital,19"21 and perceptual tasks. 1'3 22 25 A second aspect to the problem of under— standing convulsive therapy concerns the relation of the method of inducing the seizure to the therapeutic outcome. Seizure duration, type of current, and electrode placemerit are among the variables that have 65/259 �ARCHIVES OF GENERAL PSYCHIATRY been studied. While the investigations indicate that changes in behavioral and neurophysiologic indices are related to these parameters, the differences reported for the various seizure—producing methods are small and statistically insigniﬁcant. Major differ— ences, however, are observed between seizure and nonseizure groups. For example, in a recent monograph, Ottosson reported an increase in the duration of unmodiﬁed electrically induced seizures compared with those modiﬁed by premedication with lido— Although the lidocaine—treated pa— tients showed less change in indices of anxiety, retardation, and global behavior than patients treated with unmodiﬁed seizures, the differences were not signiﬁcant. In our studies, while seizure duration 17 and type of current 11 have been related to the degree of behavioral and neurophysio— logic change, there were no differences with relation to therapeutic outcome. Thus, while parameters of the seizure method may bear some relation to therapeutic efﬁcacy, the differences are slight among the techniques, provided that grand mal seizures have been induced. Further exploration of the importance of the seizure was made possible by recent experimental interest in seizures induced by inhalant (hexaﬂuorodiethyl ether, Indoklon,7), and intravenous (PM—10906) agents. This study was undertaken to com— pare the electrical and inhalant seizure—pro— ducing methods with regard to effects on clinical behavior, interseizure electroenceph— alogram, and psychologic test performance in order to clarify the role of the mode of seizure induction in the convulsive therapy process. caine.’29 ‘ In a voluntary psychiatric hospital 27 consecutive unselected patients referred for convulsive therapy were randomly divided into 2 groups using a Gellerman order.16 In 12 patients, convulsions were induced by a Medcraft alternating current in— strument using suprathreshold currents, and in 15 others by inhalation of hexaﬂuorodiethyl ether, following the method of Esquibel et al." Premedication in all cases was limited to sublingual atropine (1.0 mg). Treatments were administered 3 times per week for 10 to 24 applications, the total num- 66/260 her being determined by the clinical judgment of the staff psychiatrist. Ages ranged from 19 to 58, with a mean age of 38.5 years in the electric convulsive therapy (ECT) group; and 19 to 49, with a mean age of 35.5 years in the hexaﬂuorodiethyl ether group. The mean years of education were 11.5 years (ECT) and 12.6 years (hexaﬂuorodiethyl ether). Of the 27 subjects, 12 were classiﬁed as depressive psy— choses, 8 as schizophrenia, mixed type, and 7 as schizophrenia, paranoid type. The distribution of diagnoses, age range and years of education within the 2 samples, did not differ signiﬁcantly. Behavioral change was evaluated weekly in interviews by the patient’s therapist and by the staff psychiatrist. Such aspects as mood, ideation, memory, sleep, appetite, speech patterns, participation in group activities, and relation to staff and to other patients were recorded and changes assessed qualitatively. Electroencephalograms were done prior to treatment, weekly during the treatment course on a day after a convulsion, and 2 weeks after the last treatment. Records were measured for the amount of induced slowing (6 cps and slower) in anterior temporal-vertex leads, in 66 second samples.8 Various psychologic procedures were administered prior to treatment, during the fourth week (10—12 treatment period), and 2 weeks after the last treatment. The measures included Wechsler— Bellevue subtests (information, digit span, object assembly, and digit symbol) ; Gottschaldt type embedded geometric ﬁgures”; perceptions of pseudo— isochromatic embedded colored ﬁgures at high-speed tachistoscopic exposure,31 and a modiﬁed California F Scale.28 In addition, spine x-ray studies were done prior to and at the end of the treatment course. Observations Clinical Behavior.—The inhalation of hexaﬂuorodiethyl ether regularly resulted in a grand mal convulsion, similar to that induced electrically. For the hexafluorodiethyl ether group, induction was slower and the initial cry and opisthotonic posturing were often omitted. In clonic and tonic manifestations, postseizure apnea, and post— seizure behavior, the groups resembled each other closely. In short term evaluations of clinical be— havioral change, the types of behavior manifested were similar in the two groups. Patterns of denial, hypomania, withdrawal, somatization, paranoid excitement, and confusional—memory loss were observed in both 1. Vol. 4, March, 1961 �INHALANT—INDUCED CONVULSIONS TABLE l.—Beham'0ral Patterns TABLE No. of Subjects Recovered Much Improved _—A_. ,_._ Indoklon * ETC Eupho;ia, denial, hypomania Somatization, withdrawal Severe confusion, memory loss 6 6 3 7 2 3 Improved Unimproved Indoklon 7 .5 E C ’1‘ 3 6 5 1 x2 * 2,—Discharge Evaluations < 1.0, not signiﬁcant. Hexaﬂuorodiethyi other. populations with approximately equal frequency (Table 1). Complication rates were similar. While patients tolerated the inhalation procedure, there were frequent episodes of breath holding and leakage about the mask, making this induction less reliable. Fractures were observed radiographically in 3 patients treated with hexaﬂuorodiethyl ether and in during ECT. Administrative evaluations of clinical improvement at the time of discharge from the hospital were equivalent (Table 2). Ratings of recovered and much improved were recorded for approximately half of each group. 2. Electroencephalography.—Interseizure serial electroencephalograms, both qualita— tively and quantitatively were similar in the 2 groups. Progressive symmetric slowing of dominant frequencies and an increase in voltages were apparent in all leads, with frontal and anterior—temporal preponderance. Burst and occasional spike formations were noted in both. Quantitative measures of induced slow—wave activity during each week of treatment were not signiﬁcantly different (Table 3), although the maximum EEG change appeared earlier in the hexaﬂuorodiethyl ether group than in the ECT group. 3 TABLE N o. 3. Psychologic Measures.—Intergroup analyses (Mann Whitney U Test) of the observations for each of the psychological tasks revealed no difference prior to treat— ment, during the fourth week, and 2 weeks after treatment for the 2 treatment groups. Intragroup analyses, however, showed con— sistent changes in various measures from pretreatment to the fourth week; and from the fourth week to 2 weeks after treatment (Table 4), both in the hexaﬂuorodiethyl ether and in the ECT groups. In the Wechsler—Bellevue subtests, group means showed a signiﬁcant decrease in scores (poorer performance) for each sub— test during treatment, and a return to pre« treatment levels in the post-treatment period. One subtest, object assembly, demonstrated signiﬁcantly increased scores after treatment. Similar patterns were observed for the tachistoscopic measures and the F scores. While increased errors on the embedded ﬁgure tests were observed during treatment, the difference was not signiﬁcant. After treatment, the errors in this test decreased signiﬁcantly from pretreatment scores. On the F scale there was an increase in scores with treatment, and a decrease following treatment. For each of these measures, both treatment groups reﬂected a similar pattern of change. 3.—Postconvulsive EEG Slow-Wave Activity (Average % Time) Pretreatment 4-6 Rx 7-9 Rx Wk. After Last Treatment 2 10-12 Rx Indokl'm 15 6.0 29.4 50.3 51.2 16.8 E CT 12 4.0 29.8 39.2 47.5 18.0 Fin/a et al. 67/261 �ARCHIVES OF GENERAL PSYCHIATRY TABLE 4.———Eﬂect of Hexaﬂnorodieth'yl Ether and Electrically Induced Seizures on Psychologic Test Performances (Scores Expressed as Mean Differences) Pretreatment and Fourth Week 1. Wechsler-Bellevue (weighted subtcst score) ((1) Information (b) (c) ((1) 2. 3. 4. Digit span Ind ECT Ind Ind ECT Ind Digit symbol ECT Ind Tachistoscopy (errors) Ind ECT Ind ECT F scale +1.5 1 +1.7 T +2.7 T +2.3 1 +4.1 * +4.81 +3.3 1 +2.3 1 —1.3 —2.4 * +0.2 T -—0.7 —l.9 * +0.8 . —0.4 +2.7 ‘ +3.5 +0.8 1‘ —0.1 —6.5 —4.9 +9.7 * +8.2 * +2.0 +3.3 +7.7 1 +5.2 1 ECT Embedded ﬁgures (errors) Fourth Week and Post-Treatment —2.7 ’ —1.4 —1.3 —2.5 ’r —2.4 I EC‘I‘ Object assembly Pretreatment and Post-Treatment —16.2 —13.1 i ——4.1 1 ——2.1 ——2.6 t ‘ —-—5.9 I --11.6 I —3.9 +1.2 ——4.0 T Ind = Indoklon (hexaﬂuorodiethyl ether). Using Wilcoxon’s T for paired replicates: * p < 0.02' ’r p < 0.05. EEG Correlations. The changes in performance on the psy— chologic tasks from the pretreatment to the fourth week testing period were signiﬁcant— ly related to the degree of induced EEG slow—wave activity for both groups (Table 5). Rank order correlations demonstrated that decrements in performance on the 4. Test Performance: Wechsler-Bellevue digit span and object as— sembly subtests, tachistoscopy, and em— bedded ﬁgures tasks were signiﬁcantly related to the amount of electrographic change. Similarly, an increase in F score was associated with increased EEG slowing. When the observations in the hexaﬂu— orodiethyl ether and ECT groups were individually analyzed, signiﬁcant correla— tions were noted for various tasks. In the hexaﬂuorodiethyl ether group, the deerement TABLE ~ Indoklon ECT Indoklon and ECT ‘ p < in < 68/262 :0 < 0.01. in the Wechsler—Bellevue information and digit span subtests and in tachistoscOpy was related to the degree of EEG slowing. In the ECT group, similar relations were noted for tachistoscopy, Wechsler-Bellevue digit span, and object assembly subtests and the F score. Comment Mode of I ndnction.——The inhalant and the electrically induced seizure groups were indistinguishable on the various measures of behavior at each stage of the treatment process. Since the factor common to both treatments was the induction of seizures and not the method of induction, we may conclude that the method of induction is not a signiﬁcant variable in the therapy be— in the Speciﬁcally, changes process. 1. 5.—Change in Task Performance and Degree of EEG S low—Wave Activity (Pretreatment vs. Fourth Week; Rank Order Correlations) Wechsler-Bellevue Form , I 1 Information Digit Span Object Assembly Symbol 0.73 " 0.28 0.25 0.54 i 0.72 i 0.61 ‘ 0.31 0.60 0.46 0.38 0.34 0.31 1‘ T Digit Tachistoscopy 0.62 0.80 0.67 T * * Embedded Figures 0.13 0.37 0.43 T F Scale 0.12 0.66 0.38 ’r ’r 0.01 0.05 Vol. 4, March, 1961 �INHALANT—INDUCED CONVULSIONS _ havioral and neurophysiologic indices are sider these results as reﬂecting differences dependent upon the induction of seizures, both in population samples and in methods and not dependent on any single property of scoring behavioral change. While acute of the electrical or the inhalant mode of illness and affective-depressive reactions are induction. described for the majority of subjects in Kurland et a1.26 and Chatrian and Peter— the positive studies,1‘°'27'38 70% of the sub sen5 have also compared electrical and jects in one 4 negative and 100% in another 28 inhalant seizures. Kurland and his co-work- were classed as having schizophrenic re— ers assigned convulsive therapy referrals actions. The facilities in these investigations alternately to hexaﬂuorodiethyl ether and serve chronically ill populations, and prior ECT groups. They reported that behavioral courses of convulsive therapy were recorded ratings, complication rates, psychologic test for nearly half the subjects in one group4 performances, and cardiovascular reactions and 90% in the other.” The failure to obwere similar in the 2 samples. Chatrian and tain signiﬁcant differences may also lie in Petersen, studying schizophrenic subjects the small samples used to test the null with implanted intracerebral electrodes, re— hypothesis. ported identical electrographic patterns dur— Changes in behavior are observed in all ing seizures and at various postseizure subjects receiving a course of convulsive periods for hexaﬂuorodiethyl ether, pen- therapy,1052930533,38 but those changes evaltylenetetrazol (Metrazol), and electrical uated as clinical improvement occur only techniques. in some. While induced convulsions are a In studies of seizures induced by various sufﬁcient condition for behavioral change, electrical means, equivalent behavioral, psy— they are only a necessary condition for chologic, and electrographic effects have improvement. Thus, measures of behavioral been reported.3’11’29v39 While these studies change, such as memory,25 language,19'21 equate the effects of different convulsive and perception 1332 readily demonstrate sig— techniques, various nonconvulsive methods niﬁcant differences between convulsive and such as subconvulsive, brief stimulus, uni— subconvulsive techniques within the individ— directional stimulating, monopolar stimu- ual differences in personality organization lating, and focal “convulsive” techniques of the subjects. Ratings of “improvement," have been described, and each in turn however, with the personality organ-vary discarded in routine therapy as ineffec— ization of the subject in adap— as expressed tive.1‘°"27'39'4‘° For example, Bergman,2 in tive patterns and ﬂexibility for change; describing the electrographic effects of the with such environmental variables ther— as “focal—seizure” technique noted that 75% apist, staff, and family expectations and of patients had normal records after 15 tolerance for the elicited adaptive behavior. such applications, while 70% had “abnor— and with the duration and degree of induced mal” records after grand mal seizures. Ulett neurophysiologic changes. In global esti— et al.39 have reported differences in the im- mates of “improvement” the environmental provement rates of patients receiving con— variables become prepotent. The failure to vulsive treatments (60%—80%) and those observe signiﬁcant differences in improve— receiving subconvulsive (33%), or controls ment ratings in convulsive and noncon1‘0 (38%). Our own studies also demon— vulsive groups may be related as much to strate signiﬁcantly greater degrees of these environmental variables and the perbehavioral and physiologic change for con— sonality characteristics of the subjects as vulsive than for subconvulsive treatments. to the induced physiologic changes. A number of investigators, however, have 2. Signiﬁcance of the Convulsion.——The failed to observe differences in improvement evidence indicates that convulsions are, or rates for patients treated by convulsive and reﬂect, the signiﬁcant physiologic events subconvulsive means?”8 We would con— which are basic for the therapeutic efﬁcacy Fink ct al. 69/263 �ARCHIVES OF GENERAL PSYCHIATRY of convulsive therapies. The speciﬁc role of the seizure is, however, not clear. That neither the motor aspects of the seizure nor the accompanying psychologic factors are determining variables is demonstrated by the efﬁcacy of treatments under condi— tions of muscle paralysis and anesthesia?"2 That the loss of consciousness, itself, is not the signiﬁcant variable is seen in the relative inefﬁcacy of repeated administrations of thiopental (Pentothal) or noncon— vulsive techniques under thiopental.1°'2'7’39 Although the means by which various agents achieve such changes are not speci— ﬁed, it is probable that the seizure is but one expression of a diffuse alteration in cerebral functioning?” It is this alteration in brain function which provides the neces— sary conditions for the behavioral changes of convulsive therapy.14»2°v40 Among the behavioral changes we would include the im— mediate alteration in consciousness, recall, motor patterns, and breathing; and the more persistent psychologic, perceptual, vegeta— tive, physiologic, and hormonal patterns, characteristically described in convulsive therapy. Alterations in brain function are reﬂected in neurochemical changes as the acetylcho— line and cholinesterasef"7 transaminase,36 and serotonin '34 content of the spinal ﬂuid. They are also observed in such neurophysi— ologic measures as increased delta and theta 1‘8 decreased and beta in activity8 activity electroencephalograms, and in altered elec— 33735 20"21’4‘0 behavioral re— and trographic sponsivity to intravenous barbiturates and to anticholinergic and sympathomimetic agents"!12 The correlations between the degree of neurophysiologic change and changes in perceptual test performance re— ported here are a reﬂection of these central changes, as are the perceptualf‘ovl‘?”22 lin— guisticf‘w1 and clinical behavioral 10,20 changes described in earlier studies. In a recent review'9 the signiﬁcance of the acetylcholine—cholinesterase system in these neurochemical alterations was dis— cussed. Observations With various anti— 70/264 cholinergic agents and reports of similar patterns with antihistaminic and sympatho— mimetic agents indicate the necessity for a broadly based View of biochemical and brain function relations, with emphasis on synaptic models.” A suggestive mechanism for the prolonged alterations in brain function is seen in the blood—brain barrier studies of Aird,1 who noted persistent changes in cerebrovascular permeability following in— duced convulsions. He related these to the seizure and not to the passage of electric currents, and suggested that these changes may be the enduring physiologic basis for the induced behavioral change. Thus, we would conclude that the convulsion, per se, is not a necessary condition for behavioral change, but neurochemical change, of which the convulsion is the im— mediate reﬂection, is prerequisite. Indeed, were persistent neurochemical and neuro— physiologic effects induced as readily by other means, “convulsive” methods would no longer be necessary. In this regard, the nonspeciﬁc nature of the convulsive therapy process has been repeatedly emphasized.14v4‘° Summary and Conclusions Consecutive patients referred for convulsive therapy were randomly assigned to treatment courses by an inhalant (hexa— ﬂuorodiethyl ether, Indoklon) or electrical inducing agent. There were no differences in the two groups on behavioral, electrographic, or psychological measures prior to, during, or 2 weeks after treatment. Hospital discharge ratings were equivalent. Intragroup test dif— ferences were noted on all measures in both groups during treatment. These differences were related to the degree of induced neuro— physiologic change and the pattern of such changes were similar in both treatment methods. It is concluded that the observed alterations in, brain function are equivalent to seizures induced by inhalant or electrical means. The nonspeciﬁcity of convulsions induced by hexaﬂuorodiethyl ether and the greater difﬁculty of administration are con— Vol. 4, March, 1961 �INHALANT—INDUCED CONVULS‘IONS sidered as deterrents to the continued clin— ical use of this treatment. The mode of induction of seizures is an insigniﬁcant factor in the convulsive therapy process. Seizures are viewed as one index of the persistent neurochemical alterations which are requisite to the behavioral changes of convulsive therapy. These observations are discussed within the framework of the neurophysiologic— adaptive model of the mode of action of somatic therapies in psychiatry. _ The cooperation of Smith Kline & French Laboratories in providing the hexaﬂuorodiethyl ether (Indoklon) used in these studies is grate— fully acknowledged. Department of Experimental Psychiatry, Hillside Hospital, Long Island, N.Y. REFERENCES Aird, R. B.: Clinical Correlates of Electroshock Therapy, A.M.A. Arch. Neurol. & Psychiat. 1. 79:633—639, 1958. Bergman, P. S.; Impastato, D. J.; Berg, S., and Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Focal Seizures, Conﬁnia neurol. 13:271-277, 1953. 3. Brill, N. Q; Crumpton, E; Eiduson, S.; Grayson, H. M.; Hellman, L. 1.; Richards, R. A.; Strassman, H. D., and Unger, A. A.: Investiga— tion of the Therapeutic Components and Various Factors Associated with Improvement with Elec— troconvulsive Treatment: A Preliminary Report, Am. J. Psychiat. 113:997-1008, 1957. 4. Brill, N. Q; Crumpton, E; Eiduson, S.; Grayson, H. M.; Hellman, L. I., and Richards, R. A.: Relative Effectiveness of Various Com— ponents of Electroconvulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 81:627—635, 1959. 5. Chatrian, C. E, and Petersen, M. C.: The Convulsive Patterns Provoked by Indoklon, Metra— 201, and Electro—Shock: Some Depth Electro— graphic Observations in Human Patients, EEG Clin. & Neurophysiol. 12:715-725, 1960. 6. Edwalds, R. M.; Experimental Studies with PM—1090, Int. Rec. Med. & G P Clin. 169 :469— 2. 472, 1956. Esquibel, A.; Krantz, J. C.; Truitt, E. B.; Ling, A. S. C., and Kurland, A. A.: Hexafluoro— diethyl Ether (Indoklon) : Its Use as a Convulsant in Psychiatric Treatment, J. Nerv. & Ment. Dis. 7. 126:530—534, 1958. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 78:516-525, 1957. 8. Pink 61‘ al. Fink, M.; Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Signiﬁcance for Theory of Convulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 80:380—387, 1958. 10. Fink, M.; Kahn, R. L., and Green, M.; Experimental Studies of the Electroshock Process, Dis. Nerv. System 192113—118, 1958. 11. Fink, M., and Green, M.; Electroencephalographic Correlates of the Electroshock Process, Dis. Nerv. System 19227, 1958. 12. Fink, M.; Effect of Anticholinergic Com— pounds on Post-Convulsive EEG and Behavior, EEG Clin. & Neurophysiol. 12:359—369, 1960. 13. Fink, M.; Kahn, R. L., and Korin, H.; Effects of Diffuse Altered Brain Function on Per— ception, in Proceedings of the 15th International Congress of Psychology, Amsterdam, North— Holland Publishing Company, 1959, pp. 238-239. 14. Fink, M.; Alterations in Brain Function in Therapy, in Psychopharmacology Frontiers, edited by N. S. Kline, Boston, Little, Brown & Company, 9. 1959, pp. 325-332. 15. Fleming, T. C.: An Inquiry into the Mechanism of Action of Electric Shock Treatments, J. Nerv. & Ment. Dis. 124 :440-450, 1956. 16. Gellerman, L. W.: Chance Orders of Alternating Stimuli in Visual Discrimination Ex— periments, J. Genet. Psychol. 42 2207-208, 1933. 17. Green, M. A.: Relation Between Threshold and Duration of Seizures and Electrographic Change During Convulsive Therapy, J. Nerv. & Ment. Dis. 131:117—120, 1960. l8.Hoag1and, H.; Malamud, W.; Kaufman, I. C., and Pincus, G.: Changes in Electroenceph— alogram and in the Excretion of l7—Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. 8:246-251, 1946. 19. Jaffe, J.; Fink, M., and Kahn, R. L.: Changes in Verbal Transactions with Induced Altered Brain Function, J. Nerv. & Ment. Dis. 130:235-239, 1960. 20. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Arch. Neurol. & Psychiat. 76:23-29, 1956. 21. Kahn, R. L., and Fink, M.; Changes in Language During Electroshock Therapy, in Psy— chopathology of Communication, edited by P. Hoch, and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126—139. 22. Kahn, R. L.; Pollack, M., and Fink, M.; Figure-Ground Discrimination After Induced Al— tered Brain Function, A.M.A. Arch. Neurol. 2 :547551, 1960. 23. Kahn, R. L.; Pollack, M., and Fink, M.; Social Attitude (California F Scale) and Con- vulsive Therapy, J. Nerv. & Ment. Dis. 130:187192, 1960. 24. Kalinowsky, L.; Barrera, E. S., and Horwitz, W. A.: The “Petit Mal” Response in Elec71/265 �ARCHIVES OF GENERAL PSYCHIATRY tric Shock Therapy, Am. J. Psychiat. 98:708-711, Succinylcholine, Dis. Nerv. System 16:237-242, 1942. 25. 1955. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conﬁnia neurol. 16:88-96, 1956. Kurland, A. A.; Hanlong, T. E.; Esquibel, A. J.; Krantz, J. C., and Sheets, C. S: A Comparative Study .of Hexaﬂuorodiethyl Ether (In— doklon) and Electroconvulsive Therapy, J Nerv. & Ment. Dis. 129:95-98, 1959. 27. Lancaster, H. P.; Steinert, R. R., and Frost, I.: Unilateral Electroconvulsive Therapy, J. Ment. 26. Sc. 104:221-227, 1958. 28. Miller, D. H.; Clancy, J., and Cummings, E.: A Comparison Between Unidirectional Current Non-Convulsive Electrical Stimulation Given with Reiter’s Machine, Standard Alternating Current Electroshock and Pentothal in Chronic Schizo— phrenia, Am. J. Psychiat. 109 2617—620, 1953. 29. Ottosson, J. 0.: Experimental Studies of the Mode of Action of Electroconvulsive Therapy, Acta psychiat. & neurol. scandinav. Supp. 145, 3521—141, 1960. Barrera, E. S., and Kalinowsky, L.: Variations in the Electroencephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Psychiat. 47 2367-384, 1942. 31. Pollack, M.; Battersby, W. S., and Bender, M. B.: Tachistoscopic Identiﬁcation of Contour in Patients with Brain Damage, J. Comp. & 30. Pacella, B. L. ; Physiol. Psychol. 50:220—227, 1957. 32. Reitman, H. J., and Delgado, E.: Technique for the Modiﬁcation of Electroshock with 72/266 M.; Kay, D. W. E.; Shaw, J., and Green, J.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG & Clin. Neurophysiol. 9:225-237, 33. Roth, 1957. E: Acetylcholine and Serotonin in the Spinal Fluid, J. Neurosurg. 14 222-27, 1957. 35. Shagass, C.; Mihalik, J., and Jones, A. L.: Clinical Psychiatric Studies Using the Sedation Threshold, J. Psychosom. Res. 2:45-55, 1957. 36. Stevens, J. D.; Majka, F. A., and Humoller, F. L.: Transaminase Activity in the Spinal Fluid in Neuropsychiatric Conditions, Dis. Nerv. System 20 :460-465, 1959. 37. Tower, D. B., and McEachern, D.: The Content and Characterization of Cholinesterases in Human Spinal Fluids, Canad. J. Research 27: 34. Sachs, 132-145, 1949. Ulett, G. A.; Gleser, G. C.; Caldwell, B. M., and Smith, K.: The Use of Matched Groups in the Evaluation of Convulsive and Subconvulsive Photoshock, Bull. Menninger Clin. 18:138-146, 38. 1954. 39. Ulett, G. A.; Smith, K., and Gleser, G. C.: Evaluation of Convulsive Shock Therapies Utiliz— ing a Control Group, Am. J. Psychiat. 1121795802, 1956. 40. Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects, Springﬁeld, 111., Charles C Thomas, Publisher, 1955. Printed and Published in the United States of America ��A-4t - signattscunt at Iuhultnt Inna-ad Guuvulttoun to: thrhucrr at ‘8: canvalnavu rhuranr Pronun- MI". IN; “.8. “It; 4‘. '0”. ’0‘... ”03., In It“ m. M“ m. ,“h“. MO ‘1‘“; “an“ m WM“. '0”. tho nuihud tn tndncanc cotstrc at at stunstxnanoc t8. it. In: in ”09.; m nzoc‘rncouvu1ISVI ﬁhnruyy an. tuvcsttsuﬁod ﬁr culpartn. tn Ila. ilhllﬂl‘. hllatincradilihrlothur (IndOkIOI), with it. ciuvunﬁtnnsi ozaatrical staining tnahatqun. fvuntgbnovuu can-mun Mamas“ mum‘wiu ”an" we and“ um GU» randunxV atticnld irtttlsni gringo. fruuunoaﬁ van Id3131ltnru¢ at to m m: than mi: anus-um. y» mu Thiri ﬁll at datturnann xu sun in. stein! in.bohav10ra1. aloatrlanaophnlggrnyhzu I? 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Stature 6.1.3101, twp. at currunt lad olsttrodo pInGUIauﬁ 3r: anon; tho vnrttblou that hat. boon atudlod. 33:10 it. zuvcltixattuna indicatc shit chanson in b¢hnvlorsl cad uturophyniolwcie 11415.: it. rclattd £0 £8... paranotorl, th§ dittoruncul rcyortad to: thl various icinuro trodunln; lathoda Arc anal}, tad ntutatttn‘lly tn:£¢nittesn£. lajtr d$£fﬂr¢nc$l, hivcvor, tr- ahltrvtd bntwunn totuurc and non*teisuru groups. For .xnuylu. in u raounﬁ nancarqph. 0t‘anaon roplrtad 5n incrcanu 1a tbu aurntioa it ‘nuadtticd oluctrtaal indugcd antitru: campsrud with thou. unattaod by prtnodicuﬁiun with lidocnlnt (29). Althcuah tho 1:60:1130 ﬁriatcd pttacutl ahtwtd Ital Ghana. 1: indict! of anxiety, retardaticn Old [105:1 behavinr than pttisnta truntta with anuadttxcd Itisurgs. tun datzcrtncoo worn not Iacuttxeunt. In nut attains, chili tutunro dur;t10n (17) and typf at current (11) huvc b... ttlatnd t: thu dogruc a: huhnviural gnd unit.» phyltclogic ahsnco, taut. v¢ru no ditturonccs with rolctztu to thorupoutic nutounq. this, wail. ptranttcri a: £hu saith». nu‘hod may hot: sun. rnlntion ta thnrgpo:%1a efficacy. tbs dittorcncon arc clichﬁ nians {ht tcahntguso, yrovidad that grand uni a¢tsurut havc hO$n 13¢ucod. rlrthur taplcrttsaa it thu taptrtaneo of ﬁn. IoisurQ wt: and. poautblu hr ruetst txpartutntal tntcrant 1n Itiﬁﬁrﬁl induct! by Anna» (1) ). and tau-“roam (911-1090, (6) 1 than“, ) �as)» am». n3 an “um“: 4» with um" My“. ”a“: "cm am» am. and: um «mum 50 «mm m Wt um»: “um. tum-utm- alumnmmum In an ”rim“ «m u clarity an m. o! m m. of alum “(um a a. mum» them: "maul-n mun. an �Klflﬁb: triatwutovun cantooutavu ‘sntluctnd puttanti in u vaiuatary plyehintraa hcapttal ruttrrnd tar canvu1n1Vt ﬁhcrapy Hurt rtadonlr dividtd tat. ti. gram». aging n allarn¢u ordor (16). In twlavu pattonta, convulltans utro indusod by a H¢dcrnt% alturuating entrant tanQrtnnut antic nupruthroahuld narrtntcs und in (txtton Othtrn. by inhnlntiou mt htxutlunrtw dio‘hylothnr (Inﬂation), following tn: nothcd a: Sunnibol ggﬂgm. (1). Prunodicttsou in :11 euro; vat 11311.6 to unbltnal¢1 atropaum (1.0 :3). Srcuiuantn u‘ro adniuistarcd thr¢c tint. pow v.0: tut 10 ta 2h npyllcatiin! with tan ‘otnl lllhlr ao‘arn£aod by in: clinical Judxuncut it uh: It!!! p1y¢h&ntr1at. 13¢: rtlcud iron 19 ta 58, with a rota ‘3. or 38.5 1“!au in. 3c: group; and 19 ﬁt by. with a noun ‘3. at 35.5 rust: in thc tnﬁoklun (rump. tn: Ina: what: If aducttinn nut. 11.5 yncra (83?) and 13.6 (Indaklan). 01 tho tvcntronovun libaoots, tuolvc worn «13.113106 in daprtaltvo parohnnct, light at aehsnophrnuit, 11:16 ﬁwpu. and lovnn :3 schascphr.u1a, partatid twat. Tit dil‘ributiou it diaclanol, a‘. rang. and yuar: o: tduoatloa watts» ta. tug unuplta, did not ditto: ut:ut£1u&nt1y. Ichnvisral eight. wt. tvnluaiod rockly in tattrviuun by th- pacxuat'u thgrnpiu$ aha by an. stat: piratintriut. Such nnpoctn as hand, tdantton, :anorr. $1.0», aypotitn, tycoon puttutna, participatiua in :ronp nativiﬁtua. and rclattta 8. rucnrdod $0 0950? and ¢h3n301 SIIOIIQG p£tianta wurc utttf tad quulttativoly. �lloctrocncophxlagraun var. Geno print ‘u ‘r¢ntnuat. wtokly during in: ‘ruatntut «guru: in a any ut$ar a ounvnlniau, Rocgrdn acunnrod 1.3% troatnon‘. stﬁcr sh. taro ‘8. llé I'lkl 6 ( inﬂated or uuiuat tinting ‘8. up: and cluwor) in ;ut0210r (at 66 0.0.34 tIIy1:I (a). in Icadt, tauptrtI-vurtax erliﬂﬂ plylhblnaie proooduruu var. n¢u133¢arud prtor ‘9 tritiunnt, during tan tourth your (16.12 tron‘naus pawiud). tad tun v¢¢ka uttcr tin Ina! tronilnat. 2h: unapurql xuolndtd wichalor-Iollcvun‘nib‘aa‘c (anttrnntaoa. digit tutu, 083.3% a:ncnbly and digit urah¢1)s Oottnohaxd‘ my». udhcddod guanotrla tigvron (22); parceptinnl yr ptunﬁotcachranatac Inboéd:d c.1ur‘d figure: at high Ip§ad"ueh11talatpta :xpouur: (31); and I nodal“! 6.113% I 80.11.: (23). In ﬁddltitl, lpino tori; Utmdtus «are Gnu. prior ‘c tad In than «a a: “a am”. ‘ tutu” �it. inhalatIQa ﬁt tn‘nﬂitu Insularlr ranaztua in a grand all douvulttln, 91:11:! it taut taimuut clottrinnllyu fur inc tuﬂntlou grimy, intuition «an alarm: an; the intitdl try and «patchytanto pnuturin; Hurt ﬁf‘iﬁ ouittci. In tldttc tad tonic nunttoatntisun, ycst atsnaro taunt, uni goat Intuit. botanist, in. sunny: rattnhltl ulna oﬁhtr «103.12. In chart Guru tvnltutiaun it 12in£¢d1 bahnvsural «huuxu. it. ﬁght: it buhnvltr nﬁutttaﬁud aura nilmlnr 1: tin tut urcupl. rnsttrua a: dautul. tryonnas:, uﬁﬁh‘rarax, tunntttatxnu. paranata tzuitnntut sud iontuntdniX—Innary 10:. air! htilrvﬁl in it‘s populu‘inuu watt uvpvumﬂlattly'tqnal trltittﬁr (tail. 2). I campaiaa$10n rates Etna! I “ﬁamnauau wore statics. viii. patluntn ‘oxcrutna the Inhalation priﬂlllri. Chart '0'. Iroquﬁuﬁ Upilodii a! hroathwhnltias nut lamina. Ihﬁﬁ§ tin muck, naktng ‘hin inttctiia 1:1: :vlhhlc. fruwt‘rta new. obntthd radiogrupttcgllr 1: £lrvc Indolian irattod pciﬁuﬁtn and in throw during 36!. Adminaatrattvu tVIlnnﬁiaaa a: cizuiaul ingravanaut u. £30 an at “an". :m a. was”: an msnzus "an. t). a: Itcnwnrtd and anon tnyravcd nypruxinutvly half at taah ﬁrst». Inﬁdnsu first a warn rucordui fur �inturitasuvu aiﬁina tianrocuunyhaloxruun, town qualtiai$vuiy and qumttttuttvoxy, aura aluilur in the two gvﬂtyic Frucrncnsvu arunntrtn attains ct inhinant trucuuucxtp and an tactvuuc tn Vil‘icil 1;: I’pllih‘ in :11 lnatu. with trintnl in! naiovttrmtaupiwul yruyduiarunaa. lava: and «human an. swam m «m u an. Mann” antt¢tey tutti; tilt such it ivcnI-lnt warn Ilﬁ Iaanltiauliay isttcrwut {tibia 3). taﬁhntgh tan anti!!! III stanza uypntrai «stilt: in ﬁt. thiuklnu trim! than 1: it. In! grin}. nuanurwn OI indsaud ulna Hutu tiltt 3 “~w«.*...u~ mm: 1:1er uhtorvattvau tut tack tic poyvtalociaux twat: (in. man” has It t: or ﬂu rmvuulad a. dattbruaca yriir t9 iroutulnt, ﬂaring tho lihrih unnk, and it! itch: ptntattcutnmnt for ﬁtt it! tsua$naat grﬁ‘ps. Iatrtm hiiivnr, iatlynoa, li‘l!‘ Gduttttcut ataugul in vurtuuu grit: allltfit (was pruutrautuaut it $ha tutti! tuck; and tron ti: Sturﬁh 9“! £3 two that. titty trtatnnat (luﬁli £3, bush in tho Intttiiu sat in tha IQ! grunpo. ....*.....um: I: �an,» x: it: waohalirulililvng tuhsotts, grit; lﬂﬁtﬂ unasud a ﬁllhificnﬁt «ontnama an wcortt (y‘awcr yuvlorannct) tn! Cunt .3h‘nct iuriaa irtgiunnﬁﬁ and u v-ﬁurn t. yruatrnttunut 10'!!! 3: sh: poabwtvcn‘nnut yurtod. 03¢ Ithioxt, «33.6% Inatuﬁlr, dtntastrntui tlzntrlscatar~inuvouocd Ct0r00«’ditv ‘iﬂdilil‘¢ stntltr pattern: 0": oha¢rvud fur thy tnotxutoacapiu unusarca use it. I «tints. will. incrcnund arrow: as ch» «abaddﬁd tight. tutti warn uhtuvvud daring ﬁvtutunas, t3: dt!£:roano an. naﬁ alaniriaﬁut. Paatutrautuunt, tin arrays in its: tunﬁ itartlnca signattcnutlr from prontrouﬂuaat no.9... an tha 1 anti. that; an; incrutso in isﬂrit utth trottunnt, and a Guavaauv tullduan; ‘runinust. in: each at that. unnausol. tic un clmamtl 13>psr£bmnmn¢a an £ha ynruhnaagta tucks tram tun prumﬁroniuuuﬁ riirtt itch tnttinu pnrild warn t. ti: uttnllltauttr rulttad ﬁt til angst. orstuiuuud 3!! 310' all. activity to: tutu urtupa (inhia 5). Isak grant inrcllﬁiun: inunnctvaﬁod thgi attriunuSn in porttruuntu on the'wlnluicvu Inlluvu¢ atgit cyan and thattt unocth: aubtttta; tuthiutnueupy tat rtsaruu stat; wart gignitiacntlr rtlutti to ‘ho anniat .1 oltatxagruphlc ahlnst. stuxxnrly, an innrquac in ? utcrn It! ssndaiatod hath 1nﬂriittﬂ £13 tilting. anh¢¢d¢d -a..*....., till! 5 �mmmumummzummm amalgam mt mama» mm. immt m W tum-mummy. mewmmm. ml was it. mm“... umwmnm «at a mmmuummmmnumum‘mu at: 31m. m m m. umm nun-m an and hr Wm, mnmnm in“ m at out“ numb}, mm m m min-m W 2-. l‘ �1. W!h: crimp. wuro behaviar tt aloctrioul tudnncd iatxlra £n¢£tttnguinhahlt tn ﬁn. variant statur¢t a: etch ttuxo at tun ‘RUtiliﬂt proocsl. 813:: in: 1nh&1:nt and tho taatar ens-tn ‘0 bath trOainuntu vns tn. induction st natuurit tad not thg unthnd a: inauotian, u. may Gﬂﬂﬁlud. thu$ it. netted or 1nduet1¢n 33 has a signtttctnt variihlc in th. £h¢rnpy arsenal. apceatie¢lly, chanson in tho bah:v10rn1 and attraphyiitlnsic inﬂicts ;ro dupcudant tutu the induction 0: taiinrtu, Ind not dapaudout nu nay '1ng1c property or the tluntrieul it tho inhtltnt nod. of induction. Klrland.g§J;;. (26) lad Chutriau and P¢taraoa (5) bath alto conpnrad ¢1natrtea1 ind tahnluut '013Irt3. Karinue and ht: agowurkcru niutgnnd convulylvn thnrapy ruttrraln tltcrw uttoly to Induklua and so: trontnamt cranps. :huy rapcwttd £hnt b¢havtural rataagl, acnyIScutiou rut-a. payehalagia tclt portaru£aeta and aardithluulur roaa‘itun var. 11:11:: in tho tun £3.91... ¢ha%riu| uud itnrn¢a, Itudying schano~ phrcala tahstata with anplantnd inttncurohral altatrodon, ropqrtnd 14¢:Q1aai ultc‘raarsphi¢ pttsoran durzng ncxnurna ind uﬁ vurtonn puttwltialrt psrzcﬂn It: Instilon, untrtlua and tlaatrtnsl tuchniauat. In studtu‘ it :dburan inaun¢d by varituu dlcutr1c¢1.n¢tal, Ignivnloa‘ bﬁhnviorll. ynyahtlogia and �.11. olootrocrophio ortooto hovo boon rovorﬁod (3,11,29,39). Vhtlo thooo otudtoo oqnoto tho otroeto or ditforons convuloivo ‘oehaiquoo, voriouo nonooonvuloivo nothodo ouch oo oubconvalotvo, hriot otinuluo. unidiroetlonol otionlotinx, oonopolor otiouu Intang, and tonal *oouvu1311o* toehniquoo hovo boon dooorlbod, and ooch in turn, diocordod in routino thorny: oo inotroctivo (10,27.39,h0). For oxouplo, Borgnon (2), 1n doocrthinu tho olootroarophio ottonto of tho '1ooo1-oo1:nro* touhntquo uotod that 751 o: potionto bod noraol rocordo ortor tlftoon ouoh opplicottooo, whtlo 703 had 'obaornol' records alto: aroma moi ooiauroo. Blott ggﬂg;& (39) hovo roportod diftoronaoo in tho taprovoaont rotoo at potiouto roooiviag oouvulotvo trootuonto (69.301) sad thooo roooiviag oubconvuloivo (33$), or «outrolo (385). Our own otudioo (10) also dononotroto oignirioontly groooor dogrooo of bohoviorol ond phyoioloaio ohonco zor.eon~ vnloivo than onbaonvuloivoVtrootoonto. A author or inventigotoru, hooovor. hovo toilod to oboorvo dittoroneoo 1n loprcvonout rotoo for potionto trootoa by. convuloivo ond subconvuloave noono (3,h,28). Ho would conoldor thooo rooulta to rolloctiag d;:£oronooo both in popuiotion oonploo and 1a oothodo or ocartng bohovtarol ohonco. whtlo oonto illuooo and orroetivo-dogroooivo rooottono oro doooribod for tho nojority or oubjocto to sho poolttvo otudioo (10.27.38) 70: at tho “Moots 1:. mo and! (h) and 100! 1a anothor (28) voro elooood oo schizophronio rooctiono. rho rootlitioo in thooo 1nvoot1gottono oorvo ohrontoolly 111 ‘ "an“ �~12. populottooo, ond prior oouvooo or ooovuloivo thoropy voro rooordod-tor hourly halt tho oobaooto 1n ouo group (h) and 901 in tho othor (28). 73o toiluro to obtoiu oiguttlolat dittoronooo on: oloo 11o 1n tbo atoll oooploo mood to.toot tho null hypothooto. Chongoo 1n hohovlor oro oboorvod 1a o1! onbaooto roootvio: o oouroo or oonvuloivo thoropy (lo,t9,30,33.38), but thooo chongoo ovoluotoo oo oltntool thyrovooont, occur oaly 1o oooo. whilo induood oonvuloiono oro o ooftiolont condition for hohovtorol chango, tho: oro only o noooooory condition for inprovooont. Thoo, nooouroo or bohovioro1 ohoago, cook to monory (25), longuogo (19,21) ood porooption (13,22) roodtly doooaotroto signittoont d1xtoronooo hotwoon ooavolotvo ono ouboonvuloivo toohniqooo within tho 1nd1vtdoo1 dittorooooo to poroouolity ergoniootlon of tho oohaooto. Iotlago of ”1-provonont', howovor, vary with tho poroonoltty orgootootloo of tho oubaoot oo oxprooood 1n odoptivo yottorno and Iloxibility for ohoogo; with ouch onviroaooutol vortobloo oo thoroptot. ototf and tonily oxpootottono ono toloronoo for tho o11o1tod odopttvo bohoibrg and tho ﬂotation ood dogroo of indoood nourophyoiologio ohougoo. In globol ootiuotoo of “inprovo-ont' tho onvtroa-ontol vortotloo booooo propotont. rho totloro to oboorvo significant dittoronooo 1n taprovolout voting. to rolotod on lock oonvoloivo and noo~oonvu1otvo zroopo no: to to thooo ooviroonontol voriobloo and tho yoroonoltty ohooootorlotion of tho oobaooto, oo to tho indoooo phyotolocio ohoagoo. �.13. 2. Signirtaeuee at the convulsion. The evadenee indicates thet eenvnlaiene ere, er retleet, the eigniticent phyeiolegic event: thigh ere beets tor the therepeuttc ettteeoy e: convuleive therapies. the epeeitie rele e: the eeleure 1:, however, net olenr. Thet nelther the note: eepeete e: the eeteure new the eeceepeuyiux peychelegie fectere ere determining veriehlee 1e deleuetreted by the etrioeey et treeteente under eeudltleue er neeele perelymte end eneetheeie (3!). rhet the leee or ceneeteueueee, iteelf, in net the etzuitteent veriehle 1e seen in the relative luettteeer e: repeated esuintetretiene e: peatethel or not. eenvuletve teehniquee under pentethel (10,2?,39). Without epecityinx the neeae by which verieue egente eohieve eueh oheaxee, it to vrebeble thet the eeieure 1e but one expreeeien e: e dittuee alteration in oerebrel functioning (9.13). It in this elteretien in brain fluetien which prewidee the neeeeeery canditiene for the hehevierel eheasee at oeuvuletve therapy (1h.2o,50). teen: the behevterel chengee we would include the innedzlh exteretten 1a eeueeteueueee, reoell, leter petterne, breethiaa; end the eere pereietent peyehelegie, perceptual, vegetative, phylielacto end heeeenel petterne, characteristically deeerthed in oenvulexve theeepy. titeretieue 1n hretn :enattea ere retleeted in heaven chee1ee1 chengee ee the eeetyleheline end oheltneetereee (3?), trenemueee (36), end "retain (3h) «intent of the epinel fluid. They are elee eheerved in each neurophyeielecle eeeeuree ee inereeeed delta had theta eetivitr (8) end end �«1h. outtvtty (18) out oltorod olootrocrophtc (33.35) and bohovtorol (20,21.h0) rooponotitty to introvououo borbttorotoo sad to outtoholtnorglo and oyspothoolootio ouonto (?,12). rho oorrolotiono botoooa tho dogrno or nooroyhgotologlc choos- ond changoo 1o porooptuol toot portorlouoo roportod how. oro o rotlocﬁiou of thooo coastal chongoo. oo oro tho porcoptool (10.13.22) linguiotto (19,91) ond sliniool hohovtorol (10,20) ohoagoo éoooribod an oorlior doorooood boto 1o oloctroouooyhologrooo; studios. In o roaont roviou (9), tho oicattioonoo of tho oootylnholiuéaholxnootorooo oyotoo in thooo nouroohontool sltoéotiono woo «ioouoood. Oboorvoticno with vortono onticholsoorglo ozonto out roporto or oioslor pottorao with antibiotoointc and oynpothoolnsttc ooooto. indieotoo tho noooooity for o broodly boood vtoo or hioohooiool one broth tunotton rolottoao, with oophooto on oyuoptte Iodolo (12). A oocgoot‘vo ooohoaio: so? tho prolougod oltorotioao in broin tnaotlou :- ooon in tho blood~bro1u borrior otodtoo a: Alva (1) who uotod poroiotont «honaoo 1a oorohrovooonlor porooobillty tollovinx induood couvulotouo. ﬁo rolotod thooo to tho ooiluro and not to tho pooooxo of noon-to cox-routs. out! ounootod that tho-o chongoo ooy ho tho enduring phyo1olo¢1¢ booio for indueod tho bohoviorol chongo. Thus, to would concludo thot tho ounvuloion. or no. to not o nocoooory condition for bohoviorol ehoogo, but nonro~ choliool ohongo, of which tho oouvuloion to tho ionodioto "nation, 1o pronoun“. Indood, won pox-noun noun. �015 a aha-10.1 3nd nauraphyalolosie attoeto image-d a: roadily by bu unthodn Ivnld no loncnr uooonlary. 'convuluivoﬁ other manna, In thin rogurd, tho noun-poclxta nature or «a. couvulatvo therapy proocuu has he’s ropcncndly ouphantuad (lh,h0). �an I mg. cg.mm s, conuauuttva put£¢n£u rotnrrid 1.! 5.3131317. therapy var. tunic-1: assign-i to trtutncut tour... (Ind-klcn) or ulnatrtaal inducing tgcnt. by an inhalant Thor. were no dittoroucau in tho two group. on bohavlnrﬁi, cloatregruphio or psycholcgioul natsuroa prior to, dnrtng. tr lotyttal dicohtrzc rnttnuu var. oqutvalont. tutti-group taat dirt-rtucls unto notad on 311 tun wtcka artor treatunnt. unnanrau in both granps during trnatnont. In... dittuvouaﬁl var. rclutcd to tho dcgrto a: indueod nourophyaioloxie «hang. pattern at such chanzaa not. similar in both troutlau‘ and tho I. th“‘ 0 It is concluded thut tho abhorvod nltarntioul in br‘in function :r. quivnlont with nature: inane“! by inhnlnut or alootrtctl Hanan. rho nououpceitietty of Indaklauconvulnionn and tho ctoattr difficulty of aduintatruston continued the aonnidorod to «ctorrunta clinical at. 3a if. or th£a trtatuant. The nod. or induction or nuisuroa 1: In tuntgnitic.nt (cater in tho convulsivo thornpy process. $e1uutoo tr. “and u on. two: of the ponistont autumnal"). eaavulsiio bchnvicrnl ﬁnance: a: uhioh rcquiaito to tho durum- er tharupy. Th... abuortn£ion| at. discus-ad within the tranoutrk at tho nourophyu1olozie-Idupt1vo nude! or thu of abnttic Vﬁhcr.p1nn 1n payohintry. node of action �0’17. the oo¢90rntion 0! Smith £113. a French Lahcra%orsco in providing the hazarluovodiothyiathar (Indcklon) It’d 1n tho-u atudioo 1n gratefully toknoviodgud. �.15. 1. 11rd, 3.3. clinical Gerrsllﬁta at Electroshaok Thnrapy, Pazphittg lg: 633n639, 1958. 2. larguan, P.8., rapt-tutu, 9.6., Bars, 3. and foinntoiu, a. ﬁloetrounonyhalocraphic changes talluving olqctrioll induced £0331 a-lunrca. cant. laurel. $3, 971-277, 1953. 3. lrtll, 3.0., Ornlp‘el, 8.. Iiduncu, 3., Gray-on. 3.8.. ﬂollnnn, L.I., Richards, 3.4., stra;tnan, 3.9., and Unsor. 1.1. Invuatigntioa a: sh. thorapouﬁto coupounnta and variant raetcrl .saoctatnd with tlpruvousut with olectro~ convulsive trontaontt A preliminary vapors. An, J, Ag; Arch, Huurol. & 3&2, 997e1008, 1957. Ptzghint. h. Drill, 1.0., cr‘upton, 3., atducon, 3., arnyaou, 3.I.. lilllll. 1.1.. and Richarda, R.L. Balattvn eruct$vonaao of tartan: coupon-at: a: oloctrcaonvnlotvo thurapy. nu non. lmal. a "paint. 9;, 627.535, 1959. chattiln, 6.3.. and Itoruun, u.a. Thu convuloivo paﬁt-rnc provokad by Indcklen, Hotrauol and slcetraouheck. Solo dopth clootroxruphio obscrvuticnl in hunnu patiautu. BIO Olin. lturoghzgiol. 33: 715-?!5. 1960. ldvaldn, 1.x. Bxportlnntal utudtoo with Pnn109o. Int. Rue. nod. 1- cm». a g 32;: 1:69-4:79, 1956. 7. lsquthnl, 1., lrants, J.0., tru1t£, 3.3.. Linc. ;.s.c.. tad lurltnd, 1.1. loxntluorodtothyl nth-r gindnklaa) ~ It: us. as a oonvuluant 1n psyuhtctrto trau‘ucat. ' J. larv. ﬂout. nil. 33$: SJO-SJh. 1958. �.19“ EEG end delee activity to of B.L. Kenn, 3. Ieletien link, behesierel reepeaee an electreeheck: Geeetttettve eeriel etudiee. Ant arch. leerel. e Pezehtet, E!) snsasas. 1957. 9. link, I. street of enticheItnercie egent, nietheere. ea :30 eud behevteru atsntrieenee for ﬁheery er aenvuleive theeepy. A5; trek, leurg;. e Pezghte . £21 380~387. 1958. 10- tier, I., Kenn, 3.3. ens Green, I. lapettleetel etedtee e: the eleatreeheek preoeee. Die. lerv. 813, £23 113.118, 1958. 11. r1nk, I. end oreen, n. sleetreeueepheleerephte eerreletee er ‘ the electrocheek preoeee. Die. [eyes a; . g2; 11?, 1958. 12. rink, 8. street e: entteheXLaerste eeepeunde on peetaeeaveleiee 230 end behavior. 380 clin. leergghzetel. 33: 359o369, 1960. 13. fink, ﬂ., Kenn, R.L. end Kevin, 3. Erteete or dattnee eltered brein funciieu en perception. ?ree. 1' Int. Cong. vgzphel. p. 238-239, lerth lullead Pub1., teeterden, 1959. 15. Flat, n. Alteretiune 1n bre1n reaction in therepy. Pezghe~ ghereeeolegz zgenttere, [113e, I.. ed., p. 325~332, 1959c» 39., ”.tCB, ‘1‘”., ”M Fleetng, r.c. An annuity into the lecheniee o: ectzou of electric eheek treeteente. J. lerv. lent. Die. 12h. k hho~h50, 1956. elteruettnc etienli 1n dieerininetien experieeute. I: eeuet. Patchegg 16. cellereen, L.V. v1eue1 chance orders e! g5, 207-208, 1933. 17. Green, H.A. Reletien between threshold end duretten e! eeienree end electregrephio ehenge during ooeveletve therepy. a.n.n.n. (in preee). �.2918. nugzlsnd, l.. nultnud, w.. xguruan, 1.9. and Finest, a. chant-u 1n aluotroauaophtlogrnu and in £h¢ excretion of 1? - kutorctaraoida aceonpnnyiug aluotroshook thcrnpy or agttntud doproallou. razohouon. and. g. ' ab6~251, 19h6. 19. 1n vorb:1 Ghanaoa an! Kuhn, 3.3. u. Jattc, J.. tint, trunlaataono with inducod :ltorcd hrtiu function. 1960. 23$~239, 52g: 91a, nunt: Icav: J. 90. Kuhn, I.L.. tint, a. and wuinutotu, E.A. lolntton of anubnrhttal 1.1% to clinical inprovcuont 1n oloctraé thank. Arch. laurel: and Puzohint.‘1gs 23-39. 1956. 21. Kuhn, 3.1. an: Pink, H. change. in language during electroshock thorupy. ?: who Ithola' at Communicatian, noun, P. and & Bruno 126~139, Struttou, N.Y.. 1958. Zubiu, 3., tau., 9. 22. tuba, n.L.. Pollack, I. tad rink, n. figuro~gronnd diaerintuutian ARA arch. laurel. inéaood tnnotiua. brain sitarad arts: 3,: Sim-551. 1960. R.L.. Pollack. n. and link, a. soc1;1 attitudo (California I Saul.) and convnlcivo thornpy, 1960. 187-192, ggg, J,l,l,3. 25. laltuovuky. L., Darrora, 8.8. and lorvits, v.1. The “Potst unl' roaponst in olnctrtc shook thcrtpy. Al. J. Pszchiut., 2;. 708-711, 19kt. 25. Kevin, 3., link, I. cad Kwalwnuuor. 3. Relation of ehtnxtu in aviary and luarnlns to inprovununt 1n aloctrouhaek. Gout. 303301. gg; 88-96. 1956. 26. Karinnd, 1.1.. Ibuloug, 1.3., Enquibﬁl, A.J., Kr¢ntn, 3.6. and Shoots, 6.5. A coupsratlvu utudy of hoxntlnoro~ dicthyl Rthc1 (Indoklon) and cloetraconvulaivo therapy. 19590 ”‘WQ 95"”, 21 ﬁght. 1: I‘m. 23. Kuhn, �.21. 97. Lnnouatqr, H.P., stcincrt, 3.3.. nan trout, I. ﬁntlltornl oluetroconvulstvt thcrtpy. J. Hunt. 3&1. 323: 221-997, 1958. 28. Killer, 3.8., 61:30:, J. conpnriocu between unidiroétioanl entrant nou~oanvnllivc olcatricul uttnulntaon ngon 31th nuttarta nuoh1ao. standard and cunninga, B. A ultornntaa; carraat electroshock and pontothtl in chronic uahtsophronta. An. 3. ?Izghint. £92: 617—620, 1953. 29. citation, 4.0. Exportuontll stndIGI or ‘hn node at nation at clootrooonvull1vo thnrtpy. tot; Pazghtat. & lturol. 86:34. 8322. ;§2,‘§£, 1960. 30. Pnoolla, 3.1.. Darrcra, 8.8.. Illinovlky, L. Varitttono in the oloctrocuecphnlograu unuoota‘od with aloctriu shook therapy in patiga‘a with nuutgl diaurdorn. 19h2. 367~38h. 31, laurel. szohtnt. 31. Pollack, n., Butt-ruby, v.8. and Sander, H.B. rashictosoopio identitiotttnu of content in putzcutu with brain dalnxo. J. Gagg. ’El'3°1° Pczphol. £9: 220~t27. 1957. 32. Boitnnn, !.J. and 3013140. I. technique for tho Iodxtlcatlon or cloutroshook with nuccinyloholinu. Bin. UOIV. szp. 3g: 237«2h2, 1955. 33. Roth, H., x§y, D.H.l., shat, 3., 3nd Brocn. J. Prague-1n :ad poatothal induced olcctvocncuphnlozrnphic changes in olcctroeonvulatvo trontucnt. £36 c113. luncgghzytcl, Arch. Q 2; 925.237. 1951. 3h. agent, a. tootaioholtau and lavaton1u J. louroourg. Akp 2t-21. 1951. 1n the spinal fluid. �.22. 35. Shaun... 6., ﬂxh‘lik, 4., tad Jouco, l.L. cltnxcal pirahiutrie aging tn. nodntaon thrcthuld. J, Patchoaoag a... g; h5~55. 1957. atovoaa, 4.9.. naakn, r.1. and I‘IOIIOP, I.L. Tflﬁltltutﬂl in activity 1: ﬁt. spinal fluid neuropuyehiutric EGO-hﬁs. 1959. condtttonl. 91a. Harv. gin, g2; attest. 36. 37. I taunt, 9.3., o: choliuottcrason and Bazacharn, B. It: 1n hung» nontnnt and chartuaorluattoa spinal 31:16.. Bahia, g, 31.03roh, 31: 132-1h5. 19h9. 38. 331th; and 0.A., x. 3.x. caldvoll, aloaor. o.c.. Blctt, The to. or natchod group: in thc ova1u§t1¢n at ooavulaivu and Iubeonvulttvo photo-hook. 3311. Inna. czan, 18: 138-1h6, 195k. I. 6.6. Evaluation 0: convultivo thank thoroptcn utilising a control group. £5&4£g 195$. 795-802, ;;ga rgzchtlt. ho. walnutotn, 1.5. sad Kuhn, l.&. Dania: of zllgclns ango;1c and ggzltolo‘tual nggusi. 0.6. than... sprin3t101d, 111., 19550 39. Ulc‘t, 6.1., saith, and 61.00:, �'Ws. mum, um «Mum, W In: macaw». 3mm Wu, ' 6 T 4 a 3 3 �am: as. 0 W haunt“ nun-n Electrical 7 6 iv , an: mm: 5 S :8 < 1,9, mm 1 wt “mm-is �W last-convulstvu Ila slow ﬂuv- antavt‘r $51.33;. ’ggggggt gins} :“Cu“ until"! lo. 1". 15 6.6 ”ah 50.3 51.! 1‘03 1! 30° fl.” ”o! 5705 1‘10 had I: 7*! In 10ml! I: fit Vick: A£$or �£A!§£.h 331.0% of :ntchloa an: Ilooiracllly Ialhltﬁ satsnroa an Puyulalagtn 133‘ tortﬁrlnncca (aiitil Bxprsantd us Iran 3:110:03...) MWW Prtotvnntunnt Pruntrncinnnt ﬁnd an! 1. 30.331.2«In110vun (witgltnd littcut scorn) t. III-rustic! Inc ' ‘1 new t“ ’1‘“ ant.‘ (l""') m I“ :32 3. libiddod iaulrul 13d to h. '"“C“‘C”" ' (l"'*I> ‘.‘1. lush; Ullucacu'u ! - H’.7*‘ “10‘ ~1.3 1“ ‘..”h1’ ‘ < . ‘t?’ 4 ¢ﬂ.h 1.1: *inﬁ‘ﬁi .’Q'” 9 ‘11“ o htlndﬁ 03.5% ¢ _. ,0,“ § 1.)... “'9‘”. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Inhalant-induced convulsions. Significance for the theory of the convulsive therapy process. Arch Gen Psychiat. 1961 Mar; 4:259-66. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-52-018 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Karp, Eric; Pollack, Max; Green, Martin A.; Barre, Alan; Lefkowits, Henry J. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the Archives of General Psychiatry March 1961, Vol. 4, pp. 259—266 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/86dcc852ef57150af5b9234a4c32a667.pdf 0ab52ac497e61e2b06bc38b78babd96f PDF Text Text EFFECTS OF DIFFUSE ALTERED BRAIN FUNCTION ON PERCEPTION BY MAX FINK, ROBERT L. KAHN and HYMAN KORIN ( Hillside Hospital, New York) PROBLEM Recent studies of the relation of perceptual alteration following brain damage have emphasized the role of focal damage. To determine the patterns Of perceptual changes with diffuse alterations in brain function, the following studies were undertaken. SUBJECTS AND METHOD Consecutive subjects in a psychiatric hospital referred for electroshock therapy were studied. Alteration in brain function was induced by varying the frequency, number and severity of the induced convulsions. The following tests were applied before treatment, at weekly intervals during, and two weeks after treatment terminated. A) Measures of altered brain function: Two quantitative indices were used to determine the degree of altered cerebral function: 1) the per cent time, amplitude and lowest frequency of the induced delta response in serial electroencephalograms; 2) changes in orientation and in language following the administration of intravenous amobarbital sodium. B) Perceptual Tests: 1) Tactile: Threshold perception (100 ‘X, point) of square wave electrical stimuli was determined for different body areas. Stimuli were then applied simultaneously to two body areas, with interspersed single stimuli in random fashion, and the subject was asked to report where he felt the stimulation. 2) Visual: a) Figure—Ground: Using embedded ﬁgures (Gottschaldt) of increasing complexity, subjects were requested to identify a simple geometric ﬁgure in a complex background. b) Tachistoscopic recognition: paired words were presented at rapid exposures to subjects. The words were matched according to tables of frequency in common usage, and were of two groups: relating to illness or to the body, and those not relating to illness. Words were matched \ randomly. ‘ �2 THEME 9 RESULTS With increasing degrees of altered brain function, there were increasing errors in reporting the simultaneous tactile stimuli. There was a concomitant rise in the threshold of perception. With high degrees of cerebral dysfunction, mislocalization of responses appeared, in addition to the persistent failure to report one of the stimuli. 2) The ability to isolate embedded ﬁgures was impaired in direct relation to the severity of the alteration in brain function. 3) Threshold for the perception of words increased and subjects were unable to identify two words with increasing degrees of cerebral dysfunction. 4) Changes in perception were highly correlated with other behavioral changes, indicative of an altered interaction with the environment. 1) CONCLUSION Diffuse alteration in brain function, as measured by electroencephalographic delta and orientation tests after amobarbital, results in alteration of perceptual patterns marked by an increase in threshold, impaired discrimination of stimuli, of which the ability to discriminate a ﬁgure from a complex background is a special example. 2) Alteration in perception represents one aspect of an altered behavioral interaction with the environment, rather than a speciﬁc physiological defect. This factor should be considered in perceptual studies in focal brain lesions as well. 1) ape. Inf. (Dong. ﬂieﬁoa E .- /f57 - gVH-SJa/S �3mm of Emma Altered Brain mum on Pomepticm m Fink, 11.13., mm; L. Kuhn, Bun. md than Karin, 31.33. mm gt the IV International Wrens of Psycholow, annuals, My 30, 3.957. �m at mm» Alton! Brain mum on Pauptian m of this study at alteration in Won fol-loving Mg» in «abut; mum ha been devoted to ram Mom u in nus-31m imam, dials 1!: head’ m md brain tumor. Litﬂn emphasis usually placed an the We effects of such hum on the pommml prom». In tha acme of this :tudiu in 1:ka therapy, we charred that may 13th aanaidonble neutral 0: the down at induce-d alteration of brain mum. In these studies we ware impressed with the wide variability in the behavioral and nmphyaiologie response 91‘ our subjects to apparent ‘ aquivalent mailbox-n of convulnima. madam We have Max:815? reported the a! the belaviaral napmsaa and the W: inter- dew of apparent new Widow-c manna-grandma mortistodowribgpomoptualchanmmrm conditions cf differing determine the down of diffuse alum brain relatiwahtp of the function, and 150 136th We to the indueed amm- physiologie change. I Three perceptual M113 Visual Visual mm mm utilised: perception of Gamma“ mm wave electriwl 1.3QO or mad gamma stimuli figure; :04»th of tachistooaopdcally presumed wows. �_...___.1 em: subjects were 2310 53 meetive hospitalized patients, rerun-ed fer electroshock. Brain mention was altered by meaning remitted grand m1 cemuleim under penteﬁml pmdicetim. a rmqwncy of three time per week. The convulsions were given For a control group, randomly eelected therapy; with equivalent umber of patients received eubeomalsivo Wimtim at pontothnl but with web» eonvuleive doses of electric current. All weluetiwe and same as in the experimental gmup at ~ and the type or each subject was not known to any of the tests were the thetmt in we fer investigator: until the experiment we ended. We Wmmgic indie“ were used. mameMz-ama, taken at weekly intervale an a day after an indueed maveleian, and mﬁtetively measured for the degree of incheed delta activity; and mobarbital taste for main disease. In this test, the language responses on a etenéandiled interview, are ”use“! after intravenous mobarbital. Mammal, 1W altered eembral fxemtice. denial, disorientation, and eyntuetieel as an 1nd!“ of Both changes have been enema these tests erem applied lure-armament and during the 2nd, are and 5th week: of treatment. The technique ef etch of the three pemeptual tasks will be doaeribad with the eomspmding results. For mm: a! thin mamtetien, the m mm to the quantitative «pacts only, and aa them is a wide variability in mangle response, we idu meant group data for obamatim apex-junta). and control groups wording to» the dogma at ﬁrst; mum ded- than were physiologic change. the observation: �__.____1 _. In this talk, isolated square WWW 1mm ma emu-ital atimuli were 81ml» We mmugh attnclwd 1 on .. dine electrodes. delivemd to two body point.) valwa were doteminod :or «ﬁx my part and $11“th the tasting, random single stimuli were interspersed to Meme errors due to ﬂuctuatien ef threshold. Subjects were whed to threshold (100% _ localim the npplieﬁ atimli. Slide 1 deem-1b“ the mean number of errors mtreament, and at the Widogic effect, which is manly after the 12th tram-b. The mzbeouvulsiw (mtml) group shes: a drop in the number of errors, the Mod pmotioa effect.» This canvulsivo group, tamer, Ihm height a? the induced & Meant increase in errors. patients with a who had first The immune in we: were _ manna. Pn-tmtnent,the In Slide 2, the group differences are diffemce in the number of more in the treatment course the difference: In Slide 3. the ineWimt, because ml. of the induced In the firm; section, the subjects in than Waive, and later m—tmtad been treated by a Waive course of thumpy. marked but at the height on? significant mum We is “tossed. who have had two new or thus positive to those with either no uobcrbitn tests during tmtmt are panties new. or only am. The number of errors: are higher in patients with mom positive moberbital responses. diffemnee 101' rm the pmmtmatmnt score, the group with the greater 601%! the Mm m aignificantlv different Wiologie avenge. In the second section, the encephalograpme Furthomom, in comparing the me melts response; and in physiologic inclines are oompared. ﬁlm are noted for the electro- third motion, the two new �«hm Errors in the 5:9er of ammo“ tactile mm 1mm with increasing degree: at altered brain function. 3: Bamegtim ‘01 W FM, 3: In true task, goo-atria figma embedded in a. complex dasigmd field are premtod «ml the subject is asked to tame the 9112913 figm. The slide 14 shown and subcmvulaive minim or Bath ﬁeld. simple figure is: simultaneously pmmted above thh complex the man manor warm». 'i'ha 91‘ art-era before and anhconvﬂaivo or control group, with no mnmphyaiologio change, thaws a drop Waive gramme show utter eumulaiva in the amber of an increase in true tugboa- or W mm. «mm. compared aide 5, the aubeomulaiw and Gamma” m bath befm am} mg the 5th week of treatment. man mamas, m difi'amwe in the who: of arrow is acted. It the height of tha cleara— In shock effact, the convulsive Wits We group makes aigzrii‘iomxtly more Change. the group. (31163 6) . visualized next tha in than calmly new am are divided warding to than degree of effect in Here, the Mrs than W a: the mutual to“, W Magic the oluctmonaaphnlngm, and tha mama data, there is a simficant diffemca in the mmbar of mm undo. Patients with higher dame: cf hummimgic chums mks ﬁn mt errant ”100th for their equivalence in fmmncy in mush matched, was mounted at rm. diffemnt speed: of mum Pairad words, usage and :3de taming from m to 250 rimmmdu 2130 of for a total mm. mum 13311607, the The mm m puma tn u wen-act morainewhgmupmpwmteﬁ. Harem, thumb- Wimt eonvulsive or control gmup ohm a amp in the number of while the group sham a much smaller practice effect. minim emu, �.59 In the are mud M 313.60 (8), the proutmtmat. and post-treatmnt «com The groups urination 1n the are 11611 More, untamed number of. arrears with alters-d and in both there is a brain function, Mt, the is greater than the convulsive. Thou are mt simifiaant. reduction in the aubconwlaive groups differences are and}. and In Slide 9, the role of neurophysinlagic change is again assess'eﬂ. toe, as in the wading slide,» them in a deem it: the pmtiae This is clearly effect with the greater the change in carebml now in tha canwlaxva Wagon seem, uhomtha patients with mm but Waugh Mags show a decrease in armra, while theme with the mam“. Hero, tam. Mainlogio change show a small umber of arrears. Ia this tank, in mtmat to the two pmeding on», the effect of altered 13min functim is not manifest in an increase in the umber or errors, but is seen only when the enacted immanent in performance fails WW1? mm thou-gum in «row mum In: m NM in psychiatric patients by the remand 92mm“). induction at grand m1 control Win emu perceptual in and experimental to chanson in degree when perceptual tasks, portion to the dogma er «smut-a1 cmlsim. in emu“ mp9, the mammalian) at on? «tubal ﬁguration hm baen obsozvod. increasing arrow" in pemaptian in pro- mm dwmﬁm in muréphyaiologic. indie” at mum m be observed. In addition to these pomeptual ml: changes, humor, there arm commmt altamtim in behavior, language. ariontatien, attitude and mad, and these am: highly Mama Mending upon individual 612mm“: 1n the subject“. ”the panorama). altemtima ducrihco’ here :3me but �we upset at tbs clung» in the Mom: 111th Farmer studiuﬁ cf this in ”spouse to mmbral lesions are mm hater in pmgrcsa. 91' tam. at” organism. indium mmw � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effects of diffuse altered brain function on perception. In Proc. XV Int. Congr. Psychol. North Holland, Amsterdam: 1959:15: 238-239. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-35-001 Date A point or period of time associated with an event in the lifecycle of the resource 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>; Kahn, Robert L.; Korin, Hyman Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and a publication copy. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/261abbc7e46388bc86f6597be731bd1c.pdf 0134e8d9c4e023061da7cfc3c500f0f0 PDF Text Text t Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Max Fink, McDo Robert L. Kahn Ph.D. and Hyman From Korin Ph.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks,N.Y. Institute of Mental Health, National Health Service. United Public States of Health, Institutes Aided by Grant M-927 of the National (in part) at the Divisional Meeting A.P.A., Montreal, November, 1956, and International Congress of Neurological Sciences, Brussels, July, 1957. the at Read 12-3-57 “W5, $9; WW7 A“! �Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Numerous studies have been.reported assessing the type, duration and significance of mental changes following electroshock. These reports vary widely in their descriptions and meaningful conclusion regarding the it is difficult to arrive at a relation of such mental changes to clinical response. Basic to these differences in observation are the vexing problems of the definition and the ways of measurement of organictype reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definition of the problem. In the present study, various tests of brain function were applied serially to patients in mhom‘behavicr was altered by repeated inductions of grand mal convulsions (Electroshock). The data comparing the serial changes in these indices are presented. METHOD: Definition of "organic mental changes": conventional conception The of organic mental changes includes such behavioral changes as impairment of memory and of the discrimination of differences on perceptual tasks; disorientation for time, date, or place; errors tractibility and inability to handle perserveration in speech on more than one and behavior; emotional calculation tests; dis- situation at a time; lability; and loss of interest in one's appearance and in the environment. Most studies assess the relationship of memory loss or clinically manifest disorientation to improvement following by tests of simple electroshock. The memory loss is usually measured recall, information, personal events, digit memory span, �~2r etc.: while disorientation is place, date, determined by questions the examiner, 323, name of Such tests of relating to present memory and of orientation, however, discriminate primarily only severe degrees of dysF function. In the present studies, cognizant of the difficulties inherent in clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, simple types of dysfunction. The four'measures selected as being sensitive to varying aspects and degrees of cerebral dysfunction.were: a) The degree of delta activity in the electroencephalogram (1). b) in language and orientation following the administration of amobarbital sodium - the "amytal test" for organic brain Changes disease (2, 3). c) Alteration in perception of multiple simultaneous d) Changes in tests of recall of the interpolation of reading Time of Testing: A common lists tactile stimuli (h). words, both with and without of nonsense syllables (5). second factor to be considered is the time of application of these tests in relation to the treatment program. Observers have reported the development of organic changes in the Numerous few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third at pretreatment levels, orientation is re-instituted. course of therapy the electroencephalogram is memory changes have disappeared and week following an extensive �-BIn the present studies, the electroshock treatment schedule was main- tained at three times per week with Reiter electroshock, during the all patients receiving conventional initial three weeks. In the fourth week, treatment frequency was occasionally reduced to two times per week. All patients received a out at weekly minimmn intervals of twelve treatments. All on a day following a tests were carried treatment during the course of therapy. Following termination: of therapy, weekly testing was continued until the tests returned to their initial level. third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definition and evaluation of "improvement." The evaluation of clinical Behavior Ratings: response to therapy A is a subjective value judgment by the therapist or adninistrator which reflects a divergence of goals, judgments, and compromises. Significant variables in the evaluation of "improvement" are the type, severity and duration of the pets“. ent' s illness, his premcrbid personality, the sociologic (family) constellation to which he will return, and the expectations (both conscious and unconscious) of the institution, of the patient and of the family. of the evaluation of the treannent result is also a the therapist, of Furthermore , the time most sigaificant variable. The parameters of evaluation have not been satisfactorily delineated. In this study, the following compromises have been made. All evaluations qualified psychiatrist who has no responsibility for the selection of subjects or application of the treatments. Patients are made by an independent are seen weekly and conferences are held with the therapist to assess the �.Ll. therapeutic goals before treatment and the therapist‘s estimate of the respOnse after treatment. The finai evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behavior. we have used a three-fold classification of improved" and "uninmuoved," with the and "unimproved" "much improved," "moderately intent that the categories respectively "much improved" would describe patients at the extremes of the response continuum. The patients rated as those "much improved" were showed the symptoms which brought them.to the who no longer hospital, their physicians believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The "unimproved" patients were those noticeable change in behavior who manifested no clearly or'Who became worse. The "moderately improved" patients showed some change but continued to manifest signs of'mental illness. some symptomatic relief, which was transient. They in behavior, typically showed �.5. RESULTS : Twenty-four consecutive electroshock patients were studied. these, eleven and were Of "much improved," seven as "unimproved," rated as six as "nmderately improved." (a) Electroencephalogrems: EEG records, using conventional leads, were measured for the average per cent time delta activity, and highest per cent time delta in any one lead; the Slowest frequency in the record; and the duration and amplitude of delta burst activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. The upper 1/3 of the records were described as "high delta activity" and the lowest 1/3 as "low delta activity." pretreatment records showed delta activity. During the course of electroshock delta activity appeared in all records to varying degrees. It No was apparent within the on the third with high first week following EEG week of treatment and the 7~9 treatments. The usually reached a peak results for those delta activity are seen in Table I. TABLE EEG - % I High Delta Activity 1-3 h—é 7-9 10-12 25 80 91 88 Moderately Improved (6) 0 16 50 ho unimproved (7) o o o 20 Treatment Period: much Improved (11) �~6(b) AmObarbital Test: In these tests (2, 3) the patients are asked series of questions relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in a orientation and awareness of illness are scored as "positive" amytal response, reflecting a change in brain function ascribed to “organic brain disease" (2). The results are noted in the next table. TABLE II Amvtal Test -.% Positive Treatment Period: 1-3 11-6 7-9 10-12 13-15 Much Improved (11) us 61; 100 89 100 Moderately Improved (6) 20 33 67 20 25 Unimproved (7) 1h 16 16 33 o The data of Tables The congruence I and II have been graphically portrayed in Figure of the observations of the degree of delta activity EEG l. and test responses is demonstrated. (Fig. 1) Tests: In this test (5) a list of three letter common the per cent positive amytal (c) Memos! words were presented for 10 to patients by flash cards. trials. After this, lists interpolated. The of 3 recall of the first The cards were presented letter nonsense syllables list were of'wordStmas.then tested, and the number of words recalled in each session was scored. An impairment in recall function decrement was maximal in the second was apparent and third in all subjects. This weeks of sustained as long as treatments were administered treatment, 3 times a week. and was �-7The decrease in ability to recall the word list is noted in the next table o TABLE III anaiment in Recall - Marked Decrement % Treatment Period 1-3 1456 7-9 10-12 Improved (9) o 11 33 o Moderately Improved (h) 0 SO SO 0 Unimproved (7) 0 1h 0 0 Much the scores are compared with the mprovement rating, there is no significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to When two times per week indicates that this more severe degrees test is a measure of only the of cerebral dysfmction. tests the patient is touched by the examiner simultaneously on the cheek and the hand, and asked to localize the stimuli. The tests are repeated for 10 trials using varying combinations of cheek, hand, shoulder and thigh. Persistent failure to (d) Tactile Perceptual Tests: In these report the stimuli or to mislocalize a stimulus beyond the tenth indicative, in adults, of altered cerebral function (h). one of trial is In all subjects, this test was negative before patients. In nine patients, two observed, and of these, six were in the much responses were observed in 19 of the consecutive responses were improved and three treatment. Positive 21; in the moderately improved groups. �In the next table the positive responses were charted with relation to the treatment period and of positive regaonses is to the clinical evaluation. be noted in the first A high incidence two groups, and many fewer such responses in the unimproved group. TABLE Face Hand Test IV - % Positive 1-3 h-6 7-9 10-12 13-15 Much Improved (11) 16 no in h3 60 Moderately Improved (6) 60 1:3 2:3 30 o o 16 12 11 o Treatment Period Unimproved (7) �DISCUSSION: Three aspects of these observations warrant elaboration. sensitivity and the and stability The of these indices of altered brain function significance for a definition of altered cerebral function; the relation of these indices during and evaluation; and after treatment to the clinical the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function'was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions persistently positive for one to three weeks fOIIOWing treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perceptual tests also showed changes but these appeared late (in the 2nd and remained week of treatment) and disappeared rapidly when treatment frequency was reduced. Tests of recall function and tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced to another‘variable, it is important, the operation (or test) and the Because these tests have varying change in brain function therefore, to clearly define both sensitivity of the operation which forms the basis for the estimation of altered cerebral function. sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent �~10- treatment, while changes in recall function and simultaneous tactile perception are rapidly 0f the function, clinical lost, when treatment frequency reduced. correlations possible with these tests of brain many we have selected the relation of these test results to the improvement rating. ‘With the EEG-and amytal relationships between the appearance of test changes improvement are is clearly observed. In the positive amytal tests and high degree were more marked, and were sustained EEG tests significant and much improved clinical patients, abnormality appeared early, for longer periods (on the treatment regimen) than in the unimproved patients. The same moderately improved patients were in between. relation between altered brain function and clinical response This is noted only with the data obtained during the course of therapy. There is no correlation of improvement ratings with post-ptreatment test results. This divergence is related to the timing of test applications, in the conclusions of other studies and may explain the discrepancies of this prdblem. These Observations can also be mode of action of electrochock. related to an understanding of the In 1952,'Weinstein, Linn and Kahn (6) postulated that the function of electroshock therapy was to "initiate the production of a state of altered brain function in which the patient his problems." These observations support the first part of this hypothesis. namely, that a state of altered cerebral function is can deny induced by electroshock. Also, in patients who.improved, the altered state is more prominent, appears earlier and is more persistent than in �, those who fail to improve. Of the eleven positive amytal tests (while positive test); and ten had high had one of the unimproved .11.much improved patients, all 5 of the 7 unimproved never had a EEG abnormality records, while only patients had such a record. It is our condlusion significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. that early? sustained and �4.2;» W: In a study of the relation of tests of altered brain function to improvement in electroshock, of change it was observed that while indicators in brain function vary in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. The reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is and the dependent on and early, sustained that electroshock therapy and marked changes may be in mental function; described as the non-Specific, traumatic induction of states of altered cerebral function in which the subject reacts with new patterns of adaptation. �REFERENCES 1- Fink, M. and Kahn, R.L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neural. & chhiatﬂﬁ: 516.525, 1957. _ Kahn, R.L. and Malitz, 3.: Serial Administration Test" for Brain Disease. Its Diagnostic and of "Anvtal Prognostic Value, A.M.A. Arch. Neural. & Psychiat. 217-226, 1951;. 2. Weinstein, E.A,, _’_?_I_: 3. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M,A. Arch. jieurol. 8c Psychiat" Zé: 23-29, 1956. and Bender, M.B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, NeurologX, _2_: h. Fink, M., Green, ILA. h6—58. 1952. H. , Fink, M. and Kwalwasser, 8.: Memory and Learning to Improvement Neuron-o, $6.: 88'96’ 1956. 5. Karin, Relation of Changes in in Electroshock, Conf. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat., 109: 22-26, 1952’. �--- .. anEu’mlJ-Jﬁal from , “T'he FLSL , ,.. -n Congress of Neur-ofogical ’, Brussels, 1.;7. Vol. III. EEG, Clinical Neurophysiology ces -pllepsy. Pergamon Press; London, New York & Paris 1959 "Emmi , RELATION OF TESTS OF ALTERED BRAIN FUNCTION TO BEHAVIORAL CHANGE FOLLOWING INDUCED CONVULSIONS DANS CEREBRALE FONCTIONNELLE ALTERATION D'UNE ROLE LE CHANGEMENT DE COMPORTEMENT SUCCEDANT A DES CONVULSIONS PROVOQUEES MAX FINK, ROBERT L.KAHN and HYMAN KORIN New York, U.S.A. Numerous studies have been reported assessing the type, duration and significance of mental changes following electroshock. These reports vary widely in their descriptions and it is difficult to arrive at a meaningful conclusion regarding the relation of such mental changes to clinical the in vexing observation differences to are these Basic response. problems of the definition and the ways of measurement of organic—type reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definitiOn of the problem. In the to function of applied serially brain were various tests present study, of inductions grand altered whom behaviour by in repeated was patients mal convulsions (Electro shock). The data comparing the serial changes in these indices are presented. MET HOD Definition of 'organic mental changes' The conventional conception of organic mental changes includes such of of discrimination the and of behavioural changes as impairment memory differences on perceptual tasks; disorientation for time, date, or place; handle to and more inability caICulation 0n distractibility tests; errors than one situation at a time; per serveration in speech and behaviour; emotional lability; and loss of interest in one‘s appearance and in the environment. Most studies assess the relationship of memory loss or clinically manifest disorientation to improvement following electroshock. The memory loss is usually measured by tests of simple recall, informa: while disorientation is etc. tion, personal events, digit memory span, determined by questions relating to present place, date, name of the examiner, etc. Such tests of memory and of orientation, however, discriminate primarily only severe degrees of dysfunction. In the present studies, cognizant of the difficulties inherent in simple clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, to sensitive selected four being The as of measures types dysfunction. varying aspects and degrees of cerebral dysfunction were: (a) The degree of delta activity in the electroencephalogram (l). (b) Changes in language and orientation following the administration of amobarbital sodium - the 'amytal test' for organic brain disease (2, 3). 613 ‘ �614 M. FINK, R.L.KAHN and H.KORIN (c) Alteration in perception of multiple simultaneous tactile stimuli ((1) (4). Changes in tests of recall of common words, both with and without the interpolation of reading lists of nonsense syllables (5). Time of Testing A second factor to be considered is the time of application of these tests in relation to the treatment program. Numerous observers have reported the development of organic changes in the few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third week following an extensive course of therapy the electroencephalogram is at pretreatment levels, memory changes have disappeared and orientation is re-instituted. In the present studies, the electroshock treatment schedule was maintained at three times per week with all patients receiving conventional Reiter electroshock, during the initial three weeks. In the fourth week, treatment frequency was occasionally reduced to two times per week. All patients received a minimum of tWelve treatments. All tests were carried out at weekly intervals on a day following a treatment during the course of therapy. Following termination of therapy, weekly testing was c0ntinued until the tests returned to their initial level. Behavior Ratings A third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definitiOn and evaluation of 'improvement‘. The evaluation of clinical response to therapy is a subjective value judgment by the therapist or administrator which reﬂects a divergence of goals, judgments , and compromises. Significant variables in the evaluation of 'improvement' are the type, severity and duration of the patient's illness, his premorbid personality, the sociologic (family) constellation to which he will return, and the expectatious (both conscious and unconscious) of the therapist, of the institution, of the patient and of the family. Furthermore, the time of the evaluation of the treatment result is also a most significant variable. The parameters of evaluation have not been satisfactOrily delineated. In this study, the following compromises have been made. All evaluations are made by an independent qualified psychiatrist who has no responsibility for the selection of ‘subjects or application of the treatments. Patients are seen weekly and conferences are held with the therapist to assess the therapeutic goals before treatment and the therapist's estimate of the response after treatment. The final evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behaviour. We have used a three-fold classification of 'much improved' , 'moderately improved' and 'unimproved' , with the intent that the 'much improved' and 'unimproved' categories respectively would describe patients at the extremes of the response continuum. The patients rated as 'much improved' were those who no longer showed the symptoms which brought them to the hospital, their physicians ' �Relation of tests of altered brain ﬁmction to behavioral change 615 believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The 'unimproved' patients were those who manifested no clearly noticeable change in behaviour or who became worse. The 'moderately improved' patients showed some change in behaviour, but continued to manifest signs of mental illness. They typically showed some symptomatic relief, which was transient. RESULTS Twenty-four consecutive electroshock patients were studied. Of these, eleven were rated as 'much improved', seven as 'unimproved', and six as 'moderately improved'. (a) Electro enc ephalogr am s EEG records, using conventional leads, were measured for the average per cent time delta activity, and highest per cent time delta in any one lead; the slowest frequency in the record; and the duration and amplitude of delta bur st activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. The upper 1/3 of the records were described as 'high delta activity' and the lowest 1/3 as 'low delta activity'. No pretreatment records showed delta activity. During the course of electroshock delta activity appeared in all records to varying degrees. It was apparent within the first week of treatment and usually reached a peak on the third week following the 7-9 treatments. The results for those with high EEG delta activity are seen in Table I. TABLE I EEG - % High Delta Activity Treatment Period: Much Improved (11) Moderately Improved (6) Unimproved (7) (b) 'W .....'-.——-—- a .- 1-3 4-6 7-9 25 80 91 50 10-12 —-——————__.____—_~__ 0 0 16 0 0 88 40 20 Amobarbital Te st In these tests (2, 3) the patients are asked a series of questiOns relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in orientation and awareness of illness are scored as 'positive' amytal response, reflecting a change in brain function ascribed to 'organic brain disease' (2.). The reSults are noted in the next table. �616 M. FINK, R.L.KAHN and H.KORIN TAB—Ly; Arnytal Test - % Positive Treatment Period Much Improved (ll) 1-3 4-6 7-9 10-12 45 20 Moderately Improved (6) Unimproved (7) 64 100 33 67 14 16 16 89 20 33 13-15 100 25 0 (c) Memory Tests: In this test (5) a list of three letter common words were presented to patients by ﬂash cards. The cards were presented for 10 trials. After this, lists of 3 letter nonsense syllables were interpolated. The recall of the first list of words was then tested, and the number of words recalled in each session was scored. An impairment in recall function was apparent in all subjects. This decrement was maximal in the second and third weeks of treatment, and was sustained as long as treatments were administered 3 times a week. The decrease in ability to recall the word list is noted in the next table. TABLE III Impairment in Recall - % Marked Decrement Treatment Period Much Improved (9) Moderately Improved (4) Unimproved (7) 1-3 4-6 7-9 10—12 0 0 0 ll 33 50 0 50 l4 0 O 0 are compared with the improvement rating, there is no significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to two times per week indicates that this test is a measure of only the more severe degrees of cerebral dysfunction. (d) Tactile Perceptual Tests In these tests the patient is touched by the examiner simultaneously on the cheek and the hand, and asked to localise the stimuli. The tests are repeated for 10 trials using varying combinations of cheek, hand, shoulder and thigh. Persistent failure to report one of the stimuli or to mislocalise a stimulus beyond the tenth trial is indicative, in adults, of altered cerebral function (4). In all subjects, this test was negative before treatment. Positive When the scores �Relation of tests of altered brain ﬁmction to behavioral change 61 7 responses were observed in 19 of the 24 patients. In nine patients, two consecutive responses were observed, and of these, six were in the much improved and three in the moderately improved groups. In the next table the positive responses were charted with relation to the treatment period and the clinical evaluation. A high incidence of positive responses is to be noted in the first two groups, and many fewer such responses in the unimproved group. w Face Hand Test - % Positive Treatment Period 1-3 4-6 7-9 10-12 13-15 Much Improved (11) 16 Moderately Improved (6) Unimproved (7) 60 O 4o 43 16 47 43 12 43 3O ll 60 0 0 DISCUSSION Three aspects of these observations warrant elaboration. The sensitivity and stability of these indices of altered brain function and the significance for a definition of altered cerebral function; the relation Of these indices during and after treatment to the clinical evaluation; and the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions and remained persistently positive for one to three weeks following treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perceptual tests also showed changesbut these appeared late (in the 2nd week of treatment) and disappeared rapidly when treatment frequency was reduced. Tests of recall function and tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced change in brain function to another variable, it is important, therefore, to clearly define both the operation (or test) and the sensitivity of the operatiOn which forms the basis for the estimation of altered cerebral function. Because these tests have varying sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent treatment, while changes in recall function and simultaneous tactile perception are rapidly lost, when treatment frequency is reduced. Of the many correlations possible with these tests of brain function, we have selected the relation of these test results to the clinical improvement rating. With the EEG and amytal tests significant relationships between the appearance of test changes and clinical improvement are clearly observed. In the much improved patients, positive amytal tests �618 M. FINK, R.L.KAHN and H.KORIN and high degree EEG abnormality appeared early, were more marked, and were sustained for longer periods (on the same treatment‘regimen) than in the unimproved patients. The moderately improved patients were in between. This relation between altered brain function and clinical response is noted only with the data obtained during the course of therapy. There is no correlation of improvement ratings with post-treatment test results. This divergence is related to the timing of test applications, and may explain the discrepancies in the conclusions of other studies of this problem. These observations can also be related to an understanding of the mode of action of electroshock. In 1952, Weinstein, Linn and Kahn (6) postulated that the function of electroshock therapy was to 'initiate the production of a state of altered brain function in which the patient can deny his problems'. These observations Support the first part of this hypothesis, namely, that a state of altered cerebral function is induced by electroshock. Also, in patients who improved, the altered state is more prominent, appears earlier and is more persistent than in those who fail to improve. Of the eleven much improved patients, all had positive amytal tests (while 5 of the 7 unimproved never had a positive test); and ten had high EEG abnormality records, while only one of the unimproved patients had such a record. It is our conclusion that early, sustained and significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. ' SUMMARY In a study of the relation of tests of altered brain function to improvement in electroshock, it was observed that while indicators of change in brain function vary in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. The reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study and the difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is dependent on early, sustained and marked changes in mental function; and that electroshock therapy may be described as the non— specific, traumatic induction of states of altered cerebral function in which the subject reacts with new patterns of adaptation. REFERENCES l. 2. 3. Fink, M. and Kahn, R.L. Relation of EEG delta activity to behavioral response in electroschock: quantitative serial studies. A.M.A. Arch. Neurol. and Psychiat. , 1957, 78: 516-525. Weinstein, E.A. , Kahn, R.L. and Malitz, S. Serial administration of 'Amytal Test' for brain disease. Its diagnostic and prognostic value. A.M.A. Arch. Neurol. and Psychiat. , 195.4, 71: 217-226. Kahn, R.L. , Fink, M. and Weinstein, E.A. Relation of amobarbital test to clinical improvement in electroshock. A. M. A. Arch. Neurol. and Psychiat. , 1956, 76: 23-29. �Relation of tests of altered brain function to behavioral change 619 Fink, M. , Green, M.A. and Bender, M.B. The face-hand test as a diagnostic sign of organic mental syndrome. Neurology, 1952, 2: 46-58. Korin, H. , Fink, M. and Kwalwasser, S. Relation of changes in memory and learning to improvement in electroshock. Conf. Neurol. , 1956, 16: 88-96. Weinstein, E.A. , Linn, L. and Kahn, R.L. Psychosis during electro‘ shock therapy: its relation to the theory of shock therapy. Am. J. Psychiat. , 1952, 109: 22-26. Dept. of Experimental Psychiatry, Hillside Hosp-ital, Glen Oaks, N. Y. , U.S.A. ‘ ��Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Max Fink, Rebert L. IIOD c Kahn Ph.D. and Hyman From Karin Fh.D. the Department of Experimental Peychiatry, Hillside Hospital, Glen Oaks,N.Y. Aided by Grant M~927 of the National Institute of Mental Health, National Institutes of Health, United States Pablic Health Service. (in ,art) at the Divisional Meeting A. P .A., Montreal, November, 1956, and at the International Congress oi Neurological Sciences, Brussels, July, 1957. Read 12—3-57 �Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Numerous and studies have been reported assessing the type, duration significance of mental changes following electroshock. vary widely in their descriptions and meaningful conclusion regarding the it is difficult These reports to arrive at a relation cf such mental changes to clinical response. Basic to these differences in observation are the vexing problems of the definition and the ways of measurement of organic; type reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definition of the problem. In the present study, various applied serially to patients in whom tests of brain function were behavior was altered by repeated inductions of grand mal convulsions (Electroshock). The data comparing the serial changes in these indices are presented. . METHOD: Definition of “organic mental changes": conventional conception The of organic mental changes includes sudh behavioral changes as impairment of memory and of the discrimination of differences on perceptual tasks; disorientation for time, date, or place; errors tractibility and inability to handle perserveration in speech on more than one and behavior; emotional calculation tests; dis- situation at a time; lability; interest in one's appearance and in his environment. the relationship of memory tests of simple loss of studies assess loss or clinically manifest disorientation to improvement following electroshock. The memory loss by Most and is usually measured recall, information, personal events, digit memory span, �«2- etc.: while disorientation is place, date, name of determined by questions the examiner, etc, Such tests of relating.to present memory and of orientation, however, discriminate primarily only severe degrees of dysfunction. In the present studies, cognizant of the difficulties inherent in simple clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, types of dysfunction. The four measures selected as being sensitive to varyinD aspects and degrees of cerebral dysfunction were: delta activity in the electroencephalogram (1). b) Changes in language and orientation following the administration of amobarbital sodium - the "amytal test" for organic brain a) The degree of disease (2, 3). c) Alteration in perception of multiple simultaneous tactile stimuli (h). d) Changes in tests of recall of the interpolation of reading Time of Testing: A common lists words, both with and without of nonsense syllables (5). second factor to be considered is the time of application of these tests in relation to the treatment program. observers have reported the development of organic changes in the Numerous few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third is at pretreatment levels, orientation is re-instituted. course of therapy the electroencephalogram memory changes have disappeared and week following an extensive �.3In the present studies, the electroshock treatment schedule was main- tained at three times per all patients receiving conventional initial three weeks. In the fourth week, week with Reiter electroshock, during the treatment frequency was occasionally reduced to two times per week. All patients received a out at weekly minimum intervals of twelve treatments. All on a day following a tests were carried treatment during the course of therapy. Following termination of therapy, weekly testing was continued until the tests returned to their initial level. Behavior Ratings: A third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definition and evaluation of "improvement." The evaluation of clinical is a subjective value administrator which reflects a divergence response to therapy judgment by the therapist or of goals, judgments, and com- promises. Significant variables in the evaluation of "improvement” are the type, severity and duration of the patient's illness, his premorbid personality, the sociologic (family) constellation to which he will return, and the expectations (both conscious and unconscious) of the therapist, of the institution, of the patient and of the family. Furthermore, the time of the evaluation of the treatment result is also a most significant variable. The parameters of evaluation have not been satisfactoriLy delineated. In this study, the following compromises have been made. All evaluations are made by an independent qualified psychiatrist who has no responsibility for the selection of subjects or application of the treatments. Patients are seen weekly and conferences are held with the therapist to assess the �.44.. therapeutic goals before treatment and the therapist‘s estimate of the final evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behavior. reaponse after treatment. we have used a The three-fold classification of improved" and "unimproved," with the "much improved," "moderately intent that the "much improved" and "unimproved" categories respectively would describe patients at the extremes of the response continuum. The patients rated as "much improved" were showed the symptoms which brought them those who no longer to the hospital, their physicians believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The "unimproved" patients were those noticeable change in behavior or The who became "moderately improved" patients manifested no clearly Who worse. showed some change but continued to manifest signs of'mental illness. some symptomatic relief, which was transient. They in behavior, typically showed �-5RESULTS : Twenty-four consecutive electroshock patients were studied. "much improved," seven as "unimproved," these, eleven were rated as and Of six as "moderately improved." (a) Electroencephalograns: EEG records, using conventional leads, highest lead; the Slowest frequency in the record; were measured for the average per cent time delta activity, and per cent time delta in any one and the duration and amplitude of delta burst activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. were described as "high delta activity" and The upper 1/3 of the records the lowest 1/3 as "low delta activity.” No electroshock delta activity appeared in was apparent within the on the activity. pretreatment records showed delta third with high first week following EEG all records to varying degrees. week of treatment and the 7-9 treatments. delta activity are seen in Table TABLE EEG . % During the course of The usually reached a peak results for those I. I Hiqh Delta Activity Treatment Period: 10-12 1-3 h—é 7—9 25 80 91 88 Moderately Improved (6) o 16 so ho Unimproved (7) o o o 20 ﬁnch Improved (ll) It �a (b) ~6- Amobarbital Test; In these tests (2, 3) the patients are asked series of questions relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in a orientation and awareness of illness are scored as "positive" amytal reSponse, reflecting a change in brain function ascribed to "organic brain disease" (2). The results are noted in the next table. TABLE Amytal Test - II % Positive Treatment Period: 1-3 h-6 7-9 10-12 13-15 Much Improved (11) £15 61; 100 89 100 Moderately Improved (6) 20 33 67 20 25 Unimproved (7) 1h 16 16 33 o The data of Tables The congruence of I and II have been graphically portrayed in Figure 1. the observations of the degree of EEG delta activity and the per cent positive amytal test reSponses is demonstrated. (Fig. I) (0) Memory Tests: In this test (5) a list of three letter common words were presented to patients by flash cards. The cards were presented for 10 trials. After this, lists interpolated. The of 3 recall of the first letter list nonsense syllables were of words wens then tested, and the number of words recalled in each session was scored. An impairment in recall function was apparent in all subjects. This decrement was maximal in the second and third weeks of treatment, and was sustained as long as treatments were administered 3 times a week. �.’ ~7The decrease in ability to recall the word list is noted in the next table. TABLE Impairment in Recall III - % Marked Decrement 1-3 Treatment Period Mnch Improved (9) Moderately Improved (h) ' Unimproved (7) When h-é 7-9 10-12 O 11 33 O 0 SO SO 0 0 1h 0 0 the scores are compared with the improvement rating, there is significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to two times per week indicates that this test is a measure of only the no more severe degrees of cerebral dysfunction. tests the patient is touched the cheek and the hand, and asked to (6) Tactile Perceptual Tests: In these by the examiner simultaneously on localize the stimuli. The tests are repeated for combinations of cheek, hand, shoulder and thigh. report one 10 trials using varying Persistent failure to of the stimuli or to mislocalize a stimulus beyond the tenth trial is indicative, in adults, of altered cerebral function (h). In all subjects, this test was negative before treatment. Positive two responses were observed in 19 of the 2h patients. In nine patients, consecutive responses were observed, and of these, six were in the much improved and three in the moderately improved groups. �In the next table the positive responses were charted.with relation to the treatment period of positive responses and is to the dlinical evaluation. be noted in the first A high incidence two groups, and many fewer such responses in the unimproved group. TABLE Face Hand Test IV - % Positive Treatment Period Much Improéed (11) . a Moderately Improved (6) Unimproved (7) ~ 1-3 h-6 7-9 10-12 13-15 16 ho h7 h3 60 60 h3 AB 30 O 0- 16 12 11 O �DISCUSSION: Three aspects of these observations warrant elaboration. sensitivity and stability The of these indices of altered brain function significance for a definition of altered cerebral function; the relation of these indices during and after treatment to the clinical and the evaluation; and the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function.was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions persistently positive for cne to three weeks following treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perand remained ceptual tests also showed changes but week of treatment) and disappeared . was reduced. Tests of recall function and these appeared late (in the rapidly when 2nd treatment frequency tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced to another variable, the operation (or it is test) change in brain function important, therefore, to clearly define both and the sensitivity of the operation which forms the basis for the estimation of altered cerebral function. Because these tests have varying sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent �{-10- treatment, while changes in recall function and simultaneous tactile perception are rapidly lost, when treatment frequency is reduced. Of the many correlations possible with these tests of brain function, we have selected the relation of these test results to the clinical improvement rating. With the EEG and clinical much improved patients, relationships between the appearance of test changes improvement are clearly observed. In the positive amytal tests and high degree EEG tests significant and amytal abnormality appeared early, were more marked, and were sustained for longer periods (on the same treatment regimen) than in the unimproved patients. The moderately improved patients were in between. relation between altered brain function and clinical response This only with the data obtained during the course of therapy. is noted There is results. no correlation of This divergence improvement is related to the timing of test applications, in the conclusions of other studies and may explain the discrepancies of ratings with post-treatment test this prdblem. These observations can also be mode of related to an understanding of the action of electroshock. In postulated that the function 1952, Weinstein, Linn and Kahn (6) of electroshock therapy was to ”initiate the production of a state of altered brain function in which the patient can deny his problems." These observations support the first part of this hypothesis, namely, that a state of altered cerebral function is induced by electroshock. Also, in patients who.improved, the altered state is more prominent, appears earlier and is more persistent than in �.11.. those had who fail to improve. Of the eleven positive amytal tests (while positive test); 5 of the much improved 7 patients, all unimproved never had a and ten had high EEG abnormality records, while only one of the unimproved patients had such a record. It is our conclusion significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. that early, sustained and �SUMMARY: In a study of the relation of tests of altered brain function to improvement in electroShock, of change in brain function vary it was observed that while indicators in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study The difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is and the dependent on early, sustained and marked changes in mental function; that electroshock therapy may be described as the non-specific, traumatic induction of states of altered cerebral function in'which and the subject reacts with new patterns of adaptation. �REFERENCES l. Fink, Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & PsychiatJﬁ: M. and Kahn, R.L.: 516‘5251 1957. Kahn, R.L. and Malitz, 5.: Serial Administration of "Amytal Test" for Brain Disease. Its Diagnostic and Prognostic Value, A.M.A. Arch. Neurol. Psychiat. 23;: 2. Heinstein, E.A., <3». 217-226, 19st. 3. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electro shock, A.I'I.A. Arch. Neurol. a Psychiat., 19: 23-29, 1956. h. Pink, Grren, HA. and Bender, H.B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurolo ﬂ. , _2_: 116—58, 1952. 1-1., H. , Fink, 1'1. and Kwalwasser, 8.: Memory and Learning to Improvement 5. Korin, I‘Ieinstein, 13.A., Linn, L. and Kahn, shock Therapv: Relation of Changes in in Electroshock, Conf. R.L.: Psychosis During Electro- Its Relation to the Theory of Shock Therapy, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of tests of altered brain function to behavioral change following induced convulsions. In L. van Bogaert and J. Radermecker (eds.), First International Congress of Neurological Sciences. Pergamon Press, London, 1959, 3:613-619. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-39-005 Date A point or period of time associated with an event in the lifecycle of the resource 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>; Kahn, Robert L.; Korin, Hyman Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Two [preprints] and one reprint. Reprint from The First International Congress of Neurological Sciences, Brussels, 1957, Vol. III EEG, Clinical Neurophysiology and Epilepsy. Peramon Press; London, New York & Paris, 1959 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/8d591c235c58b9d455d7cbdd43d00916.pdf ebb607fbcf115668ef8fa3c0792cd5b3 PDF Text Text PSYCHOLOGICAL FACTORS AFFECTING INDIVIDUAL DIFFERENCES IN BEHAVIORAL RESPONSE TO CONVULSIVE THERAPY MAX FINK, M.D., ROBERT L. KAHN, PHD. AND MAX POLLACK, PHD. Reprinted from THE JOURNAL or NERVOUS Volume 128, N0. 3, March Printed in U.S.A. AND MENTAL DIBEABE 1959 �JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 128, No. 3, March 1959 Reprinted from THE Printed in U.S.A. PSYCHOLOGICAL FACTORS AFFECTING INDIVIDUAL DIFFERENCES IN BEHAVIORAL RESPONSE TO CONVULSIVE THERAPY1 MAX FINK, MD.,2 ROBERT L. KAHN, PHD. AND MAX POLLACK, PHD. INTRODUCTION While convulsive therapy is generally considered speciﬁc for the symptomatic re— lief of depression and agitation, and for the relief of such “illnesses” as manic-depressive and involutional psychotic reactions, the behavioral response to such therapy is highly variable. In initial attempts at understanding this behavioral variability, differences in physiologic response were sought. Neurophysiologic change was measured in various ways (4). The quantitative measures of induced EEG delta activity (1) and changes in language after amobarbital (3, 7) provided the best indices. Considerable variability in these indices among patients with equivalent numbers of treatment was observed. We concluded that the development of an alteration in brain function, as measured by a high degree of EEG delta activity (1) and positive amobarbital tests (7) was a prerequisite to behavioral change in convulsive therapy. It was apparent, however, that such changes, although necessary, were not sufﬁcient for improvement (2). Indeed, among patients with maximal neu— rophysiologic change, all patterns of behavioral adaptation were manifest, and ratings of improvement ranged from “re— covered” to “unimproved” and “worse.” Equating segments of the observed popu— lation according to nosologic or sympto— matic categories also failed to explain the variability in behavioral response. While among patients in the manic-depressive and 1Aided in part by Grants M-927 and MY-2092 National Institute of Mental Health, US. Public Health Service. Read at the Section of Convulsive Disorders and Brain Function, American Psychiatric Association, San Francisco, May, 1958. EThe Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. involutional depressive groups a higher inci— dence of hypomanic and euphoric modes of adaptation were observed, and thus ratings of “recovered” and “much improved” were more frequent, there still were many subjects in these groups who manifested paranoid and somatization modes, and were rated “unimproved.” In the investigations of convulsive therapy, various tests of perceptual organization and indices of sociologic background have been studied which reﬂect the individual differences in the subjects. Of these, some measures correlated highly with the behavioral response to convulsive therapy. The psychological measures employed have been Rorschach responses (11), “explicit verbal denial” tendencies as measured in structured interviews with family members (12), and scores on the California F Scale (8, 10). The sociologic variables have been chronologic age, years of education and place of birth. It is the purpose of this report to summarize the observations of the relationship between these indices and the variability of the behavioral response to convulsive therapy as reﬂected in evalua— tions of improvement. METHODS The population has been consecutive referrals for convulsive therapy in a voluntary, non-proﬁt, urban psychiatric hospital. Patients were generally Jewish, of low and middle socio-economic classes with a mean educational level of 10.5 years. Ages ranged from 16 to 67 with a mean of 41 years. Diagnoses included schizophrenia, manicdepressive, psychoneurotic and involutional depressive reactions. As segments of the population were studied by various procedures at different times, the tables reﬂect 243 �244 FINK, KAHN AND POLLACK the different numbers of subjects that were included in each procedure. All patients received electroconvulsive therapy three times a week, using either unidirectional or alternating current instruments. The various psychological tests were administered Within the week prior to treat— ment. We have previously described the be— havioral changes in convulsive therapy as variations of ﬁve modes of adaptation (euphoric, hypomanic, somatization, paranoid withdrawal and panic), and emphasized that the evaluations of “improvement” in convulsive therapy are value judgments of the induced behavioral changes (2). Patients who manifest euphoric and hypomanic adaptive modes are those generally rated as “much improved” and “recovered” by therapists and administrator, while those who manifest paranoid-withdrawal, somatization or panic modes are generally regarded as “unimproved” or “worse.” For this report, evaluations of the patient’s behavior and ratings of improvement were made either two to three weeks after termination of treatment (Tables 1, 2, 3) or at the time of discharge from the hospital (Table 4). TABLE 1 Relation of Rorschach Factors to Clinical Response in Convulsive Therapy Much Improved N Moderately Improved and Unimproved Movement 39 11 (28%) 28 (72%) No Human Movement 48 28 (58%) 20 (42%) Human (M) x2 = 676* p < Form Color (FC) No Form Color 34 7 53 32 Both M and FC Either M or F0 Neither M nor FC 24 4 25 10 38 25 (21%) 27 (79%) (60%) 21 (40%) x2 = 11.57* p < .001 I X2 * .01 (17%) 20 (40%) 15 (66%) 13 = 14.83 p < (83%) (60%) (34%) .001 With Yates’ correction for discontinuity OBSERVATIONS RORSCHACH TEST PATTERNS The Rorschach tests were administered in conventional fashion and scored according to established criteria (13) for speciﬁc factors as number and type of movement, color, form, shading and total number of whole responses. For each of these factors, signiﬁcant differences were observed be— tween the group of patients rated as “much improved” and the combined groups of those patients evaluated as “moderately improved” and “unimproved.” Subjects with human movement responses were evaluated as “much improved” signiﬁcantly less often than subjects without such responses. The presence of form color responses was signiﬁcantly correlated with lack of improvement, and when this factor was combined with human movement, the ratings were signiﬁcantly poorer than when neither form color nor human movement were reported (Table 1). Similarly, patients rated “much improved” gave fewer total responses, fewer total movement responses and fewer content categories; but the per cent whole, popular and form responses were signiﬁ— cantly greater than in the groups rated as “unimproved” and “moderately improved” (Table 2). “DENIAL PERSONALITY” SCORE In their study of denial of illness, Weinstein and Kahn (14, 16) described the characteristics of an “explicit verbal denial” personality type.3 In an initial group of convulsive therapy patients, the hypothesis was tested that those patients who most closely approximated this personality type would be most likely to be rated as “much improved.” “Denial personality” scores were 3“They were people with compulsive drives, a great need for prestige and the esteem of others, and a record of always having denied felt inadequacies. ...Life experiences had been valued not for their intrinsic satisfactions but as a means of maintaining prestige and “security.” (14). �245 PERSONALITY ASPECTS OF CONVULSIVE THERAPY established pretreatment in independent structured family interviews. Fifteen spe— ciﬁc areas of behavior were assessed and scores of 0, 1, and 2 were assigned for each of these areas according to whether the subject least, moderately or most approximated the characteristics of the “explicit verbal denial” personality type. In interviews with relatives of 47 patients, scores ranged from zero to twenty-ﬁve, with a median of eleven. Subjects with scores above eleven were classed into a high denial group, while those with scores below, into a low denial group. Patients with high denial personality scores were most likely to be rated as “much improved,” with only one patient rated as “unimproved.” Of patients with low denial scores, clinical ratings occurred on a chance basis in each evaluation category (Table 3). The difference in the denial scores be— tween the much and moderately improved patients, when compared to the unimproved patients, is statistically signiﬁcant at the one per cent level (12). In a further elaboration of these personality types, studies of the total in—patient population were undertaken. Certain sociologic and psychological factors were studied in all patients in residence on March 7, 1957. These included the California F Scale, age, years of education and place of birth (8). TABLE 2 Relation of Rorschach Factors to Clinical Response in Convulsive Therapy Dif— N Mean S. D. ference Number of Responses Much Improved 3813.00 6.7 Moderate, Unimproved 48 19.5 12.8 52 ' 7*... 6 Per Cent Whole Responses 38 37.6 21.013 Much Improved ' 23 ' 0*... Moderate,Unimproved 4824.4 18.2 Per Cent Popular Responses Much Improved Moderate,Unimproved Number Movement sponses Much Improved 38 37.7 21.6 11 1 2 8** ' ' 48 26.6 14.3 Re- Moderate,Unimproved 38 2.3 48 4.9 Number Content Categories 38 3.8 Much Improved Moderate, Unimproved Per Cent Form Responses Much Improved Moderate,Unimproved 4.9 48 2.7 5 1 2.2 2.3 2 ' 62 ' 7,“. 1 ' 12 ' 1* 38 71.8 19.0 9 ' 92 ' 2* 48 61.9 21.4 Signiﬁcant at .01 level Signiﬁcant at .05 level ** * TABLE 3 Relation of Denial Personality Scores to Clinical Response in Electroshock Mod- N CALIFORNIA F SCALE The California F Scale consists of a series of extreme or stereotyped statements con— cerning social and personal attitudes. The subject reads each statement and then reports the extent of his agreement or disagreement. Originally presented as a guide to a subject’s capacity for ethnocentrism and authoritarianism, the method has recently been explored as a measure of stereotypy and rigidity in communication (8, 10). The test was presented to all patients prior to treatment and scored on a scale of ten to seventy. The ﬁgures represent maximal dis- t Personality Score High Denial—(11—25) Low Denial—(040) 24 23 NEE] erately ImImproved proved proved 14 7 9 9 l-| 7 agreement (low score) and maximal agree— ment (high score) with the statements. There was a signiﬁcant relationship (p < .05) between the pretreatment test scores and evaluations of the clinical response to convulsive therapy (Table 4). For patients rated as “recovered,” the mean F score was 53.1, while for those rated as “unimproved” �246 FINK, KAHN AND POLLACK TABLE 4 Relation of Social Factors to Discharge Ratings in Convulsive Therapy N Recovered Much Improved Improved and proved Unim— 8 26 23 $3 “*3 a ‘3 >§ E5 2 2 2 a. &° 53.151.6 9.4 50 41.843.810.6 35 39.732.312.3 17 the score was 39.7, reﬂecting greater degrees of agreement with the stereotyped statements of the test for the “recovered” group. SOCIOLOGIC FACTORS When analyses were made of the relation between improvement ratings in convulsive therapy and age, years of education and place of birth, signiﬁcant relationships were observed for each of these variables. The “recovered” patients were signiﬁcantly older (p < .001) and had signiﬁcantly fewer years of schooling (p < .05) than the “unimproved” group. While a larger percentage of the “recovered” patients than the “unimproved” patients was foreign-born (50 per cent vs. 17 per cent), the differences were not signiﬁcant. In each category, the “much improved” subjects fell in between (Table 4). DISCUSSION We have noted that measures of perceptual organization, personality traits and sociologic data are related to the degree of improvement shown by subjects with cone vulsive therapy. These observations pr0v vide an understanding of the individual variability in the behavioral response to convulsive therapy under conditions of ap~ parently equivalent degrees of altered brain function. In their studies of patients with brain disease, Weinstein and Kahn described be— havioral patterns as ludic behavior (15), increased smiling and laughter, denial of illness, minimization and displacement of symptoms, and altered sexual behavior achieving prominence in the milieu of a1— tered brain function. They suggested that the manifestation of these behavioral patterns also provided the basis for the evaluation of improvement in convulsive therapy (16). In these studies of patients in con— vulsive therapy the same patterns of laughing and smiling, denial, displacement, minimization and altered sexual activity do indeed occur in the milieu of the induced altered orientation and discrimination (2). It is the patients demonstrating these altered behavior patterns who are rated as “recovered” or “much improved”; while those patients failing to show these patterns or doing so transiently are evaluated as “unimproved” or “improved.” Recent studies of changes in language with convulsive therapy have further ampliﬁed an understanding of these behavioral responses. Alteration in syntactic aspects of language has been related to clinical ratings (9). Patients evaluated as “recovered” and “much improved” demonstrated signiﬁcantly greater use of the past or future tense and the third person mode with qualiﬁca— tion, evasion, denial, displacement, clichés, and cryptic and stereotyped expressions during treatment than did “unimproved” patients. More recently, Jaffe et al. (6) reported that formal speech patterns also were characteristically altered. In dyadic interactive speech analyses (5), increased repetitiveness and stereotypy were associated with syntactic language changes during convulsive therapy. In the studies reported here, aspects of personality organization have been deﬁned which are related to the type of behavioral response incident to convulsive therapy. The Rorschach patterns of the more favorably rated group are generally associated with greater degrees of conventionality and stereotypy, and little introspectiveness, imagination, empathy and creativity. Similarly, the higher F scores of the more favorably rated group is consistent with greater �PERSONALITY ASPECTS OF CONVULSIVE THERAPY degrees of ethnocentrism, authoritarianism, rigidity and conventionality. In present day urban culture older patients generally have less formal education and a greater number are foreign born than younger patients. These sociologic factors are also associated with greater adherence to conformist ideologies and ethnocentric identiﬁcation. We may conclude that those patients who ap— proximate the “explicit verbal denial” personality type, and who are non—empathic, non-introspective, stereotyped, rigid and conventional are most likely to manifest the euphoric and hypomanic modes of behavior under the conditions of altered brain function induced by repeated convulsions. Such patients also rely primarily on nonverbal patterns of communication, and with treatment evince increasing use of the lan— guage patterns of repetitiveness, denial, displacement and third person. These changes in language and behavior are the cues to which psychiatrists and administrators respond in their evaluations, and thus provide the basis for the clinical ratings of “re— covered” and “much improved” (9). In contrast, those subjects who are em— pathic and introspective, who are not rigid, conventional or stereotyped, and who rely primarily on verbal patterns of communica— tion are less likely to manifest the ludic behavioral modes of euphoria and hypomania. With the induced alteration in brain function they manifest increased somatiza— tion, withdrawal, projection, anxiety, panic and intellectualization. Their speech is pre— dominantly in the present tense and in the ﬁrst person mode without displacement, denial or clichés. Clinically, such patients are rated as “unimproved” or “worse.” Thus, while altered brain function is essential for a behavioral change in convulsive therapy, individual differences in personality organization provide the basis for the variability in the types of behavioral changes and in the clinical ratings of improvement. In another report (12) it was suggested that the personality attributes 247 which provide the background for improve— ment with convulsive therapy also provide the basis for the depressive adaptation ini— tially. It was noted that numerous authors had described a characteristic pre-depressive personality type, with a prominence of the features of perfectionism, rigidity, con— scientiousness, and stereotypy. The social factors, Rorschach and F scale patterns described here also support such a suggestion. Ludic patterns of depression and mania are more prominent in older, less educated sub— jects. The conventionality, rigidity and stereotypy associated with the ﬁndings on the F scale and the Rorschach test are also prominent in depressive illnesses. It is probable that the depressive psychotic reaction and the euphoric-hypomanic behavioral re— sponse in convulsive therapy may be as— pects under different neurophysiologic con— ditions of an adaptive pattern in subjects with a personality organization marked by stereotypy, rigidity, conventionality and poor capacity for introspection and em- pathy. CONCLUSION In studies of convulsive therapy, differences in personality organization and sociologic aspects of history have been related to differences in behavioral response. Persons who are stereotyped, rigid, non-empathic and non-introspective, as deﬁned by explicit criteria in Rorschach, F Scale and structured family interviews, and who are less edu— cated, older and foreign born are more likely to manifest behavioral modes of euphoria and hypomania and to be evaluated as “recovered” and “much improved.” Patients who are introspective, empathic, non-stereotyped, native born, better educated and young are more likely to manifest somatiza— tion, paranoid—withdrawal and panic modes of behavior with convulsive therapy, and to be rated as “unimproved” or “worse.” While an induced alteration in brain func— tion is necessary for behavioral change in the convulsive therapy process, personality �248 FINK, KAHN AND POLLACK organization and sociologic factors are de— terminants of the type of behavioral change, and of the clinical ratings of degree of improvement. 1. REFERENCES FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock: quantitative serial studies. A. M. A. Arch. Neurol. & Psychiat, 78: 516— 525, 1957. 2. FINK, M. AND KAHN, R. L. Behavioral patterns of induced states of altered brain function. Presented at the NY. Divisional Meeting A.P.A., Nov. 1957. 3. FINK, M., KAHN, R. L. AND GREEN, M. A. Experimental studies of the electroshock proc— ess. Dis. Nerv. System, 19: 113—118, 1958. 4. FINK, M., KAHN, R. L. AND KORIN, H. Relation of tests of altered brain function to behavioral change following induced convulsions. In Proceedings I nternat. Congress N eurologic Sciences, Brussels, 1958 (In press). 5. JAFFE, J. Language of the dyad. Psychiatry, 21: 249—258,1958. 6. JAFFE, J., KAHN, R. L. 7. AND . 216—228, 1957. . KAHN, R. L. AND FINK, M. Changes in lan- guage during electroshock therapy. In Psychopathology of Communication, Hoch, P. and Zubin, J., eds. Grune & Stratton, New York, 1958. 10. KAHN, R. L. AND FINK, M. The relation of F score to behavioral and physiologic response with altered brain function. Presented at Eastern Psychological Assoc, Phila., April, 1958. 11. KAHN, R. L. 12. 13. 14. FINK, M. Com- munication patterns with altered brain function. Presented at Eastern Psychological Assoc., Phila., April, 1958. KAHN, R. L., FINK, M. AND WEINSTEIN, E. A. Relation of amobarbital test to clinical im— provement in electroshock. A. M. A. Arch. Neurol. & Psychiat, 76: 23—29, 1956. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in selection of therapy in a voluntary mental hospital. J. Hillside Hosp., 6: 15. 16. M. Prognostic application of psychological techniques in convulsive therapy. Dis. Nerv. System (In press). KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock therapy. Conf. Neurol. (In press). KLOPFER, B. AND KELLEY, D. The Rorschach Technique. World Book Co., New York, 1942. WEINSTEIN, E. A. AND KAHN, R. L. Personality factors in denial of illness. A. M. A. Arch. Neurol. & Psychiat., 69: 355—367, 1953. WEINSTEIN, E. A. AND KAHN, R. L. Ludic behavior in patients with brain disease. J. Hillside Hosp., 3: 98—106, 1954. WEINSTEIN, E. A. AND KAHN, R. L. Denial of Illness. C. C. Thomas, Springﬁeld, Ill., 1955. AND POLLACK, ��m.v..ww.. _._’—_w L. ��unma‘mww ”WNW. mwmmmmmmem M'Wt Wmemwmmg mmmmmm a .‘ Wmimﬁmxmtmmwwu mummmammmmhum MWWFW(%M}§ mwmmm mwmmatmmmmum. mum umwamm‘ ‘ “at“ - ��wmmmwummumtmm Wm»m:mwwm,m,rm WWWMrotmm. mmdmu ﬂuMWu’MWWWaWWM «in» ' m W “W“ mwmmmmmvmmm mm w «- and “mmuwmawmmmuWa-m WMWMMmemuImeW (ma). mm,mummww”tw mmmwwcmm. mm ‘ ��ms s: 3 {8 a 5 M 3.5:: flat? 8.2. h! 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Punt _ �Psychologic Variables and Neurophysiologic Reaponsivity In Convulsive Therapy Max Fink 14.13., Robert L. Kahn Ph. 13., PollacK Ph.D., Max Eric Karp B.A. and George Krauthamer Ph.D. / MiConsecutive referrals for convulsive therapy of psychologic were studied by a measures prior to treatment, and by variety; electro- encephalogram prior to and at weekly intervals during treatment. Alterations in brain function, as reflected Wm and amplitude were examined EEG frequency, modulation, pattern variables’W in relation to these and improvement on in by changes to behavioral change and a clinical gating of teminatMtreafmren‘t . Significant relationships ”if”; were observed induced change and the following pre-treatment variables: EEG (W m W (a) Educational level > ‘ between the degree of -”M(b) . i5- Rorschach criteria ' (c) ‘ (d) . 0} . Mnemr, 8.4,, M Ma... {@3/apmaw {magmg /,~:.,W2M7/5,,+. - «1' Jul deft“ WW 4% significant relationship ia-legiesee existed between alteration of brain function and treatmet induced behavioral change. degree Metfffrﬁfiﬁfrtmm_.._.a,._m.,...,hz:€.5...» 7‘» «9 a' “W” ' delta a ~- . A clinical rating of improve“be!” 0 ,mx fwﬂ’ A h #5.» da » - QC . (Hréy 50’4”“? “ﬂaw mentm‘honever, was contingent” upon high degree delta activity4ude pretreatment psychologic pattem‘W) , sociologic status and environmental '- “)2, «Km , expectationxr. Conclusions: ﬁ’ehavioral change was related to electrographic change. while—a— rating of "improved" socio—psychologic 0b Iivz'taa-additionally dependent upon a factors. Mor-eover, neurophysiologic (rate ﬁgme of change) to induced convulsions \ pretreatment psychologic variables. ,1' , ' constillation responsivity of 46“ significantly related to ’4' �l' “ s —2- W .. Past studies of the relation of electrographic change to behavioral change M have yielded con radictony results. These variations in outcome may be due to differences in the personality characteristics of the populatioz%tudied since L... patternsm related not only to the type and duration of socio-pscyhologic induced behavioral change but to the degree of electrographic change as well. ) , present results underline the fact that a univariate analysis of neurophysiologic and. behavioral relationships is no lonser adeouate to the problems of experimental psychiatry, and the application methods of The multivariate analysis is From / recommended. the Department of Experimental Psychiatry, Hillside Hospital Glen Uaks, _ of” L.I., 3/31/60 1,12 ‘W'o Am. N.Y. EEG �Peychologic Verieblee end Heurephyeielogic neeponeivity In Convaleive Therepy H.D., Robert L. Kehn Pb. B., Hex Polleek Ph. 9., Eric Kerp 8.1. end Gear‘s Kreuthemer Ph. D. Hex Fink caneecutive reterrele for convulsive therepy were etudied by e veriety of psycholcgic neeeuree prier to treetnent, end by electreeneephelogrene priortc end et weekly intervals during treat» sent. Alterations in brein funetian, ee reflected EEG by changes in frequency, modulation, pattern and emplitude were exemined in relation ta these verieblee, retinx of impraveuent an and to behavioral chense and e elinieel termination at treatment. aignificent relationship: (ch12) degree otinduced EEG change end the were cheerved between the tellewin; pro-treatment verieblee: / (e) Educetianel level (b) Borechack criterie at Movenent, cola: end number at reepanaee Embedded figures tent 5c) d) Alphe index A eignificent reletionnhip also existed between ulteretien of brain functien and treatment induceé behavioral change. a: behavioral chenge clinicel retina wee The releted to the degree at doth activity. degree A of improvement an the ether hand, wee contingent net only upan high degree delta activity but 1139 upen pretreatment �-2psycholozic puttcrna, acciolugic atatuu and :nvironmontal czpoetu» tians. In convulsiva thornpy, bchuvieral china. 1: concluaianl: rolntnd tn oloctrojruphic ahango. ally doplndont upon n A rgtin; at "iaprovod" is udditienu conttullutien of nocia-puychalogic fucters. Haruovor, nourophyniologie rolponnivity (rate or dogrco or chug.) to induced convulntian any :13» be ainnitiauntly rulgtod to prttrtat~ meat 0! p'ycholugic itriabloa. Putt studio: at tn. rclution or uloctroxrnphic chums. to bchnvieral chancc 1n aonvnlaivo thar¢py hgvo yieldod contradietery results. Thoad variations in outeon. may be due to dirtcraneca in the per-antlity ehnrtgtoristtel at the papulntinns atadiad sine. aocio~puychelogic pattorno may be relatud act only ta th. type tad durntion of induced behavioral chang¢,but to the dagrue a! cloetron graphic chance as well. The proutnt ralultu undarlino tho itct that a univtriato unllyais or nouraphyaiologic and bah;vioru1 rolatianahipa is no lengur aduqutto to the prablonl a! prorinonttl psychiatry, und the npplication or methods or From rocommandad. the Dopnrtuqnt of Exporinontnl Psychiatry, Hillaido Hospital Glon Oaks, 1v: nultivaridn analysis in h/l/éc 3.1. L.I., Am. 320 �‘ ,é?" /' / (o 1/, "y .4 Psychologic Variables and Neurophysiologic Responsivity In Convulsive Therapy Max Fink M.D., Robert L. Kahn Ph. D., Max Pollack Ph. D., Eric Karp B.A. and George Krauthamer Ph. D. Consecutive referrals for convulsive therapy were studied ﬁg: a. variety of psychologic measures préer—te treatment, by a and by electroencephalograms priogﬂb and at weekly intervals during treatment. Alterations in brain function, as reflected 91/ ~EEG “ﬁg; r5313r «35? a». in affﬂzf‘ﬂgﬁ" Qi’e‘u frequency, modulation, pattern and amplitudeﬂwere examined in relation to these variables, rating of improvement on and to behavioral change and degree ofinduced a ébg: m Educationa Rorschacﬁ e \.of reaponses Embedded figures test Alpha index 0 "d A and the 25% a clinical termination of treatment. Significant relationships (chizi xi, 3F 5.3,“,change of 2‘33; by changes were observed between the following pre— treatment variables: A, ovement,A color, and number of significant relationship also existed between alteration brain function Aand treatment induced behavioral change imbald£££§§WW, WW C56Mamet, (Wheg “Mbehaxlnnalxchangemuas.relaxed.tewthedegreeofwdglﬁ33%;:gﬁrw £17MM4/sgéf “3...: W clanaeelwrati“g“cﬁmimprgyementan“: an s: {:Lﬂﬂu 49; ‘odZEfMM,4 9% only upon high degree 3%”;ng Clzbwi ,1? W4 'Mcthermnaﬁdwwwas My»: delta activity but also upon y A 'x contingent not pretreatment �\ -2psychologic patterns, sociologic status and environmental expectae tions. Conclusions: In convulsive therapy, behavioral change is i related to electrographic change. ally dependent upon a A ' is addition— rating of aou:;;:::ew3‘ constgllation of socio—psychologic factors. Moreover, neurophysiologic responsivity (rate or degree of chage) to induced convul€2§0n§may also be significantly related to pretreat— ment ,/ psychologic variables. Past studies of the relation of electrographic change to behavioral change in convulsive therapy have yielded contradictory results. 'These variations in outcome may be due to differences in the personality characteristics of the populations studied)since socio—psychologic Kﬂwaaah patterns meynbe related not only to the type and duration of induced behavioral change,but to the degree of electro— graphic change as well. dwadﬁfffﬂ present results mad-niIl-Iib-iﬂiit thatdﬂ‘univariate analysis or ngﬁsﬂb 4o of neurophysiologic and behavioral relationships gﬁkno longerﬁadequate The \ tojthe problems of experimental psychiatry, ’ and the . application of 1 methods of multivarian analysis is recommended. From the Department of Experimental Psychiatry, Glen Oaks, L. I. 1v: h/1/60 Am. N. Y. EEG Hillside HOSpital - �01:? ////’ m ' Individual Differences in Neurophysiologic Responsivity to Convulsive Therapy Previous studies indicated that an alteration in brain function was requisite to/tkéfbehavioral change and ratings of improvement in convulsive therapy. has been The type of behavioral change related to various perceptual,psychologic, and social aspects of the individual's history and behavior.The present study demonstrates significant relationships between the degree of 037' -convulsive neurophysiolegic change and amobarbital test (EEG slow wave activity response) and pro-treatment perceptual{MW‘ 4, , ' personality functioning (educational level, Rorschach, figure5 \ . {A 1‘ 1 groun While Mylo “W“; ’/ f relationshipeztsﬁuu'n neurophysiolegic “a. 3mm meeewneﬁ a-dL J3 ”(a[7w // ,3 5‘ 1%?!” ”Z personality measures have generally not been-establisheéi these observations indiate that the rate and degree of change] in neurophysiologic .m (mm/Me may indeed be related to personality cognitive Illﬂlllﬂr(perceptualenillI-Ig style). AM; ,3. ﬁzz/)4! %x Fly if! ﬂ/s’éx. 6mg“! KC A9- 3. (buff ﬂags/.4 ,4”? ’7 g/Qt MM 6“ My 1501 6:1 ’- / 1L ,‘ I/I/ff SM 3191” 739/5 I Wm? / £421 /9’ - er, 4.! 4452;; J). /Vé(fm'«£ﬁ AV/f’S-Qi? �Iu¢$viéun1 attrarnuaés in laurgzhywtaivgtc acupuaatvitr w. Eﬂwftliﬁfi trip: Sadiugtaa thlt an ultawutiaa in brain to-hohavﬁawtl altar: «at rﬁtlﬁli a: 1x 'fﬁ'ﬁi ﬁﬂﬁVQIﬂ$ti tharnrr. ran try. it hnhuvioral atgnga in: ﬁtlh vclntid ‘Q,Vﬁiﬁtﬂ£ paranptuul, payuhaxactc, and.a¢uiul maptatn #1 taaivtdial': htttﬁ 3nd hakartor. prtuwut atudy «cannatmutua niauitianai t! ﬁicaahtpa htiuuou tau dﬂlvtu ut’pwctucauvuluavu usurnphywitisxin thlﬁtt (35$ glam invﬂ tnttvaty Ina unuhmrbttal gait rntycnu¢3 Ind ﬁrmwtﬁuniuunt-§ortwptau1~wur*6mtlitr tunatttuﬁnc (a: traritus atndxnu at: 1nragtisitn txantayn ‘ it: it. » aduuutiaut&,10111,‘luriuhnah puttarm, taguVwaraunA ﬁtﬂ‘rtﬂiﬁi$1ﬁﬁ)t wail: studxgn u: Ringlt ampuuta or nttrtvhrmzcanggu IS‘ rtrtunllt hﬂﬁﬂ‘rﬂi but. annurallr Raﬁ tntnbitshnd tisuttinaut to .ttiuﬁhtpa, than: Qiuutvutlaaa tnﬂieuﬁﬁ that $hn vain nnd iuarug ﬁt ah:act an xuurtpaauitlngis ratptuaﬁ uzritgdand ht rtInSaa ta yﬁﬁiﬂnﬂltiw§(ptt‘i’ﬁtﬂlﬁﬁlcttﬁtwﬁ _ 7 . : y n\. ‘I‘ﬁﬂii! inn fiat, ”.36. rrwn tn: btpartnuut u: .111 11/59 ﬁlms Wilt, ﬂute: 5“. 1.1; ‘R4 nﬁbﬁft Ly i333, ?h§na inp§r$mmnta1 Payuhxatry, 3%.}; ’Ufﬂht tillntén ﬂuupiﬁnl. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Psychological factors affecting individual differences in behavioral response to convulsive therapy. J Nerv Ment Dis. 1959 Mar;128(3):243-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-36-002 Date A point or period of time associated with an event in the lifecycle of the resource 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>; Kahn, Robert L.; Pollack, Max Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 3 items. 1: Reprint from THE JOURNAL or NERVOUS AND MENTAL DISEASE Volume 128, N0. 3, March 1959. 2: [preprint]. 3: 2 drafts and one abstract. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/ee9acc31c3d43280c2889e28c2a5cbdf.pdf bf2464ff0c5b85a41fb05f4bcfd6dfb6 PDF Text Text Inlnary tor All (—1143 . turner 0’ Ilill'lﬂﬁﬂﬁ IA‘IIIHIhTI 6' Pllﬁlpilﬂﬂ In: #13:. u.n.. Horton lathnnsoa. I¢E., villi: a. nits-an, I‘D. tad Harris I. laudmr, l.n. ottoat at antravuaona barbiturutu an tbs parcnptxen of Itltlpl. saunltunoauu antantoun atmnuli In. obsnrvud in lawn. groupa o: nor-s1 subjectt. puttantu with Iiitﬂlt and lawn! our.» bani 41:051., tptlul word 10-103. and psychoconic disordqu. Itch in. attain-d hetero and utter the :10! idltltltrtm ties of 2 1/25 uulution of Indian snytsl tn dost: o: 3‘15 to 6.50 an. to nyatusnnu. slurred upcoah, ‘ttxza and drauaantsu upponrcd, The haltnd tun simulttunoua tacit}. tints war. :9plind. 2h: assaincr ntunltaanounty tauahnd tn. lubjout In two plaacs - such ll tn. abbot and tho hand - and tutti his ta p.9ort that wt: ialt* ib3t§ tart rupaatnd with Vtrtoul boa: «ouhtlltiens. tad thu report: rueardod. It» ottcnts a! median atrial on Indul1:30: 0th.: than touch ‘Qf. sane inronttgntcd. In :11 labJoctn Indian ‘Iﬂt‘l etuuod arrow. in tin par~ caption a! tbs uisnltaaaaﬁn stimuli. Ibrﬂtl nuhjoats taunt tun tnxxuaact e1 tn. barbiturate trcqauntly rcportod only «In at tho two stinnlt (onttantton); a. ., tn tho acubtnutton at £30. and hand only the stimulus to tat tnao was royortud. It‘s. trrarn into tt3nsannt :nd tlnntuntod during tho parted a! «was :atton. tn. indoetlan was 31.11:: bohavtar van untod £3 »»1¢, duproauian. paticntniv1th paychoanatu dtnovdurn schisophrnntu)¢ - 1 u �In puttoats with acrobrnl disease, uaytul brought out anioets ant privaoualy appaiunt or oxnguuruttd oxinttng .113: of 63:1uautioa. In this group tun orrnru U‘t. not. pronounced, porstntcd tor lessor porleds, ind abound 1's: tluatuttlon thﬁn :3 ch. nor-n13. 1h 9&ttontc with~£oanl carohrul dlﬂitit with 00:50:: daftots continua to any urea at thn body. anytaz brought out utter: which var. ant apparcnm ova: vith Ixnnltnanou: test: Ind 1t daftnnd tort nightly tho oxtnnt of tho teaser: disturbanco. Qttiuntn with diffuse aorubrul dyntuantion rho pruvtounly and. no orroru on atuultnnnoun tnatllo tautg, lhﬂﬂid rcpoatod Otters a: cxttnntton tug diuplnecnnnt as both 314.: at tn. body utter anal: dalos o: a-wtal. Pntxonts who angina uxtinattan or displgoonnnt prior to tha anytnl pertornod attiarantly sitar tin drug tn: xtvcn. Errata heath» nypnrnnt in body part: which print to tho naytnl ‘DIO rupartad oarruatly. Furthnr-oru, tho phannuoa: o: oxouounuthnsia (displaoalant to astrupﬁrnoall apnea), allcun than (duplwmnt to tho «man. an) «mom» son: (incenplntc apailatcrsl displneoaunt) var. also ovidont. In ‘11 pationta with orgnnio unatll uyndron. tn. duration at tho porcoptuul otter: ‘3: troqunntly 1033.: than the OUOrt 31.3; of drug sattan. Th. porcuptuﬁl ahtﬂlhi lustod lancer thin in noruul m mt»: “suchctu attor stutznr downs tad var. norc canntstcat. :3 10310:. of tho aptnal nard, tho scanary dl£octn banal! not. ;ppnront: cutinntion could ho clxaitod «var : mutant unit and tho 1.?!1 at sonnet: 4.103: bouts» not. ﬂittinct. In two �inntsnoOI. hounvur, t prsvtounly duturnlnod tensor: 1:!31 could not be olinltod :ttur tho anytul. In tout. o: othor century functions, nystncuun on datcct torvnrd can. In: ‘holiuhod during the potion at drug n¢tten, tad ch. concomitsat vxlutl disturbunncn (blurring and oaalllopllu) use unwed. suzmu, ”that: an tiuitm «mm a shelttton uanll d1.1:ution of this syupton nttor tho insection at of unytul. ow downs val thorn ta ultor tho porcupttoa a! ntuult¢nooun tacttln stimuli in all nubjoots. Thar. was an nltaratson in annnrtl paracptutl tauntian as wall as th. 19¢t1~ laud porutptunl luantlout. ’laistzng nonuary dyltuactiau its oumutod with the ”actuation of «not: not previously mm at. it... slt-tntxonn 1n porecption var. 31.11:: to thou. lollowtax prolonsud unsuthnutn er cloctrolhuck thortpv. Intrsvonoun barw bituruto any to a «metal tdaunat in oltattin; or oxnggnrutlnc nournl dystunottun. that. routtnn nuanzaatiou yield: equivocal 53553513 rumults. Xutruvonoau unytul �\V‘ “I ' Reprinted from TRANSACTIONS AMERICAN NEUROLOGICAL ASSOCIATION 1953 NEIIRIIPHYSIIILIIEY LABZ’IIA'TII'W’ HILLSIDE HOSPITAL GLEN OAKS, N. Y. EFFECT OF INTRAVENOUS BARBITURATE ON PERCEPTION MAX FINK MORTON NATHANSON PHILIP S. BERGMAN AND MORRIS B. BENDER NEW YORK The effect of intravenous barbiturate on the perception of multiple simultaneous cutaneous stimuli was observed in large groups of normal subjects, patients with diffuse and focal cerebral disease, spinal cord lesions and psychogenic disorders. Each was examined before and after the slow administration of 2% per cent solution of sodium amytal in doses of 0.15 to 0.50 Gm. As nystagmus, slurred speech, ataxia and drowsiness appeared, the injection was halted and simultaneous tactile tests were applied. The examiner simultaneously touched the subject in two places—such as the cheek and the hand—and asked him to report what was felt. Tests were repeated with various body combinations, and the reports recorded. The effects of sodium amytal on modalities other than touch were also investigated. In all subjects sodium amytal caused errors in the perception of the simultaneous stimuli. Normal subjects under the inﬂuence of the barbiturate frequently reported only one of the two stimuli (extinction) ; e.g., in the combination of face and hand only the stimulus to the face was reported. These errors were transient and ﬂuctuated during the period of drug action. Similar behavior was noted in patients with psychogenic disorders (psychoneurosis, depression, schizophrenia). In patients with cerebral disease, amytal brought out defects not previ— ously apparent or exaggerated existing signs of dysfunction. In this group the errors were more pronounced, persisted for longer periods, and showed less ﬂuctuation than in the normals. In patients with focal cerebral disease with sensory defects conﬁned to one area'of the body, amytal brought out errors which were not apparent even with simultaneous tests and it deﬁned more clearly the extent of the sensory disturbance. Patients with diffuse cerebral dysfunction who previously made no errors on simultaneous tactile tests, showed repeated errors of extinction and displacement on both sides of the body after small doses of amytal. Patients who showed extinction or displacement prior to the amytal per— formed differently after the drug was given. Errors became apparent in body parts which prior to the amytal were reported correctly. Furthermore, the phenomena of exosomesthesia (displacement to extrapersonal space), allesthesia (displacement to the opposite side) and partial displacement . 244 5’) «L I �Fishman—Intracranial Pressure 245 (incomplete ipsilateral displacement) were also evident. In all patients with organic mental syndrome the duration of the perceptual errors was frequently longer than the Overt signs of drug action. The perceptual changes lasted longer than in normal subjects after similar doses and were more consistent. In lesions of the spinal cord, the sensory defects became more apparent; extinction could be elicited over a larger area and the level of sensory defect became more distinct. In two instances, however, a previously determined sensory level could not be elicited after the amytal. In tests of other sensory functions, nystagmus on direct forward gaze was abolished during the period of drug action, and the concomitant visual disturbances (blurring and oscillopsia) also disappeared. Similarly, patients with tinnitus reported an abolition or diminution of this symptom after the injection of small doses of amytal. Summary: Intravenous amytal was shown to alter the perception of simultaneous tactile stimuli in all subjects. There was an alteration in general perceptual function as well as the localized perceptual functions. Existing sensory dysfunction was exaggerated with the production of defects not previously apparent. These alterations in perception were similar to those following prolonged anesthesia or electroshock therapy. Intravenous barbiturate may be a useful adjunct in eliciting or exaggerating neural dysfunction, where routine examination yields equivocal results. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effect of intravenous barbiturate on perception. Trans Am Neurol Assoc. 1953; 3(78th Meeting): 244-5. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-12-016 Date A point or period of time associated with an event in the lifecycle of the resource 1953 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>; Nathanson, Morton; Bergman, Philip S.; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprinted from Transactions American Neurological Association. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0cb0657cbbdab38351d56e14b15f8cbf.pdf 7766c5312815a1dcb5171a3528e92d6e PDF Text Text Reprinted from The Journal of the American Medical Association April 12, 1958, Vol. 166 Copyright 1958, by American Medical Association COMPARATIVE STUDY OF CI] LORPROMAZINE AND INSULIN COMA IN THERAPY OF PSYCHOSIS Max Fink, M.D., Robert Shaw, M.D., George E. Gross, M.D. and Frederick S. Coleman, M.D., Glen Oaks, N. Y. With the advent of “newer” drugs for the treatment of psychiatric illnesses and the concomitant awareness that the effectiveness of insulin coma therapy was limited, a control drug therapy—insulin coma study was undertaken. Preliminary trials with various medicaments available in 1954 demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports had noted its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. The study was designed to assess the therapeutic efﬁcacy and indications for intensive chlorproma: zine therapy, compared to classic insulin coma therapy, an in open-ward, voluntarily hospitalized psychiatric population. Subjects and Method All patients referred for insulin coma therapy during the period Sept. 1, 1955, to Dec. 31, 1956, were observed. Supervising psychiatrists made the recommendation for insulin coma therapy independent of the research group. Their criteria for referral were those implicitly held by the hospital administration and were not altered for this study, Randomly selected patients were placed on chlorpromazine therapy instead of insulin coma therapy. This selection was made by the psychiatrist in charge of the insulin therapy unit without prior notice of the referring therapist or the supervising psychiatrist. Sixty patients were referred for insulin coma therapy during the study period, and half of these received chlorpromazine. Insulin Coma.—The standard technique of Sakel for insulin coma was used. All patients received 50 comas, each of a duration of at least one hour, at the physiological level of Babinski reﬂex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous administration of glucose. Treatments were given ﬁve times weekly for a period of three to four months. Chlorpromazine.—To establish an equivalent group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased until well-deﬁned physiological effects were observed. These included rigidity, drooling and ﬁxed facies, seizures, or severe dermatitis. In most instances this was achieved below 1,400 mg. daily, although dosages were increased to 3,600 mg. in one patient. In each instance, the drug dosage was slowly reduced until From the Department of Experimental Psychiatry, Hillside Hospital. The effectiveness of chlorpromazine was compared with that of insulin coma in 60 patients referred for insulin coma therapy. One- half the group, selected on a random basis, received chlorpromazine by mouth for at least three months in doses adjusted so as to fall just short of toxicity in the individual patient,- this dosage varied from 300 mg. to 2,000 mg. daily, with a median of 800 mg. The insulin coma was induced by a standard technique 50 times in each patient. Although many minor differences were noted in comparing the effects of these two methods of treatment, the ultimate results at the time of discharge were essentially the same for the two groups of patients. Neither treatment affected the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management. a maintenance dose, just under that producing toxicity, was obtained. This varied from 300 mg. to 2,000 mg. daily with a median of 800 mg. To determine the comparability of the subjects in the random sampling procedures used in this study, the groups were compared as to their psychi— atric diagnoses and ages. Table 1 shows a comparison of the groups as to diagnoses and demonstrates an equal distribution of subjects in each category. In the analysis of the age distribution, the median age for patients subjected to insulin coma was 24 years, with a range of 17 to 38; the median age for patients receiving chlorpromazine was 28, with a range of 19 to 42. Here, too, the distribution shows no signiﬁcant difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals. After completion of the treatment period, reports of the patients’ behavior were obtained from the therapist and supervising psychiatrist. The “improvement” rating was determined by the medical director at the patient’s discharge conference and was based on the fourfold scale of recovered, much improved, improved, and unimproved. Neither the authors nor the supervisor of the insulin therapy unit participated in these evaluations. �THERAPY OF PSYCHOSIS—FINK ET AL. Vol. 166, No. 15 Observations Clinical Observations—The following clinical effects were noted in patients who received chlorpromazine and in those subjected to insulin coma therapy. Chlorpromazine: Chlorpromazine induced motor retardation in all subjects. Overactive, destructive behavior rapidly disappeared, and patients became more tractable, less negativistic, and less violent. The nurses’ and therapists’ records noted patients as “less easily excited and frightened,” “cooperating TABLE l.—P.s-ychiatric Psychoneuxosis ....................... Schizophrenia, paranoid ..... Schizophrenia, catatonic ............ Schizophrenia, mixed ................. Schizophrenia, hebephrenic .......... Manic-depressive psychosis ........... Diagnoses Insulin Coma Chlorpromazine 1 2 10 7 10 7 8 3 1 6 2 3 better in ward activities,” and “less restless and less panic-ridden.” One-third of the patients were more sociable and less seclusive and were noted to care for themselves in a more presentable fashion. In instances where severe motor symptoms supervened, however, the patients were less able to care for themselves; they became sloppy and failed to dress themselves. Such periods were usually short and could be signiﬁcantly modiﬁed either by a reduction in drug dosage or by anti-Parkinsonism drugs. Affective changes during chlorpromazine treatment were varied. Four patients became increasingly agitated, tense, and tremulous and either refused to continue on the drug regimen or were induced to do so only with difﬁculty. Such an affective “storm” appeared early in the treatment and persisted. In four other patients, depressive symptoms were relieved with an increase in affective lability and responsivity. Depressive ideation increased, associated with complaints of insomnia and anorexia in two patients. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of chlorpromazine therapy in 12 patients. Eight had a loss or a signiﬁcant diminution of their psychotic ideation. In ﬁve, hallucinatory and referential experiences were no longer reported even on inquiry, and, in three others, delusional ideas were less prominent. In one patient, phobias were relieved and the patient could once again participate in ward activities. In another, hypochondriasis was sufﬁciently modiﬁed to permit a more meaningful relationship between therapist and patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration and resulted in discontinuation of the drug regimen. 1847 Insulin Coma: The clinical observations in this group were similar to those reported by others.‘ Alteration in behavior was prominent in all patients once repeated comas were induced. Overactive, hostile behavior rapidly diminished and was replaced by alternating periods of somnolence, irritability, and withdrawal. In most patients, nausea, abdominal distress, belching, sweating, and lassi— tude were common sequelae each afternoon and assumed prominence in the recorded reports. These symptoms often interfered with the patients’ ability to care for themselves, and they became unkempt in their dress. Changes in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, dis— appearing in these on direct inquiry. Suicidal and outWardly directed destructive thoughts were modiﬁed in three patients, only to recur in each at the end of the treatment period. Mood changes were small. Increasing agitation, tension, and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms was noted early in the treatment and was sustained. In the usual practice of the treatment unit, con— current electroconvulsive therapy was instituted when behavioral control by insulin coma alone was limited. In six patients, such combined treatment was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well deﬁned alteration in behavior, but this was unsustained. None of these patients was rated as improved on discharge. Discharge Evaluation—All patients were dis— charged from the hospital within four months of the end of treatment. Table 2 lists the hospital discharge evaluations for patients treated with chlorpromazine and insulin coma. Ratings in Patients Treated with Chlorpromazine and Insulin Coma TABLE 2.-—Discharge Treatment ........................ ........................ Recovered, no. Much improved, no. .................. Improved, no. Iinimproved, no. ..................... Chlorpromazine Insulin Comaﬁ 2 0 4 17 5 15 7 10 Included in the group of patients treated with chlorpromazine who were rated as unimproved were four who received inadequate course of therapy (less than one month) because of complications of the therapy. Of the 10 patients treated with insulin coma who were rated as unimproved, four had inadequate courses of therapy, two because of complications (seizures and prolonged coma), one be— cause she became more disturbed, and one because of administrative transfer to another facility. �‘ THERAPY OF PSYCHOSIS—FINK ET AL. 1848 It apparent that there is no difference in the clinical evaluation at the time of discharge between the group receiving insulin coma and that receiving chlorpromazine. To determine whether this sample was biased because of its small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported.2 In table 3, the discharge ratings for both is TABLE 3.-—Discharge Ratings Compared for 1950 and 1956 ............................. ....................... Improved, % ......... .................... Unimproved, % ........................... Recovered, % Much improved, % _ Present Group (30 Subjects) 1950 Group (48 Subjects) 0 14 17 19 42 50 33 ‘25 years are compared. The percentage improvement rates for each category are not signiﬁcantly different. Toxicity and Complications—Patients receiving chlorpromazine and those subjected to insulin coma therapy were compared as to toxic reactions and complications, with the following effects noted. Chlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to a level producing symptoms of toxicity. In this context, all patients developed signiﬁcant drug effects. Rigidity of extremities, accompanied by a decrease in facial expression, drooling, and festination, was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Most patients became drowsy, retarded, and less active in ward activities. In four patients increased tension, agitation, restlessness, and excitement supervened, leading to a discontinuation of the drug regimen in two. Seizures occurred spontaneously in three patients. Pretreatment electroencephalograms had manifested no dysrhythmia, and no history of seizures had been elicited. In each, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema to mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine hydrochloride therapy was substituted for chlorpromazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from that noted in patients receiving chlorpromazine. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than 0.5% of subjects treated. In the preliminary studies at Hillside Hospital, 3 patients of a group of 20 developed transient clinical jaundice. J.A.M.A., April 12, 1958 Electroencephalograms were obtained in 20 of the patients who received chlorpromazine. With increasing doses, the modulation of the record became more irregular in each. A moderate amount of low-voltage 4-7 cps delta and theta activity was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow-wave activity and the drug dosage. Insulin Coma: The complications of insulin coma therapy in this series were not unusual. Insulin resistance was noted only once and was eventually overcome by the method of alternating dosages. Prolonged reactions occurred in three patients. In each, neurological examination and electroencepha— lography demonstrated signs of persistent central nervous system dysfunction for at least 10 days. Aphasia, hemiparesis, and paresthesias were frequent in ﬁve patients and transient in eight others. Seizures occurred in ﬁve patients and were recurrent in three. Frequent secondary reactions, nausea, vomiting, abdominal distress, sweating, pallor, lassitude, and generalized weakness occurred in all patients with varying frequencies. The complications of both forms of treatment are listed in table 4. Certain effects, such as dermatitis and hypotension, secondary reactions, and prolonged coma are individual for each therapy, and seizures, agitation, and refusal of therapy were noted with both regimens. The frequencies of these are not signiﬁcantly different. Effects on Psychotherapeutic Relationship—Pa— tients were referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. TABLE 4.-C0mplicati0ns of Treatment with Chlorpromazine and Insulin Coma Treatment _______./\—————5 Agitation and panic .................. Dermatitis, severe ..................... ............................... Refusal of further therapy .......... Hypotension .......................... Secondary reaction, frequent ........ Prolonged coma (>6 hr.) ............ Insulin resistance ..................... Seizures Chlorpronmzine Insulin Coma 4 3 3 3 2 5 2 2 6 3 . . . 1 Chlorpromazine: During the period of effective drug action, 15 of the patients treated with chlorpromazine were described by the therapist in response to an inquiry as “more accessible,” “speaking more freely,” and “more amenable to psychotherapy.” The behavioral changes could be classiﬁed in two groups: subjects in whom tension and preoccupation with somatic symptoms became much less, and those in whom hallucinatory or delusional preoccupations ended. Such changes in �I Vol. 166, No, 15 THERAPY OF PSYCHOSIS—FINK ET AL. in— described as an we1e frequuitly '.*‘-1;welationship stww‘arease in “contact In 13 subjects, psychotherapy either was still‘not feasible” or had become less feasible because of increasing uncontrolled tension, anxiety, or preoccupation with the side-effects of wthe drug regimen. Insulin Coma: Similar observations were made in the patients treated with insulin. Of the 30 patients, 7 were noted to be less tense and less anxious during therapeutic sessions. The theiapists noted that the patient “verbalized more freelv” and was more aware of his environment.” Four patients were speciﬁcally treated with a “modiﬁed anaclitic” approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional tactics. In the remaining patients (19), while supportive, educational, and environmental manipulating techniques were applied, the therapists were no more successful than prior to insulin therapy. In 11 patients, the physiological effects of the treatments (secondary reactions, sweating, nausea, vomiting, and weight gain) were reported as interfering with psychotherapeutic attempts. Comment Clinical Considerations—In these patients, nei— ther chlorpromazine in high therapeutic doses nor insulin coma speciﬁcally modiﬁed the psychotic had of 88% these Since a diagpatients process. nosis of schizophrenic illnesses, we concluded that neither treatment has a speciﬁcity in altering the schizophrenic process. When given in adequate dosage, however, both treatments are potent methods for the alteration of behavior. In the discharge evaluations, the treatments are similar. In only 20% of the patients were induced behavioral patterns persistent, with the rating “much improved” or “recovered.” For the others, the induced behavioral changes were transient or minimal. Since these therapies fail to induce a recovery from the psychotic process, consideration should be given to their ameliorative, palliative, and supportive aspects. Symptomatic relief was frequent but generally limited to the treatment period. Patients were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is little advantage in either therapy. Both methods were said to enhance relationship therapy, although the therapists’ evaluations favored chlorpromazine therapy. Excluding those who deveIOped increased agitation, patients were more comfortable, more alert, and physically better able to discuss their feelings and experiences while on chlorpromazine treatment. It is clear that“interpretive” psychotherapy is not enhanced, rather, 1849 supportive, educative, reorienting, and directive types of therapy are. When there is a modiﬁcation of agitated, hallucinatory, depressed, manic, or aggressive behavior, both the therapist and the patient are more comfortable and better able to discuss the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assume decisive signiﬁcance. To maintain such therapy after discharge and continue thereby the relationship established in the hospital setting may be an important element in sustaining the behavioral changes induced by hospitalization. Other Studies.—While many reports of the treatment of psychosis by chlorpromazine have appeared, we are aware of only one similar comparative study. Boardman, Lomas, and Markowe,3 after a review of the problem, reported a study of 100 patients randomly divided into two groups of 50 and treated with either insulin coma or chlorpromazine. The chlorpromazine dosage was lower than that used in the present series (average 300 mg), but the drug period (three months) was the same. Their observations are directly comparable to this study. They reported no difference either in discharge evaluations or in symptom assessments for either treatment group. The patients treated with chlorpromazine, however, remained in the hospital an average of 6.2 weeks less than the subjects treated with insulin. This was a signiﬁcant difference between the groups. They concluded, “There is inconclusive evidence that chlorpromazine has advantages over insulin in the treatment of schizophrenia [but] insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the ﬁrst treatment of choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been conﬁrmed by an adequate follow-up study.” Boardman and his co-workers emphasize the problem of evaluating the therapeutic efficacy of insulin coma. They note a number of reports that raise doubts as to the efficacy of insulin coma therapy in schizophrenia. Bourne,4 in an extensive review of the merits of insulin therapy in schizophrenia, concluded, “There is no proof of any speciﬁc therapeutic effect, and the long term prognosis is in no way influenced.” The recent observations of insulin treatment of 5 schizophrenia by Ackner, Harris, and Oldham are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbiturate coma in the same ward and under similar conditions. Evaluations of results were made by psychiatrists without knowl- �1850 THERAPY OF PSYCHOSIS—FINK ET AL. edge of which treatment the patients received. The authors noted a similar outcome, whether the loss of consciousness was induced by a barbitufate or by insulin, and concluded that insulin was not a speciﬁc therapeutic agent in the outcome. In the follow-up studies done in this hospital,2 the therapeutic results of insulin coma therapy were disappointing. Patients referred for insulin coma had the longest period of hospitalization (6.5 months, as against 6.04 with'psychotherapy and 4.95 with electroshock), the poorest discharge‘ rating (33% recovered and much improved as against 63% with psychotherapy and 67% with electro— shock), and, within four years, a 50% rehospitalization rate (compared to 33% with psychotherapy and 29% with electroshock). While these observa— tions reflect the idea that the more severely ill patients are referred for insulin coma, they also support the belief that insulin coma is not a specific treatment for the patients referred. From these reports we would conclude that, despite considerable study and the passage of many years, insulin coma therapy has not been shown to induce persistent behavioral changes more frequently than other nonspecific, less dangerous, and less expensive therapies. To the list of alternate therapies of limited value in the management of psychosis we may now add Chlorpromazine, not— ing, however, its advantage of lesser risk and ease of administration. Dosage of Chlorpromazine.—F0r the purpose of assuring an adequate level of Chlorpromazine dosage for evaluation, the amount of medicament given was increased in all subjects to t0xic levels. This level was too high for its behavioral effects, as evidenced by the reduction in all responsive cases to maintenance levels of 300 to 2,000 mg. It is our impression that Chlorpromazine affects the function of the central nervous system (as evidenced by changes in modulation and per cent time delta in the electroencephalogram and the systemic phenomena of rigidity and lassitude) and results in a nonspeciﬁc alteration in behavior.6A Such behavioral change is varied and is dependent on a variety of factors, of which the personality organization and the expectancy of the milieu are signiﬁcant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness, and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances where an affective “storm” supervenes, continuation of therapy at ].A.M.A., April 12, 1958 higher levels, with concomitant administration of trihexyphenidyl hydrochloride (Artane) and benztropine (Cogentin) methanesulfonate should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology and to the present concept of the mode of action of electroshock therapy.6 Summary In a.study of patients referred for insulin coma therapy in an open-ward, voluntary psychiatric hospital, patients received randomly either insulin coma therapy or intensive Chlorpromazine therapy. Chlorpromazine was found to be as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications, or effects on the psychotherapeutic relationship for either therapy. In comparison to insulin coma, Chlorpromazine is safer, easier to administer, and lends itself to long—term management. Patients receiving chlorpromazine therapy are more comfortable than those receiving insulin coma. No evidence has been educed that either therapy has altered the basic schizophrenic process, nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. 75—59 263rd St. (Dr. Fink). This study was supported by the Board of Directors" search Fund of the Society of the Hillside Hospital. Re— The chlorpromazine used in this study was supplied as Thorazine by Smith, Kline & French Laboratories, Philadelphia. The promazine hydrochloride used in this study was supplied as Sparine by Wyeth, lnc., Philadelphia. References and Hoch, P. H.: Shock Treatments, Psychosurgery, and Other Somatic Treatments in Psychiatry, ed. 2, New York, Grune and Stratton, lnc., 1952. 2. Rachlin, H. L., and others: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. 5:17-40 (Jan) 1956. 3. Boardman, R. H.; Lomas, J.; and Markowe, M.: Insulin and Chlorpromazine in Schizophrenia: Comparative Study in Previously Untreated Cases, Lancet 2:487—494 (Sept. 8) 1. Kalinowsky, L. B., 1956. 4. Bourne, H.: Insulin Myth, Lancet 2:964—968 (Nov. 7) 1953. 5. Ackner, B.; Harris, A.; and Oldham, A. J.: Insulin Treatment of Schizophrenia: Controlled Study, Lancet 2: 607-611 (March 23) 1957. 6. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A. M. A. Arch. Neurol. 81 Psychiat. 78:516— 525 (Nov.) 1957. 6A. Fink, M.: Uniﬁed Theory of Action of Physiodynamic Therapies, J. Hillside Hosp. 6:197-206 (Oct.) 1957. �Printed in U. S. A. �Cjéz,,4./rv./¢ COMPARATIVE STUDY OF CHIDRPROMAZINE AND INSULIN COIvIA IN THE THERAPY 0}”? PSYCHOSIS *- Max ColemanAM.D. Fink M.D., Robert Shaw M.D., George E. Gross M.D., and Frederick S. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. Supported by the Board of Directors' Research Fund of the Society of the Hillside Hospital. 7-22-57: IV �Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Peychosis for the treatment of psychiatric illnesses, and the concomitant awareness that the effectiveness of insulin With the advent of "newer" drugs limited, a control drug therapy-insulin coma study was undertaken. Preliminary trials with various medications available in l95h demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports coma therapy had noted was its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. study was designed to assess the therapeutic efficacy and indications for intensive chlorpromazine therapy compared to classical insulin coma therapy in an openaward, voluntary hospitalized psychiatric population. The Subjects and Method All patients referred for insulin coma therapy during the period September 1, 1955 to December 31, 1956 were observed. Supervising psychiatrists made the recommendation for insulin group. Their criteria for referral coma therapy independent of the research were those implicitly held by the beepital administration, and were not altered for this study. Randomly selected patients were placed on chlorpromazine therapy instead of insulin psychiatrist in charge of the insulin therapy unit, without prior notice of the referring therapist or the super- coma. This selection was made by the vising psychiatrist. Sixty patients were referred for insulin during the study period, and half received chlorpromazine. coma therapy �.2... a) Insulin Coma: The patients received standard technique of Sakel was used. All 50 comes, each of a duration of at least one hour at the physiologic level of Babinski reflex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous glucose. Treatments were given five times weekly, b) Chlorpromazine: was given team and To for a period of B-h months. establish an equivalent group, chlorpromaziner for at least three months. Dosages were determined by the research were rapidly increased until well defined physiologic effects were observed. These included rigidity, drooling and fixed facies, seizures or severe dermatitis. In most instances this was achieved below lhOO mgm daily patient. In each instance, slowly reduced until a maintenance dose, just under although dosages were increased to 3600 the drug dosage toxicity, was was obtained. a median of 800 mgm in This varied from 300 one mgm to 2000 mgm daily with mgm. To determine the comparability of the subjects resulting from the in this study, the groups were compared as to their psychiatric diagnoses and ages. Table I compares both groups as to diagnoses, and demonstrates an equal distribution of subjects in random sampling procedures used each category. ‘M% c: such-on .m & Chlorpromazine supplied as "Thorazine" through courtesy of Smith, Kline 3 French, Inc. �.3TABLE I PSYCHIATRIC DIAGNOSES Insulin Psychoneuresis Coma Chlorpromazine 1 2 10 10 Schizophrenia, Catatonic 7 7 Schizophrenia, Mixed 8 6 Schizophrenia, Hebephrenic 3 2 HaniooDepressive Psychosis l 3 Schizophrenia, Paranoid In the analysis of the age distribution, the patients was 21; for the insulin with a range of 17 to 38 ; while the chlorpromazine patients had a median age of 28 and a range of 19-122. shows no median age Here, too, the distribution significant. difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals . Following completion of the treatment period, reports of the patients' behavior were obtained from the therapist and supervising psychiatrist. Medical Director The "improvement" at the patient's Discharge four~fold scale of recovered, rating was determ‘ned by the Conference and was based on the much improved, improved and unimproved. None of the authors, nor the supervisor of the insulin therapy unit, participated in these evaluations. �Observatigns 1. Clinical Observations all subjects. Overactive, destructive behavior rapidly disappeared, patients in ghlgrpromazine: Chlorpromazine induced motor retardation a) became more tractable, less negativistic and less violent. and The therapists' records note patients as "less easily excited and frightened," "cooperates better in ward activities," and "less restless and less panic ridden." One-third of the patients were more sociable and less nurses' and seclusive, and were noted fashion. In instances patients were to dress. modified to care for themselves in a more presentable where severe motor symptoms supervened, however, the less able to care for themselves; Such periods were usually short, became sloppy and significantly and could be either by a reduction in drug dosage or by anti-Parkinson drugs. Affective changes during chlorpromazine were varied. became failed increasingly agitated, tense continue on and tremulous and patients either refused to the drug regimen or were induced only with difficulty. affective "storm" appeared early in the treatment other patients, depressive affective lability and symptoms were medication was persisted. In four relieved, with an increase in patients. The continued, however, with an eventual alleviation. In most mood changes were Ideation and Such an reaponsivity. Depressive ideation increased, assoc- iated with complaints of insomnia patients, Fbur was and anorexia, in two small. dramatically altered during the period of chlorpromazine therapy in twelve patients. Eight had a loss or a significant diminution of their psychotic ideation. In five, hallucinatory and referential experiences �.5. inquiry were no longer reported even on once in three others, delusional patient, phobias were relieved and the again participate in ward activities. In another, ideas were less prominent. In patient could and One hypochondriasis was sufficiently modified to permit a more meaningful relatedness of therapist became more prominent. and patient. In one patient, paranoid ideation This was associated with increasing anxiety and panic during drug administration, and resulted in discontinuation of the drug regimen. b) Insulin similar to those reported prominent in all patients clinical observations in this group'were others (1). Alteration in behavior was The Coma: by once repeated comes were induced. hostile behavior rapidly diminished, of somnolence, irritability and and was replaced by Overactive, alternating periods withdrawal. In most patients, nausea, distress, belching, sweating and lassitude were common sequellae each afternoon, and assumed prominence in the recorded reports. These abdominal symptoms often interfered with the patient's ability to care for themselves, and ﬂiey became unkempt in their dress. in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, disappearing in these on direct inquiry. Suicidal and outwardly directed destructive thoughts were modified in three patients, only to recur in each Changes at the end of the treatment Mood period. changes were small. Increasing agitation, tension and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms were noted early in �-6the treatment, and was sustained. In the usual practice of the treatment unit, concurrent electroconvulsive therapy was instituted when behavioral control by insulin limited. In six patients, such combined treatment was coma alone was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well defined alteration in behavior, but this sustained. None was un- of these patients was rated as improved on discharge. 2. Discharge Evaluation All patients were discharged from the hospital within four months of the end of treatment. Table for both the chlorpromazine and II lists the hospital discharge evaluations insulin coma TABLE treated patients. I}; DISCHARGE RATINGS Chlorpromazine Insulin 1. Recovered 2 O 2. much Improved h 5 3. Improved 17 15 h. Uhimproved 7 10 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate course of therapy (less than one month) because of complications of the therapy. four Of the ten unimproved insulin had inadequate courses of therapy (seizures, prolonged - coma patients, two because of complications coma), one because she became more fourth by administrative transfer to another facility. disturbed, and the �-7. It is apparent that there is no difference in the clinical evaluation at the time of discharge between the insulin coma treated groups. To determine whether this sample and the chlorpromazine its was biased because of small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported (2). In Table III, the discharge ratings for both years are compared. TABLE Present Group 1950 Group (30 subjects) (h8 subjects) 0 1h% 17% 19% Improved 50% h2% Ikrhmproved 33% 25% Recovered Much The III Improved percent improvement rates for each category are not significantly different. 3. Toxicitx and Complications a) ghlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to symptoms of toxicity. In this context, all patients developed significant drug effects. Rigidity of extremities, accom— in facial eXpression, drooling and festination was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Host patients became drowsy, retarded, and less active in ward panied by a decrease activities. In four patients increased tension, agitation, restlessness and excitement supervened, leading in two. to a discontinuation of the drug regimen �-8Seizures occurred spontaneously in three patients. Pre-treatment electroencephalograms had manifested no dysrhythmia and no history of elicited. In seizures did not develop at the seizures each, the drug medication was reduced, and had been lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema ato mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In dze third, promazine* therapy was substituted for chlorpromazine, with a was relief of the dermatitis. The indistinguishable in this patient behavioral effects of the promazine from that noted for the chlorpromazine group. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than %% of subjects treated **. Electroencephalograms were obtained in twenty of the chlorpromazine patients. With increasing doses, the modulation of the record irregular in each. activity A became more moderate amount of low voltage h-7 cps delta and theta was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow wave activity b) series were and the drug dosage; Insulin Coma: The complications of insulin not unusual. Insulin resistance eventually overcome by the method of coma therapy in this was noted only once, and was alternating dosages. Prolonged reactions * Supplied as "Sparine" through courtesy of Uyeth & Co. as In the preliminary studies at Hillside Hospital, three patients of a group of twenty developed transient clinical jaundice. �-9occurred in three patients. In each, neurologic examination and electroencephalography demonstrated signs of persistent central nervous system dysfunction for paresthesias at least ten days. Transient aphasia, hemiparesis, were frequent transient in eight others. were recurrent in three. Frequent in five patients, Seizures occurred in five patients, and and secondary reactions, nausea, vomiting, abdominal lassitude and and generalized weakness occurred distress, sweating, pallor, in all patients in varying frequencies. The complications of both forms of treatment are listed in Table IV. Certain effects, as dermatitis and hypotension, secondary reactions and prolonged coma are individual for each therapy, and seizures, agitation and refusal of therapy were noted in both regimens. The frequencies of these are not significantly different. TABLE IV COMPLICATIONS Chlorpromazine Insulin Agitation and Panic h 3 Dermatitis, severe 3 - Seizures 3 5 Refusal of further therapy 2 2 Hypotension 2 — Secondary reaction, frequent - 5 Prolonged Coma ( + Insulin Resistance 6 hours) 3 l Coma �.10.- h. Effects on the Psychotherapeutic Relationship In.this setting, patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effective drug action, treated patients were described by the fifteen of the chlorpromazine— therapist in re6ponse to an inquiry as "more accessible," "Spoke more freely" and were "more amenable to psychotherapy." subjects in The behavioral changes could be classified into two groups: whom tension and preoccupation with somatic symptoms became much hallucinatory or delusional preoccupations ended. Such changes in relationship'were frequently described as an increase in "contact." In thirteen subjects, psychotherapy was either still "not feasible" less, and those in whom less feasible because of increasing, uncontrolled tension, anxiety or preoccupation with the side effects of the drug regimen. Similar observations were made in the insulin treated patients. Of the thirty patients, seven were noted to be less tense and less anxious during or had become therapeutic sessions. more freely" The therapists noted that the patient "verbalized and "was mere aware of his environment." Four patients were specifically treated with a "modified anaclitic" approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional ive, educational therapists tactics. In the remaining patients (19), while support- and environmental manipulating techniques were were no more successful than applied, the prior to insulin therapy. In eleven patients, the physiologic effects of the treatments (secondary reactions, sweating, nausea, vomiting and'weight gain) were reported as interfering with psychotherapeutic attempts. �-11Discussion 1. Clinical Considerations In these patients neither chlorpromazine in high therapeutic doses nor insulin specifically modified the psychotic process. Since 88% of these patients were diagnosed as suffering from schizophrenic illnesses, we concluded thatiieither treatment has a specificity in altering the schizocoma phrenic process. shen given in adequate dosage, however, both treatments are potent methods for u1e alteration of behavior. the treatments are similar. ioral patterns persistent In only and others, the induced behavioral Since these therapies 20% rated as of the patients were induced behav- much improved or recovered. For the transient or minimal. Chang 5 were fail to In the discharge evaluations, induce a recovery from the psychotic process, then consideration should be given to their ameliorative, palliative and supportive aSpects. Symptomatic to the treatment period. Patients relief was frequent, but generally limited were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is advantage of either therapy. Both methods were said to enhance little relationship therapy although the therapists' evaluations favored chlorpromazine therapy. Excluding those who developed increased agitation, patients were more comfortable, more alert and physically better able to discuss their feelings and experiences while on chlorpromazine, than on insulin coma. It is clear that "interpretive" psychotherapy is not enhanced, but rather supportive, educative, re-orienting and directive types of therapy. When there is a modification of agitated, hallucinatory, depressed, manic or aggressive behavior, than both the therapist and the patient arernore comfortable and able to discuss �-12the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assumes decisive significance. To maintain such therapy after discharge continue thereby the relationship established in the hospital setting an important element in sustaining the behavioral changes induced by and may be hospital- ization. 2. Other Studies While many appeared, we reports of the treatment of psychosis by chlorpromazine have are aware of only one similar comparative study. Boardman, Lomas and Harkowe one hundred (3), after a review of the problem, report their study of patients randomly divided into two groups of SO and treated either insulin coma or chlcrpromazine. The chlorpromazine dosage was lower than that in this series (average 300 mgm) but the drug period (3 months) was the by Their observations are directly comparable to same. no difference in the discharge evaluations, nor in this study. They reported assessments for symptom either treatment group. The chlorprcmazine treated patients, box-raver, remained in the hoslaital less than the insulin treated subjects. This was a significant difference between the groups. They concluded that: "There is inconclusive evidence that chlorpromazine has advantages over insulin in the an average of 6.2 weeks treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness on the nurses. Chlorpromazine is the phrenia, but this conClusion and has is for the patients first and greater strain treatment of choice in schizo- based on the immediate results of treatment not yet been confirmed by an adequate follow-up study." �«n13- his co-workers emphasize the problem of evaluating the Boardman and therapeutic efficacy of insulin coma. They note a number of raise doubts as to the efficacy of insulin coma reports that therapy in schizophrenia. (h), in an extensive review of the merits of insulin therapy in Boume is no proof of any Specific therapeutic the long term prognosis is in no way influenced." schizophrenia concluded that "there effect, he and recent observations of insulin treatment of schizophrenia by Harris and Oldham ( S) Aclmer, are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbit- urate coma results in the same ward and under were made by patients received. similar conditions. Phraluations of psychiatrists without The knowledge of which medication the authors noted a similar outcome whether the loss of consciousness was induced by a barbiturate or by insulin, and concluded that insulin was not a specific therapeutic agent in the outcome. In the fol] oar-up studies in this hospital (2), the therapeutic results for insulin coma therapy were disappointing. In that report, patients ferred for insulin coma had re— the longest period of hospitalization (6.50 months for electroshock), poorest discharge rating (3325 recovered. and much improved, 1?. 63:5 for psychotherapy and 67% for electroshock), and within four years, a 5015 re-hospitalization rate (compared to 33% for psychotheram and 29% for electroshock). while these observations reflect 1g 6.0).: for psychotherapy and 14.95 the observation that the more severely coma, it also ill patients are referred. for insulin supports the belief that insulin coma is not a specific treatment for the patients referred. From these reports and the passage of many we would conclude years, insulin that, deepite considerable study coma therapy has not been shown to �.mpersistent behavioral changes more frequently than other non~specific, less dangerous and less expensive therapies. To the list of alternate induce therapies of limited value in the chlorpromazine, noting, however, management of psychosis we may now add its advantage of lesser risk and ease of adninis tration . 3. Dosage of Chlorpromazine for For the purpose of assuring an adequate level of chlorpromazine evaluation, the medication This level was too high duction in was increased in all subjects to toxic levels. fox-its behavioral effects, as evidenced by the re- all responsive cases to maintenance levels of 300 to 2000 mgm. our impression that chlorpromazine affects the function of the central nervous system (as evidenced by changes in.modulation and percent time delta in the electroencephalogram and systemic phenomena of rigidity It is results in a non-Specific alteration in behavior. Such behavioral change is varied and is dependent upon a.variety of factors, of which the personality organization and the expectancy of the milieu are sigand lassitude) and nificant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity, and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances uhere an affective "storm" supervenes, continuation of the drug at higher levels, with concomitant artane and cogentin, should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology, and to the present concept of the action of electroshock therapy (6). mode of �.15Conclusions 1. In a study of patients referred for insulin open ward, voluntary insulin coma psychiatric hospital, patients coma therapy in an randomly received either therapy or intensive chlorpromazine therapy. 2. Chlorpromazine was as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications or effects on the psychoﬂaerapeutic relationship for either therapy. 3. In comparison to insulin administer, and lends itself to coma, dilorpromazine long term management. is safer, easier to Patients receiving chlorprcmazine therapy arernore comfortable than those receiving insulin coma. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. b. No evidence has been educed �REFERENCES l. Kalinousky, L.B. and Hoch, P.H.: Shock Treatments, Psychosurgery, and. other Somatic Treatments in Psychiatry, Grune and Stratton, 13.15. 3 1952. Rachlin, H.L., Goldman, (3.5., Gurvitz, $1., Lurie, A. and Rachlin, L.: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. §_: 174.0, 195 6. 3. Insulin and Chlorpromazine Comparative Study in Previously Untreated Cases, Lancet, Sept. 8, 1956, pp. 1:87—1:91. Boardman, R.H., Lamas, J. in Schizophrenia - and liarkma‘e, M.: A Boume, H.: The Insulin Myth, Lancet, Nov. 7, 1953, pp. 961;~968. Ackner, B. , Harris, A. and Oldham, A.J.: Insulin Treatment of Schizophrenia - A Controller} Study, Lancet, March 23, 1957, pp. 607-6110 Fink, 1-1. and Kahn, R.L.: Relation of ETTG Delta Response in Electroshock: Quantitative Arch. Neurol. and Psychiat. (in Activity to Behavioral Serial Studies, AJ'LA. press). �January 31, 1957 Subject: Drs. From: To: - Insulin Control Chlorpromazine Max Study: Interim Report Fink, Robert Shaw, George Gross and Fred Coleman Dr. Joseph S. A. Miller, Dr. Simon Kwalwasser and the Research Committee of Medical Board Following insulin During is a summary of the observations in the control chlorpromazine- study, instituted September 1, 1955 and completed January 1, 1957. coma this period, 59 patients were referred for insulin coma Half therapy. of the group was placed, by random sampling, on chlorpromazine * therapy in- stead of insulin coma. Four patients received both insulin and chlorpromazine therapy. of the patients of therapy of less than who received chlorpromazine, seven received courses one month. patients, three had an of the 29 insulin inadequate course of therapy. I. During the period l95h—1955, preliminary PROHLEH: azime resulted in the awareness and safe. In view of the unusually poor trials of that the drug showing of was the insulin chlorpromp both potent coma populat- ion in the 1950 Fbllowaup Study (1), and the appearance of numerous articles in the psychiatric literature recommending chlorpromazine as a therapy schizophrenia, a comparative study of chlorpromazine taken. The a) - insulin for coma was under- following questions were postulated: What b) What is the clinical effect of adequate doses of chlorpromazine? is its therapeutic efficacy'when compared to insulin coma therapy? 0) ‘Ehat are the indications (and contraindications) for the use of chlorpromazine and/or insulin coma? * Chlorpromazine supplied as "Thorazine" through the courtesy of Smith, Kline and French 00., Philadelphia. Rachlin, H,L., Goldman, G.S., Gurvitz, M., Lurie, A., and Rachlin, L.: Follow—up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside HOSp., _5_: 17-ho, 1956. (1) �«2. II. All patients referred for insulin SUBJECTS: coma therapy during the period September 1, 1955 and December 31, 1956 were observed. Supervising psychiatrists made the recommendation independent of the research group. Their by the hospital administration, patients made by coma therapy criteria were those implicitly held and were not were placed on chlorpromazine for insulin altered for this study. Selected therapy. selection The was random and the supervising psychiatrist of the physical therapy unit, without prior notice of the referring therapist. III. a.) Insulin nga; EETEQQ: standard technic of Sakel was used. The All patients received 50 comes, each of a duration of one hour or longer at the physiologic level flex or deeper. Recovery ous glucose. of Babinski reflex or absent was induced by gavage and lid re- occasionally by intraven- Treatments were given five times weekly, for a period of 3-h months. b.) Chlorpromazin : To establish a complementary therapeutic group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased clear-cut physiologic effects ifest rigidity, drooling, ere dermatitis. were observed. These included and fixed clinically mans facies; or toxicity, as seizures or sev- In each instance, the drug dosage was slowly reduced a maintenance dose, until just under toxicity, was obtained. until This was maintained for the duration of the observation period. Laboratory blood counts, tests were carried out at irregular intervals liver function tests, glucose tolerance tests and included and electroenceph- alogramS. In both experimental groups, behavioral observations were made at'weekLy intervals. Following completion of the treatment period, reports of the ther- �4-3- apist and supervising psychiatrist were obtained. The rating of "improvement" Conwas that established by the Medical Director at the patient's Discharge ference. IV: RESULTS: Chlorpromazine A. l. until signs creased rapidly of was achieved in daily dosages to 3600 in mgm. 2000 mgm. one patient. of chlorpromazine was in- The dosage QEEEEE.22.22EQEEEEEEEEEEF rigidity appeared. In most instances this below lhOO mgm. although dosages were increased The maintenance dose varied from 300 mgm. to daily. 2. Clinical effects of chlorpromazine: motor retardation in all subjects. Chlorpromazine induced a Overactive, destructive behavior rapidly disappeared, and the patients were more tractable, less negativistic and less violent. The nurses' and therapists' records relate that patients are "less easily excited and frightened," "cooperates better in "less restless and less panic-ridden." ward activities," and One-third of the patients were more sociable and less seclusive, and were noted to care for themselves in a more presentable fashion. In the instances where severe parkinsonism supervened, however, the patients were less able to care for themselves; became sloppy and failed to dress. by Such periods were short or could be significantly modified anti-parkinson drugsn Affective changes during chlorpromazine were varied. In four instances, the patients became increasingly agitated, tense, tremnlous and either refused to continue on the drug regimen or were induced only with difficulty. Such an persisted. In four other instances, depressive symptoms were significantly relieved, with an increase in affective lability and responsivity. In two patients, deaffective "storm" appeared early in the therapy and �.u. pressive ideation increased and was associated with complaints of insomnia. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of-chlorpromazine therapy in twelve of the patients. Eight patients had a loss or a significant diminution of psychotic ideation. In five, the hallucinatory and referential xperiences were no longer reported even on inquiry; and in three others, delusional ideation was less prominent. In one patient, phobias were relieved to a degree that the patient could participate in ward activities. In another, hypochondriasis was sufficiently modified to permit of a more meaningful latedness of therapist and re— patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration, with resultant discontinuation of the drug regimen. 3. Effects en the psychotherapeutic relationship; Patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effectiwadrug activity, ten of the patients were described by the therapist in reSponse to an enquiry as "more accessible," "spoke more freely" and were "more amenable to psychotherapy." The responses could be classified into two groups: the subjects whose tension and pre— occupation with somatic symptoms became much less and those in whom halluc- inatory or delusional preoccupations ended. In each instance, the therapist described the change in relationship as an increase in "contact". In twelve subjects, psychotherapy was either still "not feasible" or "less so because of increasing, uncontrolled tension." �-5. In no instance did the problem of drug addiction or drug dependence play a role, nor was there an appreciation that drug therapy altered the therapeutic relationship adversely. h. §g§igg§ twenty four have left the hospital. thirty patients in this series, or the 93 "improvement": Table I lists the number of patients evaluated by the Discharge Conference, according to the four-fold classification in use in the hospital. For comparison, the discharge ratings of the insulin coma therapy patients, following the TABLE same criteria, have been included. I DISCHARGE RATINGS Chlogpromazine Insulin l. Recovered 1 O 2. Much Improved 3 1 3. Improved 15 10 h. Unimproved S 8 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate courses of therapy (less than one month) because of complications of the therapy. or the eight unimproved insulin coma patients, four had inadequate courses of therapy - two because of complications (seiz- ures, prolonged coma), one because she was a severe the fourth by administrative transfer to the V. A. 5. Toxicity g£_chlorpromazine: management problem; and Inherent in the design of were the high doses of chlorpromazine, pushed to symptoms of this study toxicity. In this context, all patients developed significant drug effects. In all, rigidity of extremities appeared; frequently accompanied by a decrease in facial expression, drooling and festination. In a number of patients the pafkinsona. �~6— ian features appeared as the drug dosage was reduced. symptoms were became drowsy, relieved when retarded, the drug and was discontinued. less active in ward In.each patient the Almost all patients activities. In four pat- ients, increased tension, agitation, restlessness and excitement supervened, to a degree that led to a discontinuation of the drug regimen. Seizures occurred in three patients. Ineaach, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. Severe, intractable skin reaction occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine * therapy was substituted for chloru promazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from the chlorpromazine group. All patients developed a skin photosensitivity so that on exposure to sun, transient erythema developed. Refusal of further medication because of drug effects occurred in two patients. Both developed severe tension and agitation. In two other instances, agitation resulted in the therapist insisting upon a change in treatment regimen. Table II lists the complications of both treatments. Certain effects are individual to the type of therapy, as dermatitis for chlorpromazine; and prolonged coma, severe secondary reactions and nausea and vomiting in insulin coma. 0there, as seizures, fainting spells, and increased are seen in both. *- Surplied as "Sparine" by the courtesy of Hyeth and Co. states of agitation �'77“ II TABLE COMPLICATIONS Insulin _Chlorpromazine Coma “ Agitation h and Panic 2 - Dermatitis, severe 3 Seizures 3 3 Refusal of further therapy 2 2 Hypotension 2 - Secondary reaction, frequent - 5 - 3 ~ 1 Prolonged Coma (+ 6 hours) Insulin Resistance In this chlorpromazine series, no patients developed clinical jaundice. This complication has been variously reported as occurring in less than %% of the subjects treated.* Liver function and blood element studies were done in this group of patients. Changes were small, and at the recommendation of the medical consultant, the studies were discontinued. Electroencephalograms were obtained patients. and On in fifteen of the chlorpromazine adequate doses, a moderate amount of low voltage theta activity was induced. This activity h—7 cps.delta was exaggerated by hypervent- ilation. There was a suggestive relationship between the degree of the induced slow wave activity and the drug dosage. 6. Adjuvants tg_Chlorpromazine: With the development of rigidity, festination, and drooling, patients received cogentin or artane medication. Both drugs relieved the symptoms, and in a few instances, to a significant * In the initial studies at Hillside twenty developed Hospital, three patients of a group of transient clinical jaundice. �-8degree. Concomitant with the relief of the rigidity a feeling of euphoria and wellabeing was occasionally noted. In one of the patients who developed effect. therapy, anti- an affective "storm" the administration of artane had a salutary In patients who developed seizures during insulin coma convulsant medication (dilantin, phenobarbital) has been routinely employed. Such agents were on lowered not used with chlorpromazine as the seizures did not recur dosages. Insulin B. Coma Theragz clinical effects, complications, the treatment results of insulin ccma therapy have been exhaustively reported. In this series, twenty-nine patients began insulin coma therapy. Of these, nineteen have completed their period of hOSpitalization and ten are either completing their treatment perThe iod or are awaiting discharge. The over-all ratings of "improvement" are listed in Table I. When comp pared with the Hillside HOSpital Follow-up Study of 1955, the percent improve— ment in each category is not significantly different, although the trend is less optimistically than the 1950 group. In Table III the percentages are listed for each evaluation category of this to rate the present series somewhat group compared to the 1950 populatidn. TABLE INSULIN III COMA THERAPY Present Group E 1. Recovered 0% 2. Much h% 19% 3. Improved 52% h2% h. Unimproved hh% 25% Such a Improved difference in trend, if sustained, 1h% may reflect a variety of factors, including changes in criteria of "improvement;" prior administration �.9... tranquillizing agents exerting a selectivity on the population admitted to the hOSpital; and changes in staff criteria for referral for in» of the newer Sulin coma therapy. complication rate in this insulin group is comparable to published studies. No unusual complications, and no deaths were observed. The role of psychotherapy in patients undergoing insulin coma therapy The is complex. In this group, four patients were treated with a "modified anaclitic" approach and an effort at establishing a working psychotherapeutic relationship was made. In the remaining patients, no unusual efforts at psychotherapy were made, with the consensus that a supportive, educative, enviru onmental-manipulative, reassuring type of therapy was achieved, to varying degrees. Therapists reported (in 7 instances) that patients were less tense less anxious during sessions while in coma therapy. In eight patients the physiologic effects of the treatment (secondary reactions, sweating, nausea, vomiting, weight gain) interfered with relationship therapy to a significant and degree. C. Therapeutic Results in Relation to Final Diagnosis Table IV lists the final diagnostic categories for the patients in each group. All diagnoses were represented in each series with an equivalent distribution. TABLE IV EBYCHIATRIC DIAGNOSES Insulin Coma Chlorpromazine Psychoneurosis l 2 Schizophrenia, Paranoid 0\ we U1 O\ U1 \n \» to +4 DD Schizophrenia, Catatonic Schizophrenia, Mixed Schizophrenia, Hebephrenic Manic Depressive Psychosis �~10— No diagnostic group had a significantly better treatment response than any other with either form of therapy. V. DISCUSSION: A. Comparison of Chlorpromazine and Insulin Coma Therapies: Neither chlorpromazine in high therapeutic doses, nor insulin are Specific treatments for schizophrenia. The discharge evaluations both treatments are not significantly different. There is, coma, for however, a def- inite tendency for more patients in the chlorpromazine group to be rated in the better classifications than in the insulin coma group. The trend assumes significance when both the type of sampling and the qualitative aspects of the treatments are taken into account. the The random sampling is exemplified by resultant matching of diagnoses. Since these treatments have not resulted in a recovery from the psychotic process, then their ameliorative, palliative and supportive aSpects must be considered. The insulin coma patients are usually uncomfortable throughout their treatment period. Nausea, vomiting, secondary reactions, are Prolonged coma common. loss of is a and drowsiness realistic threat; as well as the threat to life. The chlorprcmazine patients also suffered considerable disagreeable side effects. Parkinsonism, drowsiness, and skin reactions are significant, must be considered as concomitant management problems. and Seizures and jaundice are the most severe reactions, and to date, have not been permanent. It is possible to modify the significance of these side effects to a considerable extent by anti-parkinson and anti-convulsant medication. There is no question, furthermore, as to the ease with which chlorprom- azine can be administered, in contrast to insulin coma. A significant element in the use of these agents in the therapy of schiz- �.11... ophrenia is concomitant psychotherapy. Such relationship therapy by both It was therapies. apparent in the therapist's evaluations, however, that the chlorpromazine regimen was apy. Patients, excluding those comfortable, alert iences while on and was enhanced more conducive to concomitant verbal who developed ther- increased agitation, were more physically able to discuss their feelings and exper- chlorpromazine, than insulin coma. In another respect, the ease of administration of chlorpromazine advantage. Patients who respond to drug therapy can is of be maintained on such therapy for as long as needed, even on an outpatient basis, while the "course" of insulin coma is limited. Are these treatments equivalent? Can one be substituted for the other? While these questions cannot be answered by the data the negative can be denied. groups are not The in a positive assertidn, results of these treatments in equivalent different with regard to the discharge evaluation. The changes in behavior noted and the symptoms alleviated are not significantly different. In this series, three patients had adequate courses of both regimens. Two have been discharged"improved," and the third is still in the hospital. There has been no significant differences in their reSponse to either form of therapy. Comparison With Other Studies: B. While many studies of chlorpromazine in schizophrenia have appeared, only one report of a controlled study is available. gt_al_ (2) after an excellent review of the problem, report their results in one hundred patients, coma randomly divided into two groups of SO and Boardman, treated either by insulin or chlorpromazine. Their chlorpromazine dosage was lower than in this series (average 300 mgm) but the drug period ( 3 months ) was the same. Their observations are directly comparable to this series. They noted that the over(2) et a1: Insulin and Chlorpremazine in Schizophrenia — Study of Previously Untreated Cases, Lancet g5 h87-h9l, Comparative (September) 1956. Boardman, R.H. A �all clinical results were slightly more favorable in the chlorpromazine group than in the insulin group judging both by interview status and by a rating scale of difference was not of high statistical signif- The symptom change. state, however, that the chlorpromazine patients remained in the hospital an average of 6.2 weeks less; and that this difference was statistically significant. They concluded that: "There is inconclusive evidence icance. They did that chlorpromazine has advantages over insulin in the treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the first treatment of -choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been confirmed by an adequate follow-up study." In Boardman‘s review, due cognizance therapeutic efficacy of insulin come. He is given to the problem of the notes the number of'dissident re- ports that raise doubts as to the role of insulin In this regard, for insulin it is therapy in schizophrenia. important to note the results of the Hillside Follow-up in which patients referred for coma, coma such therapy had the period of hOSpitalization, poorest discharge ratings, and a ization rate (compared to 33% for psychotherapy and 29% 50% longest rehosPital- for the electroshock therapy groups). Two other control studies of chlorpromazine in psychoses are relevant to this report. "blind" study ment at Feldman gjgggp (5) Topeka reporting the observations in a controlled, State HOSpital noted a significant degree of improve- for chlorpromazine. They<eoncluded that "thorazine was found to be useful in converting acutely disturbed psychotics into tractable, accessible patients who could (S) Feldman, P.E. then participate more actively in the hOSpital rehabili- et al: A Controlled, Blind Study of Effects of Thorazine Clinic, a9; 25-h7, 1956. on Psychotic Behavior, Bull. Men. �.13... tatidn program." Tenenblatt and Spagno (6), describing the St. Elizabeth's Hospital eXperience, in another control study, noted significant behavioral effects in psychotic illnesses other than involutional psychoses. Effect of Study D. An on Staff: inherent factor in a control study of any therapeutic modality is the effect that the knowledge of random selection of patients or the use of placebos has on the therapist in his choice of therapy. sulin coma referrals were to be given Knowledge that in- either chlorpromazine or insulin coma created a feeling of insecurity and impotence in the therapist. Their control of the therapeutic situation was in a decrease in the drug effects, and number of felt as severely constricted. This resulted referrals, an exaggeration of the physiologic in the patients expressing doubts as to the therapeutic efficacy of the drug despite significant changes in ward behavior. On numer- therapists called to enquire which therapy their patient, referral for ICT had not yet been made, would get. Prior prejudice ous occasions, ‘whose suitability of either therapy resulted in the therapist's expressing disappointment at the modality used. In two instances, such preabout the judices led to early discontinuation of chlorpromazine therapy, when the pat~ ient experienced eanLy signs of drug effects. E. Dosage of Chlorpromazine: For the purposes of assuring an adequate level of chlorpromazine for evaluation, the medication was "pushed" in level in was too high all all subjects to toxicity. This for its behavioral effects, as evidenced responsive cases to maintenance levels of by the reductidn hOO-lOOO mgm. The effects of parkinsonism, drowsiness and lassitude are prdbably necessary concomitants (6) Tenenblatt, 3.8. and Spagno, A.: A Controlled Study of Chlorpromazine Therapy in Chronic Psychotic Patients, Quart. Rev. Peych. & Neurol., �1":114- of the therapy; and should be induced effect is desired. In instances where in all patients in an whom a therapeutic affective "storm" supervenes, con- inuation of the drug at higher levels, with concomitant artane or cogentin, should be considered. VI. CONCLUSIONS: In a control study of patients referred for insulin coma therapy, chlorprcmazine therapy was found to be as effective in modifying psychotic behavior patterns as insulin charge ratings to be coma therapy. is There better for the chlorpromazine a tendency for the group than dis- for the insulin coma group. In comparison to insulin coma to administer, more controllable in therapy, chlorpromazine is safer, easier its effects, and has fewer side effects. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity for either form of therapy for schizophrenic illnesses. No evidence has been educed �February 3, 1958. that at a bucuti 1.. t :1 1251 : or EEG Dona Maturity to Bohuioml Quaint-Adv. 801-111 Studiu, “Hg, . kaponn in metro-hock: a: Arch. chhnt. 18; 516-525. 1957. Fink, H. and Kuhn, my a.L.s 3818321511 . Mime ﬂux-spin, Units.“ Theory of the Action of 1957. 197-306. g. Hillside 3032. 9: ILL: Significance of Individual Variability in ma human to moctmlhock, g. Bullio- Raga. Q: 229-21“), 1957. link, 91.: A 3. m, h. Join, 5. Kuhn, 3.1.. and $. him, 8.1... J. «In An abacus.” Study of Went-.1031 £111.16. Hog. 9,: 207.215, 1957. link, In blink, PchhiaMc Interview, Figural Artur Induced mm (1957). g: Perception of m5. Puma)... mum, Altered Bruin 1n 361 H. and Pink, 15.: Social Salaam of Factorl 1n 216-228, 1957. 7. 3. and Pink, Ha Role or Stimulus Intensity 1n Pomcpuan tom, ' Simultaneous Gunman: Electrical Stimuli, 1. munch Hog). 9" 2181.250; 195?. at ‘ mama“ 8. Karin, 8. (With Tameka, 8. and Friedman, 8.): Pomeptim Stw o: Ambit-lanai, mg, hard, I: inching.. 1Q: 1&7-176, 19 7. 9. Punter. in; H. (with Geldfarb, Lgﬂé. knack, H. LE. 322‘ E a g Md it): gaunt. ﬂ! (with‘marb, m): Test in Schilophrcnic 0111mm, 6354-6132, 1957. htum of Orientation in Childm in 303.1de Instant. for 8mm Bonnier Daemon, her. J. Mama . 213538-552, 195?. n. (with Battarnby, v.3. and Radar, 14.3.): Tnchia’wteopic hunk, “minimum of Contour 1n ﬂuent: with Brain mange, J, Cog. algal. gm 61° ﬂ. 3’ 220.227, 1957. Pollack, K. (with Battersw, $1.3. and War, 11.3.): Visual Deficit After Brain Damage in Man as Hammad with Rupidlyakpoud chromatic Stimn, mr. BIS-“2.9;. £2} 7’ 1‘68, 19570 0 13. Pollack, u. (with 00161111), in): cum-a1 ma Ehviromntal Factors attracting Complex Exception in the Institutionaliud Aged, ,1. Gomntolu l2“: ’1, “374‘38’ 19570 �Wf— ,. . , , . ~v-wwwavw—wmvwwnw—wu—va . «m <-~w—-~ uv-v—r rvs—«wv ﬂv‘w—I-‘V n V'Wuzwr- may, mm "—31-— "Wu Flbmuy 3, 1958. Imagination! in Pro”: 1. 3., Mfo, J. humor, with mantra-hook 2. Pink, 3. Pink, IL, Shut, R... Grass, 0. and Colo-Inn, F.3d and Kuhn, Yuma“, J, 3.1.: chhomompenuc Techniques Hang. (in press). was 8.. [$11, 3.1.. tad anon, 14.1.: ﬂuctuahook Prone-l, m, luv. “perinatal M. mama). J. r ‘mo (in Phi.)i and Insulin Cm in the Studio: of the (in press). Omani» Study of Therapy of Psychosis, * h. Pink, 5. ma, LL. 11.: 2E8 Laura}. Gnu Gun. In macaw. a u m- Indu a! the Sedation Munch}, in press). W. and Pink, 24.: humanity Factors (in nutmnhock Therapy, in Buhuioral mu). name to .- v- w. 1r, ,mrnv .7 w K, - �Luvzuv-amwnvww «7,. w—nwrruwm...»~.\,..—... W. WA R .. ran n-«cmvrrme—u»:‘v' February m. »u r’er’I-‘vs 3 , 1958 . many: in m Rayon-buy. Inﬂow“ York, Pom-my 1957. 1. Fink, IL: Individual 2. ﬁnk, Mu cut-m 3. Pink, 3., Kuhn, 8.1:. 1nd km :1; the Sociow no scanty, In 1n Enluation of Clinical Bolivian}. physiologie Alp-ct... Presented at LBJ... at Motropoutan Band Change: Neuro- ma tabla, Chicugo, by 1957. Exporiunm Gm, LL: of Biological Pm“. Juno 1957. Studio: of the msctmahock Psychiatry, Atlantic City, H. and Kuhn, R.L.I mum of amt-wean: Role of Alteration in Brain Function in Bah-dot. Pnsented at. Int. Congas: of Pnychntry, Zurich, Sept. 1957. h. ﬁnk, S. I!” xﬁn, 3.14. ”d “an, 3.! “ICC“ Qt 01:!qu “tend 3w m’Function on Pomaption. Pruemad at the 17 Int. Congrats of Psycholog, Ema-1c, August 1957. ' 6. Fink, II. and him, 3.1“: Random Pattoml in Induced Stat» of Aland Road at w. New Ion Divisional Hating, A.P.A. 1m. 1957. Brain 7. Pink, Mu 8. on m ma sumnwm tar hoary of Le Enact. or M,Pmaou of Conwlaivo Thu-um. Read It. Mom “Inﬂation of manna mum. of m quancy Shirt for Plychintz-y. Simian“SOQCW‘ HoY: 30'. 1957- ”Mum EEG 13101313511). anecphalographm, Nov 9. 10. Road at. M30, 4.: 1621:, Doc. 1957. Bahamian). chug” Plyohomum in Evaluation of Clinical Round Tabla, Chicago, Hay 1957. lingnhuc “pom. Fromm at A.P.A., in hymn-Le Interview. NationA.P.A.. Nov. 1957. MIC, J.: Lu Obj-«tin Study of had at um How Iork Divisions). Mating, in Buhuioral Euponu to metre-hock Thonpy. haunted at meta-omen}: Research “mention, [11:21, 3.1.. and Pink, 11.: Pomonality Factor! Chicago, Ram, New 1957. LL. and link, Aland Brain Mu Pompticn or Function. Road We! Figures Arte:-InInduood Ierk, August 1957. at Ann. Plyehol. Luau” Karin, H. (with runabout, S. and Friedman, 84): Pomption Expouunu in a Study of Allah-Amen. End at Suction on lourolog I: Plychintry of Ed. of Kodiak)! and LY. Roux-01. Socioty, NJ. Jm. 1957. low �__. _.__ .7...._—M wvwwﬁwww «V . ., m«m1.1m: 1. _ (5....»“1 .._ _ w. ....,._-,_..,..._.. «1...; .I.-....._.L,,.r..». w“ynw-WMW r‘m-vnr—Vwﬂtnﬂw’all ' 7 I-vrn" “rm” ‘ nun—mm.—.,.m~ I2 (Iith Italahau; s. and lhindnan, 3.): th- Relation a: Ambasulnneo Mansion and Monty 1n Wan-antic mum... and at Amt. Mabel. Ame. Sept. 1957. (New Kerk). 15. Karin, B. (with Tarmac»: and Mama, 8.): Stun” in “bitumen. 1h. lbrin, H. to Pnlantad boron Sahildar Sociew, M York, 00%. 1957. 16. Pamak, H. (with Galena), W. and Dam, 14.): Pain mucus in Schumann 02:11am. Haunted at Mr. Orthapaychntrio mac. Chicago, Marah 1957. 17. ‘ M.‘(v1th Integer, H.P.)I.Oan1mtor'and Bantam Put-m 1n o: lamina, Sahisophnnia Wldran. P's-mug! at Mr. knack, Am 18. Pollack, H. (with Butterﬂy, v.3. and Bond-r, 11.8.): ﬁgure-mane! Pamphlet: Tumor. But! *Enmm Payahol. uses... In York in Plunges with 13111 0“.an 19 7o it Pollack, K. (with Batu-thy, H. 3. and Bondar, 3.3.): Datum in Visual Phraoption in Brain mm:- Patten“. Flaunt-d baton Int. Congrats or ngcha1., aux: 1957. (Brunloll). .20. anuok, K. (with Battarnby, v.3. and Bondar, 14.3.): Visual M1611: After with Rapidly-kpand Chmtia 9mg. a Mutant! Assoc" Nu Int-k, Sept. 1957. Pmud at Ann. PaychoI. Brain 1:: Man Stimuli. Pollack, H. (with Goldhrb, A.): Cultural and Environ-um Factor: Aged. Presented “hating (De-plan: Pox-caption in tin Institutiamliud at the “analogical Society, Cleveland, 00%. 1957. 22. Pollack, 11.: Brain Dung... Pmanud It. Nil mm Inhalation and Childhood Sauomania. Hating, MPJ. new. 1957. York Divisions). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-31-008 Date A point or period of time associated with an event in the lifecycle of the resource 1958 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>; Shaw, Robert; Gross, George E.; Coleman, Frederick S. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint and reprint]. Reprint from The Journal of the American Medical Association April 12, 1958, Vol. 166. Observation letter. 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Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/dd6aa613ad864b41d42710aa943de4df.pdf e331912b9bfc1f22ac2706d3f155e8a5 PDF Text Text 5 ,ﬁ, . 1 Confinia Neurologica 9/ NEURQPHYSWLUEY [ABQRMURY HILLSIDE HOSPITAL GLEN OAKS' N' Y- Borderland of Neurology -— Grenzgebiete der Neurologie Les conﬁns de la Neurologie Edidit: E. A. SPIEGEL Basel S. KARG ER Separatum Vol. 12, Fasc. 4 (1952) : 3 . New York Printed in Switzerland From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellevue Hospital, New York City A Clinical Evaluation of Carotid Angiography by MAX FINK and JOSEPH M. STEIN ._.I I ‘ f .3 I Since carotid angiography has become a routine procedure in the management of intracranial conditions, an evaluation of its use is necessary. Both the indications and hazards of the procedure must be considered in recommending it for diagnostic purposes. It seemed valuable, therefore, to review the angiograms done on the neurological service of a general hospital. During the past 20 months, 117 percutaneous diodrast angiograms were completed by members of the resident house staff. The majority were done di- rectly by the authors. A variety of neurological conditions including suspected brain tumors, vascular anomalies, subdural hematomas, vascular diseases and diffuse degenerative diseases were selected by the attending staff as suitable candidates for angiography. In each case, a percutaneous carotid angiogram was performed according to the usual descriptions (1). Either local inﬁltration by novocaine or general anesthesia by pentothal or surital was used. A CournandGrino needle was inserted into the carotid artery at the level of the thyroid cartilage. In most instances the common carotid artery was cannulated; in a few instances the internal carotid alone. Ten to twelve cc. of 35 % diodrast solution were used in each injection. A simple manual multiple cassette holder was used. This permitted three consecutive lateral ﬁlms and a single anteroposterior (A—P) view. In each case the A—P and lateral ﬁlms were immediately developed, and, if indicated, the injection was repeated. If no pathology was noted on these ﬁlms, the procedure was repeated on the other side whenever advisable. Bilateral procedures were carried out in 26 subjects. �182 Max Fink and Joseph M. Stein Results Diagnoses of various conditions were made prior to angiography. Of these, “brain tumor suspects” made up the largest group; suspected vascular anomalies and subdural hematoma were the next largest groups (see Table I). The interpretation of the ﬁlms was based on descriptions by Moniz (2 a), Lima (2b), and Green and Arana (l b) . Brain Tumor Suspects Of 55 patients in whom intracranial masses were suspected, angiographic diagnoses of brain tumor were made in thirty. Of these, 25 were conﬁrmed by subsequent surgery or air studies. Conﬁrmation was not obtained in three patients because further studies were contraindicated by patient’s age or family’s refusal to give permission. In two cases the angiograms were interpreted incorrectly and these cases are described. Case I: D.H. a 48 year old woman was admitted to Bellevue Psychiatric Hospital because of headaches and progressive confusion. The examination revealed early papilledema, left central facial palsy, skull tenderness on the right and memory deﬁcits. An electroencephalogram showed a right cerebral focus. Bilateral carotid angiography under general anesthesia revealed deﬁnite elevation (displacement) of the parietal branches of the right middle cerebral artery. Subsequent to this procedure the spinal ﬂuid syndrome was noted to be positive for active syphilis. Anti-luetic treatment was instituted and the patient improved rapidly. Five weeks later, the right carotid angiogram was repeated. These ﬁlms showed the parietal vessels to have a normal conﬁguration. Case II: 0. 0., a 64 year old male was admitted because of recent onset of grand mal seizures and left-sided weakness. Examination revealed a mild left hemiparesis, most marked in the lower extremity. There was a positive Babinski response and increased reﬂexes. The cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under local anesthesia was performed and demonstrated good ﬁlling of the anterior and middle cerebral arteries. There was straightening and depression of the pericallosal artery on the lateral views; and increased vascularity near the termination of the anterior cerebral artery on the A—P ﬁlm. These changes were interpreted as evidence of a parasagittal tumor mass displacing blood vessels. A pneumoencephalogram was done and this did not demonstrate the mass. The patient improved without treatment and was discharged. He was readmitted a few weeks later with evidence of an acute brain stem syndrome. In View of the course of the illness and multiplicity of lesions, it was believed that the patient’s symptoms were due to degenerative changes, and not a neoplasm. No further studies were undertaken. In this group of suspected brain tumors 22 angiograms did not show any pathology. Eleven of these were conﬁrmed by air studies or autopsy. In two patients, however, satisfactory angiograms failed to demonstrate lesions later demonstrated by other studies. �A Clinical Evaluation of Carotid Angiography 183 III: F. M., a 57 year old man was admitted to the hospital because of left hemiparesis, bladder and bowel incontinence, and grand mal seizures of 4 weeks duration. On examination, there were severe personality changes, and a spastic left hemiparesis with pathological reﬂexes. Cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under pentothal anesthesia was done. Two sets of lateral ﬁlms and one A—P view were taken. The ﬁlms showed no evidence of cerebral tumor. One week later a ventriculogram demonstrated a large right fronto-temporal mass. The presence of a malignant glioma was conﬁrmed by surgery. Case IV: J. S., a 49 year old man developed left sided seizures and aphasia during hospital treatment for furunculosis. On neurological examination there was evidence of a lesion in the right hemisphere. On skull x-ray the pineal shadow was shifted to the left. An arteriogram on the right side under general anesthesia was done and no pathology demonstrated. A pneumoencephalogram, however, revealed a deformity of the right frontal born. The patient expired one month after angiography and at postmortem, multiple cerebral abscesses were demonstrated bilaterally. Case Other erroneous angiographic diagnoses were made in patients who proved to have vascular thromboses. In two patients with signs of a brain tumor, the angiograms revealed an avascular area in the parieto-temporal region with displacement of middle cerebral vessels. Surgical exploration revealed edematous necrotic brain tissue, without evidence of tumor. Each case came to autopsy, and TABLE I ANGIO GRAPHIC DIAGNOSES Group No. of Patients Intracranial Mass Vascular Anomaly and Aneurysms Suhdural Hematoma Occlusive Vascular Disease Other (f) 55 _ Pos. 30 Pos. Neg. Not Diagnosis Diagnosis Incorrect Neg. Diagnostic (3) Conﬁrmed Conﬁrmed Diagnosis 22 3 25 1 2 21 17 9 9 (d) ll 11 7 13 2 4 10 8 — — l ll 4 (b) 1 (c) 9 6 (e) 7 — 1 —— 5 —— —— Notes: (a) Technically unsatisfactory ﬁlms. (b) Two cases conﬁrmed by surgery but 7 other patients'with anomalies demonstrated on arteriograms were not subjected to further studies. (c) The 11 patients with negative arteriograms were not subjected to further study. ((1) Includes seven diagnoses of subdural hematoma, one of intracerebral hematoma and one of brain tumor. (e) F ailurc of the anterior or middle cerebral, or internal carotid artery to ﬁll on at least two consecutive injections, while the remainder of the circulation ﬁlled well. (f) Includes three “follow-up” angiograms, seven patients with diﬁuse degenerative disease and three patients with lesions of the skull. �184 Max Fink and Joseph M. Stein in both, thrombosis of a branch of the middle cerebral artery was found. The angiograms could not be differentiated from those seen in cases of tumors in the same region. Vascular Anomalies: Twenty-one patients suspected of intracranial vascular anomalies or aneurysms were subjected to angiography. The angiograms were bilateral in only three of these, and unilateral in the other nine. One set of ﬁlms were not satisfactory and were not repeated. Seventeen of these patients had manifested spontaneous subarachnoid hemorrhages. In nine cases an anomaly was clearly outlined on the arteriogram. Five of these were aneurysms at the base, and four, vascular malformations of the hemisphere. No anomaly was demonstrated in eleven cases. Conﬁrmation of ﬁndings by other methods of study was most difﬁcult to obtain in this group. In the nine cases where the anomaly was demonstrated, further conﬁrmation was achieved in two cases. In one, an angiomatous malformation was amputated at operation. In the other, an aneurysm of the anterior communicating artery was dissected at post mortem. Air encephalograms were normal in two patients, despite the angiographic evidence of a large angioma of the cerebrum. The speciﬁcity of angiography in the diagnosis of vascular malformations is demonstrated by such cases. Of the eleven patients with negative angiographic ﬁndings, two were subjected to air studies. These ﬁlms were normal. The other nine patients were discharged without further study. Subdural Hematoma: The diagnosis of subdural hematoma was made angiographically in seven of seventeen patients suspected of traumatic intracranial hematomas. The characteristic separation of the vascular patterns from the internal table of the skull as seen on the A—P projection was the basis for these diagnoses. In each of these cases the diagnosis was conﬁrmed by trephination. Furthermore, in the eight patients in whom a diagnostic vascular pattern was not seen, diagnosis of no blood in the subdural space was made. These diagnoses were all conﬁrmed by pneumoencephalography. In two patients angiography demonstrated an intracerebral mass, rather than a subdural process. In one case, this diagnosis made it possible for the surgeon to approach the lesion by a well localized and deﬁnitive procedure. The diagnosis was conﬁrmed in the second at autopsy. Vascular Disease: Angiographic studies were done in 11 patients in whom occlusive vascular disease was believed to be the basis �A Clinical Evaluation of Carotid Angiography 185 for their neurological ﬁndings. Failure of a portion of the vascular distribution to ﬁll on two consecutive injections was observed in seven of these cases, and normal vascular patterns were seen in the other four. In the ﬁrst group incomplete ﬁlling of the middle cerebral artery was seen in four cases; of the anterior cerebral artery in one case; and of the internal carotid artery in two cases. The vessels which appeared involved on the ﬁlms were in each instance the same vessels as indicated by the patient’s clinical syndrome. In four of these patients pneumoencephalography demonstrated areas of atrophy in the involved region of the brain. In one case, post mortem studies conﬁrmed the angiographic ﬁndings. No conﬁrmation was obtained in the other six cases. Miscellaneous Group: Of the 13 angiograms in the group, seven were done in patients with diffuse cerebral disease of a degenerative type. These ﬁlms were not characteristic but in each case air studies demonstrated an enlarged ventricular system without shift or deformity. In three patients with lesions of the skull angiography failed to demonstrate any cerebral involvement. Pneumoencephalograms were done in only two of these patients and were normal. Complications: In an evaluation of the indications for a diagnostic procedure the incidence and severity of complications must be considered. In this series of 117 angiographic studies, 36 patients suffered a total of 43 complications. There were ﬁve cases with severe and permanent complications. In all other instances the complications were mild and transient. Of the transient complications, 22 hematomas of the neck were recorded. This was recorded only when the hematoma was large. In one case, in a child, the hematoma was large enough to cause tracheal shift and respiratory difﬁculties. It was necessary to intubate the patient and maintain the airway during the evening of the procedure. Transient hemiparesis or transient increase in an existing hemiparesis was seen in 7 cases, and a grand mal seizure was observed in 2 patients. In each instance the phenomena disappeared within 48 hours. In 4 cases urticaria, chills and vomiting followed angiography, and seemed to represent an allergic response to the diodrast. In one patient, in whom a vascular anomaly was demonstrated, fresh blood was manifest in the spinal ﬂuid the morning after the procedure. Of the severe complications, death occurred within 24 hours of angiography in two patients (cases V, VI). In three other patients �186 Max Fink and Joseph M. Stein severe complications were directly related to angiography. In a young child an osteomyelitis of the transverse process of the ﬁfth cervical vertebra resulted after a difﬁcult cannulization (case VII). A permanent mixed aphasia (case VIII) and an intensiﬁcation of a pre-existing hemiparesis (case IX) were also observed. Case V: G. B. male, 62. Craniotomy, three months before arteriography, had demonstrated a right middle fossa spongioblastoma polare which was spreading along the sphenoid ridge and had crossed the midline. The patient completed a course of x-ray therapy and was alert and ambulant. A vertebral angiogram was suggested to evaluate the intracranial mass. The patient was sedated with demerol, scopolomine and luminal. Three injections of 11 cc. each of 35% diodrast, were made. The record states that: “while attempt was made to enter right common carotid, patient became cyanotic, respirations shallow, and pulsations of the artery, which were strong, became weak.” The patient expired within 20 hours after developing hematemesis, melena, and two grand mal seizures. No autopsy was obtained. Case VI: R. W., a 40 year old male, was admitted because of sudden onset of headache and stiff neck. The spinal ﬂuid was grossly bloody and the diagnosis of a spontaneous subarachnoid hemorrhage made. Patient developed pneumonia and ran a septic course. This responded to antibiotic therapy and patient seemed well one month after admission when he developed a second episode of subarachnoid bleeding. One week later, while patient was comatose, a right carotid angiogram was done. The ﬁlms were not diagnostic and patient expired within 18 hours of the procedure. An aneurysm of the anterior communicating artery with hemorrhage extending into the lateral ventricles was seen at post mortem. Case VII: N. B., a 5 year old girl, was admitted because of petit mal seizures for two months. Examination demonstrated left homonymous hemianopsia and an electroencephalographic focus of abnormal activity on the right parieto-occipital region. A right percutaneous carotid angiogram was done under general anesthesia, with difﬁculty, and a normal vascular pattern demonstrated. Patient had a large hematoma of the neck with tracheal shift, necessitating intubation that night. Patient recovered rapidly, but complained of pains in the neck and kept the head ﬁxed with chin turned to the left. Repeated x-ray examinations eventually disclosed an area of rariﬁcation in the transverse process of the ﬁfth cervical vertebra. This responded to immobilization and chemotherapy. When seen six months later, the child had recovered completely. Case VIII: M. C., a 30 year old male, was admitted to the neurological service because of left sided headaches of a few years duration and three episodes of loss of consciousness during the previous six months. On examination there was diminution in perception of tactile stimuli in the right hand. This defect was exaggerated by double simultaneous stimulation. Electroencephalography demonstrated a persistent focus in the left parietal region. The pneumoencephalogram was normal. A left percutaneous carotid angiogram was done. Four injections of diodrast were made. After the last injection a complete hemiplegia, hemisensory syndrome and hemianopsia was observed on the right. The patient was totally aphasic but responsive. During the ensuing weeks the weakness and sensory changes cleared, so that when seen one year after the episode, only minimal sensory changes in the �A Clinical Evaluation of Carotid Angiography 187 right upper extremity were observable. The aphasia, however, after some initial resolution, persisted. The patient expressed himself with difﬁculty and made many errors, could not carry out complicated commands, and made errors in imitating mouth and hand movements. The angiographic ﬁlms were interpreted as within normal limits except that the vessels of the middle cerebral group were few in number and widely separated. Case IX: E. B., a 64 year old man, was admitted because of headache and “nervousness” of some months duration; and repeated episodes of loss of consciousness without convulsive movements for one month. On examination there were mental changes, hyperreﬂexia and a positive Babinski on the left, but no manifest weakness or sensory changes. A right percutaneous angiogram was done with local anesthesia using four injections of diodrast. Immediately after the last injection the patient lapsed into a torpid state, his eye movements became dissociated, and the left upper and lower extremities were ﬂaccid. During the ensuing days, the torper diminished until the patient could respond verbally to command, but the hemiplegia became spastic. It persisted until the patient was transferred to another hospital one month later. The angiograms were interpreted as normal. A pneumoencephalogram revealed bilaterally dilated ventricles Without shift or distortion. A number of factors such as sensitivity to the contrast medium the amount of drug and rapidity of injection (3b), and existing hypertension (3 c), have been suggested as causes for complications. In the present series, these factors are not outstanding in the patients who developed complications when these are compared to the uncomplicated cases. Either conjunctival or intradermal diodrast sensitivity tests were carried out in every subject. In one case, the onset of wheezing, sweating, and palpitation after the intradermal test caused us to cancel the studies. In all other subjects, including the patients with complications, the sensitivity tests were negative. This was notably true in the four patients who developed “allergic-like” reactions of urticaria, chills, and vomiting, following the angiography, but who failed to react to the test dose. There is no apparent relation in the data between complications (excluding hematoma of the neck) and the number of injections of diodrast (see Table 2). (3 a), TABLE II No. of Injections No. of patients with complications No. of patients without complications * 1 1 3 more than 2 0 9 3 6 4 5 6 6 2 1 6 0 27 22 13 8 3 Total" 16 85 Excluding 16 uncomplicated cases in whom total dosage was not recorded. Similar analyses of the factors of anesthesia and the number of carotid punctures at one session (unilateral or bilateral angio- �188 Max Fink and Joseph M. Stein graphy), reveal no signiﬁcant correlation between these factors, taken singly, and the incidence of complications. Arterial hypertension was not a contraindication in the selection of patients for angiography. Ten hypertensives (all with diastolic pressures of 100 mm. Hg. or more, and systolic pressures of more than 160 mm. Hg.) were subjected to angiography, and in none of these were there any complications. Of the patients with severe or transient complications (other than hematoma of the neck) none had hypertension. Discussion Recent reviews have emphasized the diagnostic reliability of carotid angiography in vascular anomalies (4), suspected brain tumors (lb, 5), traumatic cerebral states (6), and occlusive vascular diseases (7). Our observations conﬁrm the recommendations of the authors in the ﬁrst three groups. Prior to angiography’, the diagnosis of vascular anomaly could not be conﬁrmed except by surgical exposure or autopsy. Since air studies are not reliable in demonstrating vascular anomalies or is choice of in establishing the procedure angiography aneurysms, such diagnoses. In 43 % of the patients in this series in whom such a lesion was suspected, the anomaly 'was satisfactorily demonstrated by angiography. In an unpublished series of similar cases studied by one of us (Fink) at Monteﬁore Hospital, ﬁve aneurysms were demonstrated in 14: suspects. Similar results are recorded by other authors (4), and numerous recommendations have been made to increase these results. Routine vertebral injection, combined with bilateral carotid punctures, will demonstrate anomalies in the posterior portion of the Circle of Willis (14). Oblique A—P views at 45 degrees have been recommended to demonstrate small aneurysms of the carotid (4 (1). With these modiﬁcations in the procedure, it is to be expected that the incidence of positive identiﬁcation of anomalies will increase. The role of angiography in the management of spontaneous subarachnoid hemorrhage is not clear. Recent reviews emphasize the importance of demonstrating the lesion where surgical intervention is indicated (4b, e). The effect of angiography during the acute phase of bleeding has not been clariﬁed. Many authors have recommended angiography only after the bleeding has ceased. Others, such as Wechsler and Cross (7 b), suggest early use of angiography during active bleeding. This principle of waiting until bleeding ceased was adhered to in the cases in this series, and no statement of the effect of angiography on bleeding can be made. �A Clinical Evaluation of Carotid Angiography I89 Angiography is the diagnostic procedure of choice when a supratentorial brain tumor is suspected. It is recommended for lesions located in the anterior two-thirds of the cerebrum. Occipital lobe, posterior fossa and some midbrain tumors are not consistently demonstrable by this technique. Angiography is recommended in subjects with papilledema, since this procedure, unlike air studies, does not make immediate surgical intervention necessary (5, 7). Furthermore, numerous reports emphasize the differences in the patterns made by gliomas, meningiomas, intracerebral hematomas and vascular tumors (1, 2, 3c, 5). Such clues are helpful to the surgeon in planning the operative procedure. In a few of our cases, multiple foci of a metastatic tumor were demonstrable on the ﬁlms, clarifying the management of the case. Such discriminations are usually not possible by other diagnostic techniques. The diagnostic reliability of angiography in cases of brain tumor is high. In this series, 25 of 29 conﬁrmed brain tumors were outlined by angiography. In a series of 96 brain tumor suspects, 39 of 42 veriﬁed neoplasms were demonstrated (5 a). In the series from Monteﬁore Hospital angiography revealed the neoplasm in 45 of 52 conﬁrmed cases. Similar satisfactory correlations are seen in the negative angiograms of these three series. This diagnostic reliability of 88 % compares favorably with encephalography. The value of air studies in brain tumor diagnoses has been frequently reported. In one such study by Grant (8), ventriculography demonstrated the lesion in 130 of 150 cases—an incidence of 87%; while pneumoencephalography in 69 cases, revealed the tumor in 81%. Further indications for angiography are in cases of traumatic intracranial hemorrhage. Numerous reviews emphasize the displacement of the anterior cerebral artery and separation of the ﬁne vessels from the calvarium on the A——P ﬁlm as diagnostic of subdural hematoma (6). Furthermore, angiography differentiates intracerebral and subdural lesions, altering the surgical approach (6 a). This was clearly demonstrated in two of our patients in whom subdural hematoma was suspected, but in whom the angiogram demonstrated an intracerebral mass. In cases of cerebral vascular accident angiography appears less helpful. Failure of a vessel to ﬁll may be due to a variety of reasons including slowing of the circulation, vascular spasm, and anomalies of the system. These factors have been emphasized (7b). Angiography, however, is not contraindicated in vascular disease. It provides a useful means in differentiating a thrombosis from an intracerebral clot, or from a tumor, in cases where the diagnosis is unclear. �190 Max Fink and Joseph M. Stein While the indications for angiography are many, they cannot be evaluated without a discussion of the risks involved. The complications of the procedure are of three types: (a) transient local phenomena; (b) transient cerebral vascular phenomena; (e) permanent severe deﬁcits. In the ﬁrst group of transient phenomena are burning pains in the head during injection, hematoma of the neck, and allergic reactions. Hematoma of the neck is a potentially dangerous complication (see our Case VII) but in a recent review no sequellae were observed (9). Allergic reactions are infrequent and usually mild. It was noted in this series that the routine intracutaneous or conjunctival testing for sensitivity was not found satisfactory in predicting these complications. Transient hemiparesis, aphasia, seizures and elevated blood this In (10). have been following angiography reported pressure series these complications were observed in nine cases—an incidence of 8%. A similar incidence was observed in the Monteﬁore Hospital series. That these phenomena are probably due to temporary vascular insufﬁciency (spasm?) is evidenced by the clinical pattern of neurological ﬁndings and their duration. Of seven patients with hemiparesis, the deﬁcits had disappeared within three hours in three patients, while in three others it was gone in 24 hours. In one of the subjects angiography was repeated in the other side six days later, without complication. In the seventh patient, arteriography had demonstrated an aneurysm of the internal carotid artery on the left and the common carotid artery was ligated on that side. One month later, angiography was repeated on the right side and following the ﬁrst injection of diodrast, the patient developed a right hemiplegia. This disappeared during the ensuing 72 hours. Vascular syndromes of the anterior and middle cerebral arteries have been observed. In one patient a lower limb monoplegia developed after two injections of diodrast. A third injection on the same side was done within 15 minutes of the appearance of the defect. The arterial views obtained showed good ﬁlling of all branches. The monoplegia disappeared within 12 hours. These complications were not observed in patients with hypertension. Deterioration of a patient’s condition or death following angiography has been reported in a number of instances. Bull (5d) summarizes the mortality rate of the procedure as 3 per 1000, which he states compares favorably to ventriculography. More recently, Dunsmore, Scoville and Whitcomb (10b) report three fatalities in 147 cases, and Olsson (11) reports three cases of “deterioration of patient’s condition” in a series of 360 angiograms. �A Clinical Evaluation of Carotid Angiography . 191 There were two fatalities in our present series, and one patient had a severe aggravation of a pre-existing hemiparesis. Each of these patients, like those of Dunsmore, Scoville and Whitcomb and Olsson, were severely ill before the procedure. In contrast to this are the large series of Curtis (5b), Wickbom (1 c), Torkﬂdsen (Sc), Lindgren (la), and Green and Arana (1b) wherein no deaths were related to the procedure. It is possible that with widespread use of angiography, subjects with more advanced cerebral lesions are selected for these studies and the risks thereby increased. A number of reports by Olsson and associates (3b, 11, 12) emphasize the summation of the toxic effects of large doses of diodrast given over a short period of time. They indicated the nature of the toxicity as an increased permeability of the blood vessels and a change in hemodynamics. Furthermore, the relation between concentration of diodrast and toxicity was demonstrated by Cross (13) when he introduced diodrast for angiography. His observation that seizures follow the use of 50% and 70% diodrast has been conﬁrmed by numerous investigators. Despite the use of 35% diodrast and low total dosages of diodrast, in this series, complications ensued. There was no signiﬁcant relation between dosage and complications. Other factors must be operative and some hint has been given in the observation on circulation time (41') and the effect of other injurious agents summating with diodrast (3). Conclusion Angiography is preeminent in the management of cases of intracranial disease suspected of vascular anomalies, supratentorial tumors, and traumatic hematomas. It is a satisfactory non-surgical method of demonstrating a vascular anomaly, malformation or aneurysm. In the diagnosis of supratentorial masses it will outline 90% satisfactorily. In addition to establishing the presence of a tumor, arteriography is superior to other diagnostic technics in yielding evidence as to the type of mass and its locus. In cases with papﬂledema, surgery is not made immediately mandatory by the procedure. It is not a satisfactory method in demonstrating obscure and diffuse lesions of the ventricular system, or tumors of the posterior fossa or occipital lobe. In cases of traumatic intracranial lesions, angiography is a satisfactory method in outlining subdural hematomas, and differentiating such lesions from intracerebral hematoma or tumor. �192 Angiography is Max Fink and Joseph M. Stein thromboses cerebrovascular in not clearly helpful and hemorrhages. would and not transient, the for most part, Complications are, are The complications in cases. most the limit procedure seem to bilatnumber or anesthesia, not directly related to hypertension, factors a Other play diodrast. of erality of injections, or amount is necessary. further and role study more important Summary reviewed were carotid angiograms A series of 117 percutaneous in involved angiography. risks and for indications the to evaluate studied including supraconditions were intracranial of A variety and hematoma traumatic anomalies, vascular tentorial tumors, of intraevidence with disease. patients Fifty-ﬁve cerebrovascular cranial tumors were subjected to angiography, and a positive in conﬁrmed were These diagnoses diagnosis was made in thirty. ﬁlms misinterpreted. the were subjects In two only of the cases. 83% in in conﬁrmed 50%; were the diagnoses Of the negative ﬁlms, demonlater lesion show fail a to did the angiograms only two cases intracranial with suspected 21 Of patients strable by air studies. of In two outlined angiography. by vascular anomalies, nine were air manifest on not revealed anomaly an these, the angiograms traumatic of suspected of seventeen patients studies. In a group in made seven was diagnosis positive intracranial hematoma, a in cases, eight ﬁndings the well negative as as These diagnoses cases. all conwere in two demonstrated cases, intracerebral tumors and lesions cerebrovascular of In studies. cases ﬁrmed by subsequent complications Transient value. of diagnostic not angiography was consisted and of the one-third patients, in of angiography were seen In urticaria. and seizures, of hematoma of the neck, hemiparesis, These and severe permanent. ﬁve patients (4 %) complications were discussed. factors the and described cases are cerebral of angiorisks limited the conclude that authors The of the in usefulness management its from detract do not graphy intracranial vascular malformations, suspected supratentorial tumors and traumatic lesions. Zusammenfassung 117 durch perkutane Injektion in die Arteria carotis gewonnene und Indikationen der Gesichtspunkte Angiogramme werden vom Gefﬁﬁanomalien, Tumoren, Gefahren besprochen. Supratentoriale der GehirngefﬁBe und Erkrankungen Haematome traumatische �A Clinical Evaluation of Carotid Angiography 193 werden besprochen. 55 Patienten mit Zeichen von intrakraniellen Tumoren wurden mit Angiographie studiert; in 30 wurde eine positive Diagnose gestellt. In 83% der Falle wurde die Diagnose bestatigt. In 2 Fallen wurden die Filme falsch gedeutet. In 50% der negativen Filme wurden die Diagnosen bestatigt. Nur in 2 Fallen vermochte das Angiogramm nicht eine durch Luftfiillung demonstrierbare Lasion zu zeigen. In einer Gruppe von 21 Patienten mit vermuteten intrakraniellen GefaBanomalien wurde in 9 Fallen die GefaBstﬁrung demonstriert. In 2 dieser Falle zeigte Angiographie die Anomalie, wahrend Luftfiillung ein negatives Resultat ergab. In einer Gruppe von 17 Patienten mit Verdacht auf traumatisches intrakranielles Haematom wurde eine positive Diagnose in 7 Fallen gestellt. Diese Diagnosen, wie auch die negativen Befunde in 8 Fallen, und intracerebrale Tumoren, die in 2 Fallen demonstriert wurden, konnten durch weitere Studien bestatigt werden. In Fallen von Gehirnlasionen, die durch GeféiBprozesse bedingt waren, hatte Angiographie keinen diagnostischen Wert. In 1/3 der Falle kam es zu voriibergehenden Komplikationen (Haematoma des Halses, Halbseitenlahmung, Kréimpfe, Urticaria). Bei 5 Patienten (4%) waren die Komplikationen schwer und dauernd. Diese Falle und ihre Besonderheiten werden besprochen. Die Autoren gelangen zu der SchluBfolgerung, daB die begrenzten Risiken der cerebralen Angiographie von der Anwendung dieses wertvollen Verfahrens in F ﬁllen von GefaBanomalien, supratentoriellen Tumoren und traumatischen Lasionen nicht abhalten sollen. Résumé Les auteurs passent en revue une série de 117 angiographies carotidiennes percutanées, dans le but d’évaluer les indications et les risques qu’elles comportent. La série d’aﬁ'ections intracraniennes étudiée comprend des tumeurs supratentoriales, des anomalies vasculaires, des hématomes traumatiques et des affections vasculaires du cerveau. Cinquante-cinq patients présentant une symptomatologie de tumeur intracranienne furent soumis a l’angiographie et un diagnostic positif put étre fait dans trente cas. Ces diagnostics se conﬁrmérent dans 83% des cas. Chez deux patients seulement, les radiographies furent mal interprétées. Parmi les angiographies négatives, 1e diagnostic clinique fut conﬁrmé dans 50% des cas; dans deux cas seulement les angiogrammes ne montrérent pas de lésion qui, plus tard, put étre mise en évidence par injections d’air. Parmi 21 patients suspects d’anomalie vasculaire �194 Max Fink and Joseph M. Stein intracram'enne, 9 purent étre révélés par l’angiographie. Dans deux cas, les angiogrammes révélérent une anomalie que les ventriculogrammes n’avaient pas rendu manifeste. Dans un groupe de 17 patients suspects d’hématome traumatique intracranien, un diagnostic positif fut conﬁrmé dans 7 cas. Ces diagnostics, de meme que les résultats négatifs de 8 autres cas, et les tumeurs intracérébrales démontrées dans 2 cas, furent tous c0nﬁrmés par des études ultérieures. Dans les cas de lésions cérébrales d’origine vasculaire, l’angiographie est restée sans valeur diagnostique. Des compli— cations passagéres de l’angiographie furent observées dans un tiers des cas et consistérent en hématomes de la région du cou, hémipareses, crampes, et urticaire. Chez 5 malades (4%), des complications durables et plus graves apparurent. Ces cas sont étudiés en détail et les facteurs on cause discutés. Les auteurs concluent que les risques limités de l’angiographie cérébrale ne sauraient faire renoncer a une méthode aussi utile pour le diagnostic des malformations vasculaires intracraniennes, des tumeurs supratentoriales et des lésions traumatiques. 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It «and valuable, thereto”, to an.” tn «non-m am on tho Wei-clan um.“ or u acuml human . Min; m put to math, :17 panama“: Mount animu- nn can» put“ him-n or the minim hm amt. m mama were «at directly by tho “than . 5 variety of “urological amnion: including 11min Mon, moan: alt-mun, ”Maul hunts-nu, vascular dunno: Ion “law by tho dam“ and arm. “twang um: u with» «Midﬁe- ror WWW. In «ch mu, 9020qu met“ mien-u was performed «cording to the W1 «Manama (1) .' mum.- 10011 infiltration by normal” A 01f 3mm manhunt. by mutant}, or «mm m and. Gem-Grin» mu. m inﬁrm into the mend artery at tho 101010: 1'.» thyroid M11130. In no“ mum» the «non «3th WM" 0.. carotid artery 13th “an. .‘ m mm; in a In butane“ tho into!!!) M 1:0 mm: u. ref 35! “can“ inﬂation. A solution were and in «on «1:91. mm). “18133110 auntie Miner m and. that amounts." luau). 11m tad a um. mun. m: 130th yuurior (5-21 view. m In «on me the Au! and lateral £11m mantel: «#010904. lad, 1: indium. the injection In mutant. 1: no It: noted on than mm, the other 11¢. than» manna. pathology the vacuum at Bilateral mum on panam- urn �2. «aid but in 36 gnaw». .. mm amtlm‘ mu nu prior mum. Wu at the», ”bum W mu“ am 1m.“ my. :0 of " up the muted moun- manna lad «mu but... an an mt “m “wanna” or the film's!" («0 m1: m: mod tn «mimic» t7 In“ (a). amt»),- md ﬁrm I Am: 1m.» 1-). (1b). ‘ ‘ ' m amount). mm «spotted,at ammo nun-u «WWMMthMy. than. nu «ma «haunt sum or as: .m». continuum m not attained in turn ”that: boom mm than m quM B: gaunt“ m or “all”: W M cm ”mm“. In on» the mom I»! 1&th described. than» of 55 pun-nu in were by 25 - two tumour m m» m an A; 3.3». a #8 na- a:s.“ W m «Ilium to 1011mm humane mam been“ mm m manna" amt-n. m ail-inﬂux mallard «1-11 mum-u, 10ft mm rum pa”. mm Wu 0:: the ”at and nun «11:18:. m An rim 3mm}. “on Ilium-n1 mm magma under new“ mamas mound donut. olmtim (”apnea-ant} or the mum Who. of tho right W). Mm. museum in this ﬂaunt/annulus”: the a. .-. w. uphill mm Indra” m not“ to be We posits." for “’61" until” . Annama- mm: m taunted ' 11pm“ with. nw inks later, the right and the mum: mum mum as meat“. �“ > luv In want-um“ m ﬁr NHI II , mkamm WWW (Minimum: mutant—imam m» H CW u (CHI-um m ‘ . .‘ WWW‘rude-buﬂm �3. it... (11:: Innuud tho par1ota1 vantols ta have n nomlll cen— figuration. 6.3. II: 0.0., a yin: 91¢.la10 an: Idlitted buotule at roeunt onset at grina.unl aniline. .nﬂ lortantdcd untknoia, lxnuhntion rO'Dnlid a I114 10th bullpIrCItl, taut unwind in the 6% lénbr caﬁrunity. lhnru in: a punitive llbiulki response and incr¢:sod rutlaxtn.Moorutvuop1n31 fluid OIRQrUID III nounu1. A right curatld nn¢1o¢run undar local unauthonia III pur~ rarlnd and dIInnIttltod 390d 21111n¢ at tin Interior and l1ddlo oorobrn1 uttering. that. Ill straightening and dcprognian at tho pertain“). mar: am- the an... on up mm; um; and manned yum-mt: “mum. at cm manor mm: at»; on the 1.1- an. changes wort intorprutod Ian- 41-piuozn; blood vetucln. ll avtdlnoo at a pnruaagsitnl tumor ‘ pnnunninaophnlocrul,ula done and thin did not dclnnntruec thy IIII. It. patiant anarovud withaut troutncnt and lit dinohnrsod. In It: rtlanattod a to! lick! 1:10: with avid-not or an aunt. talin Ital syndronn. In '10! a: tin ¢uuruo a! uni 111ncll and.nultxplxoity of 1051.33, at in: bolicvod that the pntiaut'n uyggtanl A 1 ' taro duo to doccatrntiio ahnaccs, and net a unoplaun. lo turthgr Itudiou var. andnrtaknn. In this group or lunpcatod brain tumors 22 ausiogruln 414 not than any pathnlo;7. ilovcn at that. 10:. canrialnd by I1! studio: or tntapsy. In tun pationts, houovcr, untilrtotery angiogra-s failed to dalunltrutc lesions lttcr other Itudicl. mum to m danmmstrntod by an. m; n... .1 57:»:- em m m hospitdl koala-c of lift Inilplroutu, bladaor and and mud no.1 gum: or 1; inks aux-«zen. 6:: bcuul incontinence, man. than �#. never. poroonnlity ohoncoo, and o opootlo loft honiporoo1o with pathological roam: . embrupinll nun snare-o was nor»). . were right oorottd onciogron.undor pontothnl onoothnoin on: dono. outs of lotorll £11.. and on. to? via! Into taken. in: films A two thouod no ovidonoo or lorehrol tumor. can rock Into: a vantrtoulogrln dolonotrotod a large right con“ trontooto-porol IISI. Ibo protons. of a malignant slioln ill tin-0d by ournory. : Goo. IV; 3.3.é°:bzzkzoor old man developed loft stood toizuroo Iphlliu during/$rottlont for turunonlooil. on anurolucicll ennuinltion chore woo ovidonoo at n lotion in tho risho honiophoro. en Ikull x—ro: tho piuill outdo! In: shirtod to tho 102%. An ortorioaru on on right nu scum). mom-1a m and done ond no pathology dononotratod. ma A pnounoonoophnlosrln, houovor, revollod a dofornity of the right frontal horn. in: patient uzpirod on: lonth otter oust-graph: and ot pout. norm, mum} emu-u 0”qu mm anon-mm autumn. 9th.: erroneous onaiocrlphio d1oanoIOI our. and. in patient. who provod #0 have vooonlor throubosoo. In tlo potionto with Iisnl the oncxosru-o rovoolod on oraoaulnr are: in tho poricto-tonporol vision with dioplooonont o: Iiaolo oorohrll voooolo. Surgical exploration rovoolod odouotono necrotic brain tilooo, without ovidonoo of tolor. loch oooe oono to antopoy and in both or I brain only». man:- or . branch or. on. man «mm mm m rm. o:m angiogruno onulo not be dittoronttotod from thou. noon in on... tnnoro 1n the Inn: raglan. Vaoogggg.tnoup11oog ﬂuonty~ono patient: Iuopootod or intro» ' ornniol vaooulor Inouolioo or Quintin-o not. oubjootod to lnslo~ stools. 1h» Insaosrunl wort billtdrtl in only throo or thooo. and ��7. mt N contact“. um“. m nu In this aorta of 117 WWMB 36 ”tum- “from a to“: at is «unusual. and peanut «mutation. In an mm can with the «mutation and at in Of the a»: mo «Quantum. 22 m «W mm m an mum. man: mm. mm MmmuMuHthmm-uw. ammo. in am. mutumnmwummmmm' manta: mun It as mm to tntubtn m yum: mmmmmmmmmumpmmm; mun mom mm: man a «um mummuwmu. mnmmnmmomm a nun“. :3 Wk mm. m within . an ou- pm mm #8 W. talcum-Wont... cummmuurmmwowhy. all no.“ to rcpt-aunt an mung mpm h m atom-Mt. Inmautmh umummmmmmmrua Hummutumnmauammmm W.a: m mm causation. loath um um Mr. in in ”man (mu 7. n). In tum ash-r W or 1“ mm. Inamcuul‘uumum otmmvmupmuat th:mn mm mm mm m s difficult W31“ (mo m). W: m spa-nu (em um m mmmuu-n a: Mum mm“ («m I!) m an. «W. mum: sum emanation we «may “um 80 an A m mm. panamamumnmmmmmmmmmuu a Wow. than. 11mm Mm m twink“ I mm mm. tau ”Omnimtm ma. all... 63. elm was... an muons am and Mt. A completed a 13W and as most“ to «3.1qu war» a: may mm mam was ��10. at 1a.; or np1nud¢c on. mth. aunne1ausntgt u1thout convulu1vo unvunnne: for «nan-11:11:,» and a pou1t1vt lub1nlk1 on than mm mm tbs 10:1.ths no I sensory «Itasca am», Winn lua1tcut weaknass a: ‘ 1 31331 percutancona In31u3zun was inns u1th 10011 tainthna1n nn1n3 {our 1njoot1ons of diodralt. >xllad1a$oly Ittcr tho last 1nJ¢¢t1an thy pat1ont lapsed 1319 a 102911 3:11., M1: cyuruovanantt 3101.0 d1llo¢18ttd, and tan loft layer and In!!! tatul1t1o§ I09. N mum nonpanﬂ anon. am the tmu Mum mm m Vtrhully to «allnnd. but tum han1pl¢31t booinpit10at 00114 tplnt1c. It porn1ltad ant11 tn. put1on1 its trunnruraod to ancillt anap1¥I1 can nanth 11102. tn31usrnll I110 tatcrprttod an annual. A pnaulalnoaphnlo~ 3run.rovualtd b1latcrnlxy 61.301 vuntr1c10u u1thout nh1tt er 1%. .d1lvort1an.1 walker (31) the at stator: that’s: Ions111v1ty tn the eonsrust Indtwn, amt a; m me many at 1111009103 (33), and mum tar «aupl1ant1onl In in. prusuat 19:10., till. {natori It. nut ant-taun1n3 1n tn. pat1enta uh. 107110301 «unpliont1aa- when tunic tr. 01.31301 10 tin hwptrtonn1un (38), havu bola a133Ot$ed as OIIIOI _ unoonpl1enta1’onacs. l1thsr eonsaapt1v11 at 1ntaadnrlal aiadrnst gonn1t1v1ty tent: turn cnrr1od out 13,0?!93 luhaoot. In out cute, in: cane: at «humus, means, an: myzuum mu- the m: am» an to ouncol tan I9I11II. 3111th mm 1B1: In 111 1mm: 1n51ud1n3 an. athgr turnouts, amuuum, m Im1t1uty to». m mun. Ill notably true 1n tbs {tar pat1outs who dtvu1opod “n11.331c~ rsaot1ons of urtiolr1t, oh111n,“ van1t1n3, tolleu1a3 tho In31osraphy. but who £11101 to rule: to tbs tent 4916. Shaw. 1: an apparent rolae1an 1n tho ant: bntanon «anp11out1ons 11km” �13.. (luntudias hunttuun If In. it. acct) and tin ms it 13:00t10an 1 2 3 mania: or 1n1¢otzunn t 5 6 Iﬂﬂ"th‘ﬂ‘6 lo. .1 patiouta 11th cu-pzioctiaun'l e 6 6 I 1; lo. at pt... without «uncanny 3 9 1m :38 ' it Ebﬁazﬁ ' o 16 '3 as *Ixnluata; 16 Inna-plsnusad «Isa: 13.1huu tutu: data.» uua ngt rocordnd. o: m t’utoru or nae-than and m' author I: carotid punstaraa at on. Ion-1:: (unilaturtl or bilaterll Iagiacrlph!) rtvttl as significant entrolltton botluon thtao riotorl. 3mm mm» t3. inolaunno at calvlaltxaau. Arm-1n max-«mun m in a eonmuuan in m. poxootxon or patzants tar Ingtosrlphy. ihn.hw)hrtoanzvoa (:11 with diastnlia prisaurio at zoa-n. It. or'nnvi. and urtialto ar0§turtu at more than lﬁaun. In.) It». subjueted to nasitgrOphy, and in nan. at Shut. the. that. lay tonplioaticna. .0: thn paticnta with Icvorc up titan singly. and -- ‘tsnnszont oclplzsaﬁiaan («chit than hGIRQﬂlﬂ ot‘tho unak) aunt and V hrpdrﬂlnlzan. unseat mortal: hart alphlatlid tan diagnottta rtlzuhalat: it alrutid lasincruah: 1n vascular nan-alto: (k), auapoetod brutu talnru (lb. 5), tram-I310 aurchmt1~utdbn (6). tan ooaluntvu vascular axsaaaon (7). our ebucrvataons coatirn.thn rocounnadatzana at tho ham 1:. um run m m.in. _ diagnnst- a: van¢u1nr nan-n17 could nut he ountlmuld Cincpt iv insulin} Impaiurt at luttpuy. Itnte sir trudiyi are nut vuiiuilo 1n dlnanntrntins vautnlur annualaos a!”IEIIrIIIITMInﬂtﬂcrlrhr“tﬁmiﬁlﬁpiiﬂtiuri"ttwin%00w%nwiiitblllhins Iran? to ausiouruphw. �13. sign ailsnnsts. Xn-haﬁ at th@“p&t10nﬁs in this surint-An shun.nnth , n luntan was unspoctea, tho yam-p1: was natzutaggarilr“dauauntmatad um «am: or miagrap‘hy; man ‘mnu‘blishad w am» um“ lbnte£tta0lnbsp£bai, five anenrwnnn wore dn-waatritoa-an la anapoota. ﬁtnilar ”caulk: are rooardea by tthar ﬁlth!!! {¥), can anagrams mmemuona have. hem nae ta inn-cue than Wis. Routine mtehml injectim, scanned with bilateral 6:th panama. will «laminate maladies 1n the posterior portion at the 611-010 at ‘ﬂillin (1!). Oblique A.P views tt #5 403:... have been ruoanuoadnd to damonltratc until aneurysms er tn. aaratid (#d). with thtne noditicatiana 1n~the prooed&re, 1t 13 to—bq§gxpeoted that the incidence at positive 1d¢ntﬂiut1m at will the rule of angiogrnphy 1n the management or apontansaua am” mm. Iuharaahnoid hannrrhnes 13 not alear. Recent review: emphlstxo in. 1n»9rt&a¢e of alnnnltrtting tha Xenian nhmrs turaiaal intervaattun 1! indiettnd (ﬁt. a.) !hc affect of Iaszonxlphw 03:13: twat. it. 53:10 a: blending his act beta a1nr::1¢d. lung nuthnra tutu roan-acalid :a;1¢lxnphy only :ttor tho blending has 09:306. 0th.». such an (m. mm «:1: m u mama-v man m nun mm. m. mun um... um um mu m tn in 5::o0t in mum: and adhorul at 4 or the cases thin 3095's, and no ntutqnnnt of tho Inciozraphw an binoding can be undo. Aagiogrnyh: in tho diagnoctio panoodnro o: «halt. visa a Quaratoatawiil human tumor :1 auspoetod. it 1: rcounnandnd tar Ionian: lecaﬁol in :3. Iatortcr tlu~thsrds a: tht_¢¢rolvun. ana$p1tt1 1th.. posterior toast and nuns unabrszu innnru a». uni conntttnntly Mutable by this Hath pip111@dama, team”. 11mm“! in lawn” WW ant unltki ztntc than venucdnro, lit ntuditc. anon ��1‘. In snot: or cnrcbgll vuucniqr;acutdant,Inciﬂlllvi¥~tnrﬂﬁrl,1003 helpful. .rlilurv 0:,a rental to £111 any Do an: t. u.vurtety t: mamas 310m»:ntm1umut1m. .mmm min. in! ”mm at m sum. mm mum mm boon ”but!“ (75). 1;- aot ,imwmwludzu Mimi!» mum man. It proud” \- mam. mu 1i: arm-gamut” o. twain tron m tntrusarnhmtl 010%, or f!!! a tunes, in OIIOI Ihnre tho I1tsnonll-as mucus W. unelcwr. ' ﬂhile the indications tar angiography are many, that cannot be evaluated uithuut ; aincuauian at thy risk: involved. ‘iha emm911a1~ ,tiuau or the praceanre are a: turccthpoat.(n) trunnient latul phcnunanlg (b) trannient cerebral vascular phenlnnnlg (o) pcmlanant 2mm «£1411». , xn the vburaias Dﬂlnl 1n the :1“:ng at trmniont mama m m It‘d during 1nJooeton, hauttuul in.tho noak, and ullorzie venetiann.. numatann.1n the acek in a potentially dangcraus samplicntien (see aur.Caso VII) but in a ragent review no Inqucllas varc,aha§rve¢=(9). »Allor¢10 notation: «we larreqaant and usually llld. .1: in: nat¢¢ in thin action that ﬁns manila. intvaautlanouu or csngunntivua talking tar sensitivity It: not fauna untitraotorw $n prudiottus ﬁnale-clnpliotticnl. lblnninat,hun1paanszs. aphlltl. :eiunros nna citritod blaod pruuunre haw: hath reported fallouina unstogrtphv (16). In that series than. qunmlieationn n!!! OttarVQdfin nine canal »~ an incidenae of 35. {A similar tantdanao uni-nhucrvud In tho lbntcrluao Ibnpaell 30:103. lint.th030 Philll'n!.!rﬁ pribttly in: to tunporary vaaaulnr innutriuionﬂr (I’lﬂlﬂ) 1: I71lnnn¢d by the cliniunl pattorn at nourolngzctl findings and thair‘dnrutzun.. at asv¢u 3:310:90 with �it. M101” 15. m an tin-00 unwanted 01ml: than. 0m:- it no so” in an laws. In m panama, mu m of the amsun autograph: m "mm in a. 0M um 01: an um, 01MB «manna. In tho 0mm: mum, Woo-0m banana-«10, and tm mammmuumamummuamnmm left me the 0min 1mm that m m»: later, in» first 0m may m 0100. an mm m mind”that run an tho 0100 and mum M01090! 0 right M4- 13:00:10! 0: 01941-0“. tho MWMmth-Wﬂm. Vacant OW M 0mm mm.» 9103“. of that mun-101- hue been observed. 02:0: m 13300151”: in: do» within 15 010010 plant 0 1000: am manna 007010904 0:? “can”. third Quintin 0: m "I! 0140 In an. A mm 0: tin 09m“ 3: m «rent. an. m mumnmnwsmnmgumma. within Wu. omnuum m0 not unwind: 61mm m. 19 in ”#103150 01th W103. 6menoun-1mm.» a: 0 ”um '0 condition or men nun-1a; wemyhymummmmammumm. mud) , them-.1319“: ormpmuamxm. mam Mm :um «mare; “may to «unanimity. um many. and mu.» (1») mart «no 1080110100 mm.and80011110 0: “data-imam u: clown (11) than 1n mu mm. anus, 1." ”that“ ”mum” in a «£100 a! 36° won-000. no" mo in «hung: in an:- pmmt 005-100. an: m patient and 0 «m. nunvation 0f than at 0. pvt-mung Mum. 111 b01020 W10. 80071110 and tin pmodm‘e. in contrast 00 this In! 0! than 90810330, 111:. mum at 910003. 1:090 0010:“: m the 10:30 has.“ of M1: (53); , �(5e), Won (14), m um he), muten w deaths ﬂare related ta precadure.‘ (1b) thawein no 16. and mm It 13 tum passablc adrlannd that with vidnupread use a: angzoeraphr, Iubﬁeatu titl.naro cerebrul lesions tru selccted far these stud1eu and tha rink: ﬁharlhv 1n¢rcanod. A what 9: mm: by 01:36:: am manta: (BB. 11, 12) alphantxs tho-launntxon at tho taxis atteatn o: 31:30 limit a: diodmalt given ovar a abort 99:10! a: ﬁans. '1hor tailgatic in. nature at the toxicity Is an inoréégea permanbility at tho blood 1.33:1! and u chanxe 1n hennaynlaieh. Furthlxﬂﬂliy aha rolatian between canoentrt~ ma taunt; m, mean-am I» am: (13) when no am or introauegd dladraxt far Instagruphy. a1: abtathtiun that seizures £0116! thc use at 595 and 70% éiearaut has been ovatimnné by unmitiul amt invautizatarb. auspite thc use at 351 diodrast and law total Gasman: er diodraat, in this series, eumplications ensued. share I81 no nisni~ tioaat rnlntiaa between.dosasc 1nd canaliettionn. ethar raetars ' not he ”mum and same elrculntian tint (#t) and mung ma «team: V ' H 31.3 ‘71... i mummy mt. has been given in the “amnion an tau affect of other 1nJurious ﬂaunts (a). eri 8h. moment a: em: or man. cranial aiaenaa :uupoeted or raueular animalios. an;znt¢atar1t1 talcum. and traumatic hu-Itunns. IS 1: n natintcetory non*lurzie¢1 ntthad at dtnunutrntina I Visuallr annuals; nnltoznation or ‘nourrnn. 1. 1:: in: dilsnoail of Iupratuntorill.llnlts it will takiinc 9Q! tttinruntarlly. In,udﬂ1t1¢u to catnblzlhinz thn pzoqanao at a kunnr. :rtorauarapny 1! unparacr ta 0th.: asnannstto tookaios 1n yialazna calling. I: to it. typo ot’lnul lad 1t. local. In Cl!!! with In �17. a not and. Wkly “at”: by tn mm ohacuro 13 mined-II». It alt a Inttlthstaww'litind'13.!UIlaatulﬂmaa or ﬂu. and mm. mum of tho nah-unlu- min, or mimic: fun w ”0199.15”. I»... 1. a in «us of tantrum mam, m Mm» «turns»: arm "ﬂunk: mm proucdnri. m: mm mm. a intricarutrll hilatlll tiastlt-Ilah MW m emu mum «now am» mu. at taunt. 10.113» tram 1: 1. eon-punts” mg. “I? tho mt pm, Wink. and would not in no“ mu. he savanna.» m no. tn was ﬂu not "mm u human-1m math-nu, min or tutor: uncanny d: tunings. a sum: of «mu. r010, and "My 1. mum. pm a mu W mm m W «mud Woman part-mt Mm m rm an: m mm "an“ mm: mm”no: a: A 117 hum. mam o: ta risk: of Ingiography. no author. «mum: that the 1mm taliﬁttionl and mt: ot at the mum” do «mu m autumn: an the meant or mean: alumna”, mum mmtarial brain Wm ms! was not 13th 1.1;- 10am. ' u ,____ __ _#».47.L_...;M._.z _,_..._.,___L__, .__u “A, . �RUIIARY eeriee a: 117 pereuteneoue oerotid ensiosreee were revieeed to eveiuete the indidetione for end rieke involved in engiosrephy. Petieute with e veriety or intredreniei conditione were etudied including eupretentoriel tenure, veeeuier endeoliee. A treaeetio heeetaee end eerebroveeduler dieeeee. titty-rive petiente with evidence at intreoreniel tenure were eueJeeted to engiogrephy, end e poeitive diesnoeie eee eede in thirty. fheee diesnoeee were auntie-ed in 83$ or the eeeee. ’ In duly tee eabjedte were the tiiee eieinterpreted. or the aegetive tilee. the diegnoeee were dentineed in 50!; in only tee men an the ensiosreee teii to aim e leeion um- deeenetrehie b7 eir etudiee. or 21 petiente eith euepeeted intreereniel veeduler endedliee, nine were outlined by ensiosrephy. In tee of theee, the engiosreee reveeled en end-e11 not eeniteet on eir etudiee. In e group at eeveuteen petiente euepeeted o: treneetie intreoreniei heeeteee, e poeitive diesnoeie wee eede in seven eeeee. Theee diesnoeee ee well ee the necetive findinse in eight ceeee, end intreeerehrei theere deeonetreted in ten ceeee, eere e11 contimeed by euheeeuent etudiee. In oeeee at cerebroveeduier leeione ensiogrephy wee not at diecnoetio veiue. Treneient ddeplieetione of engiogrephy were eeen in one—third of the petieute, end edueieted or heeetaee or the neck, heeipereeie. eeieuree, end erticerie. In five petiente (I!) eoepiicetiene eere eevere end peeeenent. Sheee oeeee ere deeerihed end the restore diecueeed. Ehe ‘Vl eethere deecrihe the ueetulneee or engiosrephy in �“Hermann“ been»: intact-mill condition: . they canal“. that tho united risk: of cerebral miomphy 69 not data“ from it: ”0mm”. in the summon: a: mammal vacant alternations. unopened «panama-1.1 man and human hum. the variety or ��mm rams. LG. and mummy, L: mum...» my... warms,anion-mph: ma cox-chm than”. mu.lgu_gnl.mz¢hiat. omml Q}, 359“"368: ‘9’11: 39”intmmiu (1) new. I. : mummy in polt~trmtio 2w¢2583 “tam; 19‘9. 910‘ ES. 4““ WWI. m at in the (1») lumbar, 19W. intmmid 3.: 9mm}. maximum? 755468, W001: (o) 5. 6. WI! New ' . _ mm. 3!; 3.8.: m dammit er mum. B. m 3.!" mm, by intact-unis! tutu-mic humane axiom”. J. Imam- . (6) Q5, 363~376o N17. 1951- LB. and um. ‘.l.8 Eh. contribution at «roam 1950. mm. angina-mm in “tannin. «mam. : m $2-3m, catcher, of (3) mm. 3.3. and mm. 1.6.: Wriemphic visualisation 600-618, 251. lesions. mh.!m1.ggzehiu. ammuni19‘6“3.; (b) mm. 1.3. and mm, mm carom}. Marion-why in191.8. nub-mountain Mum. g.i.l.i.. 1.36: 517-581, M... (a) mzm. 1.1:. am mm. 6.6.: mum-min autograph: in the tmmnt at «1'0an maul” accident: . can: .M. , m (4) 7. ,_ V (a) LA. and mm, 9.3.: carotid minmtw; It: ".1130 sum. in pun-.11 t 121th conditim. M£11mgorth “or. , 8. m, the mmmolwruzohint. 31; : thrionlmaphy m mmmmw. mu- um. be. 1.31m: . localization had tram: or 111%”:er 1310-13“. June, 1932. m, P. and Pmuunum «mud miouaphy: m, "farm” ine“ iota blob. laurel” I»: complications in th- and pun-ms. ‘10 . 11. b with special 11: been to the larynx. 16;; 1-6, Juan-r1. 1951. 1. sad mum-amen, 1.2.: umimt 3.6., trauma,with. cyan. union-why. Lima“. unbnl 32-191. in unpainted 19‘9466 “ll, number. g; of (b) mm, 3.. 36mm. VJ. and unseen, 3.: cmuaum 1951. 110418, angina-why. g4, mum. , g; ham, India a: tar emtmt 0. cerebral unplug £01m» won, 312-316, lov.,19't9. a: dim» type. 1 .lmu Joni-elm. "paint. E; (u) a » to a aid 01,8861. 0.: 103.3ch of «mm: bland vouch 336~3#8, Indian or the “adult group. mm We}... 32; lava-tho, 1m. pines in aux-01min]. 13. @038, am. u 8mm}. ”tomography: It: 704-711., Oct... 12 . 1*. mm, contra-t ‘1'. ‘ «lanolin. Arch.lm¢1.ﬂgguat.. 53!. 6.. mm , run. and 3.3.: Vertebral 'W tokﬂﬂnt. ‘ rm. 166.5182, "bm’lg‘g. ‘ u‘doMc; £12. 19“. Wm. 83131 o � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A clinical evaluation of carotid angiography. Confin Neurol. 1952; 12(4): 181-95. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-5-007 Date A point or period of time associated with an event in the lifecycle of the resource 1952 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>; Stein, Joseph M. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and publication. Confinia Neurologica. From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellvue Hospital, New York City. 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 Basel; New York: Confinia Neurologica Contributor An entity responsible for making contributions to the resource Spiegel, E. A. Published http://exhibits.library.stonybrook.edu/mfp/files/original/00442514cc7c4740e6535ae86cb27a98.mp4 ca0462dd7c4eebcdd294288b69b8223c 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 Biographical Files Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. 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 An Interview with Max Fink, MD: World-Leading Expert on Electroconvulsive Therapy Subject The topic of the resource Neuropsychiatry (MeSH) Suicide (MeSH) Electroconvulsive Therapy (MeSH) Psychoanalysis (MeSH) Catatonia (MeSH) Description An account of the resource <span>Max Fink, MD, Professor of Psychiatry and Neurology Emeritus, Stony Brook University, was interviewed by Lorraine Botti on March 18, 2018. The location was Special Collections in the Melville Library at Stony Brook University, where his archive is housed. In the interview, Dr. Fink discusses: the circumstances which brought him to Stony Brook University in 1972 including his appointment by Dr. Stanley Yolles; his administration of electroconvulsive therapy (ECT) services; the Second World War and Sigmund Freud; psychoanalysis vs. ECT then and now, and its effect on suicide; and catatonia verification and treatment.</span><span> </span> Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548">Fink, Max, 1923-</a> Publisher An entity responsible for making the resource available Stony Brook Medicine Date A point or period of time associated with an event in the lifecycle of the resource 2018-03 Contributor An entity responsible for making contributions to the resource Interviewer: Lorraine Botti Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="https://rightsstatements.org/page/InC-EDU/1.0/?language=en">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> <a title="https://rightsstatements.org/page/InC-EDU/1.0/?language=en" href="https://rightsstatements.org/page/InC-EDU/1.0/?language=en">https://rightsstatements.org/page/InC-EDU/1.0/?language=en</a> Stony Brook University owns the rights to this video. Max Fink, MD owns the Intellectual Property Rights. Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource video/mp4 Type The nature or genre of the resource MovingImage Identifier An unambiguous reference to the resource within a given context mfp_MaxFink_videos_20190301 Source A related resource from which the described resource is derived Stony Brook Medicine's YouTube Channel published this video in 2019: <a title="https://www.youtube.com/watch?v=_dxp3N12uAY" href="https://www.youtube.com/watch?v=_dxp3N12uAY">https://www.youtube.com/watch?v=_dxp3N12uAY</a> Biographical http://exhibits.library.stonybrook.edu/mfp/files/original/e80dbde06dd20201f1e94a10beff3999.pdf 14b484b6bedc00163228f7cd6f29a33a PDF Text Text Reprinted from the A. M. A. Archives of Neurology and Psychiatry August 1954, Vol. 72, pp. 233-255 Copyright, 1954, by American Medical Association PATTERNS OF PERCEPTUAL ORGANIZATION WITH SIMULTANEOUS STIMULI MORRIS B. BENDER, M.D. MARTIN A. GREEN, M.D. AND MAX FINK, M.D. NEW YORK TUDIES of function of the nervous system by any one method will show patterns. This is a general law which applies to motor, perceptual, and psychic functions. Patterns of functions are present in the normal as well as in the abnormal state. For example, normal subjects show variations in the ability to discriminate two closely applied points in different regions of the body. Thus, the pattern for two—point discrimination is one in which the ﬁnest differentiation is at the tongue or ﬁnger tips, while other parts of the body, such as the back or the thigh, require a greater distance between two points before discrimination of “twoness” 2 be made.1 Pearson the pattern for the normal sense of vibration to According can is one in which the threshold is low at the clavicle and high over the sacrum. In vision discrimination of targets under daylight illumination is best in the central, and poorest in the peripheral, portion of the perimetric ﬁeld. And so it is with all other modalities. Each sensation has a pattern in space as well as in time. Each of these patterns is obtained by adopting procedures in which a single stimulus ﬁgure is used in testing the subject. In measuring sensation, we know that there are many factors which inﬂuence the perceptual response. Intensity and duration of stimulus, the stimulus ﬁgure, the locus in the sensory ﬁeld, the attention and intellectual capacity of the subject are but a few of the determinants. Recently we have stressed symmetry as having a bearing on perception.3 Still another factor is age.4 For instance, there are some perceptual examinations which could not be carried out in children because the ability to respond to these tests depends partly on the ability to concentrate on a particular problem and to cooperate over a matter of many minutes. These are two properties which most very young children do not possess. Moreover, we have found that reactions in the old are not the same as those in the younger subjects. Another condition which inﬂuences the perceptual response is the number of stimuli employed at one time. Two stimuli when applied simultaneously may yield responses which are different from those to stimuli applied in succession. Simultaneous touch of the face and hand may be perceived only on the face, whereas when each of these parts is successively touched with an interval of one or more Post—Doctorate Fellow, United States Public Health Service (Dr. Green). Paper read at the Fifth International Neurological Congress, Lisbon, Sept. 7—12, 1953. This work was aided, in part, by a fellowship grant from the National Foundation for Infantile Paralysis and the Neurologic Research Fund of the Mount Sinai Hospital. From the Department of Neurology of the Mount Sinai Hospital, and the Department of Neurology and Psychiatry, New York University College of Medicine. �2 seconds, the same subject perceives each stimulus. The simultaneous application of more than two stimuli may yield other types of perceptual reactions. Cohn5 applied three stimuli all at once and obtained results which were different from those elicited with conventional single stimuli in the same areas. In 1893 Krohn 6 investigated the effects of simultaneous touch stimulation of multiple (seven) regions of the skin in normal subjects. Parts of the trunk, extremities, forehead, and, at times, the chin were touched simultaneously by tambours. With these tests the subjects made errors in localization of the applied stimuli. However, no distinct pattern was sought. In analyzing Krohn’s material, we found a suggestion of a pattern in that there were less errors over the back than over the front. This study was interesting but not very illuminating. The technique of double simultaneous stimulation had been known since the 7 of 1882 time Hippocrates. In Oppenheim mentioned the method in his textbook. Since this description there had been few intensive studies of the method until 1943, when one of us began a series of investigations. During the past decade we have examined several thousands of subjects with this technique. As we gathered our data, it was noted that in tests involving asymmetrically placed stimuli certain regions of the body yielded correct .responses, while others yielded consistently incorrect responses. On numerous simultaneous stimulations of the face and hand a distinct pattern of response has been observed in which errors in identifying and localizing the stimuli on the hand became apparent. Conversely, there were very few errors in perception of the stimuli on the face. In this test situation the face was “dominant” to the hand. Face dominance has been found in normal adults, but it is particularly evident in patients with disease of the brain, in very aged persons, and in normal children, 3 to 6 years of age. This pattern of response, namely, face dominance, has been found so consistently that it prompted us to study body combinations other than that of the face and hand. The object of this investigation was to determine the order of dominance when various combinations of two parts of the body were tested in this manner. A preliminary note on this study was reported at the 76th Annual Meeting of the American Neurological Association, in June, 1951.8 METHOD AND SUBJECT MATERIAL The method of testing was the same as that described for the face-hand test in previous communications.9 The subject was requested to close his eyes, and two parts of the body were simultaneously touched or stroked. He was asked what he felt and to localize the stimuli. If only one stimulus was reported, the subject was then asked if another was felt. The subjects used in these studies consisted of patients and normal adults and children. Series I: Patients who showed mental changes or an organic mental syndrome* as a result of disease of the brain, such as arteriosclerotic encephalopathy, senile psychosis, severe cerebral trauma, Alzheimer’s disease, toxic encephalopathy, or brain tumor. In general, patients with severe mental changes who made many errors on simultaneous stimulation tests were chosen for a special study group. Patients with aphasia, hemiparesis, or a hemisensory defect were included in another group. Series II: Normal children and adults. The normal children were taken from a day—care center and an orphanage. The normal adults were patients on the wards of the general hospital, those attending hospital clinics, and Army inductees. None of the normal The mental changes which make up the organic mental syndrome consist of a combination of at least three or more of the following manifestations: impairment in orientation, memory, calculation, or general information; rigidity and concreteness in mental performance, and marked ﬂuctuations and inability to perform when there is more than one aspect to a situation. * �3 children or normal adults had manifest disease of the nervous system. They had not been previously examined by the method of double simultaneous stimulation. We also examined a group of older people. These were presumably normal, although cerebral arteriosclerosis could not be entirely excluded in people between the ages of 65 and 90 years. Series III: Patients with schizophrenia or manic depressive conditions. These patients were adults in the wards of the Bellevue Psychiatric Hospital and Manhattan State Hospital. No attempt was made to study the speciﬁc types of schizophrenia. Most of them were of the paranoid, mixed, or simple schizophrenic varieties. Inasmuch as previous investigations have shown that patients with severe mental changes due to disease of the brain and normal young children made frequent errors in tests of simultaneous stimulation, it was natural that we should make the most extensive studies on these two groups.10 Also, since normal adults make few errors after the ﬁrst two to three trials on double simultaneous stimulation, it was not possible to detect a pattern in these subjects. From these three series of cases we studied several groups in detail. Group A, which was studied in the greatest detail, consisted of 20 patients with organic mental syndrome (10 males and 10 females). These subjects were tested with the method of double simultaneous stimulation of different parts of the body and in multiple combinations. The following parts of the body were examined: face, shoulder, hand, back, breast, penis, pubic region in females, buttock, thigh, and foot. Patients were tested while they were completely nude and, for the most part, while they were standing. The speciﬁc areas stimulated for certain parts of the body were as follows: the dorsum of the hand; the dorsum of the foot; the anterior aspect of the thigh; just below the scapula on the back; close to the midline on the buttock; the nipple and areolar area of the breast; the lower quadrant of the abdomen; the tip of the penis or the mons veneris. Of these body parts there were 45 possible double combinations. It should be noted that the combinations were of regions distributed along the longitudinal axis of the body. Each patient was tested in all 45 combinations in. a random but similar order. Twelve tests were done for each combination. These consisted of ﬁve tests of the two body parts in a homolateral relation, ﬁve tests of the two body parts in a heterologous relation, and two tests in a homologous relation, one for each of the body parts. There were 240 tests in every combination for the total group. Each patient received 540 tests. The other group, Group B, which we studied in great detail, using thousands of trial tests, consisted of 40 normal children between 3 and 6 years of age. In 20 of these children (12 boys and 8 girls), all body combinations of two were tested except those involving the genital zone. In the other 20 children (12 boys and 8 girls), the genital region combinations were tested as well as some of the other body combinations. The testing was carried out in the same manner as described for patients with disease of the brain except that only half as many tests in each combination were done. The genital zone was usually touched directly, with the child partially nude. The remaining unexposed body parts were usually tested through the clothing. To supplement these studies, we also examined a group of 692 normal adults, 605 schizophrenic adults, and 664 patients with organic mental syndrome. However, these subjects were not tested as intensively as those of the above two groups. Different body combinations were tested in different subjects. Only one of the following body combinations was tested in any one subject for 10 trials or more; face—hand, face-breast, face—penis, face-back, face-foot, face— shoulder, shoulder—hand, breast—hand, penis—hand, thigh-hand, foot-hand, thigh-foot, breast-foot, breast-thigh, buttock—foot, penis-foot, shoulder—foot, and shoulder-breast. The two parts of the body were ﬁrst touched in two heterologous relations and then in the two homolateral relations. Particular attention was directed to the ﬁrst response. If an error was made in any one test, that particular test was repeated until the patient was correct, or for at least ﬁve times if the error persisted. At least 10 trials were done on each patient. Stimulation of the unexposed parts of the body, except for the penis, was done through clothing. The penis was touched directly. The pattern of dominance has also been studied incidental to other investigations on perception in groups such as Group C, comprised of patients with focal brain disease manifested by hemiplegia or aphasia 11; Group D, patients with long—standing or congenital blindness; Group E, patients who had congenital or long—standing deafness; Group F, normal adults recovering from general anesthesia or while under the effect of intravenous amobarbital (Amytal) sodium 12; Group G, psychiatric patients receiving electroconvulsive therapy; Group H, mentally �4 defective adults,13 and Group I, very aged or senile adults.4 It must be emphasized, however, that we did not test all the possible combinations of body parts in every one of these groups except in Groups A and B. The emphasis was mainly on determining the relationship of the face and the hand to the rest of the body areas. The results obtained in these incidental studies showed that the pattern of dominance was similar to the one obtained in this study of patients with severe mental changes due to disease of the brain. RESULTS The responses on double simultaneous testing of any two parts of the body fell into several groups. Using the face—hand combination as an example, the subject may report the following responses, as recorded in Table 1. Responses in which there was extinction or displacement“? of the stimulus over one area in any combination were tabulated as a single type of response. For example, in the face-hand combination responses in which the face stimulus was correctly perceived but in which extinction or displacement of the hand stimulus TABLE 1.—Pattem of Responses to Double Simultaneous Farce-Hand Tests Combination of Body Parts Simultaneous touch of face and hand ‘ Possible Response (a) Face-hand Classiﬁcation Correct (b) Face only Extinction Face Extinction Hand Displacement Face (c) Hand only (d) Face-face Dominance None (e) Hand-hand Displacement Hand (f) Face-other part of body Displacement Face (9) Hand-other part Displacement Hand (h) Face-and a in space part Exosomesthesia Face Exosomesthesia Hand of body (i) Hand-and a part in space occurred were tabulated together under “face” responses. Each of the responses indicates dominance of the face over the hand. Hence, the reason for grouping them under “face dominance.” Face dominance responses were much more fre— quent than any of the hand dominance responses. The responses for all the body combinations were tabulated in a similar manner. For the patients with organic mental syndrome and for the normal children tested in all body combinations, the “dominant” responses for one part of the body as compared with those of the other part of the body in each combination were analyzed by the t test. The initial responses of the normal and schizophrenic adults and of the other patients with organic brain disease tested in a single combination were analyzed by the method of chi-square. There were a small number of responses The failure of the subject to report one of two simultaneously applied stimuli has been called “the phenomenon of sensory extinction,” or “extinction.” The part of the body where the stimulus is perceived is said to be “dominant” to the part of the body where the simultaneous stimulus is not perceived. When the subject reports two sensations but mislocalizes one of them, the “displacement” of a percept is said to have occurred. Displacements are usually in the direction of the dominant stimulus and may be partial or complete. Occasionally, one or both stimuli are displaced into the extrapersonal space. This has been termed “exosomesthesia.”14 1' �5 TABLE 2.—Res[>onses of Twenty Patients with Organic Mental Syndrome to Simultaneous Tests of Different Body Combinations Dominant Dominant Responses Other Total Errors* Face Part Face Combinations Face-genitals .................. FACE-abdomen i .............. FACE-buttock ................. FACE-breast .................. FACE-foot .................... FACE-back .................... FACE-shoulder ................ FACE-thigh ................... FACE-hand .................... 68 109 79 122 89 105 154 37 78 60 104 66 95 127 85 145 104 149 31 31 19 18 23 10 27 19 4 Responses Genitals Combinations Genitals-face ................... GENITALS-abdomen .......... GENITALS-buttock ........... GENITALS-breast ............. GENITALS-foot ............... GEN ITALS-back .............. GENITALS-shoulder .......... GEN ITALS-thigh .............. GEN ITALS-hand .............. Total Errors Geni- Other 68 121 78 106 138 98 90 124 143 Dominant Hand Combinations Hand-FACE .................. Hand-GENITALS ............ Total Errors Hand-ABDOMEN ............. Hand-BUTTOCK ............. Hand-BREAST ............... Hand-FOOT ................... Hand-BACK .................. Hand-SHOULDER ........... Hand-THIGH ................ 149 143 152 132 163 136 97 127 142 ____/Lﬁ Other Hand Part 4 145 132 131 109 134 117 69 107 114 11 21 23 29 19 28 20 28 H% Buttock Combinations Buttock-FACE ................ Buttock-GENITALS ........... Buttock-abdomen ............. Buttock-breast ................ .................. BUTTOCK—back ............... BUTTOCK-shoulder ........... Buttock-thigh ................. BUTTOCK-hand Buttock—foot ............... 79 78 99 94 118 104 93 105 132 Other 19 12 38 55 43 79 65 45 109 60 66 61 39 Part 75 25 28 60 23 Abdomen Combinations Abdomen-FACE ............... Abdomen-GENITALS ......... Abdomen-buttock ............. Abdomen-breast ............... Abdomen-foot ................. Abdomen-back ................. Abdomen-shoulder ............. Abdomen-thigh ................ ABDOMEN—hand .............. 109 121 99 111 104 97 90 115 152 r Foot-FACE .................... Foot-GENITALS .............. Foot-abdomen ................. Foot-buttock .................. Foot-breast .................... Foot-back ..................... Foot-shoulder ................. Foot-thigh ..................... FOOT-hand .................... 89 138 104 118 100 105 96 125 136 23 23 58 75 41 49 51 77 117 66 115 46 43 59 56 45 48 19 Breast Combinations Breast-FACE .................. Breast-GENITALS ............ Breast-abdomen ............... Breast-buttock ................ Breast-foot .................... BREASToback ................. Breast-shoulder ................ Breast-thigh ................... BREAST-hand ................. 122 106 111 94 100 77 121 85 163 Shoulder Combinations Shoulder-FACE ................ Shoulder-GENITALS .......... Shoulder-abdomen ............. Shoulder-BUTTOCK ........... Shoulder-breast ................ Shoulder-foot.................. Shoulder-back ................. Shoulder-thigh ................. SHOULDER-hand ............. 154 90 90 93 121 96 131 93 127 der Part 27 20 32 28 69 45 53 58 107 127 70 58 65 52 51 78 35 20 Responses ' ' _ﬁ 18 22 56 39 59 55 52 48 134 104 84 55 55 41 22 69 37 29 Responses Back Combinations BaCk-FACE .................... Back-GENITALS .............. Back-abdomen ................. Back-BUTTOCK............... Back-BREAST ................. Back-foot ...................... Back-shoulder ................. BACK-thigh ................... BACK-hand .................... Total Errors 105 98 97 104 77 105 131 127 97 r—A—ﬁ Other Back Part 10 15 53 25 22 56 78 86 69 95 83 44 79 55 49 53 41 28 Dominant Responses Responses Total Errors 21 Dominant Dominant f—A—‘l Shoul- Other 131 Total Other Errors Breast Part Responses Foot Combinations 29 61 55 46 44 58 76 78 92 38 56 58 53 32 39 31 Dominant Dominant r———A‘—ﬁ Other Total Errors Foot Part 37 29 12 22 23 15 20 30 11 ,__JL_____ Total Ade- Other Errors men Part Responses Buttock 31 92 66 84 115 83 70 94 132 Responses Dominant Total Errors Part Dominant Responses '— tals Thigh Combinations Thigh-FACE ................... Thigh-GENITALS ............. Thigh-abdomen ................ Thigh-buttock ................. Thigh-breast ................... Thigh-foot ..................... Thigh-BACK ................... Thigh-shoulder ................ THIGH-hand .................. Total Errors 104 124 115 105 85 125 127 93 142 r-_A_—ﬁ Other Thigh Part 19 30 39 60 37 48 41 35 114 85 94 76 45 48 77 86 58 28 Two hundred tests done in each combination were analyzed statistically. The remaining 40 tests in each combination were of homologous body parts and did not lend themselves to this type of analysis. i Capital letters indicate dominant part as evidenced by a t test value of 5% or less. * ‘ �6 which were difﬁcult to interpret, and there were a few that showed characteristic perseveration in behavior. These responses were not included in the statistical analysis. Extinction and displacement occurred in all of the body combinations tested in all groups. The incidence of these phenomena varied with the method of testing. On testing body parts in a heterologous but bilateral relation, extinction and displacement occurred with approximately equal frequency. With tests involving ipsilateral body parts, the majority of errors consisted of extinction. 1. Patients with Organic Mental Syndrome—In Group A 20 patients were tested in all the combinations of the body; there were 27 combinations in which the difference in the frequency of extinction and that of displacement in the two body parts tested was statistically signiﬁcant, as evidenced by a t test value of 5% or less (Table 2). This difference occurred in combinations of the face and TABLE 3.—Response on the Initial Trial in Patients with. Organic Mental Syndrome Tested in a Single Body Combination Responses Indicating Dominance of Body Part Combination of Body Part ,——-——A———ﬁ B A FACE * FACE FACE FACE FACE SHOULDER BREAST PENIS FOOT THIGH FOOT BUTTOCK PENIS Shoulder Shoulder * Hand Breast Penis Back Foot Hand Hand Hand Hand Hand Thigh Foot Foot Foot Breast N o. of r—A gﬁ Other Responses .. Subjects Correct 156 15 17 136 44 8 7 21 1 0 17 21 17 37 23 2 4 O 0 1 2 5 2 2 0 2 0 71 30 30 30 9 32 51 12 7 31 6 10 49 23 60 35 40 23 13 8 19 5 8 1 3 B 5 6 30 7 15 25 21 O 30 12 5 Capital letters indicate dominant part as evidenced by a chi-square value of 4 12 8 4 1 1 9 1 5 0 5% 1 or less. other parts, the genital region (penis in males and pubic region in females) and other parts, or the hand and other parts. In combinations involving the face or the genital region, errors in perception were infrequent. Therefore the face and the genital region may be termed as dominant to all other parts of the body. In combinations involving the hand, the opposite phenomenon occurred; errors in perception were more frequent in the hand. The hand may be classified as the least dominant area of the body. Thus, in face-hand tests the results may be expressed either as degree of face dominance or that of hand errors. There were four additional combinations in which dominance was manifested. The buttock was dominant to the back and shoulder, the breast was dominant to the back, and the back was dominant to the thigh. The remaining 18 combinations showed no domi— nance between the two body parts tested, as evidenced by t values greater than 5% (Table 2). These 18 combinations were retested in a different group of 20 patients. The method was similar to that described previously except that the order of testing was more randomized. When the statistical probabilities of the two series of tests were combined, all of these combinations again failed to manifest dominance. �7 An analysis of the responses of the group of 664 patients with organic mental syndrome tested in single rather than multiple body combinations showed a similar pattern (Table 3). There were no instances in which dominance in this group was different from that of the preceeding group. However, some combinations manifested dominance which was not shown in the ﬁrst group. Thus, the face was dominant to the genital region; the foot was dominant to the thigh, and the buttock was dominant to the foot. In summary, the foregoing results show that double simultaneous stimulation tests of parts of the body exhibit a deﬁnite relationship of one part to another. This is manifested by varying degrees of dominance, which may be considered as a gradient of sensation. At the top of the gradient is the face, the most dominant part of the body. The genital region is slightly less dominant than the face but is dominant over all other parts of the body and is thereby the next body area in the order of dominance. At the other end of the gradient is the hand, the least dominant part of the body. The remaining areas of the body fall in the gradient between the ‘ loo— I’ACE PERCENTAGE 0r ooutNAN'r RESPONSES GENITAL R [6| 0 N ABDOMEN BUTTOCK BREAST 6° 5° FOOT BACK SHOULDER TH IGH 4° HAND 30 20 no 0 BODY PART FIG. I. ORDER OF DOMINANCE IN PATIENTS WITH ORGANIC BRAIN DISEASE face and genital region and the hand. These parts include the shoulder, foot. thigh, and the areas on the trunk. W'hen tested in combination with each other, these body parts failed, for the most part, to yield differences in dominance among one another. There was a tendency, however, for the buttock, abdomen, breast, and foot to be dominant to the back, shoulder, and thigh. The order of dominance of all body areas may be illustrated by comparing the total number of dominant responses for each area in the group of 20 patients tested in multiple combinations (Fig. l). N ownal C lzildrew—It has been shown that normal children make errors in simultaneous cutaneous sensory tests just as do patients with an organic mental Syndrome. There was one striking difference, however, between the two groups. 2. Children tended to learn the correct response as the tests were repeated over a period of days, whereas patients with an organic mental syndrome showed but temporary learning tendencies. They soon forgot what they learned and again made the errors. When various combinations of two parts of the body were tested in the young children, an order of dominance became apparent, just as in the patients with an �8 organic mental syndrome. The order of dominance in normal children resembled, to a considerable extent, that found in patients with diffuse brain disease. The face was the most dominant and the hand the least dominant area (Fig. 2). The genital region was not so dominant as in patients with organic disease of the brain, since it failed to show dominance to the shoulder, back, and breast, although it was dominant to all other areas. In tests involving the genital region many children snickered, laughed, or showed other signs of special awareness of the sexual organs. Some refused to be touched there and became uncooperative. Because of this atti— tude, it was necessary to obtain the parents’ permission for the test. The order of dominance for the rest of the body areas in these children also showed little difference from that noted in patients with disease of the brain (Table 4). In only one of these combinations was dominance different from that demonstrated in patients with an organic mental syndrome. In children the foot was dominant to the buttock. The same combination tested in the group of patients with an organic mental syndrome showed the buttock dominant to the foot. IOO so PERCENTAGE 0‘ DOMINANT RESPONSES °° ,0 FACE GENITAL REGION SHOULDER roor co aurrocx BREAST so BACK THIGH 4° ABDOMEN HAND 30 20 l0 0 BODY PART FIG. 2. ORDER OF DOMINANCE IN NORMAL CHILDREN 3-6 YEARS OF AGE Normal Adults.—Several groups of normal adults were studied. In previous communications the responses of simultaneous touching of the face and hand were reported. The results showed a high face dominance. Examination of other body combinations showed a tendency to similar pattern, as recorded in the foregoing paragraphs (Table 5). However, the data obtained in combinations other than the face-hand were not very reliable, because the number of experiments were too few in number. It should be noted that the normal adult very readily grasps the idea of “twoness,” or the concept that two stimuli are being used. Consequently, his chances of yielding a single response on repeated tests are small, especially if he once correctly reports the perception of the stimuli. Thus, it would be most difﬁcult for us to get a large number of statistically significant data for other body areas. In order to obtain reliable data it would be necessary to test a very large number of normal adults by statistical methods. For the time being, most of our emphasis was placed on testing patients with organic brain disease, young children, and very old adults. Judging from our data, it may be presumed that the complete order of dominance observed in patients with organic disease would also be present in the normal subject if a greater number of subjects were tested. 3. �a m 9 TABLE 4.—Responses of Normal Children Three to Six Years of Age to Simultaneous Tests of Different Body Combinations Dominant Dominant Responses Face Combinations FACE-genitals i ............... FACE-shoulder ................ FACE-buttock ................. FACE-foot .................... FACE-breast .................. FACE-back .................... FACE-thigh ................... FACE-abdomen ............... FACE-hand .................... Total Errors* 57 79 52 77 74 74 47 66 71 Responses ,._—A_ﬁ Other Face Part 38 65 35 65 65 55 38 19 14 17 51 64 Genitals Combinations Genitals-FACE ................ Genitals-shoulder .............. GENITALS-buttock ........... GENITALS-foot ............... Genitals-breast ................ Genitals-back .................. GENITALS-thigh.............. GENITALS-abdomen .......... GENITALS-hand .............. 12 9 19 9 15 7 Total Errors r—Aﬁ Other tals Part Geni- 57 56 65 87 74 62 81 19 28 45 78 46 39 65 65 79 81 88 Dominant Hand Combinations Hand-FACE ................... Hand-GENITALS ............. H and-SHOULDER ............ Hand-BUTTOCK .............. Hand-FOOT ................... Hand-BREAST ................ Hand-BACK ................... ................. Hand—THIGH Hand-ABDOMEN .............. 71 7 88 66 72 72 79 85 76 86 9 7 5 9 17 15 27 15 Other Part Shoulder Combinations Shoulder-FACE ................ Shoulder-genitals .............. Shoulder buttock .............. Shoulder-foot .................. SHOULDER-breast ............ SHOULDER-back ............. SHOULDER-thigh ............. 64 79 59 67 63 62 70 49 SHOULDER—abdomen. .. . . . . . SHOULDER-hand ............. 71 Total Errors 79 56 67 63 77 84 59 Buttock Combinations Buttock-FACE ................ Buttock-GENITALS ........... Buttock-shoulder.............. Buttock-FOOT ................ Buttock-breast ................ BUTTOCK-back ............... Buttock-thigh ................. BUTTOCK-abdomen .......... BUTTOCK-hand ............... 52 65 67 66 59 76 66 56 72 Part 17 20 42 21 30 49 31 40 67 35 45 25 45 29 27 35 16 5 74 66 Foot Combinations Foot-FACE .................... Foot-GENITALS .............. Foot-shoulder ................. FOOT-buttock ................. Foot-breast .................... Foot-back ..................... FOOT-thigh ................... FOOT-abdomen ............... FOOT-hand .................... Total Errors 12 9 32 45 32 31 47 40 63 Breast-FACE .................. Breast-GENITALS ............ Breast-SHOULDER ........... Breast-buttock ................ Breast-foot .................... BREAST-back ................. Breast-thigh. . ................ BREAST-abdomen ............ BREAST-hand ................. 74 74 77 59 61 64 50 64 79 9 28 21 29 29 42 26 47 62 65 46 56 30 32 22 24 17 17 Dominant . Back Combinations Back-FACE .................... Back-GENITALS .............. Back-SHOULDER ............. Back-BUTTOCK ............... Back-foot ...................... Back-BREAST ................. BACK-thigh ................... Back-abdomen ................. BACK-hand .................... Thigh Combinations Thigh-FACE ................... Thigh-GENITALS ............. Thigh-SHOULDER ............ Thigh-buttock ................. Thigh-FOOT ................... Thigh-breast ................... Thigh-BACK ................... THIGH-abdomen .............. THIGH-hand .................. * 47 81 59 66 65 50 77 66 76 r—A—ﬁ Other Thigh Part 9 16 20 35 18 24 28 42 49 38 65 39 31 47 26 49 24 27 Part 65 78 31 21 29 35 18 17 9 Total Errors 74 62 84 76 66 64 77 61 85 r- Responses Back 19 23 29 27 35 22 49 27 70 Other Part 55 39 55 49 31 42 28 34 15 Dominant Responses Total Errors Other Dominant F—‘A—ﬁ Other Breast Part 65 28 42 32 21 29 20 26 7 Foot- 77 87 63 66 61 66 65 57 72 Responses Breast Combinations 14 28 25 31 56 55 Responses Dominant Total Errors Part Dominant __Jk_ﬁ Other tock der 39 48 59 Responses f—But- 9 Shoul- Other Dominant Total Errors 28 23 16 16 Responses r-“—"'"—-—\ Hand 9 Dominant Responses Total Errors 38 28 20 Responses Abdomen Combinations Abdomen-FACE ............... Abdomen-GENITALS ......... Abdomen-SHOULDER ........ Abdomen-BUTTOCK .......... Abdomen-FOOT ............... Abdomen-BREAST ............ Abdomen—back ................. Abdomen-THIGH ............. ABDOMEN-hand .............. r———*—ﬁ Total Ade- Other Errors men Part 66 81 74 56 57 64 61 66 86 15 16 26 16 17 17 34 24 71 51 65 48 40 40 47 27 42 15 One_hundred tests done in each combination were analyzed statistically. The remaining 20 tests in each combination were of homologous body parts and did not lend themselves to this type of analysis. 1 Capital letters indicate dominant part as evidenced by a t test value of 5% or less. �10 In testing normal subjects it was noted that they responded by mentioning the face as being the area touched and only when questioned further did they mention the hand. In other words, there was a preference for the face in the response. In another series of simultaneous tests of 20 normal adults the following method was used. Twenty normal adults were informed that they were to be touched on two regions of the body and that they were to report only one of the two places stimulated. The eyes were closed during these tests. Ten tests were done in 8 body combinations in a random fashion (tests involving contralateral and homolateral used in working out the order of in similar that of the to a manner body) parts TABLE 5,—Response on the Initial Trial in N ormal Adults Tested in a Single Body Combination Responses Indicating Dominance of Body Part Combination of Part r———&———-—m Body A FACE * FACE Face Face Face Face BREAST Shoulder Penis Thigh Foot Thigh Breast Shoulder Breast * No. of: B Subjects Correct Hand 160 94 17 30 31 30 76 30 30 30 54 30 30 32 18 77 58 Breast] Shoulder Penis Back Foot Hand Hand Hand Hand Hand Foot Foot Breast Thigh 9 25 22 26 40 24 17 17 44 16 23 19 9 78 29 6 4 6 5 0 0 2 0 2 2 0 0 3 2 2 7 2 6 7 2 1 3 9 6 7 6 o 1 2 4 3 of. 5% 0 or less. 6.—Simnltaneons Touch Stimulations of Various Body Combinations Body Combination Face-hand ............................................... Face-thigh ............................................... Face-shoulder ............................................ Face-foot ................................................ Shoulder-hand ........................................... Hand-thigh .............................................. Thigh-foot ............................................... Hand-foot ............................................... There were . . 0 4 31 2 11 . Other Responses 5 2 2 1 1 Capital letters indicate dominant part as evidenced by a chi-square value TABLE * ,———J\—-q A B 200 * r—«Choices Given—ﬂ Hand 40 Face 160 Face Face Face Shoulder Hand Thigh Hand 175 142 167 158 141 103 114 Thigh Shoulder Foot Hand Thigh Foot Foot 25 58 33 42 59 97 86 tests for each combination. dominance in Groups A and B. There were 200 tests in each combination. The 6. in Table recorded results The not are investigated. genital regions were From an analysis of Table 6 it is obvious that the face is the part of the body which is chosen oftenest when it and other parts of the body are touched simul— taneously. These ﬁndings support the results obtained by other methods. However, this method of selection, when the subject knows that two parts of the body are being touched, did not reveal the expected hand inferiority. This ﬁnding does not necessarily detract from observations obtained by the methods described above, where the subject was to report what he perceived after he was touched in two places without warning. After this series of tests each of these 20 subjects was asked to indicate which part of the body they were the most and the least aware of during testing. The results are tabulated in Table 7. �11 Of signiﬁcance in both sets of these experiments is the fact that the face shows a high dominance. However, it must be stressed again that the last two methods do not reﬂect the low order of hand dominance. 4. Adults with Schizophrenia—When these patients made errors, the errors were similar to those obtained in normal adults under the age of 65. Each patient showed signiﬁcant dominance of the face to the hand as well as to the foot, the breast to the hand and foot, and the penis to the hand and foot (Table 8). The relationship of all the body areas has not been worked out so completely in these subjects as in the preceding groups. The difﬁculty in demonstrating the a“ TABLE 7.——Responses of Twenty Patients as to Areas of Greatest and Least Dominance Body Part Most Aware of Face .................................. Face and foot ........................ Face and thigh ....................... Hand .................................. Foot No. of Body Part Least Aware of Subjects Thigh .................................. 10 Subjects 16 1 1 1 .................................. TABLE No. of 1 Foot .................................. Hand .................................. Shoulder and thigh ................... Foot and shoulder .................... Not asked .............................. 1 1 8,—Response on the Initial Trial in Schizophrenic Adults Tested in a Single Body Combination Combination of Body Part ,——————J% A B FACE * Face Face Face FACE Face Shoulder BREAST PENIS Thigh Foot Thigh BREAST PENIS Shoulder * 4 3 1 Hand Breast Penis Back Foot Shoulder Hand Hand Hand Hand Hand Foot Foot Foot Breast No. of Subjects Correct 72 24 52 23 29 25 81 30 42 37 13 31 77 43 2 19 29 2O 3!) 31 15 30 30 30 28 15 9 17 15 9 Responses Indicating Dominance of Body Part f————N———ﬁ A B Other Responses 46 2 11 2 4 4 2 2 14 3 7 12 8 8 44 19 11 8 4 19 8 3 0 3 3 0 0 1 3 3 9 1 1 6 2 10 1 1 1 2 3 8 2 1 Capital letters indicate dominant part as evidenced by a chi-square value of 5% or less. complete pattern in schizophrenic patients was the same as that encountered in normal adults. They showed fewer perceptual errors on simultaneous tests than did either patients with organic brain disease or children. These errors occurred only during the intial trials, so that one subject could be tested for only one body combinationi~ There were a number of patients with schizophrenia who presented bizarre responses. The touch stimuli were occasionally misidentiﬁed and were reported as “a burning” or “a ﬂy crawling.” At times the number of percepts were multiplied. Instead of perceiving the two applied stimuli, they reported three or more percepts in a variety of body parts. Similarly, a single stimulus was reported as two or more percepts, the locus of the original stimulus being occasionally omitted. Such patients usually persisted in the bizarre responses on repeated testing on subsequent days. Several of the paranoid patients refused to close their eyes but permitted examination provided they could see. I}: �12 Senile Adults.—Studies of body combination tests in senile adults 65 to 96 of the disease in with found those of similar results showed to patients age years brain and in very young children.‘ The most dominant region was the face and the least dominant the hand. In plotting the errors on face-hand tests in normal subjects of all ages, we found that children under the age of 6 years and adults over the age of 65 show the greatest incidence. 6. Supplementary Studies of Blind or Deaf Subjects.——While we were conducting the foregoing experiments, we, naturally, tried to ﬁnd an explanation for face dominance. One of the thoughts we entertained was that normal subjects developed the concept of the face being foremost in importance. It might be assumed that the earliest sensory image a subject experiences would be the sight of the mother during infancy. Therefore, the earliest memory of a person and his selfidentiﬁcation would be the visual image of a face. Moreover, young children who are asked to draw the picture of a man draw the face ﬁrst and foremost, paying less attention to other parts of the body. Goodenough 15 made similar observations on the drawings of mentally retarded persons and patients with disease of the brain. Since visual memory and imagery of a face would seem to be important in one’s sensory experience, it was thought that the congenitally blind might not respond as the normal subject does when he is tested with cutaneous stimulations. With this in mind, a series of congenitally blind children and another series of adults with an organic mental syndrome and long-standing acquired blindness were tested with double simultaneous stimulation of the face and hand. Results showed that there was no difference in the pattern of response between the blind and the normal subjects. A. Blind Subjects: I. Children. Forty-two normal children (3 to 14 years of age) with congenital blindness were tested in face-hand and hand-foot combinations. Ten tests (heterologous and homolateral parts of the body) were done for each combination in a random order. The results obtained were as follows: 1. Of all children 6 years of age or younger who were congenitally blind, 79% showed persistent errors after 10 trials of testing. 2. In the face-hand combination tests the following responses were obtained: 5. Face Only Face-Face Hand Only Hand-Hand 202 34 2 1 3. In the foot—hand combination tests the responses were as follows: Foot-Foot and Partial Displacement of Hand-Hand Hand Stimulus Hand Only Foot Only 51 26 26 9 4. The pattern of all errors throughout the testing was the same as that for normal children without blindness. II. Adults. Ten adults with an organic mental syndrome and blindness acquired after childhood were tested with multiple face—hand tests. All showed persistent errors. The analysis of all the errors are as follows: Face Only 100 Face-Face 7 Hand Only Hand-Hand 1 1 From this analysis it is obvious that preservation of vision in infancy is not essential for face dominance. �13 B. Deaf Subjects: We also thought of other causes for face dominance, namely, that the touch applied to the face was not only felt but reinforced by the sound stimulus produced by the touch on the face, which is so near the ear. To establish or exclude this possibility, we studied a series of deaf people. Thirty-two adults with deafness acquired in early infancy or childhood were tested with multiple face—hand tests. These subjects were otherwise normal. They had no evidence of disease of the brain. The results are indicated in Table 9. Again we found face dominance. Hearing did not seem to be a factor in face dominance. COMMENT From the foregoing studies it is obvious that we have been investigating perceptual functions from the standpoint of patterns. For many years Lashley§ has been stressing the fact that the data obtained on neurologic examination should always be analyzed with reference to pattern of activity. We did this in the compilation of our own results. By clinical observation we learned that when the cutaneous sensory ﬁeld is examined under conditions of simultaneous stimulation a distinct pattern is discerned. The pattern is most apparent in testing two non— TABLE 9.—Incidence of Errors for Deaf Subjects, Initial and Subsequent Trials Total No. of Initial Trial—*ﬁ—ﬁ Subjects Correct Face Only Face-Face 32 Hand Only 9 19 2 2 r—-———~—Initial and Subsequent Trials———ﬂ Face Only 86 Face-Face Hand Only Hand-Hand 1 4 0 symmetric regions, far removed from each other and situated along the longitudinal axis of the body. The resultant interaction between these two sensory stimuli yields a characteristic pattern. In studying the data, it was learned that the face is the most dominant region of the organism. The genital zone is next in the order of dominance, while other parts of the body follow in a gradient, with the hand mani— festing the least dominance. Thus, the most conspicuous gradient is between the face and the hand. The pattern of response we obtained by testing with the method of double simultaneous stimulation has been found consistently on numerous occasions, under a variety of conditions, and in many groups of subjects. In considering our results, we naturally ask what the organizing principle of this perceptual pattern might be, or with which neurophysiologic or psychophysio— logic data it may be correlated. Why is the face the most dominant and the hand the least dominant? Why does the genital region show a high dominance? What determines such an order of dominance? Is it acquired by learning; is it inherent, or is it a product of each? If it is inherent, what role does the body image play? Anatomic or Neuro-“Electrical” Studies—In considering the anatomic substrate, we ﬁnd no apparent correlation of ﬁndings elicited on electrical studies of the cerebral cortex with areas of the body which show dominance by our method of stimulation. Some aspects of tactile sensory interaction have been discussed by § References 16 through 18. �14 1" in their and Bard Marshall, Woolsey, mappings of the cerebral cortex of the cat and monkey by the method of evoked action potentials. The map of the “sensory cortex” as determined by electrical stimulation or evoked action potentials does not serve to explain the order of dominance. It might be supposed that the degree of dominance found in a part of the body would be proportioned to the area in the cerebral cortex in which this part of the body is electrically represented. However, this is not the case. The face and the hand, the most and the least dominant areas. respectively, in our system of testing, have approximately equal representation in the homunculus of the human cortex as determined by the method of electric stimulation of the cerebrum.20 It is not certain whether electrical studies on neuron action will give us the answer, for, as Lashley has repeatedly pointed out, most studies are made on surgically isolated or anesthetized animals, and these are far from being in a physiologic state. Our own clinical studies show patterning of sensory interaction in the physiologic state of man, whether there is or is no disease of the brain. This is a physiologic fact. The meaning of this fact, however, is not as yet clear. This patterning of sensory interaction does not occur in any one region of the cortex. It is the result of integration of perceptual function, which takes place in the entire brain at the cortical, thalamic, and even lower levels of the nervous system. There is no doubt that sensory interaction occurs, but that this interaction is patterned and how it is patterned is still a mystery. Psychophysiologic S‘tudies.—Our own psychophysiologic data also fail to shed any light on our problem. Studies of thresholds of cutaneous sensations, types and nature of stimuli, and attention of subject and sensorimotor responses did not offer clues to a solution. Critchley,21 in his interesting article on tactile functions in the blind. suggested that face dominance may be due to the sensitivity of the skin. It does not seem to be a matter of thresholds,” for we have been working with crude supraliminal stimulations. The stimuli we employed consisted for the most part of ﬁrm taps or scratching and slapping of the face and hand, or repetitive or moving stimulations, such as rubbing. Moreover, the tactile thresholds. as obtained in different regions of the cutaneous sensory ﬁeld by use of the method of von Frey,23 using von Frey’s hairs (Table 10), or with a stimulus such as pinprick (Table ll), show no strict correspondence to the “dominance” values obtained by the method of simultaneous tactile or pinprick stimulations. The use of stronger or more noxious stimuli, such a pinpricks, will reveal a lower incidence of errors, but the pattern of dominance will be the same. Nor is there any correlation between the acuity of the sense of two—point discrimination and the order of dominance. It will be recalled that the ability to discriminate two points at the ﬁnger tips or at the hand is much greater than that at many other parts of the body, excluding the lips and tongue; yet the hand shows the lowest order of dominance. This lack of correspondence is contrary to the hypothesis proposed by Denny-Brown, Meyer. and Horenstein, who studied patients with lesions of the parietal lobe.“ In our studies of normal subjects and of patients with disease of the brain, including that of the parietal lobe, we ﬁnd no correlation between incidence of errors as elicited by the method of double simultaneous stimulation and the two-point discriminative potentialities of a given cutaneous area. �15 Still another factor to consider is that of attention. Critchley,“ in a series of papers, claims that it is a lack of attention which causes the imperception of one of the two simultaneous stimuli in patients with lesions of the parietal lobe. As expected, this type of sensory defect is apparent only on the side opposite the cerebral lesion. It is especially pronounced in the hand and least manifest in the face, thus reﬂecting a pattern with an order of dominance similar to the one illustrated in normal children and in subjects with diffuse disease of the brain. If this pattern in the parietal lobe lesion is interpreted as due to a lack of attenTABLE 10.—5timulus Threshold for Pressure, in Grams per Square Millimeter, After von Frey Cornea ................................... 0.3 Conjunctiva ............................. 2.0 Tongue ................................... 2.0 ...................................... 2.0 2.5 ....................................... Finger tip ................................ 3.0 Eyelid (edge) ............................. 3.0 Infraorbital area ........................ 3.0 Forehead ................................. 3.0 Hollow of palm .......................... 7 Dorsum of ﬁngers ........................ 5.0 Upper arm, ﬂexor surface ................ 7 Thigh, inner side .......................... 7 Forearm, ﬂexor surface .................. 8 Nipple .................................... 8 Anterior edge of deltoid ................. 9 Anterior edge of axilla .................. 11 Xyphoid process ......................... 11 Mucosa of. check .......................... 12 Nose Lip 12 15 16 16 16 16 17 26 26 26 27 27 27 28 Prepuce ................................... Spinous processes ........................ Medial edge of scapula ................... Deltoid muscle ............................ Upper arm, extensor surface .............. Abdomen .................................. Oriﬁce of urethra ......................... Thigh, outer side ......................... Areola of breast .......................... Undersurface of breast ................... Sole, noncalloused part ................... Tibia ...................................... 28 Forearm, extensor surface ................ 33 Inguinal area ............................. 48 Glans penis ............................... 111 Sole, calloused part ....................... 250 11.—Stimulus Threshold for Pain, in Grams per Square Millimeter, After van Frey TABLE Cornea .................................... Conjunctiva .............................. ..................................... Abdomen ................... ............... Forearm Flexor surface ........................ Extensor surface . E yelid 0.2 2 10 15 . Upper arm ................... Flexor surface ........................ Outer condyle of humerus ................ ..................................... ....................................... Cheek Calf Hand, dorsum ............................ Foot, dorsum ............................ Calf ....................................... 20 30 30 30 30 30 Upper thigh Outer surface ------------------------ 30 Inner surface ......................... 30 Extensor surface ..................... 40 50 FOOL dorsum ............................ . 1v Edild’ dorsum 100 llbla """""""""""""" ...................................... Internal malleolus ....................... Hand, palm .............................. Sole, callouscd portion ................... Finger tip ................................ 00 110 130 200 300 tion, it must be that the inattention is only on one side of the body, and particularly in the hand. In other words, the term inattention becomes synonymous with defective perception produced by the parietal lobe lesion. Nevertheless, attention tends to modify perceptual responses. According to William James, “when the things to be attended are small sensations and when the effort is to be exact in noting them it is found that attention to one interferes a good deal with the perception of the other.”46 But does this explain the pattern in dominance or in errors in perception as illustrated in Figures 1 and 2? It might be claimed that man pays most attention to the face because he is most interested H References 25 through 28. �16 in this part of the body. Such reasoning may explain face dominance, but it does not account for the frequent errors made in the hand stimulus. The latter ﬁnding would imply that man pays the least attention to the hand, less than to any other part of the body. Now, it is hardly likely that one pays less attention to one’s hands than to one’s back. Yet, according to our data, the back dominates over the hand, implying that man is more interested in his back than in his hand. This is contradictory, and it becomes obvious that attention does not account for the order of dominance as depicted in Figures 1 and 2. A defect in attention may crystallize but not determine the pattern of perception as elicited by the method of double simultaneous stimulation. Further evidence against the attention theory are the recent experiments by Hooker.29 He found an order of dominance in sensation, using double simultaneous touch stimulations, in the human fetus. Eventhough the response to stimuli in his experiments involves an order lower than that implied in our results, there was a distinct pattern under his conditions of testing in which attention was not a factor. When there was simultaneous cutaneous stimulation of the face and hand, the dominant motor response was that typical of the face. An important principle to consider in the study of patterns of response to sensory stimuli is that every sensation has a motor component. Thus, when we request the subject to report what is felt when the face and hand are touched simultaneously, there must be an efferent, or a motor, element. The patient replies verbally and tends to point to the spots touched. In a series of face—hand combination tests or in combinations involving the face and another body part, it was shown that the face is the ﬁrst to be indicated, whether it is pointed to with the hand or announced verbally (Table 6). Since the hand is used in the pointing, it would be the last of the two (face and hand) perceived regions to which the sub— ject would point. On the contrary, the face would be the ﬁrst to be indicated. This, however, is not always the case, for when both stimuli are perceived, the hand is sometimes the ﬁrst to be indicated. This is particularly evident in combinations which do not include the face. When both hands are stimulated, the incidence of errors is very low and the subject often uses either hand to point to the other. Learned and Inherent Perceptual Organization—Perceptual organization or sensory correlation may proceed along two lines: (1) learning or individual acquisition of perceptions and (2) inherited or genetically determined perceptual patterns. Acquired perceptions are organized in the course of experience by the postulated mechanisms of pattern identiﬁcation, by a selective process, by sym— bolization, and by conceptual organization. As Nissen states, “Symbolization helps in perceptual organization also in connecting percepts with concepts to speciﬁc 30 responses.” 1. Learning Factor: There are many who believe that all perceptions and perceptual patterns are acquired. Most perceptual reactions are learned during the maturation period or infancy. In our own studies of perceptual patterns under conditions of double simultaneous stimulation, we believe that awareness of the part of the body, such as the genital region, is an example of learning. Infants or children learn of and become aware of their genitals. Initially, when the pattern was demonstrated in adults with disease of the brain, the high dominance manifested in the genital region was not too surprising. The interpretation was that, due to its special sexual connotation acquired by learning, there is more “awareness” of �17 stimuli applied in this area. The question then arose as to what the pattern would be in very young children. If sexual “awareness” was not yet operative, that is, if the child had not yet learned of the social signiﬁcance of the genital organs, one might assume that there might be less dominance of the genital zone than in adults. However, in our studies we found that young children were indeed “sensitive” about their genitals. Most of the children under 6 years of age, even the very youngest, who were just about able to cooperate in the perceptual tests, were reluctant to expose this area or showed some form of embarrassment or curiosity when their genitals were touched. Some refused to have more than a few tests done at one time. Evidently this increased “awareness” is learned prior to 3 years of age. Since we found a high dominance for the genital area in children, it might be inferred that this high dominance is related to a sexual awareness which was probably learned in the ﬁrst two to three years of life. Schilderﬂ pointed this out in his discussion of the principles concerning the libidinous structure of “the body image.” # He stated: The attitude toward the different parts of the body can be determined by the interest the persons around us give to our body. We elaborate our body image according to the experiences we obtain through the actions and attitudes of others. The actions of others may provoke sensations when they touch and handle us. But they may inﬂuence us also by words and actions which direct our attention to particular parts of their body and our own body. . . . Early infantile experiences are of special importance in this connection but we never cease gathering experiences and exploring our own body.31 These principles of symbolization in perceptual .organization apply to genital as well as to other regions of the body. From the psychoanalytic, or Freudian, point of view the face and the mouth participate in the oral stage of body image, or, more correctly, of body schema development. The same school emphasizes that the genital region plays a great role in the development of the organism. Therefore, it should not be surprising to ﬁnd the face and genital regions almost on the same level of dominance as determined by double simultaneous stimulation. References 31 and 32. # Smythies,33 in a philosophical paper, criticized the confusion and the loose use of the term “body image.” Thus, (a) there is “the body image” which describes “a visual, mental, or memory image of a human body, one’s own or someone else’s.” Body images are experienced. (b) Body schema should be used only in its original sense. It is part of the subconscious mind, and thus its presence is inferred, and not experienced. The experiments of Stratton are a good example of almost a pure disorder of the body schema. (c) Body concept is a conceptual constellation and depends largely upon the proper function of the relevant memory mechanisms. Anosognosia is an example of disorder of the body concept. (d) “The perceived body,” or another name for it, “postural model of the body,” a term to be applied to the somatic sensory ﬁeld—directly experienced inside central consciousness. An example of this is the experience of having a phantom limb or autotopagnosia. The perceived body is identiﬁable with the “body image in the brain.” (e) Actual physical body is a physical object and not the same as the perceived body. What one perceives as to body parts does not always correspond to the actual position of the physical body and vice versa. An example of this is found in the patient’s experiences in mescaline intoxication, where the perceived body is not the same as the physical body. Also the postures assumed in some of the dyskinesias are not always perceived. (f) Body image in the brain of the physical body (theory of psychoneural identity). The homunculus as determined by electrical stimulation or destruction of brain tissues is an example. While we agree with Smythies criticisms, it is sometimes extremely difﬁcult to use his classiﬁcation of “experiences and description of the human body.” Nevertheless, in our subsequent discussions we shall try to use his terms wherever possible. ﬂ �18 Even though Schilder * proposed these theories, there are no clear—cut experi— ments to show that the face is sensitized the most, and, for that matter, that the hand is sensitized the least, in the maturation of the normal infant or child. As a matter of fact, in the same book Schilder emphasized the importance of other structures in the construction of the “body image.” In considering “sexual sensitization” of body parts in adults, one must compare such erogenous zones as the breast and buttock with the genital region. Yet analysis of our data reveals no undue dominance of the breast and buttock over nonerogenous regions, such as the foot or abdomen. Perhaps there would be no incongruity in dominance of erogenous zones if we interpreted our data from the standpoint of age, sex, personality, and social background of the subject. Under such conditions we might have found different gradients in each group and concluded that sensitizations of the body parts by learning are, after all, important, but not necessarily the principal factor in determination of the pattern. In this connection the question of the development of the “body image” arises. How does the “body image” develop? Schilder admits that we have no reliable information as to how this development takes place. He said that there is “reason to believe that there is an inner development, maturation, . . . and there are inner factors, which are given in the organism and comparatively independent of experience which determines this development.” He also believed that “the process of maturation gets its ﬁnal shape through individual experience.” Thus, there is a factor of maturation which forms the basic structure of the body image, whereas experience and learning inﬂuence the trends of the development. Maturation and learning are essential features of all types of development, whether it is body image, body schema, body concept, perceived body, or perception itself. These conclusions are partly supported by the experiments of Gesell.34 If this sort of reasoning, namely, development of the body image in infancy, accounts for face—genital dominance, what explains the inferiority of the hand, as determined by this series of tests? When the hand is considered in the spectrum of the “body image,” there seems to be no prominent reason for its inferior position. According to Schilder, the hand is an important structure in the formation of the “body image.” The “body image” is continuously inﬂuenced by the almost constant optic image of its hands. One sees his own hands more frequently than any other part of his own body. In fact, perceptually and from the motor standpoint the hand is one of the most important structures in the “perceived body.” Katz 35 says that the hand makes the most vivid impression. Despite this, it is curious that the hand is least dominant when it is tested simultaneously with another body part. 2. Inherent Factor: Thus far we have discussed the factor of learning in perception as the basis for the pattern we obtained on double simultaneous stimu— lation. It is possible that “learning” during infancy might explain part of, but not the entire, pattern of sensory organization under conditions of double simultaneous stimulation. However, our results show that the factor Of “learning” did not enter in our own tests. An analysis of the responses obtained on the ﬁrst trial in many children showed that the face was most dominant and the hand was least dominant. In this situation there was no opportunity for learning; yet this pattern was found on the initial tests in most subjects. The same consistent initial response was obtained * References 31 and 32. �19 in tests of combinations of other body regions, such as the hand and the thigh, etc. These ﬁndings strongly suggest that the patterns we obtained are not the result of a learning process during testing but may be due to inherent sensory organization. This theory is supported by the preliminary studies of Hooker.29 Working with human fetuses, he found that double tactile simultaneous stimulation of the face and hand resulted only in the face reactions. When the hand and foot were tested, there was only the hand response. Thus, there was an order of dominance in which the face dominated over the hand and the hand over the foot. Although the pattern Hooker obtained in the fetus is not exactly the same as the one we obtained under our conditions of double simultaneous stimulation in young children, the fact remains that a pattern has been observed before the organism had an opportunity to learn. Carmichael,36 after reviewing the available experimental data, concludes that there is only little evidence that learning modiﬁes fetal behavior. If it is assumed that the pattern is determined inherently, one should consider the role the body image plays in organization of perception or in the order of perceptual dominance. 3. Organization of Perception in the Perceived Body, Body Image, and Body Concept: (a) Perceived body. In a discussion of the inherent properties of perception we must consider the role of the “perceived body.” There is a theory that mid— line structures of the body dominate over the lateral or peripheral parts. In his monograph on the body image, Schilder emphasized the dominance of the midline structures. This theory considers the long axis of the body as being the dominant over other regions. Part of the same theory is that proximal parts of a limb dominate over distal regions. In our own experiments it is true that the face and the genital region, both midline or axial regions, are the most dominant parts of the perceived body. However, this axial theory does not account for the gradients as depicted in the graph we plotted from our data. There are some midline or axial structures which show no signiﬁcant dominance over the lateral parts. Thus, the foot, a lateral area, is dominant or equal to the thigh, which is a proximal area, and to the buttock, which is an axial structure. Moreover, there is a differentiation of dominance along the longitudinal axis of the body itself. Thus, the face or the genital region is dominant over the abdomen, buttock, or midback. A second hypothesis is the one proposed by Cohn.37 This is similar to the ﬁrst. Cohn proposed that the pattern of dominance, as elicited by the method of double simultaneous stimulation, is inherently organized on the basis of rostral dominance, i. e., the theory that the face is the most dominant part of the organism, while the remaining body areas show a descending gradient along the longitudinal axis. The rostral parts are dominant over the more caudal areas. This theory is consistent with the extensive observations on the development of the vertebrate nervous system, in which a rostral—caudal gradient is demonstrated in phylogenesis.38 This gradient is manifest in the progressive differentiation of the rostrum until, in Mammalia, the cerebrum is fully differentiated. The gradient is also manifest in biochemical and physiologic reactions at each phylogenetic level. Similar gradients have been demonstrated for the musculoskeletal and gastrointestinal systems. A rostrocaudal order of sensory development has also been shown to exist in onto— genesis in studies of the fetus with single stimulations.39 More recently, Hooker 29 found such an order in human fetuses when the face and hand, or hand and foot, were touched simultaneously. Our own data support this theory of rostrality only in part, inasmuch as there is face dominance. However, other facts tend to contra- �20 dict the theory of rostrality. There is no continuous downward gradient between the rostral and the caudal region. Even though the face is most dominant, there are caudal body parts which are dominant over some of the more rostral regions. For example, the foot is dominant to the hand and the thigh. Most signiﬁcant is the dominance of the genital region to all more rostral areas except the face. From the foregoing data one must conclude that the concept of rostrocaudal order of be the fetal There the is not beyond applicable stage. organization may sensory factor of learning and maturity in the postnatal stage. More studies of double simultaneous stimulation in different parts of the body of the human fetus, particularly the genital region, may shed more light. Similar studies in the ﬁrst year of life will help us in understanding the development and organization of perception in man.40 (1)) Body image and body concept. Another theory can be evolved in considering the relation of the body to its inner self or that of the ego to its outer world. This concept implies that the ego has a center and a periphery region, just as the perceived body has an inside and an outside. We observe ourselves (inside) as we observe others (outside). When one thinks of himself, what Schilder called autoscopy,32 there is an image of one’s own face. This is a good example of what is meant by body image. Children in making drawings of a man indicate the face, while other parts of the body are less often illustrated.15 Even congenitally blind children, in whom the hands and ﬁngers are of especial importance, model the head 41 and the region of the mouth as being the most conspicuous”? too large as being In expressing the concept of the ego in terms of body parts, the face is visualized is face the most The other than structure. the to more foreground comes any or distinguishing part of the organism itself. The face represents the most central or inner portion of the ego. In narcissism the self-interest in one’s body is directed chieﬂy to the face. Claparéde,42 in his studies on localization of the self, concluded that the ego is conceived as being in the head. More speciﬁcally, he believed the center of the ego is situated between the eyes. As for the genital region, there are of the this would who body the identify area psychoanalysts, particularly many, with the inner part of the ego. The part of the body which has to do with reproduction is probably just as “deeply in” or central in the organism’s concept of the body as is the head, with its face, mouth, eyes, etc. In considering the genital region, it is not always easy to determine whether the importance attached to this part of the body is due to inherent or to acquired factors. There is a great deal of literature on this subject, but it is still difﬁcult to ascertain what role the inherent factor plays as opposed to the learning factor. Applying the theory of centrality, i. e., that the face-genital regions are innermost in the ego and in the body concept, we are faced with the problem of ﬁtting the hand into this theory. In contrast to the concept of the face or genitals being central, the hand is mostly on the periphery. The hand is the medium with which we or our ego makes contact with the peripheral or outside world. The hand is on the periphery of our ego structure and, with the aid of vision, is the most important tool for exploration of the outer world. One might argue that the foot, although a distal structure, also makes contact with the outer world. However, in this task the 1' von Stockert, F.: Quoted by Critchley.21 �21 hand, in most instances, is used more than the foot. Moreover, the impression gained is that the foot is more inward—it seems more protected and hidden by shoes. In summary, it would appear that from the standpoint of body concept organization within the ego, the face and the genitals are the most inwardly situated, while the hand is least centrally or most peripherally situated in the conceptual organization of body parts within the ego. Now if we correlate the latter hypothetical pattern with the pattern we found in our perceptual tests, we create some sort of congruity between the two, namely, (a) face dominance as obtained on perceptual tests with face as the most inner portion of the ego, and ([9) hand inferiority with hand as the most peripheral portion of the ego. From this it might be inferred that the ego may play a role in the determination of the perceptual pattern. We realize that this is a highly theoretical explanation. Obviously, the concept of the hand being the most distal, and the face the most central, portion in the organization of perception in body image needs testing. We also realize that our results may be colored by an obscure artifact, although we have checked our data by a variety of methods and conditions of testing. If this concept is at all valid, it should be applicable to functions other than those of cutaneous senses. Thus, the concept of “central” portions dominating over the periphery may be found in studies of vision. Observations drawn from patients with mental changes consequent to diffuse brain disease show domination of central over peripheral vision. Goldsteini and others have found that in these patients constricted ﬁelds of vision are not uncommon. When such a patient is instructed to ﬁx at a central target and report whether he sees another target simultaneously in the periphery of the ﬁeld, the response is that the central target is observed and not the one in the periphery.45 In studies of visual responses of these patients to rapid exposures of images with groups of ﬁgures, it was noted that they reported what they saw in the central portion of the ﬁeld only, often not observing the peripheral ﬁgures. Similar results were obtained in tachistoscopic examinations of mentally defective persons. In all these cases the results were uniform, namely, the perception of the central, but not of the peripheral, ﬁgures. Thus, when the cutaneous sensory ﬁeld is compared with the visuosensory ﬁeld, the face seems to correspond to the macular region, and the hand, to the most peripheral part of the ﬁeld of vision. On further com— parison, it might be inferred that central vision is identiﬁable with the ego in the same manner as is the face. The optic image we have of ourselves or of others is situated in the central portion of the ﬁeld of vision. Our ego is projected in the central regions of the perceptual ﬁeld. In considering these patterns for perceptual function, we touched on the topic of conceptual functions. When the subject of the ego is discussed, a pattern for thinking becomes obvious. It is well known that most of our thoughts are pointed directly or indirectly toward ourselves, and we think least of what is most peripheral to or away from the ego. This subject has been amply discussed by William James in his “Principles of Psychology.” The object of mentioning the parallel was to point out the principle that similar patterns exist in all types of perceptual functions, as well as in conceptual and motor functions. :1: References 43 and 44. �22 SUMMARY Tests of simultaneous tactile stimulation involving many different body combinations were applied to patients with an organic mental syndrome, normal children, normal adults, and schizophrenic adults. By the use of these simultaneous touch stimuli, a pattern in cutaneous perception was demonstrated in which the face, as well as the genital region, was the most perceptive or dominant body area, whereas the hand showed the least dominance. The remainder of the body regions fell between these two extremes in the form of a mild gradient. No one theory adequately explains the organization of this pattern. Learning and maturation are probably factors, but it appears to be mostly inherent. The pattern is found in the normal subject but is accentuated in the presence of disease of the brain. REFERENCES Head, H., and others: Studies in Neurology, London, Oxford University Press, 1920. 2. Pearson, G. H. J.: Effect of Age on Vibratory Sensibility, Arch. Neurol. & Psychiat. 20:482-496, 1928. 3. Jaffe, J., and Bender, M. B.: Factor of Symmetry in the Perception of Two Simultaneous Cutaneous Stimuli, Brain 75:167—176, 1952. 4. Green, M. A., and Bender, M. B.: Cutaneous Perception in the Aged, A. M. A. Arch. Neurol. & Psychiat. 69:577-581, 1953. 5. Cohn, K: On Certain Aspects of the Sensory Organization of the Human Brain: III. Patterned Response to Three Simultaneously Applied Cutaneous Stimuli, Neurology 2‘»:140-143, 1. 1952. An Experimental Study of Simultaneous Stimulations of the Sense of Touch, J. Nerv. & Ment. Dis. 20:169-184, 1893. 7. Oppenheim, H.: Diseases of the Nervous System, Neurol. Centralbl. 4:529—533, 1885. 8. Green, M. A.; Fink, M., and Bender, M. B.: Order of Dominance in Cutaneous Perception, Tr. Am. Neurol. A., pp. 238—240, 1952. 9. Bender, M. B.: Disorders in Perception, American Lectures in Neurology, No. 120, Springﬁeld, 111., Charles C Thomas, Publisher, 1952. 10. Bender, M. B.; Fink, M., and Green, M. A.; Patterns in Perception on Simultaneous Tests of Face and Hand, A. M. A. Arch. Neurol. & Psychiat. 66:355—362, 1951. ll. Bender, M. B.; Shapiro, M. F., and Schappell, A. W.: Extinction Phenomenon in Hemiplegia, Arch. Neurol. & Psychiat. 62:717-724, 1949. 12. Jaffe, J., and Bender, M. B.: Perceptual Patterns During Recovery from General Anesthesia, J. Neurol., Neurosurg. & Psychiat. 14:316-321, 1951. 13. Fink, M.; Green, M. A., and Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects, J. Nerv. & Ment. Dis. 117:43-49, 1953. 14. Shapiro, M. F.; Fink, M., and Bender, M. B.: Exosomesthesia or Displacement of Cutaneous Sensation into Extrapersonal Space, A. M. A. Arch. Neurol. & Psychiat. 68:481-490, 6. Krohn, W. 0.: 1952. Goodenough, F. L.: Measurement of Intelligence by Drawings, Yonkers-on-Hudson, N. Y., World Book Company, 1926. 16. Lashley, K. 5.: Problem of Cerebral Organization in Vision, Biol. Symposia 7:301-322, 15. 1942. Lashley, K. 8.: Functional Interpretation of Anatomic Patterns, A. Res. Nerv. & Ment. Dis., Proc. (1950) 30:529—547, 1952. 18. Lashley, K. 5.: Serial Ordering of Action, in Cerebral Mechanisms in Behavior, edited by L. A. Jeffress, New York, John Wiley & Sons, Inc., 1951. 19. Marshall, W. H.; Woolsey, C. N., and Bard, P.: Observations on Cortical Somatic Sensory Mechanisms of Cat and Monkey, J. Neurophysiol. 4:1-24, 1941. 17. �23 20. Penﬁeld, W., and Rasmussen, T.: The Cerebral Cortex of Man: A Clinical Study of Localization of Function, New York, The Macmillan Company, 1950. 21. Critchley, M.: Tactile Thought, with Special Reference to the Blind, Brain 76:19-35, 1953. 22. Berlin, L. ; Goodell, H., and Wolff, H. G.: Relation of Pain Threshold and Pain Intensity to the Phenomenon of Extinction, Tr. Am. Neurol. A., pp. 229-231, 1953. 23. von Frey, M.: Beitrage zur Physiologie des Schmerzsinns, Ber. u. Verhandl. konigl. siichs. Gesellsch. Wissensch., Leipzig, Math.—phys. C1. 47:185-196 and 283-296, 1894. 24. Denny-Brown, D.; Meyer, J. S., and Horenstein, S.: The Signiﬁcance of Perceptual Rivalry Resulting from Parietal Lesion, Brain 75:433-471, 1952. 25. Critchley, 26. Critchley, M.: The Parietal Lobes, London, Edward Arnold & C0., 1953. M.; Russell, W. R., and Zangwill, 0.: Discussion on the Parietal Lobe Syndromes, Proc. Roy. Soc. Med. 44:337-346, 1951. 27. Critchley, M.: Problem of Awareness or Non-Awareness of Hemianopic Field Defects, Tr. Ophth. Soc. U. Kingdom (1949) 69:95-109, 1950. 28. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions, Brain 72:538-561, 1949. 29. Hooker, D.; Early Human Fetal Behavior with a Preliminary Note on Double Simultaneous Fetal Stimulation, A. Res. Nerv. & Ment. Dis., Proc., to be published. 30. Nissen, H. W.: Phylogenetic Comparison, in Handbook of Experimental Psychology, edited by S. S. Stevens, New York, John Wiley & Sons, Inc., 1951. 31. Schilder, P.: The Image and the Appearance of the Human Body, Psyche Monograph No. 4, London, George Routledge & Sons, Ltd., and Kegan Paul, Trench, Trubner & C0., Ltd., 1935. 32. Schilder, P.: Mind Perception and Thought in Their Constructive Aspects, New York, Columbia University Press, 1942. 33. Smythies, J. R.: Experience and Description of the Human Body, Brain 76:132-145, 1953. 34. Gesell, A.: Maturation and Infant Behavior Pattern, Psychol. Rev. 36:307-319, 1929. 35. Katz, D.; Gestalt Psychology, translated by R. Tyson, New York, The Ronald Press C0., 1950. 36. Carmichael, L.: Ontogenetic Development, in Handbook of Experimental Psychology, edited by S. S. Stevens, New York, John Wiley & Sons, Inc., 1951. 37. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation, J. Nerv. & Ment. Dis. 113:471, 1951. 38. Child, C. M.: Origin and Development of the Nervous System, Chicago, University of Chicago Press, 1921. 39. Hooker, D.; Prenatal Origin of Behavior, Porter Lectures, Series 18, Lawrence-Kansas City, University of Kansas Press, 1952. 40. Carmichael, L.: Onset and Early Development of Behavior, in Carmichael, L., Editor: Manual of Child Psychology, New York, John Wiley & Sons, Inc., 1946. 41. Bakwin, R.: The Blind Child, J. Pediat. 35:120-128, 1949. 42. Claparede, E.: Note la localisation du moi, Arch. Psychol. 19:172, 1924. 43. Goldstein, K.: Constriction of Visual Fields, Arch. Neurol. & Psychiat. 50:486-487, 1943. 44. Goldstein, K.: Mental Changes Due to Frontal Lobe Damage, J. Psychol. 17:187-208, 1944. 45. Bender, M. B., and Teuber, H. L.: Ring Scotoma and Tubular Fields: Their Signiﬁ- cance in Cases of Head Injury, Arch. Neurol. & Psychiat. 56:300-326, 1946. 46. James, W.: The Principles of Psychology, New York, Henry Holt & C0., 1890; reprinted by Dover Publications, 1950. Printed and Published in the United States of America �F‘J‘ 5‘ ~24" amass or by Doctors: PM“. cameraman urn axmrunous mm: lorriskl‘. lender, sum A. a... m In: nun Several series of noraal adults, norsal children. patients with organic aental eyndroee and patients with schisophrenia.were tested‘ i for the1r ability to perceivesiaultaneoue tactile stiauli. Iith his eyes closed. the subject was touched sisultaneonelyx on two different areas of his body and ashed to report what he perceived and to localise the percepts. the responses to this aethod of testing , in all subjects fell into two general groups. The subject either reported both stisuli correctly or reported only one correctly and either did not perceive the second stiaulus (extinction) or sislocalised it (displaceaent). If the right face—left hand were tested, for 'esasple. the subject sight report the face stiaulus correctly and either not perceive the stisulus on the hand or aislocalise the hand stianlns to the left cheek and so report that he felt a single stisulus on each side of the face. *1sentyy patients with organic sental syndroae and 20 noraal children 3-d years of age were tested in all possible coabinations of two between the aajor body areas. lach subject received 540 tests in a randos order.. Testing was done with the subject cospletely nude. When the incidence of errors in the different body areas was analysed by statistical sethods, a significant and similar relationship between these areas was found in both groups of subjects. lrrors were least fequent in the face and genital sons. These were designated as the scat dominant regions. lrrors were aost frequent in the hand when it was tested with any other body part. when all the body parts were thus coapared, a gradientias established with the following order of dosinance: the face and genital region. followed by abdoeen. breast, buttock, foot. back. shoulder and thigh. Bosinance was least apparent “in the hand. �Thros other groups consisting of 593 norssl adults, 53: schizophrsnio adults sod 527 pstionts with orgsoio’ssntslisynorons ' sore tsstodwin.vsrioos body ooshinstions. In those coshiostions is lvhich.¢osinsnos was sppsrsnt, the order of dosinsnoo sss.sinilar. 'to that found in tho prooooding groups. this ordor oi.dosinsnco on oisoltsnoous stinulstion sppssrs .to ho so ishsrsnt psttsrn or organisation. It is prosont in nor-31 children 3~8 yosrs of sgs sad in nor-slisdults. Tbs psttsrn is sxsggorsfod sad Inch sors sppsrsnt in pstissts with disosss of tho brsin. h I I V _ lerioos thsoriss oxplsining this psttsrn, particularly.tho‘ closonsss of tho toes sud gsnitsl rsgions, sill ho disousssd. ,' , '.‘ 4 I C’v w?” 4.4/{L4/1A r” . If- 7” (Ia . .\ ﬁn. .‘ " , an.“ "the 1 ‘3 a, , v .h ‘7“ ‘v‘ _. A ‘ ,3. '1 I" .iv / as“ f’ M “ , a 3i“ x' - ‘ , ' z’ i » � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns of perceptual organization with simultaneous stimuli. AMA Arch Neurol Psychiatry. 1954 Aug; 72(2): 233-55. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-7b-011 Date A point or period of time associated with an event in the lifecycle of the resource 1954 Creator An entity primarily responsible for making the resource Bender, Morris B; Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from the A.M.A. Archives of Neurology and Psychiatry August 1954, Vol. 72, pp. 233-255 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/355c4b9504ee5dda4b99daee2b72cb14.pdf 32103451b1f3d9d0d60a0a834fb27af9 PDF Text Text Reprinted from—JOURNAL or THE HILLSIDE Vol. I, No. 1, January, 1952 HOSPITAL _ TACTILE PERCEPTUAL TESTS IN THE DIFFERENTIAL DIAGNOSIS OF PSYCHIATRIC DISORDERSl MD.2 and MAX FINK, M.D.3 New York, N. Y. MORRIS B. BENDER, Visual perceptual performance tests like the Rorschach, Thermatic Apperception and Bender Visual Gestalt tests are widely used in the evaluation of psychiatric disorders. Recently, a simple test of tactile perception—the face-hand test—has been described (2). By this test, characteristic performances of normal adults (2) and patients with diffuse cerebral dysfunction (3) have been differentiated. The face-hand test is an application of the technique of multiple simultaneous stimulation (1) . The examiner lightly touches, simultaneously, the cheek and the hand of the subject. The latter is then asked to describe and localize the stimuli. Normal adults readily name and localize the two stimuli within the initial few trials of the test. Once correct, they are thereafter correct on all similar tactile stimulation tests. In contrast to normal subjects, patients with psychoses due to disease of the brain are not able to perceive or correctly localize one of the two simultaneously applied 'stimuli, even after many trials of the face-hand test. They consistently make errors in the stimuli to the hand (and con.versely, they rarely make errors in the perception Of the stimuli to the face). This type of response has been observed in 90 per v ' From the Department of Neurology and Psychiatry, New York University College of Medicine, Bellevue Psychiatric Hospital and the Hillside Hospital. This work aided. in part, by grant #MH 139 from the U. S. Public Health Service, National Institutes of Health. 2Director of Neurologic Service, Hillside Hospital, Glen Oaks, N. Y. 3 Aided by a Fellowship from the National Foundation for Infantile Paralysis. 1 , 21 �22 BENDER — FINK cent of the patients with diffuse brain dysfunction, and has been described as a sign of the organic mental syndrome (3) . These simple tactile perceptual tests have now been applied to patients with hysteria, schizophrenia and psychic depression. The responses of these patients to repeated trials of the face-hand test will be described. SUBJECTS The subjects were patients from the wards of Bellevue Psy- chiatric HOSpital. These patients had one of the following conditions: schizophrenia, psychoneuroses, psychic depressions or organic psychoses. The patients with schizophrenia manifested the various clinical varieties of the disorder. The patients with psychoneuroses were those hospitalized for severe anxiety, reactive depression, or behavioral outbursts necessitating inpatient observation. The patients with depression in this group were predominantly young adults in whom the psychiatrist obtained a history of recent stress precipitating admission to the hospital. In addition, patients with diagnoses of “character disorder” or “behavioral disorder,” and without evidence of psychosis, were included in this group. Patients with depressions were studied in two groups. The young adults with “reactive depressions” were included in the group of patients with psychoneuroses. The second group were the older adults, in whom the diagnosis of involutional psychosis was made. In some instances, these patients presented evidence of impairment of memory, concentration, calculation, and orientation. The diagnostic differentiation of their disorder from psychoses due to disease of the brain was difﬁcult. The diagnoses were usually made after extended periods of observation and with the aid of psychometric studies. The patients classiﬁed as having organic psychoses manifested the usual memory disturbances, disorientation, emotional lability and confusion characteristic of the “organic mental syndrome” (3) . The etiology in these cases varied between central nervous system syphilis, posttraumatic states, senility, presenile dementia and alcoholism. �TACTILE PERCEPTUAL TESTS 23 METHOD During a routine examination, the face-hand test is applied. The patient is asked to close his eyes. In the sitting position, with his hands lying naturally in his lap, the patient’s cheek, and dorsum of the hand on the side opposite to the cheek, are simultaneously touched by the examiner’s ﬁngers. The patient is then asked “What did you feel?” The normal adult usually points to the cheek and states: “You touched me here" or “I felt something here,” making no mention of the stimulus to the hand. The patient is again asked to close his eyes, and the stimulation repeated. This time the opposite cheek and hand are touched. He is asked whether he had felt anything. The usual response is a correct localization and identiﬁcation of both stimuli. If only one stimulus is reported, it is the stimulus to the cheek. At this time, the examiner asks: “Did you feel another touch anywhere else?” The normal subject usually points to the hand stimulated and admits: “I felt something there—I thought you may have brushed against it.” On the third and fourth trials of the face-hand test, the cheek and hand of the same side of the body are stimulated—ﬁrst on one side and then on the other. Finally, both cheeks and then both hands are stimulated. This sequence of six tests is repeated. Subsequent to these trials, other parts of the body are tested in a similar fashion, such as cheek and foot, or breast and hand. Cutaneous stimuli other than a light touch have been used such as multiple light touches (rubbing), single pinpricks, multiple pinpricks, and less frequently, temperature tubes (hot-cold) and tuning forks (c128). With these cutaneous stimuli the obserVations are qualitatively the same as with touch stimulations, although the frequency of errors is much less (2). In each case where defects were apparent on face-hand tests, standard tests of single stimulation by touch and pinprick were applied. Only a few subjects, those with evidence of focal cerebral damage, myelopathy or peripheral neuropathy, made errors on these single stimulation tests. Their reactions were not considered in these results. ' ' �24 BENDER — FINK RESULTS The usual responses of the normal adults to the face-hand test were: (a) perception of one stimulus only—usually the one to the cheek, and only rarely the one to the hand; (b) perception of the two stimuli, correctly localized; and (c) perception of two stimuli, but one mislocalized. This mislocalization was almost always a mislocalization of the hand percept, which was displaced to the homolateral cheek. Such "displacements" were rare in the normal, but frequent in subjects with disease of the brain. Normal adults manifested incorrect type (a) and (c) responses on the initial few trials only. As reported previously, 50 per cent of the normal adults made errors on the initial trial of the facehand test; 22 per cent on the second trial; and errors became less and less frequent until by the tenth trial, less than 1/2 per cent still made errors (2). It is apparent that normal adults can readily discriminate two tactile stimuli and accurately localize these within the ﬁrst few trials of the test. Also, once the normal adult was correct on one trial, he was found to be correct on all subsequent trials regardless of the body part tested or the rapidity with which the tests were applied. Adults with Psychoneuroses: Most of the subjects with psychoneuroses responded in a fashion similar to normal adults on both the initial and on multiple trials of the face-hand test. Subjects with manifest anxiety, after identifying the cheek stimulus on the initial trial, perseverated in this response. Through many trials they persisted in naming only the cheek stimulus, even insisting that there was no other stimulus. This type of report was maintained until the examiner emphasized that there were two stimuli. As soon as the subjects realized that there were two stimuli they were correct both in naming and localizing subsequent simultaneous stimuli, as well as single stimuli interspersed at random. During the time that errors were apparent on multiple trials of the face-hand test, these anxious patients never displaced a stimulus, i.e., recognized that there had been two stimuli, but mislocalized one to another body part. It was as if they were in a mental set of “oneness," and this set persisted until broken by �TACTILE PERCEPTUAL TESTS 25 the examiner. When they got into a mental set of "twoness," they were correct on all subsequent trials, perceiving and correctly localizing the two stimuli. In a majority of patients with hysteria, including those with hysterical amnesia, the face-hand tests showed normal responses. In a few the responses were abnormal. Thus there were some who reported the sensation on one side of the body correctly, but denied all stimuli on the side which showed a hysterical type of sensory defect. There were some patients who showed "allocheiria.”4 They mislocalized a stimulus from one side of the body to a homologous part on the opposite side. This mislocalization or displacement occurred from the side with hysterical defective sensation to the side with normal sensation. Adults with Schizophrenia: Most patients with schizophrenia were able to discriminate the stimulus applied to the face and hand correctly on the ﬁrst few trials just as normal adults could. However, there were a number of patients in this group who presented bizarre responses. The touch stimuli were occasionally misidentiﬁed and were reported as “a burning” or “a ﬂy crawling.” Frequently, the number of percepts were multiplied. Instead of perceiving the two applied stimuli they reported three, four or even six percepts in a variety of body parts. Similarly, a single stimulus was reported as two, three or four percepts, occasionally omitting the locus of the original stimulus. Such patients usually persisted in the bizarre behavior on repeated testing on subsequent days. In two instances, there were bizarre responses even when the test was applied with the eyes open. A number of the paranoid patients refused to close their eyes and permitted examination provided they could see. Obviously, under this condition, they were correct on all trials of the face-hand test. Patients with schizophrenia, admitted to Bellevue Hospital for frontal lobe “topectomy” operations, were able to perceive and 4The term allocheiria should be distinguished from allesthesia. According to Ernest jones, the British psychoanalyst, the crossed sensory displacement manifested by patients with hysteria is to be called allocheiria, while that shown by patients with disease of the nervous system is to be called allesthesia. Based on our experience the distinction between the two is made largely on the total clinical picture. In one there is the long history and symptoms typical of hysteria, while in the other the history and neurologic signs show patterns characteristic of organic disease (4). �26 BENDER — FINK localize the two simultaneous stimuli during the initial period of testing. During the ﬁrst two weeks after topectomy operations, however, the patients manifested the “organic” type of response to the face-hand test. As will be described later, this pattern consisted of omissions and mislocalizations of stimuli on repeated testing. As the patients recovered from the operation, the errors on repeated trials of the face-hand test decreased. Ultimately, they correctly reported the simultaneous cutaneous stimuli and reacted in a manner no different from the nonoperated schizophrenic patients or normal subjects. Patients with Psychic Depression: Patients with “reactive depression" were co—operative and usually correct on the initial as well as on subsequent trials of the face-hand test. Their responses were most like the normal pattern. Of the patients with severe involutional melancholia, some were frequently unco-operative. They were suspicious of the request to keep their eyes closed and if they permitted stimulation, would report only one of the stimuli. The stimulus they reported was the one to the face. They omitted the one to the hand. Like the patients with manifest anxiety, they frequently persisted in giving one response through many trials— until the idea of “twoness” was apparent to them. Thereafter, they were usually correct in their responses (Case I). Patients with a manic excitement correctly identiﬁed the two stimuli on the initial trial of the face-hand test. On subsequent trials they were frequently unco-operative, commenting that the test was too easy, or silly; when co-operative they were usually correct on subsequent trials. Organic Mental Syndrome: The reactions of the patients with organic mental syndromes to multiple trials of the face-hand test are different from those observed in normal subjects or patients with neurosis or schizophrenia. Ninety per cent of all patients with organic mental syndrome repeatedly fail to report one of the two stimuli, or when reporting two, mislocalize one of them. Again the perceived stimulus is the one applied to the face. The Stimulus to the hand is usually not perceived or it is mislocalized. This type of response is consistent and highly predictable. A patterned response is also apparent in tests of body areas other than the face and hand. An “order of dominance” in tests �TACTILE PERCEPTUAL TESTS 27 of other body areas could be established in these patients. In this order the face is the most dominant with penis, trunk, breast, foot, thigh and hand less dominant, in descending order. When tactile stimuli are simultaneously applied to any two body areas, the errors in localization will occur in the part of lesser dominance. For example, if stimuli are applied simultaneously to the cheek and penis, the patient will report the cheek stimulus alone; but if the stimuli are applied to the penis and the hand, then the stimulus to the penis will be reported. These omissions and mislocalizations of percepts persist for many trials and on many days of testing. The inability of the patient with an organic psychosis to discriminate two cutaneous stimuli is so consistent, that it is considered a sign of the organic mental syndrome (3) (Case 2). Eﬂect of Electro-Convulsive Therapy: In patients with schizophrenia or psychic depressions, electro—convulsive therapy induces a similar “organic" type of reaction to the face-hand test. During the period of confusion immediately following the treatment, the patients consistently report only the cheek stimulus or mislocalize the hand stimulus to the check. This is transient during the ﬁrst few treatments, but near the end of a course of therapy these reactions persist for longer and longer periods, until they are apparent hours or even days after the treatment. Patients who had a course of electro-convulsive therapy and were readmitted to the hospital after a lapse of months failed to show this “organic” re- action. CASE REPORTS The following case reports are selected as illustrating the types of responses observed. Case I: S. S., a forty-year-old woman, was admitted to the neurological service complaining of backaches in recurrent episodes of eight years. During the past year she noted difﬁculties in recollection and in her ability to calculate. She had been a bookkeeper and now found herself unable to calculate accurately or rapidly enough to continue work. On occasions she had misplaced valuable family possessions only to ﬁnd pawn tickets in their place. �28 BENDER — FINK During interviews under sodium amytal she cried readily and related many recent family difﬁculties, including the suspension of her husband’s license as an auctioneer and her son's classiﬁcation in IA by Selective Service. Her difﬁculties apparently began with these events. Medical and neurological examinations were negative except for some varying areas of hypesthesia and hyperesthesia. Psychiatric examination revealed marked psychomotor retardation. There were deﬁcits in memory and calculation. She was able to relate details of her history and of world events, but was unable to relate details about her work or family affairs. These latter details were readily apparent, however, in interviews under the inﬂuence of sodium amytal. On simple calculation tests she made few errors, though she was slow in response. On more complex tests commensurate with her occupation as a bookkeeper, she made numerous errors and showed many hesitations. Many answers were reported questioningly. The admission clinical diagnosis was “organic disease of the brain.” This was based on such symptoms as psychomotor retardation, memory deﬁcits and difﬁculties in calculation. Face-Hand Test: On the initial face-hand testing the patient persisted in giving the cheek response only for eight trials, but thereafter, was consistently correct for twenty trials. There were no displacements of percepts. On subsequent days she was correct on the initial and all subsequent tests. These ﬁndings suggested that the symptoms were not due to disease of the brain. Course in Hospital: To exclude organic disease the patient was subjected to a series of tests. Neurological examinations, electroencephalography and pneumoencephalography revealed no evidence of organic brain disease. A psychological survey revealed an average intellectual capacity (IQ 106) without any evidence of organic deterioration. The personality survey revealed severe anxiety and depression, with some bodily preoccupations. The ﬁnal diagnosis was depression and the patient was discharged for further care in the psychiatric clinic. Comment: This case illustrates the problem in the differentiation of psychic depressions and organic psychoses. As a rule we found that the preservation of the ability to discriminate and �TACTILE PERCEPTUAL TESTS 29 localize double tactile stimuli speaks against organic disease. Only 10 per cent of patients with organic mental syndrome showed normal response to the face-hand tests. The converse was not true. There were no instances in which a normal person made persistent errors on face-hand tests. If errors are made, it usually turns out that the patient has disease of the brain, no matter how bizarre the mental picture may be. This is illustrated by the next case. Case 2: H. B., an elderly white male appearing about sixty years of age, was admitted by the police who found him wandering about the streets. He was unable to give his name or home address. He did not answer questions, though he spontaneously requested water and food. A few days after admission he began to speak freely, gave his name as “The Messiah” and his home as the hospital. He was facetious, quick in speech and coherent. A complete delusional system relating to God, the patient’s previous sojourn in heaven, his mission on earth, etc., was related. No other anamnestic data were available. Under further observation he showed the Ganser syndrome. For all questions of orientation, general information and calculation, he answered relevantly but was only approximately correct. He was almost but not quite right. He did not answer any questions of personal history except for the distant past and then he related a disjointed, rambling, confabulatory story. To many observers it seemed as if the patient had a “hysterical” type of psychosis. During examination on admission the patient appeared chronically ill. The blood pressure was 180/100 and urine contained four plus sugar. There were hemorrhages and exudates in the ocular fundi. Neurological studies showed absent ankle jerks, diminution of vibration sense in toes and ankles, with normal position, touch and pinprick perception. Other defects were apparent on special sensory studies. Face-Hand Test: On the face-hand test this patient presented an “organic" pattern. In the initial testing, he repeatedly reported only one of the two stimuli—that of the face. After many trials and a number of trials with eyes open, he began to report the two stimuli but now mislocalized the hand percept to the cheek. In testing on consecutive days, similar mislocalizations and omiso sions were apparent, both on the face-hand test and on similar �BENDER — FINK 30 tactile tests of other body parts. An abstract of the record, which evinces the “organic” pattern on double simultaneous stimulation testing with light touch stimuli is presented here. Stimulation Right cheek, left hand Left cheek, right hand Right cheek, right hand Left cheek, left hand Right and left cheeks Right and left hands Right cheek, left hand Left cheek, right hand Left cheek, left hand Right cheek, right hand Response Right cheek Left cheek Right cheek Left cheek Correct Correct Right and left cheeks Right and left cheeks 2 percepts left cheek Right cheek » Further neurological studies revealed a diffusely abnormal electroencephalogram; a symmetrically, diffusely dilated ventricular system on pneumoencephalography; and evidences of organic deterioration on the psychological tests. Course in the Hospital: Under observation the patient showed a gradual and persistent improvement. After six weeks in the hospital he recalled some facts whichled to his entering Bellevue. He remembered his address and social security number. As he improved clinically errors on the face-hand tests became infrequent. When the errors were sparse, intravenous administration of three grains of sodium amytal produced once again the persistent omission and mislocalization of percepts characteristic of the organic mental syndrome. Comment: Here is a patient who was thought to be hysterical but the face-hand test contradicted this impression. The persistence of errors on multiple trials of the face-hand test made us think of an organic disorder. The subsequent special Studies conﬁrmed this suspicion. CONCLUSION ‘ As with visual perceptual tests, such as the Rorschach, this simple tactile test- the face-hand test—has been found to be useful �TACTILE PERCEPTUAL TESTS 31 in evaluating psychiatric patients. Anxiety, paranoid attitudes, autistic thinking and misinterpretation of environmental stimuli are manifest on face-hand tests. Characteristic behavior patterns are seen in some schizophrenic and hysteric patients. In the evaluation of patients with mental changes due to dysfunction of the brain the face-hand test is of diagnostic signiﬁcance. The inability of these subjects to discriminate the two simultaneous stimuli on repeated trials and the characteristic errors of omission or mislocalization of the hand stimulus are unique. Such errors are not observed in normal, schizophrenic, hysteric or depressed adults. REFERENCES (l) Bender, Morris B.: “The Advantages of the Method of Simultaneous Stimulation in the Neurological Examination." Med. Clin. North America, 32: 755-758, 1948. (2) Bender, Morris B., Fink, Max and Green, M.: “Patterns in Perception in Simultaneous Tests of Face and Hand." Trans. Am. Neurol. Assoc, 75: 250-252, 1950; and Arch. Neurol. da- Psychiat., 66: 355-362, 1951. (3) Fink, Max, Green, M. and Bender, Morris B.: “The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome.” Neurology, 2, 1952. (4) Jones, Ernest: “The Pathology of Dyscheiria." Rev. 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Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Tactile Perceptual Tests in the Differential Diagnosis of Psychiatric Disorders. Journal of the Hillside Hospital 1: 21-31, 1952. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-4-006 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from Journal of the Hillside Hospital Vol. I, No. 1, January, 1952 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/348b7ac617e184efef2c6c30c847fca6.pdf 36100719e5c813fdabfca556caa0ba68 PDF Text Text Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION 1950 PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER MAX FINK AND MARTIN GREEN NEW YORK In previous studies we found that the method of double simultaneous stimulation showed defects in sensation (extinction) which were not apparent on routine single stimulation. In testing two different regions of the body and various combinations it was found that extinction was apt to occur most often in the hand and least in the face. Conversely, “dominance” was greatest in the face and least in the hand. In the present communication we wish to report the results obtained on simultaneous stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syn— drome; 4) schizophrenia; 5) no disease of the brain (normal adults) and 6) normal children between the ages of four to ten years. Patients in groups 2 and 3 showed severe memory defects, confusion, poor orientation, difﬁculties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or ﬁngers) were touched Simultaneously. Care was taken to make the two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked to report what he felt, and following this, where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the ﬁrst examination: a) a touch on the face only (face dominance), implying no Sensation in the hand (extinction) ; b) a touch on both sides of the face (there being “displacement” from the hand to the ipsilateral face) ; or c) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that on subsequent tests he was expectant of more than one stimulus. In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislocalization was towards the face it appeared as if the face determined the direc250 �251 Perception in al.——Patterns Bender, et of type a this was that therefore, said, be might It than tion of the displacement. common less was displacement, or (b), Response dominance. face the patients in often most seen was (b) Response extinction. or (a) testing. response repeated despite persisted and with the organic mental syndrome, comment. special needs no and normal expected the was face The (c) response ipsilateral the when noted werealso Extinction and displacement including tested, subjects the all In tested. sides and hand were simultaneously left and right the between difference no was there aphasia, with those - ' of the body. the in shown is various groups the in obtained results Analysis of the following table: Hand ;/,’// Group Face Response Extinction or Displacement Number of Subjects 2 ‘4 22 20 5 53 ' 3 20 . 0 14 24 , 19 ‘ 0 6 20 ' Response _ 9 12 15 12 1 Face and Head Response ‘ 2 6 28 0 ' ‘ - 0 0 0 . j . l l of is dominance there whenever that obvious is it; foregoing the From. the hand in Dominance face. the in is it apparent another over sensation the in one "uniformly almost found was dominance Face once. notedonly did was patients These 2 and 3).. (groups changes mentalwithsevere in. _ subjects few a In repeated'testing. after hand even the not report sensation in were or stimuli, two were there told the were patients after even stances, percept one only reported they stimuli, of the of asked to watch the application sides both of stimulation simultaneous cases Inthese one. displaced these that or objection the excluding thus correctly, the face was reported once. things at _. two perceive do or able to not were those in and patients with aphasia subjects in dominance face of The'incidence, in .. patients 1 and 4) was less. In contrastto with schizophrenia (groups correctly sensations both 1 4 reported and in those groups 2» and 3, the hrst groups done not had soon if they trials, fourth third or second, the domiface on of. incidence the 5) adults (group normal of the In group the trial. on found only it was though even signiﬁcant, still but least, dominance nance was face of incidence the. children normal of series In trial. a dominance ﬁrst face children 3. In 2 and young in groups as the same almost was examination. ﬁrst the after trials several tested was present even hand were the than other body of the When theface and parts The apparent. still was dominance face 3, 2 and in" groups calf, simultaneously thigh, penis, (breast), trunk shoulder, face, was dominance order of hand. and foot, arm . . _ �252 Weights (IL—Discrimination of Bender, et CONCLUSION In a wide variety of subjects the phenomena of extinction and displace- consistent A demonstrated. stimulation simultaneous were ment on double dominant most face the which in was established of pattern perception was and abnormal the in both noted These ﬁndings were and the hand the least. the normal subjects. In the abnormal subjects with severe mental changes, be that consistent they may extinction were so face dominance and hand used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, be to brain diffuse disease, with in appear patients which are so prominent exaggerations of the patterns found in the normal subjects, especially children. �um II mama! 0' MES 0! I‘M! w 3mm my- A! Harris 3. Bender, ILD. Pink, IL». m and lax-tin anon, LB. of lumbar ﬁpi‘fﬁnﬁ '75; Buivenity cones. of Mieinc, 555 Sinai City. tort lelpiul, In m lupin ' 101E law c ﬁy Edi-y,1 and that Haunt 3.11m. from the mum; grant a ”starch by part) (in This work was aided a. by grant and part) (in service Public With of math, Institutes Inc York . city. in Cmbral of In council his: Coordinating the I‘m �1.' Previously it was shown thst exsnihstioh of the cutaneous uodelitiec by the method or double siuultsneous etisnlstion elicited defects in perception which were not sppsrent on single “extinctiont” ”obscuration,” The ss defects, desctihed etihhlstion. "displacement” and "eliesthesis'.were observed in groups of or the centrsi nervous disesse diffuse with localixed or patients systen (1) (a) (3). In esch group the defects in cutaneous per» most were stimulation double sismitsneous obtsined on ception of the rhe fece. hand the sud object in the lesst in appsrent or the was responses determine to patterns investigation present in nonnsi subjects, sduits and children,to simultaneous stisu1s~ Yarns "fece~hs.nd” observe~ head and teat the face of the tion tions in this nonnsl group were then cospsred to sole extent with the responses of pstients with orgshic mental syndrases, sphssis sud cchisophrenis. IAEIR£égc the ”non-s1“ subjects were children and sdulte. These there. subjects were persons attending hcspitsl clinics, in was no evidence or disesce or the brsin; and school children, start of disorder manifest who: no was there sud in students, personnel been had Hone of then previously system; the central nervous exslined by the nethod or double sisultsneous stimulation. the to according sge: three into groups classified were subjects 12 “adults” end 6 over end years. 7 to 3 children or to it years, For comparison with the noml goup we studied patients on 'There were three Bellevue wards of Psychiatric the iospitsl. the sod lo attempt sphssis. psychoses ~ organic schizophrenia, group: whom �2. .uno and. to separately study each or the clinionl typo: of schisophronil. ﬂoat of tho puticntu ours or the paranoza, mixed or iinplc vurietiel of Iohixophrenin. the patient: uith organic montnl changes showed doreota 1n nonorw, orient¢t1on and onloulution, a: wall In other signs and symptom: oharuoteriltio or dxtruoo dileIIO of tho brain. Tho clinical diagnoael in loot of,those onuou was Althoincr'n dilt&§c, urtorionolcrotio onoop~ haloputhy, severe oorobrll ordain, brain tumor or toxic ano¢p~ who with thou mm uphuu. lubjootl mommy. ohnrnotcriltio difficultiob in columnioation. Theta who had a oonoolitant hmnipnroail or I huuiscnlory aorta? noticeable on single Itilnlation war. not inorudod in thin Curios. m '3th maroon: 2h: subject val instruotcd to‘olouo tho cyan. When thia 1p3111tcéll (chock) and tho oontrav done or either tho-root it: our. hand ninnltnnooully on. (any hand digit.) at or part lateral touohcd or stroked with tho examiner‘s ringorl. the subject: whoa two sonsntionn; only one percept one or either reported no: reported tho subject was naked 1: than. at: 3:111 unothor, and 1: no, to indiooto its loontion and quality. Following the initial trial, in each subject, tho opposite chuck Ind hand aura stimulatod 1n the 1.80 nunnor. Those tout: poquepoatod and tho result: reoordod, until tho subject: oon~ who those In both auhjootl otinnli correctly. nistontly roportod toiled to localize tho two Itinuli oorruotly otter at: or eight word an touted t1oo~ttoc,'hand~ body the of 0th.: part: triala, room-hand tho with uumung ma, “mama, penis-hand, em, tout. �otinuleé eerie! ot.stndies pin prick tions sere used in s sinilsr fsshion.w In both series, cere use taken to apply the stimuli at the me time and with the em thst'snhdects who‘nede consistentt was spherent intensity. It he would correct as soon es the stinuli were errors in reporting rsther thsn sinnltsneoutly, even if the spplied consecutively tine leg betseen stinuli was that or one or two nonente. It was slso necesssry to use neive norssl subjects, since sthects previously tested did not show the.petterns noted below. In e second sepsrste 8 ones; lhe responses obtained on the tnce~hsnd test fell into four groups: (s) s touch on the face and the hsnd, indicstins the correct end expected perception; (h) e touch on the fees only, in the head; (c) I touch on both sides or implying no eensstion the tees: and (d) s touch on the bend only, implying none on the race. ﬂhen only one stimulus III reported the subject use ssked if there uss any other sensstion. the oocesionsl reply sue that there use snother percept, and the sthsct correctly pointed to the second locus. lhny hdhaects, however, reported thst they hsd not perceived snother stimulus, neuslly sdding the state-cut: ”In use not paying sttention - do it seein' or, ”I'm not sure - Isvhe of here" end somewhere the the was direction in over pointing it side of the body or the poorly felt stimulus. In some instances, second while correctly locslising the percept, they Iinnteered the ststenent: "It use not es strong es the other one,“ or "It doesn't seen as sharp.” Before we proceed with the results we rust define the connnnicstions other the failure or the need. In special terns �#. luhjoet to report ohm or two ninnltnnmaunly applied stimuli ha: of been called “tbs phhnhnenon gunnery extinction“ hr ”extinction“ 1n utid wharu stinmlu; tho poreeived or body the (1). the part Ill uxnultanuhulh to he "danihnnt” ta the part of thh body where thn Itinnlun nun net perceived, or parceivcd faintly. the latter aensatieh was terncd ”obnouration.' or a the diminution in quality whah tho uuhject ruparted tun nonnatiehn, hut ninloenlilod one or thun, the "ditplhccncnt' a: a peroapt in .315 to hire oeeurrea (2). ndsplaccnentu Ir. ununlxy 1n the direction or tht daninnnt ’ntinnxup and as: he puttinl hr eqnpxgte. rhe‘dilplaccucnts nttcd man» chock the side. of hand.to th1§.ner1gp tn. were :ran.the in Rarely did the displscahehts cedar to the hack or thauldor. tram the nthhdpoint {hm snalyuod result; \Ih1t1h1‘2r1hxs uqrt of initial and nuhluqnont thee¢hnnd test with touch trilla. en Ithhlltion tn. initill trial or the Inhjcetn, taco deninnnec uuu appurant 1h :11 use granny. 'lhrc_thnn half or such and none in thc race the in the schnation udulta rcported nonntl hand. lhrno Cubdoetn ninlaehlisod tho lentation 1n the hand to thn £160. In thn green: of hon-n1 children 90! under the use of hand the percept hiuloealizcd thee the or hereopt :1: reported only tha {teeddhinhnoe in a: also 1: seen face. the Ibis pattern to children tram 7~12 years of age hat.th a 10:30: extent. hand the adults‘reportod or the ham-ll suhjaotl, five indtidl or example dinplaeenont In thn an trial. only Ittnulus noted. hand was tram race to by hand extinction or by daninanee face or Ill pattern the more apparent was tune even th hind percopt of.the dinplncclant 1n nornnl �in thn patients aznninad. Xt uun.noat evident in patients with arggnic gantal chanset, 935 or when did not repert bath stimuli corrnctly. In callinntion. or uchixqphrunio lub:ectn and patinntu with aphnail runponneu lililnr to thnse of thc annual adult were observed on tum intill trial. land doninnnoe was accllionllii seen in the patient and vital: in tn. net-:1 Iahjpat. In «use. of hand dominance the race' not the reported the but percent; It was seen manual I in the initial trial on m five different net-11 Malta .. In the” instano§3. tun nubaoct ropnrtod both.ttanu11 carrectiy oh nubaoauunt tinting. In the patidntt with organic mental changes hand dauinnnee III In inconntant rtupanto and rcpeated touting the sale day or on unbloquant dawn danonntrated thy amt! usual poruiutunt pattern or dominanco. "" ' rm 1 stilulttion ,Rolponso on initini roueh 19ml Adult lam]. «mm, low emu. Totalicorrcot Pace Only luaowraae land Only 160 77 15 3 5 3-6 564 m 23 18 a 7.12 76 33 27 9 2 7: 26 n5 1 2 syndrome 120 9 9n n 3 o o Schisoyhranin (“malt-niried) mute luau: trill . i Apmu Submgguont I 23 Erialla or the 12 83 11 narnti adult. uh» nude errata initial trial, #3 were correct on the uecond and 12 on the third triul. In a to! sub: '“Vfﬂiaur. five at Ii: trill! var. the nucOIsary berare the tun stimuli Into corructly localised. than. on �6.‘ ta be annual, althuugh complete psychologiaal (tennion during that noted VII anxiety It the with to'ploaae) interfered desire strong callinltton,er.n annual :11 aubaeetl, In rncognition the of ntiauli.v torruct early aubjoets ware Inlunnd tent. wcro.not dune. the IIB correct once those rosponae with anxiety, including abtn1npd (oven all ﬁtter an was iith elicited error.) it trials number warn or if n¢cncd a an tritll It many aubnequont_teut1ns.: ”aét“ axmnlnntion, the at the into neoenuary_ror tn. anbaect'ta set evon cccurutoly, trtcr the ha ntinnli riported the once in tad set, of any WI; ”9,10.an in that was apparent child annual wanna th: it In testing inst canon Inn: tail: war. nocolsnry.h¢£ore the correct rotpanse was «enlistently elicited. Alta, tan child at. not tlltya dayu. many over tasting lopeutcd tubaugunnt touting. an correct of Ibis tuna daninlncc, in: shin tbs patterns hauever, olicittd natod in 36 of tho 56 childrtn tottqd, ‘In a number of instances than and reportcd tho stimuli appz1¢nttan can o; Intchcd en. child was thy But repeated an test noon corroetly. percept1onn tbs t; stimulus. on. repertod child tho «my with tm «you acted. min or “int” the tn» in: not into could tho get ehild evident that It oxtninntion, even with viaunl anal. 311 In children. in not wag apparunt vary thin diffieulty t6 the 76 give the failed 17 at anly (age: 7-12) the older group correct renponse utter th; inititl tau trials. 1.: at the nae-hand on the reports obtained repeated. A: relieved connintent s pattern. test: in mgr-:1 nubjecta also tubsocti. on tbs initial trial, face daninnncc was trivalent in all or or‘ obsmatien (a) extinction by It was: unite,” uthor " tr: m �8. or the autumn te displacement fees, or er me atmii ”.in aevertl insteneea the displacement we. in a direction tantra (1)) by O3 ' em taco. In contrast to normal adults, patient; with organic mental change: were unuhie te regert the two stimuli earreetly even utter many triele. When_the yetient reported the pereept in ane teet eorreetly, he frequently failed on tubuequent testing; It was tine Ipperent that touting en subsequent‘daye etiii elicited in and er stimuli. extinction dieeinemt m: u ntrang who made seldom unmet: to tn error apparently subject: centreet on subsequent tritiu, day: after the initial examination. the responses obteined in this group demanetrated the pattern: at tee. teetfﬂ deninnnee in meet or the niepiaeenent of the hind percept to the tune was frequent. In tame instances dieplneement or extinctien was preeent deepite the {get that the putiont watched the applitutiea of the etinnii to the fete and hand. Extinetien was very taxman en hencieterni or heterologoun teeting while ~ ﬁne apparent dilpieoenent neatly on heterolegeun teats. 514; the and nyhneie patient: the uehisephrenie reports gayb which were «1:111: te normal adulte. After the first tie trial: the pertentnge of errer in hand sensation was slightly higher than in the normal greup. reraietent bistrre reepoaeee were elicited from a number or the schizophrenic Inbdeetl. lheee reperte ineluﬁed multiple responses to mingle or daubie stimuli, pereietent displacement: to one area from any other body area, ineonsittent verve end 'mimrreveruls or localiutien. day: As normal the to free with an day examinetien_and eating consecutive an the aphasia subject Iehixephrenie touting or idnlt, M �days roiled to elicit extinction phenonehe once the been eccorltely reported before. test hen ‘ comparison of the reeponeee or each or theoe groove to nultiple teeting in chain in fig. 1. A ﬁrﬁ 54’” Pin Phick Btiuuietioh: It in known thet the type or etinuiue epplied influence: the result: in perception. To denonetrete the importance or thie rector einiier groups of subject: were tested ueing two pin prick ineteed or two touch etilnletione. With pin prick etinnieticn ct tece end hencﬂfece dominance wee egein uehiteet in all the groupe. however, the incidence of error in perception of the pin prick in the head III lower than with e touch etinnloe. Ihe reeulte are recorded in IhhﬂcIIt Elna! II :1 ' aﬁzaiiﬁfmﬁ’ﬁm lttei tor-ll Adult correct Pace only Feccqrece Hind an}: 68 51 15 2 c ﬂannel child, 3~6 yearn #5 lorlml Child,7~12 your! 39 50 Schizophrenin 16 26 2 1 25 1h 0 0 36 13 9 1 arsenic lentei syndrome #7 9 33 3 2 Repeated testing with two pine in the nccnﬁi adult subject: elicited the correct reeponeee in the initiel three trieie. Fever at the chiloren ﬁgiﬁcd to report the teat eccuroteiy after the initiel trials. ~It we: poeeibie ih_e hunter or instance: to alternate touch and pin prick etieuietiohe, end demonstrate extinction to touch, but correct localization to pin prick. loreover, with �m. abre intehae pih prick atianlatieh, extinction and diaplaeeaant were lean frequently ebaerved. vzheae phendaena, haaely extinction and diaplaeeaent were eveh.nbre apparent in the patiehta with erzahie mental ayadreaea. Bdaplaeeaeht or touch ltd-311 eauld be alternated with oerreet Idealiaatibn of pin brick atzaulatiah. A ddubihatxon or touch tb the fade had pin prick te the hand evinced the edubinetibn at displacement and obaenratioh, an the patient reported “a teach an the fade, and a dull the en the other aide {or the face).' Pin prick to the eheak and teach to the hand raaulted 1n extinction hand the pareept; be, oeeaaiehally, the rephrt or a pin prick of both an the cheek and hand. rhe aehizephrenie aubaeete were able to loealiae the pin prick accurately after the initial ten trials, an had the aerial mule: . Blﬂaﬂbazﬂl: mains the nethbd er dabble ainnltaneoua atinulatibn in teuta or the face and the hand a eenaiateht pattern bf reapeneea baa been observed in a variety hr aubaeota. the atinnlua to the m.’ 1: non readily perbeived than the one 1:: the me. «never, the pareept in the race influences the due in the hand, frequently canning the displacement of aehaatibh. 1h1a pattern a: reapbhaee haa been repeatedly deaehatrated in bath the annual and abnormal eubJeeta, and 1a aahireet 1h extinetibn, obaeuratibn and diablaeeaant. Extinction 1: abet and diaplaeeaeht :- leaet frequent. In eatinetien, the race pereept 1a correetly reperted aa te quality and leans, but the hand attanlua 1a not perceived at all; In all hf the rereading teat: or patient or abrnaz aubJeeta§*uhether By �11; ' tha reaponaaa were aaeurate tr not, it uaa notod that tbs stiuuius yointad to the face tirat. aubjaet almost invariably pattoived and 1a ourrectly hand perecpt tha Octaaianally iooaliaed, but anamnea a qualitative differonce, always of diaiﬁntion. In displaeunant tha percent in the hand 1: 113* such an the or rage, tho it direttitn the face, or localiscd tn to tan ahauldor er nuak. In aunt instance: if tha taco cud tho hand at the lama aid: are stimulated, tho lubaeet occasionally 1a thaae phnnancna of 1n lane the taco. raporta tut paroapta ah: or these un1eh one with the rrtquancy haphaaard. nail. varia« druga, be attention, observed affected by may erraeta 1: tion in atilnli, ate., it: pattern 1: eonaiatent. Thea. raaponaaa to tha face-hand teat arc undifiad by nan: (b) attenttan. factor] arc ﬂame influnnning of tbs fa) factora. or atinnlna, (a) type of stimuli, (0) simultanaity d: subject, aga (o) atrensth a: stilnlua, (t) locua of atilnlation and (3) internal with tha fragment, Etna; alter fatter! lax atate or organiaa. aﬁpeur do change net but and that displaccnaut which Ixtinetien tbs pattern or face dalinanso. 1a in factor of tha teat a.na:or Iuardnaaa the aubaact'a 80th attention extinntiun. a: thy phannncnon of tho appearance ’)( awarenaai€£)1n.a and priviona axpnrionoa tun bring stimuli to two to were informed who Itinnli that unra adulta atria: or twanty Baoauaa proviaua of applied abouad extinction parcepta. be non. tan abet-nary rcaerd ta uaa intluensa.a response it experience in.ha1ve ﬂatbed aw this aubjccta. tha.f1ndinga on initial trial At the Ian» wan aintniacd. experience or previoua en. tactar number the ”alert" for he the on tine tbs aubjcct was not apt to ' �of stimuli he an: ta reeeive. cannequently ene night nay thet the reason the subject perceived only one Itinulul or perceived ene and diupleeed the the other at he atinnluu in that peﬁfypt 4 was not peying ettentlen. this aritieinn may be valid but the Iiznifieant fact it 9 //¢w » % that the error III always aide in the hand and net in_the‘teee. I: it were mere inattention one utula expect 50! or the single response: ta dauble einultaneeue stimulation ta be in the hand end 50% in.the flee. But this type or ehance enter was not ebterved. it the single reepenaes ta double lilultaneeul Iti-nluticn 95% were at the fete percent and 5% at the hand pereept. Iain pettern of race daninnnee or hand extinction examinetionl. further during subsequent eitublilhed Ill lereovee, when dinplneenent II. seen in normal aubJeetn, it was to the race and not ta the hand. ihin pattern at face daninnnee to deuble tinultnneaul stimulation was fauna to be exnggereted in nan-.1 young children, when 83$ deuanetrated either 33nd.extinetion or displeoenent at er the hand pereept to the face an the initial triel. loreover, this high percentage of face duuinnet reiponnet peruisted on eubuequent trielE. In the elder children ulna tece delineate we: consistently demonstrable. It It: noted that the younger the ahild, the more distinct In: thie puttern of race daninnnee. awn extinetion night he Ittributed to an mummy to perceive two ltﬂluli at once. Ehiu particulir detect has been noted in patient: with severe until change? (“Zlf'ﬁﬁevm in patient: with severe lentel changed or in young children itinuli epplied to both cheek: or both hands or.eny other two hanglegonn body even: were correctly reported as tee uenentione. Ihere it: _ �neither extinetion nor displacement. aaldstein'eKohuervatien, therafere, cannot be used an an explnnetion for hand extinetion. what matter daninanne in noted apparent flee that at It is types or etimnlltion was used. Simulteheoun pin prick stimulation: revealed the pattern of face daninenee, elthaugh with e leaner frequency than touch etinhiltiona. ether duteneeua utinuletion such :1 two tuning forks, hot and cold telperature tuhel, rtpetitive rubbing and repetitive pin prick Itianletian were Ipplied and neniteet regardless of the cuteneeun utilnletiun race daninence is ﬂied. inphrtmee of the ainulteneity or the ”man. has nlrudy been alluded to. In eubJeetn in when extinctidn In: persistent, consecutive epplieetion or the stimuli invariably resulted in the permeption or two stimuli. In actual Idultn consecutive the nun-L1 the on the even of two trial, we ma. etiluletion extihetioa. never resulted in -euuni thin thy nerd ntinuli intensity. at these ethdien In aux-aux, the for in inn-pom: the in pattern mum eliciting ”I. stimuli here teemingly mare readily perceived than equal etiuuli. After the first few trials the etheet was able to perdeive the two stimuli, even it one we: pnintul and the other not. In and diaextinction mental hhuevee, with chnhses, organic patient: quality, the wide dinorepency in pleeenent were manifest despite a of the stimuli. aw Altering the etrength a! the Itinhli, it ran hand the at the tram extinction response pdlaihle to alternate th teak) the' ta diepleaenent were hand the stieuli percept (if .gheek (if the head stimuli were utrang). The sneeze than extinhtien ulst the the at by quality elidited altering run displacement to The ' ‘ �13. touch the to ,Ievertheleac, frna prick. pin that ia atiunli, a at. a,ua oe'aaa the part: of the body being aianltanecnaly atianlated are have patterna. theae I! etudying consideration in another already alluded to the fact that extinction ie anat cannon in the hand and leaat in the face. In teating other body areaa the incidence of extinction and diaplaceaent ia leaa than in teating and ahcnlder thigh nay hand. and the testing the face Ithat is, not elicit extinction or cbacnraticn,where the faceehand teat will. Alec, in patients with leaicnn or the brain or apinal cord, the pattern or relationahip cf the body parts tc aiaultaneoua atinnlaticn.nay be altered in a characteriatic haniaenaery or ”level leaicn' ayndreae. Aa fer the aignificance cf the pattern be can the leaning before prayer further atndiea are neceaaary would be time purely thin deducticn.aade Any at interpreted. that by gained atating ia nothing For inatance, speculative. dcainance (7). of inpliea order aenccry rcatral a daninance face Such hypetheaia ia ccntradicted by at leaat one tact, naaely the ‘chaervaticn that when the hand and fact are atimlated eimltanecualy data are hand. after'ncre Perhapa the dcninatea over the fact accumulated a aatiafactcry theory night he obtained. , QUIIIRI: hand haa and race the cf teata in pattern in perception method cf the abnaraal and anh:ecta.hy been elicited in actual dcnble simultaneous atianlaticn of cutanacua uhdalitiea. hand the of percent extinction by Face delinance, aaniteat an a in seen the hand to race, the or percent or dicplaceaent the~ and in non-a1 the adulte, in naniteatcd normal phancaencn, aeriea. the exasined in and anhaaie cchiacphrenia with patienta A �15. with in m in menu:It 1: mcntod young «mum and what ,of ditpnouont the «unﬁt.» bran in an...” mitten: utter may}. mun . . um. m 1: at run or unite“ denim” usual.” pattern m: 1n the a only clung. {chucking the autumn- nodanw team, a! 11th in type “mum. .cxtincuoa' at rmugnay am. ‘ �m, mm W :m. In,” Wtiﬂl m t ‘4; “1,5151 m m m «some. mm m.“ 1.!” Id. “.3. mo mm. m, 19”.Mum-sic 3.: (I) cum... mm m mm. m, at unusual than. ”pm ma. a; M ammo 3.1.: Aug-mu m m ' Mm m mummy Mmkwém Datum 81mm!“ 11W. m. mnnmuumumumwmm mum. £1. Pittm‘03.; I. w m mum m; m. u-mmmuormmomm -.-.m: 1. (I) W 3.3. 1‘ “ ‘3) 2. (a) 3. I ‘ if... .5 . --... 08 , and - ...., 610: «.5 an .LL. -. > , ' and 813-191, 5 . 1 am. 1.1. 11.3.;and in 11.: @1162!!! 5. mwﬂw W mm. mmm In ﬁt an 6. . W Warm. to mom chum- as «W 1M6 61m 72: 5 nth m to frontal am “so. «poets of m may W Auwmmmm 5mm mm manna-mm. cm, R. and m max. mam... at 1956. tn “1. 1959. and 501.515. ,5 -. ‘0 117.121., _ ‘ 8.3. ILL! (o) 50 phonon-manor 1n 5......- 1'. 9: 3.1.: 9:135:19: wholes“ 1 ”“33; of pm1p1uuea m and 11014: 11.8.: (h) m1 mm mum. an 6.1.: w by 191111101111 166-1685 19195 tuna-Mon. �PATTERNS IN PERCEPTION By: ‘I 0—m— ON SIMULTANEOUS TESTS OF FACE AND HAND Morris B. Bender, M.D., Max Fink, M.D., and Martin Green, In previous studies we found that the method of double M.D. simultaneous stimulation showed defects in sensation (extinction) testing In which routine were not apparent on single stimulation. ; the two of body and various combinations it was different regions \, found that extinction was apt to occur most often in the hand and least in the face. Conversely, "dominance" was greatest in the face and least in the hand. In the present commuhication we wish to report simultaneous on obtained the results stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syndrome; disease 5) of the no 4) schizophrenia; ,‘ brain (normal adults) and 6) four of between normal children the ages to ten years. 'Patients in 5 2 showed and severe memory defects, confusion, poor orientation, groups difficulties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or fingers) were touched simultaneously. Care was taken to make two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked tox°eport what he felt, and following this, Where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the first-examination: a) a touch on the face only (face dominance), implying no sensation in the hand (extinction); . $1.1mMuTﬁzA kﬁWJqM 5.4.1:. �2. b) a touch on both sides of the face (there being "displacement" from the hand to the ipsilateral face); 0r 0) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that than one stimulus. on subsequent tests he was expectant of more In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislobalization was towards the face it appeared as if the face determined the direction of the displacement. It might be said, therefore, that this was a type of face dominance. Response (b), or diaplacement, was less common than response (a) or extinction. Response (b) was seen most often in the patients with the organic mental syndrome, and persisted despite repeated testing. The (c) responSe was the expected normal and needs no special comment. Extinction and displacement were also noted the ipsilateral face and hand were simultaneously tested. In all the subjects tested, including those with aphasia, there was no difference between the right and left sides of the body. Analysis of the results obtained in the various groups is shown in the following table: when �3. Group of Subjects Number 1 15 2 12 3 Face Response Extinction or Face and Hand‘ Hand Response Response ~ Displacement 9 6 O 12 O O 22 20 2 O 4 20 14 6 O 5 55 24 28 6 20 l l From - p . 19 o it is obvious that whenever there is sensation over another it is apparent in the face. the foregoing dominance of one p Dominance in the hand was noted only once. dominance Face was found almOSt uniformly in the subjects with.severe mental changes (groups 2 and 5.) These patients did not report sensation in the hand even after repeated testing. In a few instances, even after the patients were told there were two stimuli, or were asked towratch the application of the stimuli, they reported only one percept or displaced one. In these cases simultaneous stimulation of both sides of the face was reported correctly, thus excluding the objection that these patients were not able to<io or perceive two things at once. The incidence of face dominance in subjects with aphasia and those in with schizophrenia (groups 1 and 4) was less. In contrast to patients in groups 2 and 5, those in groups 1 and 4 reported both sensations correctly on the second, third or fourth trials, if they had not done so on the first trial.‘ In the group of normal adults (group 5) the incidence of face dominance was least, but still ' significant, a even though it was found only on the first trial. series of normal children the incidence of face dominance was In �In young children face dominance was present even several trials after the first examina- almost the same as in groups 2 and 5. tion. the face and parts of the body other than the hand were tested simultaneously in groups 2 and 3, face dominance was‘ The order of dominance was face, shoulder, grunk apparent. still When (breast), penis, thigh, calf, foot, arm and hand. In Conclusion: a wide variety of subjects the phenomena of extinction and displacement on double simultaneous stimulation were demonstrated. A consistent pattern of perception was established in which the face was most dominant and the hand the least. These findings were noted in both the abnormal and the normal subjects. -In the abnormal subjects withseVere mental changes, face dominance and hand extinction were so consistent that they may be used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, which are so prominent in patients with diffuse brain disease, appear to be exaggerations of the pattern found in the normal subjects, especially children. I � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. Trans Am Neurol Assoc. 1950;51:250-2. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2a-003 Date A point or period of time associated with an event in the lifecycle of the resource 1950 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Two preprints] and a reprint. Reprint from Transactions of the American Neurol Assoc. 1950;51:250-2. (abstract). Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a>; Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/abb942c109b57ff8986a7757e43563c2.pdf 23a7bbd876571d7517224c266ad15ea2 PDF Text Text Patterns in Perception on Simultaneous Tests of Face and Hand _ N...”- —-. MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK Reprinted from the Archives of Neurology and Psychiatry Septmnber 1951, Vol. 66, pp. 355-362 COPYRIGHT, 1951, .‘BY AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET CHICAGO 10, ILL. Printed and Published in the United States of America �Reprinted from the A. M. A. Archives of Neurology and Psychiatry September 1951, Vol. 66, pp. 355-362 Copyright, 1951, by American. Medical Association PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK it PREVIOUSLY was shown that examination of the cutaneous modalities by the method of double simultaneous stimulation elicited defects in perception which were not apparent on single stimulation. The defects, described as “extinction,” “obscuration,” “displacement,” and “allesthesia,” were observed in groups of patients with localized or diffuse disease of the central nervous system.1 In each group the defects in cutaneous perception obtained on double simultaneous stimula— tion were most apparent in the hand and least in the face. The object of the present investigation was to determine the patterns of in normal subjects, adults responses and children to simultaneous stimulation of the face and hand—the “face—hand” test.2 The observations on this normal were then compared to some extent group with the responses of patients with organic mental syndromes, aphasia, and schizophrenia. MATERIAL The “normal” subjects were children and adults. These subjects were persons attending hospital clinics in whom there was no evidence of disease of the brain, and school children, staff personnel, and students, in whom there was no manifest disorder of the central nervous system. None of them had been examined previously by the method of double simultaneous stimulation. From the Department of Neurology and Psychiatry, New York University College of Medicine; Bellevue Hospital, and the Mount Sinai Hospital. This work was aided (in part) by a research grant from the National Institutes of Health, United States Public Health Service, and (in part) by a grant from the Coordinating Council of Cerebral Palsy in New York City, Inc. 1. (a) Bender, M. B., and F'urlow, L. T.: Phenomenon of Visual Extinction in Homonymous Fields and Psychologic Principles Involved, Arch. Neurol. & Psychiat. 53:29—33 (Jan) 1945. (b) Bender, M. B.: Extinction and Precipitation of Cutaneous Sensations, ibid. 54:1—9 (July) 1945; (c) The Phenomenon of Sensory Displacement, ibid. 65:607-621 1951. (May) (d) Bender, M. B.; Shapiro, M. F and Schappell, A. W.: ., Extinction Phenomena in Hemiplegia, ibid. 62:717-724 (Dec.) 1949. (e) Bender, M. B. ; Wortis, S. B., and Cramer, J.: Organic Mental Syndrome with Phenomena of Extinction and Allesthesia, ibid. 59:273-291 (March) 1948. (f) Bender, M. B.; Shapiro, M. F., and Teuber, H. L.: Allesthesia and Disturbance of Body Scheme, ibid. 62:222-231 (Aug) 1949. (g) Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, ibid. 64:501—515 (Oct) 1950. 2. Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of the Face and Hand, Tr. Am. Neurol. A. 75:250—252, 1950. �2 The subjects were divided into three groups according to age: children of 3 to 6, and 7 to 12 yr., and “adults” over 12 yr. of age. For comparison with the normal group, we studied patients in the wards of the Bellevue Psychiatric Hospital. They were divided into three groups on the basis of their disease— schizophrenia, organic psychoses, and aphasia. No attempt was made to study separately the clinical types of schizophrenia. Most of the patients had the paranoid, mixed, or simple variety of schizophrenia. The patients with organic mental changes showed defects in memory, orientation, andcalculation, as well as other signs and symptoms. characteristic of diffuse disease of the brain. The clinical diagnoses for most of thesegpatients was Alzheimer’s’ disease, arteriosclerotic encephalopathy, severe cerebral trauma, brain tumor, or toxic encephalopathy. The subjects with aphasia were those who showed characteristic difﬁculties in communication. Those who had concomitant hemiparesis or ‘a hemisensory defect noticeable on single stimulation were not included in this series. MET HOD The subject was instructed to close the eyes. When this was done, the face (cheek) and either the ipsilateral or the contralateral hand (any part of the hand or digits) were simultaneously touched or stroked with the examiner’s ﬁngers. The subjects reported either one or two sensations. When only one percept was reported, the subject was asked if there was still another and, if so, to indicate its location and quality. After the initial trial, in each subject, the opposite cheek and hand were stimulated in the same manner. These tests were repeated and the results recorded, until the subjects consistently reported both stimuli correctly. In those subjects who failed to localize the two stimuli correctly ‘after six or eight trials, other parts of the body were tested in such combinations as face-face, hand-hand, face-breast, or penis-hand, these stimulations alternating with the facehand test. In a second, separate series of studies, pinprick stimuli were used in a similar fashion. In both series, care was taken to app-1y the stimuli at the same time and with the same intensity. It was apparent that subjects who made consistent errors in reporting would be correct as soon as the stimuli were applied consecutively rather than simultaneously, even if the time lag between stimuli was that of one or two moments. It was also necessary to use naive normal subjects, since subjects previously tested did not show the patterns noted below. RESULTS The responses obtained on the face-hand test fell into four groups: (a) a touch sensation on the face and the hand, indicating the correct and expected perception; (b) a touch sensation on the face only, implying no sensation in the hand; (6) a touch sensation on both sides of the face, and (d) a touch sensation on the hand only, implying none on the face. When only one stimulus was reported, the subject was asked if: there was any other sensation. The occasional reply was that there was another percept, and the subject correctly pointed to the second locus. Many subjects, however, reported that they had not perceived another stimulus, usually adding the statement: “I was not paying attention; do it again,” or, “I’m not sure; maybe it was somewhere over here,” and pointing in the direction of the side of the body of the poorly felt stimulus. In some instances, while correctly localizing the second percept, they volunteered the statement: “It was not as strong as the other one,” or “It doesn’t seem as sharp.” Before we proceed with the results, we must deﬁne the special terms used. In other communications the failure of the subject to report one of two simultaneously applied stimuli has been called “the phenomenon of sensory extinction,” or “extinction.” 1”“ b The part of the body where the stimulus was perceived is said to be “dominant” to the part of the body where the simultaneous stimulus was not per— ceived, or perceived faintly. The latter diminution in the quality of a sensation was ' �3. termed “obscuration.” When the subject reported two sensations, but mislocalized one of them, the “displacement” of a percept is said to have occurred.1c Displacements are usually in the direction of the dominant stimulus and may be partial or complete. The displacements noted in this series were from the hand to the cheek of the same side. Rarely did the displacements occur to the neck or shoulder. Initial Trial—The results were analyzed from the standpoint of initial and subsequent trials. On the initial trial of the face-hand test with touch stimulation in normal subjects, face dominance was apparent in all age groups. More than half of such normal adults reported the sensation in the face and none in the hand. Three subjects mislocalized the sensation in the hand to the face. In the groups of normal children, 90% under the age of 6 yr. reported only the face percept or mislocalized the hand percept to the face. This pattern of face dominance is also seen in the children from 7 to 12 yr. of age, but to a less extent. Of the normal subjects, ﬁve adults reported the hand stimulation only on the initial trial. N 0 example of displacement from face to hand was noted. This pattern of face dominance by hand extinction or by displacement of the hand percept to the face was even more apparent in the patients examined. It was most evident in patients with organic mental changes, 93% of whom did not report TABLE l.—Response to Touch Stimulation on Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia (unclassiﬁed) ............ Organic mental syndrome ............... Aphasia ................................. Total 160 56 76 74 120 23 Correct Responses 77 10 38 26 9 12 Face Only 75 28 27 45 94 11 Face-Face Hand Only 3 18 9 5 0 1 2 14 3 O O 2 both stimuli correctly. In examinations of schizophrenic subjects and patients with aphasia, responses similar to those of the normal adult were observed in the initial trial. Hand dominance was occasionally seen in the patient and rarely in the normal subject. In cases of hand dominance the subject reported the hand, but not the face, percept. It was seen in the initial trial in ﬁve normal adults. These subjects reported both stimuli correctly on subsequent testing. In the patients with organic mental changes hand dominance was an inconstant response, and repeated testing the same day, or on subsequent days, demonstrated the more usual persistent pattern of face dominance. Subsequent Thain—Of the 83 normal adults who made errors on the initial trial, 43 made correct responses on the second trial and 12 on the third trial. In a few subjects, four, ﬁve, or six trials were necessary before the two stimuli were correctly localized. These subjects were assumed to be normal, although complete psychological tests were not made. It was noted that anxiety (tension during examination or a strong desire to please) interfered with the early correct recog— nition of the stimuli. In all normal subjects, including those with anxiety, once the correct response was obtained (even after many trials with errors), it was elicited on all subsequent testing. It seemed as though a number of trials was necessary for �4 the subject to get into the “set” of the examination, and that, once in the set, he reported the stimuli accurately, even after the lapse of many days. In testing the normal young child, it was apparent that in most cases many trials were necessary before the correct response was consistently elicited. Also, the child did not always give a correct response on subsequent testing. Repeated testing over many days, however, elicited the same patterns of face dominance. .This was noted in 36 of the 56 children tested. In a number of instances the child watched the application of the stimuli and thus reported the perceptions correctly. But as soon as the test was repeated with the eyes closed, the child again reported only one stimulus. It was evident that the child could not get into the “set” of the examination, even with visual cues. This difﬁculty was not very apparent in all children. In the older (ages group 7 to 12 yr.) only 17 of the 76 failed to give the correct response after the initial few trials. A\\A A\4*A\ ‘~ 90 ‘___-c\‘ ~ ‘c____ .¢—————-—._—_——__———-—c 89 Responses 70 60 Dominant Face 50 Organic Mental Syndrome c--c Children, age 5 to 6 o——o Schizophrenic Adult Normal Adult 40 % 50 20 10 1 2 3 4 5 6 10 Responses to face~hand test on initial and subsequent trials. The responses obtained on repeated trials of the face-hand tests in normal sub— jects also followed a consistent pattern. As on the initial trial, face dominance was prevalent in all subjects. It was manifest either by (a) extinction or obscuration of hand stimuli or (b) displacement of hand stimuli to the face, or, in several instances, in a direction toward the face. In contrast to normal adults, patients with organic mental changes were unable to report the two stimuli correctly, even after many trials. When the patient reported the percept in one test correctly, he frequently failed on subsequent testing. It was also apparent that testing on subsequent days still elicited displacement and extinction of stimuli. This is in strong contrast to the responses of apparently normal subjects, who seldom made an error on subsequent trials, days after the initial examination. The responses obtained in this group demonstrated the patterns of face dominance in most of the tests. Displacement of the hand percept to �5 the face was frequent. In some instances displacement or extinction was present despite the fact that the patient watched the application of the stimuli to the face and hand. Extinction was very common on homolateral or heterologous testing, while displacement was apparent mostly on heterologous testing. The schizophrenic and the aphasic patients gave reports which were similar to those of normal adults. After the ﬁrst two trials percentage of error in hand sensation was slightly higher than in the normal group. Persistent bizarre responses were elicited from a number of the schizophrenic subjects. These reports included mul— tiple responses to single or double stimuli, persistent displacements to one area from any other body area, and mirror reversals of localization. These were inconsistent during an examination and from day to day. As with the normal adults, testing the schizophrenic or aphasic subject on consecutive days failed to elicit extinction phenomena once the test had accurately been reported before. A comparison of the responses of each of these groups to multiple testing is shown in the accompanying chart. Pinprick Stimulation—It is known that the type of stimulus applied inﬂuences the results in perception. To demonstrate the importance of this factor, similar groups of subjects were tested using two pinprick stimuli instead of two touch M TABLE 2,—Respoinse to Pinprick Stimulation an Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia ........................... Organic mental syndrome ............... Correct Total Responses Face Only 68 45 39 50 49 51 16 25 15 26 14 36 9 ' 13 33 Face-Face Hand Only 2 0 2 1 0 0 3 0 1 2 stimuli. With pinprick stimulation of the face and hand, face dominance was again manifest in all the groups. However, the incidence of error in perception of the pinprick in the hand was lower than that with a touch stimulus. The results are recorded in Table 2. Repeated testing with two pins in the'normal adult subjects elicited the correct responses in the intial three trials. Fewer of the children failed to report the test accurately after the initial trials. It was possible in a number of instances to alternate touch and pinprick stimulations and to demonstrate extinction to touch, but correct localization to pinprick. Moreover, with more intense pinprick stimulation, extinction and displacement were less frequently observed. These phenomena, namely, extinction and displacement, were even more apparent in the patients with organic mental syndromes. Displacement of touch stimu— lation could be alternated with correct localization of pinprick stimulation. A combination of touch to the face and pinprick to the hand evinced the combination of displacement and obscuration, as the patient reported “a touch on the face, and a dull one on the other side (of the face).” Pinprick to the cheek and touch to the hand resulted in extinction of the hand percept. or, occasionally, the report of a pinprick on both the cheek and the hand. The schizophrenic subjects were able to localize the pinprick stimulus accurately after the initial few trials, as had the normal adults. �6 COMMENT By using the method of double simultaneous stimulation in tests of the face and the hand, a consistent pattern of responses has been observed in a variety of sub— jects. The stimulus to the face is more readily perceived than the one to the hand. Moreover, the face percept inﬂuences the hand percept, frequently causing the displacement of sensation. This pattern of responses has been repeatedly demonstrated in both the normal and the abnormal subjects and is manifest in extinction, obscuration, and displacement. Extinction is most, and displacement is least, frequent. In extinction, the face percept is correctly reported as to quality and locus, but the hand stimulus is not perceived at all. In all the foregoing tests of patient or normal subjects, whether the responses were accurate or not, it was noted that the subject almost invariably pointed to the faceixsti‘mulus ﬁrst. Occasionally the hand percept was perceived and correctly localized, but assumed a qualitative difference, always of diminution. In displacement the stimulus to the hand was mislocalized to the face, or in the direction of the face, e. g., to the shoulder or neck. In some instances if the face and the hand of the same side were stimulated, the subject occasionally reported two sensations in the face. None of these phenomena was haphazard. While the frequency with which any one of these effects was observed might be affected by attention, drugs, or variation in stimuli, its pattern was consistent. These responses to the face-hand test are modiﬁed by many factors. Some of the inﬂuencing factors are (a) attention, (b) age of subject, (c) simultaneity of stimuli, (d) type of stimulus, (e) strength of stimulus, (f) locus of stimulation, and (9) internal state of organism. These factors may alter the frequency with which extinc— tion and displacement appear, but they do not change the pattern of face dominance. The subject’s awareness of the test is a major factor in the appearance of the phenomenon of extinction. Both attention and previous experience can bring stimuli to awareness. In a series of 20 adults who were informed that two stimuli were to be applied, none showed extinction of percepts. Because previous experience can inﬂuence a response, it was necessary to record the ﬁndings on initial trial in naive subjects. By this method the factor of previous experience was minimized. At the same time, the subject was not apt to be on the “alert” for the number of stimuli he was to receive. Consequently, one might say that the reason the subject perceived only one stimulus, or perceived one stimulus and displaced the percept of the other, is that he was not paying attentio‘n.3 This criticism may be valid, but the signiﬁcant fact is that the error was always made in the hand and not in the face. If it were mere inattention, one would expect 50% of the single responses to double simultaneous stimulation to be in the hand and 50% in the face. But this type of chance error was not observed. Of the single responses to double simultaneous stimulation, 95% were of the face percept and 5% of the hand percept. This pattern of face dominance or hand extinction was further established during subsequent examinations. Moreover, when displacement was seen in normal subjects, it was to the face and not to the hand. This pattern of face dominance to double simultaneous stimulation was found to be exaggerated in normal young children, of whom 83% demonstrated either hand extinction or displacement of the hand percept to the face on the initial trial. Critchley, M.: The Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions, Brain 72:538—561, 1949. 3. �7 Moreover, this high percentage of responses of face dominance persisted on sub— sequent trials. In the older children, also, face dominance was consistently demon— strable. It was noted that the younger the child, the more distinct was this pattern of face dominance. Hand extinction might be attributed to an inability to perceive two stimuli at once. This particular defect has been noted in patients with severe mental changes by Goldstein.4 However, in patients with severe mental changes or in chil— young dren stimuli applied to both cheeks, or both hands, or any other two homologous body areas were correctly reported as two sensations. There was neither extinction nor displacement. Goldstein’s observation, therefore, cannot be used as an explana— tion of hand extinction. It is noted that face dominance was apparent no matter what type of stimula— tion was used. Simultaneous pinprick stimulations revealed the pattern of face dominance, although with a lower frequency than touch stimulations. Other cutaneous stimulation, such as application of two tuning forks or hot and cold tubes, repetitive rubbing, and repetitive pinprick stimulation, was used, and face dominance was manifest regardless of the cutaneous stimulation employed. The importance of the simultaneity of the stimuli has already been alluded to. In subjects in whom extinction was persistent, consecutive application of the stimuli invariably resulted in the perception of two stimuli. In normal adults consecutive stimulatiOn of the face and the hand, even on the initial trial, never resulted in extinction. In these studies the stimuli were of equal intensity. This factor was important in eliciting the pattern in the normal subject, for unequal stimuli were seemingly more readily perceived than equal stimuli. After the ﬁrst few trials the subject was able to perceive the two stimuli, even if one was painful and the other not. In patients with organic mental changes, however, extinction and displacement were manifest despite a wide discrepancy in the quality of the stimuli. By altering the strength of the stimuli, it was possible to alter the response from extinction of the hand percept (if the hand stimulus was weak) to displacement to the cheek (if the hand stimulus was strong). The change from extinction to displacement was also elicited by altering the quality of the stimuli, that is, from touch to'pinprick. Nevertheless, the pattern of face dominance was always apparent. The parts of the body being simultaneously stimulated is another consideration in studying these patterns. We have already alluded to the fact that extinction is commonest in the hand and least in the face. In testing other body areas, the incidence of extinction and displacement is less than in testing the face and the hand. That is, testing shoulder and thigh may not elicit extinction or obscuration, whereas the face-hand test may. Also, in patients with lesions of the brain or spinal cord, the pattern of relation of the body parts to simultaneous stimulation may be altered in a characteristic hemisensory or “level-lesion” syndrome. Further studies are necessary before the signiﬁcance of the pattern can be interpreted. Any deduction made at this time would be purely speculative. For instance, nothing is gained by stating that face dominance implies a rostral order of sensory dominance.5 Such a 4. Goldstein, K.:: The Mental Changes Due to Frontal Lobe Damage, J. Psychol. 17:187, 1944. 5. Cohn, R., and Raines, G. N.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance ‘as Determined by Ipsilateral Simultaneous Stimulation, Tr. Am. Neurol. A. 74:162-168, 1949. �8 hypothesis is contradicted by at least one fact, namely, the observation that when the hand and foot are stimulated simultaneously the foot dominates over the hand. Perhaps after more data are accumulated a satisfactory theory may be obtained. SUMMARY _. “awn—a, elicited in normal and abnormal subjects by the method of double simultaneous stimulation of cutaneous modalities. Face dominance, manifest by extinction of the hand percept or by dlsplacement 0f the handmpercept to the face, is seen as a normal phenomenon, manifested1n the normal adults andin the patients with schizophrenia and aphasia examined in the series. It is exaggerated in young children and in patients with diffuse disease of the brain, in whom extinction and displacement are persistent after multiple trials. This pattern of face dominance is manifest regardless of the cutaneous modality tested, there being a change only in the frequency of extinction with change in type of stimulus. j Printed and Published in the United States of America / f / r: L/nAJ/C’ ..... . � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. AMA Arch Neurol Psychiatry. 1951 Sep; 66(3): 355-62. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2b-004 Date A point or period of time associated with an event in the lifecycle of the resource 1951 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from the Archives of Neurology and Psychiatry September 1951, vol. 66, pp. 355-362. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/718a29ec15d25cbb6a477d3556be0fdd.pdf da7a7236e5d976ec8ac1cfd95b801264 PDF Text Text EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADERMAN, M.D., AND MAX FINK, M.D.1 [Reprinted from THE AMERICAN JOURNAL or Vol. 116, No. 9, March, 1960] PSYCHIATRY, �1960 ] CLINICAL NOTES 839 EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADEBMAN, M.D., AND MAX FINK, M.D.1 While many technics for the administration of insulin in insulin coma therapy have been advocated(3), recent reports(4) have assessed multiple divided doses as more effective and safer than other methods. Previous studies indicated that the production of coma was directly related to the level of hypoglycemia and its duration (1) and that deep coma for sustained periods was essential to the treatment result in insulin therapy(2, 3). It seemed reasonable to test the suggestion of increase-d efﬁcacy for a modiﬁed insulin administration by comparing the length and depth of coma and the blood sugar levels in patients treated both by single and divided insulin dose methods. If the divided dose schedule were more effective, it would be expected that the induced coma would be equal or greater in depth and duration; that the time for onset would be equal or shorter; and the blood sugar levels lower for divided dosage than single administration. the dose was increased in 10 unit incre— ments. At the time when coma was produced, a single dose equivalent to the 3 doses was given on the succeeding day. For each treatment, coma depth and the time of onset was determined. Coma was deﬁned as the loss of consciousness (failure to respond meaningfully to verbal signals), associated with the appearance of the Babinski reﬂex, and the loss of the lid reﬂex. An adequate coma treatment was deﬁned as the persistence of this depth of coma, or deeper (loss of pupillary or corneal reﬂexes) for at least one hour. At half-hour intervals true blood sugar levels were serially determined by the Somogyi method. The resulting blood sugar curves and their level at the time of onset of coma, were compared for each subject with the blood sugar curve and coma data obtained on a single administration of an equivalent dose. METHOD The blood sugar levels at various intervals after the administration of divided doses of insulin compared with a single dose of insulin in one patient is presented in Figure 1. This pattern has been reproduced in each of the patients studied. For each, the blood sugar curve drops rapidly in the ﬁrst hour without respect to the initial dose, and ﬂattens at progressively lower levels as the total dosage of insulin increases. Coma characteristically is reported in subjects in whom the blood sugar curve is below 21 mg.% for an extended period of time(1). The time of onset of coma and the blood sugar level at coma in each of the patients is presented in Table 1. In ﬁve of the 6 Consecutive patients referred for insulin coma therapy were given daily increasing amounts of insulin in 3 divided doses until a coma level was achieved. The same total dosage was then given in one injection. Six patients were studied in this manner. Each patient was started on the following insulin dose schedule : ﬁrst day—10 units; second day—10 units and 2 doses of 5 units each at intervals of one half hour; third day—3 doses of 10 units at half hour intervals ; and fourth day—20 units followed by 2 doses of 10 units. On each successive day From the Departments of Internal Medicine and Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. 1., N. Y. 1 [Reprinted from THE OBSERVATIONS AMERICAN JOURNAL OF PSYCHIATRY, Vol. 116, No. 9, March, 1960] �' 'n' 9 Ir" : 840 CLINICAL NOTES [ March I % TRUE BLOOD SUGAR LEVELS FOLLOWING ADMINISTRATION OF INSULIN IN DIVIDED AND SINGLE DOSE SCHEDULES 9 9° ~7‘ 9; 8° 3 O \\ .- _ \\ I \ 7o \.\ as INSULIN DOSAGE IN UNITS 20.20.20... —---— 10.70.70... .......... 90.90.90“. ———-— ...q’ \ \\ '\ ———- AT auo MINJNYEuRVALS “ " “ I20,I20.I20u." —'-— 360u. IN " " " SINGLE DOSE E K <1 0D U) D oo _J with divided doses in 4 of the 6 cases. It was identical in one and lower with the divided dose in one. As there was no evidence in these studies that the divided dose method was more effective in the production of insulin coma than the single dose method, the divided dose technic was discontinued. m CONCLUSIONS MI 3 a: [— O 60 90 IZO I50 TIME IN MINUTES AFTER ADMINISTRATION 30 IBO ZIO OF INITIAL DOSE 240 cases, there was no difference in the time required to induce coma by either the single or the divided dose methods. In one subject (Sc) coma was observed in 132’) hours with a single dose as compared with 3 hours with divided doses. TABLE 1 ONSET OF COMA AND BLOOD SUGAR WITH DIVIDED AND SINGLE DOSAGE SCHEDULES PT D G H c So V Time for Coma Blood Sugar Value (minutes) (mg. %) Insulin Divided Single Divided Single U nit: Dore Dore Dose Dose 330 360 270 390 360 210 210 210 210 180 210 135 190 210 210 90 210 150 4 14 15 12 12 8 0 4 15 7 8 20 The average blood sugar at the time of coma was lower with the single doses than The coma produced with the divided insulin doses did not occur earlier and was not deeper than that produced by the single dose. The increased effort in divided dose schedules is justiﬁed neither by increased safety nor by increased depth or duration of the induced hypoglycemia. There was no, evidence that the initial dose of insulin sensitized the subject so that subsequent doses produced a greater hypoglycemic effect. The total hypoglycemic effect of divided doses appears to be less, if anything, than the effect of a single dose. BIBLIOGRAPHY 1. Blumberg, A. G., Cohen, L., Croghan, J., and Kelsey, D.: J. Hillside Hospital, 5: 41, 1956. 2. Fink, M.: J. Hillside Hospital, 6: 197, 1957. 3. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and Other Treatments in Psychiatry. New York: Crune & Stratton, 1952. 4. Laqueur, H. P., and LaBurt, H. A.: Proc. Annual Meeting, American Psychiatric Association, Phila., 1959. �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Efficacy of divided and single dose schedules in insulin coma therapy. Am J Psychiatry. 1960 Mar; 116:839-40. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-43-009 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Blumberg, Arnold G.; Laderman, Peter; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint from THE AMERICAN JOURNAL of PSYCHIATRY, Vol. 116, No. 9, March, 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/796682f73a8899c60e07650432e2be6b.pdf 47708d42bc2c57225df86d2abf4a24c9 PDF Text Text W“ m mate” om' n“, 0" a: “e, x I! ‘e swam mature: M Md." 'ene etmluletlon or the tune and the head.w1th cuteneeue etilull e ceneleteht pattern or reepanee hee been oheerved 1a which errore in perception ere Ib’. frequent an the head then on the reae. In thle ﬂeet eltuetlon the reee 1e eeld to he dullnent over the head. the pettern or teoe dullnenhe cen he found in nah-e1 end eohleophrenle ednlte hue 1e verticalerlr evident in petleute with oreehle eentel eyndruee end in children 3 to 6 yeere or eye. rhe pattern wee eo eoneplouohe thet 1t pranpted as to etuay different etilulue ooehauetlohe in order to detehelhe whether eoneletent petterue occur for body part: other then the reee end head. The eehhod at heeelns 1n hhe preeent etudr wee elesler to theh deeorlhed prevtouely. The euhjeet wee requeeted to alone hle eyee end twh perte at the had: were teuohed eteulteneauely. he wee eehed whet he felt end to loanltee the eel-ﬁll. Teenty heeleute with arsenlo wentel eyndehee due to altruee Meet» at the brain formed the sun group or etheote . The following pert: or the body were etudledz tece, ehoulder. head. heck. hreeet, ehdalen. aenltel eeglou. buttock, thigh end toot. All #5 peeelble ouehlnetlone between these body perks were heeted e9 the: eeeh or the ereee wee teeted 1n ouehtnetlon with every other eree. fen heehe or eeoh cuehlnetloh were done in every petlent in e tench-leed cheer. !heee included teetlnz the body ereee 1n hath hetereloeoue end haeoleterel reletlohehlpe. Flee hundred and tart: teat: or elehlteneune 0n elwulteneoue etheuletlon were done on each patient. eeoond group of 178* euhgeote eoneletlhs at 660 nereel edulte, 58! echleopheenlo edulte end she patiente with arsenic hence: eyhdrnee A �studied. the etheote in theee groove eere teeted with eiualteheoue etinnli out not in en hen: oomhinetione ee eee done in were eleo the previoue group. Only 13 or the t5 poeeihle bod: continetione were studied end different groove of petiente were need for each continetion. it leeet lo teete were done on every patient. Pertiouler ettention eel directed to the initiel reeponee. the reeponeee on eilnlteneoue teeting in ell euhjeote fell into two senerel groupe. rhe etheot either reported both eti-oli correctly or reported only one etieulue ooereotly end either did not perceive the eeoond eti-ulue (extinotion) or'nielooelieed it (diepleoeeent). rho totel number or errors in peroeption over one pert or the body ee ooeoeteo to the other part of the body in eeoh continetion eere euelyeed by etetietioel lethode. In the tiret group or 20 petiente with orgenie heeiu dieeeee teeted h: the aethod of multiple triele there were 27 oolhinetione in ehioh the difference in the mocha: of extinction end dieoleoenent in the two body perte teeted eee etetietioelly eicnirieent. this occurred in ell continetione in ehioh one or the two perte nee the reee, the genital tone (nele end tenele), or the head. In the continetione involving the teoe or the cenitel none errore ih per» oeption were more frequent in pert: or the body other then theee bod: ereee. the (poo end the genital zone ney be eeid to he dolinent to ell other ereee or the body. In combinetione involving the head there eere uooeerrore in peroeption or the head etinnlue then in en: other pelted part or the body. ‘rhe hand new be eeid to be the leeet dolinlnt are. or the body. there were four additional combinationin which dominance wee Innifeeted. !he hottook wee doniuent over the heok aha ehoulder. the breeet wee dolinent over the heck, end the heck lee douinlht over the thigh. �3. 4‘.“ in anniyuil of tho rcspensca or and accend group at pitiontn with organic Iantal nvndrunn who HUI. touted in u tingle bady ounbinatien with.» than in multiplt culbinltions ahowua a liliilr pattern. inn». unto I few important axooptionn howrvor. who race an: round to b. otvonsly dominant ever tha genital tout, the foot duuinunt over the thigh And tho buttock duninant over tho fact. .. _ they. relationuhipu wart not tpplront in in. group or patients tottod by tn. Inthod of multiple trials. Th. foregoing rcuuits that that an inns. or duubic uinuitanaaul ”manna in panama um auntie mm, swarm. the "rim part: or the bear cxhibit a infinite volttianship to on. another: ﬁhin 1i aunitoutcd hi Vlrvins accrue or dnlinnnoc which.lay ht can~ Iidorod a: gradient 0: nonnation. it the top of en. gridiont in V ' . m «um Ian. in slightly 1.» doninnnt um the he. the mu. but in dalinnnt «var all other part: of tn. bad: and i: thnrgby tho host bad: tron in tho order of dalinanoc. it tho 9th.! 0nd of tho gradient is en. hand. In. runninins aria. at thu body tail bctuoon tho no. Ind um and an acne. mu. body pm. mud in oeubinntion Iii: «ﬂab other failed. for tho most part, to yield differtnoos in duninuaoc’cnous than other. Th0 combinstionl in which daninanoc who Innitontod showed a tondcncy for the hulbek, than-0n. brains, and taat to ho tho mare dominant part: uni tho hack. magniﬁer, denim“ par:- within this ﬁrm. rand cum to be the In tun series or nanlni and nahisophrcnie adult: that. uvrc only tun «albinationl in uhieh Eh. dirrorgnoo in the number at error: men in“ between the two ptrti ati-ulatod it! statintioclly significant. duninant over eh. bruit: and the brnant wax dominant ovar tn. hind. In both instance: in. pitttrn or danintnoa in: ailiitr to that Icon in patient: with organic anneal Iyndrnnn. Th. rhea III �m mm or ammo. duomtmtod by suntan-m "Inns in ﬂinch the no. Ind tho him! for! 2!!! at"... of I Mont the body pain hu :1» been dam-tum 1n mucosa other than than with eman- «mm. or the mean. when include nomx 01:11am 3 to 6 or m, nut-t1 adults with transient damnation or the built: an. to imam“, unamor among m «lacuna-hook therapy, in! under 7 your: . not all th- :utnum mu, ma), «noun Mult- with mum use ymine we: ombmuona have been «an: Mu. ﬂavour, at then ammun- um have been smut! a pattern 1: atom: in mm the no. 13 the most dominant m: and ﬂu hind the lone 60.1mm. for n the»: to «at: u. mm or 4mm“ mun, none in It appear. to b. an inherent ”turn 9: organization within the mm}. ”an“: man 1.. exaggerated in tested in than ' u «than. patient: an: u m «an. or the pram. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Order of dominance in cutaneous perception. Trans Am Neurol Assoc. 1952; 56 (77th Meeting): 238-40. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-7a-010 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource Green, M.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Bender, M.B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/c779b264e0ba3e779d39ff5db1a0879e.pdf d5ea2d1f830983dbe61a4c62d8e73b61 PDF Text Text Significance of Individual Variability in EEG Response to Electroshock Martin A. Green, From M. D. the Department of ExPerimental Psychiatry, Hillside Hospital, Glen Oaks, N. 10-11-57 "r .50 �Significance of Individual Variability in EEG The assumption Response to Electroshock is often tacitly made in studies of nervous system function that the capacity for neurophysiological change is similar for animals or humans in the groups under study. Differences in response are ascribed to different parameters of the stimulus or to differences in the location and extent of lesions, either spontaneous or experimentally produced. tion may Such an assump» Perhaps another factor in the not be warranted, however. variability of response under these conditions is an individual variability in neurophysio— logical reactivity or responsiveness. The initial "base-line" may not be similar in all individuals. The possibility of different inherent patterns of reactivity has suggested by the studies of the alterations in the have been impressed by the high degree of EEG been during electroshock. variability in such We alterations both in their quantitative and qualitative aspects. Although this variability has been described by previous investigators, it has not been stressed sufficiently; nor have possible explanations been advanced or systematically investigated. present report concerns a description of the changes in the EEG Hillside Hospital during electroshock in the/' material. The concept of neurophysiological The reactivity is presented and studies that may clarify this problem are suggested. �MATERIAL AND METHODS: Eighty-nine patients were studied. The patients who received electroshock for psychiatric illness Hillside Hospital and were voluntary admissions to the majority had not received electroshock previously. The diagnostic groups and schizophrenia. psychosis manic~depressive included psychotic depression, The largest group was patients with depression. Agesranged from 20 to 68 years, with a median of #7 years. Treatments were given three times weekly, each patient receiving at least 12 treatments. The Medcraft instrument (alternating current) was used 61 for current) for 28 patients and the Reiter instrument (unidirectional patients. Electroencephalograms were taken prior to, and two weeks following the course of treatment. EEG was abnormal were to 36 weekly Patients specifically excluded from study. 2h (from day non-treatment a an at whose intervals during, pre-treatment Tracings were done on hours following the previous treatment) with eight channel Medcraft machine using needle electrodes. Frontal, motor, and earlobe vertex temporal, posterior temporal, anterior parietal, occipital, placements were employed with scalp to scalp and scalp to earlobe combinations. �RESULTS : I. Delta Activity. A. Quantitative Differences: delta activity The to the method described by Fink and (8). Kahn The was analyzed according duration of burst activity, the lowest frequency, the average delta index in several leads, the highest measured. were lead one in time delta and the percent highest amplitude, Re— cords were classified as showing a low, middle or high degree of delta activity (Fig. 1) according to criteria previously described (8). All patients developed delta activity during the course of but differences in the amount of the slow activity and were very apparent (Table I). Some early in treatment whereas other even after serial 12 EEG's. not develop in treatments. As treatments of development patients developed "high delta activity" patients showed only "low" or "middle" changes latter patients were followed further with treatment was continued, a high degree of delta activity did some of these patients until on a daily basis. This individual variability in treatments were given change. These its rate 12 20 or more They were EEG treatments, or until resistant to neurophysiologic response was independent of the type of electroshock current employed, being present both with unidirecticnal current applications. alternating and with �- h TABLE Degree of Delta I Activity in Serial Electroencephalograms during Electroshock (2-n records were taken for each patient) No. Activity EEG No change delta activity Low Middle High B. may be ity. - EST 1 delta activity delta activity of Records in Each Treatment Period u L:..§ 3 l 37 21 7 3 20 22 10 1 28 #5 25 1 16 amount of delta the activity Although total Differences: Qualitative activ~ and of delta voltage to frequency records as differ type, similar, One prominent qualitative difference during a course of 12 treatments. is in the form of bursts which as treatments are continued. is the ratio of irregular delta In some patients the become more The show burst activity initial delta change frequent, slower and of higher voltage irregular delta activity in such records is less prominent and usually occurs at faster frequencies. In other patients the reverse occurs. form. 12 0 5 activity to bursts of slow activity. Nearly all records much - 10 Although burst Delta activity appears chiefly in an irregular and scattered activity is also present, third group of patients the amounts of it is not conspicuous. irregular delta and In a bursts are approx- imately equal (Fig. 2). These differences in the form that the delta activity assumes is usually constant during the course of treatment. At times, however, burst activity will �. become more prominent - 5 than the irregular delta only during the latter part of the course of treatment; or burst activity which appears prominent early in treatment may be overshadowed and obscured in later records by a large amount of continuous irregular delta activity. The slow activity is maximal electrodes and less pronounced at the at the anterior temporal more frontal and posterior electrodes. Often asymmetric, being of higher voltage, slower, and in greater amounts anterior temporal Only and frontal electrodes as asymmetry occurs during treatment both with is at the left to the right (Fig. 2). compared rarely is the reverse true, i.e. accentuation it on the right side. This alternating and with unidirectional currents. Another type of abnormality, though an infrequent one, of rhythmic runs of delta activity which (Fig. 2). The may continue for 10 is the to 20 seconds regularity of the frequency and voltage of the slow these runs is very striking. appearance waves in These runs are usually infrequent, but may be the most prominent alteration in the record. In many records the amount of delta activity fluctuates during the tracing. At times, some in other parts of the This variation II. is portions of a record same may appear nearly normal, while record the delta activity may be quite pronounced. independent of the electrode combinations employed. Spike or Spike-Wave Activity: A large number of records or high voltage. Most show single spike activity of low, moderate often such spikes are slower and not as prominent as �- 6 - those present in patients with seizure disorders. show spikenwave A small number of records activity. This is usually at irregular, mixed frequencies and, again, does not resemble the regular rhythmic bursts commonly seen in patients with seizure disorders (Fig. 2). III. Alpha Activity: The alpha activity shows changes both in amount and frequency. As the amount of delta activity increases the amount of alpha activity usually decreases. Changes in frequency occur but are not pronounced. will be slowed by 1-2 cps but tracing. In a small number at times will remain the same The frequency as in the pre-ECT of patients the amount and voltage of alpha activity increases during treatment. This change persists during the post-treatment period after the slow-wave activity subsides (Fig. 3). IV. Beta Activity: The fact that activity in the EEG many and the induce fast barbiturates, particularly sedatives, of administration the in controlling difficulty these drugs in this population studied makes during the course of treatment. are minimal. activity. The most it difficult to evaluate changes In most instances changes in fast activity frequent change, when present, is a decrease in the �Discussion: is that of the individual variability in the As EEG described, electroshock therapy. and of during alteration degree type and of rate slow-wave amount of its the activity manifested in: l) this is (amount slow-wave the in activity differences 2) development; qualitative The problem being raised of burst activity vs irregular delta activity, symmetry, fluctuating appearof 3) slow activity); of presence rhythmic slow of runs ance activity, Spike or spike-z-rave activity; and LL) changes in alpha and beta Previous investigations (2, h, 5, 10, have ll, activity. 12, 1h, 17, 18, 19, 20, 25) stressed possible correlations with age , sex, frequency of treatment, and clinical change. diagnosis, employed, of current psychiatric type Increasin" the frequency of treatment, for example, will increase the degree of similar sex, age and the with same the frequency treatments at given are psychiatric diagnosis same type of electroshock current, variability in the rate of development of alteration in the EEG. However, when "ratients their type anc‘. degree are still very prominent. One explanation for this variability might be the distribution of the electroshock current in the brain. Perhaps minor differences in the resistance of changes in the EEG and and blooc‘ vessels of the distribution of the skull, in their penneability or taken the pathways in differences create of tracts nerve in the arrangement the of brain portions different such Unler circmnstances, the current. by may receive more or less current in one patient as compared to another. variously these by generated of the electrical activity Differences in type affected areas might account for variability in the EEG. Available studies employing direct intracerebral measurements indicate considerable diffusion of current throughout the brain (6, 9, 16, 21). �However, a concentration of current anteriorly and along: large neuronal pathways, such as the corpus callosmn, has been demonstrated. No further infon'ration is available as to amounts of current received. by more Specific cerebral areas. Due to the high resistance of the skull only a small portion of the applied. current actually reaches the brain. The amount of current entering different portions of the brain is said to be determined by the resistance of the skull overlying these areas; the anterior concentration of current being; the result of the thinness of the temporal bone with its consequent lower resistance as compared to other parts of the skull (9, 21). Several considerations, however, indicate that individual differences in these factors of resistance and amount of areas of the brain are of minor, during-g electroshock. It is if current reaching,- different any, importance in the ELG response the occurrence of the generalized seizure 291'. §_e_, rather than the passage of electricity, which is the primary factor. During a course of grand-mall therapy induced by non-electrical means such as metrazol, EEG changes occur which are similar, with electroshock (13, 1h). Diffuse slow-wave in general, to those seen activity, accentuated of The amount described. are activity anteriorly, slow—wave activity increases during treatment but shows individual variability unrelated; to the n unber of treatments. Another observation is that electroand 81‘.de or spike-wave shock therapy nhich induces petit-mal (7, 18) or focal (3) seizures rather than grand-mal, does not produce the characteristic build-up of slow-wave activity. In addition, there is no increase in the degree of delta activity in our patients in whom grand-mal tae rapy is given with high suprathreshold stimuli as compared to those in whom threaiold stimuli are used. �-9- . Factors of current cannot be entirely dismissed, however. Even with grand mal therapy, the type of current employed may influence the we haVe EEG change. confirmed a previous study (20) showing that the rate of increase of delta activity is slower in therapy with unidirectional current than in that with alternating current. Similarly, brief stimulus therapy is said to produce smaller degrees of alteration in the EEG as compared to alternating current therapy (15). The EEG other theory to be considered in explaining the variability in re5ponsiveness, and the one which is probably more determinant, involves inherent differences in neurophysiological reactivity. By this is meant both the quantitative and qualitative aspects of the inherent capacity of the nervous system to respond to stimuli or injury. Not only the degree of response, but also the type of response, type and degree of EEG may have these determinants. The abnormalities developed during electroshock therapy appear to be the reflection of such inherent individual differences in neurophysiological reactivity. Several types of investigation Methods other than electroshock may known serve to to produce test this hypothesis. EEG alterations could be applied prior to treatment. These might include lowering the blood sugar by parenteral insulin, intravenous administration of convulsants such as metrazol or Hegimide, photic stimulation, or the intravenous administration of drugs such as barbiturate. In addition, perhaps the actual electroshock seizure ﬂzreshold or the pattern 0: severity of the seizures measure of nervous system responsiveness. Data from such could be correlated with the degree an? types of shock. In this manner it might be ELG may be a investigations change during electro- possible to demonstrate different patterns �410- classify individuals accordingly. not only help in understanding the variability in reactivity of neurophysiological Such studies may and alterations during electroshock but would have wider application to other problems in clinical electroencephalography and neurology. For example, tie basis for the development of Spontaneous seizures secondary the EEG to traumatic, vascular, or neoplastic lesions of the nervous system known. Patients with lesions comparable in type, size and location or may not develop seizures. As previously described, spike or Spike-wave activity during electroshock. difference in not may subjects some show This suggests an inherent clinical seizures or he capacity to develop is EEG seizure is reflected in the whether the to injury nervous system, "injury" following activity spontaneous or induced. Differences in this capacity may be varying patterns of neurophysiological reactivity. Differences in neurophysiological reactivity in the pre-troatment abnormal (ll), EEG. Patients in whom "instabile" (22), or axons may also be manifested the pre-treatment record is a predominant alpha rhythm (S) LEG the in during electroshock. the alteration to said develop greatest are Other investigators have not confirmed these observations (2, 23). Actually, such correlations depend on the method of analysis of the pre-treatment criteria used for "abnormality." Further investigation of this relationship is necessary. Suggesting that neurophysiological reactivity is an inherent process does not imply that a physiological basis does not exist or cannot be in- record employed and the vestigated. This may reside in the central nervous system itself, consisting of individual differences in neurochemical systems or in the permeability of cells-or blood vessels; or it may be outside the nervous system. Individual �‘11- differences in hormonal or other humeral substances produced during the stress of electrosho k may serve to "sensitize" or "desensitize" the cerebrum with regard to developing ical activity. That such factors following studies. Trypan red different may be amounts and types of electr- operative is suggested by the injected intraperitoneally in cats before a course of electroshock decreased the permeability of the blood~brain barrier and reduced the degree of EEG changes as compared to control animals (1). Atropine and scopolamine adminstered during a course of electnodiock in man blocked the development of the usual slowawave activity (2h). Electroshock therapy affords an excellent opportunity for the experimental investigation of the problem of an inherent neurophysiological reactivity. animals. The One is able to apply studies directly to man, rather than stimulus to the central nervous system can be standardized and the degree of neurophysiological change changing different parameters. controlled, within limits, by Tests of 336 responsivity can be given before such dianges are induced as well as during and after treahnent. Re-study of patients is often possible then subsequent courses of treatment are necessary. �.12.. marl: l. Indiviéual EEG the in qualitative, changes during a course of electroshock treatment in 89 patients are éifferences, both quantitative and described. 2. These differences are pronounced and are not explainable by age, sex, type of shock current, frequency of treatment, psychiatric diagnosis, or clinical change. 3. An inherent capacity for neurophysiological change that has both quan- titative and qualitative aSpects may be the primary determinant of these differences. h. Variation in skull resistance and in the amount of current reaching the brain aspear to be minor factors. 5. Investigations that might serve to described. Such studies may test the hypothesis presented are lead eventually to a classification of individuals as to different patterns of neurophysiological reactivity and clarify other problems in clinical neurology and electroencephalography. �é 13 - REFERENCES l. Aird, R.B., Strait, (1956): S.C. and Bowditch, M.K., Hrenoff, L.A., Pace, J.w., Current Pathway and Neurophysiological Effects of Electri- J. cally Induced Convulsions. Nerv. Ment. & Dis., igg: Bagchi, B.K., Howell, R.W. and Schmale, H.T. (l9h5): alographic and The J. Pszchiat., lgg: h9-61. Am. R. (1953): and S. Feinstein, Berg, Impastato, D.J., P.S., Bergman, Electroencephalographic Changes Following Focal Seizures, Conf. Neurol.hl§: Electroshock, EEG. Chusid, J.G. and Pacella, B.L. (1952): Electric 271-277. Clin. Neurgghxs., g: Shock Therapies, J. Electrically Induced Slow Wave Phenomena Callaway, E. and Boucher, F. (1950): 157~162. Neuro. Ment. H. Dis., llé‘ (1953): shock on the Cortical and Intracerebral shock Process, M. J. Nerv. and Kahn, B.L.: & Response in Electroshock: Arch. Neurol. Hayes, K.J. (1950): Arch. Neurol. & The & 95—107. Electroactivity of the l3: 287-29h. Experimental Studies of the Electro- Ment. Dis. Relation of in Effects of Electrou Brain in Schizophrenic Patients, Conf. Neurol., M., Kabn, B.L. and Green, MLA.: in Intensive The Electroencephalogram Delgado, J.M.R., Alexander, L. and Hamlin, Fink, Electroenceph- Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders. Fink, 505-512. EEG (in press). Delta Activity to Behavioral Quantitative Serial Studies, A.M.A., Pszphiat. (in press). Current Path in Electric Convulsion Shock, Psxchiat., §§: 102-109. �-1hREFERENCES 10. LC. and Pincus, Hoagland, IL, Malamud, w., Kaufman, G. (19%): in the Electroencephalogram and in the Excretion of 17 Changes Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. , 8: 11. 216-251. Kennard, M.A. and Willner, MD (1908): Electroencephalogram M. lg: 13. Serial (1955): Results from Shock Therapy, 4AM ho-hs. P83111835” £02: Igtz, Which Significance of Changes in the Changes Due to Electrotherapy, Dis. Nerv. $35., 120-122. Knott, G.R., Gottlieb, J.S., Leet, Hull and Hadley, H.D. Jr., (1943): Changes in Electroencephalograph Following Metrazol Shock Therapy: A 1h. Quantitative Study, Arch. Neurol. 8c Psychiat., 29: 529-53h. Levy, N.A., Serota, mm and Grinker, R.R. (19142): Disturbance in Brain Function Following Convulsive Shock Therapy, Arch.Neurol. PsEhiat., ﬂ: Liberson, wur. (1951): 1009-1027. Current Evaluation of Electric Convulsive Therapy, Mento ASS. Nerv. PUbl. R93. D180, 0... nun-U. Lorimer, F.M., Segal, & M.M. and Stein, S.A. 2: 199-2310 (19149): Path of Current Distribution in Brain During Electroconvulsive Therapy, EEG. 17. Clin. Neurophysiol., 3;: 318-3148. Moriarity, J .D. and Siemens, J .0. (19M): Electroencephalographic Study of Electric Shock Therapy, Arch. Neurol. & Psychiat., 21: 712-718. �- 15 REFERENCES 18. Pacella, B.L., Barrera, S.W. and Kalinowsky, L. (l9h2): Variations in of Shock Therapy with Electric Electrocephalogram.Associated the Patients with Mental Disorders, Arch. Neurol. & Pszchiat., 51: 367—381l- 19. Proctor, J.E. (l9h5): Clinical and Electra-physiological L.D. and Goodwin, Observations Following Electroshock, Amer. J. Pszghiat., 39;: 707-800. 20. Proctor, L.D. and Goodwin, J.E. (l9h3): Comparative Electroencephalographic Observations Following Electroshock Therapy using Alternating and Unidirectional Fluctuating Current, 22: 21. Raw 60 Am. Cycle J. Pszghiat., 525-530. Smith, J.w. and Wegener, C.F. (19hh): On Electric Convulsive Therapy with Control??? Electrodes of Application Parietal to a Particular Regard Neurol., et Acta Measurements, Pszchiat. Voltage Intracerebral by lg: 529-5h9. Sulzbach, W., Tillotson, K.J., Guillemin, (l9h3): A Consideration of Some V. Jr. and Sutherland, G.F. Experience with Electric Shock Various to Regard with Special Mental Diseases, Treatment in Psychosomatic Phenomena and to Certain Electro~technical Factors, 23. Taylor, R.M. and Pacella, B.L. (19h8): The Significance of Abnormal Electroencephalograms Prior to Electroconvulsive Therapy, J. Nerv. & Ment. Dis., 291: 220-227. �. 16 - REFERENCES 2h. Ulett, G.A. and Johnson, M.W. (1957): Upon Electroencephalographic Changes Induced by Electro-convulsive Therapy, 25. W911, A.A. and EEG. Olin. Negggghxsiol.,.2: 217-22h. Brinegar, wgc. (19h7): Following Electric 21: Effect of Atropine and Scopolamine 719-729. Electroencephalographic Studies Shock Therapy, Arch. Naurol. & Pszghiat., � 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 Martin A. Green: Significance of Individual Variability in EEG Response to Electroshock, 1957 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-10-010 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Green, Martin 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 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 http://exhibits.library.stonybrook.edu/mfp/files/original/ec4cf1a3f19d135cdae9a13c9adf5bf5.pdf 067f3d4f0480ecc6b50bb9561e8d4277 PDF Text Text Standardization of the Face-Hand Test Martin A. Green, M.D. and Max Fin/z, M.D. the face-hand test, has been introduced in previous studies and the responses of normal subjects and of patients with psychiatric disorders described in detail?“ The test consists of applying touch or pinprick stimuli simultaneously to the face and hand while the subject’s eyes are closed. The subject is then asked to describe and to localize the percepts. Two general types of responses occur. The two stimuli may be perceived and localized correctly, or the subject may perceive only one stimulus and either not perceive the other (phenomenon of extinction) or mislocalize the second stimulus (phenomenon of displacement).7 Most often the mis— localization or displacement occurs to another part of the subject’s body, but occasionally there is displacement into extrapersonal space or onto the examiner (exosomesthesia).R Displacement of stimuli across the midline of the body (allesthesia) may also occur.” Normal adults show errors in perception on the initial trials of the facehand test. Characteristically these errors consist of extinction of the stimulus to the hand whereas the face stimulus is perceived correctly (phenomenon of face dominance). As tests are repeated the errors disappear so that by the tenth trial nearly all subjects correctly perceive both stimuli and then continue to be correct on subsequent trials. This type of response has been termed a “negative face-hand test.” It occurs not only with normal adults but also in patients with schizophrenia, depression, or severe anxiety. In contrast, patients with an organic mental syndrome show extinction and displacement after ten trials of testing or as long as testing is continued. Such a response is termed a “positive face-hand test.” A “positive face-hand test” is also manifested by normal children, normal aged persons, and mental defectives. Because of the differential response of these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it has been noted that patients with an organic mental syndrome vary greatly in the type and A SIMPLE PERCEPTUAL TEST, From the department of neurology of the Mount Sinai Hospital and the Hillside Hos— pital, New York City. This work was aided in part by fellowships from the United States Public Health Serv— ice (Dr. Green) and the National Foundation for Infantile Paralysis (Dr. Fink). Reprinted from NEUROLOGY, Minneapolis, March 1954, Vol. 4, No. 3 211 �NEUROLOGY 21:2 frequency of perceptual errors. Also, subjects without organic brain disease occasionally manifest a positive face—hand test. The questions which arise from these observations are: 1) Is it possible to classify or standardize the different types of errors occurring in subjects with a positive face-hand test? 2) Is there a correlation between the types of responses and different groups of subjects? 3) Is there a type of response which can be said to occur only in patients with severe disease of the brain? The present study is an attempt to answer these questions. IVIETHOD AND RESULTS Previous records of the face-hand test were reviewed for almost 1,000 patients with organic mental syndrome, normal adults, and schizophrenic adults, as well as lesser numbers of normal children, normal aged persons, and sub— jects with mental deﬁciency, depression, and severe anxiety. Additional groups of some of these subjects were also tested in a systematic manner with dif— ferent types of stimuli. The criteria used to formulate a standardization of the face—hand test were: 1) type of perceptual error; 2) frequency of various errors with different stimuli (touch, rubbing or scratching, and pinprick); 3) effect on the frequency of errors when the subject observes the application of stimuli (factor of attention). Fifteen to 30 trials of the test were usually done for each subject. TABLE 1 FEATURES OF POSITIVE FACE-HAND TESTS (Persistent errors after 10th trial) One—plus Extinction only with touch stimuli. Two-plus Extinction with touch, rubbing, and pinprick stimuli. Occasional dis— placement with touch stimuli. Three-plus Extinction and displacement with touch, rubbing, and pinprick stimuli. F our—plus Same as three-plus with at least one of the following features: a) exosomesthesia, b) allesthesia, C) frequent perseveration, d) occurrence of errors while subject watches the stimuli being applied. Based on these criteria, it was possible to divide patients showing a posi— tive face-hand test into four groups. The characteristic responses for each group are summarized in table 1. These responses with examples are described more fully in the following paragraphs. One-plus face-hand test: Subjects in this group show errors only of extinction and not of displacement. These errors occur only with touch stimuli. When pinprick is used, both stimuli are perceived correctly, although errors will again appear when touch stimuli are reintroduced. Case 1.—A 64 year old man with mild diabetes was admitted with a history of difficulty in walking for the previous year and a half. For at least the same period of time he had been depressed, slept and ate poorly, and was impotent. The only neurologic ﬁnding was a slow, hesitant, shufﬂing gait. There was no evidence of peripheral vascular disease. The patient appeared depressed, showed psychomotor retardation, and cried readily. The sensorium was intact. Spinal fluid, electroencephalogram, and roentgenograms of �STANDARDIZATION OF FACE—HAND TEST 213 the spine were normal. The diagnosis was involutional psychosis, depressed type. The gait difﬁculties were thought to be secondary to the depression. This patient showed a one-plus response on the face-hand test. A sample of his responses follows: Stimulus touch touch touch touch touch touch touch touch touch touch touch pinprick pinprick pinprick pinprick touch touch Location right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand right cheek—left cheek right hand—left hand right cheek—left hand left cheek—right hand left cheek—left hand right cheek-right hand left cheek—left hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand right cheek—left hand left cheek—right hand Response right cheek left cheek right cheek left cheek correct correct right cheek correct correct right cheek left cheek correct correct correct correct correct left cheek Type of error extinction extinction extinction extinction extinction extinction extinction extinction Comment: Although this type of response occurs in patients with cerebral disease, it is not always characteristic for this group. It is also observed in patients with depression, as this case illustrates, and may occur in anxiety states, schizophrenia, and, occasionally, in normal adults. T wo-plus face—hand test: In this group extinction occurs with pinprick and rubbing stimuli as well as with touch stimuli. These errors may be just as frequent with both types of stimuli or may be more conspicuous with touch than with pinprick or rubbing. Displacement is not present, as a rule, but may occur on an occasional trial. Case 2.—A 72 year old man had a ﬁve week history of mental and behavioral changes. These consisted of disorientation, confused behavior, and intermittent mutism. Examination showed an organic mental syndrome characterized by partial disorientation, defects in recent memory, evasions and circumlocutions in answering questions, denial of illness, and pain asymbolia. There were no other neurologic disabilities. The spinal ﬂuid, electroencephalogram, and skull roentgenograms were normal. A pneumoencephalogram showed an increased amount of air over the cerebrum and increase in the size of the ventricles. This patient’s responses on the face-hand test characterize the two-plus type of response. A sample of these responses follows: Stimulus Location Response Type of error touch left cheek—right hand left cheek extinction touch extinction right cheek—left hand right cheek left cheek—left hand touch left cheek extinction touch extinction right cheek—right hand right cheek touch correct right cheek—left cheek touch correct right hand—left hand touch extinction right cheek right cheek—left hand left cheek—right hand left cheek extinction pinprick �214 NE UROLOGY Stimulus pinprick pinprick pinprick pinprick Location. right cheek—left hand left cheek—left hand right cheek—right hand left cheek—right hand Response correct left cheek right cheek left cheek Type of error extinction extinction extinction Comment: This response occurs most often in patients with cerebral dis— ease, although occasionally patients with anxiety states, depression, or schizophrenia may also exhibit it. It is not seen in normal adults. Three-plus face-hand test: This group is characterized by the occurrence of displacement as well as extinction with both touch and pinprick stimuli. The frequency of extinction and displacement may be equal or unequal and, likewise, the number of errors with touch and pinprick will be variable. Case 8.——A 57 year old chronic alcoholic was found in the street in a stuporous condition. His breath had an alcoholic odor and there was a laceration over his right forehead. There were no focal neurologic signs. During the ﬁrst hospital day the patient gradually became fully conscious. Speech was rambling and at times almost incoherent. He was completely disoriented and had severe memory defects with confabulation. He expressed paranoid ideas and was hostile and assaultive. There were no hallucinations. Spinal ﬂuid and skull roentgenograms were normal. The diagnosis was acute and chronic alcoholism with deterioration. A sample of this patient’s responses on the face-hand test, indicative of a three-plus response, follows: Stimulus touch touch touch touch touch touch touch pinprick pinprick pinprick pinprick Location right cheek—left hand left cheek—right hand right cheek-right hand left cheek—left hand left cheek—right hand right cheek-left hand right hand—left hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand Response right cheek-left cheek right hand—left hand right cheek correct left cheek right cheek—left cheek correct right cheek—left cheek left cheek—right cheek right cheek ' left cheek Type of error displacement displacement extinction extinction displacement displacement displacement extinction extinction Four-plus face-hand test: This group shows the most severe perceptual errors. In addition to frequent extinction and displacement, as seen in the three—plus group, one or all of the following phenomena may be seen with touch and pinprick stimuli: l) exosomesthesia; 2) allesthesia; 3) frequent perseveration of responses; 4) occurrence of perceptual errors even while the subject keeps his eyes open and sees the areas stimulated. Case 4.—A 60 year old man had a three year history of disorientation, forgetfulness, and loss of interest. On examination he showed a severe organic mental syndrome manifested by complete disorientation, marked memory defects, and inability to calculate. He was alert and cooperative. There were no other neurologic signs. Spinal ﬂuid and skull roentgenograms were normal. The electroencephalogram showed moderate, diffuse, bisynchronous slowing with slow alpha. A pneumoencephalogram disclosed abnormal increased amounts of air in the subarachnoid spaces overlying the cerebral cortex. A sample of the patient’s responses, indicating a four-plus face-hand test, follows: �STANDARDIZATION OF FACE-HAND TEST Stimulus touch touch Location right cheek—left hand left cheek—right hand touch touch touch touch touch pinprick pinprick pinprick pinprick right cheek—right hand left cheek—left hand right hand-left hand right cheek—left hand left cheek—right hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand pinprick ( eyes open ) right cheek—left hand Response right cheek left cheek— extrapersonal space right cheek right cheek correct right cheek—left cheek left cheek—left hand right cheek—left cheek left cheek right cheek left cheek— extrapersonal space right cheek— 215 Type of error extinction exosomesthesia extinction perseveration displacement allesthesia displacement extinction extinction exosomesthesia exosomesthesia extrapersonal space Comment: Three-plus and four-plus responses invariably indicate disease of the brain. They are never found in normal adults or in patients with psychogenic disorders. These responses have been occasionally seen, however, in normal children under the age of six,4 aged persons without manifest disease of the brain,6 and mental defectives.10 The distribution of responses of children and aged persons are related mainly to age. The youngest children and the oldest adults show three-plus and four-plus responses. With changes in age away from these extremes, one-plus and two-plus responses become more frequent. Of the subjects with mental deﬁciency, those with the lowest mental age have three-plus and four-plus responses, while one-plus and two-plus responses predominate in subjects with higher mental ages. Table 2 summarizes the distribution of the four different types of responses among the various groups of subjects. Only patients with an organic mental syndrome show three-plus and four-plus responses. Such responses may be considered diagnostic of an organic mental syndrome. DISCUSSION In answer to the questions raised at the outset of this paper, our results indicate that four general types of positive face-hand tests occur and that TABLE 2 PERCENTAGE FREQUENCY OF ONE-PLUS TO FOUR-PLUS POSITIVE FACE—HAND TEST IN DIFFERENT GROUPS OF SUBJECTS ‘ ............. ................... Patients with anxiety states ............. Organic mental syndrome Normal adults (below 60 years of age) Schizophrenic adults Patients with psychogenic depression (all age groups included) . . . ............. . Negative F-H test Oneplus 10 99 7 nearly all occasional occasional 70 22 all nearly l Twoplus 25 0 Three- plus 33 O F ourplus 25 0 rare never never rare never never 0 0 8 �216 NEUROLOGY these types can be correlated with different groups of subjects (table 2). Our attention was focused mainly on whether there was a type of response which occurred only in patients with severe disease of the brain. All adult subjects with a three-plus or four-plus response have organic brain disease. Such responses are never seen in normal subjects or patients with psycho— genic disorders, even though these groups may occasionally Show one-plus or two-plus responses. Patients with cerebral disease manifesting a four-plus response invariably show the severest or most advanced form of mental changes. Otherwise there is no good correlation between the type of positive face-hand test and the severity of sensorial defects. Some patients with severe mental changes may have only a two—plus response. In addition, 10 per cent of patients with an organic mental syndrome have a negative face-hand test. It is realized that the use of a one to four—plus nomenclature for the groups implies an increasof because used This nomenclature of cerebral was dysfunction. degree ing convenience and such an implication is not intended. This classiﬁcation of a positive face-hand test should be useful clinically. In testing neurologic patients, the exact type of positive face—hand test should be recorded, rather than the designation “the face-hand test was positive” as has been done until now. Such a procedure will make it easier to judge whether the type of positive face-hand test indicates deﬁnite cerebral disease or whether it may be a manifestation of anxiety or depression. The use of such a classiﬁcation will also make it easier to compare the response of patients at different times during their illness. In addition, it is valuable in clinical experimental work, for it has been applied in studies of the effects of drugs on perception and the responses of patients to electroshock treatment. In such studies alteration in perception can be measured by observing the duration and incidence of the variety of positive face-hand tests during the periods of testing. SUMMARY A standardization of the face-hand test is presented. A positive face-hand test is designated as one in which errors persist after the tenth trial. Four classes of positive face-hand tests are recorded. A one-plus face-hand test consists of extinction only with touch stimuli. A two-plus response is char- acterized by extinction with pinprick and rubbing stimuli, as well as with touch stimuli. A three—plus response consists of extinction and displacement with touch, rubbing, and pinprick stimuli. A four-plus response has all the characteristics of a three-plus response and in addition at least one of the following features: a) exosomesthesia; b) allesthesia; c) perseveration of observes while the of (1) applicasubject even errors occurrence responses; tion of the stimuli. Three-plus and four-plus responses invariably indicate disease of the brain in subjects over the age of six years. One-plus and twoplus responses occur in patients with brain disease but are also manifested disorders. with adults and of normal number small psychogenic patients a by �STANDARDIZATION OF FACE-HAND TEST 217 Patients with a four-plus response show the severest mental changes but the converse is not true. There is no correlation between the severity of the mental changes and the type of positive face-hand test manifested. Usefulness of this classiﬁcation in the study of patients clinically and in experimental work is suggested. REFERENCES 1. BENDEn, M. B., FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. & Psychiat. 66: 355, 1951. [O . BENDER, M. B., and FINK, M.: Tactile per— ceptual tests in the differential diagnosis of psychiatric disorders, J. Hillside Hosp. 1:21, 1952. . FINK, M., GREEN, M., and BENDER, M. B.: The face-hand test as diagnostic sign of disease of the brain, Neurology 2:46, 1952. . FINK, M., and BENDER, M. B.: Development of perception of simultaneous tactile stimuli in normal children, Neurology 3:27, 1953. . IAFFE, J., and BENDER, M. B.: Perceptual patterns following general anesthesia, ]. Neurol., Neurosurg. 81 Psychiat. 14:316, 1951. 6. GREEN, M. A., and BENDER, M. B.: Cutaneous perception in the aged, Arch. Neurol. 6: Psychiat. 69:577, 1953. The phenomenon of sensory . BENDER, M. B.: displacement, Arch. Neurol. & Psychiat. 65: 607, 1951. . SHAPIRO, M. F., FINK, M., and BENDER, M. B.: Exosomesthesia or displacement of cutaneous sensation into extrapersonal space, Arch. Neurol. & Psychiat. 68:481, 1952. 9. BENDER, M. B., and NATHANSON, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena, Arch. Neurol. & Psychiat. 64:501, 1952. 10. FINK, M., GREEN, M. A., and BENDER, M. B.: Perception of simultaneous stimuli by mentally defective subjects, J. Nerv. & Ment. Dis. 117: 43, 1953. �EIWRDIZATION OF m FAGEwm MT 3y “mm I. ‘0 “NC“, Do und In: rank. n. n. ibis tort 1;: e status Publia Hoalth dation of n‘% ' _ﬁ{ p 9'» 1 arson) and survioo (Br. thy Huttonnl ‘ <" ' ’ ' ” Faun- Infantila Paralysis (Dr. Pink). Eran an. Dognvunont or Hourology at thn noun: stnui Hospital and tho 311 lid. Houpitnl. �Introduetiunt In priviaul studies a tinplo poro‘ptuﬁl taut, uh. rnoia hnnd ﬁast. was intradnoed and tha rbnﬁonnon bf normal anbjtetn 1nd or pationta with ptyohittrio d1noranrl w¢r¢ dglcribod 1n dbttil (lab). Tho tout aanniuta or applying tough or pinpriok .ltinnli nimnltnnsounly to tha tact und.hund uhilo the aubjuot‘n ayes hr. closed. it. lubjoot in than aambd to annariba and to lootliso thn poraapta. Two gannrul type: or roaponsol Gaunt. who ﬁve stimuli may bu poreoivod and localized oorruotly. 0r, thn nubjoae may piranivo only on. atiuulus and cithor*nat porn enivo the oﬁhtr (phnnennnan at astinotian) or maniacaliaa thn sooand stimulus (phannmnnon or diuplacaannt) (7). ﬁaét ottcn ~ﬁh¢ mislaealiuntién or diaplaéqnnnt «can»! to anathnr pirt at tho wubjoot’s body, but oooailunally thtrn 1n dilplaaahont into oxtrtparuonnl apnea or onto thy axmnxncr‘(axoaamolthnaia) (8). Diﬁplgotnoht at stimuli turns: the midlino or thn body ($110.» thosln) nu: also onenr (9). ﬂornnl adult: show 0r§oru 1n perception.au tbs initinl ‘ r mu.- a: I tho tuna-hum 4 «at. cmctcrnuaaxy than error: sonaiut or oxxznetion of thy thinning to ﬁn; hand than... tho raga Itimnlna is perceived aorrcotly (phcnamonon at face again,nnuo). A: thn that: arc ropoatad thy error: d£luppoar so thnt by th. tonth trial nearly :11 subjcctu norraetly paragQﬁa both stimuli and than oontinnu to bq corruat on tubauqunnt trigll. This typo or roaponno has bran tonmnd a “nagativo raco~hnnd tout.“ It ooourn not only with manual adult: but also in pttzontn �2. ‘vith :6h1uayhruniu, dtproaaion. or savor. anxiety. Kn contrast to tho proo¢d1ng aubjaats, pa§1nnts w1th tn uorganio mnntnl nyndrumn aha! qxt1not1on and displnecnant Artur 10¢ tr1a1: or toating ar-II long It touting 1- continued. Such t npupcnlc~1n‘tpnmnd u ”posit1vu {nonwhind tout." A *poaitivu ftoo~hnnd tout" 13 claw unnLroutod by normnl uh1ldrtn, normal ugud,p¢auann. Ind:mantnl dofoat1vol. Bananas of thy dirforont1a1 rnlpenao of thaao aoviral swung! at luhjoetl, an. faoo~hnnd test has banana astral ul1n~ toally 1n dataating tho prosoneo or orggn1e brain d1aoAIo. During the court: or our stud1al, hawovor.,1t ha: boan noted >that pntiants with 1n grannie nantql syndrann Vtrylgrontly 1n the type and traquancy or porcoptuul Grrort. Also; nﬁbjactn I ' without organ1o brt1n é1aoalo occasionally mnn1t¢at a pauitivc raccuhnnd test. 1h: quantionn ﬁnish arias from that. abnorvutionn an: 1) .1: 11'. poneiblo to elmxﬁ or mandamus an. autumn 'typu: or orrafa aouurr1ng 1n'1gbjooti v1th I panit1v§ fteowhnnd 80:12:13) In ﬁbﬁro A oorrulnt1on botuuon thb typca or roqpannol and dirrorun1_gr¢upa or aub:¢atn?; 3) in than. a typ. or ronponno Ih1ah can bu ugid to ocaur gal: in pitiﬁntl v1th_nav¢ro 61301:et uh. bra1n? the proncnt Itﬁdy is an uttqipt to ‘nalur than. questionapv I. 04 1 d B! ‘ t lb roviornﬁ our provleus record: gt ‘ 1h! tuna-hand 103% in nlmnat 1000 pat1onta with organic mnntnl syndroma, normal adults, and Inhiaoyhrohia adults. an wall an in longer numdam. born of normal.ohildrun, normal 130d porlena, and ambient: with �3. m.nt:1ld¢rieigncy. dnprnaulon and lottrn anxiuty. Additional stamp! of menu of than. uubjcotl taro 31-0 toatna in a lyutmm— gtic mannar'viﬁh ﬁlrtoront typaa of stimuli. The aritoria ulna to fonmultt. a Itandnrdixntion or the raaouhrnd tout wire; 1) typo of poraoptunl 2) frnQunney of various arrays (touch, rubbing at nergtehing. and p1n~' crrnr: airroront stimuli prick): 3) offset on thy troguoney or orroru vh¢n tho cubjoet noes tha appliantion at tho I§1IM11 (taotcr or dttcntien). Firtaon to thirty tritla at tho tait wuro naually done for wiﬁh Onah cubjoet. « criterig, it in: possiblo to divida pa § tianti sharing a positive ftoomhnha tqst into {our group:. Th» oharaaterintie rouponnu: for etch gréup arc summarized in Tabla I. 'ThoIoAroapann g with oxnmplo; art angeribad morn fully in tho {allowing par‘grapha. Based an.thnUO Fuataruu a: Ponitzvo~nuac-aana’roatn _(vors1£tont prrorn attdr 10t§ ﬁriil) W 1 M." Situation Extinction W Wm» 1 am plan mt1not1on with tough, und dinpltéo— anly with tauah stimuli rubbing. and 'mant with P181314“ touch, rubbing stimuli. ,tnd pinpriak occasionul stimuli 41: laocmant Ii tauah ‘ u)oxolamauthsaiu b)nllaathsai‘ ‘ , nttmuli. a: thug... with n: loaat can or uh. following {autumn ‘ o)trnquont porn¢v~ «ration d)qc¢urr¢nen of errors while just watch»: sub~ ithmuli buing nppliod. uh? �h. gnoePlgn.Fheoen§gd Tout: Tho subjects in thia group that error: only at Ixtinatioh and not at displahanant. Thou. errata oaour only with tauoh stimuli. Whon pinpriak is usod. both utinnli up. poruoivoa aornootly, although arrhra will agnhn appatr lhln touhh stimuli urn rhihtroduaod. Gun. 1: tad with 3 A 6h your aid huh with mild dinhotpl pus t6n1ﬁ* xi your hiltary a! dittiaulty in walking. Fbr at I... patina 0: than hm had boon dnprogacd, alnpe .and ht. pearly. and It. impatanﬁ. 'Tho only unurologiaul finding was t slow, halitant, nhurfllng shit. Thor» was nh ovidnnn: 10am: tho ot‘poriphortl vuioulhr dis-coo. Eh. pationt‘nppoarud doproiaod, 'IhoVGd payahanotor rotnrdutian, tnd dried handily. The non» aorium in: intact. Spinal fluid, slactrocnhaphulogrtm, ertys at tho spin. ward normal; who tional psychoazu. dopranlod type. hheught to he sccahdnry to thi diagnosis In: involuu The gait difficultiau tar. dnpronhion. _ this patient thalcd l anonpluaerIpanlﬁ tout. A sample at his ruxponaaa follows: on tho tau-«hand ‘ ‘ Stimulus gggatiog touch right ohnak*lott hand ’ wypg of ﬁgugcns; ﬁrrar right shook: axeinotion hoxtinntion 10ft shack tough loft chock-right touah' right ehaokwright hand right South 10ft annex—loft hand touch right ohhak~lnrt ahock earnest» aerroet right handwlott hand right ohsaknloft hand right dhaok tauah touch and hand Int: chagh about» uxtinotioh cxtinotion ' extinction �5. lart ahnak~r1ght hand left «human 2mm tauah touch touch right man 101“: pinpriok pinyrick pinprl ck pinprick touoh> entrust eon-cot. riwt aha-ehwrigﬁ hand mud“: hand right absoknlort-hand lore dh¢ek»right hand right nhotkwright hand 1am; ehcokdgft ma‘ right «haiknlgrt hund wt ”chock-avian: hum loft . ~ chock check axnination «attraction aorrooh correct garnet“ «may ‘ aorroot 1st: abut: .munctxm ggggggﬁ; Althnugh thia typc or.rcnpanno aoaﬁra in patiwntl teach aorabrnl diuaano, 1t 1: not dlway: entruatcvistie for this group. It is Also abhcrvué‘tn patiunts Iiﬁhéaprolaion, wiﬁh : thlg anal illuitratas} aehisoﬁhranin, and. ocassiénally,'1n nunnnl a¢ulta; P; V,Eh.0+H Id ’rt In this graup axtinction ooeurt Iiﬁh pinpriek nag rubbing stimuli a: lull én‘vith taudh #tim» all. than; arrora mgy ha junﬁ an froqugnt with baﬁh.typta at stimuli er may be met. conspiauouj\vith-tauah‘ﬁhnn with pinﬁ prick or'rubbinga Biapluaunnnt 1; not yrbsnntg an a rule. and may occur xn anxioty at§t¢t, an & 7 L , but may auour on Case 1!: '1 tn,aoedligna1 téinls 72 year o;d man had a 5 ' . WIOK history of anneal and bahnxioral;ohangoae Eben. ganniatcd ar'éiaor10n~ tatian. confused bdhnviar. and intarldtéant muslin; On oxnmp inntion thara Inn gn organic mnntql lyndran. charactarisod by partial dinoriontation. 60:00:: in ruannt unwary, OthianI �Z~g‘ s7”! ind otteumloauhlann 1n annu¢r1ng quastians, daninl or 1113..“j and pain uuynhoiit. Thar. var. no oﬁhor nunrolagioal dilw mutton. mo spin-.1 mum. olootraonaaphuagm. and “all xnrnys Ibru ndrmal. A pnauﬁooneaphalognmn unusua'un 1n¢ro.nad «ﬂaunt of air ovor uh. aorobrum and inaroaaa in tha 3110 at tha ventricles. was: pat1¢nt§a raaﬁonloa'on tho tuco-hugd taut untran- torls. tho tvaapgul typa at ruaponao. spannon taller: samplc of thnsc raw A \ a ‘ 3352395; Tg£;o;t _“§au¢h aggntgan 1.x: abnohuright hand 10ft «hack axﬁinotian tcudh right ahaak~1at£ hnnd right thinstion ' 3tg55;un left r.t§ugna tbuah V. tough touch toudh ’ right right right right enaok~1a;m hand ‘” ' unsurpright hana din:k-1.ft-ahodk hundnlurt hand «hookvlhft hand lgtt ahnuk Oxtlnntinn right chnub extinction‘ about «errant eorruat ' pinpriek loft ghostwright hand right chock wyxtinstian 1.1: chuck oxtinctian pinpriok ptnprick pinpriok pinprlok right ahcokalort hand oorreat 1.x: ehaakwlort ngna right chant~r1ght hand lart ' oxtinutidn oxtinctian 10ft chick cxtinotion 1¢ft ahhek~right hind adamant: Thin ruaponaa eocuru mast urban 1n pntianta with cornbrul 6119110 altheugh oncasianally ptt£¢ntl with anxigty itibﬂlp dnprossion or duhinophronia naq'alto cxhibit it. It in not soon in nounnl ndulta. ahﬂak right ehnok �0‘: 75 gaggovgggg §33A~§g§§ ruAtt IhAA by thy ooaurrunco of diApLAeanAnt bath touch And pinprick atzmuli. group wall AA who And displaoumanm 1A chArAatAriAAd Axtinction with frAquAnoy of extinction AA , any bA’Aqual cr unsquAl And. likAAiAA, Aha number 0: errors Aibh touch And pinpriak'will bu AArAAbIA. 6139 III: strict in the holia odor There AArA hoapital ntuporoun oundition. A And thArA AAA thA pAtiAnt rumbling And caaplataly diacriuntod gnnfahulation. 31A brAAth hAd an Alena HA 3 lAAArAtion gradually bAoAAA fully oonaaioun. At tihnn Alnolt inoohArAnt. EA AAA. And had AAVArA salary axprAAAAd pArAnoid idAAA and A3AAA1§1VA._ whArA Aura And Akull X-rAJA AArA nanmAl. Th. diAgnosil Asamplq of thin pAtiAnt'a A tout. indiactivo or giggyggg saw. A ggaation my“ dunk-daft hand . touch loft touch right touch urt chum-hrs hAnd Quota-wright ham. ' mamm hum! touch right aha-kaloft uhAARArxsht hAnd hAnd loft hoatilo III aunt. fluid and taco-hand fallow-t right abuzz- ‘ with EpiuAl T§£§ogf 333223;; ' lnft AAA AAA rAAponAAA on Ah. thrAAapluA rauponsa, touch dAtAAtA no hAllueihAtianA. .Ahronie ALedholium with anteriorAhion. ” found in AAA ovor his right torAhAAd. no fooAl nnurologieAl signs. During uh. tirut AAy SpAAAh WA» 57 yoAr old chrenio Alcdhalio A chock ‘ diuplmmnt . hand;mm 1cm; hum! displaemne right about anemone»: came: lcts aback extination right diaplaeAaont loft ahAAk~ ohAAk �touch right hand-10ft pinpriak ; pinpriak hand comet right ahaok~lort hnnd A)right left an: 1m; chﬁokumght hand I pinpriak pinpviek Fb ' ‘ ' right chock-«right. hand lcrt «hank-lnrt‘hnnd Flu; Hand chaokn diaplaoamant «bank cheat» right ahnek right ohm: lﬁtt ; aback displaeﬁmnnt . oxemauon axtinutien ‘oat This greup shown tho aovcrast poréoptual arrara. In addiiion to rr$quont «xtination lné ainplaeomnnt, an noon in thn thrno~p1us group, on. or .11 at ﬁba folloiing , with touah and pinprlak aﬁimnli: 1) uxunanalthnninx 2) allouthoditi 3) truqnnnt pur~ agvcratian at responlttt h) tho oocurrcnnn or paranptunl arrorn ngn-uhzid ﬁnd aubjoat kaopu hxl'cytu opan and 109: tht Irilﬂ ﬁbenamnnn may be mean ﬂimuntud. Gas: 60 ycnr old man hgd a thrai your hiatary or disoricntution, forgatrulnnla. ‘ndVIOIl of intaraut. an axum~ 1n£ti¢u h. ahawqa a 3.1.». argania mantal nyndroun manirnqttd by cauploto disaritnt‘tian, marked,m¢mary actuati, and inabilo ity to atliulato. H. In: alart and cooporteivo. whore wire no other naurological algal. Spinal fluid gnd akull Xbrnya XVI ‘uuro manual. A EEG-abound anagruto, diffuse. biaynahranoul alaning with 110! alpha. A pneumnonnephalogrum discloscd dbnormal increasod amount: of air in th» aubnrachnoid apnea: overlying the anrobrti eortox. A Iamplo of tho pationt'u rnuponuua. indicating a four. plus tacowhnnd tott, tollavla ’ f �95 Stimulus. tough touah Typa . mastic»: ' right obnokuloft hand 19ft chnekhright hand ‘ » of Emu Rcaw‘ right aback axtinctian left oxosomoathoslu :- chatk~ oxtruporuonnl apa¢o tough right thehwright touch loft touch tnunh right handplaft hand right ahaak~lort hand tench loft aback-right pinpriak right aback-loft ptnpriak pinpriek pinpriok 10ft chookbright hand lart right ahookaright right 10ft ohuak~lort h:nd 1.1% chook- axoaanosthnaiu pinpriek right chopkwleft right oxaaamaathclia (ayes Open) . r. . . adamant: 1 hand chnokwlerﬁ hand right «hank right cheek torrent right aha¢k~ qxtinetion poraevoration aiaplaeanant hand 10ft chock 10ft ehaak10ft hand allouthaslt hand right displtaunant hand hand 10ft ohnak~ aback ohock . dho¢k «xeraporlonal span. shack» nztrtparuannl oxtinatien txtinctian :pton rhrno—plun and rouﬁwplul vniponsos invarisbly inninatogdinoani of thoﬁbrain. inn: 1:. nnvur fauna in normal ﬁdults or in patiants with plyahogonin diuordgru. I ﬁhnaa rbaponses have bash oocasionnlly noon, howuvor, 1n nerull childrnn undsr the as. at at; (h); agad potions withuut (6) had manual dnroetivna (19). manifoat disaaso or thﬁ brain rho diltrdbution of tha ruapanseu a! the ohildron and ugod poruanl are rolatnd ntinly ta ago. in. yaungnnt childrun and tho oldnlt adult. show thruo~p1u1 ind rourwplub rulponqon. �16. Wiﬁh thin. «hangs: in age away tram untruunu, ono~plun Ind Iroqunht. or the tubjccbs lith.nnntal dtfiei¢nny, than. with in. lowgat annual agthavo ﬁbroeoplun':nd teurvpluj roupannaa whila ona~plus and two91ua rcapensoa prndaminutu in nubjnota with highnr’mnntal twowplua rulponsaa baoama mare _ I aguu‘ II aummurises thn dintribution a: tbs four different typaa at rulpnnyeu twang tbs variau: groups or aubjoetl. Gnly Tabln ‘pgtlonts with In argania mmntal syndrana.nhow unreguplus and rourbplua teaponaoa. Such roapunaes may be aansidorad ditgu nbstio or an organic unntul ayndrumn. mm ;; Prwqusnay or 0n¢~P1uu to Faun-Elna Tﬁat in Dirforant Gwoupa nogntlvu Gaga Pku Organic Hantal syndruua adult: (below your: a: as.) Norunl taut 60 99% Schizophrtnia Adult. Patimntu with anxiety nnarly Patients with plyahn~ -7o% states , asarly genie dnproasian (all age grnupa inaludad) W! "' 19% Tue? Three Paar- Plgg‘ Plus 7% 25% 33% 25% 15 o o a dooaa~ :11 Paaittvo at Subjects Four~P1un P§uu P;ul rarg new.» navor ionglly oooas- ray. navar‘ novor all tonsil: 22% 85 o o , In unavor to the questions railed in tn» introduation, our rounltu indicnto that four gonoral typos of paaitiva �.11. faooahand touts occur‘gnd that than. typo: «an bo carrolatod with airfaront greupn at aubjoats (Tablc II). Our attention Ill fauna-d mainly on thg question cf ﬁhathar there in: a typ. or rouponse which oeaurrod only in pubinnts with savart 4180330 of chi bra1n._ All adult subjootn with u thrionplun . - or rourwplua v.3ponno haw. orgtn1o brain dictate. Suéh rua uponaou 1:3 nave: icon in manual subjgatu er patient: with payahogan1l disardnrn, even though than. group. any oocunlonnlly than onnnplun or twonplua traponnnn. ' Patigntn with atrabral dinette manifesting a four-plus nonpango invaritbly that tho novonast or must udvunnod foam of mantul abungal. Othorulao thaw. in nu good aorrolat1an botwoon thy typo at pou1tivo tiéowhand tout 1nd tho soverreyv 9f thn unhaorial daroatn. 3am: putionta with aovnro monﬁal ahnngps may'havo anxy; two«p1ua vouponso. 1n additian, 105‘ or pationtu with an orgnnIo manealinyndromn.hnvh a magazivo faaa~hand taut, It is rhalisod that tho use of I one to taut» plun nonnnoiutur. £6» Eh. groups umplies an inoronﬁing dagruc or aeropral'dyatunation. This namnnslntumo van used because of aonvonicnaa and aunh an implicition in not intended. Th1; olauitiaatlnn af 3 poauin rues-hand test should be useful elinioglly. 'In téuﬁing nouiologioal patients, uh. cxaat type or positive taco-hand tout Ihauld be renordpd. rather thtn tha datlgnation ”the tao§~haad test was positivo' until nan. Bach a proeoduro «111 makd 1t Judgo whatnot tha typo or poaitivo runomhand ﬁont as has buon don. aasiar to indicatcs dotinita oorabrnl discus. or whnthnr manifcptntiou at tnzitty or dapruauian. who it may be c use or much a ' �12. alanairication will also make it easier to ounpuio tho roayenno or patlontl at diffcrtnt tin»: during thuir illniaa. In ad» dition, 1t. 1. “1mm. in cumin). “perm-am work, for it has bean aypllod in studio: or thn urfpetn otdrugn on pircaption, and tho rutponlal at pat1¢nta t6 olootrouhook truatu want. in aueh Itudioa altnrution in pottuptian can be mat» . stand by abaovwing tbs duration and tho incidnnao cf thn varioty at positive tano~hnnd tests during tho period: of teating. Sulnagz: ' stundardizttian of tha {tonohand tout in prntontod. A positive faoouhnnd taut it danorihod In on. in uhiéh orrart portint .13.: tho_tunth trial. Pour clause: of positivo tuto— A hdnd teats urn racerdod. ann~p1ua fnoo~hand A tott aensiaﬁl of oxtination only with touch stimuli. A tro~plun renponso is charuatoriaod by axt1notion with p1npr1ck und rubbing atims uli, ﬂ as ‘ill an Iith touch stimuli. thrna~p1us nonponno tontlata or oxtinoticn and displaeumont 11th tough. rubbing, tad pinpriak stimuli. A rourbplup runyonao ha. til tho tharhl aotariatica of a throu~p1ul response and invadditian at least one at thn following ronturos: a) Oxasamntthoaia; b) ulleathnlinz A . c) poraovonntion af roaponnasz d) ooourrenao or errors even whilo tha subject 8063 tbs application at the stimuli. Throo~ plus and four-plus weaponnea invaritbly indicate dinette of tbs bra1n in subject: evor tho ago of :11 yours. 0no~plua and trauplun roapqnaea occur in ptt1antn with brain disnaac amall number of normal adult: and but are 3139 maniteathd by a ptt1ontn with paychogonia‘diaoranrt. Patients with a faur~plul �I “‘"’ 13l- tho ”want maul change; but ﬂan canny“ 1.8 not Ema. morn is no corraluion human t)» unrity of the manta), uhmgu m4 tho or punitive: rum-hind z'oapcmao show taut tn. awaited. m unfulnbu or this the study at panama clinically and in it indicatad. _ cluuu‘iutim in 01$“:de work �I -m...‘ ‘ ‘ hm W l: BEXEER, ‘BENDER. in hhn :nd GREEK, ﬂ.: .é.:355. 1951. K.B.: FINE, «option on sinnlt 2. . 3.3.; on: tout: of fans and hsnu. and FINK, Hg: airfarontill guﬁiglgﬁdo H032. Patterns in par» M. Arab. Tactile parcoptual taata diagnouia or payohiutriu diuordnrl. ital. 1952. 3. FIRE. 3.: GREEHA M. and BERDER, M.B.: The faoe~hnnd test. nign of diieasa of the bruin. yourologz‘g: :3 dig zontio .7. , FIKK, H. and.BENU£R. K.B.x . simmltnnnout 1327p 1953* J“FFE' Duvnlopmnnt tactilu stimuli in 5' ‘nd 333933* unsathanin. ggggral ,3 W md- 7. 8'. BENDER, a H.B.z SHAPIRQ. HiF0‘ BEHDER, M.B.: Th9 phcncmanun PM, . 3 «hi .‘ghzslé, . 'Wmcx. and nonnnl childronw agggggggz “'B-' Pofocptunl pace-an: follavinsj. .3 urcgﬂc a: ,GREBH. at pdrcqptian or .3 entanooun‘pcroaytion 1n uh. £29.35“. 1953» er Ionaory diuplucunynt. @607. E. and 1951- Vii-159””. “‘8‘; Exosmnthuin or displacannnt or outnnoonu nonnation inté axtraporaondl upuca‘ ﬁgg§.ﬂiggo;.&Pnzah15§. é§§hﬂl,‘1952. 9. ‘nﬁann, 3.5. and Hamunnaen, u.: Pattorna 1n alloltbouia tad thair rulation to disordnr of boay sebum. and other: scnsery phnnamann. Arah.xourol.&9azehiat. ég3501, 1952. 10. ﬂ.B¢t y.".Pt19n or I!" GREEN, MuAu ”4 51mm tanaaua stimuli b montully aorontiva subjects. J-nOPV‘aatnm:3; m1 3. 1953. m. W. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Standardization of the face-hand test. Neurology. 1954 Mar; 4(3): 211-7. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-14-018 Date A point or period of time associated with an event in the lifecycle of the resource 1954 Creator An entity primarily responsible for making the resource Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and Reprint. Reprint from NEUROLOGY, Minneapolis, March 1954, Vol.4, No.3 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published